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Abstract
Introduction Increasing trust and confidence in vaccines is a global priority, as countries have grappled with delivering COVID-19 vaccines, maintaining routine childhood vaccination rates and introducing new vaccines. Community-based vaccine promotion interventions are commonly implemented, but effectiveness evidence is limited. In 2022, supported by the Australian Government and in partnership with Fiji’s Ministry of Health and UNICEF, we codesigned, delivered and comprehensively evaluated a vaccine education and communication training programme for health workers and community influencers to promote COVID-19 and routine immunisation.
Methods The Vaccine Champions programme included three phases: (1) codesign with Fiji stakeholders; (2) vaccine education and communication training for Vaccine Champions and (3) support for Champions to deliver community vaccine discussion sessions over 6 months.
The RE-AIM framework evaluation measured programme reach, effectiveness, adoption, implementation and maintenance. Mixed-methods data were collected through interviews, surveys and field notes, integrating qualitative and quantitative data to triangulate findings. Primary outcomes included Champions’ knowledge, communication self-efficacy, trust in COVID-19 vaccines, programme satisfaction and community members’ intention to vaccinate.
Results We trained 35 Champions (27/35 female), including health workers, faith and community influencers. Half had a health background (17/35). Champions conducted 54 discussion sessions, reaching 1717 community members. Most Champions (22/35) conducted at least 1 session, with 16 running 3 or more. Champions who did not run sessions reported barriers like lack of confidence and competing duties. Training increased Champions’ communication self-efficacy and trust in COVID-19 vaccines. Community member intention to vaccinate increased from 41% (394/960) to 83% (822/991) before and after a session. The programme was well received with interest in continued engagement.
Conclusion Training health workers and community Vaccine Champions can promote vaccine confidence. Programmes require government support and engagement for sustainability. Robust evaluation frameworks are needed to build the evidence base.
- COVID-19
- health education and promotion
- immunisation
- public health
Data availability statement
Data are available on reasonable request. Deidentified individual participant data that underlie the results reported in this article, as well as the study protocol and data collection instruments, will be made available from the point of, and up to 3 years after the acceptance for publication of the main findings. Data will be shared with researchers who provide a methodologically sound proposal, for analyses that achieve the aims in the approved proposal. Proposals should be directed to jess.kaufman@mcri.edu.au. To gain access, data requesters will need to sign a data access agreement.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Systematic reviews of vaccine community engagement interventions and/or vaccine education interventions delivered in the community report that such interventions achieve reach and engagement and can improve knowledge and/or beliefs, though they report mixed evidence on vaccine uptake. Few primary studies have been conducted in Pacific Island Countries or apply implementation science frameworks to guide evaluation.
WHAT THIS STUDY ADDS
This study provides evidence that a vaccine education and communication skills training programme for community health workers and influencers in Fiji improved vaccine intentions, trust and confidence. It also furthers the field of implementation science by operationalising the reach, effectiveness, adoption, implementation, maintenance framework.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
This study’s findings support the use of interventions to engage community health workers and influencers to promote and educate others about vaccines, an issue of significant relevance given the global increase in zero-dose children, vaccine-preventable disease outbreaks and drops in vaccine confidence postpandemic. The methods applied in this study can inform implementation evaluations in other settings.
Introduction
Community engagement strategies have long been applied to increase vaccine acceptance and uptake in low-income and middle-income countries (LMICs),1 2 particularly to support polio eradication campaigns and supplementary immunisation activities.3 4 Lay health workers or social mobilisers have been deployed to share information and raise awareness about upcoming vaccination opportunities.5–7 During the COVID-19 pandemic, the value of community engagement strategies was increasingly recognised in high-income countries,8–10 as governments realised that promoting vaccines through broad media campaigns alone was not sufficient to overcome diverse access and acceptance barriers to uptake.11 Community-based strategies deployed during the COVID-19 pandemic included grassroots approaches such as codesigning culturally appropriate messaging and empowering community connectors to become ‘vaccine champions’.12–17
A 2023 systematic review of behavioural interventions for any type of vaccine found that vaccine champions significantly increased vaccine uptake.18 Among the included studies, the definition of a vaccine champion varied from health workers encouraging other staff members to get influenza vaccines to celebrities being vaccinated publicly to encourage uptake, to community members receiving training to advocate for vaccination. Nearly all the studies included in the review were conducted in high-income countries.18 More recent studies from LMICs suggest that providing detailed vaccine education and communication skills training for community members from diverse cultures, religions and workplaces can increase uptake.14 19–21 However, the assessment of impact and the features that support implementation and sustainability of such interventions in LMIC settings remains limited.
Like many countries in the Asia Pacific region, Fiji sought to increase adult and child COVID-19 vaccination and promote routine childhood immunisation in 2022. The COVID-19 vaccine was introduced in Fiji in March 2021, amidst a wave of infection caused by the Delta variant. The initial uptake of primary doses of COVID-19 vaccine among adults was relatively high, particularly following the government’s introduction of a ‘No Jab, No Job’ mandate in July 2021.22 However, by early 2022, uptake of booster doses had slowed considerably and coverage in adolescents and children was low. Identified barriers to uptake included both misinformation and accessibility issues.23 24 As the Fiji Government prepared to reopen the country’s borders with the rest of the world, the Ministry of Health sought to improve the uptake of third doses for adults and primary doses for children and adolescents.
In partnership with the Fiji Ministry of Health and UNICEF and supported by the Australian Department of Foreign Affairs and Trade, we initiated a programme to provide evidence-based training and support for health workers and community influencers to promote COVID-19 and routine childhood vaccination and address misinformation. A Vaccine Champion is someone with a trusted position in the community and encourages others to vaccinate themselves or their families. Vaccine Champions are from within the community itself so they are able to speak the local language, highlight local motivating factors and influence social norms to encourage vaccination.25 Vaccine promotion may already be part of a health worker or community health worker’s role, but Vaccine Champions do not need to have a health background. Unlike programmes that simply partner with community influencers to promote vaccination, the Vaccine Champions programme includes intensive education to provide key facts about vaccine safety and effectiveness and training in vaccine communication skills. The intervention was originally developed in Australia to support the COVID-19 vaccine rollout in 2021 and 2022,12 based on previous research on communication in clinical settings.26 Building on this experience, the Vaccine Champions programme was codesigned and adapted for Fiji in June 2022.
In this article, we describe the development, implementation and evaluation of the Fiji Vaccine Champions programme using the reach, effectiveness, adoption, implementation, maintenance (RE-AIM) framework.
Methods
Study design
This was a single-arm mixed-methods evaluation study. Effectiveness was assessed with a before-and-after study. Implementation features were assessed with mixed methods, where qualitative data provided contextual, explanatory and experiential detail to supplement and triangulate quantitative data. We report our findings across the domains of reach, effectiveness, adoption, implementation and maintenance, according to the RE-AIM implementation science framework.27 The RE-AIM framework has been widely used to transparently and comprehensively report the impacts and contextual factors affecting the implementation of complex behavioural interventions.28 29
Programme and participants
The Fiji Vaccine Champions programme was implemented over three phases involving three participant groups.
Phase 1 was a half-day codesign workshop in Suva in June 2022. Co-design stakeholders included local and national stakeholders from government, non-governmental organisations (NGOs) and community members with relevant expertise and insights. Stakeholders were identified through discussion with the Ministry of Health and UNICEF. The workshop began with a presentation on immunisation coverage in Fiji from the Ministry of Health to identify key gaps among population groups for both COVID-19 and routine vaccines. The research team then facilitated a discussion about perceived access and acceptance barriers to vaccination, mapped to the WHO Behavioural and Social Drivers (BeSD) of the vaccination framework.11 A prioritisation exercise was conducted to reach a consensus on the focus (eg, vaccines and age groups) and features of the Vaccine Champions training programme (eg, length, location and format). In the final part of the workshop, codesign participants brainstormed the types of community members who should be invited to participate as Champions, suggesting specific organisations and individuals to contact. These included sporting bodies, religious and charitable organisations, local NGOs, community health workers, teachers, village head men and women’s community groups.
Phase 2 was a 2-day training workshop with invited Vaccine Champions in July 2022 in Suva. Invitations to participate were sent by the research team to individuals or organisations identified through the codesign workshop. Invitations defined a potential Vaccine Champion as ‘someone who has a trusted position in the community and is passionate about encouraging people to receive vaccines’ and suggested the types of roles that might make good Champions, such as teachers or faith leaders. When an invitation was directed to an organisation, the organisation was asked to nominate someone who fulfilled the criteria. The workshop was delivered in English by the research team. As decided in phase 1, it focused on COVID-19 and routine childhood vaccines and evidence-based techniques to effectively communicate about vaccination. Training on COVID-19 vaccines focused on booster vaccines for adults and primary series vaccines for children and adolescents. The routine childhood vaccine schedule was introduced and explained, with an emphasis on measles. Communication training included how to share your personal vaccination experience and provide facts on disease severity, vaccine safety and effectiveness using techniques informed by vaccine communication research30–32 and Motivational Interviewing.33 Role-play activities were used to practice conversations with hesitant individuals. At the end of the training, Champions created a plan for how, when, where and with whom they would run discussion sessions. Attendees were reimbursed for travel and accommodation.
Phase 3 was a 6-month period (July–December 2022) in which trained Vaccine Champions organised vaccine discussion sessions in their communities. Champions were asked to conduct three sessions each. They were encouraged to tailor sessions to their context, which could mean holding a special village meeting or adding a short presentation to the end of an activity like a church service. The research team regularly contacted all Champions by phone and Viber text message to encourage them to organise sessions, answer questions and provide basic logistical support like sourcing pamphlets for them to distribute. Each Champion could receive FJD100 per session for up to three sessions, on submission of a completed reflection form. Phase 3 evaluation participants were the community attendees who attended a discussion session facilitated by a Champion. Community attendees could provide their contact details to participate in optional interviews.
Participants in each phase provided written informed consent (phases 1 and 2) or verbal consent (phase 3) prior to data collection. Figure 1 illustrates the theory of change.
Vaccine Champions programme theory of change.
Data collection
Each RE-AIM domain was assessed individually according to predefined indicators (table 1). We collected data from the start of the programme in June 2022 to December 2022. The timeline for data collection is illustrated in online supplemental material. Data were collected through the following sources:
Supplemental material
RE-AIM indicators and data collection details
Researcher field notes
Field notes were recorded by researchers using a standard template. Field notes mainly captured data on programme reach and implementation.
Champion reflection forms
After each community discussion session, Champions completed a standardised reflection form. This form used open-text fields to capture their experiences and personal reflections about the session, including what they planned, what actually happened and how they felt the session was received. They also recorded the number and type of community members invited and who attended the session. The reflection form prompted Champions to ask community attendees at the start and end of the session how many of them had already received a COVID-19 vaccine booster or intended to, were unsure or did not plan to get the vaccine. Data from reflection forms contributed to reach, effectiveness and implementation domains.
Surveys
Vaccine Champions completed two surveys, pretraining and immediately post-training. The first survey collected demographic details. Both surveys repeated measures of knowledge, vaccine confidence and communication self-efficacy. The three knowledge items were developed by the research team and assessed knowledge of the common side effects of COVID-19 vaccines recommended communication strategies, and vaccines on the Fijian childhood vaccination schedule. Trust and confidence in COVID-19 vaccines were measured with seven items adapted from the WHO BeSD tools.11 The 4-point response scale ranged from ‘not at all’ to ‘very much’. Communication self-efficacy was assessed through six items adapted from a scale for healthcare providers,34 with an 11-point response scale from 0 (cannot do at all) to 10 (highly certain I can do). The post-training survey assessed participant satisfaction with the intervention with four 5-point Likert scale items, ranging from ‘not satisfied at all’ to ‘very satisfied’; items were developed by the research team and used in previous research.12 Surveys were reviewed by local stakeholders. The surveys primarily provided effectiveness data.
Interviews
All codesign stakeholders, Champions and community attendees who provided their contact details were invited to participate in interviews at the end of the programme. Interviews followed semistructured guides and were generally conducted over the phone by the research team in English or Fijian. The interviews explored participants’ experiences with the programme and perceived facilitators and barriers to programme sustainability, addressing all five RE-AIM domains.
Data analysis
Categorical responses are presented as numbers and percentages. Knowledge is reported as the percentage of participants who correctly identified side effects, recommended communication techniques and childhood vaccines. Vaccine trust and confidence is reported as the percentage of participants responding ‘very much’. Satisfaction is reported as the percentage of participants responding ‘very satisfied’. Communication self-efficacy was analysed as a continuous variable with mean scores and SD presented. McNemar’s test was used to compare pretraining and post-training responses for binary variables while the paired t-test was used to compare continuous variables. Data from pretraining and post-training surveys that could not be matched to a single participant due to labelling or survey completion errors are not included in the analysis. Analysis was performed by using Stata V.18.0.35
Data from the qualitative interviews, field notes and open-text responses on reflection forms were analysed using a template analysis approach, with the RE-AIM categories applied as an a priori coding template.36 Within each RE-AIM category, the data were inductively coded and thematically grouped by one author (YM, IO, JL or HS), with a subsample coded by a second author to confirm consistency. The full research team met regularly to discuss and agree on the coding and thematic grouping decisions.
Public involvement
Influencers and members of the community were involved in the codesign workshop to inform intervention design, and in intervention delivery, as trained Vaccine Champions.
Findings
Reach
Phase 1: codesign workshop
17 stakeholders participated in the codesign workshop. These included representatives from government (Ministry of Health, Ministry of Education), not-for-profit organisations (UNICEF, WHO, Pacific Disability Forum), faith organisations (Council of Churches, Salvation Army), sporting organisations (Fiji Rugby), health workers (nurses and doctors, community health workers) and members of community women’s groups. Representatives from the Ministry of iTaukei Affairs were also invited but did not attend.
Phase 2: Vaccine Champions training
Of the 43 people invited, 35 (81%) attended the Vaccine Champions training. They included community health workers, doctors or nurses, faith organisation leaders and representatives, a village headman, public health students and representatives from Fiji Red Cross, Ministry of Health, Fiji Rugby (men’s and women’s teams) and Fiji Cricket (women’s team). Champions included people from iTaukei communities and Fijians of Indian descent. Attempts were made to invite representatives from priority populations including disability organisations, as well as media organisations, but they could not or did not attend.
Table 2 presents the characteristics of the Vaccine Champions who attended the training. Most Champions were female (77%; 27/35), and half had a health background (49%; 17/35). Most were from the Central Division (69%, 24/35) where the training was held. 15 Champions (43%) had not yet received a COVID-19 booster dose at the time of the training.
Characteristics of Vaccine Champions
Phase 3: community discussion sessions
In total, 1717 community members attended 54 Vaccine Champion discussion sessions. Community members may have attended more than one session. Attendees were primarily from the Central Division (892/1717; 52%), with the remainder split between the Eastern (20%), Western (16%) and Northern Divisions (12%). The number of attendees per session ranged from 4 to 94, with an average of 23 per session. Attendees included parents, young people, older people, teachers, Red Cross volunteers, sports teams, nurses and midwives, and church leaders.
Effectiveness
Table 3 presents pretraining and post-training changes for each outcome variable. Data are presented as numbers and percentages, except where indicated as mean (SD).
Changes in effectiveness outcomes for Vaccine Champions
While knowledge of COVID-19 vaccine side effects and the childhood vaccine schedule increased following training, most changes were not statistically significant. In the post-test, more than 90% of Champions correctly identified three of the five recommended communication techniques, with a statistically significant increase in Champions’ knowledge of the need to ‘continue the conversation’ post-training (figure 2).
Differences in knowledge (A), vaccine trust and confidence (B) and communication self-efficacy (C) post-training, compared with pretraining. Forest plots present differences with CIs as well as the pretraining and post-training percentages or means, with arrows indicating the direction of change.
Following training, more than 80% of Vaccine Champions responded ‘very much’ to each measure of trust and confidence in COVID-19 vaccines. While trust and confidence measures increased after the training, the changes were not statistically significant. There was a statistically significant increase in mean communication self-efficacy scores across all six components between pretraining and post-training.
All Vaccine Champions reported being either ‘very satisfied’ (77%; 23/30) or ‘satisfied’ (23%; 7/30) with the training.
Qualitative reflections on the training
We interviewed 26 of the 35 (74%) Vaccine Champions. The perception of the training was overwhelmingly positive. Vaccine Champions from both health and non-health backgrounds found the training interesting, relevant and presented at an appropriate level. As one community Champion said, ‘The training was very easy to follow. The information shared was simple and easy to understand’ (Champion 1). A Champion with a health background agreed: ‘This session basically was very informative for us as health workers, and it really upgraded our knowledge and confidence towards creating awareness at the community level’ (Champion 5). However, one Champion felt that the training contained too much information and found the first day particularly difficult to process.
Interviewees reported that the training sufficiently addressed the needs of their communities. One interviewee felt that the communication technique of sharing personal stories of vaccination fitted well with the Fijian context: ‘We know in the Pacific we love our stories, we relate to our stories, and we learn from listening to stories as well’ (Champion 13). Reported training highlights included gaining disease and vaccine knowledge, practising new communication skills, group work, role-plays, the broad focus on routine and COVID-19 vaccines and improving confidence in talking about vaccines in the community.
At least one Vaccine Champion reported that the training had completely changed their views of COVID-19 vaccination:
I will admit that I was one person that was against vaccination because of the rumours. I was really happy that I attended the training because it opened my eyes to see and learn more about the vaccine and the benefits of the vaccine (Champion 9).
The Champions suggested the training could be improved by adding an extra day or half day for more role-playing, group work, discussion and communication skill practice. Other suggestions included using videos to illustrate personal vaccination stories; conducting training in multiple locations within Fiji; providing clear guidance on responding to specific questions from the community; running a refresher training and mixing up the groups so attendees could speak with other Vaccine Champions.
Vaccine uptake and intention
National data reported by a representative from the Ministry of Health showed an increase in booster uptake from 44% in June 2022, 1 month before the programme started, to 54% in October 2022. However, due to the range of other factors influencing vaccine uptake at a national scale, it is not possible to attribute this change to the Vaccine Champions programme directly.
The percentage of community members who had or intended to receive a COVID-19 booster increased from 41% before attending a Vaccine Champion discussion session to 83% after (figure 3).
Attendees’ intention to get a COVID-19 vaccine, before and after attending a Vaccine Champion community discussion session.
Qualitative reflections on the community discussion sessions
Several Vaccine Champions spoke about seeing the direct benefits of their community sessions. They said some attendees decided to get COVID-19 boosters or vaccines for their children when they were previously unsure, and others became more open to learning about the importance of vaccines.
I managed to talk to a lot of parents, the ones that came to sit there, to make sure that their children get vaccinated on that day. And the message that I gave them that day changed their mindset and then they decided to receive the booster that same day (Champion 22).
We also interviewed 11 community attendees from Central, Northern and Western Divisions, who attended sessions run by Vaccine Champions. Their reflections on the sessions were mostly positive. Attendees felt that the information was relevant to their communities, well presented and informative. Some attendees reported making the decision to get their booster shot because of the information provided in the session: ‘A lot of the information there clarified about the booster, straight after her [the Vaccine Champion’s] talk and after reading through the booklet I went to get my booster shot’ (Attendee 5).
Community attendees highlighted some areas where the sessions could be improved. Some wanted more information on the side effects of the COVID-19 vaccine (perceived and real), how vaccines may affect athletes in particular and updated data on vaccine coverage in their specific community. One attendee would have liked a longer, more detailed session:
Instead of 15–30 min, if we could have more time on each slide so we can have question and answer and what we think we can do to help our people around us, especially our family, those who are not willing to take the vaccination (Attendee 4).
In addition to finding the sessions informative, multiple community attendees talked about how they had shared the information they learnt in the session with other people in their community. As one attendee said, ‘I also want to be a vaccine champ as I have found out how useful vaccines are’ (Attendee 6).
Adoption
Of the 35 trained Vaccine Champions, 22 (63%) held community sessions. A total of 54 community sessions were run over the intervention period. Three Champions held only 1 session each, 3 held 2 sessions and 16 held 3 or more sessions. Some Vaccine Champions worked together to facilitate the session with their community. The Vaccine Champions who did hold a session were a mix of health and non-health workers and included community health workers, nurses, Red Cross volunteers, the village headman, faith leaders and representatives from cricket and rugby. Most Champions who ran a session were female (86%; 19/22).
There were 13 Champions who did not hold a session (5 male). 1 of these Champions had a health background, while the remaining 12 were students, Red Cross volunteers or sports representatives. We interviewed five of these Champions to understand the barriers they faced. Two interviewees did not have time to arrange a group session due to their existing work commitments, and one person did not feel confident enough to run a session. ‘[The training] was all great but I didn’t have the confidence to conduct the session on my own, with a group of people. Because I was afraid they would ask a question, you know…’ (Champion 35). The Champion with a medical background did not feel that she was the right person to run community sessions:
After [the training] when I came home and thought for a bit, and I thought that maybe it should have been a non-health person doing it to kind of maybe embody the Vaccine Champion, where a layman has been convinced enough and convicted enough to share that message for other non-health people. To appreciate their truthfulness and you know, the good place that it was coming from. I felt like I was the wrong messenger (Champion 18).
Three were able to share the information they had learnt in the training with family and friends through informal conversations.
Implementation
The Vaccine Champions programme was one part of a large national effort to improve COVID-19 vaccination rates in Fiji. Other activities that took place during the study period included media campaigns and mobile vaccination outreach services. A measles vaccination programme was also ongoing in some divisions.
Nearly all aspects of the Vaccine Champions programme were implemented according to the programme protocol. The only adaptations made to the training workshop were minor adjustments to the running time for each activity.
Community discussion sessions were intended to be flexible to meet the needs of the individual Vaccine Champions and their communities, so some customisation in session format was anticipated. The most common format for a discussion session was a presentation followed by questions or an open dialogue. Some Vaccine Champions undertook house visits to talk about vaccines, a small number had informal discussions with family, and one ran an online training with a large group of volunteers. Vaccine Champions were originally expected to run discussion sessions without PowerPoint slides, but following requests for materials, we provided a simplified version of the slides used in the Vaccine Champions training session for use in the community. Many Vaccine Champions handed out UNICEF or Ministry of Health brochures or pamphlets at their discussion sessions to support the messages that they were sharing. These pamphlets were well received but there were not always enough available for all attendees to have one. To support this and future vaccine promotion programmes, we developed a vaccine information flip chart in the local language based on behavioural insights obtained in the community, though this was not finalised during the study period.
During the study period, several villages experienced deaths perceived to be caused by COVID-19 vaccines. To support Champions to respond to these concerns, we developed a resource to help explain causality and coincidence. We also provided additional one-on-one telephone or Zoom support for Champions on request.
Barriers to implementation
Vaccine Champions raised several challenges to running sessions within the community. These included logistical issues such as weather, accessing remote locations, finding an appropriate venue and scheduling sessions outside of working hours to maximise attendance.
Multiple Vaccine Champions also discussed the challenges of talking about vaccines with people who were mistrustful and fearful of the COVID-19 vaccine, particularly in villages where people had died shortly after receiving the COVID-19 vaccine. They also reported difficult discussions with community attendees who did not believe the vaccine was effective or necessary.
Being part of the community where the session was held was seen as both a barrier and an enabler to organising successful discussion sessions. One Champion felt that her familiarity with the community made the session attendees more comfortable, whereas another thought that being part of the community meant they were not taken as seriously. Some Champions felt it would have improved their credibility if they had a respected community leader, such as a village headman, accompanying or introducing them.
Maintenance
Vaccine Champions generally felt that the programme would be easy to sustain. Most agreed that holding formal community discussion sessions, providing information on COVID-19 vaccine recommendations, talking to friends and family about vaccines and communicating regularly with Ministry of Health representatives about vaccine issues would be easy or very easy.
Almost all the Vaccine Champions who were interviewed stated that they would be keen to continue the programme in Fiji and to stay involved themselves: ‘Yes, I can see the program is continue in the future. I will be lucky and I will be appreciated if I am still a part of the program’ (Champion 20). For the programme to be sustainable, some Vaccine Champions felt that payment was necessary, others thought that reimbursement for expenses incurred would be acceptable, and some were happy to continue to run sessions without any financial incentive. Another suggestion to improve sustainability was linking Vaccine Champions with health workers to help arrange sessions and speak with hesitant individuals.
Codesign participants and community attendees also thought that the Vaccine Champions programme should continue in Fiji. As one codesign participant said, ‘I think we really have to continue vaccination Champions, because as time goes on, we have so many vaccines coming to us in Fiji, and we need to continue with this kind of facilitating as a Champion’ (Codesign participant 2).
Discussion
The Vaccine Champions programme in Fiji was a comprehensive, codesigned community engagement intervention incorporating vaccine education and communication training. The programme trained 35 local Vaccine Champions with both a health and non-health background who reached over 1700 community members with vaccine discussion sessions across the four Divisions in Fiji. The training significantly improved Champions’ knowledge of effective communication skills and their communication self-efficacy and increased community members’ intention to vaccinate. While there were a range of factors influencing vaccine uptake, COVID-19 booster rates increased in Fiji during the programme period. The programme was well received and had strong support from the Ministry of Health and other stakeholders.
A key feature of this programme was the engagement of the community in the intervention itself. A systematic review found that interventions that build community ownership or create a new cadre of vaccine promoters are more effective than those that involve community members only in an advisory capacity.1 Our programme took a pragmatic approach to social mobilisation, engaging community members without a health background to support urgent health goals.3 We also included community health workers to extend the reach of the programme. In other settings with ongoing vaccination challenges, such as countries struggling to increase routine childhood vaccination rates, tackle disease outbreaks or introduce new vaccines, a more activist or hybrid social mobilisation approach that empowers local communities to lead the intervention design process may improve effectiveness and sustainability.3
Many community engagement interventions do not include or describe intensive training for community mobilisers in both vaccine information and communication skills, which is an important part of the Vaccine Champions programme. This extends the common notion of a Vaccine Champion as someone respected in the community who stands up to be vaccinated publicly but does not provide information or answer questions from the community. The strongest impact of our training programme was on communication knowledge and self-efficacy outcomes. The lesser impact on knowledge and confidence about vaccines suggests that the vaccine education section of the training could be improved, potentially with a longer or more tailored training session, particularly when training Champions with no health background. Improving people’s vaccine-related knowledge is intended to increase their confidence to engage in discussions where they may face difficult questions. However, our training emphasises that the Champions do not need to become vaccine experts, and their most important role is to share their personal experiences and to direct people to reliable information sources.
Two-thirds of Champions ran sessions, including both community health workers and other advocates. Our study showed that Champions do not need to have a health background to be engaged and successful. Similar results were reported in a review which found that previously untrained peer educators can reach diverse subgroups and improve vaccine uptake, knowledge and beliefs.37 Using trusted local messengers to share vaccine information can support vaccine confidence.38 Engaging a mix of individuals can also help supplement an overstretched health workforce, an issue facing many countries in the Asia Pacific region.39 However, most Champions who did not facilitate a session were those without a health background, suggesting that more tailoring is required to ensure different Champions have the confidence to speak with community members. Most Champions who ran sessions were female. This may reflect the makeup of the community health workforce in Fiji,40 but the impact of gender on ongoing engagement should also be considered in the future. Identification of Champions should be carefully discussed with local stakeholders and invitations to training should be personalised to optimise participation. A competitive process of application and assessment against key criteria could improve engagement but may limit the diversity of Champions by selecting for those with high levels of confidence and awareness. Additional resources to support Champions, such as slides, videos or flip charts, can facilitate knowledge exchange and build confidence. To scale up, a training of trainers approach could be applied to train experienced trainers such as district nurses who could run downstream training and refresher sessions.
We found that financial reimbursement was a driver of adoption, though it did not motivate some Champions to conduct community sessions and others said they would have participated even without the incentive. Ongoing incentivisation is challenging in low-resource settings, and short-term incentivisation can lead to demotivation when incentives end.6 Some similar programmes elsewhere rely on the intrinsic motivation of community champions.41 However, this increases the burden on community influencers who may already be overstretched with volunteer commitments.42 Determining the most appropriate balance of responsibilities and reimbursement is key for sustainability and must be tailored to setting and context.
As recommended in a recent systematic review,1 our RE-AIM evaluation used mixed methods to contribute critical evidence about the effectiveness and implementation features of a vaccine community engagement intervention. Collecting mixed-methods data on a range of indicators allowed us to capture details about how the programme affected Champions who attended the training and community members who attended discussion sessions. We included intermediate measures of vaccine knowledge, trust, confidence and communication self-efficacy that support our programme logic model.43 Collecting survey data at a third distal time point would improve our understanding of the sustained impacts of the programme over time. While this programme concluded naturally at the end of the COVID-19 booster rollout, sustainability is a key ongoing challenge and engagement and ownership by government stakeholders is critical to the ongoing success of similar programmes. Delivery and evaluation through a cluster randomised controlled trial is needed to establish direct evidence of a link between the intervention and vaccine uptake. Substantial resourcing for local monitoring and evaluation staff should be considered in future programmes to enhance data collection and validation, including for objective assessment of intervention fidelity and effectiveness.
Strengths and limitations
The application of the comprehensive RE-AIM evaluation framework was a strength of this study. The mixed methods of data collection allowed us to provide context to our findings and identify areas for improvement in the intervention. Paper-based surveys were preferred by participants over online surveys, however, this resulted in some incomplete data and data that could not be linked to a participant across time points. Our survey questions were reviewed by local stakeholders but were not pilot tested with community members; the ‘tick all that apply’ instructions for the knowledge questions in particular appeared to cause confusion. Social acceptability bias may have impacted self-reported measures like confidence, satisfaction and intention to vaccinate. Interview participation was voluntary and may have been subject to self-selection bias, potentially limiting negative feedback on the training and discussion sessions. It was not possible to collect vaccine uptake data from specific communities where Vaccine Champions were running sessions, so we had to rely on the self-report measure of intention. Finally, the small relative number of Vaccine Champions included in the study may have contributed to non-significant findings, particularly among trust and confidence measures.
Conclusion
The Vaccine Champions programme is a promising community engagement intervention that incorporates vaccine education and communication training to empower community influencers and health workers to become vaccine advocates. Community advocacy is crucial for current global efforts to combat measles outbreaks and eliminate vaccine-preventable diseases such as cervical cancer.44 45 This programme can reduce the burden on health workforces by training diverse community advocates without a health background to share their vaccine experiences, address misinformation and answer questions from their communities. The programme has been adapted and implemented and is being evaluated in other countries in the Asia Pacific region to build the evidence base on the effectiveness of community-based interventions to improve vaccine confidence and uptake.
Data availability statement
Data are available on reasonable request. Deidentified individual participant data that underlie the results reported in this article, as well as the study protocol and data collection instruments, will be made available from the point of, and up to 3 years after the acceptance for publication of the main findings. Data will be shared with researchers who provide a methodologically sound proposal, for analyses that achieve the aims in the approved proposal. Proposals should be directed to jess.kaufman@mcri.edu.au. To gain access, data requesters will need to sign a data access agreement.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and this research obtained ethical approval from the Royal Children’s Hospital Human Research Ethics Committee (HREC: 84863) and the Fiji National Research Ethics Review Committee (HREC: 16/2022). Participants gave informed consent to participate in the study before taking part.
Acknowledgments
The author team would like to acknowledge Suzanna Vidmar, who assisted with quantitative analysis.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Handling editor Helen J Surana
X @jessicajkaufman, @julieleask, @danchinmargie
Contributors JK is the guarantor. JK conceived the study with MaD, JL and HS. JK and MaD secured funding. All authors were involved in design of the intervention and/or evaluation. JF, JT, RD, LiV, KsJ, HD, SS and MiD made significant contributions to intervention implementation. JK, IO, MaD, KyJ, LuV and YM contributed to data collection. JK, IO, MaD, YM and MH contributed to data analysis. All authors were involved in interpretation of data and critical revision of the manuscript.
Funding This research was funded by the Australian Department of Foreign Affairs and Trade through the Australian Regional Immunisation Alliance–Regional Immunisation Support and Engagement (ARIA-RISE) scheme (grant number: n/a).
Disclaimer The funder had no role in study design or conduct or in the decision to submit the manuscript for publication.
Competing interests JF, JT, RD and LiV were employed by the Fiji Ministry of Health and were involved in vaccine program delivery during this study. The Ministry of Health reviewed the manuscript prior to publication. HS has received funding for investigator driven research from industry including Moderna within the last 3 years. This funding was not used for this study. All other authors declare no competing interests.
Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.
Provenance and peer review Not commissioned; externally peer reviewed.
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