The project studies strategies to increase public fluency and confidence in reliable scientific information about COVID-19 and COVID vaccine uptake through a “health ambassadors” outreach initiative. The intervention consists of a “health ambassadors” program in which ambassadors trained on engaging individuals about vaccine risks and benefits and will proactively engage households and offer a direct and private opportunity to discuss concerns. The randomized controlled trials will be implemented in four Anglophone and Francophone countries in sub-Saharan Africa – Côte d’Ivoire, Malawi, Senegal, and Zimbabwe. Along with Dr. Machingura, the research team in Zimbabwe includes Martin Atela and Anthony Mveyange.
We spoke to Dr. Machingura about her past work disseminating information on COVID-19 testing. We asked her about the state of vaccine hesitancy in Zimbabwe and why she believes the health ambassadors strategy can be a promising model to increase uptake.
What is your current role, and what experiences has your organization had that can contribute to the design of the intervention?
Fortunate Machingura: I am head of research on Key Populations at the Centre for Sexual Health and HIV AIDS Research (CeSHHAR Zimbabwe) and a member of the WHO 2022 technical working group on routine HIV surveillance. In addition, I am a Research Fellow at the Liverpool School of Tropical Medicine in the Department of International Public Health and a visiting lecturer at the University of Zimbabwe and Great Zimbabwe University.
In 2021, CeSHHAR was part of an initiative by the Foundation for Innovative New Diagnostics (FIND) to evaluate the feasibility of self-sampling and self-testing for COVID-19 using antigen tests among patients and health care workers in Malawi and Zimbabwe. The interventions aimed to improve the timely diagnosis of COVID-19 through self-sampling or self-testing to optimize treatment and prevention efforts. For self-sampling/testing to be feasible, CeSHHAR facilitated the development of culturally relevant, locally understandable instructions that supported accurate sampling/testing. In addition, the approach aimed to optimize self-sampling and self-testing instructions among the general population and health care workers in Malawi and Zimbabwe. We used cognitive interviews among the public and health care workers to inform how to optimize user instructions. Additionally, to determine feasibility and acceptability, we observed individuals in the public while self-sampling or self-testing using COVID-19 antigen tests.
This experience is critical for current work as it provides the formative research needed to understand priority needs for addressing trust issues – trust both in testing, vaccines and in the institutions responsible for the vaccination endeavor. Specifically, through Health Ambassadors, the current work promotes confidence in the effectiveness and safety of the vaccines and the capacity of the health ministry to manage the logistical challenges competently. However, communicating this, needs to be balanced and contextualized to convey what is and is not known clearly, and to avoid reinforcing hesitant people’s cognitive biases. It should ideally be informed by the expertise of community Health Ambassadors who are also equipped as behavioral scientists and risk communication experts – a task that the Mercury project seeks to address.
What are some of the important contextual factors to take into consideration in regarding vaccine hesitancy and encouraging uptake of the COVID-19 vaccine?
FM: It is important to acknowledge Zimbabwe’s Expanded Program on Immunisation (EPI) a robust immunisation program championed by the Ministry of Health and Child Care (MoHCC). Through its EPI, the MoHCC conducted a national readiness assessment for the COVID-19 vaccine and developed a Zimbabwe COVID-19 nationwide deployment and vaccination strategy in 2021. Zimbabwe now has an elaborate COVID-19 strategic preparedness and response plan and clear national deployment goals and training for healthcare workers. However, vaccination efforts have been negatively affected by myths, misconceptions, and misinformation, fueled by an “infodemic” spread via social media platforms and other communications channels. In this barrage of infodemics, the Afrobarometer study findings of 2021 showed that half of their survey participants (50%) were unwilling to take the COVID-19 vaccine – they were either unsure or would reject taking the vaccine. Most of the survey participants were uncertain about the vaccine’s effectiveness and lacked confidence in the vaccine’s safety. About half lacked trust in the government’s ability to ensure that the vaccine would be effective, and most participants would seek the advice of a healthcare worker first before getting vaccinated. Poor confidence in vaccine safety and effectiveness was associated with a reduced likelihood of vaccine acceptance.
Tell us a little bit about the intervention, and why Health Ambassadors may be a promising model for delivering information on vaccination.
FM: The most optimal way to address misinformation is through aggressive dissemination of accurate information about the truths of the risks and benefits of the COVID-19 vaccine at the community level through the community-based workforce. Community-based lay health workers such as Health Ambassadors are the most connected to the priorities of the populations they serve, building trusted relationships over time through one-on-one interactions and being a reliably accessible and available presence. Leveraging this trust, these Health Ambassadors are a much-needed resource to the underserved. They now fill a gap in appropriately tailored COVID-19 communication and information resources. While this approach is essential in COVID-19 health communication, it may have limited impact due to the very nature of the problems it aims to address: overexposure to conflicting information alongside distrust of the government. Recognizing this, the country needs to build on its experience with HIV and AIDS, malaria, and tuberculosis health communication strategies to mobilize a team of health promotion, communications, and technical experts to lead other COVID-19 awareness campaigns. The Mercury Project can spur these efforts by building a cadre of Health Ambassadors or strengthening existing ones such as village health workers/community health workers (as ambassadors) in communities to understand the factors influencing vaccine hesitancy and crafting targeted communication and interventions to sell the idea of vaccination to specific groups of people.
What are some of the outcomes that you hope the research collaboration will produce?
FM: We hypothesize that this collaboration will address the perceived uncertainties about vaccines through communication about the risks and benefits by Health Ambassadors and ultimately improve vaccine uptake and intention to get vaccinated. Thus, the level of risk communication is aimed at communicating effectively about high-concern, high-stress, emotionally-charged or controversial situations concerning COVID vaccines. We envisage a two-way and multidirectional communication and engagement with communities in some highly-charged, poorly-vaccinated social groups and geographical areas so that they can make informed decisions to protect themselves and their loved ones. Appropriate communication channels and collaboration with respected and equipped Health Ambassadors are critical for building trust. These community-based Health Ambassadors have an advantage when communicating about the benefits of vaccines. Based on learning from the Zimbabwe national EPI, we know that solid recommendation from a lay health care worker such as a Health Ambassadors or healthcare provider is the strongest predictor of compliance with vaccination.