Risk Communication & �Community Engagement ��for �Community Health Workers to support �COVID-19 Response and Vaccine Uptake

Acknowledgment

This training package was developed to build national capacities and strengthen the skills of Community Health Workers to support the COVID-19 response including vaccine acceptance in the Eastern Mediterranean and North Africa (MENA) region.​ The training material was jointly developed by WHO EMRO, IFRC MENA and UNICEF MENARO. This work was based on their previous work on training content in RCCE for community health volunteers. 

The content development was led by Dr. Dalia Samhouri, Peggy Hanna, Dr. Samar El Feky and Tamer El-Maghraby from WHO EMRO, Elham Elkafafy and Assem Saleh from IFRC MENA, Neha Kapil, Dr. Amaya Gillespie and Ken Limwame from UNICEF MENARO. Special thanks to Nadulpan LLC led by Dr. Nancy Claxton with contributions from Dr. Lisa Moussaoui for developing innovative training methodologies and approaches to foster adult learning for this package.

Sincere acknowledgment to WHO Syria Country Office, WHO Egypt Country Office, IFRC Syria Country Office, Syrian Arab Red Crescent, Egyptian Red Crescent and UNICEF Syria Country Office, and UNICEF Egypt Country Office for pilot testing the package in Syria and Egypt. 

Contents

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08

Introductory �Peer Coaching Session

Introductory Peer Coaching

01

SESSION

Learning objectives

As a result of this session, active learners will be better able to:

​

• Explain how personal biases and perceptions can affect vaccine acceptance and how to address these as part of their role.
• Identify and manage infrastructural barriers and enable factors to empower their community in COVID prevention, detection and response.
• Define strategies to identify and connect health agencies and existing RCCE mechanisms with community needs and capacities.

​

Introductory Peer Coaching

01

Get into Home Groups of 4 participants each.

Each participant introduces themselves and answers the question:

“A CHW’s most important job is…”

Back to Home Groups to share what was learned in Share Groups

1

COVID

transmission

routes

2

COVID

Prevention

strategies

3

Vaccine risks

& benefits

Plenary

4

Building trust

in community

minutes

5’

10-15’

30’

20’

Now count off by 4 to see which Share Group to join.

Introductory Peer Coaching

01

Get into home groups of four participants each

Introductory Peer Coaching

01

Now count off by four in your group

1

2

3

4

1

2

3

4

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2

3

4

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2

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4

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2

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4

1

2

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4

Introductory Peer Coaching

01

Discuss: the CHW’s most important role

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4

minutes

5

Introductory Peer Coaching

01

All the 1s get together to discuss COVID transmission.

Get into share groups

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2

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4

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4

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2

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4

All the 2s get together to discuss COVID prevention.

All the 3s get together to discuss how vaccination protects us.

All the 4s get together to discuss how to address rumours.

minutes

15

Introductory Peer Coaching

01

Back to home groups to share what was learned

minutes

30

1

2

3

4

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3

4

1

2

3

4

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2

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4

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4

Introductory Peer Coaching

01

Plenary

minutes

20

Introductory Peer Coaching

01

Introductory �Peer Coaching Session

Communication Strategies

02

SESSION

Learning objectives

As a result of this session, active learners will be better able to:

• Explain how personal biases and perceptions can affect vaccine acceptance and how to address these as part of their role.
• Identify and manage varying levels of vaccine acceptance in community and apply appropriate communication and community engagement strategies to address different audiences.
• Define strategies and plan for CHWs to keep physically safe and mentally well amidst the evolving situation of a pandemic.
• Define strategies to identify and connect health agencies and existing RCCE mechanisms with community needs and capacities.

​

Communication Strategies

02

Consequences to misinformation

Communication Strategies

02

Communication Strategies

Mythbusting

FACT:

FACT:

FACT:

02

How to respond

Overview

Myth: the vaccine is too new – it can’t be safe

Applying an Evidence-Based Formula

to Misinformation, Rumors & Myths

Reiterate fact

Address the myth

Start with fact

State the myth

SOURCE: Adapted from Lewandowsky, Stephan; Cook, John; Lombardi, Doug (2020): Debunking Handbook 2020. Nyhan B, Reifler J, Richey S, Freed GL. Effective messages in vaccine promotion: a randomized trial. Pediatrics. 2014 Apr;133(4):e835-42. doi: 10.1542/peds.2013-2365 . Epub 2014 Mar 3. PMID: 24590751

02

How to respond

Communication Strategies

Start with fact

Some of the approved COVID-19 vaccines have been developed with messenger RNA (mRNA). The mRNA vaccine technology has been studied & developed for 10+ years, including in the development of vaccines for Zika, rabies and influenza. These mRNA vaccines have been rigorously assessed for safety. Clinical trials show that they provide a long-lasting immune response. mRNA vaccines are not live virus vaccines and cannot interfere with human DNA. The COVID-19 vaccine relies on ten years of mRNA research.

Lead with the facts - make it clear and easy to remember. Make it concrete and plausible.

Don't simply state 'That is not true'. Your goal is not to debate/argue with them. You want to present the facts to start.

​

"There’s a lot of information out there, and some of it is true, and some of it is not true. Let me tell you what I know.’”

02

Myth: the vaccine is too new – it can’t be safe

How to respond

Communication Strategies

A common myth is that the COVID-19 vaccine is too new to be safe, therefore people want to wait to see if it is safe.

Preface that a myth or misinformation is about to be stated. Repeat the misinformation that is being said - but only say it once. Say it directly before you say the correct information in the next step.

"A common myth is that the COVID-19 vaccine is too new to be safe.”

02

Myth: the vaccine is too new – it can’t be safe

State the myth

How to respond

Communication Strategies

This myth does not recognize the fact that these vaccines are built on DECADES of mRNA research. The COVID-19 vaccine uses the existing mRNA technology for the COVID-19 variant. The COVID-19 vaccine was tested through a rigorous process with multiple steps to ensure safety. All the vaccine components are rigorously tested to ensure it is safe for humans in different stages before it ever comes to you. The manufacturing of the vaccine undergoes many regulatory checks. The COVID-19 vaccine is safe as given to over 500 million people and counting. Each day that you wait, you continue to be at risk and put your family at risk for becoming seriously ill from COVID-19.

Explain - without judgment - how the myth misleads people.

"But thousands of doctors & scientists have worked for over ten years to develop the technology that was ultimately used to develop the COVID-19 vaccine. There were multiple steps to develop, test, trial and continuously check the efficacy and safety of the vaccine . Over 500 million people of every race, gender and age who are now vaccinated are safe from possible death and long-term consequences of COVID-19.”

Rather than simply telling them they are wrong, use empathy.

Point out the inconsistency(ies) in the logic that underlies the misinformation or myth.

02

Myth: the vaccine is too new – it can’t be safe

Address the myth

How to respond

Communication Strategies

Millions of people have safely received COVID-19 vaccines. All the approved COVID-19 vaccines have been carefully tested and continue to be monitored. Like all vaccines, COVID-19 vaccines went through a rigorous, multi-stage testing process, including large clinical trials that involved tens of thousands of people. These trials are specifically designed to identify any safety concerns.

​

COVID-19 vaccines have been tested in large, randomized controlled trials that include people of a broad age range, both sexes, different ethnicities, and those with known medical conditions. The vaccines have shown a high level of efficacy across all populations. Vaccines have been found to be safe and effective in people with various underlying medical conditions that are associated with increased risk of severe disease, including high blood pressure; diabetes; asthma; pulmonary, liver or kidney disease; and chronic infections.

​

Finish by reinforcing the fact.

Respond to misinformation appropriately & show that you are listening to their concerns:

"I know this is a scary time. Tell me your concerns and I can share with you what I know.”

Repeat the fact multiple times, in different ways. If you can explain it seven times total, you are on the path to changing attitudes and behaviors.

"COVID-19 is a deadly disease and has killed millions thus far. The COVID-19 vaccine is one of the most powerful weapons against infection. It has been tested repeatedly across many groups over different spans of time and is proven to be safe and effective in preventing severe sickness and death"

​

02

Reiterate fact

Myth: the vaccine is too new – it can’t be safe

Plenary

Communication Strategies

minutes

20

02

Questions to reflect upon

For those playing community members:

• Which approaches/answers/attitudes were most effective for you about your concern? Why?
• Did any of the CHWs change your mind personally about any issue?
• What feedback would you like to share?

​

For those playing CHWs:

• Which vaccine concerns did you hear about?
• What strategies were most effective?
• What can you take away from this activity?

Communication Strategies

02

Final thoughts

Let’s look at the concerns/issues/myths that were identified in our brainstorm, but that we did not address in this session.

​

Identify the top two issues and we will brainstorm strategies that a CHW could use to address these concerns.

Communication Strategies

02

Introductory �Peer Coaching Session

Community with Varying Vaccine Acceptance Levels

03

ROLE PLAY

Learning objectives

As a result of this session, active learners will be better able to:

• Identify and manage varying levels of vaccine acceptance in community and apply appropriate communication and community engagement strategies to address different audiences.
• Identify and manage infrastructural barriers and enabling factors to empower your community in COVID prevention, detection and response.

Community with Varying Vaccine Acceptance Levels

03

Barriers that affect vaccine uptake

Community with Varying Vaccine Acceptance Levels

Source: https://resourcecentre.savethechildren.net/library/little-jab-book18-behavioral-science-strategies-increasing-vaccination-uptake.

There are common barriers that you will need to overcome

Structural barriers

​

• Cost
• Access
• Poor infrastructure

Behavioral barriers

​

• Inertia
• Prevailing social norms
• Present bias
• Forgetfulness
• Lack of determination
• Friction
• Misperception
• Social motives and meanings

Informational barriers

​

• Misinformation
• Lack of adequate information
• Complexity of information

03

Role Plays – Community with Varying Levels of Vaccine Acceptance

Vaccine hesitancy:

Vaccination is accepted but with delays, or it is rejected outright, despite availability (acceptance, delay, and/ or rejection of certain vaccines).

Active demand:

The public actively demands the services.

Rejection of all vaccines

Passive acceptance:

The public accepts vaccination services without seeking them out

Supply and access:

Availability of services and vaccinators for example, immunization services, knowledge and skills of health personnel.

Source: Adapted from SAGE Group on Vaccine Hesitancy. Report of the SAGE working group on Vaccine Hesitancy [Internet]. 2014

03

Spectrum of vaccine hesitancy/�acceptance

Community with Varying Vaccine Acceptance Levels

Moving along the spectrum

Community with Varying Vaccine Acceptance Levels

Hesitating

Rejecting

Activist

Accepting

Demanding

Advocating

03

Reasons to vaccinate or not vaccinate in the general population�

Recommendations of health staff or national guidelines

Self-protection

Recommendations of friends, family, colleagues

Awareness, knowledge about the disease or the vaccine

Perception of seriousness of the disease

Perception of high susceptibility to the disease

Belief in the benefits of the vaccine

To protect those around them

Social norms

Access

Religious reasons (e.g. Jewish obligation “to save lives“)

People around them are hesitant

Feeling it is not important to follow medical guidelines

Distrust of the pharmaceutical industry

Too old to get an HPV vaccine

Unnecessary to get vaccinated if everyone around them has

Not convenient to get vaccinated

High cost

Religious reasons

Sexual transmission of HPV and too young to be vaccinated

Vaccine not recommended by their doctor

Not enough information about the disease or vaccine

Belief in homeopathy or avoidance of medicine

Lack of knowledge about the disease or vaccine

Lack of concern

Distrust of government sources

Low perception of severity of this disease

Perception of ineffectiveness of the vaccine

Fear of needles or of the pain of vaccination

Other

Perception of low risk of getting the disease

Fear of adverse offense and regarding vaccine safety

Reasons for support

Reasons for hesitancy

Source: Adapted from Yaqub O, Castle-Clark S, Sevdalis N, Chataway J. Attitudes to vaccination: A critical review. Soc Sci Med. July1, 2014; 112:1-11.

03

Managing our own hesitancy/acceptance

Community with Varying Vaccine Acceptance Levels

Vaccine not recommended by their doctor

Not enough information about the disease or vaccine

Lack of concern

Low perception of seriousness of the disease

Fear of needles or of the pain of vaccination

Other

Lack of knowledge about the disease or vaccine

Lack of time

Perception that the vaccine is ineffective

Perception of low risk of contracting the disease

Fear of adverse events and regarding vaccine safety

To protect patients

Self-protection

To protect others (excluding patients)

Access

Awareness, knowledge about the disease and the vaccine

Perception of high risk of contracting the disease

Belief in the benefits of vaccines

High perception of seriousness of the disease

To avoid missing work

Reasons for support

Reasons for hesitancy

Reasons to vaccinate or not vaccinate and health workers

Source: Adapted from Yaqub O, Castle-Clark S, Sevdalis N, Chataway J. Attitudes to vaccination: A critical review. Soc Sci Med. July1, 2014; 112:1-11.

03

How to respectfully address hesitancy

• Don’t directly contradict people’s mistaken ideas about vaccine dangers.
• Approach people with empathy by acknowledging historical reasons for medical distrust, perhaps among people of colour, and work with leaders within their communities.
• Rather than contradicting someone’s views, use empathy.
• Respond to misinformation appropriately & show that you are listening to their concerns:

"There’s a lot of information out there, �some of it is true and some of it is not true. Let me tell you what I know.”

Community with Varying Vaccine Acceptance Levels

03

Communicating about AEFIs

Community with Varying Vaccine Acceptance Levels

• Communicate first
• Be frequent in updating people
• Be transparent and honest about what has happened
• Avoid over-reassuring people
• Be empathetic
• Respond to questions and be honest if you don’t know something
• Let people know how they can get in touch for more info

​

03

Transcript

• Nadia is a CHW in an urban area. She is a trusted member of the community. Nadia is tirelessly preparing her community members in acceptance of the COVID-19 vaccine as it is slowly becoming more available. She regularly expresses her willingness to get the vaccine when it is offered to her but she herself is nervous about it. Nadia talks to her community members about the safety of the vaccine and how any risk of getting COVID-19 far outweighs the risk that she thinks getting the vaccine may pose. She feels that many people are in agreement with her but there are a vocal minority who tell her about rumors or misinformation they have heard from others or on social media.
• Nadia is going to community meetings and households to talk about the vaccine to sensitize people in preparation to get the vaccine. Nadia goes to one household where the mother is in active demand of the vaccine for her family but the father is vaccine hesitant because of discussions he heard from friends about the speed in which the COVID vaccine was developed. She must carefully address this misinformation respectfully and appropriately to save face for the father while supporting the mother.
• In a community meeting, Nadia talks to a group of young mothers who saw on Facebook that one of the COVID vaccines is dangerous to women of their age group. The other COVID vaccines did not pose the same concerns, however a small, but vocal, group say that they are distrustful of all COVID vaccines. The other mothers are quiet and she is unsure of their feelings.

Community with Varying Vaccine Acceptance Levels

03

Spectrum levels and strategies

Community with Varying Vaccine Acceptance Levels

Spectrum levels

Strategies

03

Let’s rate how Nadia does

Community with Varying Vaccine Acceptance Levels

• Manages myths/misinformation
• Provides accurate information
• Is respectful
• Shows confidence in COVID-19 vaccine
• Explains the risks in refusing the COVID-19 vaccine
• Is convincing

1

2

3

1

2

3

03

Community with Varying Vaccine Acceptance Levels

Spectrum levels

Strategies

In groups of four, identify 1-2 strategies per spectrum level.

03

Plenary

Community with Varying Vaccine Acceptance Levels

minutes

20

03

Introductory �Peer Coaching Session

Peer Coaching on Norms and Perceptions

04

SESSION

Learning objectives

As a result of this session, active learners will be better able to:

• Explain how personal biases and perceptions can affect vaccine acceptance and how to address these as part of their role. 

Peer Coaching on Norms and Perceptions

04

Factors influencing how people perceive of COVID-19 vaccine safety

Peer Coaching on Norms and Perceptions

Hesitating

Rejecting

Anti-Vax Activist

Accepting

Demanding

Advocating

overview

04

Factors influencing how people perceive of COVID-19 vaccine safety

Peer Coaching on Norms and Perceptions

Anti-Vax Activist

Reduce impact on other groups.

Oppose all / just COVID-19 vaccination, engage in protests. �May source and share misinformation about vaccine safety, particularly via social networks.

04

Factors influencing how people perceive of COVID-19 vaccine safety

Peer Coaching on Norms and Perceptions

Rejecting

Minimize the group size by good management of vaccine safety issues.

Rejection often based on safety concerns, but experience, perceptions and values could be involved.

04

Factors influencing how people perceive of COVID-19 vaccine safety

Peer Coaching on Norms and Perceptions

Hesitating

Listen and address concerns. Facilitate access to evidence-based information.

Due to the newness of disease, novel vaccine platforms and uncertainty surrounding vaccine safety, hesitancy/acceptance is dynamic and can be influenced by communication with trusted health care.

04

Factors influencing how people perceive of COVID-19 vaccine safety

Peer Coaching on Norms and Perceptions

Accepting

Address questions, provide resources.

Depends on motivation to be vaccinated, social/professional influences and the availability and access to a vaccine. May have questions about potential side effects.

04

Factors influencing how people perceive of COVID-19 vaccine safety

Peer Coaching on Norms and Perceptions

Demanding

Address questions.

Absolutely want a COVID-19 vaccine. High demand with low supply could lead to conflict and perceptions of “favoritism” that may diminish trust in the overall programme.

04

Factors influencing how people perceive of COVID-19 vaccine safety

Peer Coaching on Norms and Perceptions

Advocating

Provide tools that address safety concerns.

Motivated by a personal experience or strong support of vaccination. Asset in safety communication, sharing information rapidly via their social networks.

04

Get into Home Groups of 4 participants each.

Each participant introduces themselves and answers the prompt:

“My community is…”

Back to Home Groups to share what was learned in Share Groups

1

Building and maintaining trust

2

Factors that affect vaccine acceptance

3

Exploring CHW vaccine hesitancy

Plenary

4

Managing misinformation

minutes

5’

10-15’

30’

20’

Now count off by 4 to see which Share Group to join.

Peer Coaching on Norms and Perceptions

04

Peer Coaching on Norms and Perceptions

Get into home groups of four participants each

04

Now count off by four in your group

Peer Coaching on Norms and Perceptions

1

2

3

4

1

2

3

4

1

2

3

4

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2

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2

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4

04

Discuss: my community is…

Peer Coaching on Norms and Perceptions

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2

3

4

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4

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4

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2

3

4

1

2

3

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2

3

4

minutes

5

04

All the 1s get together to discuss building & maintaining trust.

Peer Coaching on Norms and Perceptions

Get into share groups

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

All the 2s get together to discuss factors that affect vaccine acceptance in community.

All the 3s get together to discuss exploring vaccine hesitancy/�acceptance in CHWs.

All the 4s get together to discuss managing misinformation.

minutes

15

04

Back to home groups to share what was learned

Peer Coaching on Norms and Perceptions

minutes

30

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

04

Plenary

Peer Coaching on Norms and Perceptions

minutes

20

04

Introductory �Peer Coaching Session

CHWs Staying Safe in the COVID-19 Pandemic

05

SESSION

Learning objectives

As a result of this session, active learners will be better able to:

• Define strategies and plan for CHWs to keep physically safe and mentally well amidst the evolving situation of a pandemic.
• Define strategies to identify and connect health agencies and existing RCCE mechanisms with community needs and capacities.

CHWs Staying Safe in the COVID-19 Pandemic

05

Brainstorming challenges

05

Question set to facilitate towards solutions

• How do you know when problem X is present?
• How do you contribute effectively to solving problem X? �(This includes how it affects you personally and how it affects others.)
• What prevents you from doing this or taking these actions all the time?
• Do you know anybody who is able to frequently solve problem X and overcome barriers? What behaviors or practices made their success possible?
• Do you have any ideas?
• What needs to be done to make it happen?
• Who else needs to be involved?

CHWs Staying Safe in the COVID-19 Pandemic

05

Plenary

CHWs Staying Safe in the COVID-19 Pandemic

minutes

20

05

Introductory �Peer Coaching Session

Vaccine Uptake

06

DEBATE

Learning objectives

As a result of this session, active learners will be better able to:

• Explain how personal biases and perceptions can affect vaccine acceptance and how to address these as part of their role.
• Identify and manage varying levels of vaccine acceptance in community and apply appropriate communication and community engagement strategies to address different audiences.
• Define strategies and plans for CHWs to keep physically safe and mentally well amidst the evolving situation of a pandemic.

Vaccine Uptake

06

Vaccine Uptake

06

Vaccine hesitancy:

Vaccination is accepted but with delays, or it is rejected outright, despite availability (acceptance, delay, and/ or rejection of certain vaccines).

Active demand:

The public actively demands the services.

Rejection of all vaccines

Passive acceptance:

The public accepts vaccination services without seeking them out

Supply and access:

Availability of services and vaccinators for example, immunization services, knowledge and skills of health personnel.

Source: Adapted from SAGE Group on Vaccine Hesitancy. Report of the SAGE working group on Vaccine Hesitancy [Internet]. 2014

Spectrum of vaccine hesitancy/�acceptance

I do not want the vaccine

CON

I want the vaccine as soon as I can get it

PRO

Vaccine Uptake

06

Debate overview

minutes

15’

3’

3’

1.5’

3’

3’

1.5’

3’

3’

1.5’

1’

1’

06

Vaccine Uptake

COVID-19 vaccine uptake debate guidelines

The facilitator will keep time. You may not go beyond your allowed time. �The teams will get time to prepare before each debate round.

Only the two chosen representatives from each team may talk during the debate.�During the team discussion and prep times, the representatives will meet with their team to plan the next round.  Talking is encouraged!

Team members may pass written notes to the speakers during the debate.

Vaccine Uptake

06

Plenary

Vaccine Uptake

minutes

20

06

Introductory �Peer Coaching Session

Infrastructural Barriers

07

ROLE PLAY

Learning objectives

As a result of this session, active learners will be better able to:

• Identify and manage varying levels of vaccine acceptance in community and apply appropriate communication and community engagement strategies to address different audiences.
• Identify and manage infrastructural barriers and enabling factors to empower their community in COVID prevention, detection and response.
• Define strategies to identify and connect health agencies and existing RCCE mechanisms with community needs and capacities.

Infrastructural Barriers

07

Infrastructural Barriers

Maya

​

a CHW from a small community.

“Let’s brainstorm some ways that Maya might respond.”

07

Obstacles and strategies

Infrastructural Barriers

Obstacles

Strategies

07

Let’s rate how Maya does

Infrastructural Barriers

• Manages myths/misinformation
• Provides accurate information
• Is respectful
• Shows confidence in COVID-19 vaccine
• Explains the risks in refusing the COVID-19 vaccine
• Is convincing

1

2

3

1

2

3

07

Infrastructural Barriers

Obstacles

Strategies

In groups of three, identify 1-2 obstacles

07

Role plays

Infrastructural Barriers

• Groups of 3
• Roles:
• CHW
• Infrastructure
• Observer
• Groups of 3
• Choose 1-2 obstacles
• Plan dialogue
• Perform for another group

​

07

Plenary

Infrastructural Barriers

minutes

20

07

Introductory �Peer Coaching Session

Vaccinate Me

08

GAME

Learning objectives

As a result of this session, active learners will be better able to:

• Explain how personal biases and perceptions can affect vaccine acceptance and how to address these as part of their role.
• Identify and manage varying levels of vaccine acceptance in community and apply appropriate communication and community engagement strategies to address different audiences.
• Identify and manage infrastructural barriers and enabling factors to empower their community in COVID prevention, detection and response.
• Define strategies and plan for CHWs to keep physically safe and mentally well amidst the evolving situation of a pandemic.
• Define strategies to identify and connect health agencies and existing RCCE mechanisms with community needs and capacities.

​

Vaccinate Me

08

Vaccinate Me game

The purpose of the game is to see the financial, physical, mental and emotional struggles that a person will likely face if they refuse the vaccine.

Vaccinate Me

The goal of the game is to reach the finish line successfully having at least 1 Health Coin (HC) in your ‘bank statement.’

​

08

The board game components:

• Game board and die
• Health Coins statement sheet
• Cards

Vaccinate Me

08

08

Play the game

Plenary

Vaccinate Me

minutes

20

08

Evaluation

LEVEL 1

Conducted today

LEVEL 2

Conducted today

LEVEL 3

Sent to you in three months.

We will check in on how you brought this learning back to your community.