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      The COVID-19 vaccines rush: participatory community engagement matters more than ever

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          Abstract

          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.

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          Most cited references13

          • Record: found
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          Is Open Access

          Vaccine hesitancy: Definition, scope and determinants.

          The SAGE Working Group on Vaccine Hesitancy concluded that vaccine hesitancy refers to delay in acceptance or refusal of vaccination despite availability of vaccination services. Vaccine hesitancy is complex and context specific, varying across time, place and vaccines. It is influenced by factors such as complacency, convenience and confidence. The Working Group retained the term 'vaccine' rather than 'vaccination' hesitancy, although the latter more correctly implies the broader range of immunization concerns, as vaccine hesitancy is the more commonly used term. While high levels of hesitancy lead to low vaccine demand, low levels of hesitancy do not necessarily mean high vaccine demand. The Vaccine Hesitancy Determinants Matrix displays the factors influencing the behavioral decision to accept, delay or reject some or all vaccines under three categories: contextual, individual and group, and vaccine/vaccination-specific influences.
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            • Record: found
            • Abstract: found
            • Article: not found

            A global survey of potential acceptance of a COVID-19 vaccine

            Several coronavirus disease 2019 (COVID-19) vaccines are currently in human trials. In June 2020, we surveyed 13,426 people in 19 countries to determine potential acceptance rates and factors influencing acceptance of a COVID-19 vaccine. Of these, 71.5% of participants reported that they would be very or somewhat likely to take a COVID-19 vaccine, and 61.4% reported that they would accept their employer’s recommendation to do so. Differences in acceptance rates ranged from almost 90% (in China) to less than 55% (in Russia). Respondents reporting higher levels of trust in information from government sources were more likely to accept a vaccine and take their employer’s advice to do so.
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              • Record: found
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              • Article: not found

              What Led to the Nigerian Boycott of the Polio Vaccination Campaign?

              Jegede discusses the recent controversy surrounding polio immunization in Nigeria, in which three northern states boycotted the immunization campaign.
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                Author and article information

                Journal
                Lancet
                Lancet
                Lancet (London, England)
                Elsevier Ltd.
                0140-6736
                1474-547X
                10 December 2020
                2-8 January 2021
                10 December 2020
                : 397
                : 10268
                : 8-10
                Affiliations
                [a ]UCL Institute for Global Health, London WC1N 1EH
                [b ]Centre for Global Health and Equity, Swinburne University of Technology, Hawthorn, VIC, Australia
                [c ]AU-ASRIC Afro-centric COVID-19 Working Group, Faculty of Health Sciences, Imo State University, Owerri, Nigeria
                [d ]Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
                [e ]William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
                [f ]Division of Gastrointestinal Sciences Christian Medical College, Vellore, TN, India
                [g ]Department of Paediatrics, College of Medicine, University of Ibadan, Ibadan, Nigeria
                [h ]Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Italy
                [i ]Department of Health Care Management, Technical University Berlin, Germany
                [j ]Department of Preventive Medicine and INCLIVA, University of Valencia, Valencia, Spain
                [k ]School of Psychology and Neuroscience, St Andrews University, Fife, UK
                [l ]Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
                Article
                S0140-6736(20)32642-8
                10.1016/S0140-6736(20)32642-8
                7832461
                33308484
                91d96e34-5a72-4790-be34-7c8d4f4bbc26
                © 2020 Elsevier Ltd. All rights reserved.

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

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