Community health workers’ knowledge, attitudes, and perceptions of risk for COVID-19: A cross-sectional survey in Haiti, Malawi and Rwanda Community health workers’ perceptions of COVID-19 in Haiti, Malawi, and Rwanda
Main Article Content
Abstract
Background: Community health workers (CHWs) are a trusted source of health care information for rural communities in many low- and middle-income countries. This became particularly relevant during the COVID-19 pandemic when individuals had restricted access to facilities and required sufficient knowledge to prevent infection. This paper assesses CHWs’ level of knowledge, attitudes, and risk awareness towards COVID-19 and willingness for and concerns about vaccination against COVID-19 among CHWs in Rwanda, Malawi and Haiti.
Methods: Between June 2023 and October 2023, we surveyed 525 CHWs – 175 CHWs per country in Haiti, Malawi, and Rwanda – affiliated with 54 health care facilities. Data on CHWs’ demographics, COVID-19 knowledge, attitudes, risk perceptions, and vaccine intention were collected. Participants indicated on a Likert scale their perception of COVID-19 in terms of its risk-worry-severity-control. We analyzed mean trust scores, correct answer rates and answer frequencies and reported global p-values, assessing any difference and pairwise p-values, assessing country-specific differences, using rank-based and ANOVA tests.
Results: Across all countries, CHWs perceived COVID-19 as a relatively controllable disease of little worry and considered their risk of contracting the virus lower than or average as compared to other diseases. In Rwanda and Haiti, CHWs showed strong knowledge of COVID-19 and the COVID-19 vaccine (correct answer rate Rwanda: 87.5%; Haiti: 81.3%), while CHWs knew considerably less in Malawi (correct answer rate: 12.9%). The vast majority of CHWs believed COVID-19 presents a serious threat to the public (Haiti: n=168, 96.0%; Malawi: n=159, 91.0%; Rwanda: n=173, 99.0%) and were confident that their country would win the battle against the COVID-19 virus (Haiti: n=149, 85.0%; Malawi: n=133, 76.0%; Rwanda: n=171, 98.0%).
Conclusions: The knowledge of COVID-19 and the COVID-19 vaccine among CHWs, along with their attitudes and perceptions of the virus, varies across countries and is likely influenced by cultural and political factors. Given the CHWs’ roles to disseminate knowledge among communities in Haiti, Malawi, and Rwanda, targeted CHW education and communication training could improve community responsiveness in the future.
Keywords:
COVID-19 vaccines, health risks, community health workers, public health, global health, misinformation
Article Details
How to Cite
DUBIQUE, Kobel et al.
Community health workers’ knowledge, attitudes, and perceptions of risk for COVID-19: A cross-sectional survey in Haiti, Malawi and Rwanda.
Medical Research Archives, [S.l.], v. 12, n. 12, dec. 2024.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/6012>. Date accessed: 06 jan. 2025.
doi: https://doi.org/10.18103/mra.v12i12.6012.
Section
Review Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
1. Prabhu M, Gergen J. History’s Seven Deadliest Plagues. VaccinesWork. November 15, 2021. Accessed August 15, 2024. https://www.gavi.org/vaccineswork/historys-seven-deadliest-plagues
2. Sorci G, Faivre B, Morand S. Explaining among-country variation in COVID-19 case fatality rate. Sci Rep. 2020;10(1):18909. doi:10.1038/s41598-020-75848-2
3. Yao L, Aleya L, Howard SC, et al. Variations of COVID-19 mortality are affected by economic disparities across countries. Sci Total Environ. 2022;832:154770. doi:10.1016/j.scitotenv.2022.154770
4. Grome HN, Raman R, Katz BD, et al. Disparities in COVID-19 Mortality Rates: Implications for Rural Health Policy and Preparedness. J Public Health Manag Pract. 2022;28(5):478-485. doi:10.1097/PH H.0000000000001507
5. Moghadas SM, Vilches TN, Zhang K, et al. The Impact of Vaccination on Coronavirus Disease 2019 (COVID-19) Outbreaks in the United States. Clin Infect Dis. 2021;73(12):2257-2264. doi:10.10 93/cid/ciab079
6. Our World in Data. Total COVID-19 vaccine doses administered. Our World in Data. Accessed August 15, 2024. https://ourworldindata.org/grapher/cumulative-covid-vaccinations?tab=map
7. Ahlberg BM, Bradby H. Ethnic, racial and regional inequalities in access to COVID-19 vaccine, testing and hospitalization: Implications for eradication of the pandemic. Front Sociol. 2022;7:809090. doi:10.3389/fsoc.2022.809090
8. Bayati M, Noroozi R, Ghanbari-Jahromi M, Jalali FS. Inequality in the distribution of Covid-19 vaccine: a systematic review. Int J Equity Health. 2022;21(1):122. doi:10.1186/s12939-022-01729-x
9. World Health Organization. WHO Guideline on Health Policy and System Support to Optimize Community Health Worker Programmes.; 2018.
10. Ahmed S, Chase LE, Wagnild J, et al. Community health workers and health equity in low- and middle-income countries: systematic review and recommendations for policy and practice. Int J Equity Health. 2022;21(1):49. doi:10.1186/s12939-021-01615-y
11. Mukherjee J, Farmer P. An Introduction to Global Health Delivery: Practice, Equity, Human Rights. 2nd ed. Oxford University PressNew York; 2021. doi:10.1093/oso/9780197607251.001.0001
12. Ballard M, Johnson A, Mwanza I, et al. Community Health Workers in Pandemics: Evidence and Investment Implications. Glob Health Sci Pract. 2022;10(2):e2100648. doi:10.97 45/GHSP-D-21-00648
13. Oliver J, Ferdinand A, Kaufman J, Allard N, Danchin M, Gibney KB. Community health workers’ dissemination of COVID-19 information and services in the early pandemic response: a systematic review. BMC Health Serv Res. 2024;24 (1):711. doi:10.1186/s12913-024-11165-y
14. Countries. Partners In Health. Accessed November 14, 2024. https://www.pih.org/countries
15. Mukherjee JS, Barry D, Weatherford RD, Desai IK, Farmer PE. Community-Based ART Programs: Sustaining Adherence and Follow-up. Curr HIV/AIDS Rep. 2016;13(6):359-366. doi:10.1007/ s11904-016-0335-7
16. 5 Unique Elements Driving Partners In Health’s Work. Partners In Health. June 8, 2021. Accessed November 14, 2024. https://www.pih.org/article/5-unique-elements-driving-partners-healths-work
17. Global Coronavirus Response. Partners In Health. March 13, 2020. Accessed November 14, 2024. https://www.pih.org/article/global-coronavirus-response
18. Chery MJ, Dubique K, Higgins JM, et al. COVID-19 vaccine acceptance in three rural communes in Haiti: A cross-sectional study. Hum Vaccines Immunother. 2023;19(1):2204048. doi:10. 1080/21645515.2023.2204048
19. Aron MB, Connolly E, Vrkljan K, et al. Attitudes toward COVID-19 Vaccines among Patients with Complex Non-Communicable Disease and Their Caregivers in Rural Malawi. Vaccines. 2022;10(5) :792. doi:10.3390/vaccines10050792
20. Niyigena A, Girukubonye I, Barnhart DA, et al. Rwanda’s community health workers at the front line: a mixed-method study on perceived needs and challenges for community-based healthcare delivery during COVID-19 pandemic. BMJ Open. 2022;12(4):e055119. doi:10.1136/bmjopen-2021-055119
21. Partners In Health. Haiti. Partners In Health. Accessed May 1, 2024. https://www.pih.org/country/haiti
22. Partners In Health. Malawi. Partners In Health. Accessed May 5, 2024. https://www.pih.org/country/malawi
23. Admon AJ, Bazile J, Makungwa H, et al. Assessing and improving data quality from community health workers: a successful intervention in Neno, Malawi. Public Health Action. 2013;3(1):56-59. doi:10.5588/pha.12.0071
24. Condo J, Mugeni C, Naughton B, et al. Rwanda’s evolving community health worker system: a qualitative assessment of client and provider perspectives. Hum Resour Health. 2014; 12(1):71. doi:10.1186/1478-4491-12-71
25. Wang C, O’Neill SM, Rothrock N, et al. Comparison of risk perceptions and beliefs across common chronic diseases. Prev Med. 2009;48 (2):197-202. doi:10.1016/j.ypmed.2008.11.008
26. Lee SK, Sun J, Jang S, Connelly S. Misinformation of COVID-19 vaccines and vaccine hesitancy. Sci Rep. 2022;12(1):13681. doi:10.1038/ s41598-022-17430-6
27. Bakdash T, Marsh C. Knowledge, Attitudes, and Beliefs Regarding the COVID-19 Pandemic Among Women in Kansas. J Community Health. 2021;46(6):1148-1154. doi:10.1007/s10900-021-00994-1
28. Joseph SA, Jerome JG, Boima F, et al. Attitudes toward COVID-19 Vaccination: Staff and Patient Perspectives at Six Health Facilities in Sierra Leone. Vaccines. 2023;11(8):1385. doi:10.3390/ vaccines11081385
29. Musanabaganwa C, Cubaka V, Mpabuka E, et al. One hundred thirty-three observed COVID-19 deaths in 10 months: unpacking lower than predicted mortality in Rwanda. BMJ Glob Health. 2021;6(2):e004547. doi:10.1136/bmjgh-2020-004547
30. Karim N, Jing L, Lee JA, et al. Lessons Learned from Rwanda: Innovative Strategies for Prevention and Containment of COVID-19. Ann Glob Health. 2021;87(1):23. doi:10.5334/aogh.3172
31. Uwizeyimana T, Manirambona E, Saidu Musa S, Uwiringiyimana E, Bazimya D, Mathewos K. Achieving COVID‐19 herd immunity in Rwanda, Africa. Public Health Chall. 2023;2(1):e75. doi:10. 1002/puh2.75
32. Louis-Jean J, Cenat K, Sanon D, Stvil R. Coronavirus (COVID-19) in Haiti: A Call for Action. J Community Health. 2020;45(3):437-439. doi:10. 1007/s10900-020-00825-9
33. Chilumpha M, Chatha G, Umar E, et al. ‘We stay silent and keep it in our hearts’: a qualitative study of failure of complaints mechanisms in Malawi’s health system. Health Policy Plan. 2023;38(Supple ment_2):ii14-ii24. doi:10.1093/heapol/czad043
34. United Nations. Overcoming COVID myths and fears in Malawi. United Nations News: Global perspective Human stories. May 2, 2021. Accessed August 16, 2024.https://news.un.org/en/story/2021/05/1090972
35. Olaniran A, Banke-Thomas A, Bar-Zeev S, Madaj B. Not knowing enough, not having enough, not feeling wanted: Challenges of community health workers providing maternal and newborn services in Africa and Asia. Tappis H, ed. PLOS ONE. 2022;17(9):e0274110. doi:10.1371/journal. pone.0274110
36. Wake AD. The Acceptance Rate Toward COVID-19 Vaccine in Africa: A Systematic Review and Meta-analysis. Glob Pediatr Health. 2021;8:23 33794X2110487. doi:10.1177/2333794X211048738
37. Feldman M, Lacey Krylova V, Farrow P, et al. Community health worker knowledge, attitudes and practices towards COVID-19: Learnings from an online cross-sectional survey using a digital health platform, UpSCALE, in Mozambique. Di Gennaro F, ed. PLOS ONE. 2021;16(2):e0244924. doi:10.1371/journal.pone.0244924
38. Li Y, Liu G, Egolet RO, Yang R, Huang Y, Zheng Z. Knowledge, Attitudes, and Practices Related to COVID-19 Among Malawi Adults: A Community-Based Survey. Int J Environ Res Public Health. 2021;18(8):4090. doi:10.3390/ijerph18084090
39. Kainja J, Makhumula C, Twabi HS, Gunde AM, Ndasauka Y. Cultural determinants of COVID-19 vaccines misinformation in Malawi. Humanit Soc Sci Commun. 2024;11(1):1193. doi:10.1057/s415 99-024-03743-6
40. Magagula A. Level of knowledge about COVID-19 and vaccines among CHWs in Malawi. Published online July 25, 2024.
41. Faure JA, Wang CW, Chen CHS, Chan CC. Assessment of the Functional Capacity and Preparedness of the Haitian Healthcare System to Fight against the COVID-19 Pandemic: A Narrative Review. Healthcare. 2022;10(8):1428. doi:10.3390/ healthcare10081428
42. Miller J. Sustaining Health Care as Crisis in Haiti Escalates. Harvard Medical School. March 21, 2024. Accessed October 26, 2024. https://hms.harvard.edu/news/sustaining-health-care-crisis-haiti-escalates
43. Al-Hanawi MK, Angawi K, Alshareef N, et al. Knowledge, Attitude and Practice Toward COVID-19 Among the Public in the Kingdom of Saudi Arabia: A Cross-Sectional Study. Front Public Health. 2020;8:217. doi:10.3389/fpubh.2020.00217
44. Zhong BL, Luo W, Li HM, et al. Knowledge, attitudes, and practices towards COVID-19 among Chinese residents during the rapid rise period of the COVID-19 outbreak: a quick online cross-sectional survey. Int J Biol Sci. 2020;16(10):1745-1752. doi:10.7150/ijbs.45221
45. Yoseph A, Tamiso A, Ejeso A. Knowledge, attitudes, and practices related to COVID-19 pandemic among adult population in Sidama Regional State, Southern Ethiopia: A community based cross-sectional study. Erbil N, ed. PLOS ONE. 2021;16(1):e0246283. doi:10.1371/journal. pone.0246283
46. Azlan AA, Hamzah MR, Sern TJ, Ayub SH, Mohamad E. Public knowledge, attitudes and practices towards COVID-19: A cross-sectional study in Malaysia. Tu WJ, ed. PLOS ONE. 2020;15 (5):e0233668. doi:10.1371/journal.pone.0233668
47. Kaungav SB. How have Malawi’s courts affected the country’s epidemic response? The London School of Economics and Political Science (LSE). November 13, 2020. https://blogs.lse.ac.uk/africaatlse/2020/11/13/how-have-malawis-courts-law-affected-epidemic-response/
48. Mzumara GW, Chawani M, Sakala M, et al. The health policy response to COVID-19 in Malawi. BMJ Glob Health. 2021;6(5):e006035. doi:10.1136 /bmjgh-2021-006035
49. Moradzadeh R, Nazari J, Shamsi M, Amini S. Knowledge, Attitudes, and Practices Toward Coronavirus Disease 2019 in the Central Area of Iran: A Population-Based Study. Front Public Health. 2020;8:599007. doi:10.3389/fpubh.2020.599007
50. Pan American Health Organization (PAHO). Haiti receives 500,000 vaccines donated by the United States through COVAX. PAHO: Pan American Health Organization. Accessed July 8, 2024. https://www.paho.org/en/stories/haiti-receives-500000-vaccines-donated-united-states-through-covax
51. World Health Organization. WHO COVID-19 dashboard. World Health Organization Data. Accessed October 26, 2024. https://data.who.int/dashboards/covid19/vaccines
52. Nkambule E, Mbakaya BC. COVID-19 vaccination hesitancy among Malawians: a scoping review. Syst Rev. 2024;13(1):77. doi:10.1186/s1364 3-024-02499-z
53. Sethy G, Chisema MN, Sharma L, et al. ‘Vaccinate my village’ strategy in Malawi: an effort to boost COVID-19 vaccination. Expert Rev Vaccines. 2023;22(1):180-185. doi:10.1080/14760 584.2023.2171398
54. Bwanali AN, Lubanga AF, Mphepo M, Munthali L, Chumbi GD, Kangoma M. Vaccine hesitancy in Malawi: a threat to already-made health gains. Ann Med Surg. 2023;85(10):5291-5293. doi:10.1097/ MS9.0000000000001198
55. Goel K, Sen A, Goel P, et al. Assessment of COVID-19 Vaccination Intention Among Community Health Workers: a Web-based Cross-sectional Survey During the First Wave of the Pandemic in India. Published online July 8, 2021. doi:10.21203 /rs.3.rs-675407/v1
56. Avahoundje EM, Dossou JP, Vigan A, et al. Factors associated with COVID-19 vaccine intention in Benin in 2021: A cross-sectional study. Vaccine X. 2022;12:100237. doi:10.1016/j.jvacx. 2022.100237
57. Eyal K, Njozela L, Köhler T, et al. Correlates of COVID-19 vaccination intentions and opinions about mandates among four groups of adults in South Africa with distinct vaccine intentions: evidence from a large national survey. BMC Public Health. 2023;23(1):1767. doi:10.1186/s12889-023-16584-w
58. Nomura S, Eguchi A, Yoneoka D, et al. Reasons for being unsure or unwilling regarding intention to take COVID-19 vaccine among Japanese people: A large cross-sectional national survey. Lancet Reg Health - West Pac. 2021;14:100223. doi:10.1016/j. lanwpc.2021.100223
59. Sánchez-González L, Major CG, Rodriguez DM, et al. COVID-19 Vaccination Intention in a Community Cohort in Ponce, Puerto Rico. Am J Trop Med Hyg. 2022;107(2):268-277. doi:10.4269/ ajtmh.22-0132
60. PIH’s Strategy for Achieving Equity in COVID-19 Vaccination. Partners In Health. Accessed November 14, 2024. https://www.pih.org/learning-collaborative/pihs-strategy-achieving-equity-covid-19-vaccination
61. Warren AM, Bennett MM, Da Graca B, et al. Intentions to receive COVID-19 vaccines in the united states: Sociodemographic factors and personal experiences with COVID-19. Health Psychol. 2023;42(8):531-540. doi:10.1037/hea0001225
2. Sorci G, Faivre B, Morand S. Explaining among-country variation in COVID-19 case fatality rate. Sci Rep. 2020;10(1):18909. doi:10.1038/s41598-020-75848-2
3. Yao L, Aleya L, Howard SC, et al. Variations of COVID-19 mortality are affected by economic disparities across countries. Sci Total Environ. 2022;832:154770. doi:10.1016/j.scitotenv.2022.154770
4. Grome HN, Raman R, Katz BD, et al. Disparities in COVID-19 Mortality Rates: Implications for Rural Health Policy and Preparedness. J Public Health Manag Pract. 2022;28(5):478-485. doi:10.1097/PH H.0000000000001507
5. Moghadas SM, Vilches TN, Zhang K, et al. The Impact of Vaccination on Coronavirus Disease 2019 (COVID-19) Outbreaks in the United States. Clin Infect Dis. 2021;73(12):2257-2264. doi:10.10 93/cid/ciab079
6. Our World in Data. Total COVID-19 vaccine doses administered. Our World in Data. Accessed August 15, 2024. https://ourworldindata.org/grapher/cumulative-covid-vaccinations?tab=map
7. Ahlberg BM, Bradby H. Ethnic, racial and regional inequalities in access to COVID-19 vaccine, testing and hospitalization: Implications for eradication of the pandemic. Front Sociol. 2022;7:809090. doi:10.3389/fsoc.2022.809090
8. Bayati M, Noroozi R, Ghanbari-Jahromi M, Jalali FS. Inequality in the distribution of Covid-19 vaccine: a systematic review. Int J Equity Health. 2022;21(1):122. doi:10.1186/s12939-022-01729-x
9. World Health Organization. WHO Guideline on Health Policy and System Support to Optimize Community Health Worker Programmes.; 2018.
10. Ahmed S, Chase LE, Wagnild J, et al. Community health workers and health equity in low- and middle-income countries: systematic review and recommendations for policy and practice. Int J Equity Health. 2022;21(1):49. doi:10.1186/s12939-021-01615-y
11. Mukherjee J, Farmer P. An Introduction to Global Health Delivery: Practice, Equity, Human Rights. 2nd ed. Oxford University PressNew York; 2021. doi:10.1093/oso/9780197607251.001.0001
12. Ballard M, Johnson A, Mwanza I, et al. Community Health Workers in Pandemics: Evidence and Investment Implications. Glob Health Sci Pract. 2022;10(2):e2100648. doi:10.97 45/GHSP-D-21-00648
13. Oliver J, Ferdinand A, Kaufman J, Allard N, Danchin M, Gibney KB. Community health workers’ dissemination of COVID-19 information and services in the early pandemic response: a systematic review. BMC Health Serv Res. 2024;24 (1):711. doi:10.1186/s12913-024-11165-y
14. Countries. Partners In Health. Accessed November 14, 2024. https://www.pih.org/countries
15. Mukherjee JS, Barry D, Weatherford RD, Desai IK, Farmer PE. Community-Based ART Programs: Sustaining Adherence and Follow-up. Curr HIV/AIDS Rep. 2016;13(6):359-366. doi:10.1007/ s11904-016-0335-7
16. 5 Unique Elements Driving Partners In Health’s Work. Partners In Health. June 8, 2021. Accessed November 14, 2024. https://www.pih.org/article/5-unique-elements-driving-partners-healths-work
17. Global Coronavirus Response. Partners In Health. March 13, 2020. Accessed November 14, 2024. https://www.pih.org/article/global-coronavirus-response
18. Chery MJ, Dubique K, Higgins JM, et al. COVID-19 vaccine acceptance in three rural communes in Haiti: A cross-sectional study. Hum Vaccines Immunother. 2023;19(1):2204048. doi:10. 1080/21645515.2023.2204048
19. Aron MB, Connolly E, Vrkljan K, et al. Attitudes toward COVID-19 Vaccines among Patients with Complex Non-Communicable Disease and Their Caregivers in Rural Malawi. Vaccines. 2022;10(5) :792. doi:10.3390/vaccines10050792
20. Niyigena A, Girukubonye I, Barnhart DA, et al. Rwanda’s community health workers at the front line: a mixed-method study on perceived needs and challenges for community-based healthcare delivery during COVID-19 pandemic. BMJ Open. 2022;12(4):e055119. doi:10.1136/bmjopen-2021-055119
21. Partners In Health. Haiti. Partners In Health. Accessed May 1, 2024. https://www.pih.org/country/haiti
22. Partners In Health. Malawi. Partners In Health. Accessed May 5, 2024. https://www.pih.org/country/malawi
23. Admon AJ, Bazile J, Makungwa H, et al. Assessing and improving data quality from community health workers: a successful intervention in Neno, Malawi. Public Health Action. 2013;3(1):56-59. doi:10.5588/pha.12.0071
24. Condo J, Mugeni C, Naughton B, et al. Rwanda’s evolving community health worker system: a qualitative assessment of client and provider perspectives. Hum Resour Health. 2014; 12(1):71. doi:10.1186/1478-4491-12-71
25. Wang C, O’Neill SM, Rothrock N, et al. Comparison of risk perceptions and beliefs across common chronic diseases. Prev Med. 2009;48 (2):197-202. doi:10.1016/j.ypmed.2008.11.008
26. Lee SK, Sun J, Jang S, Connelly S. Misinformation of COVID-19 vaccines and vaccine hesitancy. Sci Rep. 2022;12(1):13681. doi:10.1038/ s41598-022-17430-6
27. Bakdash T, Marsh C. Knowledge, Attitudes, and Beliefs Regarding the COVID-19 Pandemic Among Women in Kansas. J Community Health. 2021;46(6):1148-1154. doi:10.1007/s10900-021-00994-1
28. Joseph SA, Jerome JG, Boima F, et al. Attitudes toward COVID-19 Vaccination: Staff and Patient Perspectives at Six Health Facilities in Sierra Leone. Vaccines. 2023;11(8):1385. doi:10.3390/ vaccines11081385
29. Musanabaganwa C, Cubaka V, Mpabuka E, et al. One hundred thirty-three observed COVID-19 deaths in 10 months: unpacking lower than predicted mortality in Rwanda. BMJ Glob Health. 2021;6(2):e004547. doi:10.1136/bmjgh-2020-004547
30. Karim N, Jing L, Lee JA, et al. Lessons Learned from Rwanda: Innovative Strategies for Prevention and Containment of COVID-19. Ann Glob Health. 2021;87(1):23. doi:10.5334/aogh.3172
31. Uwizeyimana T, Manirambona E, Saidu Musa S, Uwiringiyimana E, Bazimya D, Mathewos K. Achieving COVID‐19 herd immunity in Rwanda, Africa. Public Health Chall. 2023;2(1):e75. doi:10. 1002/puh2.75
32. Louis-Jean J, Cenat K, Sanon D, Stvil R. Coronavirus (COVID-19) in Haiti: A Call for Action. J Community Health. 2020;45(3):437-439. doi:10. 1007/s10900-020-00825-9
33. Chilumpha M, Chatha G, Umar E, et al. ‘We stay silent and keep it in our hearts’: a qualitative study of failure of complaints mechanisms in Malawi’s health system. Health Policy Plan. 2023;38(Supple ment_2):ii14-ii24. doi:10.1093/heapol/czad043
34. United Nations. Overcoming COVID myths and fears in Malawi. United Nations News: Global perspective Human stories. May 2, 2021. Accessed August 16, 2024.https://news.un.org/en/story/2021/05/1090972
35. Olaniran A, Banke-Thomas A, Bar-Zeev S, Madaj B. Not knowing enough, not having enough, not feeling wanted: Challenges of community health workers providing maternal and newborn services in Africa and Asia. Tappis H, ed. PLOS ONE. 2022;17(9):e0274110. doi:10.1371/journal. pone.0274110
36. Wake AD. The Acceptance Rate Toward COVID-19 Vaccine in Africa: A Systematic Review and Meta-analysis. Glob Pediatr Health. 2021;8:23 33794X2110487. doi:10.1177/2333794X211048738
37. Feldman M, Lacey Krylova V, Farrow P, et al. Community health worker knowledge, attitudes and practices towards COVID-19: Learnings from an online cross-sectional survey using a digital health platform, UpSCALE, in Mozambique. Di Gennaro F, ed. PLOS ONE. 2021;16(2):e0244924. doi:10.1371/journal.pone.0244924
38. Li Y, Liu G, Egolet RO, Yang R, Huang Y, Zheng Z. Knowledge, Attitudes, and Practices Related to COVID-19 Among Malawi Adults: A Community-Based Survey. Int J Environ Res Public Health. 2021;18(8):4090. doi:10.3390/ijerph18084090
39. Kainja J, Makhumula C, Twabi HS, Gunde AM, Ndasauka Y. Cultural determinants of COVID-19 vaccines misinformation in Malawi. Humanit Soc Sci Commun. 2024;11(1):1193. doi:10.1057/s415 99-024-03743-6
40. Magagula A. Level of knowledge about COVID-19 and vaccines among CHWs in Malawi. Published online July 25, 2024.
41. Faure JA, Wang CW, Chen CHS, Chan CC. Assessment of the Functional Capacity and Preparedness of the Haitian Healthcare System to Fight against the COVID-19 Pandemic: A Narrative Review. Healthcare. 2022;10(8):1428. doi:10.3390/ healthcare10081428
42. Miller J. Sustaining Health Care as Crisis in Haiti Escalates. Harvard Medical School. March 21, 2024. Accessed October 26, 2024. https://hms.harvard.edu/news/sustaining-health-care-crisis-haiti-escalates
43. Al-Hanawi MK, Angawi K, Alshareef N, et al. Knowledge, Attitude and Practice Toward COVID-19 Among the Public in the Kingdom of Saudi Arabia: A Cross-Sectional Study. Front Public Health. 2020;8:217. doi:10.3389/fpubh.2020.00217
44. Zhong BL, Luo W, Li HM, et al. Knowledge, attitudes, and practices towards COVID-19 among Chinese residents during the rapid rise period of the COVID-19 outbreak: a quick online cross-sectional survey. Int J Biol Sci. 2020;16(10):1745-1752. doi:10.7150/ijbs.45221
45. Yoseph A, Tamiso A, Ejeso A. Knowledge, attitudes, and practices related to COVID-19 pandemic among adult population in Sidama Regional State, Southern Ethiopia: A community based cross-sectional study. Erbil N, ed. PLOS ONE. 2021;16(1):e0246283. doi:10.1371/journal. pone.0246283
46. Azlan AA, Hamzah MR, Sern TJ, Ayub SH, Mohamad E. Public knowledge, attitudes and practices towards COVID-19: A cross-sectional study in Malaysia. Tu WJ, ed. PLOS ONE. 2020;15 (5):e0233668. doi:10.1371/journal.pone.0233668
47. Kaungav SB. How have Malawi’s courts affected the country’s epidemic response? The London School of Economics and Political Science (LSE). November 13, 2020. https://blogs.lse.ac.uk/africaatlse/2020/11/13/how-have-malawis-courts-law-affected-epidemic-response/
48. Mzumara GW, Chawani M, Sakala M, et al. The health policy response to COVID-19 in Malawi. BMJ Glob Health. 2021;6(5):e006035. doi:10.1136 /bmjgh-2021-006035
49. Moradzadeh R, Nazari J, Shamsi M, Amini S. Knowledge, Attitudes, and Practices Toward Coronavirus Disease 2019 in the Central Area of Iran: A Population-Based Study. Front Public Health. 2020;8:599007. doi:10.3389/fpubh.2020.599007
50. Pan American Health Organization (PAHO). Haiti receives 500,000 vaccines donated by the United States through COVAX. PAHO: Pan American Health Organization. Accessed July 8, 2024. https://www.paho.org/en/stories/haiti-receives-500000-vaccines-donated-united-states-through-covax
51. World Health Organization. WHO COVID-19 dashboard. World Health Organization Data. Accessed October 26, 2024. https://data.who.int/dashboards/covid19/vaccines
52. Nkambule E, Mbakaya BC. COVID-19 vaccination hesitancy among Malawians: a scoping review. Syst Rev. 2024;13(1):77. doi:10.1186/s1364 3-024-02499-z
53. Sethy G, Chisema MN, Sharma L, et al. ‘Vaccinate my village’ strategy in Malawi: an effort to boost COVID-19 vaccination. Expert Rev Vaccines. 2023;22(1):180-185. doi:10.1080/14760 584.2023.2171398
54. Bwanali AN, Lubanga AF, Mphepo M, Munthali L, Chumbi GD, Kangoma M. Vaccine hesitancy in Malawi: a threat to already-made health gains. Ann Med Surg. 2023;85(10):5291-5293. doi:10.1097/ MS9.0000000000001198
55. Goel K, Sen A, Goel P, et al. Assessment of COVID-19 Vaccination Intention Among Community Health Workers: a Web-based Cross-sectional Survey During the First Wave of the Pandemic in India. Published online July 8, 2021. doi:10.21203 /rs.3.rs-675407/v1
56. Avahoundje EM, Dossou JP, Vigan A, et al. Factors associated with COVID-19 vaccine intention in Benin in 2021: A cross-sectional study. Vaccine X. 2022;12:100237. doi:10.1016/j.jvacx. 2022.100237
57. Eyal K, Njozela L, Köhler T, et al. Correlates of COVID-19 vaccination intentions and opinions about mandates among four groups of adults in South Africa with distinct vaccine intentions: evidence from a large national survey. BMC Public Health. 2023;23(1):1767. doi:10.1186/s12889-023-16584-w
58. Nomura S, Eguchi A, Yoneoka D, et al. Reasons for being unsure or unwilling regarding intention to take COVID-19 vaccine among Japanese people: A large cross-sectional national survey. Lancet Reg Health - West Pac. 2021;14:100223. doi:10.1016/j. lanwpc.2021.100223
59. Sánchez-González L, Major CG, Rodriguez DM, et al. COVID-19 Vaccination Intention in a Community Cohort in Ponce, Puerto Rico. Am J Trop Med Hyg. 2022;107(2):268-277. doi:10.4269/ ajtmh.22-0132
60. PIH’s Strategy for Achieving Equity in COVID-19 Vaccination. Partners In Health. Accessed November 14, 2024. https://www.pih.org/learning-collaborative/pihs-strategy-achieving-equity-covid-19-vaccination
61. Warren AM, Bennett MM, Da Graca B, et al. Intentions to receive COVID-19 vaccines in the united states: Sociodemographic factors and personal experiences with COVID-19. Health Psychol. 2023;42(8):531-540. doi:10.1037/hea0001225