Responding to the Covid-19 pandemic has been not only a public health issue, but a governance issue as well. It’s not enough to develop a vaccine. Officials also need to provide access to the vaccine and convince people to take it.
Over the past year and a half, MIT GOV/LAB collaborated with four universities – Makerere University’s School of Public Health in Uganda, University of Kinshasa’s School of Public Health in the Democratic Republic of the Congo (DRC), University of Ibadan’s College of Medicine in Nigeria, and Cheikh Anta Diop University in Senegal – on phone surveys to better understand people’s attitudes towards Covid-19 vaccines in Africa and their trust in authorities during the pandemic.
The surveys, supported by the Bill and Melinda Gates Foundation, were unique in that they posed a mix of public health and political science questions. They combined MIT GOV/LAB’s perspective on trust and governance with the other universities’ public health expertise to look at how trust shaped people’s attitudes towards vaccines.
“You can’t simply apply a technical lens for vaccine development and rollout to be successful,” says Lily L. Tsai, MIT GOV/LAB’s director and founder and the Ford Professor of Political Science at MIT. “Colleagues at Makerere were reporting high levels of fatigue and burnout in the public health sector – these are social and governance issues – and our collaboration came together to gain new insights on the political and trust dimensions of public health.”
Preliminary results suggest that across all four countries, rural communities had less access to vaccines, showed that citizens value thoughtful care from staff at health care facilities, and revealed that people who trusted the Ministry of Health were more likely to be vaccinated.
The importance of well-intentioned care
The first wave of the survey in Uganda was conducted in November 2021. Based on the success of that survey, the researchers collaborated on additional surveys in the spring and summer of 2022 in the DRC, Nigeria, and Senegal, as well as a second survey wave in Uganda.
Survey participants across all four countries expressed that they were more likely to go to an under-resourced health center with well-intentioned staff than a well-resourced center with staff that did not care about the well-being of patients. This result suggests that people value receiving care from well-intentioned staff at health centers more than receiving services at well-resourced facilities.
Lula Chen, a research scientist at MIT GOV/LAB who contributed to the surveys, sees the result in a positive light. “Given that capacity in general is an issue in a lot of these countries, it’s good to learn that staff being genuine and kind and wanting to really help their patients is in some ways enough for the patients,” she says. The finding also has implications for how government workers should interact with citizens. “To be well-intentioned and genuine … is important,” she says.
The role of trust in vaccinations
Measuring levels of trust in different actors can help researchers determine which actors might be most effective at convincing people to get vaccinated, says Marc Bosonkie, a PhD student working in the nutritional epidemiology department at the University of Kinshasa who was the field coordinator in the DRC for the Covid-19 projects.
Across all four countries, people who indicated they trusted the Ministry of Health were more likely to be vaccinated than people who did not. And among the unvaccinated, those who trusted the Ministry of Health were more likely to express an interest in getting vaccinated. These results suggest that by building trust in their institutions, governments can increase compliance with public health measures.
Survey respondents also displayed a higher level of trust in the Ministry of Health than religious leaders, says Steven Kabwama, an epidemiologist at Makerere University’s School of Public Health who contributed to the research. People were more likely to say they agreed with a statement attributed to the Ministry of Health recommending the Covid-19 vaccine than the same statement attributed to religious leaders.
Past research has suggested that traditional and religious leaders typically have more credibility, Chen says. The higher levels of trust in the Ministry of Health, at least with respect to Covid-19, are “flipping the script a little,” she adds. Officials could use the Ministry of Health to share public health messaging related to vaccinations and Covid-19, Bosonkie says.
But in countries such as Uganda, levels of trust in religious and cultural leaders were close to levels of trust in the Ministry of Health. So religious and cultural leaders can still play an important role in spreading public health messaging, says Rawlance Ndejjo, assistant lecturer in the Department of Disease Control and Environmental Health at Makerere University. Ndejjo led the Covid-19 project secretariat that facilitated the project in the four countries.
Increasing access to vaccines in rural areas could lead to more vaccinations
The surveys also showed that while a smaller percentage of people living in rural areas were vaccinated compared to people in urban areas, a greater percentage of unvaccinated rural residents were interested in getting vaccinated than unvaccinated urban residents.
This suggests that fewer vaccines were available in rural areas, so the Ministries of Health could work to ensure greater vaccine availability in these places, Kabwama says. The findings show that people living in rural areas are “a group that wants to be vaccinated and they haven’t been,” Chen says.
Bosonkie also notes that in the DRC, vaccination rates were lower in rural areas where there was less transmission of Covid-19 and people were less likely to catch the disease. “The perception of risk is one of the key elements of people accepting vaccination or not,” he says.
Combining geographies and expertises
The four universities in Africa originally came together to study countries’ responses to the Covid-19 pandemic in order to develop strategies to improve the response and strengthen health systems. Collaborating across countries would allow researchers to compare response strategies across a range of contexts.
Since the researchers learned from the experience of conducting the first survey wave in Uganda, this made carrying out the other surveys more efficient and streamlined the analysis, Chen says. But the researchers were also able to adjust the surveys to make them relevant to the local contexts they took place in. The four universities in particular also had established relationships with the Ministries of Health in their respective countries, so findings could be disseminated quickly, Kabwama says.
The collaboration with MIT GOV/LAB combined the other schools’ expertise in studying public health systems with our experience looking at issues related to governance and trust in authorities. We have conducted research on how trust in authorities impacts citizens’ levels of compliance with public health measures during Covid-19. We also recently released a mini guide on the importance of trust and how we measure it.
The link between trust and public health demonstrated in the surveys is something officials need to be made aware of, Kabwama says. “We need to advise our leaders and policymakers on the importance of investing in trust,” he adds.
Photo of Uganda Health Worker Administers COVID-19 Vaccine (USAID/Uganda on Flickr).