Measuring Behavioral and Social Drivers of COVID-19 Vaccination in Health Workers in Eastern and Southern Africa

"The present study revealed various key relations with demographic variables that would help immunization programmes and implementing partners to develop more targeted interventions."

In 2021, 20 out of 21 countries in the Eastern and Southern Africa (ESA) region introduced COVID-19 vaccines. Health workers (HWs) were established as one of the priority groups for the first phase of COVID-19 vaccine roll out. HWs have heightened risk of COVID-19 infection and transmission, are one of the most trusted sources of information on COVID-19 vaccines, and can be a partner in demand promotion interventions and in the identification and implementation of (community) acceptable demand promotion strategies. Yet, with variable willingness to uptake vaccines across ESA countries, this study was conducted to better understand factors that impact behavioural and social drivers of vaccination (BeSD) by using health-worker-based individual-level data from five countries in the ESA region.

Using the theory-based "increasing vaccination model", the 4 BeSD drivers were adapted to the COVID-19 context and utilised in this cross-country assessment. Specifically, the theoretical BeSD model hypothesises paths between Thinking & Feeling, Social Processes, and Motivation. Each path reflects an association between antecedent and consequent (for example, from Thinking & Feeling to Social Processes), with analysis devoted to establishing the directionality of the path (positive, zero, negative) and size of the association. Thus, the analysis answers, for example, [if..] Thinking & Feeling receives higher scores, will Social Processes [..then] also increase, or perhaps decrease - and by how much?

Data were collected on 27,240 health workers in Kenya, Malawi, Mozambique, South Africa, and South Sudan. This process involved administering a survey of seven questions to measure all four BeSD drivers via the UNICEF Internet of Good Things (IoGT) online platform between February and August 2021. Websites built through IoGT include customised features that support bridging the digital divide and are by default data-light platforms that function on low-end mobile devices, like feature phones.

The weighted frequencies are presented in 2 tables in the paper by age, gender, and country to search for patterns across the various demographics. Table 3 captures the weighted frequencies by age and gender and Table 4 the weighed frequencies by country and gender. Select findings:

• For all questions, women provided slightly higher frequencies than men on answer options that indicated less trust, less confidence, less likeliness to give a recommendation, and less ease of access. Equally across both genders, people tended to respond more positively than negatively on all the drivers, the only apparent exception being for Practical Issues, where both genders responded more negatively about ease of access.
• Respondents from all age groups shared more positive than negative responses across drivers, and on Thinking & Feeling, Social Processes, and Motivation, HWs over 60 years of age showed more positive responses than younger respondents. The exception is Practical Issues, which appears to stay more or less stable across age.
• Various more specific contrasts highlight the presence of barriers or clear reasons why people do not take up vaccines more. For example, 55.96% of respondents thought a vaccine was very important for their health, but only 29.52% have trust in it. There is also a key juxtaposition between self and other visible in the data: Respondents are more positive about their own willingness than they are about other taking up the vaccine (65.86% vs. 49.14% for other adults and 47.93% for co-workers). In general, people are negative about the ease of uptake, with only 20.47% thinking it would be easy.
• The pro-vaccination social and work norm was not well established, since almost 66% of all respondents would take the vaccine if recommended to them, but only 49% thought most adults would, and only 48% thought their co-workers would. When testing the associations between drivers in Kenya and South Africa, it appears that when interventions are developed for specific age groups, social norms become the main drivers of intention to get vaccinated. (Incidentally, there were generally more negative attitudes and perceptions in Kenya across all questions.) Overall, the role of social norms is the most important predictor of willingness when considering age differences.

Reflecting on the findings, the researchers note that, considering that the intention to vaccinate is high in the region, demand promotion interventions should focus on activating the intentions of those who do want to be vaccinated to reinforce positive social norms, while continuing to gear trust-building interventions toward those who are hesitant.

Practical Issues was found to be a critical dimension to consider, as despite respondents being all HWs (who work in healthcare settings), many reported perceived lack of ease to access vaccination services for themselves. Findings highlight the need to get a better understanding of how Practical Issues affect the intention-action gap.

In conclusion, the researchers note that evidence-based advocacy may be necessary to appropriately adapt service delivery to reduce access barriers, simplify registration mechanisms, and ensure people know when, where, and how to be vaccinated. In particular, due to the study's finding that age and gender are sensitive demographics that shape and guide how interventions are received, tailoring programmes specifically to reach women and people of different ages may be effective in increasing vaccination demand.