Jeelo Dobara: Living Life Again by Building COVID-19 Vaccine Confidence inThree Low-Uptake Districts in Karachi, Pakistan
Abstract
The COVID-19 pandemic claimed more than 6 million lives globally, with 30,630 deaths and 1.5 million cases in Pakistan. The availability of COVID-19 vaccines from late 2020 in Pakistan gave an opportunity for widespread immunization, potentially curbing the epidemic. Social media played a role in sharing accurate information, but also allowed the spread of misinformation that led to vaccine hesitancy. COVID-19 campaigns at the time failed to tackle the underlying reasons for low vaccine confidence.
Interactive Research and Development (IRD) Pakistan launched a condensed COVID-19 vaccine-confidence project, Jeelo Dobara, which utilized formative research to devise a social behaviour-change communication (SBCC) strategy for three high-risk districts in Karachi, focusing on people’s experiences, attitudes, and practices concerning COVID-19 and its vaccines. The cohesive campaign utilized community engagement, social media and vaccine camps, resulting in more than 1,000 individuals being immunized.
Introduction
Jeelo Dobara ran from January to May 2022 in the South, East, and Korangi districts of Karachi. The project involved volunteer grassroots leaders (GRLs) supporting participatory information sessions, interactive theatre performances, and below-the-line (BTL) activations with community members. Engagement was amplified through the formation of online community-led groups on Facebook (mixed-gender) and WhatsApp (women-only), and social media micro-influencers who participated in digital campaigns. The campaigns supported community mobile camps with the help of the Government of Sindh (GoS) and the Federal Directorate of Immunization, providing at least one dose of the COVID-19 vaccine to 1,039 individuals.
Baseline and endline surveys indicate that while people may get vaccinated due to government mandates, they are less likely to be motivated by the perceived efficacy of COVID-19 vaccines, or a belief in the usefulness of adult vaccinations broadly. This understanding can help design future adult vaccine SBCC campaigns that recognize the nuances of peoples’ lived experiences in low-resourced settings in the Global South.
Who should benefit from the programme?
By the end of 2021, only 36% of people in Pakistan were fully COVID-19 vaccinated according to the National Command and Operation Centre. While the World Health Organization strategized to vaccinate 70% of the global community by mid-2022, the Institute for Health Metrics and Evaluation projected that only 49% of Pakistan’s population would be fully vaccinated by May 2022. Misinformation, conspiracy theories, lack of awareness, scepticism about possible health ramifications, and limited access to equitable services have been identified as impediments to vaccine confidence, with social media playing a significant role in the spread of unverified information. COVID-19 vaccine hesitancy was inferred from the GoS’ daily situation report which highlighted the number of active cases district-wide across Pakistan. Low-resourced populations, residing in urban slums or densely inhabited areas, were deemed at most risk of contracting and spreading COVID-19 due to lack of compliance with social distancing and lockdown restrictions, congested living arrangements, and low vaccine uptake.
Twelve Union Councils across the three high-risk districts were included based on three factors.
The first was a low uptake of routine childhood immunizations as per official records from the GoS’ electronic immunization registry — part of Pakistan’s Expanded Program on Immunization. The Korangi, South, and East districts had median vaccination rates of 33.2%, 40.6%, and 39.1%, respectively, among children born in 2020. The focus on routine childhood immunization served as a proxy for COVID-19 immunization rates, for which district-level data were not available at the time.
The second was high COVID-19-positivity rates according to the GoS’ daily situation report. The East district had the highest number of active COVID-19 cases reported in Karachi, followed by the Korangi and South districts as of 26 October 2021.
The third was high smartphone coverage to ensure social media inclusion. In recent years, social media usage among lower-income communities has increased, creating avenues for digitally-driven SBCC strategies. The project investigated how immersive social media when utilized effectively in low-resourced urban settings, with grassroots engagement, can improve COVID-19 vaccine confidence, and increase uptake through outreach services.
Engagement
The project ethos centred around participatory campaigns and user-driven content creation by communities to identify ways to ‘live life again’ after COVID-19 vaccination. Learnings from formative research resulted in the hybrid strategy which merged the benefits of interactive social media campaigns, grassroots community engagement, and outreach services in the form of health camps.
The six closed online WhatsApp and Facebook communities offered virtual safe spaces to encourage crucial conversations, exchange correct information, bust myths, and enhance confidence in COVID-19 vaccines through lived-experience sharing. They were supplemented by leveraging digital presence on WhatsApp, Facebook, Instagram, Twitter, TikTok and Snack Video to involve diverse audiences from the identified districts. To continuously increase group membership and engagement, combat COVID-19 fatigue, and spark interest in its vaccines, the project team deployed a variety of campaigns via online competitions and through local digital influencers focusing on contextualized content development based on barriers faced by communities during the pandemic — including social, economic, science, and health. This allowed the dialogue to focus on communities’ priorities, leading to meaningful campaigns to enhance vaccine confidence swiftly and improve uptake through health camps. By taking a user-led approach to digital content creation, social media was used democratically through individual users’ accounts as well as online community groups.
A volunteer GRL team connected the digital campaigns with local residents via on-ground activities, such as health-education sessions and various BTL activations, thereby scaling reach and influence, and placing the information within the context of those impacted. Both movements were synchronized to promote mobilization towards health camps held in local areas, which provided COVID-19 and routine childhood vaccines.
Implementing the project in areas with low vaccine coverage extended reach to typically resistant and underserved populations. On-ground engagement encouraged the participation of women who are often hard to engage via purely digital campaigns. Vaccination drives also ensured the inclusion of religious minorities and immigrant populations residing within the catchment areas. Moreover, the project piloted new knowledge-asset-development principles, such as building data glyphs or utilizing art installations, to share findings.
Research
Jeelo Dobara was informed by mixed-method formative research, which included a baseline survey and in-depth interviews. These were constructed to evaluate the demographic characteristics of the local population, knowledge, perceptions, and behaviour with regards to the COVID-19 vaccine, and access to and usage of social media.
In comparison to knowledge about childhood immunizations, knowledge about vaccines for adults was low. Most respondents knew about the existence of COVID-19 vaccines, where to get them, and that they can protect against the virus but were unsure about how they work. They also had low-risk self-perception, thinking there was a greater need for the elderly to get vaccinated. Those with lived or vicarious experiences of COVID-19 were more likely to believe that it was real and to be aware of symptoms and precautionary measures, while those without experience lacked scientific knowledge of the virus and its vaccines.
Reasons to get vaccinated included health concerns, vaccination cards and government mandates. COVID-19 vaccines were seen as a way to restore mobility and social relationships, in line with responses that the pandemic had adverse social and economic effects and caused social isolation. A significant impact on mental health was expressed, recognizing that the uncertainty and fear surrounding COVID-19 caused distress. However, the most prominent reason for undergoing or considering immunization was the acquisition of vaccine cards, which improved employment opportunities, the continuation of education, and the availability of other services.
While healthcare professionals were deemed the most trustworthy source of information, scientific facts, figures and explanations alone were not prioritized. Respondents relied upon local community practitioners as their main source of news. They also regarded friends and family as reliable sources, mentioning that lived or vicarious experiences influenced their confidence in COVID-19 vaccines. Mixed opinions were shared about social media information, with many respondents seeking other sources (such as family, friends, and healthcare professionals) to verify such material.
These crucial findings ascertained priorities, key messages, and delivery modalities for the project. A similar survey repeated at the health camps to gauge uptake and vaccine confidence revealed that while people were continuing to be immunized, confidence in COVID-19 vaccines was low, suggesting that mandates around mobility were key drivers to being able to ‘live life again’.
