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Dr. Cosmas Zyambo is currently the Chair for the Community and Family Health Medicine department at the University of Zambia School of Public Health. He also holds an adjunct assistant professor position in the department of Health Behavior at the University of Alabama Birmingham School of Public Health. His work focuses on a number of HIV-related studies, such as NCDs, smoking, smoking cessation, alcohol consumption, mental health, and substance abuse in adolescents and the HIV population in Zambia. Dr. Zyambo received his medical degree from the University of Zambia, his Masters of Philosophy from the University of Bergen in Norway, and his PhD from the University of Alabama, Birmingham.

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Dr. Lawrence Mwananyanda is a clinician/scientist with a wealth of experience in conducting medical and public health research. He has been Principal Investigator or Co-PI on multiple research project. His portfolio includes being the Director of the HIV Vaccines Trials Unit at the Botswana Harvard Partnership where he and colleagues worked on the first Phase 1 HIV vaccine trials to be conducted in Africa. His interest with HIV vaccines research continued with his stint at the Emory University under the Zambia HIV Research Project where they studied conformational changes of the HIV at infection in a cohort of discordant couples to aid in design of next generation HIV trial vaccines.

Dr. Goma is an Associate Professor of Physiology and Cardiovascular Health at the University of Zambia School of Medicine. He has also studied International Public Health at University of Alabama at Birmingham (UAB), USA and Tobacco Dependency Management at the Centre for Addiction and Mental Health (CAMH), University of Toronto, Canada. He is the Director for the Centre for Primary Care Research (CPCR) at the University of Zambia, School of Medicine which has been the secretariat for the Zambia Non-Communicable Diseases Alliance (ZANOCODA). His main research interests include risk factors for Non-Communicable Diseases (Tobacco & Hypertension), Palliative Care, knowledge translation (KT) and human resources for health (HRH) within the health systems arena.

Dr. Choolwe Nkwemu Jacobs is a Social Epidemiologist and public health specialist with a nursing background. I conduct research, lecture and supervise student’s research projects in the University of Zambia, School of Public Health at postgraduate level. I have expertise, leadership, training and research interest is in HIV/AIDs, bioethics, reproductive, maternal and newborn health, child health, adolescent health, communicable and non-communicable diseases, and implementation research. I am competent on a range of teaching and research methodologies including implementation research, quantitative and qualitative methods/studies, case-control studies, randomized controlled trials, cohort studies and household surveys.

Dr. Kilembe has worked at the Zambia Emory HIV Research Project (ZEHRP) now called Center for Family Health Research in Zambia (CFHRZ) since 2001 and currently serves as the Project Director in Lusaka. He is the Principal Investigator on an International AIDS Vaccine Initiative (IAVI) study to recruit a cohort of high-risk women (HRW: female sex workers (FSW) and single mothers (SM)) for studies on incidence and risk factors for HIV and STI, acute HIV infection, and preparedness activities for HIV vaccine clinical trials. In addition, he managed NIH, IAVI, and CDC funded research and program activities with heterosexual cohabiting couples, including expansion of couples voluntary counseling and testing (CVCT) within Zambia, integration of CVCT into public health facility service delivery and followed prospective cohorts to study correlates of HIV transmission and pathogenesis in order to inform HIV vaccine development and prepare for HIV vaccine efficacy trials. Currently, he is the principal investigator for a Phase 2b HIV vaccine efficacy trial sponsored the HIV Vaccine Trials Network and Janssen and Janssen (HVTN 705), into which their two Zambia research centers have enrolled 218 participants from the cohort of HRW. He is also the PI of other vaccine and therapeutic trials for HIV and COVID 19.

Dr. Kwenda is a molecular biologist with significant research, administrative and mentoring experience, and the immediate past Head of the Department of Biomedical Sciences in the School of Health Sciences at UNZA. He is also a former Fogarty Fellow at the University of Nebraska, where he was involved in studying the transmission of Kaposi’ Sarcoma-associated Human Herpesvirus (KSHV) in a Zambian population. His research interests are mainly in infectious diseases, where he uses evolutionary genomics, molecular taxonomy, field ecology, bioinformatics and experimentation to investigate clinical and environmental factors that are driving infectious diseases. Most of his work focuses on the genomic epidemiology of antimicrobial resistance (AMR) in enterobacteria, respiratory pathogens, methicillin-resistant Staphylococcus aureus (MRSA) and Cryptococcus. His ultimate research goal is focused on understanding the natural reservoir of infection and comparing it to what we already know about infectious agents that will help us understand the mechanisms behind disease, informing prevention and treatment strategies, thereby reducing the burden of disease.

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Peer-reviewed

Research Article

An evaluation of the early impact of the COVID-19 pandemic on Zambia’s routine immunization program

Contributed equally to this work with: Amy K. Winter, Saki Takahashi

Roles Conceptualization, Data curation, Methodology, Visualization, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Department of Epidemiology and Biostatistics, University of Georgia, Athens, Georgia, United States of America

Affiliation Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America

Roles Data curation, Writing – original draft, Writing – review & editing

Affiliation Department of International Health, International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America

Roles Conceptualization, Funding acquisition, Writing – review & editing

Roles Data curation, Investigation, Writing – review & editing

Affiliation School of Public Health, University of Zambia, Lusaka, Zambia

Roles Conceptualization, Data curation, Investigation, Writing – review & editing

Affiliation Child Health Unit, Directorate of Public Health and Research, Ministry of Health, Lusaka, Zambia

Affiliation Field Epidemiology Training Program, Zambia National Public Health Institute, Lusaka, Zambia

Roles Conceptualization, Funding acquisition, Investigation, Project administration, Writing – review & editing

Affiliations Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America, Department of International Health, International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America

Roles Conceptualization, Data curation, Investigation, Project administration, Writing – original draft, Writing – review & editing

• Amy K. Winter, 
• Saki Takahashi, 
• Andrea C. Carcelen, 
• Kyla Hayford, 
• Wilbroad Mutale, 
• Francis D. Mwansa, 
• Nyambe Sinyange, 
• David Ngula, 
• William J. Moss, 
• Simon Mutembo

• Published: May 2, 2023
• https://doi.org/10.1371/journal.pgph.0000554
• Peer Review
• Reader Comments

Implications of the COVID-19 pandemic for both populations and healthcare systems are vast. In addition to morbidity and mortality from COVID-19, the pandemic also disrupted local health systems, including reductions or delays in routine vaccination services and catch-up vaccination campaigns. These disruptions could lead to outbreaks of other infectious diseases that result in an additional burden of disease and strain on the healthcare system. We evaluated the impact of the COVID-19 pandemic on Zambia’s routine childhood immunization program in 2020 using multiple sources of data. We relied on administrative vaccination data and Zambia’s 2018 Demographic and Health Survey to project national disruptions to district-specific routine childhood vaccination coverage within the pandemic year 2020. Next, we leveraged a 2016 population-based serological survey to predict age-specific measles seroprevalence and assessed the impact of changes in vaccination coverage on measles outbreak risk in each district. We found minor disruptions to routine administration of measles-rubella and pentavalent vaccines in 2020. This was in part due to Zambia’s Child Health Week held in June of 2020 which helped to reach children missed during the first six months of the year. We estimated that the two-month delay in a measles-rubella vaccination campaign, originally planned for September of 2020 but conducted in November of 2020 as a result of the pandemic, had little impact on modeled district-specific measles outbreak risks. This study estimated minimal increases in the number of children missed by vaccination services in Zambia during 2020. However, the ongoing SARS-CoV-2 transmission since our analysis concluded means efforts to maintain routine immunization services and minimize the risk of measles outbreaks will continue to be critical. The methodological framework developed in this analysis relied on routinely collected data to estimate disruptions of the COVID-19 pandemic to national routine vaccination program performance and its impact on children missed at the subnational level can be deployed in other countries or for other vaccines.

Citation: Winter AK, Takahashi S, Carcelen AC, Hayford K, Mutale W, Mwansa FD, et al. (2023) An evaluation of the early impact of the COVID-19 pandemic on Zambia’s routine immunization program. PLOS Glob Public Health 3(5): e0000554. https://doi.org/10.1371/journal.pgph.0000554

Editor: Jong-Hoon Kim, International Vaccine Institute, KOREA, REPUBLIC OF

Received: March 28, 2022; Accepted: March 31, 2023; Published: May 2, 2023

Copyright: © 2023 Winter et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: Study protocol and dataset can be made available upon request to Godfrey Biemba, director Zambia National Health Research authority ( [email protected] ). Data were obtained under data sharing agreements from Zambia Ministry of Health and the Zambia National Health Research Authority and will only be shared with permission from the Ministry of Health.

Funding: This work was financially supported by the Bill and Melinda Gates Foundation ( https://www.gatesfoundation.org ) in the form of a grant (OPP1094816) awarded to AKW, ACC, KH, WJM, and SM. No additional external funding was received for this study. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

As of December 23, 2022 SARS-CoV-2 has been responsible for 652 million confirmed cases of COVID-19 globally [ 1 ]. Implications of the pandemic for both the population and the healthcare system are vast. In addition to direct morbidity and mortality from COVID-19, the pandemic also has the potential to cause disruptions to local health systems. Disruptions of particular concern are to routine immunization programs used to control the spread of other infectious diseases [ 2 ]. Disruptions to immunization programs could lead to outbreaks of vaccine-preventable diseases [ 3 ]. Reasons for disruptions include supply-side issues including international and domestic supply chain disruptions, border closures and trade restrictions, reduced capacity and health care service offerings, restrictions on movement, and assignment of vaccination staff to COVID-19 control activities [ 4 – 7 ]. Additionally, demand-side related issues may also negatively impact uptake of vaccines such as parental reluctance to seek vaccinations for their children because they do not want to risk being exposed to SARS-CoV-2 at health facilities.

As a result of the pandemic and the measures implemented to control the spread of SARS-CoV-2, routine immunization programs underperformed [ 2 , 8 ]. According to the World Health Organization (WHO) the suspension or disruption of vaccination services in over 68 countries during the early stages of the pandemic put over 80 million infants younger than one year of age at risk of vaccine preventable diseases [ 6 ]. While countries are working hard to maintain optimal vaccination program performance, we have started to see the result of some of these disruptions. For example, in 2022 after years of having eliminated wild poliovirus, Malawi and Mozambique reported an outbreak of wild poliovirus and wild poliovirus cases have popped up in the United Kingdom and the United States of America [ 9 ]. Additionally, the World Health Organization has warned of “perfect storm” condition for measles outbreaks given measles high transmissibility, pandemic-related disruptions, and displaced populations due to conflicts or crises [ 10 ].

We evaluated the disruption of the COVID-19 pandemic on Zambia’s national vaccination program and its impact on the number of missed vaccinations at the sub-national level. As it is difficult to establish a causal link between the pandemic and vaccination programs, we compared pre-pandemic and pandemic vaccination program performance and attributed the difference to pandemic-related disruptions. The time of assessment was January 2020 –October 2020, which encompassed one wave of COVID-19 cases in July 2020. Findings from this analysis were used by the Zambian Ministry of Health to inform country-specific 2020 vaccination strategic responses in light of the COVID-19 pandemic.

We focused our analysis on the administration of routine bivalent measles-rubella vaccine dose 1 (MR1) and the pentavalent diphtheria, pertussis, tetanus toxoid, hepatitis B and Haemophilus influenzae type b vaccine doses 1 and 3 (Penta1, Penta3). In Zambia, the recommended childhood vaccination schedule includes three Penta doses at 6, 10, and 14 weeks of life and two MR doses at 9 and 18 months of age. We evaluated disruptions to measles-containing vaccines because clusters of few susceptible individuals pose a high risk of measles outbreak. We additionally evaluated disruptions of the pentavalent vaccine given that coverage of pentavalent vaccines are used as an indicator of immunization program performance [ 11 , 12 ].

To understand if and how COVID-19 related health care disruptions impacted the risk of vaccine-preventable diseases, we estimated changes in the national routine immunization program during the COVID-19 pandemic year 2020, and its impact on the number of children who missed vaccination (and risk of measles outbreak) at the district level (administrative level 2). This included first estimating a pre-pandemic routine vaccination coverage rate at the district level from a population-based representative survey. We then evaluated the changes in routine vaccination in pandemic year 2020 by estimating a percent reduction in the rate of vaccination using administrative data. Reported vaccination coverage for MR1 and Penta1 had stabilized prior to the pandemic such it is reasonable to attribute changes to vaccination coverage in pandemic-year 2020 to the pandemic; Penta3 showed slight declines in 2018 and 2019 leading up the pandemic ( S1 Fig ). Finally, we calculated the number of children missed for each month of disruption. For measles, given the particularly high transmissibility among susceptible individuals, we took one step further and explored measles outbreak risk with and without vaccine disruptions, and evaluated the impact of a two-month delay of the national MR vaccination campaign. See Fig 1 for a methodological roadmap, and the following sub-sections detailing each analytic step.

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https://doi.org/10.1371/journal.pgph.0000554.g001

District-specific pre-pandemic routine vaccination coverage

We relied on childhood vaccination coverage data from Zambia’s 2018 cross-sectional Demographic and Health Survey (DHS) made publicly available by ICF International to estimate routine vaccination coverage by district in Zambia. For each child, we extracted the following data from the DHS: age at the time of survey, whether the child had ever received an MR1, Penta1, and Penta3 vaccine dose (based on vaccination card or report of the parent or guardian), and age at the time of vaccination (if a vaccination card was available). Data were available for 112 of the 116 designated districts in 2018 and for 5,670 children between the ages of 0 and 36 months. We conducted a modified survival analysis accounting for uncensored (i.e. child with vaccination date on vaccination card), left censored (i.e., mother reported vaccination but date of vaccination unknown), and right censored (i.e., child unvaccinated at the time of the DHS survey) data on the age of vaccination, extending a statistical approach previously described [ 13 ]. The probability that an individual was vaccinated with each vaccine by a given age depends on two estimated parameters: district-specific lifetime probability of being vaccinated through routine vaccination services ( ρ i ) and the district-specific rate of receiving the vaccine through routine vaccination ( λ i ) ( S2 Fig ); the latter accounts for differences in the timeliness of receiving routine vaccination as a function of age. To estimate these district-specific parameters, we assumed they were multivariate normally distributed with a district-specific mean that was specified by a conditional autoregressive model. We extended the granularity of DHS provincially representative data using spatial models that account for the data structure. As a result, district estimates depended on assumptions inherent in the conditional autoregressive model. See S1 Text for more details.

National reduction in the pandemic year 2020 vaccination rate (compared to pre-pandemic years 2018 & 2019)

Administrative data on the number of vaccine doses delivered per month in each district from January 2018 to October 2020 for MR1, Penta1, and Penta3 was obtained from the Zambia Expanded Programme on Immunization (EPI). These data were used to estimate changes in the rate of routine vaccination in pandemic year 2020. Administrative vaccination data is generated by district health officers each month who aggregate health facility reports of the number of administered vaccine doses based on clinic records including registries.

We estimated national disruptions in the rate of routine vaccination because the administrative vaccination data were not sufficient to evaluate sub-national disruptions to routine vaccination ( S3 – S5 Figs). Given the seasonal nature of vaccine delivery due to Child Health Weeks ( S6 Fig ), we compared the vaccination coverage each month in 2018 and 2019 to 2020. We selected 2018 and 2019 as the baseline years for consistency with analysis on pre-pandemic vaccination coverage (i.e., DHS data). Note, we did not include administrative data in our estimate our pre-pandemic vaccination coverage (see the previous section) because these data are considered more unreliable due to incomplete or inaccurate reporting of vaccination, mistakes compiling the data across administrative units, and inaccurate population denominator estimates [ 14 ]. Rather, we only used administrative data to evaluate time trends or the change in vaccination. If data collection and associated biases in administrative vaccination data and estimated birth cohort are consistent across years, then estimated rates of disruptions would be robust to biases within the data.

We fit a binomial model to the 2018/2019 data and to the 2020 data, N it ∼ Binomial ( B i , γ t ), where N it is the number of doses administered in district i and month t, B i is the size of the birth cohort in district i , and γ t is the estimated proportion of individuals vaccinated in month t . We estimated the size of the birth cohorts in 2018/2019 and 2020 for each district by B i = P i b k , where P i is the size of the population in the district i estimated by aggregating WorldPop annual population estimates in 10x10 km grid cells over district polygons for the respective years [ 15 , 16 ], and b k is the proportion of the population who are newborns (age 0) for the respective province k in which district i is located based on Zambia’s central statistical office projections.

We estimated the disruption per month as the percent reduction in 2020 vaccination rate (compared to 2018/2019 vaccination rate) based on 2,000 draws of the 2020 posterior distribution of γ t and 2,000 draws of the 2018/2019 posterior distribution of γ t . We calculated the mean and 95% uncertainty intervals of the precent reduction each month t . Given monthly variation, we then calculated the mean across 10 months (January 2020 –October 2020) to generate a national mean and 95% uncertainty interval of the percent reduction in routine rate for each vaccination dose, and assumed it was constant into the future.

District-specific number of children missed by vaccination

We directly applied the national mean percent reduction in the rate of routine vaccination to the estimated district-specific pre-pandemic rate of routine vaccinations ( λ i ) to estimate a modified district-specific proportion vaccinated over age in months in 2020. The duration of disruption determined the duration of time individuals were exposed to the reduced rate of vaccination compared to the baseline rate of vaccination. Therefore, for each month of disruption, we estimated a district and age-specific proportion vaccinated between 9 and 36 months of age. The number of children not vaccinated in each district was calculated as the sum of the number of individuals 9 to 36 months old times the proportion unvaccinated between 9 and 36 months (i.e., 1—proportion vaccinated). Individuals who aged out of this age group and remained unvaccinated were not included in these totals. These estimates were aggregated across districts to obtain national estimates.

District-specific measles outbreak risk

We evaluated the district-specific additional risk of a measles outbreak for each month of disruption in 2020 and the impact of a national delay in the vaccination campaign from September to November 2020. We focused on measles given its high transmissibility and herd immunity threshold. To estimate outbreak risk, we first needed to estimate age-specific susceptibility. Population susceptibility was determined separately for three age bins: birth to 9 months, 9 months to 36 months (i.e., the age range of individuals with relevant measles vaccination data in the DHS survey), and 36 months to 49 years. We assumed that all infants from birth to nine months old had a level of protection by maternally derived antibodies beginning with 100% at birth and dropping by a rate of 0.45 until 8 months of age, and are susceptible thereafter until vaccinated [ 17 ]. We assumed no immunity from natural infection given the small number of measles cases reported since 2016 (average of 11 annual cases between 2016–2019) [ 18 ].

We estimated susceptibility of individuals between 9 months and 36 months old by applying an age-specific vaccine effectiveness rate to the disruption modified district-specific probability an individual was vaccinated by age in months (as estimated above). We assumed all changes in the proportion susceptible by month of disruption was constrained to the 9- to 36-month-old age group who were eligible for MR1 and receiving it at a reduced rate, thereby ignoring the potential role that natural infection may have to reduce the impact of susceptibility on individuals younger than 9 months or older than 36 months. This assumption is justified by the lack of major measles outbreaks in 2020 in Zambia. The febrile-rash surveillance system in Zambia reported only 69 measles cases in 2020 to the World Health Organization, similar to the previous six years [ 19 ].

To estimate susceptibility among individuals older than 36 months, we relied on a hierarchical spatial model fit to measles seroprevalence data collected in 2016 [ 20 ]. Serological data provides the most direct estimate of measles immunity, obtained through vaccination or natural infection [ 21 ]. The measles IgG 2016 serological data came from a nested serosurvey within the Zambia Population-Based HIV Impact Assessment consisting of 9,852 blood samples collected from individuals one month to 49 years old across all 72 districts at the time [ 20 ]. The model relied on routinely collected epidemiological data (i.e., vaccination coverage, suspected case data) and demographic data (i.e., age, district, province) to explain the variation in the cross-sectional 2016 seroprevalence data. To project measles seroprevalence in subsequent years, selected covariates from those years were combined with posterior estimates of model parameters. We did not have data on individuals over 49 years of age. We do not have estimates on susceptibility among populations over 49 years of age. However, given these birth cohorts were children when measles virus transmission was endemic in Zambia, it is reasonable to assume they would have been naturally exposed to measles virus and would therefore not be susceptible [ 22 ]. See S2 Text , and S7 – S10 Figs for more details.

Lastly, to estimate outbreak risk, we calculated the measles effective reproductive number (R e, i.e., the average number of individuals an infectious individual will infect in a partially susceptible population) for each month and district taking into account age-specific susceptibility and age-assortative mixing patterns [ 23 ]. See S3 Text for more details.

Ethics statement

For the 2016 measles seroprevalence data, participants provided written informed consent, parental permission was obtained children under 18 years old, and assent was obtained for participants 10–17 years old. This serosurvey was conducted in accordance with relevant guidelines and regulations. Ethical approvals for protocols were provided by Johns Hopkins Bloomberg School of Public Health (00008423) as well as the Tropical Disease Research Center and the National Health Regulatory Agency in Zambia (TDRC/C4/01/2019).

In our pre-pandemic estimates of routine vaccination coverage using the 2018 Zambia DHS, we identified variation in district-level estimates of the lifetime probability and monthly rate of being vaccinated across age ( Fig 2 ). The median lifetime probability of receiving MR1, Penta1, and Penta3 across districts was 0.94 (range 0.67 to 0.98), 0.99 (range 0.81 to 1.00), and 0.95 (range 0.56 to 0.99), respectively ( Fig 2A–2C ). There was some consistency in the estimated lifetime probability of being vaccinated across the three vaccines, i.e., districts with relatively lower lifetime probability of vaccination with MR1 also had lower probabilities of vaccination with Penta1 and Penta3 vaccines compared to other districts (correlation MR1 and Penta1 = 0.834; correlation MR1 and Penta3 = 0.764; correlation Penta1 and Penta3 = 0.801). The median monthly rate of routine vaccination for MR1, Penta1, and Penta3 across districts was 0.51 (range 0.29 to 0.72), 0.65 (range 0.38 to 0.85), and 0.41 (range 0.26 to 0.58), respectively ( Fig 2D–2F ); this is equivalent to a median average age of vaccination (among those vaccinated) of 9.96 months (range 9.39 to 11.48), 1.95 months (range 1.58 to 3.04), and 4.64 months (range 3.92 to 6.10) ( S11 Fig ). Districts with a lower rate of vaccination for MR1 did not necessarily have a lower rate of vaccination for Penta1 and Penta3 (correlation between MR1 and Penta1 = 0.44, correlation between MR1 and Penta3 = 0.46), although the rates at which Penta1 and Penta3 were administered was correlated (correlation between Penta1 and Penta3 = 0.75). The resulting median and 95% uncertainty intervals in the estimated proportion vaccinated over age in months are displayed in S12 – S14 Figs and show good model fit to the raw DHS data.

District-level (112 / 116 districts) median parameter estimates of the lifetime probability of being vaccinated via routine vaccination through 36 months of age (saturation parameter) (A-C), and monthly rate of receiving routine vaccination (D-F) for MR1 (A & F), Penta1 (B & E), and Penta 3 (C & F) vaccine doses. There are no parameter estimates for four districts colored in grey due to the lack of any DHS sampling clusters in these districts. Shapefile available CC BY 4.0 license via https://data.grid3.org/datasets/GRID3::nsdi-zambia-administrative-boundaries-districts-2022-published-by-grid3/about .

https://doi.org/10.1371/journal.pgph.0000554.g002

For all three vaccines, we found an increase in the proportion of the annual birth cohort vaccinated in the month of June (2018/2019 compared to 2020) because of Zambia’s Child Health Week ( Fig 3 ). The estimated rate of disruptions in routine vaccination during the COVID-19 pandemic varied between MR1, Penta1, and Penta3. Routine vaccination with MR1 in 2020 was lower from January through May compared to in 2018/2019; however, the Child Health Week in June helped to catch-up some missed children. There was a higher proportion of routine vaccination with Penta1 and Penta3 in September and October in pandemic year 2020 compared to 2018/2019. We noted a slight catch-up of missed children in June 2020 for Penta3 vaccination, similar MR1. The mean percent reduction in routine vaccination in the 2020 estimates from the 2018/2019 estimates for MR1 ranged from 15.66% to -6.04% across months (i.e., an increase by 6.04% in June 2020 compared to June 2018/2019); the mean percent reduction across months was 6.29% (95% uncertainty interval, 5.33% - 7.23%). The mean percent reduction in routine vaccination in the 2020 estimates from the 2018/2019 estimates for Penta1 ranged from 12.31% to -6.61% across months; the mean percent reduction across months was 3.73% (95% uncertainty interval, 2.79% - 4.69%). The mean percent reduction in routine vaccination in the 2020 estimates from the 2018/2019 estimates for Penta3 ranged from 12.14% to -6.88% across months; the mean percent reduction across months was 2.65% (95% uncertainty interval, 1.67% - 3.64%).

Disruption to routine vaccination for MR1 (A), Penta1 (B), Penta3 (C) based on administrative vaccination data. Top row is the proportion of the birth cohort vaccinated January to October in years 2018/2019 and 2020 (mean and 95% uncertainty intervals represented by points and error bars). Bottom row is the percent reduction in proportion vaccinated each month (black lines) and mean and 95% uncertainty intervals across months (red lines).

https://doi.org/10.1371/journal.pgph.0000554.g003

The number of additional children missed by vaccination in pandemic year 2020 was minimal compared to the total number missed in our pre-pandemic years 2018/2019. In the pre-pandemic years of 2018/2019, we estimate that 225,114.27 (95% CI 148,588.93–354,188.33) children missed MR1, 143,342.54 (95% CI 106,127.06–230,346.80) missed Penta1, and 268,572.48 (95% CI 179,582.99–419,802.18) missed Penta3 ( Fig 4A–4C , S15 Fig ). Given the median number of missed vaccinations in a non-disruption year, the percent increase in the number of doses missed in 2020 was largest for MR1 (2.80%) followed by Penta1 (2.13%) and Penta3 (1.19%). An additional 6,305.43 (95% CI 5,250.25–7,273.84) children missed MR1 after 10 months of disruption compared to the median number vaccinations missed in a non-disruption year ( Fig 4A ). Fewer additional children missed Penta1 and Penta3 vaccinations compared to the median number of vaccinations missed in a non-disruption year (Penta1 3,052.22 (95% CI 2,288.11–3,918.34), Penta3 3,198.74 (95% CI 1,994.91–4,302.01)) ( Fig 4B and 4C ).

The national estimated cumulative median number of children missed by vaccination for MR1 (A), Penta1 (B), and Penta3 (C) by month of disruption (red line) across the range of disruption rates (red ribbon) based on the median number of children missed in reference year (black line). Broken down by district (112 / 116 districts) is the median number of children missed by MR1 (D), Penta1 (E), and Penta3 (F) vaccination after 10 months of disruption. Shapefile available CC BY 4.0 license via https://data.grid3.org/datasets/GRID3::nsdi-zambia-administrative-boundaries-districts-2022-published-by-grid3/about .

https://doi.org/10.1371/journal.pgph.0000554.g004

There was large variation in the number of unvaccinated children across districts ( Fig 4D–4F ). For MR1 and Penta 3, Lusaka and Luangwa Districts (both located in Lusaka Province) had the highest and lowest number of children missed in a district, respectively. For Penta 1, Lusaka and Milenge Districts had the highest and lowest number of children missed in a district, respectively In Lusaka District, an estimated 25,352.04 children did not receive MR1, 16,895.25 children did not receive Penta1, and 32,405.49 children did not receive Penta3. In Luangwa District, an estimated 336.00 children did not receive MR1 and 313.15 children did not receive Penta3. In Milenge District an estimated 216.58 children did not receive Penta1. There were also a cluster of districts in Copperbelt Province that had a high number of unvaccinated children.

We also evaluated the impact of the COVID-19 pandemic disruptions to routine immunization services on the risk of measles outbreaks for each district over the course of the pandemic prior to the national MR vaccination campaign in November 2020. We found minimal impact on outbreak risk because of pandemic-year disruptions in routine vaccination or delay in fall 2020 MR vaccination campaign. Over the course of 10 months, measles R e increased on average across the districts by 0.05% (range 0.02% - 0.18%) ( Fig 5 ). There was little to no change in R e during the two-month delay in conduction the MR campaign in all districts ( Fig 5 , S9 Fig ).

Each line represents a different district (112 / 116 districts), the color represents the province that each district is located.

https://doi.org/10.1371/journal.pgph.0000554.g005

We performed a detailed analysis to estimate changes in the national routine immunization program in Zambia during the pandemic year 2020, and its impact on the number of missed children (and risk of measles outbreak) at the district level (administrative level 2). The methodological framework developed for this analysis can be used to estimate COVID-19 pandemic disruptions and its impact at the subnational scale in other countries or for other vaccines. Compared to pre-pandemic years 2018/2019, this study estimated minimal pandemic-related disruptions to childhood MR1, Penta1, and Penta3 vaccination in Zambia in 2020.

We estimated that the average percent reduction in proportion vaccinated between January and October 2022 was 6.29%, 3.73%, and 2.65% for MR1, Penta1, and Penta3 respectively. This is equivalent to an absolute reduction in the monthly proportion vaccinated by 0.005, 0.003, and 0.002. This translation to absolute reduction is in line with estimates generated by Causey et al. 2021, who estimated 0.5% (95% uncertainty intervals 0.3–0.6) and 0.2% (95% uncertainty intervals 0.1–0.5) reduction for MR1 and Penta3 respectively in Zambia in 2020 [ 2 ]. Among the 94 countries for which 2020 changes in routine vaccination were estimated by Causey et al. 2021, Zambia is in the top 10% of countries with minimal disruption (i.e., <0.5% decrease in 2020 MR1 coverage) [ 2 ].

Continued routine and catch-up immunization services during the pandemic have shown to be a net benefit in modelling studies [ 3 ]. Regardless, there remain concerns about the potential for SARS-CoV-2 transmission during routine or campaign vaccination activities because of interactions with healthcare workers or other individuals seeking services. Zambia’s Child Health Weeks conducted in June and November of 2020 took place despite the pandemic. The purpose of Zambia’s Child Health Week, held biannually, is to reach eligible children who had not yet received their routine vaccines. This purpose was critically fulfilled during the pandemic year 2020 when the June Child Health Week resulted in a greater increase in the number of vaccinated children from the pre-pandemic years 2018/2019 for MR1 and Penta3. The MR vaccination campaign that was delayed two months was instituted during Zambia’s second yearly Child Health Week in November 2020. This analysis demonstrates the benefits of continuing with routine immunization services during the pandemic and using catch-up vaccination activities to vaccinate those children who may have missed due to COVID-19 pandemic disruptions.

Ongoing collaborations and established research programs on measles and rubella in Zambia allowed a timely assessment of the impact of COVID-19 disruptions on routine immunization services and the impact of delaying a MR vaccination campaign for two months. For example, rich measles serological data collected in 2016 from a national serosurvey was used to set a baseline R effective for assessing changes in measles outbreak risk over months of disruption [ 20 ]. We identified minimal increases in risk of a measles outbreak due to postponing the MR vaccination campaign by two months; over 10 months measles R e increased by 0.05% on average across districts. R effective is the average number of people a typical with disease will go onto infect. It is an imprecise summary measure that hides variation and tends to have large uncertainty bounds [ 24 , 25 ]. Assuming R effective is 1.00, a 0.05% increase means R effective is now 1.005; this is a minimal change relative to the variation in these estimates. In the end, the MR campaign was indeed delayed with no outbreaks reported over the course of those two months.

This study is subject to several limitations. The first is our assumption that differences in routine vaccination rates in 2020, compared to 2018/2019, is attributable to COVID-19 related disruptions. Given the stability of MR1 and Penta1 vaccination coverage leading up the pandemic year 2020, this assumption may hold. However, Penta3 was slightly declining in the 2018–2019 meaning that the changes we saw in 2020 to Penta3 vaccination may not be due to the disruptions from the pandemic. We surprisingly saw the smallest disruptions to Penta3, compared to Penta1 and MR1 vaccinations, rather than the expected largest disruptions in Penta3 if there was indeed an additive factor of decreasing pattern to the pandemic disruptions. Regardless, there is the potential for time-varying covariates, unrelated to the pandemic, that we did not consider within the analysis that could have explained the slight reductions in MR1, Penta1, and Penta3. Second, we focused on the potential of the COVID-19 pandemic to disrupt vaccination programs negatively. There are other potential ways the pandemic can impact the burden of vaccine-preventable diseases. For example, non-pharmaceutical interventions, such as movement restrictions (either personal or state enforced), can reduce transmission of directly transmitted infectious pathogens. Minimal disruption of routine vaccination programs coupled with decreased movement and transmission of vaccine-preventable diseases can inadvertently lead to local eliminations with minimal additional risk of resurgence. However, decreased circulating viruses can also create a short-term illusion of control without considering the potential risk of increasing susceptible populations [ 26 , 27 ]. The third limitation is that the administrative vaccination data was not sufficient to estimate sub-national disruptions to routine vaccinations; rather, we estimated a national rate of reduction with uncertainty based on district level data. Variation in the number of unvaccinated children across districts was driven by district-specific size of birth cohorts and pre-pandemic district-specific vaccination coverage and did not include the heterogeneities in disruptions to routine services over space. As a result, the variation in the number of unvaccinated children is likely smaller than truly exists and should be interpreted through this lens. Fourth, our estimate of district-specific change in measles outbreak risk could be averaging across potential within-district heterogeneities in susceptibility [ 28 ]. Lastly, the hierarchical seroprevalence model was not suitable to generate districts’ predicted risk of a measles outbreak during the pandemic, but simply the change in risk. Using our hierarchical model that includes district-specific random intercepts to predict seroprevalence profiles in 2020 would require a strong and unlikely assumption that the underlying district-specific impact on seroprevalence is constant from 2016 to 2020. A key area of future work is to build models that can reliably extrapolate seroprevalence to other years from rich population-based cross-sectional serological data. As suggested by this analysis, this may require individual level data on mechanisms of seroconversion (i.e., history of vaccination or measles infection) linked to the serum samples.

Since this analysis was completed, there has been additional waves of COVID-19 cases in Zambia. The implications of the pandemic on Zambia’s childhood vaccination program are not fully realized. For example, the return wild poliovirus in Malawi and Mozambique in 2022 after many years of elimination, highlights the vulnerability of vaccination programs to disruptions to routine vaccination [ 29 ]. Further analysis is needed to evaluate the ongoing disruptions and understand potential subdistrict variations in the impact of the pandemic on childhood vaccinations.

Published literature has shown that the COVID-19 pandemic has resulted in disruptions to health systems including immunization programs worldwide, although lots of variability across countries [ 2 , 4 , 6 , 8 ]. In this manuscript, we presented an analysis conducted early in the pandemic (mid-2020) in Zambia to estimate changes in the national routine immunization program in during the pandemic year 2020, and its impact on the number of children with missed vaccinations and measles outbreak risk at the district level. We estimated minimal pandemic-related disruptions to childhood MR1, Penta1, and Penta3 vaccination in Zambia in 2020, compared to pre-pandemic years 2018/2019. We found that continued supplemental immunization activities (e.g., child health week) were important to catch-up children who had missed their routine vaccination, and should continue to be prioritized, albeit safely. Lastly, this work highlights the utility of rich immunity profiles from serological data to evaluate changes in measles outbreak risk.

Supporting information

S1 text. estimating pre-pandemic routine vaccination coverage for mr1, penta1, and penta 3..

https://doi.org/10.1371/journal.pgph.0000554.s001

S2 Text. Estimating measles susceptibility by age (4 to 49 years old) using a model fit to serological data.

https://doi.org/10.1371/journal.pgph.0000554.s002

S3 Text. Estimating R effective.

https://doi.org/10.1371/journal.pgph.0000554.s003

S1 Fig. National level time trends in MR1, Penta1, and Penta3 vaccination coverage in Zambia 1980–2019.

https://doi.org/10.1371/journal.pgph.0000554.s004

S2 Fig. Impact of estimated parameters lambda and rho on the proportion vaccinated over age.

https://doi.org/10.1371/journal.pgph.0000554.s005

S3 Fig. District-specific administrative MR1 coverage estimates by month in years 2018, 2019, and 2020.

https://doi.org/10.1371/journal.pgph.0000554.s006

S4 Fig. District-specific administrative Penta1 coverage estimates by month in years 2018, 2019, and 2020.

https://doi.org/10.1371/journal.pgph.0000554.s007

S5 Fig. District-specific administrative Penta3 coverage estimates by month in years 2018, 2019, and 2020.

https://doi.org/10.1371/journal.pgph.0000554.s008

S6 Fig. Raw administrative vaccination data.

https://doi.org/10.1371/journal.pgph.0000554.s009

S7 Fig. Results of leave out district analysis.

https://doi.org/10.1371/journal.pgph.0000554.s010

S8 Fig. Results of leave out age analysis.

https://doi.org/10.1371/journal.pgph.0000554.s011

S9 Fig. Sensitivity analysis of percent increase in Reff per month of disruption based on different starting estimates of proportion susceptible across ages 4 to 49 years old.

https://doi.org/10.1371/journal.pgph.0000554.s012

S10 Fig. Comparison of estimated immunity by age (9–36 months) using seroprevalence data and 2018 Zambia DHS data.

https://doi.org/10.1371/journal.pgph.0000554.s013

S11 Fig. District-level estimates of the average age of vaccination among those that receive vaccination for MR1, Penta1, and Penta3.

https://doi.org/10.1371/journal.pgph.0000554.s014

S12 Fig. District-level MR1 baseline routine proportion vaccinated over age in months.

https://doi.org/10.1371/journal.pgph.0000554.s015

S13 Fig. District-level Penta1 baseline routine proportion vaccinated over age in months.

https://doi.org/10.1371/journal.pgph.0000554.s016

S14 Fig. District-level Penta3 baseline routine proportion vaccinated over age in months.

https://doi.org/10.1371/journal.pgph.0000554.s017

S15 Fig. Estimated number of children missed by vaccination of MR1, Penta1, and Penta3.

https://doi.org/10.1371/journal.pgph.0000554.s018

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Original research

Perspectives on the covid-19 vaccine uptake: a qualitative study of community members and health workers in zambia, cephas sialubanje.

1 School of Public Health, Levy Mwanawasa Medical University, Lusaka, Zambia

Nawa Mukumbuta

2 COVID-19 Advisory Centre for Local Authorities, Local Gover Government of Association of Zambia, Lusaka, Zambia

Mary Ng'andu

3 Health Sciences, Levy Mwanawasa Medical University, Lusaka, Zambia

Ernest Malangizo Sumani

Mpala nkonkomalimba.

4 Administrative unit, Local Government Association of Zambia, Lusaka, Zambia

Daniel EM Lyatumba

Alick mwale, francis mpiana, joseph makadani zulu, basil mweempwa.

5 Decentralisation for Development (D4D), Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH /German Cooperation, Lusaka, Zambia

Denise Endres

Maurice mbolela, mpatanji namumba, wolff-christian peters, associated data.

bmjopen-2021-058028supp001.pdf

bmjopen-2021-058028supp002.pdf

bmjopen-2021-058028supp003.pdf

Data are available on reasonable request. Data are available on reasonable request from the corresponding author and with permission of the UNZABREC Institutional review board.

Since introduction of the programme in April 2021, COVID-19 vaccine uptake has been low at less than 20%. This study explored community members’ and health workers’ perspectives on the COVID-19 vaccine uptake and its influencing factors in Zambia.

Study design

A qualitative study employing focus group discussions (FGDs) and in-depth interviews (IDIs).

Study setting

Sixteen primary healthcare facilities selected from Lusaka, Copperbelt, Central and Southern provinces.

Participants

A total of 32 FGDs comprising local community members and 30 IDIs including health workers, traditional, religious and civic leaders (n=272). FGDs were separated based on age (youth and adults), sex (male and female) and place of residence (urban and rural).

Both FGD and IDI participants agreed that vaccine uptake was low. Limited knowledge, access to information, myths and misconceptions, negative attitude, low-risk perception and supply in remote areas affected vaccine uptake. Overall, FGD participants expressed limited knowledge about the COVID-19 vaccine compared with health workers. Further, FGD participants from urban sites were more aware about the vaccine than those from rural areas. Health workers perceived the vaccine to be beneficial; the benefits included prevention of infection and limiting the severity of the disease. Moreover, FGD participants from urban sites expressed a negative attitude towards the vaccine. They believed the vaccine conferred no benefits. By contrast, participants from rural communities had mixed views; they needed more information about the vaccine benefits. Participants’ attitude seems to have been influenced by personal or family experience with the COVID-19 disease or vaccination; those who had experienced the disease had a more positive attitude. In contrast, most young people believed they were not at risk of the COVID-19 disease. Misinformation from social media influenced their attitude.

These results provide starting points for future policies and interventions for increasing COVID-19 vaccine uptake.

STRENGTHS AND LIMITATIONS OF THIS STUDY

• Purposive sampling of participants comprising health workers and community members with different demographic and socioeconomic characteristics (sex: male and female; age; place and province of residence: urban and rural settings) allows for comparing and contrasting of participant views, which in turn provides an in-depth understanding of the subject under investigation.
• Use of different data collection techniques (focus group discussions and in-depth interviews) as well as data sources allow for triangulation of findings and increases internal validity of the study.
• Training data collectors and use of an inductive approach to data analysis increase the internal validity of study findings.
• Conducting the study at the beginning of the COVID-19 national mass vaccination when the programme was still new in the country may have affected the views of the participants.
• Use of the qualitative design affects external validity and limits generalisation of the study findings.

Introduction

SARS-CoV-2 has spread to most parts of the world, including Zambia. 1 2 As at the end of August, 2022, a total of 332, 058 cases and 4016 deaths had been reported in the country. 3 To prevent further spread of the virus and increased mortality in the country, the Zambian government enacted the public health statutory instrument number 22, 4 5 which instituted preventive and control measures—restricting social gatherings (ie, work places, church services, weddings, kitchen parties, casinos, funerals), local and international travel, and closing public institutions such as schools and markets. 6 In addition, the Zambian government implemented a national mass vaccination campaign 7 following approval of the COVID-19 vaccines in developed countries. 8–10 Initially, the COVID-19 national vaccination programme targeted the health workers and persons aged above 65 years. 10 The criteria were later revised to include all persons aged 18 years and above. 10 A second revision was made to include children aged 10 years and above. Three types of COVID-19 vaccines have been administered: Oxford/AstraZeneca, Sinopharm, John and Johnson and Pfizer vaccines. Access to the COVID-19 vaccine is voluntary and free in the country; people do not need to pay anything. 11 To be protected, one needs to receive two doses of the Oxford/AstraZeneca vaccine−8 weeks apart. On the contrary, only one dose of Johnson & Johnson vaccine is needed to be fully immunised. 12 13

Over the centuries, vaccines have been shown to be an effective way to combat outbreaks and the only efficient and reliable method for disease prevention. 14 15 COVID-19 vaccines—with an efficacy ranging from 70% to 95%, have been shown to provide protection against the virus 15 by preventing its spread in the community, mitigating the severity of the disease and reducing mortality among the infected people. 16 17 Studies and ongoing clinical trials 18–22 have shown that COVID-19 vaccines offer the best means to control the ongoing pandemic. They are effective in preventing a wide range of COVID-19-related outcomes, reduce symptomatic cases, hospitalisation, disease severity and death among the infected individuals. Nevertheless, national reports show that the vaccine uptake has been low in the country. At the end of August 2022, a total of 5 576 827 have been fully vaccinated with the AstraZeneca, Sinopharm and Johnson & Johnson vaccine since the commencement of the programme in April 2021. This represents a national vaccine coverage of 52.9% of the eligible population. 23

Limited supply and vaccine hesitance—the delay in acceptance or refusal of vaccination despite availability of vaccination services 24 —have been attributed to the low vaccine coverage in the country. Vaccine hesitance has been reported both in Zambia and other countries, and has been shown to be an important obstacle to the fight against COVID-19. 25–27 For example, in their recently published article, Mutombo et al 28 observed that the gradual effort to distribute COVID-19 vaccines to low-income and middle-income countries (LMICs) is threatened by the ubiquitous vaccine hesitancy, especially in Africa, where it undermines efforts to fight the COVID-19 pandemic. A qualitative study 29 using focus group discussions (FGDs) with mothers who brought their children for measles vaccination in southern Zambia a few months before the COVID-19 national vaccination programme was implemented, reported that, although parents were willing to allow their children to receive the vaccine, majority expressed substantial uncertainty and hesitancy about receiving the vaccine themselves. The study also revealed beliefs around COVID-19 risk and severity, as well as vaccine safety and effectiveness affected the participants’ intention to be vaccinated. However, vaccine hesitance is not peculiar to the COVID-19 vaccine. For example, Garcia and others 30 reported low levels of Cholera vaccine acceptance among community members and health workers in the slums of Lusaka, Zambia. The authors also showed that religious beliefs and distrust towards western medicine, fear of injections and adverse events, low perceived need for immunisation and limited understanding of how vaccines work were important factors affecting acceptance of the cholera vaccine.

Although these studies provided important insights on vaccine hesitance and its contributing factors, most were conducted outside the country. The one conducted in Zambia explored mothers’ intentions to receive the COVID-19 vaccine and not the actual behaviour. Moreover, the study was conducted before the COVID-19 was implemented. The other Zambian study focused on the Cholera vaccine. It thus, not clear how the Zambian population perceive the COVID-19 vaccination programme. Available evidence suggests that vaccine hesitance is complex and context specific, varying across time, place and vaccines. A study is therefore needed to explore people’s perspectives and attitude towards COVID-19 vaccine uptake in the country. The aim of this study, therefore, was to explore community members’ and health workers’ perspectives on the COVID-19 vaccine uptake and the reasons that affect its uptake in Zambia. This information can provide insight to the COVID-19 vaccine hesitancy and the contributing factors, which in turn, can inform design of interventions to increase vaccine intentions and uptake in the general population. To date, no such study has been conducted in Zambia.

This study employed a qualitative design comprising FGDs and in-depth interviews (IDIs) as the data collection techniques. FGDs have been used in public health research for over three decades now. 31 They aim to explore participants’ experiences, beliefs and attitudes towards a target behaviour, by using group processes to stimulate responses and gain insights through participants’ exchanging views, questioning and challenging one another. 32 IDIs enable the researcher to understand participants' lived experiences through their own words and perspectives. 32 33 Use of both FGDs and IDIs allows for in-depth exploration and understanding of various aspects regarding the subject under investigation. The approach also allows for triangulation and corroboration of the FGD and IDI findings, which, in turn, increases the internal validity of the study. 34 35

The study was conducted in 16 primary health facilities and their catchment communities—3 from Lusaka city, 2 each from Chongwe, Ndola, Masaiti, Kabwe, Chibombo and Kafue, 1 one from Mazabuka districts. Selection of health facilities was done in consultation with various stakeholders including health staff working in the COVID-19 vaccination programme and health promotion departments at the provincial and district health offices, Zambia National Public Health Institute and Ministry of Health (MoH) headquarters. To be selected, health facilities needed to have been providing COVID-19 vaccination services as well as other COVID-19 prevention, control and care services including screening, contact tracing, isolation and treatment facilities. In addition, health facilities needed to be accessible by road during the study period. Health facilities from Lusaka and Copperbelt provinces were selected because they were COVID-19 epi-centres due to huge populations and commercial activities; Central province is a transit area for traffic from Tanzania and the Democratic Republic of Congo in the north and north-east, respectively; Southern province is a transit region for travellers from the Southern region (South Africa, Zimbabwe, Namibia and Botswana)—all of which reported high numbers of COVID-19 cases. 36 37

From each health facility one community was selected, in consultation with the health facility managers and local community leaders. Efforts were made to ensure an equable distribution of urban and rural communities in the study. To be included in the study, communities needed to be accessible with passable roads, and within 2 hours drive from the health facility. In addition, the local community leaders needed to authorise the team to conduct the study in the community.

Participants and sampling technique

Fgd participants.

A total of 32 FGD (n=242) were conducted with community members. Each FGD comprised between 6 and 10 participants (n=242). To gain insight into the differences and similarities in the participants’ views, FGDs were separated based on age, sex and place of residence. Half of the FGDs (50%) were held in urban communities and the other half in rural settings. To compare and contrast the views based on sex, separate FGDs were held with male and female participants. In addition, a total of eight FGDs were separately held with the youth to gain insight into their perspectives on the subject. Efforts were made to balance the eight FGDs on sex (four male and four female) and place of residence. Initially, a total of 40 FGDs (10 per province) were planned by the research team. However, after conducting 10 FGDs in Lusaka province (men=4, women=4, youth=2), the point of saturation was achieved (ie, no further substantial information was obtained from the participants). At this point, the research team decided to reduce the number of FGDs and conduct only a few more FGDs in the other districts. At the end, 24 FGDs were conducted with the adults (males=12, females=12) and 8 with the youth (18–24 years) (see table 1 ).

Distribution of FGDs

FGDs, focus group discussions.

Using a purposive sampling technique, community health workers assisted by local community leaders (traditional and civic) conducted the recruitment of FGD participants from the local communities. Purposive sampling allows for selection of participants with similar experiences regarding the health behaviour under investigation (ie, perspective and attitude towards COVID-19 vaccine), while, at the same time, allowing for recruitment of participants with different demographic and socioeconomic characteristics—such as age, sex and place of residence and occupation. This, in turn, helps provide insight into the similarities and differences in the participants’ experiences with regard to the health problem under investigation.

Recruitment of the participants was done in multiple steps. First, the research field supervisor together with the district health promotion officer held meetings with the local health facility staff, community health workers and community leaders to inform them about the study and its objectives, and to identify the communities where the FGD participants would be recruited from. Following this meeting, community health workers and local leaders called for a meeting to inform the community members about the study. Community members willing to participate in the study were asked to register with the community health workers and leave their details (place of residence and phone number). A few days after the meeting, the community health workers contacted the potential participants to provide more details about the study and assess their suitability to participate in the study. The assessment was based on the participant eligibility criteria described below. Next, the community health workers compiled a comprehensive list of community members who were eligible to participate in the FGDs and made arrangements for the selected participants to come for the actual discussion to an agreed on place (usually the headman’s place, school or church) on the set time.

In-depth Interviews

To gain insight into the views of the local health staff and community leaders, a total of 30 IDIs (n=30) were conducted. IDI participants were recruited from their places of work and homes. Health promotion officers helped recruit the health staff; community health workers recruited the community leaders. Following identification of the potential participants, the recruiting staff compiled a comprehensive list of IDI participants and contacted them before the day of the interview. Health staff were selected from the district health offices and local health facilities and comprised public health officers, clinicians, nurses and community health workers (n=16). Community leaders were selected from the local communities and included traditional, religious and civic leaders (n=10). In addition, staff (n=4) from non-governmental organisations (NGOs) working with the MoH in the provision of COVID-19 services at the local district level were included in the study.

Eligibility criteria

To participate in both the FGDs and IDIs, participants needed to be:

• Aged 18 years and above.
• Residing or working in the study area for not less than 3 months.
• Health workers involved in the COVID-19 vaccination programme from the selected primary health facilities.

Prisoners and mentally ill people were not included in the study.

Before each FGD/ IDI, written informed consent was obtained from each participant; those who could not read or write were asked to mark with an ‘X’. To make it easy for the study participants to understand, the consent form ( online supplemental material 1 ) was translated into the local language (Bemba, Nyanja and Tonga). After signing the consent form ( online supplemental material 2 ), each FGD/IDI participant was asked to complete a short demographic questionnaire ( online supplemental material 3 ). To make it easy for those who could not read or write, research assistants read the consent form and the short questionnaire and filled it in for them.

Supplementary data

Training of data collectors.

Research assistants were a group of six (three male and three female) final year Master of Public Health (MPH) students recruited from the Schools of Public Health at the University of Zambia (n=3) and Levy Mwanawasa Medical University (n=3) in Lusaka. MPH students were selected because they were skilled and experienced in qualitative research methods: facilitating FGDs and conducting IDIs. To avoid information concealment during FGDs and IDIs, efforts were made to select students who spoke both English and one or two of the local languages, Nyanja, Bemba or Tonga. Before commencement of the data collection process, research assistants underwent a 5-day training in FDG facilitation and interviewing techniques: 3 days of theory and 2 days of practical fieldwork. Topics covered during the 3 days theoretical training included: (1) basic principles of qualitative research, (2) objectives of the study, (3) FGD facilitation techniques, (4) interviewing techniques, (5) research ethics and informed consent in human subjects’ research and (6) FGD and IDI interview guide. Phase 2 of the study was a practical exercise in FGD facilitation techniques, conducting interviews and obtaining informed consent. On the first day of the pactical phase, the research assistants worked in pairs and took turns to facilitate an FGD with their fellow trainees. They also took turns interviewing each other. At the end of eachFGD/IDI, research assistants were asked to provide feedback on each other’s performance. At the end, the trainer also provided feedback and guidance on group dynamics, participant interaction, body language, avoiding conflict and managing it when it arises. On the second day, the team was taken into the nearby neighbourhood to facilitate FGDs with community members and conduct IDIs with health staff and community leaders. The FGDs and IDIs were transcribed and analysed, after which the FGD and interview guides were revised based on the analysed data and feedback from the data collectors.

Data collection

Each FGD was facilitated by a pair of research assistants: one facilitated the discussion and took notes, the other one was in charge of the digital voice recorder. As they facilitated the FDGs, research assistants ensured that each participant was given an opportunity to speak; they also tactfully controlled the dominant individuals and prompted the passive ones to speak. They also ensured that the discussion flowed smoothly among the participants without turning it into an interview, personal attack or conflict. Where necessary, the facilitator asked for elaboration, clarification or probed for detail. Interviews were also conducted by a pair of research assistants: one conducted the interview and took notes; the other recorded the interview with a digital audio recorder. IDIs were conducted at the participant’s preferred place including the office or home. On average, each FGD lasted between 1 hour and 1.5hrours. IDIs lasted between 30 and 45 min. To ensure quality in data collection, a digital voice recorder was used for both IDIs and FDGs.

Data collection tools

FGDs/IDIs were conducted using a paper-based, FGD/interview guide ( online supplemental material 2 ). The FGD/interview guide had predetermined themes, including: (1) perspectives on acceptance of the COVID-19 vaccine and (2) factors affecting vaccine uptake. The second theme had several probes including knowledge and information sources, and attitude towards COVID-19 vaccine. The same interview guide was used for both the FGDs and IDIs, with minor elaboration for the IDIs to elicit some detail. During the FGDs, the focus was on the community perspectives; for IDIs the focus was more on the participant’s perspectives regarding the issues under investigation. In addition, a short questionnaire ( online supplemental material 3 ) was prepared to collect FGD and KII participants’ demographic, socioeconomic and vaccination data. To ensure internal validity, the FGD/interview guide went through a rigorous development process. First, the principal investigator with vast experience in qualitative research and familiar with the subject, drafted the initial version. The themes in the FGD/interview guide were adapted from various sources, including review of the available literature on COVID-19 vaccine and the researchers’ experience in qualitative research methods. Next, the document was shared with the research team members for their comments and feedback. The document was revised based on the research team’s comments. Two independent bilingual experts translated the document into the local languages, Bemba, Tonga and Nyanga. The translated document was pretested in an urban slum of Lusaka during the research assistant training, after which both the KII and FGD recordings were transcribed and analysed. The tool was then revised based on the pre-test findings and feedback from the data collectors.

The data management and analysis

Audiorecordings from the FGDs and IDIs were transcribed and translated into English by four independent people who never participated in the data collection, and were proficient in English and the local language. To check for accuracy, 10% of the transcripts were back-translated into the local language. NVivo V.11 MAC was used for coding and analysis. To make it easy to compare differences and similarities in the participants’ perspectives by different attributes, a separate codebook was created for FGD and IDI data using a framework based on the FGD/interview guide. An inductive approach to data analysis was used, ensuring that subthemes were derived from the predetermined themes and grouping all similar statements concerning particular themes. In order to determine similarities and differences in the responses, findings for the FGDs and IDIs were analysed separately, according to the FGD participants: age (adults vs youth), sex (male vs female) and place of residence (urban vs rural). Summary and descriptive statistics were computed for FGD and IDI participants' demographic characteristics using SPSS V.25 (IBM SPSS Statistics 25)

Quality assurance and control

The team ensured the quality of data collection by: (A) recruiting skilled and experienced data collectors who were trained for 5 days on the theoretical and practical aspects of the study, (B) ensuring that data collectors worked in pairs, (C) using an interview guide (translated into the local language), (D) using a digital voice recorder and taking extensive notes during the FGDs and interviews, (E) by comparing notes and voice recordings each day after the interviews, (F) using experienced and independent staff to transcribe the recordings from the FGDs and KIIs.

Patient and public involvement

Study participants and the public were not directly involved in the design of the study. Rather, the study was designed in response to the call for consultancy for a research proposal on COVID-19 vaccine issued by the COVID-19 Centre, funded by GIZ in Lusaka. However, selection of the primary health facilities, communities and study participants was done in collaboration with stakeholders from the provincial, district and primary health facility and community levels. First, prefield meetings were held with the provincial and district managers to select primary healthcare facilities and local communities to be included in the study. Next, local district managers selected the primary health facilities to be included in the study. In turn, primary healthcare facilities together with the local community leaders recruited the FGD participants and made arrangements for them to come for the actual discussion; they also contacted and prepared a comprehensive list of IDI participants. Finally, a report was written and shared with the funding organisation, GIZ and the COVID-19 centre for dissemination of study findings.

Demographics

Our sample comprised a total of 272 respondents (FGD=242 and IDIs=30). The majority (51.5%) of the participants were female, with a mean age just above 34.04 years and between 2 and 3 children. Almost half (47.1%) of the participants were married. Most participants (55.2%) had secondary school education, 18% had tertiary level education and 1.5% had never attended school. Majority (62.1%) of the participants had an average income of less than K500 per month. Most of the participants (69.5%) mentioned that they were aware about COVID-19, and 52.9% reported that the COVID-19 vaccine was beneficial. Less than 1/10th (9.9%) of the respondents were vaccinated (see table 2 ).

Demographic characteristics of the respondents (n=272)

Theme 1: perspectives on acceptance of the COVID-19 vaccine

Analysis of the findings from the short demographic questionnaire administered to the respondents before each FGD and IDI showed that less than 1/10th (9.9%) of the total sample (FGD and IDI participants) had received the vaccine ( table 2 ). Out of the 27 (9.9%) that reported being vaccinated, 18 (66.7%) were health workers. Our analysis of IDIs also confirmed that most health workers and participants from the NGOs had a positive attitude towards the COVID-19 vaccine and were willing to be vaccinated. Both the community leaders and participants from the NGOs confirmed that they had accepted the vaccine and that many people were willing to be vaccinated. They clarified that the low vaccine coverage reported, especially in rural areas, was a result of the limited access, low supply and stock-out of the vaccine. They mentioned that the vaccine was mainly available and administered in the urban health facilities. Those that lived in remote areas, far from the health facilities, had difficulties accessing the vaccine.

The vaccine has been accepted…. because people have been vaccinated; if they had not accepted the vaccine, they wouldn't have been vaccinated ( IDI informant, health worker, Ndola district ). They aren’t so many people that have been vaccinated. It is because the people vaccinating are rarely seen here ( Community leader, IDI participant, Pemba district ). For those who live in far-flung places, we don’t know if they get vaccinated. I think it would be best to ask them ( Community leader, IDI participant, Mazabuka district )

Most adult participants (both male and female) confirmed that they had not been vaccinated. However, most expressed willingness to be vaccinated. Especially, participants from the rural sites mentioned that many people would accept the vaccine if they had adequate information about its benefits and if it were made available in the health facilities. Our analysis showed no much difference between male and female FGD participants with regard to their attitude towards the COVID-19 vaccine and their intention to be vaccinated.

We can accept the vaccine, but we need sensitisation because even when we were going to school, our parents would tell us whether to accept the vaccine or not ( FGD participant, Lusaka ).

In contrast, analysis of FGD findings showed a striking difference in perspectives between the youth and adult participants. Most youth participants (from both the urban and rural areas) believed that the vaccine was not beneficial and confirmed that most young people had not accepted it.

We have not accepted the vaccine because we don’t know how it’s going to affect the life of someone in future. In short, we don’t know what the life span of people will be. This is the reason why we have not accepted it in our communities ( Youth FGD participant, Kabwe district ).

Theme 2: factors affecting acceptance of the COVID-19 vaccine

Our analysis of both FGD and IDI data showed various factors contributing to the low acceptance of the vaccine among study participant including lack of knowledge and information, myths and misconceptions, and negative attitude towards the vaccine. These factors are presented below.

Knowledge about COVID-19 vaccines

Overall, IDI participants (ie, health workers and participants from the NGOs) expressed better knowledge about COVID-19 vaccine than the FGD participants. Health workers and participants from NGOs knew the types of the COVID-19 vaccines, their mode of administration, benefits and side effects. They also knew about the COVID-19 national vaccination programme. Although most community members (both IDI and FGD participants) perceived the vaccines to be beneficial, majority lacked information about the vaccine-–the various types, mode and frequency of administration. They explained that many would accept the vaccine if they had adequate information. Limited access to information, especially in rural areas, was cited as the main reason for the low acceptance of the vaccine. Community leaders and health workers were unanimous on the information gaps in their communities.

People don't have the truth about the vaccine. The health team should come to educate us on how the vaccine works. They should come to communities, gather people and teach them about the COVID-19 vaccine ( Female FGD participant, Masaiti district )

A contrast was noted among the FGD participants with regard to their knowledge about the vaccine. In general, participants from urban areas expressed better knowledge than those from rural communities. Differences were also noted between the adults and youth FGD participants. Although most youth confessed that they did not know much about the vaccines, they explained that young people had heard about the vaccine, especially those from urban areas.

We know about the COVID-vaccine…most of us youth have heard about COVID-19 and know about the new vaccine ( Youth FGD Participant, Chainda, Lusaka city )

Limited access to information about the COVID-19 vaccine

Overall, our findings show that there was limited access to correct and quality information about the COVID-19 vaccine among most community members who participated in both the FGDs and IDIs. Limited access to information was mentioned as a major reason for the low vaccine acceptance among the participants. Participants from urban settings had better access to information than those from rural areas. Both the IDI and FGD participants confirmed that mass media (radio, televion (TV)), internet and social media were the main sources of information on the COVID-19 vaccine.

A contrast was observed in perspectives on the access to information between the FGD participants from urban and rural settings. Most adult FGD participants from urban sites confirmed that they had access to the major sources of information—media (radio and TV). However, they complained that they could not understand most messages on TV and radio because they were in English. They observed that broadcasting the same messages in local languages would greatly help increase community awareness about the vaccine.

Many people get the information from the radio and TV. They listen to the radio and TV to hear what the Minister is saying. ( Community leader, IDI participant, Chongwe district )

Participants from rural sites did not perceive the media (TV and radio) and internet to be the main sources of COVID-19 information. Poor TV and radio signal reception limited their access to information. Rather, they received information from the health staff, schools, churches, community health workers and community leaders (during community meetings). Health staff disseminated the information about the COVID-19 vaccine when people visited health facilities for various health needs. Community health workers shared the information during community meetings; community members, in turn, would share the information with their families and social networks.

Many people don’t watch TV here….they try to listen to the radio… They have TVs but they can’t see anything….the signal is poor. Government needs to improve TV and radio signal here ( Health worke, IDI participant, Pemba district )

Although community health workers played an important role in disseminating information about the COVID-19 vaccine in the community, most IDI and FGD participants (mainly community leaders and health staff) expressed concerns about the accuracy of the information. They complained that most community health workers did not have adequate knowledge about the vaccine and that, in some instances, the information was incorrect and distorted. As a result, most people did not trust the information they received from the community health workers. They suggested that people in their communities needed more sensitisation and education about the COVID-19 vaccine. They bemoaned that the local health facility staff did not do much to disseminate the information about the COVID-19 vaccine in their communities. Asked on the kind of information their communities needed, most community health workers and leaders mentioned information on the vaccine benefits, safety and the associated risks or side effects. They believed that accurate and adequate information would help the community members make an informed decision about taking the vaccine.

People in this area know nothing about the vaccine because they have never been sensitised. We need to be told what we can do so that we have an idea, but the way it is at the moment, we don't have any idea ( Community leaders, IDI participant, Pemba district ) We just hear from others in the community, because here most of the things we just hear them from these health workers when they pass and tell us, so we also believe what they tell us ( Female FGD participant, Masaiti district ).

In contrast, most young people, especially from urban sites, cited the internet and social media accessed through their phones as their main sources of information for COVID-19-related matters including the vaccine. However, poor internet and mobile phone signals in rural and remote areas made it difficult for most young people to access information.

Most of us use our phones to get information….we get everything from social media on our phones ( Youth FGD participant, Ndola city )

Myths and misconceptions about the COVID-19 vaccine

Our findings elicited many myths and misconceptions about the COVID-19 vaccine among both the IDI and FGD participants. Especially FGD participants were unanimous on the existence of various myths and misconceptions concerning the vaccine. These myths and misconceptions had a negative influence on people’s attitude towards the COVID-19 vaccine and seem to be some of the most important reasons for the high vaccine hesitance.

One of the myths held among most FGD participants (especially in urban settings) was that western countries brought the vaccine in order to eliminate the African population. According to them, westerners brought the vaccine because they wanted to collect people’s blood and kill them. They were concerned why certain vaccines given to the Africans had been rejected in Western countries.

There is a rumour that people in our community are spreading that the medicine [vaccine] was made to kill us Africans because we are too many. So even as we accept that this must be true ( Community leader, IDI participant, Ndola ).

The other strongly held belief by both male and female FGD participants from urban and rural sites (but not the youth) was that the vaccine was brought into the country for political reasons. They explained that politicians had gone into some contractual agreement with western countries to administer vaccines to their people in exchange for money. The money would then be used for political campaigns since it was a presidential and parliamentary election year (2021) in the country.

Some people are saying that they have brought the vaccine in an election period because they want them [community members] to die after giving them the injection so that they are sacrificed ( Female FGD participant, Lusaka )

The other firmly held belief (especially among rural participants) seemed to be influenced by participants’ religious background or inclination. They explained that people believed that the COVID-19 vaccine was part of the mark of the beast (666) mentioned in the Bible (see Revelation 13) and that those who receive the vaccine are initiated into the ritual.

Some people say this is 666, that’s what I heard others say. So that’s why we are scared, because we think that they will initiate us into the 666 rituals ( Female FGD participant, Kabwe ).

Other beliefs seem to be influenced by health reasons. For example, both the FGD and IDI participants from rural and urban settings explained that people in their communities believed that the vaccine is a slow poison which health staff introduced into the body. They believed that the vaccine dries up and makes the blood clot and that one will die after several months or years. Some participants also believed that after receiving the vaccine, one would start fitting and die immediately after being vaccinated; those who survived would only live for a few years afterwards.

Some say when you get vaccinated, you will just live for a few years, and then you get sick and die; that is why we are scared of getting vaccinated ( Traditional leader, IDI participant, Mazabuka district ).

Attitude towards the COVID-19 vaccine

Overall, our analysis of the data from the short demographic questionnaire showed that half (52.9%) of participants (both the FGD and IDI participants) perceived the vaccine to be beneficial ( table 2 ). However, analysis of FGD and IDI data shows that participants expressed different types of attitude towards the COVID-19 vaccine: positive, negative and ambivalent. The detailed findings on these attitudes are presented below.

Most health workers and some FGD participants from both urban and rural settings expressed a positive attitude towards the COVID-19 vaccine and perceived it to be beneficial. Perceived benefits were that the vaccine confers protection against the coronavirus infection among the vaccinated individuals. They also believed that the vaccine reduces the chances of a vaccinated individual to transmit the virus to other people. The other cited benefit was that the vaccine reduces the risk of developing severe disease. If one got infected, the disease would not be as severe as it is among those who are not vaccinated.

Most FGD participants expressed a negative attitude towards the COVID-19 vaccine. Interestingly, our findings did not show differences in attitude between male and female participants. Rather, rampant myths and misconceptions about the COVID-19 vaccine and personal or family’s previous experience with the COVID-19 disease or vaccination seemed to have influenced the participants’ attitude. In general, individuals or families who had not experienced the disease or seen someone suffer or die from COVID-19 disease expressed a negative attitude. They believed that the vaccine was not beneficial. Further, lack of information (especially in rural areas) and wide spread misinformation about the COVID-19 vaccine—such as exaggeration of the vaccine side effects—seemed to influence participants’ attitude towards the COVID-19 vaccine.

I know the benefits are building our immunity and we don’t get a chance to catch COVID-19, though people are saying even those that got the jab have tested positive, they don't have severe disease (IDI participant, Health worker, Ndola district).

Moreover, cultural beliefs and stigma about COVID-19 seem to have affected many people’s attitude and prevented them from accepting the vaccine. Especially health staff explained that some people did not believe in the existence of COVID-19. They cited examples of communities where a family member would suffer and die from COVID-19, but relatives would hide the information and mention another disease, such as asthma, as the cause of death. Because of denial and low-risk perception, such people refused to take the vaccine.

Lack of confidence in the health workers (who came from outside their communities) was perceived as an important factor influencing participants’ attitude towards the vaccine, especially among the community leaders and FGD participants from rural communities. They argued that people in their communities would only be convinced to take the vaccine if the health workers from their local communities administered the vaccine.

The people to vaccinate us must be from our community; otherwise, when an outsider comes to vaccinate us, we will be sceptical because we don't know them ( Village headman/IDI participant, Chongwe district )

In addition, most participants from rural towns and communities expressed an ambivalent attitude towards the vaccine; they were not sure about the benefits of receiving the vaccine. They argued that they did not know the vaccine benefits because they had not seen anyone take it. They explained that they would only believe in the vaccine benefits if someone or a group of people who had taken the vaccine went to explain how they felt after receiving it.

We do not know the truth, and we are scared, that is why we don't go for the vaccine injection. We have been told that the vaccine injection is harmful to consumers ( Male FGD participant, Masait district ). What we are saying is that they should bring us someone who has been vaccinated so that they tell us about the goodness of being vaccinated ( Male FGD participant, Chongwe district) We don't know how these things came, we are scared that we may die, and we can also be infected with other diseases. We don't see people who have been vaccinated, to tell us how they feel ( Civic leader, IDI participant, Masaiti district).

In general, young FGD participants from both urban and rural communities had a negative attitude towards the COVID-19 vaccine. Low-risk perception seemed to influence their attitude towards the vaccine. They believed that they were not at risk of getting the infection and that those who got infected would have mild or no symptoms at all. They also believed that the vaccine was not beneficial. Access to the internet and use of social media among the young people (especially from the urban communities with good internet connectivity) seems to have exposed them to incorrect information regarding the benefits and side effects of the vaccine. This, in turn, influenced their attitude. In addition, poor mobile phone signals, TV and radio reception in rural areas made it difficult for most young people to access information about the COVID-19 vaccine.

The aim of this study was to explore community members’ and health workers’ perspectives on the COVID-19 vaccine and the reasons that affect its uptake in Zambia. Overall, our findings showed low vaccine uptake among the participants. Several factors including limited knowledge, access to information, myths and misconceptions, negative attitude towards the vaccine and low-risk perception about the COVID-19 disease contributed to vaccine hesitance among the participants.

Our finding corroborates previous studies from LMICs and elsewhere which reported vaccine hesitance among health staff and community members. For example, a study conducted in Zambia 29 reported substantial uncertainty and hesitancy about receiving the vaccine among parents, despite expressing high intentions to have their children receive the COVID-19 vaccine. Similar findings were reported by Botwe et al 38 in Ghana who reported a vaccine hesitance of 44% among the health staff. These findings are also consistent with those by Baniak et al 39 who reported vaccine hesitance among nursing staff in the USA. The authors concluded that, despite the increase in vaccine uptake during the active vaccine rollout, there was still widespread and sustained hesitancy and unwillingness to take the vaccine. Other authors, Wong et al 40 and Luk et al 41 in Hong Kong also reported a low intention to vaccinate. They concluded that vaccine hesitance was a major challenge to effective programming and implementation. Thus, formulation and implementation of evidence-based vaccination strategies focusing on increasing the intention to take the vaccine has a potential to mitigate vaccine hesitance

Limited knowledge about the COVID-19 vaccine, its benefits and potential harms, was found to be one of the important barriers to effective vaccine uptake. The media (TV, radio and internet) play an important role in informing people about the vaccine. However, poor TV and radio signal reception in rural and remote areas limit access people’s access to these important sources of information. This explains the stark contrast in the levels of knowledge about the COVID-19 vaccine between participants from rural and urban communities. Moreover, our findings suggest that social media accessed through the internet on mobile phones is a major source of information among young people. However, poor internet and mobile phone signals in rural areas make it difficult for young people to access information. This finding is consistent with previous studies 42–46 which reported low knowledge levels concerning the COVID-19 vaccine. Interestingly, these studies showed that knowledge about the vaccine was positively correlated with one’s vaccine uptake. This finding suggests that information is an important factor influencing vaccine acceptance, and that lack of information affects peoples' willingness to take the vaccine. This result is consistent with the theory of reasoned action which highlights the importance of background factors such as knowledge and access to information in influencing people’s intention to adopt a health behaviour such as COVID-19 vaccination. 47–49 Public health interventions aiming at mitigating vaccine hesitancy and increasing vaccine uptake could benefit from focusing on knowledge and access to information about the COVID-19 vaccine, its benefits and safety.

Widespread myths and misconceptions about the reality of the COVID-19 disease and the benefits of the vaccine appear to be an important factor contributing to vaccine hesitance among our sample. These myths and misconceptions seem to be more rampant in rural communities where there is limited or no access to accurate information about the benefits and safety of the vaccine. For example, due to limited access to accurate information, many people in rural communities depend on the information from health workers and traditional leaders. Our findings suggest that such information, though important, is either inadequate or inaccurate with a potential to be misinterpreted. When people discover that such information is inaccurate untrustworthy, they seek alternative sources such as social media−which may also be misleading, resulting in the emergency of conspiracy and rampant myths and misconceptions. 49 However, especially in urban areas the situation is different; most myths and misconceptions seem to be influenced by the incorrect information spread by social media users, especially young people, with ready access to the phone and internet. For example, many participants (both FGDs and IDIs) believed that the vaccine is a poison: it dries up one’s blood, causes it to clot and eventually kills the victim. Our findings suggest that these strongly held beliefs have a negative influence on people’s intention to take the vaccine. These findings corroborate those reported elsewhere 50–53 regarding the importance of social media in propagating myths and misconceptions about the vaccine. These findings are also consistent with previous studies, for example, Bertin et al , 54 which reported that myths and misconceptions do not only instil fear among the people, but also influence them not to take the vaccine. Public health interventions can benefit from provision of correct and accessible information to prevent and address myths and misconceptions which negatively influence people’s perspectives and adoption of health behaviour, such as vaccine uptake. Thus, increasing access to correct information in the community has the potential to prevent and address the widespread myths and misconceptions about the vaccine and help mitigate vaccine hesitance. 55

Our findings suggest that attitude towards the COVID-19 vaccine has an important influence on the intention to take the vaccine. Although half of the participants perceived the COVID-19 vaccine to be beneficial, most had mixed attitudes towards the vaccine: positive, negative and ambivalent. Participants’ attitude seems to have been influenced by various factors including place of residence, age, access to information, myths and misconceptions about the vaccine, and one’s experience with the COVID-19 disease and the vaccine. Participants who had either experienced the disease, seen a friend or family member suffer from the disease expressed a positive attitude towards the vaccine compared with those who had not. Similarly, those who had either been vaccinated, seen or heard about someone who had been vaccinated appreciated the benefits of the vaccine and expressed a more positive attitude than those who had no such experience. Protection against COVID-19 and reduction in the severity of the disease if one got infected were the main perceived benefits. Perceived benefits appear to play an important role in influencing people’s attitude towards the vaccine. Participants who perceived no benefits from the vaccine expressed a negative attitude. This finding is in keeping with the reasoned action approach which postulates that, before engaging in a healthy behaviour, people evaluate the benefits against the risks. 56 An individual’s attitude, therefore, will depend on their evaluation of the perceived benefits compared with the risks. Those who perceive more benefits are likely to have a positive attitude towards the target behaviour, and possibly adopt it. This finding is also consistent with those reported by Elhadi et al in Libya. 57 These authors found that people who had a family member or friend infected with COVID-19 were more likely to accept the vaccine. Strategies that use a collaborative approach with community role models who have either experienced the disease or received the vaccine have the potential to change community attitudes towards the vaccine and possibly increase vaccine uptake.

Finally, our findings on low-risk perception and personal susceptibility to the COVID-19 disease, especially among young people, are worthy noting. It appears that young people’s ‘false sense of safety’—that they are not susceptible to the COVID-19 disease and that, if they get infected, the disease would not be severe—seem to influence their attitude towards the vaccine. Access to social media and incorrect information from the internet, especially among the young participants from urban communities, appears to contribute to the low-risk perception and vaccine hesitance. Interestingly, we did not find a striking difference in risk perception between the male and female participants or according to place of residence (urban or rural). This finding contradicts Elhadi et al 57 who reported low vaccine hesitance among young people—that, compared with older people, young people were more likely to accept the vaccine. However, this finding is in line with Lazarus et al 58 who (in their survey of over 13 420 people from 19 countries) reported that young people were less likely to accept the vaccine than older people. The finding is consistent with previous studies that reported that age, and not sex, had a significant association with one’s attitude towards acceptance of the vaccine. These studies also reported a positive correlation between age and vaccine acceptance. They also showed that high risk perception about the severity and one’s personal susceptibility to the disease, benefits from the vaccine, cues to action and trust in the healthcare system or vaccine manufacturers were positive correlates of vaccine acceptance. Interventions that use social media to provide correct information to young people—about their personal risk and susceptibility to the disease—has a potential to mitigate vaccine hesitance among this age group. To be successful, such interventions should focus on addressing behavioural beliefs, risk perception and outcome expectancy. 59

Study limitations

Potential limitations of our study should be noted. First, this study was conducted at the beginning of the COVID-19 national mass vaccination programme in the country when people’s knowledge about the vaccine was still limited; it is not clear how knowledge in the community has evolved over time. Second, like other qualitative study designs, this study could not establish a causal link between knowledge and attitude, and vaccine uptake. Further research with a longitudinal quantitative design is required to measure knowledge and attitude, and test their relationship with vaccine uptake in order to establish the causal pathway.

Nevertheless, we believe that use of FGDs and IDIs comprising adult male and female as well as young participants from both urban and rural settings provided in-depth information on vaccine uptake and the influencing factors, based on the views of the health workers and community members. We believe this study design increased the validity of our findings. Furthermore, selecting participants (both community members and health staff) from both urban and rural settings, increased the internal validity of the study. It also provides a balanced view of the Zambian people’s perspectives on the subject under investigation. Our study also highlights the importance of using an integrated community-based approach to maximise vaccine uptake. This approach is in accordance with the WHO guidelines, 60 which suggest that a comprehensive approach, targeting multiple facets of social interaction, is more likely to dispel COVID-19 myths and misconceptions, and address vaccine hesitancy. Thus, our findings can save as basis for policy and intervention design to mitigate vaccine hesitance and increase vaccine uptake. To our knowledge, no such study has been conducted in Zambia; this is the first one.

Our findings demonstrate low vaccine uptake among our participants; it also highlights several factors—including limited knowledge and access to information, myths and misconceptions, negative attitude towards the vaccine and low-risk perception about COVID-19 disease–which affect vaccine uptake. These results can provide starting points for future Public health policies and interventions which, in our opinion, should focus on: (A) increasing access to information and knowledge about the benefits and safety of the vaccine; (B) addressing myths and misconceptions about the vaccine; (C) increasing risk perception and perceived personal susceptibility to the COVID-19 and its severity, especially among young people; (D) making the vaccine accessible, especially in the rural and remote areas; (E) identifying role models in the community who have either experienced the disease or received the vaccine; (F) establishing linkages and collaboration between health workers and role models; (G) establishing a community operational and vaccine delivery mechanism through strengthened linkages with key community leaders such as local traditional, civic and religious leaders, and (H) addressing systemic barriers such as human resource shortage and stock-outs of the vaccine to increase access to the vaccine in the rural and remote communities.

Supplementary Material

Acknowledgments.

We thank Levy Mwanawasa medical University, Mary Ng’andu for supervising the data collection and the research assistants who helped with the data collection. Our gratitude also goes to the study participants for their valuable time and input into the study.

Contributors: All authors contributed substantially to the development of the manuscript. CS designed the study. Under the oversight of CS, MN supervised the data collection process. CS and NM conducted data analysis. CS wrote the first draft of the manuscript. NM, EMS, W-CP, JMZ, DEML, AM, BM, DE and MM read and provided feedback on the draft manuscript. CS, NM and EMS revised the manuscript. All other coauthors advised on the final draft of the manuscript. All authors read, commented on and approved the final manuscript. CS had access to the data, controlled the decision to publish and is the study guarantor.

Funding: The study was made possible by grant number 20.2095.6-001.00 from Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ)/German Cooperation through the Decentralisation for Development (Zambia).

Competing interests: None declared.

Patient and public involvement: Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.

Provenance and peer review: Not commissioned; externally peer reviewed.

Supplemental material: This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

Data availability statement

Ethics statements, patient consent for publication.

Not applicable.

Ethics approval

This study involves human participants and was approved by University of Zambia Biomedical Research Ethics Committee (ref: 1774-2021). Participants gave informed consent to participate in the study before taking part.

Health Promotion Research Programme

The Health Promotion Research Programme follows through the health issues since 1992,  where the Government of the Republic of Zambia has been implementing major health reforms. The main purpose of the health reforms have been to increase efficiency and effectiveness in the provision of health services.  The health reforms, however, were characterized by a number of challenges including (i) a huge disease burden due to both communicable and non-communicable diseases; (ii) insufficient and declining international and domestic financial resources; (ii) donor dependency; (iii) Human Resources for Health crisis; and (iv) a poor governance record. The National Health Strategic Plan (NHSP) 2011-2015 outlines an ambitious course to streamline the process of health service delivery through prioritization and the implementation of high impact interventions.  The 2011-2015 NHSP was criticised for not attaching the commensurate weight to preventative and community based health care.  To this end, essential departure of the 2016-2021 is its emphasis on the socio-economic determinants and bias toward community health.

The Health Promotion Research Program (HPRP) seeks to address some of these challenges being faced in the health sector by undertaking research that will help strengthen health systems and policy. The program seeks to implement research that will contribute towards the acceleration of the health related SDGs research that will help to strengthen linkages between the health facilities and the community; seek to conduct research activities on environmental issues, Non-Communicable Diseases (NCDs), Communicable diseases (Malaria, TB, HIV/AIDS) and behavioural health issues.  In the next five years, the HPRP will primarily focus on the following areas for research:

• Social determinants of health
• Models of strengthening health systems
• New born, child and maternal health.
• Infectious diseases (HIV and AIDS, Malaria and TB)
• The social determinants and consequences of non-communicable
• Behaviour change communication.

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Health research knowledge translation into policy in Zambia: policy-maker and researcher perspectives

Affiliations.

• 1 Department of Health Policy and Management, School of Public Health, University of Zambia, P.O. Box 51110, Lusaka, Zambia.
• 2 Department of Medical Education, School of Medicine, University of Zambia, P.O. Box 51110, Lusaka, Zambia.
• 3 Department of Health Policy and Management, School of Public Health, University of Zambia, P.O. Box 51110, Lusaka, Zambia. [email protected].
• PMID: 33761935
• PMCID: PMC7992358
• DOI: 10.1186/s12961-020-00650-5

Background: The translation of public health research evidence into policy is critical to strengthening the capacity of local health systems to respond to major health challenges. However, a limited amount of public health research evidence generated in developing countries is actually translated into policy because of various factors. This study sought to explore the process of health research knowledge translation into policy and to identify factors that facilitate or hinder the process in Zambia.

Methods: This work was an exploratory qualitative study comprising two phases. Firstly, a document review of health policies and strategic frameworks governing research was undertaken to understand the macro-environment for knowledge translation in Zambia. Secondly, key informant interviews were conducted with those responsible for health research and policy formulation. The study interviewed 15 key informants and a thematic analysis approach was used.

Results: The document review showed that there are policy efforts to promote knowledge translation through improvement of the research macro-environment. However, the interviews showed that coordination and linkage of the knowledge creation, translation and policy-making processes remains a challenge owing to lack of research knowledge translation capacity, limited resources and lack of knowledge hubs. Emerging local research leadership and the availability of existing stock of underutilized local health research data provide an opportunity to enhance knowledge translation to feed into policy processes in Zambia.

Conclusions: Public health research knowledge translation into policy remains a challenge in Zambia. To enhance the uptake of research evidence in policy-making, this study suggests the need for improved coordination, financing and capacity-building in knowledge translation processes for both health researchers and policy-makers.

Keywords: Knowledge translation; Policy-makers; Researchers; Zambia.

• Administrative Personnel
• Health Policy
• Policy Making*
• Translational Research, Biomedical*

• Open access
• Published: 23 September 2016

Health research priority setting in Zambia: a stock taking of approaches conducted from 1998 to 2015

• Pascalina Chanda-Kapata 1 ,
• William Ngosa 1 ,
• Busiku Hamainza 2 &
• Lydia Kapiriri 3  

Health Research Policy and Systems volume  14 , Article number:  72 ( 2016 ) Cite this article

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Priority setting in health research is an emerging field. In Zambia, like many other African countries, various priority setting activities have been undertaken with a view to identify research activities to which the available resources can be targeted while at the same time maximising the health impact for resource allocation to support evidence-based decision-making. The aim of this paper is to document the key elements of the various priority setting activities that have been conducted since 1998, identifying the key lessons and providing recommendations to improve the process.

A comprehensive review of the previous priority setting activities and processes in Zambia was conducted. Both published and unpublished reports were reviewed in order to identify any research priority setting processes that have been undertaken in Zambia. We developed a framework, based on the priority setting literature, to guide our abstraction and synthesis of the literature.

The earliest record of priority setting was conducted in 1998. Various priority setting approaches have been implemented in Zambia; ranging from externally driven, once-off activities to locally (in country) initiated comprehensive processes. However, there has been no systematic national process for priority setting. These priority setting processes in Zambia were characterised by limited stakeholder buy-in of the resulting national research or programmatic research agenda. Most striking was the lack of linkages between the different initiatives. There seems to have been no conscious recognition and building on previous priority-setting experiences of previous initiatives.

There were gaps in the priority setting processes, stakeholder engagement and application of a defined criterion. There is a need for a priority setting framework coupled with local capacity developed across a range of stakeholders.

Peer Review reports

Prioritisation of health research is an area that requires attention in the light of scarce resources considering its importance in ensuring that the relevant evidence generated from it addresses national priorities [ 1 ]. Since the provision of health services has become entirely dependent on quality and timely availability of evidence-based decision-making, research has assumed a strategic and important role in providing new scientific knowledge and insights. The research priorities tend to determine the research agenda, practices and technologies of a given national health research system [ 2 ]. Besides voicing of research priorities and strategies, the maximisation and utilisation of research outcomes are extremely important ingredients in this process.

Most low- and middle-income countries face severe resource constraints, making it difficult for sufficient resources to be allocated to the health sector and health research. Priority setting is important because it guides investments in healthcare, health research and respects resource constraints [ 3 ]. Setting priorities for health research is essential to maximise utilisation of the meagre resources allocated to the health sector and is regarded as a key factor in the effort to strengthen national health research systems [ 4 ], especially in low-income countries, where government expenditures on health are less than US$ 20 per capita per year [ 5 ].

A 1990 report by the Commission on Health Research for Development created momentum for researchers and policymakers to become interested in priority setting both at country and international levels [ 6 ]. It recommended that countries should develop a national plan for conducting health research and that each country should set its own priorities for health research. As a result, a number of low- and middle-income countries, such as Zambia, began to experiment with setting priorities for health research to guide various stakeholders from the health and non-health sectors [ 7 ].

Zambia’s health research system has undergone a great deal of growth. Until recently, there was no single governance body that provided leadership in health research. The responsibility was shared between the Ministry of Health and Ministry of Science, Technology and Vocational Training. A major breakthrough was scored when the National Health Research Policy was approved in 2010. This policy provided strategic direction for the promotion, conduct, prioritisation, financing and institutionalisation of health research [ 8 ]. This culminated into the enactment of a landmark piece of legislation in March 2013. The Health Research Act, among other things, provided for an institutional framework for the prioritisation of areas for health research, dissemination, monitoring and evaluation, and a Trust Fund for funding national research priorities [ 9 ]. The identification and prioritisation of areas for research and eventual funding would help the country not to rely on external donors when deciding which areas of research to fund as donor priorities may not always conform to national priorities [ 10 ].

A significant amount of health-related research has been carried out in Zambia over the past decade. However, while the process of identifying research gaps has been ongoing since 1998, there has been no sustainable system for regularly coordinating research priorities. Priority setting for health research has been ad-hoc, with little consideration for ongoing or previous health research activities [ 11 ]. Additionally, there has been no systematic synthesis of the approaches and lessons learnt from previous priority setting activities. A synthesis of these lessons would be critical in informing future efforts. We present here a description of some of the priority setting approaches which have been conducted in the country from 1998 to date.

A comprehensive review of the previous priority setting activities and processes in Zambia was conducted. Both published (peer reviewed) and unpublished reports (institutional documents) were reviewed in order to identify any priority setting processes which have been undertaken in Zambia. The search terms for the published literature included: “Zambia”, “priority setting” and “health research”. The databases searched included the COHRED Website and PubMed. Five retrieved articles were relevant for this analysis, of which four were reports from priority-setting exercises undertaken by the Ministry of Health (MoH).

The literature review was undertaken between September 2014 and June 2015. The identified records were reviewed in order to identify any priority setting processes involving health research regardless of the focus of the priority setting.

We developed a framework, based on the priority setting literature [ 12 ], to guide our abstraction and synthesis of the literature. This framework included aspects that are deemed relevant to priority setting, e.g. explicit processes used, stakeholder involvement, guiding framework/approaches employed, criteria used, and the outcome of priorities once set. The abstracted information was synthesised and summarised according to these themes. In the results section, we present each priority setting initiative and discuss the details under each of the identified themes.

This study received ethics clearance from McMaster University and The University of Zambia Humanities and Social Science Ethics Committee, IRB # 00006464. Permission to conduct the study was received from the MoH in line with local guidelines.

Our review revealed that, to date, five health research priority setting initiatives have been undertaken in Zambia, namely (1) the National Health Research Advisory Committee (NHRAC) of the MoH initiative; (2) priority setting for health research as part of the general priority setting for health driven by the National Health Strategic Plan 2006–2011; (3) priority setting by the National Science and Technology Council (NSTC); (4) priority setting by The Zambia Forum for Health Research (ZAMFOHR), a comprehensive priority setting process for MoH programs; and (5) priority setting by the MoH in partnership with the World Health Organization Implementation Research Leverage Fund (WHO-IRLF) on Maternal, Neonatal and Child Health (MNCH); we discuss each in detail (Table  1 ). Overall, the priority setting processes which have so far taken place fall short of the fairness criteria described by Kapiriri et al. [ 13 ] since information on publicity, revisions and enforcement was found to be lacking.

The first priority-setting exercise was conducted in 1998 by the NHRAC of the MoH. The Ministry of Science, Technology and Vocational Training was involved through the NSTC, which is a statutory body that oversees research for all sectors in the country. The MoH was involved through the NHRAC, which was established in 1998 to monitor developments and identify needs for action in health research [ 14 ]. This exercise involved tracking what research had been done through small group brainstorming sessions. A National Health Research meeting was called, bringing together different stakeholders. The stakeholders were composed of representatives from government program officers, researchers, funding agencies, non-governmental organisations (NGOs), and academia. The details of the nature of the stakeholders were not clearly stipulated, but an estimated 200 to 300 people were part of the process. After this, a team of experts synthesised the input from stakeholders. Thereafter, a National Health Research meeting was held, bringing along different stakeholders to further synthesise key research findings. This resulted in a list of recommendations which were then submitted to a sub-committee of experts to analyse, refine and package the extensive list that came out of the meeting. The committees’ effort was subjected to a consensus meeting that provided additional feedback and input. The seven national health research priority areas which were obtained from this exercise were malaria, child health, nutrition, diarrheal diseases, reproductive health, sexually transmitted disease (including HIV/AIDS), tuberculosis, and water and sanitation. There are no reports to show the further break down of these priority areas. The priority areas were then disseminated in 1999 though hard copies and emails. After the priorities were set, funding agencies were informed to help mobilise resources to fund the identified priorities. However, there was no evaluation of the extent to which these priorities were implemented [ 14 ].

The lessons learnt

The main positive outcome was that this initiative integrated the various priority setting processes into a coordinated system, thereby developing processes through which research outcomes could be continually fed into national level policymaking, programme implementation, and identification of a process for updating the priorities. However, there were several challenges associated with this initiative. First, there were limited funds allocated to conduct research in the priority areas because the MoH continued to focus on curative services. Second, although provincial and district officers, NGOs, members of parliament and researchers were represented, the process was perceived as not being representative and inclusive by certain sections of the research community [ 14 ]. Third, according to some researchers, donor interests contributed to skewing health research priorities, whereby funds were only available for the research issues donors were interested in. As a result, limited funding was only available for tuberculosis, malaria and HIV.

For the period 2006 to 2011, the priority setting for health research was part of the general priority setting for health driven by the National Health Strategic Plan 2006–2011 developed by the MoH [ 15 ]; although it primarily focused on the health sector, it also fed into the Fifth National Development Plan for Zambia, which is part of the Medium-Term Expenditure Framework [ 16 ]. The annual planning cycle started with the Provincial Medical Offices and other provincial officials attending the national planning launch at the MoH’s national offices, where guidelines and central issues for consideration in the following year’s budgets are presented and discussed. The Provincial Medical Offices were presented with indicative figures from the central level (MoH) which each district within the province is expected to follow when setting their priorities [ 16 ]. The main lesson learnt here is that priority setting for health research may also take place as part of the general priority setting for health.

The NSTC has been conducting annual priority setting since 2007. It is not very clear what framework they use, but the process involves receiving priority areas from all sectors (namely agriculture, health, education, energy, commerce, mines, defence, etc.). The criteria for coming up with the sector-specific priorities is not predetermined, but is largely informed by the sector strategic plans and the national development plans. The priorities submitted from each sector are reviewed by the Sector Advisory Group, composed of sector representatives with a background in research and development, who select the final list of priority areas. Once the Sector Advisory Group approves the final list of research priorities, it constitutes the list used for a call for proposals. The call is advertised using the national print media and online. Since it is an annual process, the priorities are revised and updated based on monitoring findings of the previous year’s performance.

The process is multi-sectoral and funds are allocated to fund the identified priority research areas. It is transparent, with a standard call for proposals, standard proposal evaluation and predictable funding. Furthermore, it is efficient and most important locally driven. The disadvantage with this process is that, although guided by the Five-Year National Strategic Development Plans; the priority processes within each sector are not standardised. Furthermore, the total number of projects which have been funded through this mechanism could not be verified.

ZAMFOHR, an NGO, also conducted a priority-setting exercise for sexual and reproductive health between August 2010 and March 2011 on behalf of the MoH. Participants ranged from public servants, community-based organisations and researchers working on sexual and reproductive health. The process involved giving summarised worksheets of topics to participants. The initial list of priorities was developed by the Technical Committee on reproductive health. The participants were then divided into working groups and generated research topics. The topics which were generated were ranked by the two groups; the details of the process are summarised in a report [ 17 ]. Information on further publication and funding of priorities was not available.

The process was participatory involving stakeholders working in reproductive related programs. The method used was transparent and participants were actively involved in compiling the list of priority topics. Input from stakeholders who were not present at the workshop was received after the workshop. However, some participants who were present may have been overshadowed by their outspoken counterparts, leading to some vital contributions being left out [ 17 ].

A comprehensive priority-setting process for MoH programs was performed in 2010, whose purpose was to provide the government and partners with priority health research areas for resource allocation, mobilisation and implementation. The process was initiated by the Research Unit of the MoH creating guidelines or rules of engagement for the process. These guidelines were disseminated to program managers within the MoH. After that, each program manager convened a technical working group (TWG) in their respective areas of service delivery. These included malaria, child health, reproductive health, non-communicable diseases, mental health, HIV/AIDS, tuberculosis and health system strengthening. The program-specific TWGs deliberated on issues affecting the implementation of their respective programs. After deliberation, a list of potential study areas was identified. The list was submitted to the secretariat for compilation. The secretariat did not further synthesise the lists provided. After all TWGs had completed their consultations, a national dissemination meeting comprising funders, academicians, implementers and policymakers was held; the meeting involved about 100–150 participants. The compiled priority areas were presented to the stakeholders for further discussion in a one-day workshop held at national level. The discussion was moderated by the national research TWG of the MoH. All the meeting participants then provided further input either by adding more priorities or refining the phrasing of the priorities; others who needed extra time for submission were requested to do so through email. Finally, a final list of research priority areas was developed in form of a document and submitted to stakeholders for reference [ 18 ]. As a result of this exercise, some priority research areas in malaria, tuberculosis, maternal health and health system strengthening were funded and conducted during the period under review [ 19 ]. The other areas which were not funded were still maintained on the priority list; this is what was termed as a research agenda. As an example of partners using the outcome of this priority-setting process, the MoH, in collaboration with 3DE program (an initiative of the Clinton Health Access Initiative and IDinsight in partnership and funded by the Department for International Development) began conducting selected impact evaluations [ 20 – 23 ]. The projects were selected from the national priority areas for research [ 18 ]. The main lesson learnt from this general priority-setting process was that a national research system with already set priorities is likely to attract stakeholder buy in and may lead to implementation of some of the set priorities. Additionally, policy relevant research is conducted, and thus the likelihood that such research will inform local policies is high [ 24 ].

The MoH, in partnership with the WHO-IRLF on MNCH, conducted a priority-setting process for implementation research in October 2011. The participants were drawn from local research institutions and provincial/district level MNCH implementers (academia, NGOs, private and public). Participants received an introductory presentation on implementation research. After that, the Child Health and Nutrition Research Initiative (CHNRI) method [ 25 , 26 ] for priority setting was introduced to the participants as a tool to apply during the priority-setting process. Thereafter, participants were split into small working groups to brainstorm on potential implementation research questions which could be implemented in order to improve the MNCH situation in the country. Each group compiled a ‘shopping list’ of questions. After group presentations, all the questions which were identified were pooled into a long list of research questions. The participants were then requested to apply an objective ranking method by attaching scores to come up with a form of ranking using the CHNRI method. The criteria of selection included feasibility of the research being conducted, cost, likelihood of informing policy, and nature of the question. The results of the priority setting were transparently displayed in order of the questions getting the highest score. The top scoring 10 research questions were then adopted as the priority areas for MNCH implementation research in Zambia [ 27 ]. The list was communicated to all stakeholders working in MNCH in Zambia. There was no provision for the amendment of the list after the workshop. One proposal was funded; however, there was neither post-monitoring/evaluation of the process nor documentation of the impact of the study conducted. The main lesson learnt from this process was that, when setting priorities, there is an assumption that there exists adequate capacity to conduct research on the identified priorities. In this case, it was observed that the researchers did not apply themselves to the requirements of implementation research. This led to low implementation of the set priorities even though the funding to implement the research activities was available from the funding agency that conducted the priority setting.

Various priority-setting approaches have been implemented in Zambia; ranging from externally driven, once-off activities to locally initiated comprehensive processes. It was found that there was a lack of linkages between the different initiatives, there seems to have been no conscious recognition and building on previous priority-setting experiences between these initiatives. Each seems to have been a stand-alone, and often one-off, initiative. This paper fills this gap by providing a synthesis of these initiatives, identifying key lessons which can inform future priority-setting initiatives.

Our analysis showed that all but one of the priority-setting activities had some explicit process of participatory nature. However, the general public was not involved in any of the priority-setting activities. General stakeholder involvement was evidently being practiced. There was a lack of a clearly defined priority setting framework guide applied, with the exception of the MNCH, which used the CHNRI method. Additionally, all but one did not have explicit priority-setting criteria and there was a general lack of implementation and monitoring plans. With the exception of the MNCH CHNRI method, there was no incentive for adhering to the set priorities.

The availability of a clear policy environment and, most recently, a legal framework, promises to help improve the manner in which priority setting is conducted. There will be a need to develop priority-setting expertise locally so that the process can be sustained. In order for this to happen, it is proposed that a priority setting institute be developed in country with the goal of building local capacity.

The common issue for all the activities which were undertaken was the obvious involvement of technical experts and technical committee members (funders, implementers, academicians, etc.). However, the major disadvantage was the exclusion of the community level participants. Nonetheless, the gate keepers of community interests were all involved, so it can be argued that there was some representation or attempt to reflect the needs of the communities. The presence of district stakeholders in a priority-setting meeting has been shown to have potential to reflect community interests for health intervention priority setting in Kenya, Tanzania and Zambia [ 28 ]. It is yet to be established whether this is true for health research priority setting.

The priority-setting exercises which were locally driven, such as the one by the Ministry of Science and Technology, appeared to have led to research activities being implemented. This underscores the need for priority setting to be institutionalised within the local health system and increases the chances of success in terms of funding allocation, participation of stakeholders and likelihood of yielding actual research activities. This is an important lesson if priority setting is to be viewed as an important function of the health research system in the country.

Another observation was the limited capacity among stakeholders to apply themselves appropriately to the set priority areas. Therefore, apart from capacity building, incentive mechanisms for adhering to the set priorities need to be developed. Enforcement of the legal framework will be cardinal to ensure that the results of the priority-setting exercise are adhered to. One of the causes for low adherence was also the fact that funding for research is largely external [ 29 ]. The fact that the funding for health research mostly comes from external sources has implications for the identification and setting of priorities for health research. In order to minimise external influence on research priorities, the legal framework stipulates that only research identified on the priority list will be funded using government resources [ 8 ]. Other modalities include holding consultative meetings with funding agencies to include national work plans in their funding calls. A good example is the European & Developing Countries Clinical Trials Partnership funding modality, where countries provide input into what they would like to see in international calls for funding; the sources of information are the country work plans submitted prior to calls being made [ 30 ].

The process of allocating funds for research provides only limited incentives for researchers to focus their work on identified priorities. A standard national priority setting tool is also required to ensure uniformity of approaches. Such a framework should be based on the lessons learnt to date from the Zambian experiences with priority setting for health research and should include (1) an explicit framework, that is chosen or agreed upon by the relevant stakeholders to guide the process; (2) clear mechanisms for monitoring and a framework for evaluation of the priority setting process and the implementation of the identified priorities; (3) annual feedback mechanisms to ensure the implementation of the identified key lessons; and (4) a clear priority-setting process, explicit criteria and processes for ranking the research options, clear mechanisms for wide stakeholder engagement – especially those from the sub- national levels, and mechanisms for considering a wide variety of evidence to guide priority setting.

There is need for strong global forums where country experiences can be shared. This will further serve to not only validate available frameworks but also provide ongoing processes for improving priority setting. The global forums can also serve as opportunities to engage international stakeholders on the importance of adhering to national health research priorities. One such example is ESSENCE on health research, which is an initiative of funding agencies to improve the coordination and harmonisation of research capacity investments [ 31 ] and to harmonise their activities and procedures with the priorities of the countries in which they operate [ 32 ] according to the principles of the 2005 Paris Declaration on Aid Effectiveness and the 2008 Accra Agenda for Action [ 33 ].

Future research on how the priority-setting processes used and challenges faced by Zambia are relevant to other countries facing similar tasks is recommended.

This paper presents the first synthesis of lessons learnt from the health research priority setting initiatives in Zambia. We found that locally driven processes appeared to have yielded more positive results than externally driven processes. There appears to be systems within which priority setting can be institutionalised in the health system of Zambia both in the health sector and at a multi-sectoral level. Enforcement of the legal framework and implementation of incentives for promoting adherence to national research priorities will be necessary if the health research system is to benefit fully from a well organised priority setting process. However, the lack of strong monitoring mechanisms makes evaluation difficult. There is a need for standardised priority setting approaches with well thought through monitoring mechanisms so that the process can be improved. Non-representation and inadequate funding of identified priorities still remains a challenge.

Abbreviations

Clinton Health Access Initiative

Child Health and Nutrition Research Initiative

Implementation Research Leverage Fund

Maternal, Neonatal and Child Health

Ministry of Health

non-governmental organisations

National Health Research Advisory Committee

National Science and Technology Council

Technical Working Group

Zambia Forum for Health Research

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Acknowledgements

The authors acknowledge the input from Mr Tindo Liboma and Mr Joseph Mwanza in the development of the manuscript. The authors wish to acknowledge Ms Mwiche Siame N.P. for reviewing the manuscript.

This work is partly funded by the Canadian Institute for Health Research (CIHR) for the project entitled “Capacity strengthening for national health research in low income countries” sub-grant No. McMaster 20000775. The funding body had no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.

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Authors’ contributions

PCK and LK conceptualised the study, participated in the review and writing of the manuscript. BH and WN conducted the document reviews and provided input for the writing of the manuscript. All authors reviewed and approved the final version of the manuscript.

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The authors declare that they have no competing interests.

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Ethics approval and consent to participate

This study received ethics clearance from McMaster University and The University of Zambia Humanities and Social Science Ethics Committee. Permission to conduct the study was received from the Ministry of Health in line with local guidelines.

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Department of Health, Aging and Society, McMaster University, Hamilton, ON, L8S 4L8, Canada

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Chanda-Kapata, P., Ngosa, W., Hamainza, B. et al. Health research priority setting in Zambia: a stock taking of approaches conducted from 1998 to 2015. Health Res Policy Sys 14 , 72 (2016). https://doi.org/10.1186/s12961-016-0142-z

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Received : 04 December 2015

Accepted : 01 September 2016

Published : 23 September 2016

DOI : https://doi.org/10.1186/s12961-016-0142-z

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Zambia National Public Health institute (ZNPHI) Pillars

Strategic planning and information management.

Technological and analytical innovations have emerged in recent years as a method for facilitating the rapid transmission of public health surveillance data, thereby assisting in the timely detection and response to outbreaks and other public health events. In order to cope with current global trends, the ZNPHI developed the electronic IDSR using the DHIS2 and was deployed at sub-national level. This system collects, collates, and analyses public health data on all notifiable diseases and events. The department has a deliberate policy on data interrogations, informatics, data security, and storage as well as data use, working with the other departments that collect data, however, there is a gap in electronic data capturing gadgets, human resources, multiple parallel systems (COVID- 19 trackers, excel sheets, COVAX) for reporting public health data from subnational to national level, resulting in discrepancies in data being reported on the disease or event. e.g. COVID 19 to efficiently affect these polices.

Furthermore, the infrastructure for data management including collection, analysis, and storage is inadequate. There is a challenge in collating data that is collected through different systems including SDI, EPR, and LSN. Data and systems interoperability with the clinical and ‘one health’ systems remain key and therefore a need to have health information systems that are flexible and broadly encompassing, including mechanisms that allow for scaling up or down of information. The ZNPHI ACT allows for the establishment of a data repository. A draft Statutory Instrument is in place to facilitate the establishment of the Public Health Data Repository.

Data harmonization and data sharing are key components. The ECHO platform is used for communication with the subnational levels. ZNPHI has equipped 29 districts with equipment. There is a need to establish and implement the ECHO platform and a Community of Practice for stakeholders in public health security in all districts.

On the other hand, the institute has no planning department which is essential for coordination of program implementation and performance to ensure realization of the institute`s objectives. Consequently, the institute rides on the existing departments’ routine annual planning and budgeting for public health programs.

Regarding research, the institution’s public health research agenda has focused on operational research, secondary analysis, and knowledge translation of routinely collected data and outbreak investigations. The ZNPHI has full access to data on notifiable diseases of public health significance. Detailed analysis of this and other data helps the institute to timely prepare and respond to public health emergencies as well as inform program and policy direction. Research is driven through all the departments. SIM coordinates research requirements such as applications for Ethics approval and authority from NHRA. The department is in the process of establishing a TWG on Research to expand capacity in research. Research requires additional human resources, finances, and capacities in grant writing.

Public Health Policy, Diplomacy and Communication

While the institute recognizes public health policy, diplomacy communication as an essential strategy that can make important contributions to promoting and improving the health of individuals, communities, and society, it lacks institutional internal and external communications strategies as well as dedicated structures for public health policy, diplomacy and communication. The institute has in the last five years anchored on the Ministry of Health’s polices, mainstream communications strategies and implementation.

The institute recognizes the community as a core stakeholder in public health, particularly in prevention and control of disease and adoption of public health and social measures of interventions. Social behavioral change communication is an important strategy, to move this agenda, rapid assessment and KAP studies must be conducted to ensure evidence based strategies are drafted and in use.

To facilitate efficiency in public health communication, the ZNPHI has leveraged the following channels of communication: The Health Press Zambia, an institutional public health bulletin, high-level reports; parliamentary statements; press briefs, a website; traditional and social media platforms, and a call center. Most of the communication has been given through the Ministry of Health mainstream by either the Minister of Health or the Permanent Secretaries. The media are considered a key partner in public communication. The institute will need to strengthen partnerships and build capacity in health reporting.

As a result of COVID-19 Pandemic, The Health Press has not been updated efficiently and is a year behind. Furthermore, the call center leverages on the DMMU toll-free number and this many a time is crowded leaving a gap in communication to the public.

Surveillance and Disease Intelligence (SDI) Cluster is mandated to ensuring early detection and reporting of potential health threats, notifiable diseases, public health events and changes in epidemiological trends through the timely collection, analysis, and dissemination of data for action. The aim is to strengthen and equip the national surveillance system to generate timely, high quality data about all nationally notifiable and priority diseases. The mandate is facilitated through the following functions performed by the cluster which involve to :

• Coordinate and provide oversight to surveillance activities across the country.
• Equip and strengthen surveillance system at all levels to generate timely, high quality data.
• Conduct non-communicable diseases surveillance
• Coordinate cross border surveillance and surveillance of all national priority diseases, conditions and events
• Conduct routine analysis and operational research using surveillance data that will facilitate policy making
• Conduct sentinel and event based surveillance
• Coordinate and collaborate with animal and environmental health sectors and other stakeholders to implement one health approach to disease surveillance and control.
• Implement a one health approach in disease surveillance

Field Epidemiology Program

The International Health Regulations (IHR) 2005 require that all countries have the ability to detect, assess, report, and respond to public health events. Ensuring the health security of Zambia and the world at large depends on a skilled public health workforce in line with the IHR 2005, the Africa We Want and the African Union’s Health Strategy 2016-2030. One of the core elements WHO Joint External Evaluation measures capacity to comply with the IHR 2005, is having a field epidemiology training program; specifically having one field epidemiologist per 200,000 populations. Thus the main aim of the Zambia Field Epidemiology Training Program (Zambia FETP), within the pillar, is to strengthen field epidemiology capacity and effectively contribute to addressing epidemics and other major public health problems in Zambia.

The Zambia FEP is an applied epidemiology training program designed to strengthen public health capacity within ZNPHI and the Ministry of Health. Zambia is currently running Frontline and Advanced FEP. Frontline FEP’s focuses on district-level health security while the Advanced FEP focuses on national level health security. This mirrors the public health surveillance system in Zambia. The mandate is facilitated through the following functions performed by the cluster which involve to :

• Assure the quality of FEPs and FEP network-level elements.
• Build knowledge and skills of the FETP community
• Strengthen and prepare a field epidemiology workforce and define its role in global public health systems.
• Continue organizational excellence of the Field Epidemiology Program Secretariat.
• Expand the FETP to serve all regional member states.

Public Health Laboratory Systems

The main function of the Public Health Laboratory Service (PHLS) cluster is to develop an effective, fit-for-purpose public health laboratory system that encompasses a network of laboratories. This is essential to provide specialized capabilities for the detection, prevention, control and response to diseases, public health threats and events of public health significance. Actualizing this entails, the establishment of an adequately resourced dedicated national public health reference laboratory appropriate infrastructure, equipment and competent staffing. The reference laboratory will serve as the ‘Apex’ laboratory in a multisectoral network of public health laboratories and institutions. In addition to establishing dedicated public health laboratories, efforts will continue to strengthen the capacity (human resource, equipment, systems, practices, etc.) of existing clinical laboratories, animal health sector laboratories, research laboratories and other participating entities. Based on their competencies and comparative advantage, these existing laboratories are recognized as a key component to enable the national public health laboratory system function optimally, in the spirit of ‘One Health’. On the whole, the national public health laboratory system is key to anchoring a coordinated and holistic system for surveillance, prevention and control of public health threats and the conduct of research. The mandate is facilitated through the following functions performed by the cluster which involve to :

• Establish a functional National Public Health Laboratory System to support surveillance, prevention and control of disease threats and other conditions of public health interest.
• Strengthen laboratory systems and networks to support emergency response to public health threats.
• Establish and maintain a Biorepository for collection, curation, storage, preservation and containment of specimens and materials from disease outbreaks, public health events, and other situations of public health interest.
• Reduce the threat of antimicrobial resistance (AMR) and stem its spread.

Public Health Security System Strengthening

The Human Resource Management (HRM) pillar shall be responsible for managing the Institute’s human and other resources to improve organizational performance and ability to effectively detect, assess, report, and respond to public health events. In addition, the pillar shall be responsible for the provision of administrative and logistical support services to enhance smooth operations of the Institute. The mandate is facilitated through the following functions performed by the cluster which involve to :

• Facilitate the identification and deployment of trained staff to support public health security.
• Coordinate and identify training needs in various functional areas
• Coordinate short, medium and long-term training to build health security capacity
• Create a conducive work environment for staff to efficiently carry out the ZNPHI mandate
• Conduct staff awareness programmes for ZNPHI staff
• Performance Management

Emergency Preparedness and Response

ZNPHI developed a number of strategic documents which include guidelines and SOP’s for use in public health emergencies although others still await finalization. The completed documents include EVD, Covid-19 guidelines and All Hazards plan. Efforts are underway to finalize other key documents such as the VRAM, NAPHS, PHEOC, Integrated SOPs and Contingency plans. Further, as we endeavour to strengthen public health security, a number of key documents need to be developed in line with emerging public health threats such as illnesses of Public health potential (SARS, COVID, MERS etc). Other diseases include Cholera, Typhoid, ECOLI and Viral Hemorrhagic fevers. As a National Focal Point for IHR 2005, ZNPHI anchors IHR activities under the EPR pillar which coordinates the implementation including policy and compliance, conducting State Parties annual reviews, and Joint External Evaluations. Coordination of IHR activities is mostly done at the national level whereas sub-national levels and stakeholders currently do not have the technical know-how on IHR implementation, Compliance, Monitoring and Evaluation. Plans are underway to form the National, Provincial and District TWGs so as to expedite processes and activities needed for IHR coordination. EPR also coordinates the National Epidemic and Response Committee and supports the subnational levels in terms of guidance and logistical support. As a standard, Epidemic and Response Committee meetings are supposed to be held quarterly and sometimes ad-hoc in emergency settings as they are meant to inform the technical teams on epidemic management. Currently it has been observed that NEPC, PEPC, DEPC have not been fully functional at all levels due to luck of TORs. Since its establishment ZNPHI has built capacity in different cadre of healthcare workers for public health security. These include Rapid Response Teams trainings that were conducted countrywide in view of the 2017-2018 Cholera outbreak and the of COVID-19 pandemic. Although a significant number of healthcare workers were trained as RRTs, coordination remains a challenge as the program lacks clear programming because of absence of TORs and non-availability of inventories for surge staff especially at sub-national level. There is an established operational Optimal Emergency Operation Center (EOC)at National level which predominantly has mainly been focussing on covid-19 and other specific diseases such as cholera. With threats of emerging and re-emerging diseases such as polio, EVD and others, scope needs to be widened as to extend to other diseases of public health concern. Currently, EOC at national level is somewhat fragmented as some diseases are managed by specific units designated to coordinate such as Vaccine Preventable Diseases under the Child Health Unit at ministry of health. Public Health Security also entails having in place safeguards for epidemic preparedness and response, this includes infrastructure, Logistics management for preparedness – understanding key commodities ready for deployment, contingency for various response activities, emergency stockpiles ready for deployment and emergence funds for quick action. However, there is inadequate capacity especially at lower levels in Incident Management System (IMS) skills, IMS structure are not present both at policy and implementation level to facilitate easy coordination to disease preparedness and response.

Transport Maintaining an effective transport system is essential for public health security. The institute continues experiencing transport constraints, which adversely impact operations. currently the institute has 30 utility vehicles at national level and out of the 116 districts, no district has dedicated utility vehicle for public health activities and only about 20% of the 116 district have motorbikes for courier of specimen from facility level to district level.

Physical Infrastructure Physical health Infrastructure is a vital physical input for improving public health security, therefore Zambia has a plan to construct a national public health institute with support from partners. Despite these plan, significant gaps still exist in the area of physical health infrastructure in that at national level the rented office spaces are inadequate as the institute is expanding, Furthermore, Zambia has inadequate public health laboratory infrastructure to support diagnostic function of public health events detected in districts to inform timely response. This infrastructure challenge affects the point of entry to adequately serve populations in and across the long and porous borders with its 8 neighbours. In addition, there is inadequate spaces designated for use as isolation facilities for infectious diseases in clinics and hospitals.

Public health Financing ZNPHI financial support is mainly through cooperating partners and GRZ. whose goal is to attain adequate sustainable and predictable financing, through existing and new sources. The GRZ through the ministry of health allocated an average of 0.13% to the institution from 2017 to 2022.The budget allocation to the intuition has been increasing from 0.06% in 2017 to about 13% in 2021.

However, despite these observable increments in the budget, the funds allocated are still inadequate for the institutions day to day operations in regards to public health security. Other challenges include the following: erratic funding of the allocated GRZ funds, delayed in the debasement of funds by partners. slow burring rate on budgeted activities due to bureaucratic process and lack of harmonization of donor funding in the health sector, leading to duplication and inefficiency.

Governance Framework Leadership and governance will deal with the interrelationships, roles, and activities of the ZNPHI in the provision of public health security. The framework for leadership and governance focuses on the regulatory framework; strategic vision; transparency, accountability, and institutional arrangement The organizational structure governing these processes is considered in dealing with the leadership and governance issues.

Regulatory Framework The Zambia National Public Health Institute Act of 2020 provides the regulatory framework for the continued existence of the ZNPHI and sets out the mandate and functions which include coordination of public health security, the establishment of the Public Health Emergency Operations Centre, National Public Health Laboratory and the National Public Health Emergency Fund.

The Act requires the appointment of a Board by the Minister to be the governing body of the Institute and provide a strategic direction. The Board will also be required to approve the annual budget estimates and financial statements of the Institute, annual work plan, action plans and activity reports of the Institute. Furthermore, the board approves the policies, programs and strategies of the Institute and monitors and evaluates the performance against approved budgets and plans. The Board will execute its mandate and functions through the Director-General who is appointed by the Board.

Strategic vision The ZNPHI has a clear vision of a desired future state that members of the institute identify with themselves. This has fostered the energy, commitment, and purpose among the ZNPHI staff and has helped to clarify the institute’s direction on what to do.

Transparency and Accountability ZNPHI structure has in place an Internal Audit Unit, which is aimed at enhancing accountability at all levels of service delivery within the Institute. The roles of Internal Audit, as established under section 17 (1) of the Public Finance Management Act No. 1 of 2018 will be; to ascertain that the risk management and internal control systems are in place and continually being improved and optimised in response to an ever-changing environment; to provide reasonable assurance to the Controlling Officer, Sub-Warrant Holders, and the Secretary to the Treasury that internal controls exist and are being complied with as required by the law and other regulations; and to ascertain, evaluate, and improve on the governance processes put in place by management.

ZNPHI has governance structures that help to enhance accountability such as the Finance committee, the Audit and Risk Committee, the Technical Committee, and the Human Resources and Administration Committee ZNPHI is mandated to communicate matters of public health emergency to the policy makers, program managers, and the public. The Communications unit provides information through various channels such as high level health security update report, parliamentary reports, ministerial statements, situation reports, outbreak reports and press statements. Most of these are uploaded for public use on the ZNPHI website. Furthermore, a call center is in place for interactive communication with all stakeholders particularly the public. This tool also provides efficiency for Event Based Surveillance as the public continuously alert the institute of events of public health events in the communities. While the call center is an efficient bridge between ZNPHI and public, the toll free line available is under the Disaster Management and Mitigation Unit. During emergency preparedness and response, a multi-sectoral Incident Management System is used to coordinate response activities. This platform for all stakeholders to access timely information on epidemic status, strategies employed and resources availed or required.

In order to enhance transparency and accountability, the ZNPHI is set to adopt a grievance redress mechanism (GRM) which is a set of arrangements that enable local communities, employees, and other affected stakeholders to raise grievances with the institute and seek redress when they perceive a negative impact arising from the ZNPHI’s activities.

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With a Clinic on Wheels, ICAP Moves Research on Opioids and HIV Into the Passing Lane

In summer 2021, a state-of-the-art mobile clinic began making rounds in the streets of Harlem and the Bronx, drawing attention with its bright graphics. But beneath the colorful exterior is a serious proposition – to address the intertwined public health crises of opioid addiction, HIV, and hepatitis C among people who inject drugs.

Drug overdose is the leading cause of accidental death in the United States, with nearly 108,000 fatalities in 2021, the highest number of overdose deaths recorded in any 12-month period. Factors such as lack of access to health care, poverty, mental health disorders, use of multiple illicit substances, stigma and discrimination combine to increase the risk of HIV transmission and acquisition and other health issues among people who inject drugs.

The mobile clinic is at the center of ICAP’s participation in the nationwide INTEGRA study (HPTN 094), which aims to determine whether using mobile health units to deliver integrated health services for people with opioid use disorder can improve addiction, HIV, hepatitis C and substance use outcomes compared to standard of care. At locations frequented by people who inject drugs, ICAP study team members engaged with individuals, provided them with information regarding the study, enrolled participants and followed up with them throughout their study participation.

Participants in the study are randomized to receive integrated care on the “van” – as the study team calls it – or to receive the services of a health care navigator who will assist the participant in finding care in the community.

“The integrated care model means they will be able to receive their buprenorphine [a medication to treat opioid use disorder] prescription from the van,” said Rashaunna Redd, NP, site clinician for ICAP’s Bronx Prevention Center, which conducts the study. “And they will also be tested for HIV, STIs, and hepatitis, and screened for routine primary care problems such as diabetes and blood pressure issues.”

After six months, all participants transition to care in the community. Follow-up after the study extends to 12 months.

“Our goal is to make it as close to one stop as a possible. Although we recognize that some people will have serious medical conditions that require them to see specialists – and we will help them with that,” said Ellen Morrison, MD, site lead at ICAP’s Bronx Prevention Center.

Since the study began, initial findings revealed a high prevalence of mental health disorders such as anxiety, depression, and post-traumatic stress disorder among participants.

“This finding is particularly important because recreational drug use may be used as a form of self-medication,” said Alan Padilla, BA, community educator at ICAP’s Bronx Prevention Center. “Our team is actively promoting the need to address these underlying factors to fully provide addiction services.”

As the van proclaims in bright lettering, ICAP is driving health forward . Mobile health units, along with this study, are providing the engine necessary to reach that mission.

Funder: U.S. National Institute of Allergy and Infectious Diseases (NIAID) with funding from the U.S. National Institute on Drug Abuse (NIDA)

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Charting LGBTQ+ Health Challenges in New York City During COVID-19

As COVID-19 swept the globe, its ruthless trajectory exacerbated the challenges and inequities already faced by the lesbian, gay, bisexual, transgender, and queer (LGBTQ+) community, including employment and housing discrimination, inequitable health care, and more. To gain insight into the burden and impact of COVID-19 on this community, and assess vaccine uptake, ICAP conducted a study that reached more than 1,000 LGBTQ+ New Yorkers aged 18 to 68 years.

While LGBTQ+ individuals in NYC reported a similar burden of COVID-19 and vaccine uptake compared to the general population of the city, the study revealed this community is more likely to experience increased financial and emotional challenges due to the pandemic, particularly among the most stigmatized, such as gender minorities and among those with multiple minority identities. For example, 81 percent of LGBTQ+ individuals reported experiencing financial hardship as a result of the pandemic. This important evidence base will inform strategies to reach unvaccinated individuals and assist policymakers in developing further programs to support those most negatively impacted by the pandemic.

Funder: Rockefeller Foundation

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COVID-19 and Older Adults in New York City: A Landmark Study

In New York City, older adults had seven times the mortality rate from COVID-19 compared to all other ages, but there was little known about the mental health and social ramifications of the pandemic on this population – especially those who were still living at home and not in nursing homes.

To gain a better understanding of the effects of the pandemic on this vulnerable group, ICAP launched the SARS-CoV-2 Impact on Lives and Views of Elderly Residents (SILVER) study, aimed at understanding the physical, emotional, and economic effects of the COVID-19 pandemic on older adults living at home. A total of 676 participants 70 years and older were enrolled – overall, 18 percent of older adults screened for depression and 17 percent for anxiety, with a greater percent of Latinx older adults reporting loneliness than other races and ethnicities. Almost one-third of older New Yorkers reported financial challenges and almost one in ten reported not having enough to eat.

With new funding, ICAP launched a second SILVER study seeking to learn more about the impact of the pandemic on participants’ ongoing health and wellbeing. The second round of data collection expanded topic areas, pursuing further details about participants’ access to resources such as telehealth, housing, internet, social support, and use of city services. Attitudes toward the COVID-19 vaccine, booster doses, and the influenza vaccine were also evaluated. In addition to following up with the first SILVER study participants, the second study included new participants, specifically Asian New Yorkers, to better represent the diversity of New York City. The ultimate goal of the study was to provide policymakers in New York City and other communities with more accurate information on how to best serve and assist older adults during times of crisis.

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Usaid and unicef join hands to strengthen the government of the republic of zambia’s cholera response, $100,000 in funding from usaid allows unicef to strengthen a cross-sectoral cholera response plan, coordinating with key partners and the government of the republic of zambia at local and national levels..

Lusaka, 18 April 2024 – Through support from the United States Agency for International Development (USAID), UNICEF will continue to strengthen the ongoing cholera response efforts by supporting the Ministry of Health in the Southern Province. Cholera cases have been found in all ten provinces of the country, but specifically in high-density locations like Lusaka or hotspots like the fishing camps in the Southern Province. While Zambia has seen a sharp decrease in cases since the outbreak’s peak in January, Lusaka, Copperbelt Central and Southern provinces continue to report cases. In addition, there are concerns that the ongoing drought in Zambia will exacerbate the cholera situation as people may be more likely to resort to unsafe sources of water.

Through this support from USAID, UNICEF will focus on strengthening coordination among government bodies at the local and national level, improving the public health response with a focus on early identification, treatment, and referral of cases and expanding support of Risk Communication and Community Engagement (RCCE) for improved uptake of lifesaving interventions. 

"USAID has a long history of partnering with the Government of the Republic of Zambia to face tough challenges together. Whether it is preventing and responding to infectious disease outbreaks like cholera or partnering with farmers to mitigate the effects of the climate-induced drought, USAID will continue to work with the people of Zambia to develop more resilient systems and communities," said USAID Mission Director, Peter Wiebler.

This USAID support will allow UNICEF to strengthen and expand successful programmes in coordination with the Government, like training of Community Based Volunteers (CBVs) on early case finding, community case management and the dissemination of cholera prevention materials among households and equipping them with the necessary supplies and medical commodities. With this support, UNICEF will be able to set up 30 Oral Rehydration Corners (ORCs) and train 120 CBVs to operate them in three of the districts in the Southern Province that have been disproportionally impacted by the cholera outbreak. This funding will improve community structures and build capacity among staff and volunteers allowing them to reach a wider population with critical support. 

“Training a community to identify, track and prevent cholera is fundamental to ending cholera nationally. The work of our Community Based Volunteers (CBVs) has been crucial to allowing us to reach more families with support right in their communities and identify cholera cases quickly. It will take everyone from families, communities, districts and government ministries to join forces and build strong structures of support to respond to cases and prevent cholera in the future,” said Dr. Penelope Campbell, Representative, UNICEF Zambia.

This support from the United States comes at a crucial moment as cases have now reached 915 with 21 deaths in the Southern Province. This funding is key to expanding the work UNICEF and partners are already actively doing by improving system coordination, community prevention, health services and WASH programmes. 

About U.S. AGENCY FOR INTERNATIONAL DEVELOPMENT (USAID)

On behalf of the American people, the U.S. Agency for International Development promotes and demonstrates democratic values abroad, and advances a free, peaceful, and prosperous world. In support of America's foreign policy, USAID leads the U.S. Government's international development and disaster assistance through partnerships and investments that save lives, reduce poverty, strengthen democratic governance, and help people emerge from humanitarian crises and progress beyond assistance. Learn more at www.usaid.gov  

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Maria Fernandez, Chief, Communication, UNICEF Zambia, [email protected]

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For more information about UNICEF and its work for children in Zambia, visit www.unicef.org/zambia.

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How You Pay Drives What You Choose: Health Savings Accounts versus Cash in Health Insurance Plan Choice

A marked feature of health insurance plan choice is inconsistent choices through the overweighting of premiums relative to out-of-pocket spending. We show that this source of inconsistency disappears when both types of spending come from the same source of designated funds. We focus on the MediSave program in Singapore, whereby residents can pay their health insurance premiums with cash or MediSave funds, but are subject to limits that vary by age and over time. By exploiting variations in those limits, we consistently find that when individuals are able to pay their health insurance premiums with MediSave funds, they are less price sensitive and more willing to enroll in more generous plans—which results in lower spending levels and variance, and lower adverse selection in the market. The results suggest a strong role for mental accounting in insurance decisions.

Lin, Liu, and Yi gratefully acknowledge support from Singapore’s Ministry of Education Academic Research Fund Tier 1 (WBS R-122-000-303- 115). The views expressed herein are those of the authors and do not necessarily reflect the views of the National Bureau of Economic Research.

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Mental health and the pandemic: What U.S. surveys have found

The coronavirus pandemic has been associated with worsening mental health among people in the United States and around the world . In the U.S, the COVID-19 outbreak in early 2020 caused widespread lockdowns and disruptions in daily life while triggering a short but severe economic recession that resulted in widespread unemployment. Three years later, Americans have largely returned to normal activities, but challenges with mental health remain.

Here’s a look at what surveys by Pew Research Center and other organizations have found about Americans’ mental health during the pandemic. These findings reflect a snapshot in time, and it’s possible that attitudes and experiences may have changed since these surveys were fielded. It’s also important to note that concerns about mental health were common in the U.S. long before the arrival of COVID-19 .

Three years into the COVID-19 outbreak in the United States , Pew Research Center published this collection of survey findings about Americans’ challenges with mental health during the pandemic. All findings are previously published. Methodological information about each survey cited here, including the sample sizes and field dates, can be found by following the links in the text.

The research behind the first item in this analysis, examining Americans’ experiences with psychological distress, benefited from the advice and counsel of the COVID-19 and mental health measurement group at Johns Hopkins Bloomberg School of Public Health.

At least four-in-ten U.S. adults (41%) have experienced high levels of psychological distress at some point during the pandemic, according to four Pew Research Center surveys conducted between March 2020 and September 2022.

Young adults are especially likely to have faced high levels of psychological distress since the COVID-19 outbreak began: 58% of Americans ages 18 to 29 fall into this category, based on their answers in at least one of these four surveys.

Women are much more likely than men to have experienced high psychological distress (48% vs. 32%), as are people in lower-income households (53%) when compared with those in middle-income (38%) or upper-income (30%) households.

In addition, roughly two-thirds (66%) of adults who have a disability or health condition that prevents them from participating fully in work, school, housework or other activities have experienced a high level of distress during the pandemic.

The Center measured Americans’ psychological distress by asking them a series of five questions on subjects including loneliness, anxiety and trouble sleeping in the past week. The questions are not a clinical measure, nor a diagnostic tool. Instead, they describe people’s emotional experiences during the week before being surveyed.

While these questions did not ask specifically about the pandemic, a sixth question did, inquiring whether respondents had “had physical reactions, such as sweating, trouble breathing, nausea, or a pounding heart” when thinking about their experience with the coronavirus outbreak. In September 2022, the most recent time this question was asked, 14% of Americans said they’d experienced this at least some or a little of the time in the past seven days.

More than a third of high school students have reported mental health challenges during the pandemic. In a survey conducted by the Centers for Disease Control and Prevention from January to June 2021, 37% of students at public and private high schools said their mental health was not good most or all of the time during the pandemic. That included roughly half of girls (49%) and about a quarter of boys (24%).

In the same survey, an even larger share of high school students (44%) said that at some point during the previous 12 months, they had felt sad or hopeless almost every day for two or more weeks in a row – to the point where they had stopped doing some usual activities. Roughly six-in-ten high school girls (57%) said this, as did 31% of boys.

On both questions, high school students who identify as lesbian, gay, bisexual, other or questioning were far more likely than heterosexual students to report negative experiences related to their mental health.

Mental health tops the list of worries that U.S. parents express about their kids’ well-being, according to a fall 2022 Pew Research Center survey of parents with children younger than 18. In that survey, four-in-ten U.S. parents said they’re extremely or very worried about their children struggling with anxiety or depression. That was greater than the share of parents who expressed high levels of concern over seven other dangers asked about.

While the fall 2022 survey was fielded amid the coronavirus outbreak, it did not ask about parental worries in the specific context of the pandemic. It’s also important to note that parental concerns about their kids struggling with anxiety and depression were common long before the pandemic, too . (Due to changes in question wording, the results from the fall 2022 survey of parents are not directly comparable with those from an earlier Center survey of parents, conducted in 2015.)

Among parents of teenagers, roughly three-in-ten (28%) are extremely or very worried that their teen’s use of social media could lead to problems with anxiety or depression, according to a spring 2022 survey of parents with children ages 13 to 17 . Parents of teen girls were more likely than parents of teen boys to be extremely or very worried on this front (32% vs. 24%). And Hispanic parents (37%) were more likely than those who are Black or White (26% each) to express a great deal of concern about this. (There were not enough Asian American parents in the sample to analyze separately. This survey also did not ask about parental concerns specifically in the context of the pandemic.)

Looking back, many K-12 parents say the first year of the coronavirus pandemic had a negative effect on their children’s emotional health. In a fall 2022 survey of parents with K-12 children , 48% said the first year of the pandemic had a very or somewhat negative impact on their children’s emotional well-being, while 39% said it had neither a positive nor negative effect. A small share of parents (7%) said the first year of the pandemic had a very or somewhat positive effect in this regard.

White parents and those from upper-income households were especially likely to say the first year of the pandemic had a negative emotional impact on their K-12 children.

While around half of K-12 parents said the first year of the pandemic had a negative emotional impact on their kids, a larger share (61%) said it had a negative effect on their children’s education.

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