Targeting the “Movable Middle:” Generating Demand for Vaccinations in Côte d’Ivoire

By Stephanie Schorow for the Global Mass Vaccination Site Collaborative

In December of 2021, VillageReach, a nonprofit with the mission of transforming health care delivery to reach everyone, was preparing to launch a COVID-19 vaccination site in Côte d’Ivoire. They faced a host of logistical considerations – not least of which was where to locate the immunization site in Abidjan, the country’s economic capital. 

Should it be in a district such as Cocody-Bingerville, a high-income area which already exhibited a high demand for vaccination? Or should it be in Yopougon Est, a low-income level, low demand, district?

After much discussion with the government, a site in Yopougon, near a testing center, was chosen, explained Yvan Agbassi, country level lead of Côte d’Ivoire for VillageReach, in a Feb. 18 presentation for the Global Mass Vaccination Site Collaboration, an initiative by Ariadne Labs and the Sabin Vaccine Institute’s Boost Community. The hope was that by installing the site in the low-demand area, vaccine uptake would improve. But “our strategy had to be very targeted, affordable and easy to deploy,” Agbassi noted. 

To that end, organizers aimed to:

  • Focus on reaching those who wanted to get the vaccine and those who could be persuaded to get it rather than trying to reach those who were set against it. In other words, they targeted those in the “movable middle” and the “vaccine enthusiasts.” 
  • Recruit site clients as ambassadors and encourage them to recruit three family members/friends for immunization. 
  • Build approval from community leaders. For example, faith leaders were invited to the site opening to answer their questions and address any concerns.  
  • Create strong, positive social norms around COVID-19 vaccination and underscore its safety. 
  • Use radio interviews with site operators to promote the site to make people aware of the site and to stress the ease of getting a shot. 
  • Utilize referrals from the nearby testing site to drive traffic to the immunization site. 

Agbassi acknowledged that demand was first low, but by utilizing the above activities it began increasing in January, although bad weather closed the site for a week. “We are learning from what we are doing,” he stressed. 

Do not assume, he noted, that “If you build a site they will come.” Flexibility is important. Community outreach and community is essential. “Collaboration is key.” Much will depend on discussions with the Côte d’Ivoire government. 

In response to a question, Agbassi said word of mouth and radio were the most effective ways to lead to more vaccination uptake.

The Feb. 18 meeting also included a presentation by Brian Pedersen, technical advisor for FHI360, a nonprofit human development organization that advances integrated, locally driven solutions. In partnership with VillageReach, FHI360 conducted interviews with the local population in Yopougon to strengthen outreach strategies and gather data on why people were not coming in for vaccinations. In effect, this was weaving in social science research in real time, Pedersen said. Using the Fogg Behavioral Model, FHI360 devised four core rapid intercept survey questions and asked them on the street and in markets and malls as part of a pilot: 

  1. Are you vaccinated?
  2. Why aren’t you vaccinated? 
  3. What could be done to help you overcome [stated barrier]
  4. If you decided to get vaccinated, what would [make it easier] to do it today?

More research is needed but the initial pilot found that the primary reasons for not vaccinating focused on “concerns about vaccine safety,” especially fertility among young women, and a “low perceived threat of COVID-19.” Some young people stated they would not get vaccinated because their parents did not want them to get vaccinated.

FHI360 will do other interviews with VillageReach with providers, clients – including asking them what they are hearing in their social circles – and area influencers such as religious leaders. The creation of a second vaccination site may give the opportunity to compare and contrast approaches for better solutions, Pedersen said.

Many of the themes of the presentation resonated with other site operations. “We partnered with community trust brokers to identify churches, schools and other sites in communities that had limited access to mass vaccination sites,” commented Eric Goralnick, MD, MS, Principal Investigator for Ariadne Labs’ Global Mass Vaccination Site Collaborative, who worked on setting up mass vaccination sites in Massachusetts. 

The Global Mass Vaccination Site Collaborative was launched as a way for stakeholders directing vaccination campaigns around the world to come together and learn from each other’s efforts. This blog series was created to record and share the learning and insights gained from this collaboration. Read blogs from our previous meetings here.