Training Health Workers and Community Influencers to Be Vaccine Champions: A Mixed-methods RE-AIM Evaluation

"This study's findings support the use of interventions to engage community health workers and influencers to promote and educate others about vaccines, an issue of significant relevance given the global increase in zero-dose children, vaccine-preventable disease outbreaks and drops in vaccine confidence postpandemic."

Community engagement strategies have long been applied to increase vaccine acceptance and uptake in low- and middle-income countries (LMICs), particularly to support polio eradication campaigns and supplementary immunisation activities. Community-based strategies deployed during the COVID-19 pandemic included grassroots approaches to increase trust and confidence in vaccines. In 2022, supported by the Australian Government and in partnership with Fiji's Ministry of Health and the United Nations Children's Fund (UNICEF), this group of researchers codesigned and delivered a vaccine education and communication training programme for health workers and community influencers to promote COVID-19 and routine immunisation and to address misinformation. This paper describes the development, implementation, and evaluation of the Fiji Vaccine Champions programme using the reach, effectiveness, adoption, implementation, maintenance (RE-AIM) framework.

The Vaccine Champions programme included three phases:
 

1. Codesign with 17 Fiji stakeholders - Phase 1 was a half-day codesign workshop in Suva in June 2022. Co-design stakeholders included local and national stakeholders from government, non-governmental organisations (NGOs), and community members. As part of the workshop, the research team facilitated a discussion about perceived access and acceptance barriers to vaccination, mapped to the World Health Organization (WHO) Behavioural and Social Drivers (BeSD) of the vaccination framework. In the final part of the workshop, codesign participants brainstormed the types of community members who should be invited to participate as Champions, including sporting bodies, religious and charitable organisations, local NGOs, community health workers, teachers, village head men, and women's community groups.
2. Vaccine education and communication training for 35 Vaccine Champions - Phase 2 was a 2-day training workshop with invited Vaccine Champions in July 2022 in Suva. The workshop focused on COVID-19 and routine childhood vaccines and evidence-based techniques to effectively communicate about vaccination. Communication training included how to share your personal vaccination experience and provide facts using techniques informed by vaccine communication research and Motivational Interviewing. Role-play activities were used to practice conversations with hesitant individuals. At the end of the training, Champions created a plan for how, when, where, and with whom they would run discussion sessions. Attendees were reimbursed for travel and accommodation.
3. Support for Champions to deliver community vaccine discussion sessions - Phase 3 was a 6-month period (July-December 2022) in which trained Vaccine Champions organised vaccine discussion sessions in their communities. Champions were asked to conduct three sessions each. Many Champions handed out UNICEF or Ministry of Health brochures or pamphlets at their discussion sessions to support the messages they were sharing. They were encouraged to tailor sessions to their context, which could mean holding a special village meeting or adding a short presentation to the end of an activity like a church service. Phase 3 evaluation participants were the community attendees who attended a discussion session facilitated by a Champion. Attendees included parents, young people, older people, teachers, Red Cross volunteers, sports teams, nurses and midwives, and church leaders.

The RE-AIM framework evaluation measured programme reach, effectiveness, adoption, implementation, and maintenance. Mixed-methods data were collected through interviews, surveys, and field notes, integrating qualitative and quantitative data to triangulate findings. Primary outcomes included Champions' knowledge, communication self-efficacy, trust in COVID-19 vaccines, and programme satisfaction, as well as community members' intention to vaccinate.

The programme trained 35 Champions (27/35 female), including health workers, faith leaders, and community influencers. Half had a health background (17/35). Champions conducted 54 discussion sessions, reaching 1,717 community members. Most Champions (22/35) conducted at least 1 session, with 16 running 3 or more. Champions who did not run sessions reported barriers like lack of confidence and competing duties.

Being part of the community where the session was held was seen as both a barrier and an enabler to organising successful discussion sessions. One Champion felt that her familiarity with the community made the session attendees more comfortable, whereas another thought that being part of the community meant they were not taken as seriously. Some Champions felt it would have improved their credibility if they had a respected community leader, such as a village headman, accompanying or introducing them.

Training increased Champions' communication self-efficacy and trust in COVID-19 vaccines; at least one Champion reported that the training had completely changed their views of COVID-19 vaccination. Champions from both health and non-health backgrounds found the training interesting, relevant, and presented at an appropriate level. One interviewee felt that the communication technique of sharing personal stories of vaccination fitted well with the Fijian context: "We know in the Pacific we love our stories, we relate to our stories, and we learn from listening to stories as well."

Community member intention to vaccinate increased from 41% (394/960) to 83% (822/991) before and after a session. Several Champions spoke about seeing the direct benefits of their community sessions. They said some attendees decided to get COVID-19 boosters or vaccines for their children when they were previously unsure, and others became more open to learning about the importance of vaccines. In addition to finding the sessions informative, multiple community attendees talked about how they had shared the information they learned in the session with other people in their community. As one attendee said, "I also want to be a vaccine champ as I have found out how useful vaccines are."

Almost all the Vaccine Champions who were interviewed stated they would be keen to continue the programme in Fiji and to stay involved themselves. Codesign participants and community attendees also thought that the Vaccine Champions programme should continue in Fiji.

National data reported by a representative from the Ministry of Health showed an increase in booster uptake from 44% in June 2022, 1 month before the programme started, to 54% in October 2022. However, due to the range of other factors influencing vaccine uptake at a national scale, it is not possible to attribute this change to the Vaccine Champions programme directly. Other activities that took place during the study period included media campaigns and mobile vaccination outreach services. A measles vaccination programme was also ongoing in some divisions.

Reflecting on the findings, the researchers note that a key feature of this programme was the engagement of the community in the intervention itself. Many community engagement interventions do not include or describe intensive training for community mobilisers in both vaccine information and communication skills, which is an important part of the Vaccine Champions programme. The researchers suggest that, "In other settings with ongoing vaccination challenges, such as countries struggling to increase routine childhood vaccination rates, tackle disease outbreaks or introduce new vaccines, a more activist or hybrid social mobilisation approach that empowers local communities to lead the intervention design process may improve effectiveness and sustainability."

In conclusion: "The Vaccine Champions programme is a promising community engagement intervention that incorporates vaccine education and communication training to empower community influencers and health workers to become vaccine advocates. Community advocacy is crucial for current global efforts to combat measles outbreaks and eliminate vaccine-preventable diseases such as cervical cancer....This programme can reduce the burden on health workforces by training diverse community advocates without a health background to share their vaccine experiences, address misinformation and answer questions from their communities. The programme has been adapted and implemented and is being evaluated in other countries in the Asia Pacific region to build the evidence base on the effectiveness of community-based interventions to improve vaccine confidence and uptake."

Full list of authors, with institutional affiliations: Jessica Kaufman, Murdoch Childrens Research Institute and The University of Melbourne Department of Paediatrics; Isabella Overmars, Murdoch Childrens Research Institute; James Fong, Republic of Fiji Ministry of Health; Jemesa Tudravu, Republic of Fiji Ministry of Health; Rachel Devi, Republic of Fiji Ministry of Health; Litiana Volavola, Republic of Fiji Ministry of Health; Luisa Vodonaivalu, Murdoch Childrens Research Institute; Kylie Jenkins, Murdoch Childrens Research Institute; Julie Leask, The University of Sydney Faculty of Medicine and Health; Holly Seale, University of New South Wales; Yasmin Mohamed, Murdoch Childrens Research Institute; Kshitij Joshi, UNICEF Pacific; Halitesh Datt, UNICEF Pacific; Sonya Sagan, UNICEF Pacific; Michelle Dynes, UNICEF East Asia and Pacific Regional Office; Monsurul Hoq, Murdoch Childrens Research Institute, Murdoch Children's Research Institute; Margie Danchin, Murdoch Childrens Research Institute and The University of Melbourne Department of Paediatrics