Knowledge and Readiness of Community Health Volunteers to Lead Sensitization of Communities on COVID-19 Vaccination in Kenya: A Crosssectional Study

Vaccination is anticipated to bring the COVID-19 pandemic to an ultimate end. Community health volunteers (CHVs) are the link between communities and the formal health system and are therefore a vital factor in successful vaccine rollout in Kenya. However, the ability of CHVs to lead community sensitization on COVID-19 vaccination was uncertain. The aim of this study was to assess the knowledge of CHVs on COVID-19 vaccination, and determine if their knowledge is adequate to lead sensitization of communities in the national COVID-19 vaccination programme. This was a mixed methods study comprising a cross-sectional survey and key informant interviews. Quantitative data were collected from 413 CHVs in four counties of Kenya through telephone interviews; 12 key informants were also interviewed through telephone interviews. SPSS version 25.0 and R script programming were utilised to analyse quantitative data. Qualitative data were analyzed using MAXQDA software.

Nevertheless, as the world moves towards rolling out mass COVID-19 vaccination, it is likely to be hindered by vaccine hesitancy, opposition and conspiracy theories. Vaccine hesitancy and opposition may result from several factors including low knowledge, myths and misconceptions, deliberate misinformation, and social, cultural, religious and political opposition 5 . Moreover, concerns about the safety and e cacy of the COVID-19 vaccine may in uence uptake levels and increase vaccine hesitancy, especially given the short time to develop and trial the vaccines 3 .
The phenomenon of vaccine hesitancy is present in all parts of the world and is spreading fast through globalized social media 9 . The situation in Africa is no different from other parts of the world. A study from the Democratic Republic of the Congo revealed that only 27.7% of healthcare workers were willing to accept the vaccine if available 7 . With communities becoming fatigued and frustrated by the protracted nature of the pandemic, and with more and more people abandoning basic control measures, there is a high possibility that scepticism, distrust and de ance against COVID-19 prevention measures will continue to grow. Within this increasing negative context and amid globalised conspiracy theories spreading through social media, vaccine uptake is likely to face challenges unless measures are put in place to strengthen community receptiveness. Having community health volunteers (CHVs)s lead COVID-19 vaccine community engagement will play a vital role in creating con dence in COVID-19 vaccination, increasing acceptance, and reducing vaccine hesitancy and opposition among community members.
The knowledge level of community health volunteers on the importance of COVID-19 vaccination is critical for enhancing the effectiveness of vaccination programmes. Studies have shown that inadequate knowledge levels and perceptions of people on the importance of vaccination, which is related to misinformation spread on social media and anti-vaccination campaigns, in uences their decision to accept COVID-19 vaccination. According to Facciolà et al. 2 , physicians and health workers were the main sources of information leading to vaccine opposition and hesitancy among community members. When healthcare workers and community health volunteers have the right information about the bene ts and importance of vaccination, they are therefore likely to in uence the public to accept vaccination and lower hesitancy levels. Community health volunteers have direct contact with community members and any information they provide is likely to be readily adopted by the community (Facciolà et al., 2019).
This study aimed at assessing the knowledge, attitudes, values and practices of community health volunteers (CHVs) on COVID-19 vaccination in Kenya, and identifying knowledge gaps, conspiracy theories, negative beliefs and readiness to accept vaccination.

Methodology
Study design, sample size, and participants Cross-sectional surveys and key informant interviews were conducted in four counties in Kenya (Mombasa, Nairobi, Kajiado, and Trans Nzoia), from March to April, 2021. Purposive sampling was used to select the study counties based on their level of urbanisation, with Mombasa and Nairobi counties representing urban counties, and Kajiado and Trans Nzoia representing rural counties (nomadic and agrarian communities respectively). The list of CHVs registered with the Ministry of Health in the selected counties formed the sampling frame, and simple random sampling was used to select the study sample. 413 community health volunteers were randomly chosen proportionate to the population size of each region: Nairobi 209 (51%), Mombasa 84 (21%); Kajiado 54 (13%); and Trans Nzoia 66 (15%).
The eligible study population were CHVs registered to practise, those attached to a link health facility, and those who had worked as a CHV for at least one year. CHVs who had retired or had worked for less than one year were excluded from the study. Key informant interviews (KII) were conducted with county directors of health, county community strategy focal persons, sub-county community strategy focal persons, community health extension workers (CHEW) or community health assistants (CHA), a representative community health volunteer, and community leaders from each selected county.
The survey questionnaires and key informant guide were derived, adapted and conceptualised from the WHO SAGE vaccine hesitancy matrix (WHO, 2011). The questions focused on testing knowledge of CHVs on COVID-19 vaccines; and were set in English, one of Kenya's o cial languages. The questionnaire had two sections: part one consisted of the socio-demographic characteristics of the participants, and part two contained the knowledge questions. The key informant guide was developed from the gaps identi ed after quantitative data analysis.
In line with protocols for combating the spread of COVID-19 disease, telephone interviews were adopted to collect quantitative data while virtual meetings were held to collect qualitative data. Research assistants were trained on the study and study tools, and how to collect data through telephone interviews. Interviews were conducted after receiving verbal consent to participate from the respondents. KIIs were conducted through virtual meetings after consent for participation and recording was obtained.
Interviews were recorded for quality purposes.

Data management and analysis
The collected study data were cleaned, coded and entered into SPSS version 25 for analysis. Quantitative variables were organised and summarised using frequencies and percentages. For objectives 1 and 2, quantitative data were explored using descriptive and Chi-square statistics. Signi cant categorical variables were further analysed using binary logistics regression to determine odds ratios. Qualitative data from the key informant interviews were transcribed, cleaned, coded and analysed thematically.

Results
Socio-demographic characteristics of the CHVs Table 1 shows the socio-demographic characteristics of the total sample of 413 CHVs who consented to participate in the study, comprising 108 (26.2%) men, 301 (72.9%) women, and 4 (1%) who indicated 'others'. Most respondents were 35 years of age and above (64.4%); the age distributions were 18 − 24 years (7.5%), 25 − 35 years (28.1%), and above 35 years (64.4%). Religion distribution was Catholics 98 (23.7%), Protestants 233 (56.4%), Islam 38 (9.2%), and others 44 (10.7%). The majority had worked for more than 5 years (62.2%) as CHVs. The education level distribution was none (0.7%), primary level (28.1%), secondary level (49.5%), and others (21.5%). CHVs who had attended approved COVID-19 training by the Ministry of Health were 74.6%; 5.8% were not sure if they had attended, and 19.6% had not attended any COVID-19 approved training; 86.2% of the CHVs had taken part in educating the community about COVID-19, but 13.8% had not been involved in any COVID-19 education of the community. The main source of income for CHVs was non-formal employment (51.1%), while 43.1% of the CHVs obtained their income from CHV work, and 5.8% obtained their income from other formal work.     From the key informant interviews on the training needs required to equip CHVs with proper knowledge on COVID-19 vaccination included educating CHVs on the content of the COVID-19 vaccines because many CHVs did not know what the vaccines contain, how they work, how they are administered, the possible side effects of the vaccines, and who should be vaccinated.
"...CHVs need written information on the vaccine, what kind of vaccine it is, how it is administered, the side effects and overall information on it. And they need also to understand who does not qualify so that they can clear that with the community. Having written material acts as a reference point whenever a CHV is required to give information on the vaccine. It's a source document." KII The key informants reported that the safety concerns and importance of the COVID-19 vaccine need to be incorporated into the training of CHVs, so they are able to demystify myths and misinformation circulated through social media. Some of the myths and misinformation which were reported to be spread through social media on safety concerns of COVID-19 vaccine included: COVID-19 vaccine causes blood clots; the vaccine causes death; the vaccine causes impotence in young men and infertility in women of reproductive age.
"...we need to put a lot of effort in enlightening CHVs on the safety of this vaccine, safety of this vaccine is very important. … and then there are so many rumours and misconceptions on the vaccine on social media. So they need to be cleared, especially those that are on social media; they are affecting the understanding of the importance of a vaccine to a CHV. So this needs to be cleared, so that they can separate fact and ction."~ KII "The other one they say that when it gets to the body, it causes the blood to stop, blood will not ow. We are hearing in America there was something to do with clot so they don't want to. So they are saying that we are not going to be experimental. We are not going to volunteer ourselves to be jab only to die. Those are the fears and the misconceptions." ~KII "They say that it will harm his/her life, because it destroys the blood. That when you are vaccinated the vaccine goes to the blood. "~KII "Personal beliefs I have heard which are weird and which we must confront is that people are saying that these vaccines, if you are vaccinated then women will be impotent. They will not have, I mean they will not bear children. Things like that. We are hearing very weird way of reasoning about this vaccine. That if it is a younger man it will interfere with some DNA and the young man he will also be impotent he will not sire children. Those are the things we are confronting in the villages." ~ KII The key informants indicated that the types of COVID-19 vaccine and period of protection after vaccination requires to be included in the CHVs' training on COVID-19 vaccination. The training contents should also include demonstrations of the different types of vaccine so the CHVs are able to differentiate them.
"... how long is the vaccine preventing them from getting COVID-19, the people who believe that if you get the vaccine you no longer get COVID-19, who are the people that should be vaccinated, the different types of vaccines that are there, you know they also read and they know there are several types, they should be told, where they are administered, they have also seen the other vaccines how they look like, how different is that from this other one because they are the people who will pass the information to the common citizen and they should tell them it is a vaccine like the other vaccines. When one is vaccinated how long does it take for one to be protected? You know the issue of protection after getting the vaccine. "~KII "The trainers can use demonstrations to show how the vaccine looks like, where the vaccine is injected into the body… and the type of the vaccines available." ~KII

Discussion
Vaccination is one of the most effective techniques for preventing spread of infectious viral diseases globally. Vaccination has been proved effective for control of polio, rubella and measles, and was solely responsible for the eradication of smallpox 1 .
Therefore, there was urgency by scientists to develop new vaccines to protect populations from COVID-19 6 . According to the Theory of Planned Behaviour, people make informed, reasoned, and logical decisions to take part in a speci c behaviour by examining the information accessible to them 10 . They will then perform the behaviour depending on the perceived usefulness of the information they have. The results of our study revealed that CHVs in four counties of Kenya felt inadequately informed to educate community members on COVID-19 vaccination. This low knowledge level is concurrent with the emergency introduction of vaccines in the country as was reported by many respondents from the key informant interviews. The low knowledge of CHVs on COVID-19 vaccines could also be explained by the high level of misinformation from social media and other forms of media as these were indicated as major sources of information on COVID-19 vaccines. CHVs who had been previously engaged in training communities on COVID-19 vaccination had a higher knowledge of COVID-19 vaccines compared to those who had not engaged in educating communities. CHVs with higher education levels had greater knowledge about COVID-19 vaccines compared to those with lower education levels; this was associated with access to information on COVID-19 vaccines CHVs who had concerns on how the vaccines work had greater hesitancy towards uptake of vaccination.
Television and radio were reported to be the most used channels of communication by CHVs to access information on COVID-19 vaccination. Others reported that social media such as WhatsApp and Facebook were being used to propagate misinformation about COVID-19 vaccines. This is an unfortunate result of lack of Ministry of Health efforts to rapidly avail the right information to the public about COVID-19 vaccination; without available authoritative information, people opt to search for information about the vaccine from social media.
The county of origin of the CHVs had a signi cant association with the level of knowledge of COVID-19 vaccination. A study to determine COVID-19 hesitancy from various countries indicated that preference for the vaccine varied depending on rural-urban residence and regions. This might be caused by the knowledge level of the population on COVID-19 vaccines, their safety and effectiveness. Lack of correct information about COVID-19 vaccines was stated to be the major cause of COVID-19 vaccine hesitancy in sub-Saharan Africa and globally 11,12 . Moreover, our ndings indicated that CHVs lacked knowledge of the contents of COVID-19 vaccines, a reason the CHVs felt inadequately informed to educate the community on COVID-19 vaccination.

Conclusion
CHVs were found to have inadequate knowledge to be able to effectively lead community sensitisation on COVID-19 vaccination: 50% did not feel informed at all and 37% felt informed only to a small extent. CHVs had mixed knowledge on vaccine eligibility, need for preventive measures after vaccination and need for vaccination by COVID-19 survivors. Major differences in readiness to engage with communities on vaccination were dependent on county of origin and especially on whether CHVs has previously participated in sensitising communities on COVID-19. CHVs with low levels of knowledge reported they were not con dent enough to carry out COVID-19 vaccine sensitisation. However, with the safety concerns, importance of the vaccine, demystifying of myths and misinformation, and the types and period of protection after vaccination incorporated into the training of CHVs, the con dence of the CHVs to carry out community vaccination education could be increased.

RECOMMENDATION
1. The ndings of this study suggest the importance of training community health workers on COVID-19 and its vaccines to reduce hesitancy, and funds for training must accompany vaccination porgrammes.
2. The study ndings recommend supporting CHVs in Kenya to enhance COVID-19 vaccine rollout and vaccination campaigns, through training, provision of equipment, deployment of CHVs and monitoring their performance.

Figure 1
Sources of information on COVID-19 vaccination