Social Inclusion and Immunisation

"Successful COVID-19 vaccine roll-out will only be achieved by ensuring effective community engagement, building local vaccine acceptability and confidence, and overcoming cultural, socio-economic, and political barriers that lead to mistrust and hinder uptake of vaccines..."

As of this writing, discussions are underway about the social, cultural, and ethical challenges of ensuring fair access to COVID-19 vaccines within and across countries, and which groups should be prioritised. Groups historically excluded and marginalised in terms of healthcare, already vulnerable to COVID-19 infection, will suffer even more if COVID-19 vaccines, tests, and treatments are not delivered equitably. This K4D Helpdesk Report explores challenges related to the roll-out, distribution, and access of COVID-19 vaccines, tests, and treatments - highlighting how these challenges impact certain marginalised groups. Lessons learned on this issue are offered from the literature on previous pandemics and vaccine roll-outs in low- and middle-income countries (LMICs). Specifically, case studies are provided throughout from sub-Saharan Africa (the Democratic Republic of Congo (DRC), South Africa) and South/South East Asia (India, Indonesia).

People in vulnerable situations who are often neglected when it comes to health services, goods, and facilities include: women; indigenous peoples; people living with disabilities (PLWDs); older persons; minority communities; internally displaced persons (IDPs); persons in overcrowded settings and in residential institutions; people in detention; homeless persons; migrants and refugees; people who use drugs; and lesbian, gay, bisexual, transgender, queer/questioning, and intersex (LGBTQI) persons. Many of them may have experienced poverty and find themselves in situations where they are most likely to be exposed to the risk of contagion; however, the literature shows they are the least likely to be protected from COVID-19 or supported by adequate and timely tests and health services. This could result in higher levels of mental distress.

An example of barriers people in these situations may face when accessing COVID-19 treatment: Migrants and refugees in Kenya, Somaliland, and Niger have reported suspicion and mistrust growing among the native-born population due to the belief that immigrants are bringing COVID-19 to their countries. Interviews conducted by the Mixed Migration Centre with immigrants highlighted their fear of facing racism and discrimination in accessing health services for COVID-19. With regard to vaccine-related barriers, for instance, older people have in some cases been excluded for socio-economic reasons. In Indonesia, instead of vaccinating older people in the first phase, after frontline workers and support staff, vaccinations will only be provided to citizens aged 18-59 years because they make up the public work force, which needs to be protected first to boost the economy. But the main demand-side factors that have been found to influence vaccine uptake are religious beliefs and lack of trust/misinformation.

Overall, the literature reviewed for this report notes that a lot of lessons learned about roll-out involve communication - including that the government should under-promise what it can do and then over-deliver. The roll-out of the H1N1 or swine flu vaccine in 2009 was plagued by shortages and miscommunication, which led to a drop in public confidence. Any campaign must aim to create trust and involve local communities in planning processes. Before a vaccine is rolled out, trusted messengers can play a key role in helping to increase awareness and acceptance and in encouraging behaviour change.

Other key points to emerge:

• Discussion in the literature of "hard-to-reach" groups focuses on vaccine delivery (high levels of demand, but face low supply), whereas issues around "hard-to-vaccinate" groups centre on vaccine uptake and acceptance (low levels of demand despite high supply). Both groups are impacted by social challenges, resulting in adverse health outcomes and socio-economic inequalities. However, some have argued for the term "hardly reached" because, for example, PLWDs can be hard to reach (e.g., due to lack of mobility) and hard to vaccinate (e.g., due to mistrust of health systems).
• COVID-19 has had a disproportionate impact on racial and ethnic groups in high-income countries; however, there are a lack of similar data from LMICs. United Nations (UN) data show that COVID-19 has a disproportionate impact on LGBTQI persons, but the literature on this is limited.
• Certain minority groups may be more at risk of being left behind in COVID-19 vaccination programmes. Looking at the Ebola epidemic, the BaTwa indigenous group were at a greater risk of exposure to and transmission of Ebola due to gender norms and discrimination, which also made them hard to vaccinate.
• Assessments of vaccination coverage for the general population may not be sufficient. Spatial heterogeneity (i.e., uneven distribution within an area) has been used to determine the success of immunisation programmes, as well as risk of disease persistence. Gap analysis, such as that by EBODAC (Ebola Vaccine Deployment, Acceptance and Compliance), can identify vaccine roll-out supply and demand needs and adherence. The South African COVID-19 Vulnerability Index (VIndex) online mapping tool has been developed to identify populations that are at multiple risk, and to identify areas where the population are considered most vulnerable, to COVID-19.

The report considers lessons learned from previous pandemics (e.g., Ebola, polio, Zika) and vaccine roll-outs, including:

• Build local vaccine acceptability and confidence - e.g., through: community liaison and social science teams who can work with clinical teams to strengthen trust; development of information, education, and communication (IEC) materials; and use of community champions.
• Conduct effective community engagement (reciprocity, dialogue, and respect) - e.g., through: involvement of religious and local leaders; efforts to understand social dynamics when designing interventions; and consultations with community members to inquire whom they would trust and nominate to speak on their behalf.
• Undertake vaccine compliance management to ensure those intended to be reached are the ones receiving the vaccine - e.g., through: development and implementation of innovation in health systems to identify vulnerable groups; use of surveillance systems from other vaccination roll-outs for vulnerable groups; and regular testing and sampling to identify priority groups.
• Facilitate closer collaboration - e.g., through: awareness of positive and negative outcomes in collaborations; involvement of surrounding communities in public health interventions; establishment of social relationships with communities; and use of multiple local logistical options to access hard-to-reach groups.

Based on the above suggestions, the report concludes with a number of lessons learned for COVID-19 vaccine roll-out strategies. Here is a small selection:

• Strengthen global and national cooperation for increased uptake.
• Update policies for universal health coverage (UHC).
• Work to overcome cultural barriers to healthcare (e.g., by training health professionals to explain COVID-19 risks to vulnerable groups), as well as socio-political barriers to healthcare (e.g., by negotiating access with local-level militant leaders).