COVID-19 Vaccine Roll-Out in South Africa and Zimbabwe: Urgent Need to Address Community Preparedness, Fears and Hesitancy

"The factors contributing to vaccine hesitancy in the two countries are multifaceted and thus require equally complex strategies to be addressed..."

In Sub-Saharan Africa, the COVID-19 pandemic has resulted in additional pressure to already-strained health systems; thus, vaccination has been an eagerly anticipated tool in the response. South Africa and Zimbabwe received their first deliveries of the vaccine in February 2021. Approximately 65-80% of each country's population has to be vaccinated to achieve herd immunity. However, several communities in Africa have always resisted vaccines, and surveys have reported concerns and doubts specific to the COVID-19 vaccine. This article unpacks the threat of COVID-19 vaccine hesitancy in South Africa and Zimbabwe, while also offering recommendations for COVID-19 vaccine communication strategies in these contexts.

In addition to the global "infodemic" - whereby the technology we rely on to keep connected and informed is leading to information overload, misinformation, and the spread of myths - there are some issues specific to South Africa and Zimbabwe that might jeopardise COVID-19 vaccine uptake. For instance, in South Africa, some health workers have questioned the efficacy of the COVID-19 vaccine; "[w]hen there is a lack of clarity, uncoordinated approaches, and differences amongst the public health experts, COVID-19 vaccine hesitancy among communities will be unavoidable." In Zimbabwe, debate among scientists and researchers about the efficacy of ivermectin in the treatment of COVID-19 has the potential to shift community attention (and intention) toward treatment options versus vaccines.

Furthermore, as noted by polio vaccination hesitancy research in northern Nigerian states, failure by the governments to deliver on key areas of their mandate such as security, water, sanitation, and food security may breed mistrust in other areas such as vaccination. In these contexts, communities are likely to perceive any interventions provided by the government with suspicion. For the COVID-19 vaccine, these beliefs include that it was most likely procured without following due process or that the available vaccine has poor efficacy. Zimbabwe may fit into this model, as decades of poor service delivery and cases of high-profile corruption within the COVID-19 national response may compromise communities' trust in the vaccine.

In this context, the article outlines steps toward COVID-19 vaccine acceptance in South Africa and Zimbabwe, including:

• Undertake journey mapping: Taking stock of the process each individual or community goes through in their quest to seek good health can help policymakers tailor messaging to meet the particular needs (e.g., the fears about the COVID-19 vaccine) of each audience. "Continuous mobilization and community engagement using simple non-medical terms at an individual level will go a long way in ensuring COVID-19 vaccine acceptance." The socio-ecological model (see Figure 1 in the paper) can help decipher the social norms and beliefs in the two countries' contexts - from the individual level (knowledge, attitudes, behaviours) to the interpersonal level (family, friends, social networks), through to the community and beyond. "The general preparedness of communities to receive and accept the vaccines needs to critically take this model into context."
• Address risk perception as a priority: The acceptance of the COVID-19 vaccine is premised on the risk perception that communities have of COVID-19 as a threat to their health, families, and livelihoods. However, the low effect at a personal level of COVID-19 in its first wave in Africa contributed to a widespread belief that COVID-19 is "not an African problem". Thus, in Zimbabwe, Population Services International (PSI) launched the "COVID is closer than you think. Take Care!" campaign, with the aim of increasing the risk perception of COVID-19 infection and hopefully heightening awareness of the need for and acceptance of vaccines.
• Position the COVID-19 vaccine as a tool for economic strengthening: "The benefits of the vaccine should be communicated from the perspective of the individual and what is of high value to them (family, health, welfare, lifestyle)....Correctly positioning the emotional and immediate economic benefits of the COVID-19 vaccine to the individual will likely sway their acceptance of the vaccine."
• Segment the COVID-19 vaccine market: Research into COVID-19 vaccine attitudes in the two countries could help design communications and enhance understanding of the intended audience's characteristics, attitudes, beliefs, values, behaviours, and determinants, benefits, and barriers to behaviour.
• Pursue a coordinated and strategic approach to COVID-19 vaccine communication, which might involve the government pursuing the following:
  1. Undertaking joint efforts between government agencies and civil society to reach communities: "Civil society Organizations (CSOs) have historically been pivotal in mobilizing the support of the public through working directly with vulnerable populations and the invaluable access and reach they have, particularly to some of the hard-to-reach communities...Further, CSOs will play an important role because of their ability to establish trust at the grassroots level, with communities, families, and individuals....When engaged, CSOs have the capacity to complement government efforts to ensure the preparation of local communities' awareness and ultimately acceptance of the COVID-19 vaccine."
  2. Utilising popular online social media platforms, such as WhatsApp and Twitter, to raise public awareness of the benefits of the COVID-19 vaccine: It is recommended that such campaigns incorporate emotive language and imagery and address unscientific false claims on the COVID-19 vaccines that may be spread by anyone.
  3. Strengthening use of traditional media to reach out to those who may not have access to or interest in digital media: It is worth attending to how the media constructs and frames messages about vaccination programmes.
  4. Engaging popular, influential individuals in society, such as musicians and/or the clergy: Zimbabwe and South Africa are characterised by mega-church preachers who draw large number of followers; efforts should be made to educate these church leaders so as to ensure they spread correct information about the COVID-19 vaccines.
  5. Involving representatives of community groups affected by COVID-19 in communicating scientifically sound messages to the public in simplified, easy-to-understand language: Their words, and their experiences, could go a long way to encourage acceptance of the prospective COVID-19 vaccine.

In conclusion: "[C]ommunity vaccine hesitancy should be understood and respected. The strategies to overcome it must be guided by the provision of sufficient information using the correct message delivery approaches to the community to allay any concerns they may have regarding the vaccines. The public needs to be aware of all issues concerning COVID-19 vaccines to have the confidence that they are safe. COVID-19 vaccine roll-out programs must be done in a manner that encourages discussions with and engagement of all stakeholders to address and ensure that communities get the correct information to make the correct decision. The national COVID-19 vaccination programs of both South Africa and Zimbabwe could benefit from champions such as artists, politicians, and religious leaders providing the correct information to raise community awareness and ensure vaccine acceptance."