Impact Evaluation of a Youth Led Intervention to Increase COVID-19 Vaccine Uptake in Kwazulu-Natal, South Africa

"Community intervention programmes to communicate important factual and scientific information using members of the community can be effective on improving COVID-19 vaccination uptake as demonstrated in this evaluation study."



COVID-19 vaccination rates in South Africa remain low, with 51% of all adults having received at least a single COVID-19 dose as of January 11 2023. Several studies have shown that young South Africans who felt they had a lower risk of being seriously sick from COVID-19 disease were more hesitant to take-up COVID-19 vaccination compared to older adults. The VaxScenes study that informed the intervention reported in this paper reported various factors as being associated with COVID-19 vaccine hesitancy in South Africa according to the World Health Organization (WHO)'s behavioural and social drivers of vaccination framework (BeSD). This paper reports on the evaluation of a youth-led community-based programme implemented in Wentworth, Kwazulu-Natal, one of the four communities in South Africa where the VaxScenes study was implemented.



The BeSD of vaccination acceptance model was used as the framework for the Wentworth Youth Community Project. The BeSD model has 4 domains: (i) what people think and feel, which captures concerns about vaccine safety, fear of side effects, and vaccine effectiveness, (ii) social processes, which captures social norms about vaccination and vaccine behaviour of influencers and trust in government, (iii) motivation, which captures individuals' motivation and intention to get a vaccine, of which vaccine hesitancy is a factor, and (iv) access, which captures easiness, affordability, and access to vaccination. Specifically, the Wentworth Youth Community Project focused on the "what people think and feel" and "social processes" modifiable factors that can increase motivation and reduce vaccine hesitancy.



The intervention ran for 9 weeks between June and August 2022. Its aim was to promote vaccine uptake in multi-generational households in Wentworth, thus providing protection to the most at-risk population from serious disease and reduce the number of hospitalisations and deaths in this community, a community with a high rate of vaccine hesitancy". All young people (aged 18-24 years) who were recruited to deliver the intervention had completed 5 years of high school but were unemployed at the time of their recruitment. After a 4-day training in week one, the young people worked together as a team in the intervention site with weekly supervision visits by a regional field officer. Their activities included:

• Conducting door-to-door, face-to-face interactions: After an additional 2 days of training, the team worked in pairs and visited all the households that had participated in baseline data collection. The community engagements were supported by the distribution of 1,500 information sheets that highlighted the reasons why one should consider being vaccinated against COVID-19 infection and possible side effects of the vaccine. The door-to-door work was supported by a verbal script of open-ended questions that the young people used to invite residents to share their concerns and that in turn facilitated the young people reinforcing the main education messages. This work was deemed the most productive component of the campaign, resulting in 1,723 household visits over the intervention period.
• Organising local outreach: Local community contacts known to the research team helped facilitate access to local educational institutions/schools (n = 4) and faith-based organisations/churches (n = 5). These meetings were used to disseminate the same messages described above. As shown by these small numbers, the young people struggled to organise a programme of talks in local institutions. It was unclear if the organisations that participated disseminated the information further within their own networks.
• Producing social media postings: The team generated weekly content, which was posted on the campaign's official Facebook page (now Meta), the campaign's Twitter page (now X), and personal WhatsApp groups used by the young people themselves. (As a result of low numbers of followers on both Facebook and Twitter, the study could not implement standard social media analytics.)

To assess if the Wentworth Youth Community Project had an impact, data were collected before the intervention and after the intervention in Wentworth and in Newlands East, a control site (also in KwaZulu Natal). Using the health belief model, the following outcomes were assessed: (i) knowledge and perception score, (ii) intention to get vaccinated for those not vaccinated or partially vaccinated, (iii) vaccination status, both (iiia) fully vaccinated and (iiib) partially vaccinated/those with at least one dose of the COVID-19 vaccine. These outcomes were assessed using difference-in-difference (DID) methods.



At baseline, 1,150 participants agreed to take part in the study; 916 (80%) were followed up after the 9-week intervention period. Selected findings:

• There was a decrease in the proportion of people saying they were somewhat concerned/very concerned about COVID-19 - from 67% at baseline to 28% at follow-up among Newlands (control) participants - while there was a slight increase in Wentworth, from 42% at baseline to 46% at follow-up on the same sentiment. The positive increase in the proportion of people in the intervention group indicating the importance of being vaccinated and getting boosters for themselves as well as being vaccinated to protect other people contrasts to the control group in Newlands, which showed the opposite of these sentiments.
• There were noticeable increases of the percentage of study participants indicating trust on the government's COVID 19 programme: from 24% at baseline to 48% after the intervention in the intervention group (vs. 26% baseline and 29% at follow-up in the control group). In Wentworth, there was a 10% (absolute) increase on the percentage of participants' saying they believed that healthcare workers provided reliable information - 58% at baseline and 68% at follow-up - but little change in the control group (56% and 57% for baseline and follow-up, respectively).
• Intention to get vaccinated for COVID-19 was higher (DID 20%, 95% CI confidence interval (CI) 6%-35% higher) in Wentworth compared to Newlands East.
• More people were fully vaccinated (DID 10%, 95% CI 0%-20%) or partially vaccinated (DID 16%, 95% CI 6%-26%) in Wentworth compared to Newlands East. At the end of the intervention period, full vaccination rates in Wentworth were higher (59%) than in those observed in Newlands East (54%), higher than the national average (51%), and also higher than those observed in Kwazulu-Natal province (45%). Similarly, while 71% of study participants in Wentworth reported being partially or fully vaccinated, the national average stood at 59%, while the provincial figure stood at 62%. Note that the figures reported in Wentworth were as of September 2022, while the reported national and provincial estimates were as of January 2023, i.e., 4 months later. Thus, the differences may be even larger.

Per the researchers, the success of the programme can be attributed to factors including the local design of the programme (messaging, medium of implementation, social media, face-to-face engagements) and in-field follow-up and support by field staff. There was also likely to be higher levels of trust by community members of youth drawn from their own communities who implemented the programme.



In conclusion: "Based on the BeSD framework, the results are consistent and support the higher vaccination rates reported in Wentworth, thus supporting the hypothesis that the intervention achieved its desired impact of decreasing vaccine hesitancy and thus increasing COVID-19 vaccination uptake....Given the low COVID-19 vaccine coverage in South Africa and across the African region, as well as the new emerging variant of concern (XBB 1.5), there is an urgent need to scale up such intervention at the community level to address persistent misinformation and promote vaccine equality."