Real Time Assessment (RTA): UNICEF's Ongoing Response to COVID-19 in Eastern and Southern Africa - COVID-19 Vaccine Demand Promotion

"It's those on ground, local organisations who...have been most effective because they have been engaging people directly....and that's what's brought about a huge change." (Frontline worker, South Africa)

Worldwide, mistrust in government, doubts about vaccine safety and efficacy, rumours and misinformation, as well as questions about access, have led to behaviours that do not prevent COVID-19 transmission and that drive vaccine hesitancy or refusal. Thus, UNICEF's COVID-19 risk communication and communication engagement (RCCE) strategy aims to promote knowledge of COVID-19, sustain preventive behaviours to reduce transmission, and increase vaccine demand and uptake. To understand how this strategy was working, UNICEF's Eastern and Southern Africa Regional Office (ESARO) commissioned Oxford Policy Management (OPM) to carry out a real-time assessment (RTA) of UNICEF's response to COVID-19 in 21 countries in the Eastern and Southern Africa Region (ESAR). One of several reports produced as part of the RTA process, the present report focuses on UNICEF support to COVID-19 vaccine demand promotion in ESAR and is based on qualitative research in 4 countries. The aim is to support UNICEF's reflection on its ongoing work on COVID-19 vaccine demand promotion (success factors and challenges) and to draw lessons learned.

The RTA involved 2 phases:

• Phase I (research undertaken from October to December 2020) had a broad multi-sectoral basis. It included a light-touch regional analysis and deep dives in 6 countries (South Africa, Somalia, Uganda, Kenya, Madagascar, and Namibia). Click here to access the Phase I reports.
• Phase II (research undertaken from June to September 2021) focused on 3 thematic areas and 4 focal countries (Rwanda, South Africa, South Sudan, and Ethiopia): (i) COVID-19 vaccine supply; COVID-19 vaccine demand promotion (communication for development, or C4D) - the focus of this report; and (iii) education (the safe return to school). Click here to access the Phase II reports.

The RTA is based on a review of documents and interviews with 31 respondents across the 4 focal countries: UNICEF country office (CO) staff (4), partners (17), and frontline workers (9), and 3 C4D staff from UNICEF's ESARO. No direct beneficiaries were interviewed. The interviews were conducted from June to July 2021. Focused on COVID-19 vaccine demand promotion, the study addressed questions related to UNICEF's:

• Partnerships and fund mobilisation: Across the locations, strong partnerships were seen as a cornerstone of the achievements to date. For example, strong technical working group (TWG) partnerships have promoted coherence and the harmonisation of key messages, which has lessened the risk of disjointed or contradictory approaches. Two key issues were widely proposed as strategic adaptions, in all 4 countries: (i) need for longer-term partnerships and funding for C4D work, including COVID-19 vaccine demand promotion, to align with the long-term nature of behavioural change; and (ii) need to build sub-national capacity for all components of the vaccine demand promotion work. Embedding technical assistance in sub-national government structures was widely proposed as a preferred approach to this.
• Data collection tools: UNICEF COs have played a key role in supporting the collection of data to inform C4D/RCCE on COVID-19 vaccine demand promotion. Respondents widely perceived that in-person community-based data collection tools were the most effective, as they provided more nuanced information, enhanced understanding of feedback, and built trust. Yet, the need for multiple sources of information was widely appreciated: Online tools were faster and required less human resources and provided more ongoing information. A key challenge was the inadequate contextualisation of tools that were developed outside of the focal countries. Key lessons learned were the benefits of:
  • Data collection tools that also enable immediate engagement on issues raised and training frontline workers to be able do this;
  • Targeted tools to understand vaccine hesitancy among health workers, which were used in Ethiopia, Ethiopia, and South Africa; and
  • Pre-testing of tools and sufficient time allocated to training fieldworkers, despite the need for fast roll-out in emergencies.
• Use of data to inform plans and action: In all 4 countries, data are being used to inform and adjust COVID-19 vaccine demand promotion plans and interventions, and UNICEF has played a leadership role in this. The key enablers have been strong TWG coordination, a learning and adaption approach, and UNICEF guidance on how to use the data in the development of action plans. Making use of existing community feedback mechanisms and local organisations to implement community-based data collection was another widely perceived success factor: Such organisations know the communities, are able to communicate with them effectively, and have a network of people in place to support data collection, which enabled highly valued face-to-face interaction and trust building. Respondents perceived good attention to inclusion, such as through peer engagements (led by women's, youth, faith, and disability groups and key influencers), and in mass communications. On the latter: The knowledge, attitudes, and practice (KAP) survey and social listening data have identified notable hesitancy problems among specific social groups (e.g., religious communities), which informed targeted communication interventions.
  • Key lessons learned:
    • For C4D work in emergencies: There are benefits to acting fast on data insights (rather than waiting for "perfect information") while anticipating later adaption (South Sudan).
    • Tone of messages matters: Some messages were seen as patronising, so they were revised to convey ownership and collective effort (Rwanda and South Africa).
  • Key challenges:
    • Localised action is needed and would be supported by geographically disaggregated data and sub-national capacity building.
    • There is a need for more clarity and specificity in messages, going beyond "building demand" to provide comprehensive information about the vaccines and to explain when and how to access the vaccination - especially where the vaccine modality is different from previous campaigns.
    • There are inadequate financial and human resources to comprehensively translate findings into plans and action.
    • Issues arise in light of the sheer amount of mis/disinformation, as well as fast-evolving developments in vaccine supply.
• Community engagement and social mobilisation: The COs have provided technical and financial support to numerous activities, including community mobilisation, hotlines, media events, social media, info-dramas, and capacity building for government partners, key influencers, and journalists. (Many examples are offered in the report.) In all 4 countries, the COs' emphasis on collaborating with local civil society organisations (CSOs) and influencers, who are integrated into community contexts and ongoing community mobilisation efforts, were widely seen as central to success and supported trust-building. Survey questions on how best to reach citizens helped identify appropriate communication channels. Direct community engagements (meetings, peer influencing, religious leader participation) were perceived as more effective than indirect mass communications. Yet, use of multiple channels and mass communications were crucial for broadening reach. Community radio was seen as the most effective channel for mass communications, as messages could be localised; it provided a platform for local influencers; citizens could call in to ask questions; and it enabled some reach into hard-to-reach and insecure areas. In South Africa, a widely lauded innovation was a UNICEF-supported truck that is driven around communities to share key COVID-19 vaccine demand promotion messages. Respondents were particularly impressed that the truck intervention has tailored messages to different communities, including videos that showcase people from that community - which was enabled by an initial period of community engagement. Respondents made the following suggestions moving forward:
  • Intensify the vaccine demand promotion work, and consider a longer-term, holistic approach in which COVID-19 vaccine demand promotion is integrated into wider behavioural change interventions in health and beyond.
  • In light of the fact that poverty was widely reported as the key barrier to the effectiveness of the vaccine demand promotion work (e.g., need for food taking precedence over vaccination), consider citizens' "whole lives" in demand promotion activities, such as by providing information on other services.
  • Further multiply communication channels to reach additional social groups - e.g., via dissemination in everyday spaces (Rwanda) and adaptions to better reach youth (South Africa) and those in remote or conflict areas (Ethiopia and South Sudan).
• Operational and programmatic modalities: Among the suggestions here: Secure dedicated budget lines for C4D/RCCE to raise the profile of achievements and challenges; establish more long-term supplier agreements at country level to enable faster CO access to technical assistance; and ensure ongoing documentation of the response to enable C4D lesson learning and visibility.

Following a workshop to discuss the RTA findings, the ESARO and CO C4D focal staff liaised to agree on the following priority action points:

• Embed social and behaviour change (SBC)/RCCE dedicated human resources in national and subnational governments to strengthen demand promotion skills and sustain delivery.
• Reinforce and/or scale-up time-series disaggregated SBC data collection to inform targeted, pro-equity, and gender-sensitive SBC planning and interventions.
• Leverage existing community-based platforms (e.g., youth and women networks, faith-based organisations) to support trust-building interventions.
• Advocate for the integration of COVID-19 vaccine demand into ongoing SBC/RCCE interventions to avoid vertical programming.
• Establish long-term partnerships and secure specific RCCE funding prior to emergencies to ensure adequate preparedness and reinforce the emergency-development nexus.
• Ensure that SBC/RCCE is included in all response planning and reporting formats with specific objectives, interventions, and budget lines to strengthen accountabilities.
• Sustain ongoing efforts to document the response to enable SBC lessons learning and visibility.

Approaches from the experience that the RTA concludes should be sustained or replicated:

• Use of existing community feedback mechanisms and collaboration with local CSOs and key influencers who are integrated into community contexts and ongoing community mobilisation efforts. Such approaches help build trust.
• Close partner collaboration (through RCCE country platforms) in data review and efforts to harmonise key social and behaviour change communication (SBBC) interventions.
• Accelerated funding and standby agreements.