The announcement of effective and safe vaccines for COVID-19 has been greeted with
enthusiasm. Discussions continue about the ethical challenges of ensuring fair access
to COVID-19 vaccines within and across countries, and which groups should be prioritised.1,
2 There are concerns about equity in access to COVID-19 vaccines. Estimates as of
Dec 2, 2020, suggest direct purchase agreements have allowed high-income countries
to secure nearly 4 billion confirmed COVID-19 vaccine doses, compared with 2·7 billion
secured by upper and lower middle-income countries.
3
Without such agreements, low-income countries would probably have to rely on COVAX,
which would achieve only 20% vaccination coverage.
3
States such as the UK, Russia, and Germany have promised or begun rapid access to
vaccines, some early this month.
4
While COVID-19 vaccines bring potential hope for a return to some kind of normality,
vaccine-based protection is contingent on sufficient population coverage and requires
effective governance, organisational, and logistical measures within a wider COVID-19
control strategy that includes continued surveillance and appropriate countermeasures.
5
In this new phase of the COVID-19 response, successful vaccine roll-out will only
be achieved by ensuring effective community engagement, building local vaccine acceptability
and confidence, and overcoming cultural, socioeconomic, and political barriers
6
that lead to mistrust and hinder uptake of vaccines.
From the outset it is important to distinguish between people wholly opposed to vaccination
(anti-vaxxers) and individuals with limited or inaccurate health information or who
have genuine concerns and questions about any given vaccine, its safety, and the extent
to which it is being deployed in their interests before accepting it (vaccine hesitancy).
7
In conflating and problematising the spectrum of those who do not accept vaccination,
authorities might further erode trust and confidence, thereby exacerbating rather
than resolving the factors underlying vaccine hesitancy. COVID-19 vaccines arrive
as the social contract between some governments and their populations is being eroded
8
and when many people, especially those in vulnerable groups, have little confidence
that their government will protect them. In the UK, for example, a parliamentary report
highlighted that more than 60% of Black people do not believe that their health is
protected by the National Health Service to the same extent as White people.
9
Globally, the COVID-19 pandemic has further marginalised historically oppressed and
excluded groups, including people with disabilities and growing numbers living in
precarity.
10
These groups have suffered disproportionate economic and health consequences, and
have been largely excluded from social protection and resources needed to minimise
their contracting the virus. The widespread impacts of the pandemic have illuminated
the structural violence embedded in society.
11
Now these communities are being asked to trust the same structures that have contributed
to their experiences of discrimination, abuse, trauma, and marginalisation in order
to access vaccines and to benefit the wider population.
Given such realities, it is instructive to reflect on the complex history of mass
drug administration (MDA) and vertical immunisation programmes globally, which remind
us that there are no magic bullets. For example, Sudan's Blue Nile Health Project
(1980–90), a programme designed to control malaria, schistosomiasis, and other diseases
via MDA and other ecological methods, had limited success; in some cases, transmission
rates were higher after the campaign had ended than before it.
12
Uptake of immunisation programmes, such as human papillomavirus and measles, mumps,
and rubella vaccines, has been influenced by wide-reaching historical socioeconomic
inequalities within countries like the UK and across other communities of difference.
13
In Nigeria, polio eradication campaigns in 2003 were slowed down due to valid concerns
about the motives of sponsors, inadequate testing, and consent procedures, and unsatisfactory
engagement with local knowledge about health and illness.
14
Efforts for Nigeria's polio eradication campaigns were eventually turned around through
widespread community dialogues, which helped to foster social learning, establish
equity, and generate and restore trust and participation in the programme.
14
Examples of successful immunisation campaigns, such as India's polio eradication efforts
and rubella in the Americas, are rooted in wide-scale social mobilisation and systems
strengthening.15, 16 A modelling study suggests that weaknesses in implementation
of a wide-scale COVID-19 vaccination strategy will reduce the efficacy of the vaccine
as reported in clinical trials and underlines the need for investment to promote public
confidence in vaccines and maintain other COVID-19 mitigation measures.
17
The public is not a homogeneous entity. It is complex, composed of individuals, families,
and other groups shaped by contexts, experiences, and desires in a constellation of
communities with different patterns of health literacy, values, and expectations.
18
A top–down, one-size-fits-all approach has derailed countless well meaning global
health solutions, and in the context of vaccine implementation risks leaving many
groups behind, again. Policy makers need to understand this diversity and adopt comprehensive
local approaches that give communities a voice, and the necessary resources to put
ideas into action. Such community-led strategies can ensure diverse local voices are
heard, map local concerns and alliances, and codesign programmes to maximise vaccine
uptake from the ground up.
Policy makers must accelerate dialogue and support the development of community networks,
leveraging and supporting existing local channels that influence decision making,
such as community and faith leaders, teachers, sports and youth clubs, and online
communities and networks. In this way, the public health community can gain deeper
understandings of intersecting local challenges and opportunities, while establishing
trust with communities and building effective communication and public health messaging.
Such efforts must be paired with investment in structures that enable people to contribute
to this process, including global financing to ensure low-income countries can implement
similar schemes. Participatory community engagement is cost-effective, increases uptake
of vaccines, and substantially reduces health-care resources needed to achieve high
vaccination coverage.
19
We outline recommendations to achieve meaningful engagement with diverse communities
in preparation for the COVID-19 vaccines roll-out (table
). This proposed bottom–up approach devolves the power of design and implementation
of communication strategies to local actors, supported by evidence syntheses, enabling
them to mobilise local expertise that can engage with and shift attitudes on vaccines
and wider government handling of the COVID-19 pandemic.
Table
A pathway to enabling community engagement in COVID-19 response and vaccine roll-out
Local level (boroughs, towns, villages)
Regional level (municipalities, regions, counties)
National level
Primary aim
Establish community COVID-19 vaccine task forces
Coordinate and facilitate actions of local COVID-19 vaccine task forces
Coordinate and release funding; coordinate and deliver national messaging
Key actors
Community leaders across multiple categories (eg, faith groups, ethnic or cultural
identities, teachers, family networks, expert patient groups); third-sector organisations
working locally (eg, youth organisations, NGOs); and general practice and community
clinics
Regional and public health hospital trusts or consortiumsPrimary health-care networks
Departments and ministries linked to: health, local government, community, and civil
society
Responsibilities
Map networks of relationships, trust, and social power; identify at-risk groups; map
local influencers; identify trusted communication channels; define content for locally
meaningful communication campaigns and make available in diverse formats; and work
with regional public health and community services to implement and monitor vaccination
programmes phased by priority groups, enabling locally driven expertise and processes
Work with local community leaders to implement locally defined communication strategies;
develop and strengthen regional networks to access resources for at-risk groups to
enable uptake; share information and experience that is transferable across other
regional settings; and provide data monitoring and logistical support, liaising with
local trusts and service sectors to ensure easy access to local communities and resources
are targeting the right groups effectively
Provide funding and infrastructure support to allow joined up working across related
systems and structures to enable a systems-wide approach to vaccine uptake; fund and
deliver wide-scale multiple platform mass media of positive and routine experiences
of diverse individuals, families, and communities receiving the vaccine
Mechanisms for delivery
Focus group discussions, community codesign forums, online surveys, direct outreach
(online, telephone, face to face), peer-to-peer engagements, social media campaign
Wide-ranging large and small public forums (including online delivery); production
of educational materials; coordinate delivery of vaccines; set up knowledge fairs,
where community leaders and local health coordinators can exchange perspectives; establish
new paid posts to maintain community involvement at local level
Micro grants to community task forces and community groups (including young people)
to promote vaccines and vaccination programmes in meaningful ways
Mistakes now risk cementing mistrust in the ability of science and governments to
manage the pandemic. Listening to those who have the most at stake will pave the way
for much needed change and widespread engagement with and support for COVID-19 vaccination
campaigns.