Abstract
During the COVID-19 pandemic, the CDC Foundation collaborated with implementing partners in Zambia and Tanzania to address challenges related to vaccination access and hesitancy through strategic partnership, technical assistance, and community engagement. These efforts were successful in fostering collaborations among community partners and health authorities and actively engaging the ministries of health. This article describes 2 case studies from Zambia and Tanzania involving different strategies to build health system capacity through projects that improved vaccination access and reduced hesitancy. Such projects illustrate how efforts that strengthen public health and healthcare systems have further positive implications for building localized response systems through context-tailored approaches and building capacity of local healthcare workers. The case studies are examples of public health emergency response projects that successfully increased vaccination access and reduced hesitancy in local communities by rapidly implementing projects to strengthen health system capacity and resilience.
Introduction
COVID-19 exacerbated existing gaps in healthcare delivery and highlighted the need for improvements in health system capacity and emergency response preparedness. Within a year of declaring COVID-19 a public health emergency, the CDC Foundation and its global partners rapidly launched projects to build capacity for contact tracing, surveillance programs, and promoting partnership during the response. 1 Strategies for improving and sustaining global responses to COVID-19 include enhancing the surveillance of COVID-19 cases by improving testing capacity, building public health workforce capacity, supporting enhancement of other infectious disease mitigation efforts, improving vaccination access for communities, and reducing vaccine hesitancy in communities. 2
The following case studies from Zambia and Tanzania involved different strategies to build health system capacity through projects that improved vaccination access and reduced hesitancy. Vaccination hesitancy is defined by the World Health Organization (WHO) as “the reluctance or refusal to vaccinate despite the availability of vaccines,” and is mentioned as 1 of the top 10 threats to global health identified by WHO in 2019. 3 The projects described in these case studies engaged multiple implementing partners including health authorities, formally trained healthcare workers (HCWs), community health workers (CHWs), faith leaders, and government health teams to promote vaccination uptake and reduce hesitancy. To provide equitable vaccine access and promote healthy societies, healthcare systems must work alongside communities to develop immunization programs according to local needs through context-tailored strategies, emphasizing approaches that engage relevant local political, religious, and health leaders.4,5 The case studies are 2 examples of successful public health emergency response projects with the goal of addressing vaccination access and hesitancy in local communities.
Case Study: Communication Strategies for Vaccination Hesitancy and Accessibility in Zambia
Beginning in April 2021, Zambia incorporated COVID-19 vaccines into the nation's pandemic response plan. 6 Persons aged 65 years and older were identified as the most vulnerable to severe illness and were, therefore, among the first to be prioritized for vaccination. Circle of Hope is a faith-based organization in Zambia engaged in the COVID-19 pandemic response through both prevention and mitigation efforts, including vaccine promotion at household and community levels. The overarching goals of the project were to increase COVID-19 vaccine uptake by the community—particularly among persons over age 65—through vaccine awareness promotion, and to promote care for vulnerable grandmothers, grandfathers, families, and children, all of whom face threats to their wellbeing when a grandparent or parent dies. This project supported COVID-19 vaccine uptake by providing tailored communication materials, training CHWs and HCWs on 1-on-1 treatment and vaccination counseling, and increasing the number of vaccination sites within communities.
This project sought to reduce access inequalities by building the capacity of local healthcare sites, introducing mobile vaccination sites, and engaging with church services and other community events. Establishing community posts was the primary method of increasing vaccination sites within communities. Circle of Hope had previously used the community post model to increase the reach of HIV treatment in local communities. 7 This model is a faith-engaged community approach to care using community platforms such as churches, markets, and bus stops to deliver more accessible care and alleviate the burden on overwhelmed health systems. 8
A primary aspect of the project was the framing of vaccination communications as “messages of hope.” Literature shows that crisis communication focusing on fear is more effective when coupled with a sense of hope and efficacy. As Petersen et al noted, “providing hope through actionable advice and long-term-oriented communication may be especially important during a prolonged crisis, such as a pandemic, where fatigue may otherwise demotivate publics.” 9 This project sought to determine whether this communication strategy would be effective in encouraging uptake.
Vaccine Messaging and Training for CHWs and HCWs
During the reporting period of July 1 through December 31, 2021, Circle of Hope, in coordination with the Zambia Ministry of Health (MOH), established community health sites at 38 community posts across Lusaka District. Community posts were locations purposed for dissemination accurate information about COVID-19, and 20 community posts transitioned during the project to also become vaccination sites. At these sites, community post staff focused on providing 1-on-1 patient interactions to provide accurate vaccine information to interested individuals. Conversations centered around understanding vaccination status, reasons for not being vaccinated, and provision of necessary vaccine education. In addition to these static vaccination sites, mobile vaccine centers were set up outside of churches so that interested individuals could receive the desired vaccination.
Circle of Hope provided training to CHWs who vaccinated individuals at community posts. This enabled community post staff to provide accurate and timely information about vaccinations and their uptake. Orientation sessions were also provided to community members who lived near the posts. These orientations included training on COVID-19 vaccination messaging including effectiveness, benefits, side effects, and mitigation and prevention strategies.
Guidance from local health authorities informed the creation of vaccination messaging and training for community leaders, CHWs, and HCWs. As noted earlier, vaccine education for the project was framed as “messages of hope” and included phrases such as: “By taking the COVID-19 vaccine when it is my turn, I will be a part of the solution to put an end to this pandemic” and “As a leader in my community, I choose to be vaccinated: approved COVID-19 vaccines are safe and save lives.” To promote COVID-19 vaccine uptake in the faith community, faith leaders, CHWs, and HCWs were trained to focus on the “hopeful” aspects of communications. Faith leaders were included in the conversation because of their role as local leaders and their engagement with the target population. Circle of Hope also engaged faith congregations on safety, efficacy, and availability of the vaccines.
Table. Circle of Hope Vaccination Centers' Performance Comparison to Other Non-Ministry Facilities in Zambia Providing Vaccinations Between October and December 2021
Data are disaggregated by centers within the Lusaka District where Circle of Hope conducted demand creation activities. Vaccination update data were compiled from all vaccination centers by the Zambia Ministry of Health and all non-ministry facilities. The percentage contribution to vaccination update is defined as the percentage of the total number of vaccinations given by each facility between October and December 2021.
Circle of Hope has community health posts, which are used as community rallying points by Circle of Hope community health workers, faith leaders, community local leaders, and healthcare workers as they carried out activities. Twenty community posts were used as vaccination centers during the project period.
Non-ministry facility names have been de-identified.
By leveraging existing relationships, the project was able to engage faith leaders, HCWs, and CHWs serving in posts throughout the Lusaka Region. Circle of Hope communicated with older adults in the community by providing education about vaccines and available vaccination sites. When needed, older adults were given transportation assistance to vaccination centers and provided priority service.
Training and Vaccination Site Data
Data on training and vaccination were collected by Circle of Hope and reported to the CDC Foundation during the funding reporting period. Circle of Hope trained a total of 2,106 individuals on providing vaccinations and communicating “messages of hope” regarding vaccine uptake, including 1,577 faith leaders, 461 CHWs, and 68 HCWs. As a result of including faith leaders in this project, 435,638 congregants received information about the COVID-19 vaccination during church services that occurred throughout the reporting period of the project.
CHWs worked 1-on-1 with community members at community posts by providing personalized education to 187,480 community members. During these conversations, CHWs advised on whether the person was eligible for the vaccine at that time and where they could receive it if eligible. CHWs also encouraged community members to reach out to others in their household about their experience with receiving the vaccination.
Circle of Hope, in collaboration with local district health offices, integrated a total of 20 vaccination sites into the 38 existing community posts. This enabled the provision of vaccinations in target communities and increased accessibility for the older adult population by bringing vaccinations closer to their homes and social areas. Circle of Hope also printed 14,000 copies of materials explaining COVID-19 and the vaccine, including posters and brochures, that were distributed at community posts. These were given to individuals who received 1-on-1 counseling with CHWs and faith leaders holding religious services in the community. Surrounding communities that did not have community posts also received these materials for dissemination, thereby increasing the reach of the activities.
In total, the project reported providing 587,467 people with messages about COVID-19 vaccination. Direct referrals to local vaccination services were given to 463,472 people via 1-on-1 counseling or information provided during local religious services. Of the people referred, 31% were reported to be older adults. Between October and December 2021, Circle of Hope staff and partners at their 20 vaccination sites provided 75% of all vaccinations that occurred outside of MOH facilities in the Lusaka District, with the other 13 non-ministry facilities accounting for 25% of vaccinations.
A total of 16,593 individuals were directly vaccinated from the static and mobile vaccination sites set up and implemented through the Circle of Hope community posts and faith community centers; as seen in the Table, 15,011 of the vaccinations provided during this project were distributed via the 20 vaccination centers integrated into community posts. The presence of the vaccination sites within the community created demand by improving local availability of the vaccine.
Case Study: Tanzania COVID- 19 Vaccinator Training Project
Following the outbreak of COVID-19 in December 2019, WHO ranked Tanzania as 1 of 4 East African countries at elevated risk of experiencing widespread COVID-19 transmission, due to its robust tourist economy. 10 On March 16, 2020, Tanzania reported its first confirmed case of COVID-19. 11 As of July 26, 2023, the Tanzania MOH reported 43,078 confirmed cases of COVID-19 with 846 deaths since March 2020. 12
In July 2021, the government of Tanzania received the COVID-19 vaccine as part of the COVAX initiative. 13 Subsequently, the government launched the COVID-19 vaccine campaign focused on reaching HCWs, adults aged 45 and older, and people aged 18 and older with comorbidities. 13 Vaccination access was subsequently expanded to all Tanzanians willing to be vaccinated.
At the start of the project, it was reported that only 345,000 people (0.5% of the population in Tanzania) had been vaccinated for COVID-19. 12 Low vaccination uptake was linked to barriers in accessing COVID-19 vaccines and limited knowledge of COVID-19 and vaccinations by HCWs. This lack of knowledge led to mistrust and misinformation about COVID-19 and vaccinations. 14 A scoping review and commentary conducted found that vaccination hesitancy among HCWs served as a model for communities, and it persisted throughout communities in Africa during COVID-19 vaccination distribution.5,15 Recommendations for addressing vaccination hesitancy in Sub-Saharan Africa include context-tailored approaches and integration into existing community systems, while also countering misinformation.
Training Vaccinators
As a result of the identified gaps in vaccination trends in Tanzania, the International Center for AIDS Care and Treatment Program (ICAP) at Columbia University in Tanzania, in partnership with the CDC Foundation, began the Tanzania COVID-19 vaccinator training project. The project was tailored for all 8 districts within the Mwanza Region, identified by ICAP Tanzania as a location where vaccination rates were lowest due to low perceived risk of COVID-19 infection and limited healthcare worker knowledge. The strategies implemented to address vaccination access and hesitancy included advocacy and communication meetings with regional religious community leaders, social mobilization, and demand creation by disseminating vaccine information and education. Furthermore, ICAP Tanzania provided continuous supportive supervision and mentorship to HCWs and other COVID-19 frontline workers while ensuring daily entry of COVID-19 data into the national database, Chanjo-Covid.
Through the Tanzania COVID-19 vaccinator training project, ICAP Tanzania, in collaboration with the Regional Health Management Team in Mwanza, initiated and supported the mobilization of religious and community leaders to promote COVID-19 vaccination in the region. At the start of project planning, there was a lack of desired engagement of political, religious, and community leaders due to preexisting myths and misconceptions held about the COVID-19 vaccine. Advocacy meetings and demand creation events were conducted to address this challenge. ICAP used beneficiary and provider feedback collected during advocacy and communication meetings with community and religious leaders to conduct targeted supportive supervision to address misconceptions. Demand creation events were held in high-mobility areas such as markets, bus stations, and fishing camps to encourage vaccinations within the community. Demand creation was enhanced through the scale-up of local radio advertising, sensitization of vaccination messages through regional and district health experts, engagement of religious leaders, and engagement of regional and council health management teams.
Supportive supervision sessions were conducted at facilities that provided COVID-19 vaccination services, focusing on monitoring performance toward vaccination targets and quality of vaccination services including handling, cold chain management, and service delivery. Supervisors guided appropriate data documentation and mentorship on general vaccination services at the facilities. In addition, supervisors used a supportive supervision tool to identify gaps and worked with vaccine providers to develop site-specific action plans.
District immunization and vaccination officers and regional immunization and vaccination officers worked with ICAP to train HCWs stationed at clinics on COVID-19 vaccines composition information, storage, dosage, administration, screening, and counseling techniques to identify individuals with symptoms of COVID-19 before vaccination. To ensure timely and quality data documentation, ICAP supported the training of additional data clerks in all 8 districts in Mwanza. High vaccination acceptability rates created a heavy data entry burden for existing data teams. To address this, ICAP engaged temporary data clerks in 4 districts who entered backlogged data entries into the government Chanjo-Covid system.
ICAP, in collaboration with regional and councils' public health committees, conducted meetings to finalize the mitigation plans currently being used by councils to increase the uptake of COVID-19 vaccination services. In addition, ICAP, public health committees, and village and ward executive officers conducted 10 mobilization meetings with community members to increase the uptake of COVID-19 vaccination services.
Vaccine Training Data
ICAP, in collaboration with the regional and council health management teams, accelerated COVID-19 vaccination services at health facilities and in the community through advocacy and communication meetings, supportive supervision and mentorship to HCWs, and data entry into the national database. A total of 296 religious and community leaders and 9,791 community members participated in COVID-19 vaccine advocacy meetings. ICAP Tanzania cited the engagement of religious and community leaders in delivering vaccination messages as helping to increase the uptake of COVID-19 vaccinations among community members.
A total of 70 demand creation events were conducted in high-mobility areas, such as markets, bus stations, and fishing camps. Demand creation events mobilized 108,663 people; 65,431 individuals who attended the events received vaccinations, equivalent to 4% of the cumulative vaccination data of the Mwanza Region. In addition, 12 supportive supervision visits to 165 health facilities were conducted. Data collected during supportive supervision visits were used for decisionmaking, provision of corrective actions, and feedback to the vaccinating health facilities, HCWs, and community stakeholders. As a result, the regional team observed and acknowledged improvements on data documentation and HCWs demonstrated strong ownership of the vaccination activities with timely updates on progress and challenges.
A total of 142 HCWs located at care and treatment clinics were trained on COVID-19 vaccination storage, dosage, administration, screening, and counseling. One trained HCW vaccinator at the Nyamagana District Hospital mentioned in programmatic reporting that “When we started implementing this project in February 2022, HCWs did not have enough knowledge about COVID-19 vaccination provision and data reporting […] The training we received improved our confidence on provision of COVID-19 vaccination services. We are now able to accept COVID-19 vaccines and get vaccinated, we can communicate and respond to questions from our communities regarding COVID-19 vaccines.” HCWs were also trained in timely and quality data documentation. Alongside training of HCWs on data documentation, 195 data clerks were oriented and trained to support data entry of COVID-19 cases and vaccinations. These data clerks processed a total of 136,124 or 12% of data entries into the Chanjo-Covid system. Backlog data were processed by trained data clerks; capturing these data helped the Tanzania MOH to better understand the status of the COVID-19 infectious disease response and maintain and improve treatment and vaccination plans.
Discussion
Community engagement and strengthening health systems are crucial to building capacity in emergency preparedness and response. 4 Both case studies used flexible funding to meet the needs of their communities by focusing on improving gaps in healthcare systems through context-tailored approaches determined by implementing partners. Lessons shared by community partners in Zambia and Tanzania included involving key community stakeholders in the decisionmaking process and promoting buy-in with local government officials and health authorities. Health agencies should continue to maintain relationships with government officials and advocate for the most current health information for community members, as vaccine hesitancy is often rooted in mistrust and the pervasive spread of misinformation. Promoting buy-in from and educating government officials can provide a foundation for addressing concerns and reassuring the public about vaccination safety. 5 Positive trends in Tanzania's vaccination services have been attributed to collaboration between government and acting public health partners.16,17
Building health systems resilience and preparedness relies on understanding the needs of the community from their perspective, 4 so community members and religious leaders should be included in the conversation, as these individuals have a lens into the beliefs of the local community. They can provide input into context-tailored approaches to addressing local vaccine hesitancy. 5 Vaccination access should also be improved by bringing accessible vaccination sites to local communities and meeting them where they are, as many of these communities have significant physical barriers to accessing healthcare. 15 In addition, local health workers in communities should be continuously educated on the most recent guidance and information. CHWs working to vaccinate individuals as a part of these projects mentioned that their trust in the vaccine significantly increased after receiving education and information and were therefore better able to share information to local communities. HCWs are primary resources for vaccination information, and if healthcare providers do not trust the information, there is a higher likelihood of pervasive vaccination hesitancy. 15
These case studies provide examples of how engaging with communities in context-tailored approaches, and engaging community religious and political leaders, can have a positive impact on vaccination uptake among a hesitant population.4,5 Additionally, by increasing the capacity of HCWs through training in vaccination provision and addressing vaccine hesitancy issues, 15 countries can be better equipped to provide surveillance of future health needs.
Conclusion
Case studies of COVID-19 vaccination programming in international settings provide a clear window into the need to strengthen healthcare systems capacity, invest in vaccination education at local levels, and engage the community in the process. The strategies used to expand COVID-19 vaccination access during the emergency response successfully improved vaccination-related education in local communities in Zambia and Tanzania and increased local access to vaccination sites. Such strategies include education of local CHWs and HCWs on the vaccination and its effects, engaging with and promoting buy-in from community religious and political leaders, and promoting context-tailored approaches with guidance from the community to improve vaccination uptake and reduce hesitancy. These efforts collectively resulted in an increased uptake of COVID-19 vaccinations in a previously hesitant population.