Engaging the public in decisions about emergency vaccine deployment strategies: Lessons from scenario-based discussions in Sierra Leone.

ABSTRACTThe COVID-19 pandemic has amplified discussions on emergency vaccine deployment strategies, with current perspectives often neglecting extensive community involvement in ethical, logistical and political aspects. Existing social science literature predominantly delves into factors influencing trust, overlooking the untapped potential for community engagement.Our study examines community preparedness in Sierra Leone's Kambia District, exploring diverse viewpoints on vaccine deployment strategies, emphasising Ebola and COVID-19 vaccinations. Utilising extensive ethnographic research from the Ebola vaccine trials (EBOVAC Salone) conducted in Kambia District from 2015 to 2021, including participant observation and tailored focus group discussions, we investigated various deployment scenarios with community leaders and citizens.Our findings underscore the multifaceted contributions of social science research with communities in shaping emergency vaccination strategies. These contributions span logistical insights, aligning campaigns with local livelihoods and social structures, and grounded ethical concerns assessing social justice outcomes across epidemic scenarios. This study emphasises the imperative of integrating discussions on vaccine confidence and deployment. It highlights communities' proficiency in epidemiological reasoning and their ability to bring this in conversation with salient socio-cultural, economic and religious dimensions. We therefore promote the cultivation of public dialogue, collaborative creation of impactful vaccination initiatives alongside relevant communities in recognition of their invaluable perspectives .

Continuity and Rupture in Crisis: from Ebola to COVID-19 in Sierra Leone and the eastern Democratic Republic of the Congo.

This article examines the experience of healthcare professionals working in primary healthcare provision during the first wave of the COVID-19 pandemic in North Kivu, the Democratic Republic of the Congo, and in Kambia District, Sierra Leone. Drawing on ethnographic observation, interviews and focus groups, we explore everyday narratives of 'crisis' in these two regions which had recently seen Ebola epidemics. In describing the impact of COVID-19 on their life, work, and relationships with patients, healthcare workers made sense of the pandemic in relation to broader experiences of structural economic and political crisis, as well as differing experiences of recent Ebola epidemics. There were contradictory experiences of rupture and continuity: whilst COVID-19 disrupted routine health provision and exacerbated tensions with patients, the pandemic was also described as continuity, interacting with broader structural problems and longer-term experiences of 'crisis'. In effect, healthcare workers experienced the COVID-19 pandemic at the crossroads between the exceptional and the everyday, where states of exception brought by emergency measures shed new light on long-standing tensions and structural crisis.

Experiences and Implications of the First Wave of the COVID-19 Emergency in Italy: A Social Science Perspective.

BACKGROUND: Italy was among the first countries in the world to experience the devastating consequences of the COVID-19 emergency and suffered its consequences to a devastating scale. Understanding how the country got there in spite of a relatively well-resourced public and private health system in at least part of the country, is imperative to be able to operationalise any lessons learnt for future epidemics in Italy and beyond. METHODS: The paper reports the findings from a research scoping exercise conducted in Italy in 2020. We conducted extensive archival research and collected 29 testimonies either in writing or as semi-structured interviews. We sampled purposively with a stratification strategy in mind, specifically aiming to gain testimonies from different social groups, classes, ages, and nature of employment. Our sample also reflects the different experiences between the Northern and Southern regions, a divide that has long been economically and politically salient in the country. RESULTS: Evidence and considerations of epidemiological nature normally guide public health responses to crises. This study supports the idea that socio-economic, cultural and political factors also affect transmission outcomes. We highlight specifically the role that socio-economic and health inequalities play in this respect, through factors such as overcrowded dwellings, lack of alternatives to in-person work, informal work set-ups, pervasive organised crime presence, poorly planned social support and communication strategies. CONCLUSION: A socio-economic and political lens is needed in addition to an epidemiological one to fully understand the social experiences and implications of public health crises such as the COVID-19 pandemic and to devise effective response measures that are locally relevant and acceptable. Thus insights provided by multi-disciplinary task forces can render policy-making and social support interventions as well as communication strategies more effective.

Contesting the crisis narrative: epidemic accounts in Sierra Leone, Tanzania, and Democratic Republic of the Congo.

Scientists and global commentators watched African countries closely in the early months of the COVID-19 pandemic, predicting an impending disaster: the virus was projected to overwhelm already weak health systems. These expectations were informed by imaginaries of Africa as an inevitable site of epidemic disaster. This paper draws on accounts from Sierra Leone, Tanzania, and Democratic Republic of the Congo to contrast global catastrophe framings with everyday imaginations and experiences of crisis and crisis management. Utilising ethnographic research, the paper initially explores how COVID-19 was understood in relation to previous epidemics, from HIV (human immunodeficiency virus) to Ebola, as well as political conflict. It then considers how global crisis narratives both inform and are in tension with everyday collective and personal experiences. The paper brings these empirical reflections into a conversation with theoretical debates on the discursive construction of crisis and its effects, and argues that these tensions matter because crisis framings have consequences.

Changing gear: Experiences of how existing qualitative research can adapt to an unfolding health emergency.

Long-term research projects are not always able to adapt to a new crisis and incorporate characteristics and approaches of rapid research to produce useful data quickly. Project AViD was a programme of research that ran between 2018 and 2022 to examine factors that shape vaccine confidence. The project initially focused on five country case studies looking at vaccines for Ebola, Measles, Rift Valley Fever and Zika. The COVID-19 pandemic emerged during this time and provided an opportunity to contribute to the pandemic's 'million-dollar question'-how to deploy COVID-19 vaccines. Drawing on our experience as researchers, and specifically from AViD, we propose seven factors that can influence when and how longer-term qualitative research projects can adapt and contribute to the response to an unfolding health emergency. These include: (1) the phase of research in which the emergency hits; (2) the relative significance of the emergency in the research setting; (3) the specific methods and research team capacities; (4) existing operational links; (5) supportive ecosystems; (6) flexibility in research contracting and funding; and (7) the research team attitude and approach. We close with two considerations for longer-term research projects that find themselves having to "change gear" amid a public health emergency-the need to re-assess risks and benefits and the need to protect equitable partnerships.

Human preparedness: Relational infrastructures and medical countermeasures in Sierra Leone.

This paper examines health worker experiences in two areas of post-epidemic preparedness in Sierra Leone - vaccine trials and laboratory strengthening - to reflect on the place of people in current models of epidemic response. Drawing on ethnographic research and interviews with health workers in the aftermath of Ebola, it explores the hopes and expectations that interventions foster for frontline workers in under-resourced health systems, and describes the unseen work involved in sustaining robust response infrastructures. Our analysis focuses on what it means for the people who sustain health systems in an emergency to be 'prepared' for an epidemic. Human preparedness entails more than the presence of a labour force; it involves building and maintaining 'relational infrastructures', often fragile social and moral relationships between health workers, publics, governments, and international organisations. The COVID-19 pandemic has underscored the value of rethinking human resources from an anthropological perspective, and investing in the safety and support of people at the forefront of response. In describing the labour, personal losses, and social risks undertaken by frontline workers for protocols and practicality to meet in an emergency context, we describe the social process of preparedness; that is, the contextual engineering and investment that make response systems work.

Family Planning in the Sierra Leone Ebola Outbreak: Women's Proximal and Distal Reasoning.

Sierra Leone was highly impacted by the 2014-2016 West Africa Ebola outbreak, with 3,955 recorded deaths. Already stressed maternal health services were deeply affected by the outbreak due to fears of viral transmission, reallocation of maternity staff, and broader policies to stop transmission including travel restrictions. This research sought to explore women's perspectives on delaying pregnancy during the Ebola outbreak using family planning methods. Qualitative data collection took place in Kambia District in 2018 and included 35 women participants, with women who were either family planning users or nonusers at the time of the outbreak. Women reported a variety of reasons for choosing to take or not to take family planning during the outbreak, which we categorized as proximal (directly related to the outbreak) or distal (not directly outbreak related). Proximal reasons to take family planning included to avoid interacting with health care spaces where Ebola could be transmitted, to avoid the economic burden of additional children in a time when economic activities were curtailed and to return to school when education resumed postoutbreak. Distal reasoning included gender roles affecting women's decision making to seek family planning, concerns related to the physiological side effects of family planning, and the economic burden of paying for family planning. Women's perspectives for choosing to take or not take family planning during the Sierra Leone Ebola crisis had not been explored prior to this paper. Using the lens of family planning to consider how women choose to access health care in an outbreak gives us a unique perspective into how all health care interactions are impacted by a generalized outbreak of Ebola, and how outbreak responses struggle to ensure such services remain a priority.

Attributing public ignorance in vaccination narratives.

The notion of an 'ignorant public' is attributed in outbreak scenarios through vaccination narratives that are institutionally reinforced by governments and the media across different contexts. The ignorant public narrative is a discursive shift that reduces public concerns about vaccines to a lack of knowledge, obscuring how these concerns are indicative of mistrust and anxiety or efforts to counter the dominance of acceptable and legitimate knowledge. This narrative risks a deflection of challenges in the structural determinants of vaccine uptake and depoliticise rumours and mistrust that arise during vaccination campaigns. Examples from Sierra Leone, Uganda, and India show how 'ignorant public' framings are used as explanation for vaccine hesitancy through assigned roles for institutions and publics, and the consequences this narrative has for vaccination encounters. These examples are based on ethnographic fieldwork and media analysis carried out before, during, and after outbreaks, of newly introduced vaccines for both human and animal health. Drawing on science communication and development studies, we show how this narrative then positions governmental concern about vaccine hesitancy as being a (largely) imagined issue of public ignorance. We argue that when institutions tasked with strengthening vaccine uptake see public ignorance as the key problem, this can obscure other problems, such as competing interests and experiences, and also minority group treatment. As a result, public governance is rationalised by assigning the ignorance label to certain public groups that stand in contrast to scientific and government expertise, and so accountability for low vaccine uptake is transferred onto the public.

Vaccine Confidence and Hesitancy at the Start of COVID-19 Vaccine Deployment in the UK: An Embedded Mixed-Methods Study.

Background: Approval for the use of COVID-19 vaccines has been granted in a number of countries but there are concerns that vaccine uptake may be low amongst certain groups. Methods: This study used a mixed methods approach based on online survey and an embedded quantitative/qualitative design to explore perceptions and attitudes that were associated with intention to either accept or refuse offers of vaccination in different demographic groups during the early stages of the UK's mass COVID-19 vaccination programme (December 2020). Analysis used multivariate logistic regression, structural text modeling and anthropological assessments. Results: Of 4,535 respondents, 85% (n = 3,859) were willing to have a COVID-19 vaccine. The rapidity of vaccine development and uncertainties about safety were common reasons for COVID-19 vaccine hesitancy. There was no evidence for the widespread influence of mis-information, although broader vaccine hesitancy was associated with intentions to refuse COVID-19 vaccines (OR 20.60, 95% CI 14.20-30.30, p < 0.001). Low levels of trust in the decision-making (OR 1.63, 95% CI 1.08, 2.48, p = 0.021) and truthfulness (OR 8.76, 95% CI 4.15-19.90, p < 0.001) of the UK government were independently associated with higher odds of refusing COVID-19 vaccines. Compared to political centrists, conservatives and liberals were, respectively, more (OR 2.05, 95%CI 1.51-2.80, p < 0.001) and less (OR 0.30, 95% CI 0.22-0.41, p < 0.001) likely to refuse offered vaccines. Those who were willing to be vaccinated cited both personal and public protection as reasons, with some alluding to having a sense of collective responsibility. Conclusion: Dominant narratives of COVID-19 vaccine hesitancy are misconceived as primarily being driven by misinformation. Key indicators of UK vaccine acceptance include prior behaviors, transparency of the scientific process of vaccine development, mistrust in science and leadership and individual political views. Vaccine programmes should leverage the sense of altruism, citizenship and collective responsibility that motivated many participants to get vaccinated.

Bringing the social into vaccination research: Community-led ethnography and trust-building in immunization programs in Sierra Leone.

BACKGROUND: Vaccine hesitancy is a complex, contested social phenomenon and existing research highlights the multifaceted role of trust in strengthening vaccine confidence. However, understanding public engagement with vaccination through the lens of (mis)trust requires more contextual evidence on trust's qualitative determinants. This includes expanding the geographic focus beyond current studies' focus on High Income Countries. Furthermore, obstacles remain in effectively integrating social science findings in the design of vaccine deployment strategies, and in ensuring that those who implement interventions and are affected by them are directly involved in producing knowledge about vaccination challenges. METHODS: We piloted a community-led ethnographic approach, training Community Health Workers (CHWs) in Kambia District, Sierra Leone, in qualitative social science methods. Methods included participant observation, participatory power mapping and rumour tracking, focus group discussions and key stakeholder interviews. CHWs, with the support of public health officials and professional social scientists, conducted research on vaccination challenges, analysed data, tested new community engagement strategies based on their findings and elicited local perspectives on these approaches. RESULTS: Our findings on vaccine confidence in five border communities highlighted three key themes: the impact of prior experiences with the health system on (mis)trust; relevance of livelihood strategies and power dynamics for vaccine uptake and access; and the contextual nature of knowledge around vaccines. Across these themes, we show how expressions of trust centered on social proximity, reliability and respect and the role of structural issues affecting both vaccine access and confidence. The pilot also highlighted the value and practical challenges to meaningfully co-designed research. CONCLUSION: There is scope for broader application of a community-led ethnographic approach will help redesign programming that is responsive to local knowledge and experience. Involving communities and low-cadre service providers in generating knowledge and solutions can strengthen relationships and sustain dialogue to bolster vaccine confidence.

Trust and transparency in times of crisis: Results from an online survey during the first wave (April 2020) of the COVID-19 epidemic in the UK.

BACKGROUND: The success of a government's COVID-19 control strategy relies on public trust and broad acceptance of response measures. We investigated public perceptions of the UK government's COVID-19 response, focusing on the relationship between trust and perceived transparency, during the first wave (April 2020) of the COVID-19 pandemic in the United Kingdom. METHODS: Anonymous survey data were collected (2020-04-06 to 2020-04-22) from 9,322 respondents, aged 20+ using an online questionnaire shared primarily through Facebook. We took an embedded-mixed-methods approach to data analysis. Missing data were imputed via multiple imputation. Binomial & multinomial logistic regression were used to detect associations between demographic characteristics and perceptions or opinions of the UK government's response to COVID-19. Structural topic modelling (STM), qualitative thematic coding of sub-sets of responses were then used to perform a thematic analysis of topics that were of interest to key demographic groups. RESULTS: Most respondents (95.1%) supported government enforcement of behaviour change. While 52.1% of respondents thought the government was making good decisions, differences were apparent across demographic groups, for example respondents from Scotland had lower odds of responding positively than respondents in London. Higher educational levels saw decreasing odds of having a positive opinion of the government response and decreasing household income associated with decreasing positive opinion. Of respondents who thought the government was not making good decisions 60% believed the economy was being prioritised over people and their health. Positive views on government decision-making were associated with positive views on government transparency about the COVID-19 response. Qualitative analysis about perceptions of government transparency highlighted five key themes: (1) the justification of opacity due to the condition of crisis, (2) generalised mistrust of politics, (3) concerns about the role of scientific evidence, (4) quality of government communication and (5) questions about political decision-making processes. CONCLUSION: Our study suggests that trust is not homogenous across communities, and that generalised mistrust, concerns about the transparent use and communication of evidence and insights into decision-making processes can affect perceptions of the government's pandemic response. We recommend targeted community engagement, tailored to the experiences of different groups and a new focus on accountability and openness around how decisions are made in the response to the UK COVID-19 pandemic.

Comparative ethnographies of medical research: materiality, social relations, citizenship and hope in Tanzania and Sierra Leone.

In this paper we bring together ethnographic research carried out during two clinical prevention trials to explore identities, relations and political imaginations that were brought to life by these different technologies. We highlight the ways in which critical anthropological engagement in clinical trials can help us radically reconsider the parameters and standards of medical research. In the paper we analyse the very different circumstances that made these two trials possible, highlighting the different temporalities and politics of HIV and Ebola as epidemics. We then describe four themes revealed by ethnographic research with participants and their communities but mediated by the specific sociopolitical contexts in which the trials were taking place. In both countries we found materiality and notions of exchange to be important to participants' understanding of the value of medical research and their role within it. These dynamics were governed through social relations and moral economies that also underpinned challenges to Western notions of research ethics. The clinical trials offered a language to express both disaffection and disillusionment with the political status quo (often through rumours and anxieties) while at the same time setting the foundations for alternative visions of citizenship. Attached to these were expressions of 'uncertainty and hope' steeped in locally distinctive notions of destiny and expectations of the future.

Behavioral Change Towards Reduced Intensity Physical Activity Is Disproportionately Prevalent Among Adults With Serious Health Issues or Self-Perception of High Risk During the UK COVID-19 Lockdown.

Objectives: We assessed whether lockdown had a disproportionate impact on physical activity behavior in groups who were, or who perceived themselves to be, at heightened risk from COVID-19. Methods: Physical activity intensity (none, mild, moderate, or vigorous) before and during the UK COVID-19 lockdown was self-reported by 9,190 adults between 2020-04-06 and 2020-04-22. Physician-diagnosed health conditions and topic composition of open-ended text on participants' coping strategies were tested for associations with changes in physical activity. Results: Most (63.9%) participants maintained their normal physical activity intensity during lockdown, 25.0% changed toward less intensive activity and 11.1% were doing more. Doing less intensive physical activity was associated with obesity (OR 1.25, 95% CI 1.08-1.42), hypertension (OR 1.25, 1.10-1.40), lung disease (OR 1.23, 1.08-1.38), depression (OR 2.05, 1.89-2.21), and disability (OR 2.13, 1.87-2.39). Being female (OR 1.25, 1.12-1.38), living alone (OR 1.20, 1.05-1.34), or without access to a garden (OR 1.74, 1.56-1.91) were also associated with doing less intensive physical activity, but being in the highest income group (OR 1.73, 1.37-2.09) or having school-age children (OR 1.29, 1.10-1.49) were associated with doing more. Younger adults were more likely to change their PA behavior compared to older adults. Structural topic modeling of narratives on coping strategies revealed associations between changes in physical activity and perceptions of personal or familial risks at work or at home. Conclusions: Policies on maintaining or improving physical activity intensity during lockdowns should consider (1) vulnerable groups of adults including those with chronic diseases or self-perceptions of being at risk and (2) the importance of access to green or open spaces in which to exercise.

EBOVAC-Salone: Lessons learned from implementing an Ebola vaccine trial in an Ebola-affected country.

Background/aims During the 2014-2016 West African Ebola epidemic, clinical trials were fast-tracked in order to identify prophylactic vaccines and experimental treatments that might be useful in preventing or treating Ebola. These trials included the ongoing EBOVAC-Salone study, which was established and implemented in Sierra Leone to assess the safety and immunogenicity of the Ad26.ZEBOV/MVA-BN-Filo prime-boost Ebola vaccine regimen. Methods This article describes the experiences of the EBOVAC-Salone research team in setting up and implementing the trial, and provides recommendations for research teams aiming to conduct clinical trials in future outbreak situations. Results Establishing a clinical trial during an outbreak brought some unique challenges, including those related to trial design and the regulatory environment, operational issues, and community engagement. The situation was further complicated by the weak infrastructure and limited experience of clinical trials in Sierra Leone. However, operating in an outbreak context also brought some benefits to the research team, including strong stakeholder support. The EBOVAC-Salone study recruited participants both during and after the outbreak, leading to additional challenges to trial implementation during the post-outbreak transition. Conclusion Many lessons have been learned about setting up and implementing a clinical trial during a devastating Ebola epidemic, and some of the experiences of the EBOVAC-Salone team were mirrored by those of other researchers operating in the region. Common to several of these research groups is a recommendation that research should be more closely incorporated into outbreak response planning, which could expedite the establishment of timely and appropriate research projects. We recommend that the lessons learned by researchers during the West African Ebola epidemic are built into programmes and strategies to improve the responses to future epidemics, wherever they occur.

"We are the heroes because we are ready to die for this country": Participants' decision-making and grounded ethics in an Ebola vaccine clinical trial.

The 2014-2016 Ebola epidemic presented a challenging setting in which to carry out clinical trials. This paper reports findings from social science research carried out in Kambia, Northern Sierra Leone during first year of an Ebola vaccine trial (August 2015-July 2016). The social science team collected data through ethnographic observation, 42 in depth interviews; 4 life narratives; 200 exit interviews; 31 key informant interviews; and 8 focus group discussions with trial participants and community members not enrolled in the trial. Whilst research often focuses on why people refuse vaccination, we instead explore participant motivations for volunteering for the study, in spite of prevailing anxieties, rumours and mistrust during and after the Ebola outbreak. In so doing the paper contributes to on-going debates about research ethics and community engagement in resource poor contexts, offering reflections from an emergency and post-epidemic setting. We analyse participants' perceptions of the risks and benefits of participations, highlighting the importance of a contextual approach. We focus on four types of motivation: altruism; curiosity and hope; health-seeking; and notions of exchange, and argue for the role of social science in developing grounded research ethics and community engagement strategies that can take into account context and local realities.

Power, fairness and trust: understanding and engaging with vaccine trial participants and communities in the setting up the EBOVAC-Salone vaccine trial in Sierra Leone.

BACKGROUND: This paper discusses the establishment of a clinical trial of an Ebola vaccine candidate in Kambia District, Northern Sierra Leone during the epidemic, and analyses the role of social science research in ensuring that lessons from the socio-political context, the recent experience of the Ebola outbreak, and learning from previous clinical trials were incorporated in the development of community engagement strategies. The paper aims to provide a case study of an integrated social science and communications system in the start-up phase of the clinical trial. METHODS: The paper is based on qualitative research methods including ethnographic observation, interviews with trial participants and key stakeholder interviews. RESULTS: Through the case study of EBOVAC Salone, the paper suggests ways in which research can be used to inform communication strategies before and during the setting up of the trial. It explores notions of power, fairness and trust emerging from analysis of the Sierra Leonean context and through ethnographic research, to reflect on three situations in which social scientists and community liaison officers worked together to ensure successful community engagement. Firstly, a section on "power" considers the pitfalls of considering communities as homogeneous and shows the importance of understanding intra-community power dynamics when engaging communities. Secondly, a section on "fairness" shows how local understandings of what is fair can help inform the design of volunteer recruitment strategies. Finally, a section on "trust" highlights how historically rooted rumours can be effectively addressed through active dialogue rather than through an approach focused on correcting misinformation. CONCLUSION: The paper firstly emphasises the value of social science in the setting up of clinical trials, in terms of providing an in depth understanding of context and social dynamics. Secondly, the paper suggests the importance of a close collaboration between research and community engagement to effectively confront political and social dynamics, especially in the context of an epidemic.