Contribution of community champions to accelerate the uptake of COVID-19 vaccination in Rukwa region, Tanzania, February - October 2022

Introduction Tanzania is among the African countries which started COVID-19 vaccination late (August 2021) compared to other countries in the African continent. By mid-March 2022, overall vaccine uptake was 13% of the targeted population, which was very low compared to other countries. We describe the contribution of champions in the Rukwa region that led to an increase in vaccine coverage rate in Tanzania. Methods a community-based campaign was conducted using community champions from July 15th to August 31st, 2022. A baseline assessment was conducted focusing on the key drivers, barriers, and enablers for COVID-19 vaccine uptake in the region. A working session to develop IEC materials and messages tailored to addressing the issues raised in the community to be used in the campaign in the region was conducted, followed by the campaign’s launch. Community engagement and sensitizations, which contributed to the rise of vaccinated people, were based on house-to-house visits, village meetings, and visiting community gatherings such as marketplaces, places of worship, and sports areas, which were done by champions alongside vaccinators. Results the campaign contributed to the increase of vaccination coverage because, before the start of the campaign, the vaccination coverage was 10% as of July 14th, 2022. After the campaign, which started on July 15th to August 31st, 2022, the coverage increased by 12%. During the post-evaluation exercise after the campaign, the coverage keeps increased and reached 94% by October 2022. The coverage kept increasing even after the intervention’s end due to the campaign’s positive effect. Conclusion the community still needs correct information to avoid misinformation and hesitancy, especially when introducing new disease response mechanisms such as vaccines. The community champions who are based in the community play a critical role in addressing community concerns and contribute to the effectiveness of the implementation; hence sustainability is crucial.


Introduction
Tanzania is among the African countries which started COVID-19 vaccination late compared to other countries in the African continent. In July 2021, Tanzania received the first vaccine doses donated by the US government and started vaccinating its people [1]. By mid-March 2022, overall vaccine uptake was 13% of the targeted population, which was very low compared to other countries [2][3][4][5][6][7]. The country's low vaccination rate is mainly due to rumors, misinformation, and myths about COVID-19 vaccines. The community from both rural and urban areas had different perspectives towards vaccination [8][9][10][11][12]. To support the increase in vaccination rate in the country, the World Health Organization (WHO) Tanzania and the Ministry of Health mainland implemented a project of a vaccination champion. This intervention was conducted from February 2022 to the end of October 2022 by equipping and deploying community champions to motivate, inspire, and influence the target audience to get vaccinated [2,13,14]. The WHO Regional Office proposed this intervention as a pre-test to see if the champion initiative can increase vaccination coverage. Before the implementation of the campaign, a baseline assessment was conducted to study reasons for hesitance to inform the project methodologies. The study results showed that vaccine safety was among the community's concerns, leading to vaccine hesitancy. Using vaccinated champions who became living testimony during community engagement activities was selected [3,5,14]. Another method was using religious and highlevel political leaders as champions due to the community's trust, which increased vaccination rates [8,9,11]. This paper will discuss the effectiveness of the champion campaign approach and methods through the campaign results, which are divided into phases between July 15th when the campaign was launched to August 31st, and September 1st to October 30th, 2022.

Methods
Approach: the approach used in this project was designed and suggested by World Health Organization Africa Regional Office (WHO AFRO) as a pre-test to be implemented in three low-performing African countries, Burkina Faso, Sierra Leone, and Tanzania. The campaign was designed to use community champions based in the communities to motivate, inspire, and influence target audiences to vaccinate. This strategy was implemented by adopting the idea and contextualizing it to fit our country's physical and geographical characteristics [12].
Establishment of a task force to oversee the campaign: the task force was established to plan and oversee project interventions in February 2022. The task force was responsible for developing criteria for champion selection and planning and monitoring all activities for the intervention. The task force comprised teams from the Central level, which were: the Ministry of Health (i.e., Health Promotion section, Immunization, and Vaccines Development Program), the President Officer Regional Administrative and Local Government, WHO Tanzania, United Nations Children´s Fund (UNICEF), and the Regional Immunization and Vaccination Officer/Regional Health Promotion Coordinator from the Rukwa region.
Selection of intervention area: the intervention area was selected based on low performance on the COVID-19 vaccination rate. Rukwa was among those performing poorly (6%) by the early week of March 2022. Another criterion was its similarity in terms of the setting, cultural and traditional aspects, like the Ruvuma region, which was the leading region in vaccination rate (32%) [13]. Two councils were selected (Nkasi and Sumbawanga MC) for the interventions.
Baseline assessment: a baseline assessment focused on the region's key drivers, barriers, and enablers for COVID-19 vaccine uptake [2]. The rapid exercise studied and explored community behavior and evidencebased barrier analysis and seeks to document desired behavior across the spectrum of COVID-19 vaccine acceptance and uptake outcomes in the study region. The assessment was able to look deep into the grassroots and community levels. A team from Muhimbili University of Health and Allied Sciences (MUHAS), the National Institute of Medical Research (NIMR), the Ministry of Health (MOH), and the President´s Office, Regional Administrative and Local Government (PORALG) conducted the baseline. Data were collected using a structured questionnaire customized using a mobile digital tool (DHIS App version: v2.6.2) and directly transferred to the centralized server Health Promotion Section, Monitoring and Evaluation (HPS M&E) Web-Based System). Qualitative data was collected using developed and pre-tested interview and focus group guides. Data collected were analyzed using STATA 13.1. Descriptive statistics were used to summarise socio-demographic characteristics in the frequency tables with the proportions.
Preparation of IEC/SBC materials: the results from the baseline assessment have contributed to a message development session. Messages developed aimed at responding to hesitancy from the community managing rumors and misinformation, targeting the audience in the Rukwa region with appropriate content for different population segments eligible for the COVID-19 vaccine. A workshop was conducted to prepare Information Education and Communication (IEC) materials addressing the issues raised in the community to be used in the campaign in the region.
Pay-per performance strategy: during the implementation, the task force decided when engaging community champions, they should be paid according to the pay-per-performance strategy implemented by MoH and PORALG to the other performing region. After 4 weeks of implementation, a total of 100,000 Tanzanian shillings (43 USD) was agreed to be paid as the allowance. Each champion reached 250 people who will accept to be vaccinated. This method has motivated champions to conduct community engagement activities and reach above the target.

Launching of the campaign and orientation of champions:
launching was conducted with the presence of high-level government, ministry officials as well as regional officials. The presence of high-level officials has assisted in political commitment toward vaccination. The orientation on the objectives, modality of work, and deliverables were conducted to community champions, media personnel, and coordinators who served as supervisors. The champions were provided with the working tools for the campaign, including IEC materials, job aids, and other related materials.

Community engagement activities conducted by champions:
community champions paid visits to the families of those not vaccinated and provided awareness education on the benefits and risks of not being vaccinated. Champions visited houses with vaccinators, and vaccination was done immediately after the awareness sessions. This approach is similar to door-to-door, which proved effective in health care services [11]. Also, Village meetings and gatherings were a good opportunity for the champions to sensitize their community. These meetings were scheduled at the village levels and organized by village leaders. Champions were invited or requested sessions and provided awareness sessions on the COVID-19 vaccine. Community gatherings such as the Farmer´s day, locally named "nane nane" markets events, sports events, local beer clubs, farmers markets, the Tanzania Social Action Fund (TASAF) meetings, and weekend auctions (referred to as gulio). Champions also provided COVID-19 awareness to the boda-boda stands and groups. Champions conducted awareness sessions on COVID-19 vaccine benefits and why people should vaccinate in places of worship on Saturdays and Sundays. For Friday prayer, faith leader´s champions had an opportunity to also talk about the COVID-19 vaccines during prayer sessions. For other mosques where champions are not Muslim faith leaders, champions had a chance to provide messages to the leaders for the awareness messages to be shared. Champions paid visits to the health facilities for awareness sessions to the clients who visited the Outpatient Department (OPD) and Reproductive and Child Health (RCH) clinics. At the RCH champions were able to educate women who brought their children for vaccination that the value of the COVID-19 vaccine is the same as those of children, and women were convinced and accepted to be vaccinated.
Validation of data and champion community activities: a team of experts from the MoH, PORALG, WHO country office Risk Communication and Community Engagement (RCCE), Regional Health Management Team (RHMT), and Council Health Management Team (CHMT) conducted data validation activity at the health facilities, local authorities, and community champions to see if the targets were met and community engagement activities were done.
Ethical consideration: this campaign was done following all procedures for engaging the community. People engaged during baseline assessment signed consent forms and other formalities. The approval was done by both ministries (Ministry of Health and Presidents' Office, Regional Administration and Local Government) and the regional office of Rukwa and its councils.

Results
Vaccination coverage: at the beginning of the vaccination, the target was 70% of people aged 18 and above must be vaccinated ( Table 1).
As COVID-19 vaccination progressed, the provision of the COVID-19 vaccine in Rukwa region started early on August 2021, and the number of people vaccinated was very low. The coverage continued to be low each month until the start of the campaign, which started from 15th July to 31st August 2022. Before the beginning of the campaign, the coverage of the number of people vaccinated was very low (October 2021 to June 2022, ( Table 2)). During the campaign, the number of people vaccinated was more than five times compared to any previous months before the start of the campaign. A rapid increase happened during the campaign from 10% to 22% in cumulative percentage since the beginning. A 12% increase in the of people vaccinated was higher than any change before the start of the campaign (Figure 1).
Comparison of coverage against other regions: even after the campaign, Rukwa was still the last region in vaccine coverage percentage by 24%. But at the end of October 2022, Rukwa was among the top five regions in vaccine coverage with the highest percentage increase marginal change of 70% from September to October.
Community champions contribution: during and after the implementation of the campaign, community champions used data reporting tools to document their efforts by reporting the number of people they sensitized and influenced to be vaccinated ( Figure 2). The data shows that 57% of people sensitized by community champions were vaccinated in Sumbawanga DC and 65% of people sensitized in Nkasi DC. Also, the data showed the percentage of females sensitized and vaccinated in both councils compared with males (Table 3).
The limitations of our campaign include religious beliefs among religious leaders who still believe that vaccination has no importance in human life. It was so difficult for champions to convince as it is related to faith someone has. Also, the geographical location in many places led to the inaccessibility of some areas and traveling from one place to another became difficult due to the lack of transport funds and fuel; again, changes in vaccine types were confusing the public, which increased hesitance in decision making. Despite those limitations, the champion campaign was still a success because the improvement in COVID-19 vaccine uptake coverage rate in Rukwa region was notably increased.

Conclusion
Detailed planning, collecting evidence-based data, continued advocacy, community engagement, and sensitization activities will continue to assist in tackling the number of community health challenges, hesitancy, and other contributing factors hindering the increasing COVID-19 vaccine coverage. Champion intervention contributes to the overall impact and mechanism to improve COVID-19 vaccination coverage. This initiative should be integrated into other campaigns or other disease campaigns that need to use the same approach.