Latest Case Studies/ Field Note

Advancing a Model To Tackle Disparities With Effective Listening

The data started rolling in and it wasn’t good.

Wakiso, Uganda’s most densely populated district, was peaking in two worrying categories: hardest hit by Covid-19 infections and among the lowest vaccination rates.

Uganda’s Infectious Disease Institute (IDI) especially wondered why Ugandans 50 and older, a higher-risk community, weren’t getting vaccinated. So, backed by The Rockefeller Foundation’s Global Vaccination Initiative, they launched a pilot program to uncover the reasons.

In the process, they advanced a model that can be used globally to embrace effective listening and tackle disparities through direct collaboration between public health experts and at-risk populations.

“The key objective was to launch a journey to really grasp the issues,” says Boneventure Brian Kawere, the project coordinator. “But this model can be used to address any kind of community situation—not only public healthcare issues. We can use it to understand domestic violence in a particular community or why children are not attending school.”

“The beauty of this strategy is that we select participants with similar characteristics in each group, and this allows them to speak freely.”

Image is of a Vaccination Champion speaking to a Community in Wakiso.
A Vaccination Champion Speaks to a Community in Wakiso. (Photo Courtesy of IDI)

The work also supports the U.N.’s Sustainable Development Goal #3 to ensure healthy lives and promote well-being for all at all ages. “Vaccinating the elderly is an important strategy,” Kawere says, because they are more likely to have chronic illnesses that increase their vulnerability to Covid-19.

Image is of a map of Barriers for Vaccination in age 50-plus population as uncovered by IDI.
Barriers for Vaccination in age 50-plus population as uncovered by IDI. (Photo courtesy of IDI)

“Vaccination Champions” Step In to Listen, and Fill an Information Gap

Wakiso in central Uganda, home to about 2.551 million people, borders Lake Victoria and includes parts of suburban Kampala, the international airport at Entebbe, and deeply rural pockets. The district’s density is about 700 people per square kilometer, compared with about 230 per square kilometer in Uganda as a whole. In the U.S., population density is 36 per square kilometer.

Uganda is a young country, with about 45.55 percent of the population 14 years old or younger. About 6 percent of the Wakiso District population is age 50 or older, Kawere estimates.

IDI’s secret sauce in the research into vaccine reluctance came from partnering with and training 540 already established community leaders like Police Sgt. Henry Kabatiisa, 55, and Florence Agado, 53, creating opportunities for the kind of peer-to-peer learning around vaccine behavioral and social drivers that the Global Vaccine Initiative strives to support. IDI also partnered with the District Government and the Ugandan Ministry of Health.

The “vaccination champions” led 125 community conversations to identify reasons for vaccine reluctance. They discovered that the key barriers include long distances to vaccination clinics and long waits to get a vaccine, as well as perceived unfriendly interactions with healthcare workers, and myths about the dangers of vaccines.

Image is of a map of Enablers for Vaccination in age 50-plus population as uncovered by IDI.
Enablers for Vaccination in age 50-plus population as uncovered by IDI. (Photo Courtesy of IDI)

  • Innovative partnerships based on trust and urgency is one of the bright spots that emerged in the pandemic. Rockefeller’s partnership with IDI and the vaccination champions is one of those partnerships. The challenge—and opportunity—for us now is to keep these partnerships in place to continue to address priorities beyond Covid-19 vaccination.
    Andrew Sweet
    Vice President, Global Covid-19 Response and Recovery, Health Initiative, The Rockefeller Foundation

Centering On an Overlooked Community

“The elderly often go unnoticed,” says Nurse Doreen Nabwiire, a certified “vaccination champion” trainer. “That’s why listening to them is so important. We found that many can’t afford a radio to hear the news, so they have unanswered questions. Many can’t travel long distances by foot or pay for transportation, and they can’t stand in long queues for hours.

Image is of a nurse training a group of vaccination champions.
Nurse Nabwiire training a group of Vaccination Champions. (Photo Courtesy of IDI)
Image is of nurse Nabwiire giving a vaccine to a patient.
Nurse Nabwiire gives a vaccine as her patient looks away. (Photo Courtesy of IDI)
  • Some said to me, ‘I’m living the evening years of my life. Just let me go peacefully.’ But I love working with them. We need them. Besides, I know it’s where I’m heading.
    Doreen Nabwiire
    Nurse, Certified “Vaccination Champion” Trainer

Image is of Andrew Sweet meeting with IDI officials in Kampala.
The Rockefeller Foundation’s Vice President for Global Covid-19 Response and RecoveryAndrew Sweet Meets with IDI officials in Kampala. (Photo Courtesy of IDI)

Nabwiire, 38, a mother of three whose youngest is just six weeks old, travels for hours to support the “vaccination champions” and personally spend one-on-one time with older Ugandans, listening to their reasons for vaccine reluctance and responding with clear information.

Asked if any cases stand out, Nabwiire doesn’t hesitate. “Just last week on Friday I accompanied a man in his 80s to get vaccinated; it had taken days of work to get him to go. He was afraid the injection would hurt or he would have an adverse reaction. And he definitely didn’t want to see the needle go in. So we promised to put cuffs on each side of his arm to block his view. Then I traveled to him and accompanied him to the vaccine center.”

As they arrived at the center to get the Johnson and Johnson vaccine, the man got cold feet once more.

“I had to start from zero and persuade him all over again. That was a long day,” Nabwiire recalls with a laugh. “But I’ve checked in on him since. He is fine, no bad side effects. And he’s protected.”

Nabwiire echoes Kawere that many other communities could benefit from similar deep inquiries into what prevents them from getting vaccinated or seeking health care. Consider, she says, the fisherfolk who live and work around Lake Victoria and may not be available when clinics are normally open, or the boda-boda drivers who provide motorcycle taxi service and are always on the go, more tied to the road than to a specific location.

Nurse Doreen Nabwiire trains “vaccination champions” ages 50 and older in preparation for them to lead community dialogues with older Ugandans who have not yet been vaccinated against Covid-19. From these dialogues, IDI grew to understand barriers the community faces. (Video Courtesy Andrew Sweet)
Nurse Doreen Nabwiire trains “vaccination champions” ages 50 and older in preparation for them to lead community dialogues with older Ugandans who have not yet been vaccinated against Covid-19. From these dialogues, IDI grew to understand barriers the community faces. (Video Courtesy Andrew Sweet)

Image is of Sgt. Kabatiisa speaking to a group of people.
Sgt. Kabatiisa speaking at a community vaccination dialogue in Wakiso. (Photo Courtesy of IDI)

Sgt. Kabatiisa, a police officer since 1987, is well known and respected. Since his IDI training, he has spoken at a number of small gatherings as well as one-on-one to community members about the different types of vaccines and their safety. One of the people he is happy to have persuaded was his mother, 85, who was too afraid and distrustful to get vaccinated.

“I told her, ‘I don’t want you to die, Mother. I would not tell you to do something bad for you. Please go.’” She agreed, and as an added benefit, after she was vaccinated, other women in her community went to get vaccinated also. Now Sgt. Kabatiisa is working on getting booster shots in arms.

Florence Agado, the mother of five, has long been considered a wise advisor to her community, so she too was tapped for training by IDI. “I learned that the vaccines are all safe, and that’s a message I carried,” she says.

She is sure her work has helped save lives. “Prevention is always better than a cure,” she says. “That’s what I keep telling them, and that’s what we are achieving.”

 

IDI are in text communication with their “vaccination champions,” which makes them a potentially powerful army to potentially be activated in the case of a health care emergency.

Already their research, Kawere says, has helped IDI plan for the future. The institute intends to provide additional transportation for older Ugandans who want to get vaccinated, for instance, and offer information in different languages, important in a country where 41 languages are spoken.

Image is of people gathering.
Vaccination Champions gather after an IDI Training. (Photo Courtesy of IDI)

“This project,” Kawere says, “was both deeply respectful of the community, and helped set us up to succeed in getting more people vaccinated.”

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