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COVID-19, health equity, health information, public-private partnership, vaccine access.
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Mafla-Viscarra A, Caballero E, Levy M et al. Vaccination against COVID-19 in a geographically dispersed and underserved population, challenges and solutions in access and distribution of vaccines [version 1; peer review: awaiting peer review]. F1000Research 2024, 13:1294 (https://doi.org/10.12688/f1000research.154766.1)
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Research Article
Vaccination against COVID-19 in a geographically dispersed and underserved population, challenges and solutions in access and distribution of vaccines
[version 1; peer review: awaiting peer review]
PUBLISHED 29 Oct 2024
OPEN PEER REVIEW
REVIEWER STATUS
Abstract
Corresponding author:
Michelle Grunauer
Competing interests:
No competing interests were disclosed.
Grant information:
The author(s) declared that no grants were involved in supporting this work.
Copyright:
© 2024 Mafla-Viscarra A 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 work is properly cited.
How to cite: Mafla-Viscarra A, Caballero E, Levy M et al. Vaccination against COVID-19 in a geographically dispersed and underserved population, challenges and solutions in access and distribution of vaccines [version 1; peer review: awaiting peer review]. F1000Research 2024, 13:1294 (https://doi.org/10.12688/f1000research.154766.1)
First published: 29 Oct 2024, 13:1294 (https://doi.org/10.12688/f1000research.154766.1)
Latest published: 29 Oct 2024, 13:1294 (https://doi.org/10.12688/f1000research.154766.1)
1. Introduction
Ecuador is slowly recovering from the economic slowdown caused by the pandemic, and the government is facing structural deficiencies such as reliance on oil exports, insufficient macroeconomic safeguards, informal employment practices, and disparities in accessing public services.1 With a Gross Domestic Product (GDP) of around $105 billion USD and a GDP per capita income ranging between $6,000 to $7,000 USD annually, Ecuador falls in the middle-income range.1 The country has made significant strides in reducing its illiteracy rate, which currently stands at approximately 6%.2 However, income distribution remains unequal, reflecting disparities between urban and rural areas. Ecuador’s Human Development Index (HDI) remains around 0.75, indicating moderate human development, placing the country, in the middle range among South American countries.3
The National Health System is fragmented and includes the Ministry of Public Health (MOPH), the Ministry of Social Economic Inclusion (MIES), the Ecuadorian Social Security Institute (IESS), the Armed Forces Social Security Institute (ISSFA), the National Police Social Security Institute (ISSPOL) and municipal services. The private sector incorporates all for-profit and non-profit services.4 Rural areas have health care facilities within a 2-hour walking distance from homes and up to 6 hours away from the population according to the Integrated Health Care Model (MAIS), which has been in effect since 2014. This model contains a group of strategies, norms, procedures, tools and resources that seek to provide comprehensive and equitable health care services with a focus on primary health care, community participation, and quality improvement.5 Remote areas with low population concentration receive health care through scheduled visits by comprehensive health care teams. No specific public policies exist for remote areas and unfortunately, Ecuador is considered one of the most inefficient countries in the health area.6
On March 11th, 2020, the COVID-19 outbreak was designated as a pandemic by the World Health Organization (WHO). A mere nine months after the declaration of COVID-19 as a Public Health Emergency of International Concern (PHEIC), the first vaccine on the emergency use list, the Pfizer/BioNTech Comirnaty COVID-19 (Coronavirus Disease of 2019) vaccine, was approved on December 31st, 2020.7 Other vaccines were subsequently approved on the emergency list to fill global vaccination demands.8
The MOPH managed the acquisition of 8000 vaccines as a priority to counteracting the pandemic; however, the most significant number of vaccines arrived with the COVID-19 Vaccines Global Access (COVAX) Strategy (starting on March 17, 2021) and with the implementation of the “9/100 Plan” (vaccinate 9 million people in 100 days), starting on May 31st, 2021.9,10 A National Committee for Safe Vaccination was established with the participation of scientific societies, national regulatory authorities, and the National Immunization Strategy was developed. The MOPH joined efforts with community agents, local health committees, local governments, non-governmental organizations (NGOs), international cooperation, higher education institutions, and private companies to strengthen the plan due to limited resources and the need for coverage in different geographic areas, including hard-to-reach communities.11
In the context of limited supply, low- and middle-income countries (LMICs) adopted different approaches to distribute vaccines in a manner that would have the most significant impact on controlling the pandemic.12,13 To achieve this, several approaches were proposed.14 For instance, utilizing population distribution and mobility parameters to develop a modeling technique to optimize vaccination strategies’ effectiveness.15 Zhao et al. 2021, suggested prioritizing vaccine distribution based on age groups that exhibit the highest levels of transmissibility and disease severity.16 Furthermore, Barreiros et al. 2022 proposed establishing vaccination strategies based on the duration of immunity conferred by vaccinations and previous infections.17 Hogan et al. 2021 developed a mathematical model to devise customized strategies for vaccine allocation, focusing on maximizing the number of prevented deaths.18 When vaccine supplies are limited (less than 20% of the population), the recommendation is prioritizing vaccinating the elderly.19,20 The WHO SAGE Roadmap states that countries with low initial vaccine coverage rate should prioritize vaccinating high-priority groups, particularly older adults and should explore alternative delivery methods to ensure high coverage.21 In Ecuador, it was anticipated that the most relevant allocation strategy would be guided by the WHO framework, because the vaccines originated from the COVAX Facility.
Despite early access to limited vaccination, uptake was poor, with only 2.5 million people being vaccinated, approximately 14% of the total population, up to June 2021.21,22 However, regardless of the program’s scope, by July 2021, only 57% of the total population had received the first dose, leaving the still vulnerable population in hard-to-reach areas uncovered.23 The priority groups for vaccination were healthcare providers and people aged 65 and older, based on the WHO parameters and local guidelines. The WHO established a framework for prioritizing COVID-19 vaccination based on the risk of severe disease, hospitalization, and death, these parameters can be found on the WHO SAGE (Strategic Advisory Group of Experts).18 Ecuador’s MOPH monitored the vaccination progress through ARCGIS, a geographic information system, to identify the vaccinated population by province, city, parish, and county level. Through this disaggregated data, the prioritization of the missing population and the identification of hard-to-reach areas and vulnerable populations was used to plan the upcoming vaccination campaigns.
In addition to logistical issues, vaccine hesitancy is a key barrier to vaccination in LMICs (Low- and Middle-Income Countries).24,25 MacDonald et al.’s, 2015, Vaccine Hesitancy Determinants Matrix identified numerous contextual factors impacting vaccine hesitancy, including communication and media, influential leaders, historical influences, politics, religion, culture, gender, socio-economic status, geographic barriers and the perception of the pharmaceutical industry.26 Bates et al., 2022 explored these factors on a personal level in relation to COVID-19 vaccination and found that in Ecuador,27 interventions through interpersonal communication and addressing structural concerns would have more success than single-issue mass campaigns.28 Additionally, Moola et al. identified direct engagement with communities at the local level as a potential strategy to improve vaccine acceptance. It is important to note that rural areas display the highest rates of vaccine hesitancy and fear of adverse effects from the COVID-19 vaccine in LMICs.29 In addition, considering the pandemic impact and limited resources, it became necessary to establish public-private partnerships.30 In LMICs, the active involvement of the government and the development of infrastructure can further increase the efficacy of collaborations between the public and private sectors allowing better preparedness and response.31,32
For a COVID-19 vaccination strategy to be effective in Ecuador, it was necessary to vaccinate 72% of the country’s population to achieve collective immunity. This strategy included underserved populations in hard-to-reach areas, making this the first challenge in a country with four regions, multiple ethnic groups, and limited resources. Faced with this complex emergency, the Reaching Impact, Saturation and Epidemic Control (RISE) project was established in Ecuador in September 2021. RISE was funded by USAID and led by Jhpiego, an international, non-profit health organization. An important aim was to, through a joint effort between the Ministry of Public Health (MOPH) and local actors, promote equitable access to vaccination in the country.
The goal of this case study is to describe an immunization strategy that through the collaboration of an international non-profit organization, an academic institution and the public sector, intended to effectively support the national vaccination campaign of the Ecuadorian Ministry of Public Health (MOPH) and to improve equitable access to and use of COVID-19 vaccines for underserved and hard-to-reach populations in Ecuador.
2. Methods
In November 2021, the RISE project coordinated and created partnerships with the MOPH, Universidad San Francisco de Quito (USFQ), and the Municipality of Quito (DMQ), to support the scale up of vaccinations among underserved populations in the country. Figure 1 shows the timeline and relevant events during the COVID-19 pandemic in the Ecuadorian context. Using geographic information on vaccination coverage available at the community level and micro-planning at the local level, priority populations who had not received the vaccine or who had barriers to accessing the vaccine, were identified. For this purpose, the project utilized software tools and data collection platforms, including a copyright license of ArcGIS® (geographic information systems) for operational management through vaccination dashboards and map visualizations, a copyright license of Qualtrics® and Kobo for data collection and WhatsApp for daily reporting and communication among brigades and the project coordination team.
Figure 1. Timeline of relevant events of the COVID-19 pandemic in Ecuador.
The implementation of the immunization strategy started in the provinces of Bolivar, Cotopaxi, Pastaza, Orellana, and Pichincha. By 2023 the strategy expanded to 18/24 provinces, including Cañar, Chimborazo, Esmeraldas, Galápagos, Guayas, Imbabura, Loja, Manabí, Santo Domingo de los Tsáchilas, Napo, Tungurahua, Sucumbíos, and Morona Santiago.
This research utilized anonymized databases containing vaccine coverage data and was approved by Universidad San Francisco de Quito’s Ethics Committee for Research of Human Beings/Institutional Review Board IRB# 00003994 on July 29, 2024, under approval number 2024-059IN. Informed consent was waived as the researchers used anonymized databases.
Regarding the vaccination process, this was implemented by the Ministry of Public Health’s Vaccination National Strategy against COVID-19, and informed consent to receive the vaccination followed the national guidelines “Lineamientos de obligatoriedad de la vacunación contra SARS CoV-2”, which stipulated that verbal consent was required for adults, while written informed consent signed by the parents or legal representatives was necessary for children under 18.
RISE implemented quality assurance, monitoring, and evaluation strategies, including gathering feedback from health professionals, and identifying opportunities for improvement. After receiving feedback during team meetings, a follow-up survey was distributed via WhatsApp to gather additional information on the intervention’s strengths, weaknesses, opportunities, and threats (SWOT). Verbal informed consent was obtained from the health providers that participated in the team meetings and in the survey.
2.1 Development of an Immunization Strategy
The multidisciplinary, five-phase immunization strategy, developed by the RISE Project, mobilized efforts to effectively support the national vaccination campaign of the MOPH. The phases of the plan included: (1) identification of priority populations, (2) recruitment of health professionals, (3) logistical coordination of mobile vaccination brigades, (4) health education and communication campaigns and (5) monitoring and evaluation. Figure 2 describes the phases of the immunization strategy and the objectives of each phase.
Figure 2. Flow diagram of immunization strategy.
2.2 Phase 1: Prioritization of Communities
To identify the regions with limited vaccination access, close and direct coordination was carried out with the MOPH, reviewing changes in uptake in urban and rural areas to identify settings of greater need. To establish vaccination strategies at the provincial and county level, we used information provided by the MOPH, with vaccination coverage, in terms of the number of people and as a percentage of the total immunized population. RISE supported the MOPH monitoring and information management of the COVID-19 national vaccination strategy, through the procurement of 2 ArcGIS licenses. This tool is a proprietary software that requires a purchased license, it enables efficient operational management, through vaccination dashboards and map visualization, to support decision making at the county level. An open access software option developed by Esri, Inc.® for viewing, editing, and analysis of geospatial data is QGIS (Quantum GIS). It offers features comparable to ArcGIS, however, the project selected ArcGIS because it is the software used by the MOPH. A key element in the planning process was the availability of population information, which could be integrated with other information systems to locate priority populations based on factors such as accessibility and distance from health centers. Another key element was the regular consolidation of doses administered, which were registered daily in an electronic system by the MOPH staff, allowing the daily and weekly planning of vaccination brigades.
2.3 Phase 2: Recruitment of Health Care Professionals
Key stakeholders from diverse institutions (MOPH, academic institution, health providers, community leaders, municipality, etc.) and multiple disciplines (health, social sciences, finances, logistics, administration, communication), were involved in planning and strategy development. Public-private alliances were created to guarantee qualified health care professionals, field support and consumables (alcohol, cotton, disposition containers) were allocated throughout the provinces. A private academic institution – USFQ- supported with physical space, consumables and engaging alumni from the Medical School to increase the health professionals on the field. Private companies supported with consumables and physical space adapted as vaccination sites.
Additionally, engagement, planning and implementation included the Municipality and Autonomous Governments in the Pichincha province, resulting in a robust model of mobile vaccination brigades that reached households in peri-urban and rural areas.
2.4 Phase 3: Logistical Coordination of the Mobile Vaccination Brigades
A rapid and major increase in human resources for vaccination was a primary imperative. Collaboration with USFQ resulted in the recruitment of health providers and alumni who lived and/or worked in the targeted immunization areas. This approach guaranteed teams of health professionals with knowledge and understanding of the local multiethnic and diverse Ecuadorian context.
Additionally, health professionals in charge of primary health centers were consulted to understand likely constraints on vaccination access in three high priority geographically dispersed areas within the four regions of the country: Costal (n=4), Highland (n=8), Amazon (n=5) and Galápagos Islands (n=1).
Furthermore, RISE worked with the National HIV strategy to support the vaccination of the population living with HIV in three geographical zones with the lowest vaccination rates: Zone 8 (Guayaquil and Duran), Zone 4 (Manabí and Santo Domingo de los Tsáchilas) and Zone 1 (Esmeraldas, Quinindé and San Lorenzo). These efforts were of extreme importance; according to the MOPH, up to June 2022, from 40,361 people living with HIV (27,102 men and 13,259 women) between 4 and 94 years of age nationwide, only 33,889 (84%), received the first dose, 29,982 (74%), the second dose, 16,963 (42%), the first booster dose, and merely 2,676 (7%) the second booster dose.
In each province, the collaboration of local health professionals with the RISE team supported the generation of specific plans of action that identified communities and areas where the implementation of mobile brigades was prioritized through a door-to-door approach and that contributed to a greater and faster vaccination coverage of the under-served population. Through microplanning, the overall strategy included mobilization (trucks, canoes, small aircrafts), to reach geographical areas of difficult access, recruitment of health professionals to support massive vaccination sites, mobile brigades and fixed vaccination centers, and the provision and training in the use of personal protective equipment (PPE). Mobile brigades, composed of healthcare professionals, were established as specialized mobile outreach teams, tasked with transporting smaller quantities of vaccines to challenging and remote areas. Their mission was to ensure that vaccines were deployed even to the most inaccessible regions, thus extending the reach of vaccination efforts.
2.5 Phase 4: Health Education and Communication Strategy
A health education and communication strategy was developed through a multidisciplinary team (health professionals, communicators and an anthropologist), and was adapted to the country’s sociocultural contexts. The goal of this strategy was to promote community health through the discussion of the importance of adherence to COVID-19 vaccination as well as to immunization across the life course and prevention of COVID-19. Additionally, educational messages were incorporated to caps, bags, infographics, stickers, diaries, and to a community radio jingle (Figure 3). These materials had the goal of disseminating evidence-based information, counteracting misinformation and myths, and overcoming barriers and stigma related to vaccination. Health providers at the local level mapped and disseminated the health communication and education campaign, using these materials.
Figure 3. Example of Infographic, educational material in Spanish.
To ensure consistent implementation of the immunization strategy across the country, a Health Communication Manual on COVID-19 with simple, easy-to-understand information was developed, as well as an interactive video on the proper vaccination technique. All health providers were trained with these materials. Furthermore, all health professionals were required to complete the WHO Vaccination Course.33
Misinformation about the COVID-19 vaccines caused mistrust in certain communities. To address this, RISE employed local doctors and nurses to vaccinate people and tailored communication strategy to the local language. Health messages were delivered in Quechua in Cañar, Chimborazo, and Pastaza. This approach instilled confidence and increased vaccination adherence.
2.6 Phase 5: Monitoring and Evaluation
Data collection tools were developed through digital forms on Qualtrics and Kobo platforms and daily reporting was also obtained through WhatsApp groups, including geolocation coordinates of mobile brigades. Our approach relied in the use of free mobile applications. Qualtrics® is a proprietary software developed by Qualtrics, LLC, requiring a purchased license for use, an open-access alternative is LimeSurvey. The project used Qualtrics because USFQ had a purchased license. Whereas Kobo, developed by the Harvard Humanitarian Initiative, is open-access and free to use. The data collected in Qualtrics and Kobo forms included: intervention location, number of doses administered by sex and type of vaccine, number of people from the community trained in aspects related to COVID-19 and the number of people from the community reached by radio and social media through a health education and communication campaign. The collected information was validated weekly, including periodic mapping showing coverage of population living in geographically dispersed areas and the impact at the provincial level. The population data obtained from the INEC (National Institute of Statistics and Census) was used to calculate the percentage of vaccinated individuals over time, categorized by the number of doses received and broken down by geographic distribution. Additionally, to monitor and evaluate our intervention for quality assurance a zoom meeting was carried on with the health providers in charge of the vaccination in the different provinces were strengths and areas of improvement were identified and as a follow-up to this meeting, a survey distributed through WhatsApp, was completed to acknowledge the main strengths, weaknesses, opportunities, and threats (SWOT) surrounding the intervention in the health providers regions.34 The data collection of the survey was conducted from April to September 2022. At the end of each vaccination campaign, generally in a monthly basis, the technical coordinator of the project held a Zoom meeting with the health providers to implement the survey.35 The primary objective was to receive feedback from each vaccination brigade. This mechanism allowed for continuous improvement, adjustment of the intervention strategies and optimization of teamwork. Verbal informed consent was asked to conduct the virtual meeting and for the completion of the survey.
Table 1 shows the phases of the immunization strategy, the problems identified and the approaches to overcome the challenges, within the Ecuadorian context.
Table 1. Areas of intervention and strategies of the RISE project in Ecuador.
3. Results
3.1 Outcomes and Impact
3.1.1 Number of Doses and target communities
Through March 2023, the RISE project supported the administration of 1,853,306 total vaccine doses against COVID-19, corresponding to: 114,002 first doses, 223,693 second doses, and 1,515,611 booster doses, of which 53.7% were administered to women and 46.3% to men. This strategy was implemented in 18 provinces and 58 counties nationwide, through 1,181 vaccination sites that included: 682 mobile brigades, 370 fixed sites, and 129 mass vaccination sites. Mobile brigades were our strongest asset as they reached our indigenous communities by hiking up to 12,467 ft above the sea level (in Cotopaxi and Chimborazo) (Figure 4) and remote areas with difficult access in many provinces, including the Ecuadorian Amazon, by walking, by canoes and even light aircrafts. This strategy continuously targeted underserved and vulnerable populations as the Indigenous communities (Kichwa and Cofan) and Afro-Ecuadorian communities (Chachis). In addition, RISE supported the vaccination of immunocompromised patients living with HIV and Cancer.
Figure 4. Mobile Brigades supported by Province.
The impact on vaccination rates was periodically tracked. Following the initiation of the program in November 2021, vaccination rates increased, as highlighted in Extended data36 and Figures 5-7. Overall, between February 2022 and March 2023, the mean percentage of people with the first dose of the COVID-19 vaccine increased from 24% to 91%. Over the same period, the mean percentage of persons with their second dose of a COVID-19 vaccine increased from 39% to 142%. Finally, the mean percentage of persons with a booster dose increased 10-fold from baseline.
Figure 5. Trends in First Dose coverage: gains enabled by the RISE Project.
RISE supported vaccination in 58 counties and 18 provinces nationwide since November 2021. During this period, 114,002 first doses of COVID-19 vaccines were administered.36
The average coverage of first doses in these counties increased from 54% of the total population in February 2022 to 85% in March 2023.
Source: MOPH vaccination reports.
Political Administrative Division Ecuador.
*Percentages calculated based on INEC census population data.
Figure 6. Trends in Second Dose coverage: gains enabled by the RISE Project.
RISE supported vaccination in 58 counties and 18 provinces nationwide since November 2021. During this period, 223,693 second doses of the COVID-19 vaccine were administered.36
The average coverage of second doses in these counties increased from 44% of the total population in February 2022 to 81% in March 2023.
Source: MOPH Vaccination Reports.
Political Administrative Division Ecuador.
*Percentages calculated based on INEC census population data.
Figure 7. Trends in Booster Dose coverage: gains enabled by the RISE Project.
RISE supported vaccination in 58 counties and 18 provinces nationwide since November 2021. During this period, 1,515,611 booster doses of COVID-19 vaccines were administered.36
The average coverage of booster doses in these counties increased from 14% of the total population in February 2022 to 57% in March 2023.
Source: MOPH Vaccination Reports.
Political Administrative Division Ecuador.
*Percentages calculated based on INEC census population data.
3.1.2 Health Education and Communication Strategy
As part of the health education and communication strategy and throughout its entire intervention, health education was provided to 32,138 people by health professionals in the supported communities, in health centers, schools, waiting rooms, parks, community areas and churches. Furthermore, any vaccination site, neighborhoods or houses reached, were identified by health providers as opportunities for health education through promotion and disease prevention. Myths and misinformation regarding COVID-19 vaccination were emphasized and learning included health promotion activities and audio-visual materials. Additionally, during the project’s intervention, 511,541 people were reached with vaccine messaging through mass and local media such as radio, WhatsApp groups, and social networks such as Facebook. Health education strategies included bags and caps with health promotion messaging that were given during vaccination in rural and agricultural areas. These were done mostly by single mothers, from different ethnicities who were facing economic hardship. Furthermore, health promotion messaging was printed in notebooks that were given to children in rural areas during the vaccination campaigns to motivate them and their parents to continue with their education.
3.1.3 Perceptions of Strategy Implementation
A post-intervention qualitative evaluation was developed to identify the intervention’s strengths and areas for improvement. It was conducted with the health providers in charge of the vaccination strategies and local coordination in the 18 provinces of the country. Strengths, opportunities, weakness and threats of the immunization strategy were openly discussed.
Strengths included the collaboration with technicians in primary care (TAPs) from the MOPH, who devote their time to health promotion and disease prevention within their communities. Additionally, having knowledge of the context, prior identification of underserved populations due to former or current work experience in the area, and the use of pre-existing maps in health centers identifying at-risk individuals in the community were seen as strong assets.
Opportunities highlighted comprised: optimizing immunization across the life-course such as delayed routine pediatric vaccination and influenza vaccines, that could be delivered at the same time as COVID-19 immunization. Even though, RISE applied 42,908 influenza vaccines and 5,296 pediatric vaccines, this approach was not planned, as the country faced gaps in regular vaccination schedules due to confinement and/or lack of vaccines as a result of delays in acquisition. In addition, identifying and increasing the engagement of local actors for collaboration from schools, municipalities, trustees, and spiritual or community leaders, was discussed as an approach that could increase trust and vaccine uptake. Furthermore, the vaccination strategy generated a network of health providers at the national level who promoted preventive care and primary health at the community level that could be engaged in future endeavors.
The following weaknesses were identified: the lack of mobile phone signal in certain areas and language barriers in health professionals who required the support of TAPS for translation. Additional barriers were resistance to vaccination because of misinformation in the communities; limited availability of COVID-19 vaccines; misinformation regarding the different types of vaccines; and changes in inoculation guidelines and increased doses, which elevated dropout rates between the first and the second dose in the primary series. Additionally, a lower attendance to the vaccination sites was evidenced and vaccination schedules were completed outside the recommended period.
Threats identified included natural disasters like an earthquake in Esmeraldas and the winter season in April-May that caused rivers (Orellana and Pastaza) to rise and landslides to occur (Cotopaxi and Cañar). Furthermore, a national strike on June 13, 2022, limited mobile brigades to reach targeted communities due to fuel shortage and security concerns. However, the need to access populations living in remote areas, motivated health providers to reach the final mile, and through hiking, walking long hours and mobilizing in canoes in the Amazon rivers accomplished the vaccination goals. We are entitled to their commitment and vocation.
4. Discussion
It is evident that close coordination with primary health centers, community leaders, and healthcare providers has been recognized as a crucial factor in identifying communities with limited vaccine access and in understanding the barriers to vaccine acceptance. For instance, a study conducted by Lucero et al. 2021 emphasized that involving primary health providers led to higher vaccine acceptance rates and better identification of underserved populations.37 Similarly, a study by Rosen et al. highlighted the significance of community leaders in promoting vaccine acceptance and addressing vaccine hesitancy.28
The significant increase in COVID-19 vaccination coverage that we identified reflects positive effects that have been observed in other studies. A study by Mesa-Vieira et al. 2021 evaluated the impact of targeted vaccination campaigns on vulnerable populations and reported substantial improvements in vaccination coverage.17 Identifying patients with non-communicable diseases during vaccination campaigns and providing them with appropriate treatment aligns with the integrated approach to healthcare delivery.
Through the implementation of the immunization strategy, the COVID-19 vaccination coverage increased with the first dose, second dose, and booster doses across Ecuador, including underserved populations in both urban and rural settings. The vaccination coverage increased from 37% to 134% and was seen to especially benefit areas with the lowest initial coverage rate, reaching over 1.8 million COVID-19 vaccines overall. The increased percentage exceeds 100% due to outdated data included in the MOPH platforms from a 2010 population census. Additionally, the mobile vaccination brigades seized the opportunity to access both the adult and pediatric populations and supported decreasing the gap in pediatric routine immunization and influenza vaccination, when vaccines were available. Hence, in 18% of mobile brigades, routine vaccinations were administered to the pediatric population, reaching 5,296 patients. Furthermore, through the vaccination brigades, patients with non-communicable diseases were identified and treated by the MOPH teams.
The collaboration with primary health centers, community leaders, non-governmental organizations (NGOs), international cooperation, and local governments, as well as the positive outcomes of increased vaccination rates and identification of non-communicable diseases, are consistent with findings from other studies. These collaborative efforts and integrated approaches have shown to be effective in enhancing vaccine access, acceptance, and overall healthcare outcomes within diverse populations.11
Throughout the implementation of this strategy, some key principles were identified as important to effectively support immunization for underserved populations. Special efforts were needed to promote COVID-19 vaccination and address the misinformation and distrust surrounding these vaccines. Important actions that may be applicable in future emergencies include creating spaces for dialogue and utilizing mass and local media. These initiatives aimed to offer knowledge on precautionary steps and personal maintenance in community environments. A crucial component of this undertaking involved working with female leaders of households to create bags and caps, which had the additional benefit of bolstering local economies.
It was noted that these endeavors, including the provision of bags and caps, had a favorable effect on the acceptance of vaccines. Nevertheless, the greatest impact was credited to personal discussions conducted within the communities themselves, especially with individuals who were contemplating immunization. The efficacy of these activities was apparent due to their proximity to communities and organizations, their emphasis on long-term viability, and their incorporation of local languages and cultural backgrounds.
In addition, close coordination was maintained with primary health centers, which have a deep understanding of the population they serve, as well as with community leaders and healthcare providers who, in some cases, spoke the local language (such as Cañar and Pastaza). This collaboration was crucial in accurately identifying communities lacking access to vaccination and identifying the specific barriers to vaccine acceptance. Another essential aspect of the project was the collaboration with local governments to establish mass, fixed, and mobile vaccination sites. This facilitated improved communication and a more efficient identification of individuals who had not completed their vaccination schedule.
A strong relationship with TAPS and MOPH personnel was key to establishing vaccination plans at the local level. These partnerships aided in coordinating the proposed activities, building on existing programs focused on visits and follow-up of chronic patients, drug delivery, family health records updating, and monitoring of vulnerable and underserved populations to ensure access to regions with unvaccinated individuals. Throughout the implementation of the project, it was vital to have trusted links with those who support the health system at the communities, in addition to other actors such as grassroots organizations, municipal governments, parishes, educational units, and religious sectors.
4.1 Limitations and Implications for Future Interventions
A disruption in access to monthly data at the parish level was encountered, consequently limiting the analysis to the county level. Consequently, data collection did not include age, pregnancy status, or ethnic self-identification. This data could be useful for future analysis. Additionally, issues with internet access could limit patient registration and proper follow-up of vaccination schedules.
Through our strategy, we identified steady increases in vaccination uptake, and even though we tracked the number of administered vaccine doses, we need to consider the possibility of third parties providing immunization as well, and possibly impacting the overall increase in vaccination rates.
Regarding communication, room for improvement exists, particularly developing strategies to increase the target audience through the establishment of more open community dialogue spaces addressing concerns related to vaccination and COVID-19.
Finally, the project’s initial phase was characterized by intermittent vaccine availability at various vaccination sites. Collaborative efforts with the MOPH were necessary to guarantee vaccine provision.
While many brigades were established and many individuals reached, opportunities for further expansion into additional provinces exist. Furthermore, a general lack of resources is evidenced in the Ecuador’s health sector and its effects go beyond vaccination efforts.
5. Conclusions
Our experience in Ecuador through the RISE project, in collaboration with the civil society, public and private sectors, highlighted some actions needed to both boost overall coverage, especially in low uptake settings, and to reach underserved priority populations. These actions illustrate key principles that might be applied for effective vaccination strategies for the future. Key principles include establishing public-private-academic partnerships to leverage local health professionals’ networks, empowering them to devise tailored strategies and jointly create budgets for the logistics according to each community’s needs. Additionally, real-time data collection, microplanning to identify underserved populations and weekly validation through cost-effective methods might ensure smooth project monitoring in low-and-middle-income countries. Finally, targeted communication materials foster successful collaboration among all stakeholders involved in the vaccination campaign. These experiences also highlight the catalytic contribution that international technical assistance can make, in addition to monetary aid, if it is well connected to local agencies and the primary health care sector. Therefore, other countries with comparable existing health systems could adopt a similar strategy to improve vaccination rates in vulnerable populations and support health equity.
Ethics and consent
This research utilized anonymized databases containing vaccine coverage data and was approved by Universidad San Francisco de Quito’s Ethics Committee for Research of Human Beings/Institutional Review Board IRB# 00003994 on July 29, 2024, under approval number 2024-059IN. Informed consent was waived as the researchers used anonymized databases, where it is not possible for the researchers to identify the subject-participants. Informed consent for the individuals receiving the vaccine was managed by the Ministry of Public Health.
Regarding the vaccination process, this was implemented by the Ministry of Public Health’s Vaccination National Strategy against COVID-19, and informed consent to receive the vaccination followed the national guidelines “Lineamientos de obligatoriedad de la vacunación contra SARS CoV-2”, which stipulated that verbal consent was required for adults, while written informed consent signed by the parents or legal representatives was necessary for children under 18. The consent for the vaccination process was managed by the Ministry of Public Health, which oversaw the nationwide vaccination efforts. As the project and the research team was not responsible for the consent process, we did not have a role in the ethical approval statement related to this specific aspect. However, we are providing information within the framework of the guidelines set by the Ministry of Public Health of Ecuador. Informed consent for adults was verbal, as the emergency nature of the situation due to the pandemic necessitated expedited approval processes. For minors under 18 years old, a written informed consent signed by their parents or legal representatives was required. This procedure applied to all doses of the vaccination.
The ethical approval was obtained retrospectively because the researchers procured the RISE Project’s anonymized data after the project was completed. Consequently, the researchers asked for ethical approval post-implementation. RISE implemented quality assurance, monitoring, and evaluation strategies, including gathering feedback from health professionals, and identifying opportunities for improvement. After receiving feedback during team meetings, a follow-up survey was distributed via WhatsApp to gather additional information on the intervention’s strengths, weaknesses, opportunities, and threats (SWOT). Verbal informed consent was obtained from the health providers that participated in the team meetings and in the survey. Verbal consent was approved for this specific survey and team meetings. The decision to use verbal consent, rather than written consent, was based on the need for efficiency and accessibility, particularly in the context of the nationwide vaccination efforts, where health providers were located in different provinces of the country.
Author contributions
Alejandra Mafla-Viscarra: Participated in the data collection strategy, supported the intervention, the interpretation and analysis of the data. Oversaw the logistics for field implementation. Wrote and reviewed the manuscript.
Evelyn Caballero: Participated in the data collection strategy, supported the intervention, the interpretation and analysis of the data. Wrote and reviewed the manuscript.
Mireya Levy: Performed data processing, supported on analysis of the data.
Leena Owen: Reviewed the manuscript.
Paola Yépez: Reviewed the manuscript.
Mirely Tobar: Performed data processing, supported on analysis of the data.
Bhakti Hansoti MBChB, MPH, PhD.: Reviewed the manuscript.
Michelle Grunauer, MD, PhD.: Designed the overall intervention, developed, and supported the implementation and evaluation strategy, responsible for scientific premise, stated the proposal, analyzed the data and the interpretation of results. Wrote and reviewed the manuscript.
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Mafla-Viscarra A, Caballero E, Levy M et al. Vaccination against COVID-19 in a geographically dispersed and underserved population, challenges and solutions in access and distribution of vaccines [version 1; peer review: awaiting peer review]. F1000Research 2024, 13:1294 (https://doi.org/10.12688/f1000research.154766.1)
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