Community Engagement to Increase Vaccine Uptake: Quasi-experimental Evidence from Islamabad and Rawalpindi, Pakistan

"A key lesson is that low-income or marginalized communities would be better served if the services are brought to them locally."

Developing countries have been facing difficulties in reaching out to low-income and underserved communities for COVID-19 vaccination coverage. In part, these difficulties are linked to the rapidity of vaccine development, which caused mistrust among certain subgroups. Pakistan started a multi-staged rollout of COVID-19 vaccination in March 2021 and eventually opened vaccinations to everyone aged 18 years or older in July 2021. When the original voluntary uptake of vaccines slowed down, several strategies were attempted, including reaching out to economically poor urban communities, which form nearly 30% of Pakistan's total population. This study  investigates the roles of community mobilisation and vaccination camps in marginalised, low-trust communities to promote awareness and uptake of COVID-19 vaccination - and the effects of such interventions.

The theoretical framework for the study is the Theory of Planned Behavior, which suggests that people's behavioural intentions are motivated by their attitudes, subjective norms, and perceived behavioural control. These behavioural intentions in turn can directly affect an individual's health behaviour, which the researchers hypothesised in this study as willingness translating to increased vaccine uptake among the intended population.

Through the study, behaviour change communication was carried out in the context of social mobilisation to engage the communities. The idea is that interventions aimed at mobilising communities for vaccination can help strengthen weak links in the causal chain, as they can enable one to take into account the local characteristics and implement the interventions more effectively. When information is spread through local prominent members (community and religious leaders) of the community, people become more willing to accept it and in turn, implement it.

Specifically, religious and political leaders were engaged to spread awareness of COVID-19 within public places such as shops, markets, mosques, and churches. Local mobilisers also distributed printed information pamphlets in the Urdu language that explain the processed of registering and getting vaccinated while also debunking common myths surrounding vaccines and identifying COVID-19 vaccination camps (CVCs) nearby. Since there were no CVCs in the vicinity of the selected communities, mobile vaccination camps (MVCs) were organised in the study's treatment areas in collaboration with local community-based organisations (CBOs), non-governmental organisations (NGOs), and community leaders through the team of mobilisers. The venue of the vaccination site was chosen by the community as a locally well-known and accessible location, such as a school or other landmark. Local mobilisers also advertised the MVCs in advance, and, on the day of the MVCs, they facilitated them.

The researchers used multi-level mixed effects models to estimate average treatment effects across a sample of 1,760 respondents in 5 low-income, informal localities of Islamabad and Rawalpindi, Pakistan. Few respondents (1% to 17%) reported any prior COVID-19 infection for themselves or among their families from any location. The highest rates were reported from the control area. However, 59-71% of all respondents reported being worried about COVID-19. Respondents from all areas reported similar proportions of sources of COVID-19 vaccination information and similar rates of treatment-seeking during a prior illness.

Willingness to receive vaccines increased substantially from baseline (67%) to endline (80%), more for men than women. The control area had the highest willingness for both men and women across both time periods, with one exception. However, this willingness did not translate into an increase in vaccination rates in control areas. In contrast, vaccine uptake increased in one of the treatment areas by 17.1%, compared to the control area, and the interventions increased COVID-19 vaccine willingness in two treatment areas that are furthest from city centres by 7.6% and 6.6% respectively.

Having received an SMS (text message) or call from the government about vaccination was a major motivator that led to increased willingness (adjusted odds ratio (AOR): 2.414, confidence interval (CI): 1.420, 4.103) and uptake (AOR: 1.310, CI: 1.004, 1.708) in the endline. Advice from friends, family, medical professionals, and religious leaders did not sway opinions about the willingness or uptake of vaccination. Living near a CVC was correlated with higher willingness compared to those who resided so far away that they did not know about the distance to a nearby CVC, and closer distances were associated with higher uptake (AOR: 4.14, CI: 2.370, 7.233 for less than 2 kms and AOR: 3.969, CI: 2.452, 6.423 for 2+ kms). The odds of vaccine uptake also increased if an NGO/CBO was working in the area in the pre-intervention period (AOR: 1.657, CI: 1.093, 2.514).

Vaccine uptake was higher among those with a previous infection with COVID-19, those with risk aversion (who were worried about getting infected), and those who sought treatment for their illness. Previous research has shown a positive association between health concerns and vaccine willingness; therefore, the interventions in this study may have nudged concerned people to seek vaccination. This finding implies that raising awareness, dispelling rumours, and communicating the benefits of COVID-19 vaccines can change the behaviour of people who are more concerned about their health.

The researchers describe a two-stage process. In the first, awareness increased and hesitancy decreased, following the awareness/mobilisation interventions. In the second stage, some of those who became convinced took up the vaccines. Uptake was dependent on access to vaccinations, which the interventions addressed only in part.

The results suggest that raising awareness of COVID-19 vaccination through more personalised means at community levels by using printed material in local languages, engaging with community leaders, and building partnerships with local CBOs and NGOs can improve vaccine willingness by changing the behavioural intentions of residents. Increasing uptake, however, requires improving access to vaccination services. Both information and access may be different for various communities; therefore a "one-size-fits-all" approach may not be effective and instead requires localisation. Underserved and marginalised communities are better served if vaccination efforts are contextualised.

Per the researchers, these findings may apply to other vaccinations and possibly to other health initiatives where the public may require motivation to uptake services, such as diabetes or hypertension screening or testing.