Stanford University’s digital health education campaign helps promote vaccines

“A person’s beliefs and values can influence how they understand health concepts, how they take care of their health, and how they make decisions related to their health,” says Sarah. Her tone is warm and serious, conversational and direct. She has a wealth of information; she explains without condescending.

Sarah can be a figure on screen or just a voice, depending on the needs of the community health workers (CHWs) — her intended audience — who carry her via smartphone between clients’ houses. An avatar of a community health worker developed by the Digital Medic team at Stanford Medicine, she guides listeners through a series of 10 videos on the basics of how vaccines work and how they protect against viruses, specifically against COVID-19. The video training, “Supporting Vaccination: A Digital Toolkit for CHWs” does double duty: it provides professional education for community health workers while also serving as a resource for them to share in conversations with their clients.

Digital Medic built the “Supporting Vaccination” toolkit in collaboration with community health workers and their supervisors from the organizations Philani and One to One Africa. The full training is available to view and download at the Digital Medic website and through the Digital Medic mobile app. While Digital Medic’s immediate focus was COVID-19, the broader goal was to expand understanding of how vaccines work and why they matter more broadly, with the goal of increasing uptake of vaccinations around the world.

Global vaccination efforts for COVID-19 have been made possible through the complex interplay of scientific research, government financing, and delivery logistics. But even after the daunting challenges of developing, storing, paying for, and transporting a vaccine have been surmounted, one last step can pose a barrier: individuals must be willing to receive the shot. Because of proliferating myths and disinformation about the COVID-19 vaccine, in many communities health workers must overcome people’s reluctance to be vaccinated. In some cases, the health workers themselves must be convinced that the benefits of vaccination outweigh the risks.

A recent survey of 23 countries published in Nature Medicine found an average COVID-19 vaccine acceptance rate of 79%, ranging from a low of 48% in South Africa to a high of 98% in India. Hesitancy increased in eight of the countries between June 2021 and June 2022, including in South Africa and several other countries whose acceptance rates lag below the global average — Ghana, Kenya, Mexico, and Turkey.

In other words, the final stage of vaccine delivery presents a high-stakes communications challenge.

Dr. Victoria Ward
Dr. Victoria Ward, medical director, Digital Medic
“We think of Digital Medic as a library of sorts where people can come and take books off the shelf about subjects they want to learn about and share with other people,” said Dr. Victoria Ward, medical director for Digital Medic, a unit of the Stanford Center for Health Education, and a clinical associate professor of pediatrics at Stanford University’s School of Medicine. One of her goals, when the team creates content in partnership with on-the-ground community health organizations, is to free up those groups’ resources for training and fieldwork. “Obviously every organization shouldn’t have to be writing and illustrating the textbook. It’s more efficient to share resources. It’s just that in this case, the library is digital.”

Why the focus on community health workers?
In urban and rural low-resource areas across the globe, lay community health workers visit families to offer guidance on maternal and newborn care and nutrition, as well as give assistance on other health issues. Typically, community health workers live in the communities they serve, may be employed by local nonprofits or health centers, and carry heavy caseloads. Levels of training vary, and they often receive little or no pay for their work.

Semay Johnston
Semay Johnston, learning experience director, Digital Medic
“Community health workers are trusted members of the community,” said Semay Johnston, learning experience director for Digital Medic. “We wanted to create something that would help them learn about what the vaccines are and the science behind them, but also how to communicate well with their clients and address a lot of the misinformation that they were reporting.”

During the initial phase of the pandemic, tens of thousands of community health workers in South Africa were sent out into the field to conduct screening and contact tracing, according to the Bhekisisa Centre for Health Journalism. In India, 900,000 community health workers acted as the first line of defense against the virus, but without basic protections like masks or hand sanitizer, Buzzfeed News reported in March 2020.

“Particularly in the context of the early pandemic, when people were not going to health facilities, and were not able to access medical care due to pandemic restrictions and overburdened health systems, community health workers were providing a great deal of the essential health services by going out to visit families. The workload that they were carrying was extremely heavy,” said Ward.

The videos of the “Supporting Vaccination” toolkit highlight the community health worker experience. In the first one, “The Power of Your Story,” the avatar Sarah describes how health workers can build trust with clients through sharing their own pandemic and vaccination stories. The final video offers coping strategies and self-care practices. In between, the videos offer information on how viruses and vaccines work, common side effects, specific misinformation and myths about the vaccine, how to identify reliable sources of information, and clues that a source may be unreliable.

Messaging reflects a collaborative process
Sarah, an avatar of a community health worker, explaining the protection vaccines provide
Sarah, the community health worker avatar, explains the benefits vaccines provide in the introduction to the toolkit.
For the toolkit’s illustrations and general approach, the Digital Medic content team — which is jointly based at Stanford and in Cape Town, South Africa — built on schematics that had been developed for earlier projects in conjunction with the Community Health Impact Coalition (CHIC), a group that aims to support professionalization for community health workers worldwide. The animated guide throughout the “Supporting Vaccination” series is Sarah, who speaks with a South African accent. Sarah has brown eyes, skin, and hair and wears a neat shirt and skirt with comfortable shoes. Her explanations are illustrated with more abstract figures, which resemble squat clothespins with floating circles for heads. Included among these is a community health worker, who is identified by a red cross on the chest and a green backpack and is depicted drinking tea with, listening to, and sharing stories with people in the community.

Together, the community health worker and clients move up a hill — one among many, in a green landscape — traveling on an educational journey that ideally ends with the decision to get vaccinated. The path is not always direct; there are stages of readiness, but progression through the stages can vary or stall. The health worker shares information and addresses common concerns, but does not judge.

Johnston said, “The style is meant to feel approachable and resonate broadly with viewers throughout the world.”

Ward sees common vulnerabilities across geographies. “Myths and misinformation have a tendency to spread quickly,” she continued. “It has been interesting to see how some of the salient myths we are hearing from patients in the US, are also being described by community health workers in South Africa.”

Indeed, the toolkit materials attempt to inoculate health workers against misinformation — to teach them to recognize and dispel it based on facts and reliable evidence — in a way that is analogous to the vaccine mechanisms they describe. However, the similarity is not complete; the communication strategies modeled for interacting with skeptical clients are rooted in empathetic listening, quite different from spurring an immune response.

That’s deliberate. “The ‘one of us is right, and one of us is wrong’ methodology is never productive,” said Ward. “I think oftentimes the goal is to understand people’s questions, learn about their concerns, and see where they are along a spectrum from ‘Absolutely not,’ to ‘Sure, I’ll do it,’ and meet them in that place with pertinent information.”

Aiming for global usefulness through a network of public health partners
Given the sometimes unreliable internet connectivity in the regions where the content is shared, Digital Medic designed the toolkit to be accessible for a global audience. Each of the 10 units is available for download in both video and audio-only formats on the Digital Medic website, and in video on the mobile app. While the original videos are in English, Digital Medic’s previous initiatives have operated in 140 countries in Africa, Asia, and Latin America, and the vaccine series is currently being produced in French, Sepedi, Spanish, and Xhosa. Recently, Digital Medic received funding to adapt the series’ content for projects in Kenya and Guatemala; the Guatemala-based project will involve developing related materials for the general public in two indigenous Mayan languages, K’iche’ and Kaqchikel.

The existing toolkit has been shared with UNICEF, multiple national ministries of health and nonprofits throughout Africa, and the Community Health Impact Coalition, as well as foundations and the Global Digital Health Network. It has also been promoted on YouTube and social media.

Public health agencies have noted that overall immunization rates have dropped globally since the beginning of the pandemic, with lethal consequences. The CDC estimates that 18 million children received no vaccines in 2021, most of them in low- and middle-income countries in Africa and Southeast Asia, and that a child dies every 20 seconds from a vaccine-preventable disease. Every health worker who can communicate how vaccines work and help clients develop confidence in them — not just the COVID-19 vaccine, but also those against diseases like rotavirus, measles, and rubella — can improve local health outcomes that reverberate through generations.

While the videos in the toolkit have received more than 400,000 views on social media, measuring its true impact on local vaccination rates remains a goal for the team, Ward said. She is heartened by the feedback the Digital Medic team has received. “Part of what we have found is that as we co-create content that is perceived as useful and relevant, collaborators are coming to us more and more for content that they are interested in or opportunities to work together,” she said. “So that has been encouraging.”