BroadReach Group hosted an industry webinar last week to share the latest data on South Africa’s COVID-19 vaccination roll out and lessons learned on success factors for reaching to hard-to-reach populations.
Mia Malan, founding editor-in-chief of the Bhekisisa Centre for Health Journalism moderated the robust panel discussion between Dr Lesley Bamford from the South African National Department of Health (DoH), Jane Simmonds from the SA Medical Research Council (SAMRC), Josef Tayag from United States Agency for International Development (USAID) and Dhirisha Naidoo from BroadReach Health Development.
The panel identified four key drivers to overcome the vaccine rollout challenges of access, demand creation and hesitancy, namely:
- using the data to know which populations to focus on and deploying targeted strategies to normalise adult vaccinations,
- collaborating with multi-national and regional partnerships already focused on vaccine roll out,
- creating local demand for vaccines through hyper-local influencers, personalised engagements and local language
- and simplifying public access to vaccines.
Lesson 1: Focus on key populations to normalise vaccines
Herd immunity requires 70% of a population to be vaccinated, however Dr. Bamford, a senior official in the DoH who drives the government’s vaccination rollout, said currently only 45% of adults in South Africa have been vaccinated. The most under-vaccinated segments of the population are people living in informal settlements in metropolitan areas and people in deep rural areas.
Bamford said the population could be divided into three broad categories in terms of their attitudes towards vaccination:
- The vaccine-eager who proactively seek out vaccinations
- A small group of anti-vaxxers who are unlikely to change their mind
- A large middle group of undecided or unmotivated people who may still be convinced to get vaccinated if barriers are removed.
The panel agreed that this middle group should be the primary focus of public health interventions. It was essential to generate demand for the vaccine by convincing this population that vaccination is important, and then remove everyday barriers to vaccine access.
Additionally, Tayag, Health Systems Strengthening Team Lead for USAID, said it was important to understand low vaccination motivation within the context of people’s lives, in South Africa where 20% suffer from hunger, 57% are reliant on social grants and 30% show signs of depression, seeking out opportunities to be vaccinated may not be their priority.
Simmonds, a senior research manager for the SAMRC, added that it is important to target the undecided middle group – and shift their norms towards adult vaccination. Similar to the 1990s during the emergence of the HIV/AIDS pandemic norms towards condom-use had to be shifted, ongoing adult vaccinations for the Coronavirus needs to become a new norm through public behaviour-change, she said.
“When we look at the research around the successful shifting of social norms, four things need to work together for an individual to change their behaviour: the self, your interpersonal relationships, your community and your enabling environment. For instance, for a pregnant woman to get vaccinated, she needs to want it, her partner and community need to be supportive, and her environment must allow her – for instance if the queues are too long and she has nowhere to sit, she won’t do it.” Therefore, for vaccines to be successfully rolled out, interventions need to be designed on all levels to motivate behaviour change.
Lesson 2: Partnerships: we are in this together
There are many excellent and committed organisations working towards a common goal. It is essential to harness partnerships, avoid duplication of efforts and streamline activities towards success. Speaking from direct experience, Dhirisha Naidoo – BroadReach Health Development leader responsible for the company’s USAID funded, rural vaccine demand programme – said public-private partnerships, multi-national collaborations with international donors, other implementer and national alliances are foundational to enable rapid success. This foundation enables coordination and localization.
For example, this initiative has been able to vaccinate over 50 000 hard-to-reach people in rural KwaZulu-Natal and Mpumalanga over the past three months. At the start of the programme these districts had achieved around 20% vaccine coverage.
Lesson 3: Going local and getting personal are the keys to demand creation
Identifying and collaborating with local influencers is crucial to earning a community’s trust. This means taking the time to engage with local leaders, pastors, businesses owners and influencers and working together to engage their audiences.
Once trust is built, speaking directly to individuals in their home language and addressing their personal barriers are the biggest drivers of change. Naidoo said within their programmes they have specific male community mobilisers that work to mobilise and address the concerns of men, while other teams might focus more specifically on women and girls. These teams also offer integrated services such as family planning, PrEP for HIV, diabetes screenings and other services, alongside COVID-19 vaccines.
Lesson 4: Simplify vaccine access
In many hard-to-reach populations people have to prioritise between a day’s wage and a vaccination. Therefore, simplifying where and how people can get the vaccine greatly improves uptake. Bamford added that the DoH’s long-term strategy was to bring routine COVID-19 vaccinations into the primary healthcare system, such as through community clinics.
Another effective strategy to simplify vaccine access for rural populations was to set up mobile vaccination stations where people congregated, such as taxi ranks, social grant collection points, shopping malls, sports fields and so on.
Naidoo shared an anecdote from the field. “We engaged a local farmer and he allowed us to set up a pop-up station on his farm. He led from the front and was the first to be vaccinated, followed by over 200 farm workers. The employer and employees all benefitted without losing too many hours out of their workday.”
Asked if it was worth the cost to spend valuable donor funds such as those from USAID on hard-to-reach populations – an expensive exercise – Tayag said donor-funded campaigns to vaccinate the poorest of the poor “was not about the unit cost per head”. It was a “human rights and health equity issue”, as everyone deserved the ability to make the vaccination choice for themselves once access barriers were removed. This aligns strongly to BroadReach’s underlying vision of access to good health to enable people to flourish.