Immunisation is considered one of the most cost-effective public health interventions, saving millions of lives each year, and benefiting the health of the wider community through herd immunity.
Yet, there is as much reason to worry as to celebrate. During the COVID-19 pandemic, the world witnessed a strong disruption in routine immunisation, leading to an increase in outbreaks of diphtheria, measles, polio, and yellow fever in over 100 countries. On the one hand, this can be explained by challenges with the supply of vaccines and the reduced availability of healthcare workers due to confinement policies, illness, and the diversion of activities to COVID-19.
But declining confidence in vaccines also played a role. Indeed, vaccine hesitancy, the reluctance or refusal to vaccinate, is a key barrier to immunisation and a major threat to global health.
Some make the case that vaccine demand can be actively promoted through communication campaigns. While there is a large body of evidence on what and how to communicate, less is known about who should communicate.
Recent studies from the US suggest that the public vaccination of high-profile politicians may boost vaccine confidence.
But systematic information on such vaccine role modelling is lacking. And it’s unclear to what extent results apply in different settings.
In a recently published study we set out to close these gaps.
We used the Democratic Republic of Congo as our case study. Vaccine confidence strongly declined in this country during the COVID-19 pandemic. This is acause for concern, as Africa is already lagging behind the rest of the world in achieving universal vaccination coverage.
Our focus was to understand the extent to which the vaccination of a president in public view increased vaccine uptake.
We concluded from our findings that it does, but under two conditions. Firstly, citizens must see the president as trustworthy. And secondly, the president’s vaccination must be communicated as widely as possible and include parts of the country or communities where there is low media access.
Where these two conditions aren’t met, vaccinating public village leaders or respected older adult community members might be a more effective approach to increasing vaccine uptake.
Presidents and vaccines
We found that around the world, 168 out of 173 leaders explicitly supported the COVID-19 vaccination campaign, 139 leaders (80%) made their own COVID-19 vaccination public and 108 leaders (78% of those vaccinated) distributed a picture or video of their vaccination.
President Felix Tshisekedi of the DRC received his COVID-19 vaccine live on Congolese television on 13 September 2021.
Vaccination rates in the country were low. By March 2022, only 5.7% of the population had received at least one vaccine dose, and just 1.03% were fully vaccinated. A number of factors were behind these low numbers:
low confidence in COVID-19 vaccines
a combination of limited healthcare services, poor transport infrastructure, and concerns about the safety of the AstraZenica vaccine, making the DRC unable to use most of the 1.7 million vaccine doses it received under the global Covax scheme for poorer countries
broader governance issues, including rampant corruption and political instability.
DR Congo is ranked near the bottom of the Human Development Index, occupying place 180 out of 193 countries. This indicates low levels of health, education and income. Our research took place in the country’s east, which has been plagued by violence for over two decades.
In addition, the region was facing an outbreak of the Ebola virus disease when COVID-19 hit.
Within this context, we analysed the potential of President Tshisekedi to act as a vaccine ambassador and influence COVID-19 vaccine uptake.
In September 2021, we conducted a survey with 600 people in six villages of Lubero territory, in the province of North Kivu. Lubero is a remote and mostly rural area with poor public infrastructure and little access to media or news outlets. COVID-19 vaccines were not yet available in the study area.
Our survey started before Tshisekedi got vaccinated.
We asked: “Let’s assume a vaccine against coronavirus was available for you; would you take it?”.
While 98% of respondents said they had vaccinated their children against diseases such as tuberculosis, polio or measles, only 22% indicated they would accept a COVID-19 vaccine.
From answers to open questions we learned that this mismatch can largely be explained by respondents’ general lack of trust in the COVID-19 vaccine and its efficacy, and the fear of potentially mortal side-effects.
We further found low levels of institutional trust. Only 17% of respondents indicated they trusted the president when asked to what extent they believed he represented the best interests of the Congolese population.
Respondents also reported low phone ownership and access to media. In the week prior to the survey, 91% of respondents did not watch television and 57% did not listen to the radio.
Prior to asking about COVID-19 vaccine acceptance, a random third of respondents received the prompt: “Assume the president, Félix Tshisekedi, were to take the vaccine live on television”.
We measured the impact of this prompt by comparing respondents’ stated vaccine acceptance to that of a randomly selected control group and found that trust moderated the results. For those who reported trusting the president, we found that the survey experiment boosted vaccine acceptance by 25 percentage points. Instead, for those who mistrusted the president, vaccine acceptance was lower among those who saw the prompt, by 6 percentage points.
To our surprise, the president got publicly vaccinated while our survey was in progress. Given low media access in our study region, only 18% of those interviewed after the broadcasting of Tshisekedi’s vaccination reported being aware of it. When comparing respondents with similar socio-economic profiles, access to media and levels of trust, we found that being aware of the president’s vaccination increased vaccine acceptance by 20 percentage points.
Policy implications
Our findings highlight that to serve as a vaccination model:
the leader should be perceived as trustworthy by citizens
the vaccination should be widely communicated.
When trust in national leaders is lacking, or news on their actions is inaccessible, other leaders might be more effective in boosting vaccine acceptance.