In December 2021, the Guinea-Bissau Accelerator Lab initiated a learning cycle to understand how the national COVID-19 vaccination campaigns could be reviewed in order to increase the number of vaccinated individuals in the country, the first blog of this series can be accessed here.

After the initial exploration phase, which focused on the perspectives of key stakeholders involved in the vaccination campaigns, a decision was made to explore the perspectives of citizens receiving the information. The method used to explore citizens’ views was Design Thinking. The questionnaire developed by the Lab had a total of eight questions, all translated in Criolo (the main local language of Guinea-Bissau). The questionnaire was crafted in a  conversational manner and presented to citizens in the form of a djumbai¹ to allow them to be at ease and speak openly about their experiences with COVID-19.  

Background 

With the COVID-19 pandemic continuing to affect the way we view and conduct our daily interactions; Guinea-Bissau has not been unmarred to its effects. In Guinea-Bissau, the first two cases of COVID-19 were reported on March 24, 2020, in Safim, at the Health Regions of Biombo and Cuntum Madina, which is part of the Health Region of the Autonomous Sector of Bissau (SAB). The first donation of vaccinations was received in the country in  March 2021 via a partnership between South Africa and the African Union, and the institutions responsible for administering the vaccines began sensitization campaigns in earnest.  Between April and December 2021, there were four vaccination campaigns, starting in Bissau and later spreading across the country. With vaccines being the safe and effective way to prevent the disease and save lives, the campaigns catapulted into the priority list of decision makers with the objective to vaccinate 70% of the eligible population² in the country.

Below are the statistics of the national weekly newsletter epidemiological results extracted from issue 66. 

With the support of the UNDP Accelerator Lab and in collaboration with the UNDP Health Social Protection Cluster, an analysis of the vaccination campaigns carried out in the country was conducted to understand the following:

1. Why had the target of the campaign not been met  
2. Who was involved and what was their take on the campaigns
3. How were the campaigns received by citizens 

Exploring the above factors permitted an understanding of how future campaigns can be improved at institutional and local levels. Additionally, for this analysis, the Lab utilized methodologies such as Collective Intelligence and Design Thinking to induce co-creation and sustainability of future vaccination campaigns that take on board the views of the citizens as a port of call.  

Perception of Citizens

When the Lab set out to explore the perspective of the citizens, we were aware that Bissau would not be representative of the country as whole, especially due to the declining basic social infrastructure countrywide. It was therefore imperative that we explored the other regions to understand how COVID-19 had impacted citizens across the country. The key statistics of the exploration phase are depicted below:

From the interviews carried out, there were reoccurring patterns of information that were raised by citizens regarding COVID-19 and the vaccine. Ultimately, the Lab wanted to understand why the people who took the vaccine took it, but more importantly, why those who did take it, didn’t. Identifying why citizens did not take the vaccine would allow the Lab to understand the ways in which campaigns could be adapted to increase the number of overall vaccinated citizens. Some of the most pertinent reoccurring themes are depicted in the diagram below:  

From the main themes raised through the synthesis the Lab conducted, below are the main areas of focus, with the most relevant quotes raised by citizens in the regions we visited highlighted.  

Concern with Other Diseases

The first few questions in the questionnaire focused on understanding if citizens had any concerns with theirs or their family’s health as an important entry point for storytelling in Design Thinking. From the initial questions, it was clear that more than half of those interviewed had concerns with their own health and that of their families.  

“I always feel worried about my health, nobody can tell me what I have, it is always malaria, and they give me Coartem”.

“COVID is important, but we have high cases of HIV and Malaria, more people are dying of those diseases, why are we forgetting them in favor of COVID-19?”

“There are other diseases that I think should be paid more attention to, it isn’t only COVID. Here in Guinea-Bissau, there are so many instances of TIFOIDE and there aren’t any medicines to fight this disease” 

There is a common notion, countrywide, that COVID has taken over the health system, a health system that is already considered weak and unable to respond to the basic needs of the population. With the pandemic taking away the focus of the health workers, citizens feel worried that not enough is being done to make sure that other diseases in the country are monitored.  

Diaspora Influence

The exploration revealed that outside of Bissau, citizens relied heavily on their families and friends in the diaspora to be informed on the development of the disease and the vaccines. Many citizens explained that their families abroad convinced them to take the vaccine and they felt they had enough trust to follow their advice. On the other hand, many did not take the vaccine as their family told them the vaccines being donated to Guinea-Bissau were untrustworthy.  

“I didn’t want to take the vaccine, but my grandma in Brazil told me it was safe to take.”

“My friend abroad told me on Facebook he got the disease and was in quarantine, I was afraid of getting it [COVID], so I took the vaccine.”

“My family in Senegal told me to refuse the vaccine.”

The reoccurrence of the diaspora thematic was raised throughout the exploration stage, giving the Lab insight into the influence the diaspora has in the country, especially in more rural areas where there is a bigger flow of informal information taking place.  

Unilateral Communication 

One of the questions on the questionnaire focused on how the interviewees came to know about the disease, or where to go for information. In Bissau, most citizens got information through television, radio, or social media; outside the capital, citizens got their information from the radio, ambulant health professionals or through djumbais in their communities. 

“I heard about the disease on radio and TV that people are dying of COVID, that’s why I took the vaccine.”

“I trust in the information provided by the radio, as they even have health workers on to talk about the disease.”

“I only hear about the disease outside when people are in their djumbais.”

“I always hear about this disease, but I don’t know who to ask questions.”

The results in this section demonstrated a huge gap between those in Bissau in comparison to those in regions. Most citizens in the regions, were exposed to information unilaterally, either over the radio or by ambulant health workers, which meant that they were not able to raise questions and get answers about COVID-19 as well as the vaccine. This directly led to citizens not being able to trust the disease and subsequently become more susceptible to believing rumours regarding COVID-19.

Rumours 

There was a significant number of citizens who due to lack of information, and especially those who live outside the capital, relied heavily on unilateral forms of communication (as discussed in the previous section), which raised doubts they were unable to cast aside. There was an evident correlation between unanswered doubts and the belief in rumours across all the regions.  

“They have told me that if I take the vaccine within a year, I will die.”

“There were so many rumours claiming that the vaccine was created to diminish the African population, that’s why I could not take it.”

“The first time I heard about the vaccine, I didn’t want to take it because they said anyone who took it would die.”

“In our village we heard many people took it and fell ill, so we will not take it.” 

The quotes above were all from the regions where there is little access to basic necessities such as running water and electricity. Many of the interviewees found solace in community djumbais where they got information in an informal manner from members of their village. Djumbais are a great tool of information sharing in Guinea-Bissau, however, in the case of the COVID-19 it worked as a disadvantage, because the majority of those who were interviewed, and that did not take the vaccine claimed it was due to rumours they heard informally, often in djumbais. 

Understanding of the disease & side effects 

One of the questions in the questionnaire explored how citizens came to find out about the disease and the vaccine. It became apparent that many citizens did not understand what the disease was about and how it was spread. Not understanding the disease arose from the same bottleneck of unilateral communication from radios and ambulant health workers, who either did not come back or had short timeframe to be in the regions they visited. Additionally, interviewees felt like they did not understand how the vaccine would protect them against the disease and why there were side effects.  

“I don’t know where to go if I have questions.”

“I have tried to get answers to my questions, but last time I went to the centre, nobody was there.” 

Similar to the point raised on unilateral information sharing, it is evident that the citizens felt like they learnt about the disease but did not get a chance to ask questions or understand where it came from or how it could be treated/cured. Later, the introduction of the vaccine made matters worse because citizens felt like they were not a part of the process to understand the disease and how vaccinating would immunize them against the disease.  

Taking vaccine under duress

The most significant reoccurring theme during the synthesis landed on citizens taking the vaccine against their will. At first, citizens were encouraged to take the vaccine for their protection and to prevent the wider spread of COVID-19 in the country³. Later, it became clear that the government wanted citizens to take the vaccine and began to impose barriers to key societal infrastructure such as schools⁴, so that citizens would have no choice but to vaccinate to get access. Whilst conducting the interviews, it became clear that more than half of the interviewees had got the vaccine to either: work, travel, go to school or go to the hospital, which reflected on how little they knew about the disease and its consequences but more so their need to resume normal life.

“I was forced to take the vaccine, otherwise I could not go back to school.”

“I took the vaccine because they did not allow me to travel.” 

“I cannot be by forced to take the vaccine, I have my own autonomy, why can’t I go to work without the vaccine?”

“My wife was not allowed to go to work without the vaccine card, but she had refused to take it beforehand.”

Their taking the vaccine due to the need to continue to interact with key societal infrastructures was a powerful tool used to increase the number of vaccinated citizens in the country, especially those with more scepticism. However, it had a direct impact on how much the state and stakeholders are investing in disseminating information to support the citizen's understanding of the disease and the need for the vaccine, as opposed to just taking the vaccine without the deeper comprehension.