The Vaccine Trust - Nigeria - COVID19

Nigeria: 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 Nigeria

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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

6

PROCESS

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

Analysis (ongoing)

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

In-depth engagements with Nigerians from a variety of low to low-middle income backgrounds, in 4 locations (Lagos, Edo, Kwara & Kano)

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

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)

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

25+ Internal BMGF & external expert interviews

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

Fieldwork

7

PROCESS

We conducted deep dives with respondents from different positions in Nigerian society providing us with multiple perspectives on trust and vaccine hesitancy Research locations in Nigeria

Kano

Recruitment criteria Age: Participants across generations were included

Respondent profiles Community leader

e.g., religious leader, elder

Healthcare worker e.g., doctor, nurse

Kwara

Lagos

Gender: Equal representation of both women and men was ensured

Edo

Lagos – South-west geopolitical zone. Major urban center and economic hub. Ethnically mixed.

Kwara – North-central geopolitical zone. Ethnically mixed with majority Muslims.

Edo – South-South geopolitical zone. Linked to the historic kingdom of Benin.

e.g., traditional healer, midwife

Experience with COVID

Status: Individuals who hold different Kano – North-west geopolitical zone. Majority Hausa and Muslim

Health service provider

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

e.g., direct & care experience

Local business owner e.g., shop owner

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

Youth

e.g., college student, unemployed

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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) 13

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 intervention s 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 THE 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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NIGERIA

Case study: Building trust in the promise & trust in the delivery in Nigeria Photo: Views from a respondent’s home in Mushin, Lagos 23

THE BIG PICTURE

In Nigeria, the COVID-19 crisis compounded an already-dire situation for many, and the vaccination drive has landed in a context that was already fraught

According to World Bank forecasts, the COVID-19 crisis alone is forecast to drive an additional 10.9 million Nigerians into poverty by 20221 “Poor Nigerians have enough to battle with daily searching for the means to survive than to be searching for the COVID-19 vaccines”

As of March 2021, less than 4% of households had received cash support from any level of government to combat pandemic suffering2

Everyday Nigerians face dire threats from various sides, with security risks intruding into more areas of life, and health threats like malaria and typhoid.

The pandemic lockdowns plunged many into even deeper economic suffering, and government help was often felt to be inaccessible or unfairly distributed.

- Chief Imam Sulaimon (Lagos)

The COVID-19 crisis hit Nigeria at a particularly vulnerable moment, where security issues are heightened, and the economy is floundering.

COVID-19 is added to a list of other concerns, and perception of the crisis is coloured by the fact that people currently feel especially abandoned by government 1. World Bank Blogs: Using data to combat the ongoing crisis, and the next, in Nigeria 2. World Bank Blogs: The COVID-19 crisis in Nigeria: What’s happening to welfare? New data call for expanded social protection in Africa’s most pop ulous country

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THE BIG PICTURE

Vaccine infrastructure is still lacking in Nigeria – meaning that the vast majority of Nigerians still await vaccination and face a challenging route to access Case Study: A day in a vaccination site in Ilorin, Kwara

6:01 am

7:29 am

8:03 am

8:56 am

10:20 am

11:56 am

The long wait begins

The informal list grows

A nurse briefly appears

The crowd is moved to a new location

Short of vaccines, Many are sent away

A several hours-long wait ends

To maximize chances of getting the vaccine, 4 women arrived at the vaccine site at around 6:00 am.

More people arrive and write their names on a makeshift list.

A nurse arrives at the site, and briefly checks the list.

A staff member gathers the crowd and asks them all to follow her.

The number of names is already longer than those of the rumored number of vaccines available

The crowd rushes towards her, but she quickly leaves the scene before people have a moment to ask questions.

Those who did not fall within the number of vaccines available are asked to leave and come back another day.

As they leave, their disappointment is visible

An attendee gets his vaccine card and soon after the vaccine, after having arrived 4.5 hours earlier.

There are no signs or staff indicating this is the right place.

The sign of something happening seems to bring some hope to the attendees.

He celebrates by waving his vaccine card in the air 25

THE BIG PICTURE

Due to limited reliability of authorities and institutions , people rely on themselves and their personal networks – resulting in an economy of favors which governs how people navigate much of society To help them navigate informal networks, people cultivate networks of social connections and rely on an economy of favors Everyday support Iyabo (53, Kwara) relies on her neighbors to get through hard times, and they in turn rely on her Access to goods or services Ibrahim (32, Kwara) enjoys building friendships by helping others. One of his friends recently helped him get access to a COVID-19 vaccine Professional growth VD (31, Kano) grows her fashion business through taking on apprentices, as she herself was taught the trade

These networks are also an important source of social capital – with the ability to grant favors imparting prestige and power (as well as debt) “If I can inspire, or raise, or ignite 200 people in this path…I will consider that a success” - Little Bill, a tech start-up boss and coding instructor in Kwara

Many informants describe impact on others as an indicator of their success Providing an education to siblings, implementing community initiatives, training apprentices, and even changing the country are all different forms of impact people hope to achieve – and personal indicators of having ‘made it’.

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THE BIG PICTURE

In this context, people have internalized the need to take responsibility for their own health, with autonomy over decision-making perceived as a priority Many expressed the importance of being left to make their own decisions – either as an individual or a family unit.

For some women, healthrelated autonomy was stated as a point of pride.

“When it comes to healthcare I make my own decision on who or where to go to” - Kafilat, 24, Kwara

Childhood vaccines fit into this paradigm – as they are perceived as a choice Parents expressed their strong belief in the value of childhood vaccines, often based on their own experiences with the diseases they prevent. The decision to vaccinate children feels like a legitimate choice – people are convinced of their value.

“I have seen mothers in my church encourage new mothers on vaccinations for the newborn without any fear or compulsion but out of care and trust in vaccines in helping their children”

Mandatory vaccines are therefore viewed with suspicion

“In Nigeria, when you put ‘must’ we begin to question why it is ‘must’ It is for my own benefit, not for your benefit, so why must you force me to go and take something that concerns me” -

Aunty B (54, Lagos)

- Barr. Dan (49, Edo)

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THE BIG PICTURE

COVID-19 mandates are therefore perceived in an especially negative light – eliciting strong reactions among informants, and in online conversation Recent online conversations around the vaccination roll-out in Nigeria have centered around controversy about sanctions on unvaccinated people (Data collected 01/11/2021 to 09/12/2021)

“If you want me to take the vaccine, help me understand the reason why I should take it. It is a much better approach than forcing it.

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)

Debate around sanctions on placed on the unvaccinated

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

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THE BIG PICTURE

An effective COVID-19 vaccination roll-out in Nigeria could have a profound impact on both types of trust in the pandemic response – and, critically, build trust in the larger healthcare system

TRUST IN THE PROMISE…

COVID-19 provides an opportunity to rebuild trust in the promise of healthcare in Nigeria, e.g., through tapping into salient narratives around progress

TRUST IN THE THE DELIVERY….

… OF THE HEALTH SYSTEM

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

…. OF THE COVID-19 RESPONSE

In a context where favors underpin social capital, community influencers are unlikely to recommend vaccination before the delivery is improved to avoid undermining their credibility

People navigate local ‘micro’ networks who do not provide reliable access and information throughout the vaccination journey.

This drives a cloud of uncertainty grounded in real concerns 29

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

For many Nigerians, government at all levels seems far away, dispassionate and inaccessible – encouraging reliance on community-based organizations which offer a variety of services

Government services are limited, and its officials are often perceived to be corrupt

To fill the gaps left by the government, networks of grassroots actors provide services in health and beyond

“Leaders should be able to show examples, you are enriching yourselves and people are suffering, people are dying… schools cannot work here.”

– Ahmed (46, Edo) LGAs are perceived to be a way for public officials to gain illicit income, and they tend to be underfunded, particularly with regards to health.1

These networks include competing organization and individuals who either provide services or broker access to such services, including religious, traditional and even criminal structures.

Nigeria scores 149 out of 180 countries in Transparency International’s corruption index, which largely measures the extent to which people believe public officials exploit their office for their own gain.2 Tilley-Gyado et al., “Strengthening the Primary Care Delivery System: A Catalytic Investment Toward Achieving Universal Health Coverage in Nigeria,” Health Systems & Reform (2016), Vol. 2

“My landlord is a very wealthy person, who has all the boys on the street from my beck and call and he is also connected to most of the politicians in the state” – Gloria (33, Lagos) Oftentimes, these actors sit together on the Community Development Association, which discusses matters relevant to the community.

2. Transparency International: Corruption Perceptions Index.

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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

Despite often challenging circumstances, its also clear that the desire for progress – for personal development and growth – is deep-seated, widely shared, and highly motivating in Nigeria An entrepreneurial approach to achieving one’s intertwined personal, professional and academic goals

“I am an undergraduate of Lagos State Polytechnic, I am from a family of three, I work and sell male and female accessories online. The next important phase of my life is to go to the university where I already applied... I would also like to expand my business and to be well recognized nationwide about what I do online” –Nifemi Osho (24, Lagos)

Narratives around growth shape Nigerians’ trajectories A lack of institutional support drives Nigerians to try and carve out individual spaces for their and their families’ growth. In this context, narratives around personal progress are particularly salient, and goals are overlapping, be it in the professional, academic or social spheres Professional goals “I am underutilized in Nigeria. I’m planning to consult in private hospitals… before travelling outside the country" – Debbie, a lab scientist in Edo, Nigeria Academic goals “Five years from now, i will want to obtain my masters in public health. I want my siblings to all further their education in the university.” – Jessica, a student in Kano, Nigeria Social goals “I want to travel to Saudi for pilgrimage (Hajj) and travel the world with my children for holiday. Being able to achieve my dreams is what motivates me to keep working hard” – Iyabo, a food seller in Kwara, Nigeria.

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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

The desire for progress is also present in peoples’ perceptions of health and interactions with the health system – which does not currently live up to this ambition In a context where good health is incorporated as a marker of personal success, the failure of the health system to live up to this is particularly painful.

Individuals struggle to place their trust in the government when it comes to service delivery

“If someone is healthy, it means the person is strong” – Yahya, 45 (Ilorin) defines health as a prerequisite for continuing with his daily activities (which include 2 jobs and several volunteer positions)

“The government that does not even care about our

security, how would I believe them when they say they are keeping me safe health wise? … Every day we hear about people that are killed, bandits, unknown gunmen, kidnappers… They are not arresting them… so how would I believe government, I don’t have anything to believe… The roads that were not tarred when I came are still untarred.”

– Akpabio (55, Lagos)

This is especially true for underserved communities like Mushin (Lagos), pictured above, who lack basic services and rely on self-organizing and private initiatives to access public resources 32

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

The COVID-19 vaccination campaign represents an opportunity to rebuild trust in the overall health system, e.g. by tapping into salient narratives around personal and community progress … OF THE HEALTH SYSTEM

TRUST IN THE PROMISE…

E M E RG I N G T RU S T L E V E R S : • Leveraging the need for autonomy by prioritizing dialogue and local community engagement over national mandates where possible, especially until there’s greater vaccine availability to back up the mandates • Tapping existing trust in childhood vaccines by drawing comparisons between them and the COVID-19 vaccine (as a legitimate choice) • Taking the vaccine roll-out as an opportunity to build trust in the larger healthcare system, communicating not as an isolated intervention but part of a larger goal of providing better healthcare

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

With more pressing worries, and a minimally-visible government response, COVID-19 feels far away for many Nigerians – leading to apathy and negatively affecting motivation to get the vaccine Several reasons make COVID-19 feel like a distant situation, rather than an urgent disease for which to seek a vaccine

COVID-19 appears lower in the list of concerns

Lack visible markers of COVID-19 make it feel absent

Many feel their communities are safe due to little mobility

Most feel that they don’t know people who have had COVID

“The government cares less about the high level of insecurity, thousands of people be killed, kidnapped or displaced in their homes but they are more worried about COVID" – Daniel, Edo

From Lagos to Kano, people are largely unmasked, and enforcement of SOPs is limited, which many of the clear signals of life during COVID-19 are missing

“We don’t have COVID here, at least not on the mainland. We’re all here, no one has travelled out… your church is here, your home is here, your market is here” – Student focus group, Lagos

“I have never met anyone who says they have or recovered from it. I don't even know anyone who has ever met someone with COVID” – Hassana, Kano

These factors mean that there is little perceived reason to get the COVID-19 vaccine, affecting uptake 34

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

International actions and messaging are also not doing much to build trust in the promise – highlighting the need for a national focus in this area 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.

Given that COVID-19 isn’t perceived as an urgent health threat to many, and vaccination is often more tightly linked with goals like travel abroad, uncertainty around which vaccines are accepted for travel can drive hesitancy.

“I think the COVID-19 vaccine is good, but when you see on social media that the vaccines they’re giving to Nigerians aren’t even the right ones, it’s beginning to raise some questions…

After all that pain [of vaccination], imagine showing up to the airport and hearing that it’s not even the right one”

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

– Student focus group (Musin, Lagos) 35

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

On top of this, official government announcements on the COVID-19 pandemic and vaccination effort are viewed with suspicion – further strengthening the need for other types of local influencers Recent online conversations around the government COVID-19 response in Nigeria highlighted deep distrust in government messaging (Data collected 01/11/2021 to 09/12/2021)

NPHCDA mass vaccination campaign awareness

Discussion of new restrictions linked to Omicron

For comparison When the same landscape is mapped in the other two countries, results are starkly different. In Kenya, debate is focused around recently implemented mandates Opposition to the restriction of government services for the unvaccinated

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) Distrust in official government announcements

This landscape shows social media (Twitter, Instagram, YouTube, Facebook, forums, and blogs) conversations related to the government’s COVID-19 response in Nigeria.

Inflation & economic worries

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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 many community-level influencers are dissuaded from telling people to get the vaccine, as a lack of strong delivery to support it would mean undermining their own legitimacy and social capital Religious leaders are weary of telling people one way or another

Traditional healers may opt to leave vaccine influencing to government

Seen as wise in matters of life advice, sending people towards the vaccine could be a risky move for as it can undermine their congregants’ perception if the experience is negative

Iyee, a well-established healer, says is not her role to tell others about the vaccine, and tries hard to make sure that responsibility is on the government and not her

“I tell my congregation that if they like they can take the vaccine and if they do not like they may not take it, but I don’t enforce it on them. That is for them to decide” – Chairman, Pastor (55, Lagos)

“I don’t tell people if I have taken it or if I have not taken it because I am not responsible to be campaigning on behalf of government. I would rather tell them to go and follow government procedure” – Iyee, midwife and traditional healer (85, Edo)

In an environment were giving good advice is a marker of your social and financial capital, advisors and influencers will be weary of promoting the vaccine until there’s a strong process to back them up 37

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 vaccine promise will be a drastic improvement in the process to bring key influencers onboard, as well as a focus on explaining the relevance of the vaccination effort OF THE COVID-19 RESPONSE

• Addressing key challenges in the delivery and health system infrastructure (reliable access, information and competence) in order to encourage influencers (e.g. traditional healers, religious leaders) to motivate people to get the vaccine, without fear of losing their legitimacy

TRUST IN THE PROMISE

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

• Finding ways to increase the relevance and urgency of COVID-19, preferably by linking it to issues that are already seen as critical such as economic downturns at the individual and family level

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

Navigating within a complex system of actors, Nigerians pay out-of-pocket for 72% 1 of their healthcare needs and the private sector provides over 65% of healthcare services 2 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

”I have been doing this for a time. I educate pregnant women, I worked with HIV departments…”

- Abeni, 48, Kwara

“We deal and attend to patients that come directly to us, even without a referral.”

- Madoni, 36, Kwara

“I believe reason my clients trust me because of the excellent relationship I built between myself and them” - Oja, 35, Kwara

“I started this herb business about 7 years ago. Before, I helped my mum hawk herbs” - Baba Alagbo, 42, Lagos

“I take care of pregnant women and children, asthma, fibroid, diabetes and stomach hotness” - Iyee, 85, Edo

1

CNBC

2

PharmAccess Foundation Nigeria Market

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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 – building trust in divergent areas, and relying heavily advisors TRUST IN PUBLIC

TRUST IN PRIVATE

Public Hospitals

Public Health Clinics

Pharmacists

Private Hospitals

Traditional Medicine

”My wife gave birth to my new son in a public hospital and I trust them – they will tell you what they can do” - Joseph, 47, Kano

“In this area I can trust doctors who run local clinics based on their area of specialization” – Victor, 40, Benin City

“When a health issue is emanating … one should know that it is necessary to first go to a pharmacy” - Baale , 62, Lagos

In public hospitals taking an emergency case there may be risky because they may not attend to you on time” - Dani, 37, Lagos

“I make sure I eat well and then I do use herbal medicine like Agbo for treatment when necessary” - Baba, 42, Lagos

Individuals need help navigating this diverse landscape, particularly during the pandemic, which introduced even more uncertainty and complexity

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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 the 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 process – religious leaders have struggled to engage with the highly healthand delivery-related 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 “The pandemic was painful not because of the disease but because of the procedures we needed to observe in order to contain the spread… our mosques were closed down in the name of lockdown… and people became angry” - Mallam, Imam in Edo

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.

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

Increasing trust in healthcare delivery requires identifying influencers and the type of support they are best suited provide, and tapping into their goals of building and expanding social capital

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 : • Refining current approaches to local influencers by identifying roles the community already comes to them for. This includes equipping each type of influencer with the right kind of information to best support individuals throughout their COVID health and vaccine journeys • …

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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

The current COVID-19 vaccination journey tends to be characterized by pervasive uncertainty and significant access challenges, which leads to people easily dropping out and sharing bad experiences Finding a a Finding vaccine vaccine site site

Benefits must outweigh the risks and the costs

Access issues heightened outside urban areas

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

Often filled with confusion and the need to get proof

Number of people returning for a 2nd dose remains low

Sharing stories and living with uncertainties

Concerns such as side effects, and rumors about vaccines must be overcome at least to some extent to decide to get the vaccine.

Finding a site can be difficult, especially farther away from the major cities like Lagos. In Kano, for example, awareness that the vaccines are already available locally is limited.

To register, people can go online or sign up on site. Both options involve doubt.

• Online: how do I sign up using my phone?

• On-site: where is the list and I am early enough?

In vaccine sites with minimal signage and staff instructions people navigate and hope they are in the right place.

Additionally, rumors make it hard to trust what’s going in the arm

Doubts like when to return for a second dose, how to get information about it ensure that the uncertainty extends getting beyond getting the first dose of the vaccine

At a site in Kwara, people registered on a makeshift list claiming their position in the queue

“People feel that the vaccines would have expired before it gets here, or that our temperature invalidates them” – Cappa (28, Kano)

Even after getting the vaccine, rumors, doubts not being able to go back to “normal” endure. Additionally, what people says affect others, and the cycle continues…

“After taking the vaccine I was told to keep observing COVID-19 protocol. I thought after getting vaccinated I’d be immune to COVID” – Ibrahim, 32, Kwara

Sandra below, will not take the vaccine because of the rumors she’s heard: “I don't think I will because some say the vaccine is used to reduce the number of lives in the world” – Sandra (32, Edo)

“The reason I haven't gotten my vaccine yet is because I don't have information on where to get it” – Rifkatu (55, Kano)

Registering for Getting registered the vaccine

Getting the the Getting vaccine vaccine

Life postLife postvaccines vaccines

Deciding to get to Deciding whether get vaccine thethe vaccine

Obtaining the second dose

“I have gotten my first jab of the vaccine and I will be going for the second jab next week, but I’m not sure where or how that will work" – Aan (27, Kano)

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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 and answer key questions, looking for ways to alleviate the pervasive uncertainty

Carlos, 62 from Edo, worried about the unified stance on vaccine safety

The a vaccine ~50 registration people wait desk for a at vaccine at a site in Isiolo Kwara, unclear if they will be able to get it

The “immunization” ward at a Kwara hospital, but not a COVID-19 vaccine site

A group of youth in Edo proudly displaying their vaccination cards

People have important knowledge gaps in their vaccine journey that often go unanswered…

Is the vaccine safe to take?

Will vaccines be available?

How do I navigate the site?

Will I get proof of vaccination?

Fundamentally, people still feel there’s a lot of debate and uncertainty about the safety of taking the vaccine, especially when key health information is missing

Arriving at a vaccine site and registering does not mean one will get the vaccine. In observed sites in Kwara, 15-25 vaccines were available, to 30-50 people who were present

Vaccination sites often lack visual information or active staff helping people navigate. This tends to leave questions gaps such as long it might take to get the vaccine and if people are in the right place

A key goal of getting the vaccine is to be able to access services and be ready for future travel by obtaining a vaccine certificate.

When they are not available, great uncertainty is introduced

“The vaccines are administered generally without looking at individual health differences” – Chatta (42, Kano)

“I wanted to take the COVID vaccine when they brought it to our community, but when I went there, they said… we should go to another center” – Lati (46, Kwara)

“I came 3 times, but I was in the wrong queue… I didn’t get a vaccine” – Patient at a Kwara vaccination site

“The health officers asked me to come back another time, because they haven’t brought any vaccination cards. There is no way for them to document my details."

– Patient at a Kwara vaccination site 45

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 population control explain gaps about the origin of the vaccine

Worries about co-morbidities persist due to lack of reliable information

Lack of disclosure about side effects leads to doubts about vaccine safety

Limited information about vaccine importance leave gaps for theories about its purpose

“I don't think I will take the vaccine because the rumor I'm hearing is not encouraging. Some say the vaccine is used to reduce the number of lives in the world”

“When I went (to the vaccine site) I told the woman there that I have umbilical hernia, she said I have to see my doctor first before coming to take it”

“I heard people saying that those who have taken the vaccine, get very sick after and never recover from it”

“We heard that the vaccine is a way of initiating people into a confraternity, or a new religion or something related to the antichrist regime”

– Sandra (32, Edo)

– Aunty B (54, Lagos)

– VD (31, Kano)

- JJ (50, Kano)

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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

Within the uncertainty, skillful and empathetic facilitators can play a key role in alleviating the nervousness and ambiguity that people experience while navigating the vaccine journey

“People were nervous when they came, but now they are calmed. I have alleviated their fear, I have told them what they will experience” - Abeni, a community health worker and nurse at a Kwara vaccination site

For Abeni, alleviating fear in the midst of great uncertainty involves a well-practiced 5-step process

The goal…

1. Build interpersonal rapport and ease tensions with introductions and jokes

Alleviated fears and higher likelihood of attendees encouraging others to take the vaccine

2. Provide encouragement by congratulating people for showing up despite fears and rumours

3. Explain where the COVID-19 vaccine comes from and how it works

4. Explain that people will experience sideeffects, like it is normal with other vaccines

5. Share relatable stories that can help people understand and feel more familiar with the experience

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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 a sustained focus on addressing individuals’ concerns and hesitancy throughout the vaccination journey through transparency and opportunities for dialogue 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, especially those in the healthcare space • 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 :

• …

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CONCLUSION

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

TRUST IN THE PROMISE…

…. OF THE COVID-19 RESPONSE

The COVID-19 vaccination campaign represents an opportunity to rebuild trust in the system by tapping into salient narratives around progress

A drastic improvement in the vaccination process is required to bring key influencers onboard, as well as a focus on explaining the relevance of the vaccination effort

TRUST IN THE THE DELIVERY….

… OF THE HEALTH SYSTEM

Identifying community influencers and the type of support they are best suited provide, and tapping into their goals of building and expanding social capital

Sustained focus on addressing individuals’ concerns and hesitancy throughout the vaccination journey through transparency and opportunities for dialogue - building on localized ’micro’ trust networks 49

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

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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 vaccination 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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