The Vaccine Trust - Kenya - COVID19

Kenya: Towards a Trust Framework Read more: www.thevaccinetrustproject.com

Towards a Trust Framework Purpose and agenda

Meeting purpose

To introduce ongoing work investigating the intersection of trust and COVID-19 vaccines and introduce emerging insights.

Through this, we hope to: • Gather input on other relevant ongoing work • Solicit feedback & discussion on emerging findings

Agenda 1. Context & process 2. Cross-country emerging trust framework 3. Building trust in Kenya

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ASSESSING

TRUST

As the world enters its third pandemic year and the COVID-19 virus continues to circle through the global population, the ‘post-COVID’ world is becoming an increasingly unlikely reality

The COVID-19 pandemic has been a profound lesson on the future of public health in a globalized world – highlighting the interdependencies and needs for more resilient systems Exacerbation of existing and new inequities

Rapid cross-border spread

Divergent reactions across nations

Politicization of the pandemic response

…

This may well be the new reality – living with this virus, and being prepared to better deal with the next one as a global community

“Eradicating this virus right now from the world is a lot like trying to plan the construction of a stepping-stone pathway to the Moon. It’s unrealistic” Michael Osterholm, “The coronavirus is here to stay – here’s what that means,” Nature

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ASSESSING

TRUST

The COVID-19 pandemic – and the vaccination effort in particular – has inspired a great deal of thought around trust, resiliency, and the nature of the unspoken agreements that bind societies together

Trust is critical but often overlooked…

Trust is a critical component within efficient, well-functioning, sustainable health systems. It is strongly tied to accumulated experience – making each new interaction with a health system important for growing or maintaining trust.

And yet, as the pandemic has laid bare, trust can be a nebulous and overlooked area of public health.

“Trust is paramount to the delivery of health care…[but] trust is often taken for granted, leading to neglect in the ways to maintain and build it. In turn, this results in harm to the system”

…and is tightly linked with resiliency – driven by a strong social contract A recent piece in Nature, examined national COVID-19 responses across 84 countries worldwide through the lens of trust and found that trust is positively correlated with resilience of the health system and consequently a reduction in cases and deaths/capita.

The Nature authors stress that trust is a valuable component of any government’s response to the pandemic, along with adaptive responses to the stringency of government interventions. And they conclude that the variation in resilience to COVID-19 reflects, among other things, variation in the nature and strength of the ‘social contract’ across countries2.

Felix Gille, Journal of Health Services Research & Policy (1) 1.

2.

Gille F, Smith S, Mays N. Why public trust in health care systems matters and deserves greater research attention. J Health Serv Res Policy. 2015 Jan;20(1):62-4. doi: 10.1177/1355819614543161. Epub 2014 Jul 17. PMID: 25038059.

Lenton, T.M., Boulton, C.A. & Scheffer, M. Resilience of countries to COVID-19 correlated with trust. Sci Rep 12, 75 (2022). https://doi.org/10.1038/s41598-021-03358-w

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ASSESSING

TRUST

The social contract, in particular, has been the subject of much discussion in the global health landscape, as health – and vaccination in particular – represent one of the most concrete manifestations of this contract

“The social contract is the basic set of rules, norms, and mutual obligations that bind together individuals, firms, civil society, and the state. Simply put, the social contract defines what we owe each other” -

Minouch Shafik Project Syndicate (2022)

Vaccination represents a concrete test of the social contract…

…making an understanding of trust imperative for a resilient pandemic response

As the recently announced BMGF board member, Minouch Shafik, writes: vaccine hesitancy is a symptom of the primary malady of our age: a broken social contract, and the subsequent collapse of public trust in institutions.

As the COVID-19 crisis moves from a short to a longer-term crisis, many governments have responded to the pandemic with social protection policies to strengthen the social contract.

However, these quick interventions must be balanced with the longer-term sustainability of solutions.

Vaccination, given its foundation in the marriage of individual preferences and collective interests reflects the social contract. And it demonstrates that whether people follow social protection measures is not simply an epidemiological question – it is a social one.

Examining and assessing the impact of COVID-19 vaccinations on trust – in its multiple forms – will be an important step in building a more resilient global health system.

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ASSESSING

TRUST

While the countries studied are often referred to as ‘low-trust’ contexts, trust still plays a critical role in guiding decision-making and driving behaviours All three countries studied rank low in a global context on various trust indices, including perceived public sector corruption,1 regulatory quality, governmental effectiveness,2 etc.

But even in these ‘low trust’ contexts, we spoke with people from all walks of life who use trust to guide important decision-making.

Perception of Corruption 2020 global rank1 Kenya

124th

out of 179

Pakistan

125th

out of 179

Nigeria

149th

out of 179

“You won’t believe this, but since we started the company, we have not run a single ad… People that know me and trust me are the ones hiring us”

Trust is a dynamic concept that is constantly evolving as people interact with each other and their surroundings.

The key to understanding trust will be to characterize how different types of trust are built and how they relate to each other within societies.

– Lil Bill, 28, Entrepreneur from Kwara

1. Transparency International: Corruption Perceptions Index. 2. Worldbank: Worldwide Governance Indicators

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ASSESSING

TRUST

This investigation was carried out over four major steps – leveraging the wealth of existing knowledge on vaccine acceptance to frame a deep-dive into trust Lit Review & Expert Interviews Framing of research topics was driven by a literature (manual & automated) and expert interviews

Social Media & News Listening Social media & news media listening provided direction for particularly salient public narratives to explore

In-depth engagements with Kenyans from a variety of low to low-middle income backgrounds, in 4 locations (Nairobi, Isiolo, Malindi & Kisumu)

17,500+ posts from Twitter, Facebook, Instagram, YouTube, forums, and blogs), collected June-August 2021

100+ engagements with respondents and their ecosystems (observations, deep dives, key informant interviews and focus groups)

25+ Internal BMGF & external expert interviews

200+ documents (academic, journalistic and organizational) hand-reviewed & 9,000 automatically reviewed for keywords & themes

Fieldwork

Analysis (ongoing) Analysis (ongoing) Findings from the previous steps are collectively examined to pull out themes and eventually build up to a trust framework

A 4-step process, which includes data mapping, clustering, member checking, and a final round of social media listening 7

ASSESSING

TRUST

Fieldwork: We conducted deep dives with people from different positions in Kenyan society providing us with multiple perspectives on trust and vaccine hesitancy Research locations in Kenya

Recruitment criteria Age: Participants across generations were included

Isiolo County

Kisumu County

Gender: Equal representation of both women and men was ensured

Nairobi County

Kilifi County

Kisumu – Urban and rural. Majority Luo (politically dominated ethnicity) Nairobi – Major urban center. Ethnically mixed. Clear governmental presence.

Kilifi – Rural and medium-sized cities. Large tourism sector. Strong Swahili culture.

Isiolo – Rural. Smaller government presence.

Pastoralists

Status: Individuals who hold different positions (with differing levels of power) within their communities were recruited, i.e.

• 1/3 middle to upper class • 1/3 lower middle class • 1/3 impoverished

People profiles Community leader

e.g., religious leader, elder

Healthcare worker e.g., doctor, nurse

Health service provider

e.g., traditional healer, midwife

Experience with COVID e.g., direct & care experience

Local business owner e.g., shop owner

Mobile community member e.g., truck driver, boda boda driver

Youth

e.g., college student, unemployed 8

ASSESSING

TRUST

Fieldwork: A variety of research methods were used to provide a comprehensive understanding of communities studied Recruitment funnel Micro-conversations & Focus Groups

Observations

Informant Interviews

Deep dives

Talking with students in university room

Observing a vaccination site in Isiolo

Interview with a Nairobi entrepreneur

Deep dive with a poultry farmer

10-15 minute conversations, as well as 1-2 hour focus groups, to gain entry points and quickly capture a broad range of opinions & perspectives

Staying at community or health sites to observe how people navigate their surroundings for up to several hours at a time

1-2 hour conversations with with relevant profiles who provided key opinions on health, religion, politics, and more

Multi-hour engagements with participants in their homes, workplaces and communities to get not only what they say but also what they do

21 short conversations & 8 focus groups in vaccine sites, basketball courts, vegetable markets and more

16 observations including rural villages, private clinics, places of worship, vaccinations sites

40 informant interviews, from busy health care providers to university students in final weeks

20 deep dives, from mobile community drivers at work, to mothers in their homes

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ASSESSING

TRUST

Our analysis highlights that trust broadly operates at two levels in the healthcare space: trust in the promises inherent in the social contract surrounding health and the delivery of that contract

T RU S T I N T H E

Promise

of the social contract

T RU S T I N T H E

Delivery

Of the social contract

Belief that the health system will uphold the social contract. This implied contract includes an emotional certainty in the goodwill and shared values of the systems surrounding health.

Belief that the health system is accessible, safe, and effective.

This trust relies on a cognitive understanding of the system’s competence, generally linked with past experiences.

Considerations which determine trust level:

Does the health system have my best interests at heart?

Do I believe that the vaccine has value for me?

Considerations which determine trust level:

Does the health system generally work for me?

Do I believe the vaccine is available & accessible to me?

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ASSESSING

TRUST

Each type of trust is linked with different types of health decisions – with the promise more closely linked with the social aspects of health decisions, while trust in delivery is linked the the practicalities of health

Trust in the promise drives desire to act

Tied to individual and collective life objectives

Trust in delivery drives ability to succeed

Tied to the practical reality of accessing healthcare

All health decisions impact people’s lives, and most have profound social implications. These implications are especially relevant when a vaccine touches deeply-held cultural priorities (e.g. fertility), or has the potential to impact others (e.g. the decision to vaccinate).

Healthcare decisions are also of course guided by people’s understanding of the basic mechanisms of health, e.g. how diseases are caused, managed or cured. This includes people’s understanding of how the health systems they interact with manage treatment and prevention efforts, and prioritize different populations.

Harryson (50, Nairobi), got vaccinated as a way to attract customers to his safari tour business…

… But he still felt the need to do extensive research to feel certain that the side-effects were not too harmful

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ASSESSING

TRUST

When either of these two types of trust is low or absent, vaccine uptake is hindered – with important implications for efficiency and cost necessary to drive action, and therefore impact on system resiliency A PAT H Y

AVO ID A N C E

UNCERTAI NT Y

Lack of trust in the promise drives apathy – and must be compensated for with large delivery investments.

Lack of trust in delivery results in avoidance – and must be compensated for with a compelling promise.

A lack of either type of trust leaves space for uncertainty – which is filled with both real concerns and rumors.

30% of US adults indicate they probably or definitely will not be vaccinated – and 42% of them list “Don’t think I need it” as a major reason (a possible proxy for apathy)1

In Kenya, 37% of those who are unvaccinated but want to get vaccinated perceive a lack of appointments2 as a major barrier – a real issue which also contributes to low trust

Lack of institutional trust has been linked to consumption of misinformation.3 In the UK, misinformation alone has been linked with a 6% decrease in intent4 to vaccinate.

When there is a deficit of one type of trust, the other must be high enough to compensate – increasing overall system cost to drive action.

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Case study: In all three countries studied, women are in danger of being left behind in the vaccination effort, expressing a trust deficit not only in delivery, but also in the promise of the COVID-19 vaccines

Women are often less vaccinated – and may also express less intention to vaccinate In Pakistan women represent just 38% of those who have received a first jab1 (September 2021). In Nigeria, male gender is positively correlated with willingness to vaccinate2. In Kenya, where actual vaccination rates are more equal3, unvaccinated women are less likely than men to get vaccinated in the future4.

Real and perceived practical access barriers decrease trust in delivery “There is a lady on the other side of the house who …won’t go back for the second jab because she is the breadwinner and does not want to be sick again, she can’t be sick.

At the moment I would not take a covid vaccine…because I am breastfeeding” - Lilly (32, Kisumu)

While for many women, trust in the promise is undermined by the feeling that the vaccine may not be relevant for them In all three contexts, vaccines are tied with mobility and with participation in the formal economy. Both narratives have the potential to alienate women, whose bodies may already be deprioritized.

“My wife is not vaccinated and it's not necessary for her yet because her mobility is restricted”

Closing the gender gap will require not only addressing access issues and side-effect concerns, but also building a promise which resonates more deeply with women E.g. narratives around family progress and shared community health may be particularly motivating for women – who generally play a larger role in local community development in many contexts studied.

- Hamoon (32, Lahore) 14

ASSESSING

TRUST

We looked at each type of trust in the context of the broader health system, and the specific COVID-19 response…

… OF THE HEALTH SYSTEM

…. OF THE COVID-19 RESPONSE

TRUST IN THE PROMISE…

TRUST IN THE DELIVERY….

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ASSESSING

TRUST

… and found that trust can be uniquely assessed in each of these quadrants, an analysis which highlights key areas of trust deficit within communities

… OF THE HEALTH SYSTEM

TRUST IN THE PROMISE…

…. OF THE COVID-19 RESPONSE

Low trust in the health system creates a starting point for how people assess new health interventions such as the COVID-19 response.

Experiences with the COVID-19 response will impact expectations of the health system over the longer term.

TRUST IN THE DELIVERY….

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ASSESSING

TRUST

This provides us with an emerging framework for measuring trust impact – for assessing and tracking the long- and short-term trust implications of health interventions like the COVID-19 pandemic response

… OF THE HEALTH SYSTEM

…. OF THE COVID-19 RESPONSE

TRUST IN THE PROMISE…

No trust

TRUST IN THE DELIVERY….

Measuring trust impact: a diagnostic tool for decision-makers With this tool decision-makers (e.g.

NGO’s, government actors, funders and donors) can (1) assess trust and investigate the short and long term implications of specific vaccines (e.g., the COVID-19 response) on people's level of trust and willingness to engage with the health care system and (2) track the short and long term effects of health initiatives on trust and willingness to engage with the HCS

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Case study: Using the framework for analyzing the long-term trust impact of vaccine mandates, we see how short-term vaccine interventions, while immediately effective, can undermine trust in the promise over time

Vaccine mandates remove the need for building trust in the promise, which can be an effective quick-fix for driving up vaccination rates Vaccine mandates various types (e.g. withholding government services, targeting professions) have been employed in each country studied – and in each case resulted in higher short term uptake.

E.g. Kenya, some of the highest vaccination numbers were seen after blanket vaccine mandates were introduced in December. In Pakistan, many people have been vaccinated to avoid looming government threats (e.g. a rumored cell service cut-off). In both cases, increased update was not correlated with increased desire for vaccination.

Over the long-term, however, they begin to undermine trust in the promise of the overall health system – with clear impacts on system resilience

Effective mandates are highly targeted and implemented over short periods – and paired with extremely high vaccine access

For many, mandates introduce an element of suspicion which lingers over time.

Mandates seem to cause less consternation when the goal and underlying logic are clear. E.g. healthcare worker mandates – though they can also provoke pushback when the underlying promise remains unclear – are generally easier to understand than mandates on the broader public (and have been effective in other contexts, e.g. driving flu vaccine uptake2).

“Enforcing it makes the vaccine look shady. If you have to force it down my throat, there must be something wrong with it” - Little Bill (28, Kwara)

A recent investigation into trust in a COVID-19 context also linked mandates (“stringent government interventions”) to reduced system resilience, especially when they are implemented for a sustained period of time1.

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ASSESSING

TRUST

Each area within the trust framework can be defined by a key question capturing an aspect of how the system – and specific vaccines – are experienced

TRUST IN THE PROMISE…

TRUST IN DELIVERY….

… OF THE HEALTH SYSTEM

…. OF THE COVID-19 RESPONSE

Does the health system have my and my community’s best interests at heart?

Do I believe that this vaccine has value for me and my community?

Does the health system generally work for me and my community?

Do I feel this vaccine is available & accessible to me and my community?

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TRUST

And each key question can be further subdivided into key components of this personal experience – which can eventually be linked to concrete KPIs … OF THE HEALTH SYSTEM

TRUST IN THE PROMISE…

TRUST IN THE DELIVERY….

PI K NT ER ME D TH P E R L O IR FU VE QU E D RE

ASSESSING

…. OF THE COVID-19 RESPONSE

Does the health system have my and my community’s best interests at heart?

Do I believe that this vaccine has value for me and my community?

Sub-questions & emerging KPIs: • Do people feel like the system cares about their wellbeing?

• Do people feel like the interaction is transactional or relational?

• …

Sub-questions & emerging KPIs: • What goals does this vaccine help people achieve?

• Do people feel they have the agency to choose this vaccine?

• …

Potential KPIs: elements of the Public Trust in Health Care survey (PTHC) (Straten et al. (2002)), balance of public and private care

Potential KPI: elements of the Johns Hopkins COVID-19 Behaviors dashboard (e.g. percentage of unvaccinated who choose ‘I don’t believe I need a vaccine’), presence of mandates

Does the healthcare system generally work for me and my community?

Do I feel this vaccine is available & accessible to me and my community?

Sub-questions & emerging KPIs: • Do people feel they can get care without unsustainable strain on their resources?

• Do people know how to navigate the system?

• …

Sub-questions & emerging KPIs: • Do people perceive this vaccine as safe for them?

• Do people feel they can practically access it?

• Do people know how to learn more?

• …

Potential KPIs: “In the city or area where you live, are you satisfied or dissatisfied with the availability of quality health care?” (Gallup world poll), national and household-level healthcare expenditure

Potential KPIs: elements of the Johns Hopkins COVID-19 Behaviors dashboard (e.g., percentage of the unvaccinated to report perceived structural barriers holding them back)

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ASSESSING

TRUST

This model highlights fundamental trust differences across the countries studied – pointing to different leverage points, challenges and opportunities to drive vaccine uptake and build trust in the broader HCS

Kenya … OF THE HEALTH SYSTEM

Nigeria …. OF THE COVID19 RESPONSE

… OF THE HEALTH SYSTEM

…. OF THE COVID19 RESPONSE

Pakistan … OF THE HEALTH SYSTEM

TRUST IN THE PROMISE…

TRUST IN THE PROMISE…

TRUST IN THE PROMISE…

TRUST IN THE THE DELIVERY….

TRUST IN THE THE DELIVERY….

TRUST IN THE THE DELIVERY….

In Kenya, economic pressure drives natural links between the COVID-19 vaccine and a return to prosperity. But blanket mandates & harsh enforcement of infection control measures threaten to erode this trust in the promise by failing to connect the vaccination effort to what truly matters in people’s lives.

In Nigeria, extremely low institutional trust necessitates high reliance on personal networks to secure information, access, and resources. Maintenance of personal reputation is therefore paramount – and with vaccine access difficult and limited, many influencers are not willing to take the personal risk of encouraging vaccination.

…. OF THE COVID19 RESPONSE

In Pakistan, an efficient vaccine roll-out has reached many, at least in urban centres. Less attention has been paid to the promise of the vaccines, however, with negative sanctions heavily leveraged to drive motivation. This approach risks the erosion of long-term trust in the health system promise.

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ASSESSING

TRUST

With limited resources, effective trust-building requires prioritization, which requires understanding what lies behind particularly low areas of trust – and targeting these with the right tools

1

2

3

P RO R I T I Z I N G T RU S T G A P S

FOCUSING ON A QUA D R A N T

T RU S T C O M P O U N D S OV E R T I M E

Identifying and prioritizing areas where trust is low, using the trust assessment model.

Understanding the trust basis in each quadrant and working with the right tools to address this.

Allowing natural compounding mechanisms to grow trust in other areas over time.

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BUILDING

TRUST

In each quadrant of the emerging trust framework, trust is based on different expectations – and built through different approaches

TRUST IN THE PROMISE…

TRUST IN THE DELIVERY….

… OF THE HEALTH SYSTEM

…. OF THE COVID-19 RESPONSE

Is based on a set of expectations for what the health system – and the broader systems it connects to – should provide

Is based on a clear expectations for how COVID19 vaccinations can help communities move past the impacts of the pandemic

Trust here is built slowly, through repeated interactions which confirm or challenge these expectations

Trust here is built (and destroyed) quickly and, and relies on dialogue with the right types of advisors, as well as the right experiences

Is based on an understanding of the mechanisms underlying health delivery, e.g. how new medicines are developed or the logistics of healthcare delivery

Is based on the feeling that COVID-19 responses have been logically and reasonably applied

Trust here is built through consistent positive experiences and absence of major negative ones

Trust here is built through vaccines which align with community experience, and is heavily colored by trust in health system processes overall

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K E N YA

Case study: Building trust in the promise & trust in the delivery in Kenya Photo: Street food sellers in the streets of Nairobi 24

THE BIG PICTURE

The healthcare landscape in Kenya allows people across income levels to access various levels of care in competing public and private facilities, but significant gaps remain and are exacerbated by COVID With varying levels of access to health care, gaps are likely to persist due to the pandemic...

EASY & INSURED ACCESS Miles (35, Kisumu) and his family use a medical insurance to access care both in public and private hospitals.

“Our family including our parents have a NHIF card, which ensures that we access medical care whenever we need it. We like visiting private hospitals because we are assured of drugs. The government hospitals do not always have drugs and that's their challenge” NHIF contributions depend individuals’ monthly income and do not exceed 150 KSH for low-income beneficiaries.

RESTRICTED

BY FINANCES When Melissa (26, Isiolo) came down with what she suspects was COVID19, she could only afford basic care at the hospital.

“I was admitted to Kenyatta Hospital for a few days where I was put on oxygen. Everything was very expensive… I didn’t even have money for testing right away” She supplemented the care she got with a diet of fruits and vegetables and more affordable herbal remedies.

1. “Kenya’s insurers are part of the response to the COVID-19 pandemic,” Financial Focus 2020, PWC Kenya

ACCESSLIMITING BARRIERS Due to his disability, Mike has struggled to receive care at the facility closest to his home. He has to travel further for his frequent check ups and to potentially get the vaccine.

“Sometimes, in the local hospital, a blind person can be pushed out of line… that is why we travel to Nanyuki to seek health services… We just hear on the radio there is a vaccine and the next minute it's over. It is very difficult to get to Isiolo town. It is hard to travel and also expensive. For me, someone needs to come with me.”

Treatment for those infected with serious forms of COVID puts a strain on individuals and communities COVID patients potentially incur exorbitant medical costs, which are not typically covered under most common insurance plans. In addition, insurance penetration is low1 in Kenya, often leading communities to substitute as a safety net.

“A colleague I was working with at the bank, he got COVID and he was admitted to a hospital. His bill was 3 million+ KSH. The guy passed on, left the bill, and now they're doing harambe for this man who is gone.

There are ten examples like this one I could give you.” – Sayyid, 60+, Kilifi

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THE BIG PICTURE

Beyond health concerns, COVID-19 has brought profound economic struggle for many – compounded by the fact that harsh enforcement of SOPs added additional danger to an already fraught situation People experienced deep economic suffering

Education and careers have been disrupted

For many in Kenya, the COVID-19 lockdowns wreaked economic havoc.

50% of rural households in Kenya reported skipping or meals rationing portions due to the economic fallout of the pandemic1.

For many, COVID-19 has been a forced pause in educational progress, with learning and job opportunities being put on hold – often with very negative mental health effects.

“Covid was extremely bad for our livelihoods. We all had to shut everything down… It was the end of our livelihood.”

“Before I could finish my exams, the pandemic began. My career is basically stalled. I am just waiting, waiting forever.”

“We used to have a lot of tourists from abroad. Because of COVID, it all closed very quickly, and they stopped coming”

– Musa, 37, Kisumu

– Amin, 25, Malindi

– Nicholas (hotel manager) 50, Isiolo

Flows of income from abroad were significantly impacted

For Kenyans who rely on foreign income or foreigners’ influx into the country, COVID represented a major financial and economic hurdle, with long-lasting effects on their livelihoods.

Harsh enforcement of SOPs added to the pain Throughout the pandemic, many suffered at the hand of the police as they enforced mask mandates and curfews.

“The police are very brutal on the businesses that do not close 30 min before curfew" – Purity, 67, Kilifi County

This has been felt more harshly by marginalized communities like the urban poor I don't trust the police, they are very brutal especially to slum people. When chaos erupt in Kibera, they move from house to house beating people, they even beat up children for nothing” – Max, 21, from Kibera, Nairobi

1. The Guardian, A tale of two pandemics: the true cost of Covid in the global south

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THE BIG PICTURE

The lack of a strong unified and relevant narrative has resulted in a limited consensus around COVID-19, particularly when other health and safety issues appear more critical COVID has not been strongly perceived as a unifying health threat …

Largely, COVID-19 has not been experienced as commonly as malaria, as persistently as HIV, as alarmingly as political violence, or as visibly as droughts, all key factors in perceiving an issue as one that impacts the social and not simply the individual.

The drought in Isiolo is an example of a unifying cause. As a shared issue, it tends to drive collective action like sharing water and tending to communal crops

…Instead, COVID is considered to be an individual, relatively peripheral issue, that only affects others

COVID-19 is a disease of the foreign and the wealthy

There are more critical issues than COVID-19

Perceptions of who is affected by COVID19 is often divided along racial and socioeconomic lines

Specially for marginalized groups, COVID19 tends to fall back in the list of concerns

“This is a white man's disease, not an African disease. For Africans—it’s this western lifestyle that causes people to get COVID” – Paul, 40, Kisumu

“My personal and community health worries are unexplained conditions, malaria, and high blood pressure. COVID19 is the least of my worries” – Francis, 65, Kibera (Nairobi)

COVID-19 messaging has been largely aimed at the individual Across sites, observed messaging tended to be around “take care of yourself” like in the image above (in a university in Nairobi), rather than more collective messaging around defeating the virus as a nation or even protecting families and communities

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THE BIG PICTURE

In this context, broadly applied vaccine mandates have stoked heated national debate and fierce backlash – despite their subsequent revocation Recent online conversations around the government COVID-19 response in Kenya are centered on opposition to mandates (Data collected 01/11/2021 to 09/12/2021)

Public opposition to the restriction of government services for the unvaccinated

For comparison When the same landscape is mapped in the other two countries, results are starkly different. In Nigeria, debate is focused on a lack of trust in official government communication

Lack of trust in official government announcements

Public distrust regarding government and health institutions’ expertise

This landscape shows social media (Twitter, Instagram, YouTube, Facebook, forums, and blogs) conversations related to the government’s COVID-19 response in Kenya. Darker spots indicate clusters of posts sharing a similar theme, while proximity of clusters indicates relationships in the conversations.

While in Pakistan, chatter is largely centered on the government’s role in inflation and worsening economic conditions (which COVID-19 is perceived to be part of)

Local & global inequalities of vaccine availability

Inflation & economic worries

28

THE BIG PICTURE

The mandates have further politicized the topic and deepened divides between people, the vaccine, and the authorities Following up with informants, they shared different negative reactions to mandates

Mandates are a violation of personal freedom

Mandates don’t alleviate existing fears about vaccines

Mandates did not come with vaccine access improvements

Mandates will likely lead to further police harassment

“The government says we won’t be able to access health services unless you have proof of the vaccine. How is that not a violation of our rights?”

– Diablo, 24, a student in Nairobi

“My friends are still afraid of the vaccine. That makes it weird, because the mandates do not change that.”

– Bromeliad, 20, a student in Nairobi

“You can’t just tell a cattle herder in my village to get the vaccine. If you are going to mandate it, you must make it easy to get, like with polio.”

– Martins, 32, a driver in Isiolo

“People are nervous because this means harassment from the police will be very serious, like it was with the mask mandates before.”

– Harry, 43, a driver from Nairobi

Mandates seem to have the potential to introduce a level of doubt even among those who are generally in favor of the vaccines 29

THE BIG PICTURE

As mandates have often been reserved for childhood vaccines, they have led many to compare COVID with childhood vaccines where COVID vaccines and their rollout ends up looking less legitimate COVID-19 vaccine mandates trigger comparisons to childhood vaccines…

In 1980, the Kenyan Ministry of Health established The Kenya Expanded Programme on Immunization (KEPI), to provide immunization against several childhood diseases. These vaccines became effectively mandatory, and are now widely known and generally very accepted, which means they are Kenyans’ key reference point in the topic of vaccines.

Mandating the COVID-19 vaccines makes the comparison between them and childhood vaccines much easier to draw.

“National Policy Guidelines on Immunization,” Kenyan Ministry of Health, 2013

…These comparisons decrease the positive perception of the COVID-19 vaccine, as the key points of evaluation favor childhood vaccines

Greater efficacy

More visible impact

Easier to access

Childhood vaccines are seen as very effective, while it is still possible to contract COVID-19 after getting the vaccine

Parents and elders have seen the impact of childhood vaccines in the country, while COVID-19 vaccines are still new

Childhood vaccines are seen as commonly obtained and easy to access, while COVID-19 vaccines availability is still limited

“My uncle tested positive of COVID even after getting the first dose of the COVID vaccine. It is not like that with polio.” – Chateau, 25, Kisumu

“I see how vaccines solved Polio in my lifetime. Vaccines work. The COVID vaccine will work, just give it time.”

“The majority of the Malindi have always taken their kids for all the required vaccines and they continue doing it.”

– Arb, late 70s, Isiolo

– Elsie, 40, Malindi 30

THE BIG PICTURE

Ultimately, this negative reception of the vaccine mandates could erode both short-term trust in the promise of the COVID-19 vaccine, and long-term trust in the HCS embodied by the Minister of Health

“These mandates feel like the Minister of Health just woke up one day and decided he would make the vaccines mandatory.

We don’t know how these guys make decisions. Maybe he just feels is a power thing he can say something like that.”

– Martins, a driver from Isiolo, who provided his thoughts on the mandates via WhatsApp follow-ups with the research team.

Mandates could affect people’s perception of the Ministry of health Throughout the pandemic, the MoH has been seen as a source of reliable information. However, words like Martins’ demonstrate that mandates could affect this trust, which could be detrimental for the larger pandemic effort.

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THE BIG PICTURE

In economically-optimistic Kenya, people form a natural link between vaccination and economic recovery – but hurdles in vaccination delivery, as well as the recent introduction of mandates, threaten this narrative & undermine the potential to build trust in the public HCS, its efficiency & reliability

TRUST IN THE THE DELIVERY….

TRUST IN THE PROMISE…

… OF THE HEALTH SYSTEM

…. OF THE COVID-19 RESPONSE

Though Kenyans enjoy relatively good health coverage, a public and a private health system which are pitted against each erode trust in the system having people’s best interest at heart

Though many see the economic promise in vaccination, recently introduced mandates are politicizing the vaccination drive – and introducing doubt even for believers

A carefully curated network of advisors guides Kenyans through the health system – each playing different roles. COVID-19 does not yet neatly fit into this system

A lack of information throughout the vaccination journey drives a cloud of uncertainty grounded in real concerns

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T H E H E A LT H S Y S T E M P R O M I S E

Within a healthcare system equally divided between private (48%) and public (49%) providers, 1 individuals often must choose between directly competing public and private facilities, bearing costs of access in both cases

Kenya’s scare medical resources increase competition between public and private providers

Individuals pay the price of an increasingly divided medical landscape

Kenya is not only experiencing a shortage of healthcare professionals, but its current health workforce is geographically concentrated in the country’s major centers.2

Individuals often have to bear the costs of receiving healthcare, be they financial or personal, i.e., time, energy, personal networks, etc.).

This situation incentivizes HCPs to work both in the public and private systems as compensation and working conditions in public facilities don’t match what is possible to makein the private sector1. These trends create competition between public and private health.

“There aren’t enough specialists, that’s why we wait so long for an appointment.”

“I think there are people trying to make money out of this situation…They are charging unfair prices – they extort you” – Harryson, 50, Nairobi

– Purity, 65, Kilifi 1. “Heath Financing Profile,” USAID, PREPFAR & Health Policy Project, May 2016 2. Kenya MoH, Human Resources for Health; Gaps and opportunities for strengthening

33

T H E H E A LT H S Y S T E M P R O M I S E

The private-public health dichotomy is at best inefficient, and contributes to the impression that healthcare has become transactional…

This transactional trend in healthcare undermines trust in the system and providers Health Cabinet Secretary Mutahi Kagwe

Recent controversy between the NHIF & private hospitals underlines the acrimony between the sides In the battle to bring more Kenyans under National health insurance, the Kenya Association of Private Hospitals is often cast as a barrier by the NHIF – with highly public debates over rates, and accusations of mismanagement and fraud from both sides1.

Competition between public & private facilities fosters the perception that seeking healthcare is a transaction, where doctors and HC workers make more money in the private system than in the public.

“There’s a big lack of services in our community. There are private centres that will help you because you are paying them to do so, but they are very expensive. Then there are public hospitals, where you have to wait in long queues… Hospitals will help you based on your position.”

– Journalist focus group, Nairobi

This results in an erosion of the longer-term trust in the healthcare system’s promise, in which neither system is sufficient nor reliable to respond to the Kenyan population’s health concerns

1. Pulse News, Health crisis looming as NHIF makes new changes affecting private hospitals , January 2022 34

T H E H E A LT H S Y S T E M P R O M I S E

…and, over the longer term, it erodes the longer-term trust in the healthcare system’s promise because neither public nor private are reliable or seem to be in the best interest of the patient Healtcare Divide PUBLIC Government-run hospitals and clinics

P R I VA T E Private hospitals and clinics

Pros: Affordable

Pros: Fast

Cons: • Slow service • Questionable quality of care

Cons: Expensive Advice motivated by profit

OVERALL PERCEPTION: Lazy, unconcerned and/or overwhelmed doctors and staff

• •

OVERALL PERCEPTION: Financially motivated doctors and staff

Whether patients opt for public or private healthcare, the result is a lack of trust in the medical care they receive 35

T H E H E A LT H S Y S T E M P R O M I S E

COVID-19 added to the pressure, further burdening the public system as a whole – and representing an as-yet untapped opportunity to rebuild trust in the system as a whole

“While effective interaction… between the public and private sectors was recognised as important for the… overall equity in the response to COVID-19, it was also implied that past challenges and inequalities in the relationship between the two sectors persisted, particularly in the pressurised context of a pandemic.” 1 Although the COVID-19 response was largely led by the public sector, as both private and public providers share equal parts of the healthcare landscape in Kenya. This puts a significant additional strain on the public sector – strain which persists despite recent efforts to include more private sector actors in the COVID-19 response.

Chanda-Kapata, Pascalina,“Equity in the public and private health sector responses to COVID-19 in East and Southern Africa,” Regional Network for Equity in Health in East and Southern Africa, Discussion Paper 123, July 2021 1

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T H E H E A LT H S Y S T E M P R O M I S E

COVID-19 presents an opportunity to demonstrate the synergies between public and private health systems currently perceived to be in opposition

TRUST IN THE PROMISE…

… OF THE HEALTH SYSTEM

E M E RG I N G T RU S T L E V E R S : • Positioning the COVID-19 vaccination roll-out as a responsibility shared across the health systems, e.g. through the leverage of private facilities as temporary vaccination sites • Using the COVID response to make a general lift in universal healthcare – driven by the public health system • …

37

C O V I D - 1 9 VA C C I N E P R O M I S E

For the population groups that are active participants in the formal economy, many have looked to the vaccine as a way to move forward economically within the context of the COVID-19 pandemic Proof of vaccination is required to travel abroad

Being vaccinated is critical to attract Vaccines can also help businesses tourists bring back the NGO workers

As a very regionally connected country, NGO, Tourism, and government employees are often required to travel to nearby countries for work. This requires proof of the vaccine.

Whether on the coast or in city hubs, foreign tourism is a key source of income for many.

Being vaccinated is a necessity to be appealing to the tourists that are little by little returning to Kenya.

The development sector in Kenya is a key source not only of funding, but also of income and employment. Many service providers rely on regular visits of NGO staff as a revenue stream for their work.

“The first vaccine I got in April, and I got the other one just recently. I did it because of the nature of my work. I know that when tourists come, they will ask me if I have been vaccinated.”

“The UN and NGOs, have a lot of business here. But because of COVID, it all closed very quickly, and they stopped coming. Maybe if we (hotel staff) are vaccinated, they will return in the numbers we used to see.”

“I didn’t want to take the vaccine. I hear that after you take it, you can die within two years. But my employer told me I need to travel to Tanzania, and I need the vaccine for that. That’s why I’m here.”

– Emmanuel, 27, attendee at Isiolo referral hospital vaccination site

– Harryson, 50, tour guide from Nairobi

– Nicholas, 44, Hotel and restaurant manager in Isiolo

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C O V I D - 1 9 VA C C I N E P R O M I S E

But this promise is at risk of being undermined by global health politics, as the actions of countries beyond Kenya’s borders introduce doubt in the idea of vaccines as return to prosperity In the globalized pandemic context, international actions are noticed from afar…

… and can profoundly impact motivation to access vaccines for people well beyond national borders

The rejection of AstraZeneca in some western countries, for example, made a big impression, as have sweeping Omicron-related travel bans imposed on large swaths of Africa.

Suspicions that vaccines are not being distributed equitably were voiced by many Kenyans, along with concerns about which vaccines might be accepted for international travel.

“The poor are taking AstraZeneca and the rich are taking Johnson & Johnson”

Without a reliable international ecosystem to foster trust in the promise, the pressure is on national influencers to build and safeguard this trust type.

– Fred (29, Isiolo) 39

C O V I D - 1 9 VA C C I N E P R O M I S E

In addition, the current promise of the vaccines is less relevant to women - their concerns are often not addressed and the relevance of accessing the formal economy may be less obvious Much uncertainty around the risks of COVID-19 vaccines for mothers

Low interaction with formal economies makes vaccines feel less relevant

Many women of childbearing age expressed uncertainty about the safety of COVID-19 vaccines, and struggle to find clear guidance

Women outnumber men in Kenya’s informal sectors. In many cases, they operate outside of much government regulation, reducing the perceived need for vaccination.

“At the moment I would not take a COVID vaccine. I’m afraid of it because I am breastfeeding” – Lilly, 32, Kisumu

Mary, a 56-year-old chicken farmer from Kisumu, can’t see much need for a vaccine – a contrast to Nairobi tech workers who expressed that they needed a jab to travel.

While access is critical, motivation – trust in the promise of COVID-19 vaccines – will also become increasingly important for the groups currently being left behind 40

C O V I D - 1 9 VA C C I N E P R O M I S E

Increasing trust in the COVID-19 vaccination promise will require establishing a clearer link with the goals Kenyans are pursuing when they access vaccines OF THE COVID-19 RESPONSE

• Linking current COVID-19 related messaging to people’s desire to move forward, particularly in their professional and personal economic trajectories – with a focus on ensuring relevance for women • Addressing the differences of the COVID-19 vaccination with childhood vaccines, while clearly outlining the reasons for the current mandates

TRUST IN THE PROMISE

E M E RG I N G T RU S T L E V E R S :

• …

41

H E A LT H C A R E D E L I V E R Y

Individuals seeking healthcare in Kenya are pulled in different directions along a public-private continuum, resulting in confusion and uncertainty, especially in the context of the pandemic PUBLIC

PRIVATE

CHWs

Doctors & Nurses

Pharmacists

Herbalists

Healers

Government employees, who raise health awareness at the community level

Healthcare professionals with sanctioned credentials working in both public and private care

Community-level providers with ability to provide advice on conditions and treatments

Usually trained by their parents, herbalists provide herbal products and how to use them correctly

Primarily focused on pregnancy, birth attendance, and common illnesses

“We have Volunteers (CHVs) going door to door checking the wellbeing of the community” – Nathan, 45, Isiolo

“Private hospitals are run by public hospital doctors” – Purity, 67, Isiolo

“I buy drugs over the counter, the pharmacist there knows me and my family on a personal level” – Owuor, 52, Kisumu

“I have sold herbal medicine for the last 20 years. My father did this work for over 40 years” – Hawi, 70, Isiolo

“All my life I have only known traditional medicine. My mother was a very powerful healer” – Boru, 52, Isiolo

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H E A LT H C A R E D E L I V E R Y

As people are pulled in different directions in the healthcare system, they build their own ways of navigating – with a heavy reliance on different types of advisors TRUST IN PUBLIC

TRUST IN PRIVATE

Public Hospitals

Public Health Centers

Pharmacists

Private Hospitals

Traditional Medicine

“Private hospitals can’t be trusted, most of them are not quality at all. Government-run hospitals are better” – Addi, 23, Malindi

“When I get sick, I go to our local village health clinic” – Mary, 56, Kisumu

“I prefer the pharmacy – I trust the pharmacist.

They listen when I explain my problem and I get healed” – Harry, 43, Nairobi

“I went to the public hospital … but no one attended to us … I will never go back to the public hospital” – Chateau, 25, Malindi

“There is a local brew called Changaa – It makes you crazy but it’s also a healer. It even helps with typhoid” – Paul, 40, Kisumu 43

H E A LT H C A R E D E L I V E R Y

When it comes to advice, the credibility of the advisor or source is of critical importance – and sources of credibility are differentiated by type of trust, making some better suited to building delivery trust Credibility here is derived from:

Advice building trust in the promise comes from sources with expertise in the social world

• • • •

Proximity to truth or special insight (e.g. religious leaders) Societal success (e.g. successful business leaders, some politicians) Understanding of particular circumstances & context (e.g. long-term connections) Perceived positive intentions (e.g. family)

Credibility here is derived from:

Advice driving trust in delivery comes from sources with expertise in the world of health

• • • •

Family legacy and experience (e.g. traditional healers, CHWs) Proximity and control over resources in the health care system (e.g. access to experts) Recognized accreditation (e.g. degrees, public recognition) Perceived need to retain community trust (e.g. some politicians, community leaders)

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Case study: As experts in the social world – and therefore credible advisors within the promise but not the delivery – religious leaders have struggled to engage with the highly health- and deliveryrelated COVID-19 SOPs

As experts in the social world, religious leaders are well-positioned to provide advice on a broad range of important areas In all three countries studied, religion occupies a central role in public life, and religious leaders generally poll as highly trusted (e.g. in Kenya and Nigeria, survey respondents rank religious leaders as the most trusted institutional leaders1,2).

At a community level, religious leaders are tightly integrated with their congregants, and play a key role in social cohesion.

But they rarely become involved in the practicalities of health decisions – dealing instead with the implications of health, or stepping in a last resort Religious leaders across faiths guide people through key life decisions – from marriage to career.

When it comes to health, they tend to step in to help deal with sideeffects of health, e.g. the financial implications of illness, or when no other treatment options remain.

During the pandemic, many have been asked to instruct their congregants on practical COVID19 SOPs – and many received backlash “I advised people not to shake hands, to wear their masks... You know what the reception I got was? They said this guy has become too proud” - Sayyid, Imam in Malindi

Leveraging religious leaders’ trusted role in communities better means getting them on board with the promise – enlisting their help to build motivation amongst those who trust their social guidance Religious leaders were most engaged in the COVID-19 response when they personally bought into and promoted collective interests over individual preference behind the vaccines. They are wellpositioned to build motivation in an area where they already enjoy high credibility.

45

H E A LT H C A R E D E L I V E R Y

Increasing trust in healthcare delivery will require cultivating trust-type specific influencers – and ensuring they are equipped with appropriate knowledge and tools

TRUST IN THE DELIVERY…

… OF THE HEALTH SYSTEM

E M E RG I N G T RU S T L E V E R S : • Ensuring that advisors who already enjoy high credibility within delivery-related trust are well-equipped to guide communities through the pandemic response – while those credible in the promise are also provided with the right tools • …

46

C O V I D - 1 9 VA C C I N E D E L I V E R Y

The current Covid-19 vaccination journey in Kenya tends to be characterized by pervasive uncertainty, leading to drop-offs and a growing population of the partially-vaccinated Deciding to getto Deciding whether getthe thevaccine vaccine

Finding a a Finding vaccine vaccine site site

Perceived benefits do not always outweigh the risks

The farther from urban centers, the harder to access

Possible to register online, or in-person at the site

Often filled with fear and the need to get proof

Mercy from Nairobi (below) hesitated because vaccine rumors in her community and because of her busy schedule but ultimately decided to get the vaccine

In large urban areas like Nairobi, residents can choose based on proximity.

Registering via SMS is usually available, but it requires a higher degree of tech savviness.

Rumors of fake vaccines and of possible side effects like dying after getting the vaccine often creep back in.

Otherwise, registering on-site with an ID and signature is usually available and not particularly challenging.

In Isiolo, the mood got tenser when a morgue ambulance came to pick up a corpse right by the vaccine site

Jennifer below registered online before arriving at the vaccine site in Kisumu

Additionally, not getting proof of vaccination right away means anxiously waiting for digital confirmation

Many Kenyans lack strong motivations to get vaccinated.

It is often extrinsic causes (e.g., vaccination required to enter public buildings, employer pressure) that drive uptake

For those in rural areas like Kisumu and Isiolo, people are faced with more limited options.

Mike, a visually-impaired elder from rural Isiolo, wants to get the vaccine, but the trip to the Isiolo referral hospital is very difficult to undertake

Registering for for Registering the vaccine the vaccine

Getting the the Getting vaccine vaccine

Obtaining the second dose Number of people returning for second dose remains low

People are often unsure if the same type is available. In other cases, people want to try to get a vaccine that is “better”, like Pfizer over AstraZeneca.

People often don’t know as to when they need to get the second dose Johanna below left her vaccine site with these questions unanswered

LifeLife postpostvaccines vaccines Sharing stories and living with uncertainties After getting the vaccine, a variety of uncertainties remain. This go from fear of the side-effects discussed in rumors, to concerns about the validity of vaccines to be able to travel abroad.

Additionally, people inevitable share their experience and influence others, like Liam below, whose was influenced by his boss who took the vaccine at a nearby site

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C O V I D - 1 9 VA C C I N E D E L I V E R Y

Throughout this vaccination journey, people struggle to find information to key questions like how vaccines interact with co-morbidities, how to get proof of the vaccine, and about side effects

Aggy, a 28-year-old mother from Isiolo

The registration desk at a vaccine site in Isiolo

People have important knowledge gaps in their vaccine journey…

Should I take the vaccine if I have another condition?

When and how will I get proof of my vaccine?

Pregnant, trying, or breastfeeding women specifically ask themselves this question, and feel they lack the information to make a decision on COVID vaccines.

Individuals coming to get their COVID-19 jab were particularly worried about obtaining proof of their vaccination, which they need to show employers, for instance

“About the COVID vaccine, If someone is pregnant can they get vaccinated?”

“Imagine if I took the risk of getting the vaccine and they don’t believe me. All of this will be for nothing.”

– Aggy (28, Isiolo)

– Vaccinated man in Isiolo

Vaccination line at a public health facility in Isiolo

Slogans displayed at a Kisumu vaccination site

…Yet, answers are not always readily available HCPs at vaccination sites struggle to respond to questions about the vaccines

Displayed written materials lack information about what to expect after getting the vaccine

Vaccine sites were hardly a space where patients shared their concerns with vaccinators or other healthcare professionals. In Isiolo, a crowd of patients asked about why the poor get AstraZeneca while the rich get Moderna or Pfizer, which vaccinators could not respond to

Vaccination sites lack publicly displayed information about potential side effects of the vaccine or ”next steps” more generally.

The materials available do not appear to be adapted to concerns specifically raised by our Kenyan respondents and were much more general in nature.

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C O V I D - 1 9 VA C C I N E D E L I V E R Y

In the absence of well-equipped guidance and clear answers, people turn towards other sources information like radio, television and social media, with varying degrees of perceived reliability

A BBC media study in 2018 found that 81% of Kenyans have access (at home or elsewhere) to Television1

The same study also found that 98% of Kenyans have access to radio, and is the best way to reach rural areas 1

As of 2016, 51% of Kenyans were deemed to have access to the internet, via phones, computers, and internet cafes 1

TV is seen as accessible and as a verified source that can be used to fact check

Radio is also seen as accessible, and provides opportunities for dialogue

Social media is commonly used, but brings the risk of misinformation

Channels such a Citizen TV and KTN are seen as sources of truth “If I see it on TV, then it must mean it is true.

Local languages radio is seen as a key source of trusted information.

“I listen to the Luo language radio news.

Most of my news are from radio.

– Lilly, 32, Kisumu

Social media sites, are often seen as full risk and unreliable “WhatsApp, Facebook, Instagram. There’s a lot of scams and contradicting information.”

– Liam, 28, Malindi

Radio also provide opportunities for dialogue, an important signal of trust “I listen to Shahidi radio. I call in to discuss about community issues” – Mike, 71, Isiolo

Social media, however, can be used as a gateway to more reliable sources “I get most of my news from Facebook. I subscribe to CNN, BBC, and the Nation” – Amenia, 35, Malindi

– Harrison, 50, Nairobi Many Kenyans use TV news to verify other sources of information “For me to verify anything I have read on social media, I watch news from TV” 1. – BBC Miles, Report: Kenya 35, Isiolo Media Landscape, 2018

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H E A LT H C A R E D E L I V E R Y

And look to more traditional sources of guidance like healers and herbalists – highlighted by much active social media conversation Recent online conversations at the intersection of traditional medicine and COVID-19 highlight a variety of discussion hotspots (Data collected 01/11/2021 to 09/12/2021)

For comparison When the same landscape is mapped in the other two countries, results are quite different. In Nigeria, the conversation was mostly limited to distrust in vaccines Distrust towards COVID-19 vaccines

Herbal cure recipes

Governmental investigation into herbal drugs Controversies about herbal remedies

While in Pakistan, the conversation around natural medicine was primarily focused on preventative measures over cures, physical therapy, and ineffectiveness of vaccines

Perception of higher safety for herbal remedies over vaccines

Physical therapy

Ineffectiveness of vaccines Prevention over cures

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C O V I D - 1 9 VA C C I N E D E L I V E R Y

In this confusing and uncertain information landscape, people construct their own realities about the COVID-19 and the vaccines, often filling real unanswered concerns with myth and misinformation Theories about influential people often cover the gap about the origins of COVID-19

Rumors about effects on male sexual health fill gaps about the consequences of the vaccine

Women hesitate about how the vaccine might harm their fertility

Misunderstood side effects lead people to wrongly compare with other vaccines

“When COVID was killing Americans and Europeans, Bill and Melinda Gates realized that the virus was not affecting Africans. They decided that if they could adjust the virus, they could use it to reduce the African population”

“…None of my brothers have taken the vaccine, they have made it very clear that they will not take it. There are too many stories going around. My brothers believe they will be impotent if they were vaccinated”

“We haven't been vaccinated yet even though we pass by the vaccination site here at JOOTRH every day, we neither have plans to be vaccinated due to fear that we can die or become infertile”

“All vaccines have some sort of effects that we have to live with, like family planning methods. I heard that when someone gets a family planning that is placed on the hand, the hand gets paralyzed”

– Boru, 53, traditional healer from Isiolo

– Rasta, 46, a street vendor from Kisumu

– Medical students focus group, Kisumu

– Martha, 36, charcoal seller from Isiolo 51

C O V I D - 1 9 VA C C I N E D E L I V E R Y

Equipping vaccine sites, advisors, and communicators with answers to common issues like the vaccine types, side effects, and second doses could significantly improve the current vaccination journey

Promote registration

Discuss side-effects

State vaccine availability

Equip advisors

Even those with reliable access to SMS and internet have limited awareness of online registration. Getting this information out could motivate quickly to sign up and get the vaccine

Side-effects knowledge gaps are currently being filled by misinformation. Discuss them openly and provide information to mitigate the fear and discouragement they create

Lists of vaccine types available in a site can let people quickly determine if they need to travel elsewhere for their second dose

Vaccinators & community advisors are eager to fulfill their role of helping their communities. Equipping them with additional training & reference information can empower to reduce uncertainty

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C O V I D - 1 9 VA C C I N E D E L I V E R Y

Increasing trust in the delivery will require addressing individuals’ hesitancy-driving concerns throughout the vaccination journey OF THE COVID-19 RESPONSE

• Creating more touchpoints throughout the vaccine journey that help individuals engage in honest conversations about their doubts, fears or concerns with advisors • Providing a clearer overview of the different steps of the COVID-19 vaccination journey, and helping individuals “stay in the loop”

TRUST IN THE DELIVERY

E M E RG I N G T RU S T L E V E R S :

• …

53

CONCLUSION

TRUST IN THE THE DELIVERY….

TRUST IN THE PROMISE…

Leverage points in each of the trust areas indicate that the opportunity for trust building both promise and delivery trust in Kenya is high – across the health system and the COVID-19 response

… OF THE HEALTH SYSTEM

…. OF THE COVID-19 RESPONSE

Leveraging the COVID-19 opportunity to demonstrate the synergies between public and private health systems currently perceived to be in opposition

Establishing a clearer link with the goals Kenyans are pursuing when they access vaccines

Taking a fresh perspective on identifying influencers and the type of support they are best able to provide

Addressing individuals’ concerns and hesitancy throughout the vaccination journey

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EMERGING TRUST FRAMEWORK

Next steps: this model represents an emerging theory for how trust impacts might be determined. To develop it further, practical application and measurement will be required

1. Further definition of KPIs & synthesis of leverage points

Continued analysis, including stakeholder and expert consultation, to strengthen and more tightlylink the trust framework with existing KPIs. In addition, examining the specific trust building levers which could be linked to each of these KPIs

2. Development of pilot scenarios to test and strengthen framework

Working with in-country partners to develop health interventions which might be used to measure and validate the trust framework, e.g. vaccinator training initiatives which could be used to test how improvement in trust in the delivery might be fostered

3. Iteration and strengthening of the framework based on pilot tests

The trust framework will be collaboratively developed further based on learnings from the pilots

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Appendix

Additional context & methods notes

56

APPENDIX

Context: ‘Trust’ as a concept has been well investigated, both within and outside of BMGF – for example through the identification of concrete barriers and drivers of trust A key finding throughout much of this work is that trust is a key ingredient of demand for vaccinations.

Barriers and drivers of childhood vaccination have been identified

An interdisciplinary corpus focuses on the social context of vaccine uptake

• BMGF has conducted extensive research on drivers and barriers to vaccine uptake • E.g. a pre-Covid Ipsos Global Health study provides an overview of the factors that hinder infant vaccination through quantitative, survey and interview data

A growing body of literature in fields ranging from political science to epidemiology investigates the types of social ties and structures that affect the acceptance of a variety of health interventions, including largescale vaccination campaigns (e.g., polio)

“Context, prior experience, and citizen trust are crucial factors that determine engagement and uptake [of vaccines].”

Source: Sameen M. Ali & Samia W. Altaf, “Citizen trust, administrative capacity and administrative burden in Pakistan’s immunization program,” JBPA, Vol 4(1), 2021

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APPENDIX

Project Goals: Through the Trust Framework, trust is explored as a mechanism for driving health systems change through community engagement – with three major goals Three major goals for this work STRATEGIC VISION

STAKEHOLDER ENGAGEMENT

PRACTICAL TOOLSET

The framework will provide a structure for bringing together and making sense of disparate existing data streams

Framework development – and subsequent implementation workshops – will provide a focal point for knowledgesharing

Practical tools for working with trust (and so increasing vaccine uptake) will be collaboratively developed based on the framework

This might include e.g. round table talks (such as the UNGA side event on community understanding and trust), workshops, or collaborative publications.

These might include e.g. trust KPIs or measurement guidelines, training modules, etc., refined through possible pilot initiatives with partners.

The Trust Framework does not replace existing work – but provides a lens and guidance for how existing data might fit together to provide useful guidance.

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