UCL News


Opinion: The Covid-19 vaccines rush - participatory community engagement matters more than ever

14 December 2020

The announcement of effective and safe vaccines for Covid-19 has been greeted with enthusiasm, but discussions continue about the ethical challenges of ensuring fair access to vaccines within and across countries, writes Dr Rochelle Burgess (UCL Institute for Global Health).

Dr Rochelle Burgess

There are concerns about equity in access to Covid-19 vaccines. Estimates as of Dec 2, 2020, suggest direct purchase agreements have allowed high-income countries to secure nearly 4 billion confirmed Covid-19 vaccine doses, compared with 2.7 billion secured by upper and lower middle-income countries. Without such agreements, low-income countries would probably have to rely on COVAX, which would achieve only 20% vaccination coverage. States such as the UK, Russia, and Germany have promised or begun rapid access to vaccines, some early this month.

While Covid-19 vaccines bring potential hope for a return to some kind of normality, vaccine-based protection is contingent on sufficient population coverage and requires effective governance, organisational, and logistical measures within a wider Covid-19 control strategy that includes continued surveillance and appropriate countermeasures. In this new phase of the Covid-19 response, successful vaccine roll-out will only be achieved by ensuring effective community engagement, building local vaccine acceptability and confidence, and overcoming cultural, socioeconomic, and political barriers that lead to mistrust and hinder uptake of vaccines.

From the outset it is important to distinguish between people wholly opposed to vaccination (anti-vaxxers) and individuals with limited or inaccurate health information or who have genuine concerns and questions about any given vaccine, its safety, and the extent to which it is being deployed in their interests before accepting it (vaccine hesitancy). In conflating and problematising the spectrum of those who do not accept vaccination, authorities might further erode trust and confidence, thereby exacerbating rather than resolving the factors underlying vaccine hesitancy. Covid-19 vaccines arrive as the social contract between some governments and their populations is being eroded and when many people, especially those in vulnerable groups, have little confidence that their government will protect them. In the UK, for example, a parliamentary report highlighted that more than 60% of Black people do not believe that their health is protected by the National Health Service to the same extent as White people.

Globally, the Covid-19 pandemic has further marginalised historically oppressed and excluded groups, including people with disabilities and growing numbers living in precarity. These groups have suffered disproportionate economic and health consequences, and have been largely excluded from social protection and resources needed to minimise their contracting the virus. The widespread impacts of the pandemic have illuminated the structural violence embedded in society. Now these communities are being asked to trust the same structures that have contributed to their experiences of discrimination, abuse, trauma, and marginalisation in order to access vaccines and to benefit the wider population.

Given such realities, it is instructive to reflect on the complex history of mass drug administration (MDA) and vertical immunisation programmes globally, which remind us that there are no magic bullets. For example, Sudan's Blue Nile Health Project (1980–90), a programme designed to control malaria, schistosomiasis, and other diseases via MDA and other ecological methods, had limited success; in some cases, transmission rates were higher after the campaign had ended than before it. Uptake of immunisation programmes, such as human papillomavirus and measles, mumps, and rubella vaccines, has been influenced by wide-reaching historical socioeconomic inequalities within countries like the UK and across other communities of difference. In Nigeria, polio eradication campaigns in 2003 were slowed down due to valid concerns about the motives of sponsors, inadequate testing, and consent procedures, and unsatisfactory engagement with local knowledge about health and illness. Efforts for Nigeria's polio eradication campaigns were eventually turned around through widespread community dialogues, which helped to foster social learning, establish equity, and generate and restore trust and participation in the programme. Examples of successful immunisation campaigns, such as India's polio eradication efforts and rubella in the Americas, are rooted in wide-scale social mobilisation and systems strengthening. A modelling study suggests that weaknesses in implementation of a wide-scale Covid-19 vaccination strategy will reduce the efficacy of the vaccine as reported in clinical trials and underlines the need for investment to promote public confidence in vaccines and maintain other Covid-19 mitigation measures.

The public is not a homogeneous entity. It is complex, composed of individuals, families, and other groups shaped by contexts, experiences, and desires in a constellation of communities with different patterns of health literacy, values, and expectations. A top–down, one-size-fits-all approach has derailed countless well-meaning global health solutions, and in the context of vaccine implementation risks leaving many groups behind, again. Policy makers need to understand this diversity and adopt comprehensive local approaches that give communities a voice, and the necessary resources to put ideas into action. Such community-led strategies can ensure diverse local voices are heard, map local concerns and alliances, and co-design programmes to maximise vaccine uptake from the ground up.

Policy makers must accelerate dialogue and support the development of community networks, leveraging and supporting existing local channels that influence decision making, such as community and faith leaders, teachers, sports and youth clubs, and online communities and networks. In this way, the public health community can gain deeper understandings of intersecting local challenges and opportunities, while establishing trust with communities and building effective communication and public health messaging. Such efforts must be paired with investment in structures that enable people to contribute to this process, including global financing to ensure low-income countries can implement similar schemes. Participatory community engagement is cost-effective, increases uptake of vaccines, and substantially reduces health-care resources needed to achieve high vaccination coverage.

We outline recommendations to achieve meaningful engagement with diverse communities in preparation for the Covid-19 vaccines roll-out (table in original article, linked below). This proposed bottom–up approach devolves the power of design and implementation of communication strategies to local actors, supported by evidence syntheses, enabling them to mobilise local expertise that can engage with and shift attitudes on vaccines and wider government handling of the Covid-19 pandemic.

Mistakes now risk cementing mistrust in the ability of science and governments to manage the pandemic. Listening to those who have the most at stake will pave the way for much needed change and widespread engagement with and support for Covid-19 vaccination campaigns.

This article was originally published in The Lancet on 10 December 2020.