Understanding COVID-19 vaccination choices and development of a toolkit and training for Botswana, 2022-2023

Abstract

Background: In 2022, despite initial coverage data indicating good acceptance of the vaccine by eligible groups, COVID-19 vaccination coverage in Botswana was below the Ministry of Health's goal of 80%, with underlying reasons unclear. Therefore, we conducted a study to identify facilitators and barriers to COVID-19 vaccination to inform the design and implementation of a toolkit to improve COVID-19 vaccination rates.

Methods: We conducted a sequential two-phased exploratory mixed methods study: Phase 1 (toolkit development and refinement) followed by Phase 2 (toolkit implementation and evaluation). Phase 1 involved two rounds of focus group discussions (FGDs) with general population and health care providers from various regions, followed by thematic analysis. Round 1 (32 FGDs, n = 298) aimed to identify facilitators and barriers to vaccination, while Round 2 (10 FGDs, n = 86) provided feedback to refine the toolkit. Phase 2 included training across 14 districts and evaluated knowledge and competence of vaccine providers (n = 92) through electronic pre-post questionnaires and Wilcoxon Signed-Rank Tests to assess differences.

Results: Facilitators of vaccination included access to accurate and trusted information as well as realistic expectations about vaccine benefits and side effects. Barriers included misinformation, lack of access to trusted information, difficulty accessing vaccines, and concerns about side effects. The toolkit content was tailored to the local context for providers and the public. Feedback indicated the toolkit was informative and helpful, with recommendations to add information on booster doses, vaccinating adolescents, and additional visuals, while limiting referrals to external information sources. Post-training assessments showed improvements in vaccine-related knowledge (Z = 221, p < 0.001) and competence in vaccine care and counseling (Z = 22, p < 0.001). Participants showed increased knowledge (Z = 292, p < 0.01) and competence (Z = 77, p < 0.001) in motivational interviewing.

Conclusion: Engagement with general public and providers in Botswana informed the design of an evidence-based, culturally appropriate toolkit and training that effectively improved vaccine knowledge and provider competence.

Keywords: Africa; Botswana; COVID-19; Focus group discussions; Healthcare providers; Mixed methods; Motivational interviewing; Vaccination; Vaccine; Vaccine hesitancy.