Reaching under-immunized children missed during COVID-19

Reaching under-immunized children missed during COVID-19

In the first quarter of 2022, Bamako recorded nearly fifty suspected cases of measles. Public health officials collected samples and fourteen cases were confirmed at the national reference laboratory.  Several of the 14 positive cases were concentrated in Communes I and IV of Bamako. This distribution of cases meant that Bamako had reached an epidemic threshold, which required a response in both communes and the surrounding areas. Measles is extremely contagious, and unfortunately, Mali registered in the top 10 countries for the highest number of cases reported from September 2021 – February 2022.

The primary reason for the measles outbreak is that thousands of children missed their routine vaccinations due to the COVID-19 pandemic, though the exact number of under-immunized and “zero-dose” children is unknown. But Mali is not unique in experiencing a measles outbreak. Just as we saw with Ebola, the interruption of routine primary healthcare caused by the pandemic could be as or more deadly than the coronavirus itself.

In order to support the regional health authorities in containing the epidemic, the Mali Health team initiated and supported a vaccination campaign to reach unvaccinated children in partner communities across Bamako.

The vaccination campaign mobilized more than 200 vaccination teams over a period of five days to vaccinate children age 9 – 59 months. Each vaccination team was composed of three agents including one agent for the mobilization and organization of the community, one agent to conduct the injections, and one agent to maintain the documentation and records. Though we requested 120 000 doses of VAR vaccines, only 45 000 doses were made available, along with 4,000 vaccine registry forms.

A member of the vaccination team completes the vaccine registry
A member of the vaccination team completes the vaccine registry

The vaccination campaign included the following activities:

  • Communication and outreach: The vaccination teams shared health information messages about measles and vaccination throughout 17 communities by working with the ASACOs (community health association) in each community, as well as a network of women leaders to whom we connected through our partners in the Service Local de Développement Social et de l’Economie Solidaire (SLDSES). Some of the concerns among the community included hesitation and misinformation about vaccines in general, as well as mistrust related to COVID-19 disinformation and rumors.
  • Case identification and management: The vaccination team actively searched for suspected measles cases in each community. Of those suspected, 12 cases were confirmed through the collection and analysis of samples.
  • Monitoring of adverse events following immunization (AEFI): Some minor AEFIs (fever, vomiting, pain at the injection site in older children) were reported during the campaign, which were referred to the CSCom (community health center) teams, who provided treatment and case management.
  • Safe waste disposal: The proper treatment of medical waste is one of the many areas we work on in our participatory quality improvement program, but resources can often be limited at CSComs. All injection and vaccine materials during this campaign were disposed of in safety boxes and packaged in waterproof cartons to hold them safely until they could be incinerated.
  • Sharing results: To ensure transparency and build tryst, Mali Health shared the results of the vaccination campaign with community leaders and community members from the areas served.
  • Monitoring and field supervision: To support each vaccination team, 5 additional agents in each community (85 total) were deployed alongside them to help support and manage the flow of vaccination activities, ensure the vaccination teams remained fully equipped, coordinate with the community health system (CSCom), and assist in any other needs that arose for the vaccination teams. They monitored results and progress each day and were in the field with the vaccination teams for all five days of the campaign.
During the campaign, Dr. Bathily reviews the day's progress with a vaccination team
During the campaign, Dr. Bathily reviews the day’s progress with a vaccination team

The vaccination teams deployed across 17 communities over five days achieving the following results:

  • 44,685 children vaccinated
    • 16,082 under age 1 (between 9-11 months)
    • 28,603 age 1 – 5 years
  • 94.6% of children under age 1 (15,211) received their first dose of measles vaccine (VAR)
  • 90% of children age 1- 5 years (25,754) received their first dose of measles vaccine (VAR)

Despite these results, we estimate that there are approximately 117,795 children under age 5 across the 17 target communities, leaving tens of thousands of more children in need of vaccinations. Based on the results of this vaccination campaign, it is likely that the majority of these remaining children are also unvaccinated.

While every child enrolled in our community health program received their vaccines on-time throughout the pandemic, and we worked very hard to support our partner health centers in maintaining the continuity of care for women and children in their communities, tens of thousands of children across remain unreached and under-immunized. We hope to continue vaccination activities as we search for more funding to meet urgent needs and as more vaccines are made available.

Vaccine Confidence: Results and Lessons Learned

Vaccine Confidence: Results and Lessons Learned

Our project to assess and address vaccine confidence using a local, women-designed technology demonstrated that the use of participatory methods and tools to develop and disseminate voice-based social media messages improved both knowledge of, and confidence in, vaccination against COVID-19 in underserved peri-urban communities in Bamako, Mali.

The project used a mix of qualitative and quantitative evaluation methods, including individual interviews and focus groups discussions. The project relied and built on a participatory evaluation of social and gender norms conducted in the target community before the project began.

The key results of this project include: 

  • 100% of women who accessed voice-based health messages demonstrated improved knowledge about the benefits of vaccination against COVID-19
  • 75% of women who used the application expressed confidence in vaccination against COVID-19
  • 73% of women who used the application shared the information they learned with others
  • 60% of women who used the application felt better equipped to convince others to get vaccinated against COVID-19
A woman in Kalabambougou shares her experience using Keneya Blon

Part of the purpose of the project was to generate lessons for how to use social media tools and messages to address vaccine hesitancy and misinformation. Our particular focus was on hard-to-reach populations in marginalized communities, especially women. Drawing from both our work to develop Kènèya Blon, and its application to COVID-19 vaccination, we summarize our lessons learned as:

  • Community driven: A tool designed by women living in peri-urban communities to increase access to health information proved to be relevant and impactful, despite limited access to information technology; when trying to meet the needs of hard-to-reach or marginalized communities, they should be involved at every step, including data collection and technology design
  • Targeted: Technology and digital interventions must be adapted to the realities of each community or population it is trying to serve; this adaptation can include the form and function of the application or the types of content used (language, images, etc.), but also contextual factors such as social/gender norms, the kinds of misinformation circulating, etc.
  • Coordination: When coordinating with offline health or vaccination services, ensure the quality and availability of a respondent for interactions with users, as well as the quality and availability of the vaccination service at the health center level; when possible, train these providers in the use of digital tools/messages being used in their communities
  • Ongoing: Campaigns implemented once or over a limited period of time will lose impact over time; the dissemination of messages relating to COVID-19 must be ongoing and consistent until public health and vaccination targets are reached
  • Accessible technology: Though access to technology is increasing, it will continue to be a limiting factor for millions, especially for women who have limited skills or experience that allow them to use it effectively. This project recommends the integration of relevant, local digital tools into mobilization strategies around vaccination against Covid-19 while also continuing the search for strategies that can share voice-based messages on the types of phone and technologies that are most available to marginalized communities
  • Mixed methods: Promote the use of the digital tools within target communities with on-the-ground and face-to-face strategies to build trust
Improving community awareness and confidence in COVID-19 vaccines with local women-designed technology

Improving community awareness and confidence in COVID-19 vaccines with local women-designed technology

As the world has seen and experienced during the pandemic, vaccinating populations requires much more than a vaccine. While the availability of a vaccine is one important component, a variety of factors can influence vaccination rates and coverage. Some, like geographic, logistical, and health system factors have been a challenge to ensuring complete and timely vaccination of children for underserved communities for decades; the pandemic has exacerbated these problems. Other factors can be related to gender, social norms, or misinformation.

From October 2021 to February 2022 with funding from the Vaccine Confidence Fund, Mali Health worked with women and communities to understand the factors influencing knowledge of and confidence in COVID-19 vaccination in underserved peri-urban communities. We then developed and tested messages for Kènèya Blon, the local, voice-based smartphone application that we developed with women in Sabalibougou, a peri-urban community in Bamako.

Collecting data directly from community members was essential to understanding the factors that influenced confidence in the vaccine, and therefore how to address them. The end users were involved in every step of the original development of the Kènèya Blon platform. When assessing how to use it to address vaccine confidence as a part of this project, their participation was vital again.

We used participatory methods to understand attitudes and behaviors related to vaccination, and the norms which govern them. At the beginning of project, 95% of those surveyed did not trust COVID-19 vaccines and had no intention of getting vaccinated. According to the same survey, the primary reason given was a lack of access to trusted health sources that could provide accurate information, or correct misinformation. A lack of access to health professionals and reliable health information was a key factor in acting on misinformation and the adoption of positive behavior changes.

These findings reinforced what we learned earlier during our work as a part of the WomenConnect Challenge, Then, we learned that access to reliable health information is one of the highest priorities and biggest challenges for the women we serve. Access to information was even linked to gender equality, not only in the minds of women, but in the minds of men and community leaders. Because women living in peri-urban communities had limited opportunities to go to school where they could gain reading and writing skills, they face barriers to accessing reliable information.

The Kènèya Blon platform was designed to address this primary challenge. During the project, users had access to accurate public health information about COVID-19 and that addressed rumors and misninformation circulating in their community. They were also able to access health personnel to express their concerns related to COVID-19 vaccination and receive responses to their questions. These features were designed by women, for women – using a what we call women-centered design approaches – but its impact extends far beyond its users.

We attribute the significant short-term results of the project to this rapid access to trusted information, because it met the primary need community members expressed. To learn more about the results and lessons we documented about vaccine confidence, please continue reading our next post.

How women build the support and solidarity they need to stay healthy

How women build the support and solidarity they need to stay healthy

For four years, the savings group Belle Dame, or Beautiful Lady, has met every Thursday as a part of Mali Health’s women’s health financing program. Their story begins with Mme. Koné Djénèba Ballo, the group’s founder and treasurer:

Ever since I was a little girl, I have been active and taking the lead on every activity I was a part of – whether it was organizing groups or competitions between friends in our community. One day a friend invited me to her savings group on the other side of Sikoro, but it was too far from home. So I asked if a similar group could be set up for women in our area. The animateur agreed and asked me to invite my close friends for a meeting. After 3 meetings, our group was born and we named her Belle Dame.

– Djénèba Koné

Djénèba invited other women to join the new group and soon the word spread until they grew to 25 members. Every week, they gather at their president’s home and contribute 250 FCFA (about $0.50) each – half goes to their health fund and half goes to their business fund.

Mme Djeneba Koné

Today, Belle Dame is in its fourth savings cycle, which due to COVID-19, is unlike anything they have experienced before:

The COVID-19 pandemic has profoundly affected Mali, especially us as poor women. Its arrival slowed down our activities, our children no longer go to school, our husbands are unemployed. As for our group, we could not hold our meetings. There were prohibitions related to gatherings that affected us, but because we did not have access to our small business activities, the members had trouble collecting their weekly contribution. We all sell goods and food we prepare either in the markets or on the streets, but none of that was possible for a while. In a nutshell “the country was on a answering machine” and nothing was going well.

Personally COVID-19 had a large impact on my business activity, too. Before, I could make up to 15 000 FCFA (about $30) per day. Today I find myself in the best case at 2 500 FCFA (about $6) per day.

– Djénèba Koné

But after several months, their savings meetings resumed. Now, they have regulations for distancing and handwashing with soap and water, as their animateur instructs during the health sessions with the group. To help cope with the economic consequences of COVID-19, the group has granted loans to most members to help them strengthen their small business activities, or begin new ones that are safer during COVID-19.

Women are providing each other with the support and solidarity they need to stay healthy, not only during the pandemic, but long before it.

Members of the savings group Belle Dame gather in a circle for their meeting in the peri-urban community of Sikoro.

Djénèba and her husband live in Sikoro-Sourakabougou with their six children. Before her savings group, Djénèba was afraid when a health problem arose because she didn’t know where or how to get a loan to pay for healthcare. She would ask for loans from neighbors, but didn’t want to risk gossip or getting a bad name. On one occasion, she had to use all the funds she had for her small business, forcing her to close it and losing her only source of income. She describes the stability that her savings group offers her:

Thanks to my savings in the group, I can have money to solve my family’s health problems in peace and in the utmost confidentiality. I was able to strengthen my small business, in which I was prospering a lot. As a street vendor of cosmetic products, I was able to set up a small kiosk that serves as a store for my business. Now I can provide for my little needs and that of my children.

– Djénèba Koné

In addition to having a source for loans and support for her business, her group also provides health information and help preventing illnesses:

At the end of each cycle, we buy preventive products such as soap and bleach, then we share the remaining money with all members of the group. It is a moment of joy most awaited by the members, and an opportunity for each of us to be able to achieve something like growing our businesses, take care of our children or even to have fun. There has never been a shortfall, and in our group, we are all friends. I am very happy to be part of Belle Dame and I do not intend to leave her with all the advantages that I enjoy.

– Djénèba Koné

COVID-19 continues to disrupt life in Sikoro and across Bamako, but there are no relief programs to restore what Djénèba and women like her have lost. But the networks they built to help each other stay healthy and access resources before COVID-19 continue to serve them during the pandemic. We’re committed to making sure Belle Dame and hundreds of other groups keep going strong.

Keeping communities informed about COVID-19

Keeping communities informed about COVID-19

Mali Health is dedicated to working with communities to strengthen local health systems, so that all mothers and children can stay healthy and have access to quality care. During the past eight months, we have continued to mobilize communication events and activities to help inform peri-urban communities in Bamako about COVID-19 and how to stay safe. Since the beginning of the year, our activities have included:

Two mothers at the COVID-19 caravan in Bakaribougou

1. Education talks on COVID-19

Since the beginning of the pandemic, our community health workers have continued to visit the families in their care, ensuring both the continuity of maternal and child healthcare and sharing information about COVID-19. They make sure mothers and caregivers understand what COVID-19 is, methods of transmission, how to prevent it, as well as symptoms and how to respond. Since January, they have conducted 2,810 talks in households during their home visits, reaching 4,973 people.

In addition to sharing information during home visits, our team is also sharing information at savings group meeting, which have been able to restart safely. So far, 310 talks during group meetings have reached 4,941 women.

Students demonstrate how to wear new masks at Samè COVID-19 caravan

2. COVID-19 Caravan

From mid-May to mid-June, we conducted 13 caravans in communities across all 6 Communes of Bamako, and Mandé:

  • Sikoro-Sourakabougou
  • Sotuba
  • Bakaribougou
  • Lafiabougou
  • Lassa
  • Djicoroni-Para
  • Kalabambougou
  • Sabalibougou
  • Niamakoro
  • Yirimadio
  • Badialan
  • Samè
  • Kanadjiguila

The messages shared during the caravan were those developed by the national health authorities, including a definition of COVID-19, its spread, its symptoms, and the risks of infection. The caravans were held in public, accessible locations, including schools, markets, and open fields. We estimate to have reached about 46,000 people during these caravans, including 18,500 women, 10,500 men, and 17,000 school-aged children.

The COVID-19 caravan travelled to 13 communities in Bamako.

3. Radio programming

We developed and produced two 30-minute radio programs about COVID-19 prevention on two different subjects – how to remain vigilant about COVID-19 prevention and how to manage distancing and contact with someone who is suspected to be COVID-19 positive. We also developed informational radio spots to encourage continued use of barrier measures and to combat misinformation. They also covered three key subjects being encountered in the communities we serve: stigma against recovering COVID-19 patients, protecting vulnerable populations (particularly elders), and how to manage suspected contacts. The spots are being broadcast 180 times on radio stations across Bamako.

A young woman asks a question at the COVID-19 caravan in Bakaribougou

A special thank you to IZUMI Foundation, GlobalGiving, and Fonds d’Appui à l’Autonomisation de la Femme et à l’Epanouissement de l’Enfant (FAFE) for their continued support of our COVID_19 response efforts.