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.

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.

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.

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

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

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.