From Digital Voices to Vaccine Choices: Increasing Female Vaccine Acceptance in Sudan through Social Listening

"In Sudan, social listening both validated suggested concerns and revealed new and nuanced concerns related to women's uptake of the COVID-19 vaccine that may have otherwise been missed."

The early COVID-19 vaccine rollout in Sudan experienced a gender disparity in vaccine uptake, with women accounting for less than 40% of vaccinations after four months of vaccine access. Initial analysis revealed that demand generation approaches were not sufficiently tailored to address the challenges and concerns of women. This paper presents a summary of an initiative led by the United Nations Children's Fund (UNICEF) in partnership with the Federal Ministry of Health in Sudan that applied "Talkwalker", a real-time social media monitoring and analytical tool, to address this gender disparity and encourage uptake of COVID-19 vaccinations by women.

Social listening refers to both online and offline activities. In online settings, it involves tracking public conversations on social media platforms to gauge and track changes in public sentiment towards a particular issue. In the case of Talkwalker, UNICEF began employing social listening in August 2021, obtaining data through social media conversations on Facebook and Twitter. (See Figure 1 in the paper for the number and type of COVID-19 conversations in Sudan; see Figure 2 for analysis of sentiments towards COVID-19 on social media.) Although the focus of this paper is the online component, offline feedback was also gathered by leveraging community mobilisers, field-based project staff, and service providers to engage in direct communication with populations who could shed light on the barriers to vaccine uptake and the reasons driving low vaccine acceptance - in particular, among women.

Social listening identified gender-specific concerns, indicated by women's social media conversations about vaccine-related concerns related to their fertility, the health of their unborn babies, and the safety of the vaccine during menstruation, pregnancy, and lactation. Social listening also revealed some unexpected consequences of vaccine misinformation. Some women reported taking the vaccine as a means of birth control, and some men also were avoiding the vaccine, fearing infertility.

Insights from social listening were fed back to the risk communication and community engagement sub-committee under the COVID-19 National Technical Committee on a weekly basis at the federal level and cascaded to state sub-committees. Data gleaned from social listening were integrated into health promotion capacity-building prior to the campaign design and rollout. These insights also supported the development of frequently asked questions, mobilised influencers, informed the design of female-friendly content, and ultimately led to increased two-way engagement. UNICEF found that inviting female audiences to tell their stories or ask questions was imperative in fostering a sense of trust, authenticity, and credibility.

Between September 2021 and April 2022 (one month after commencement of social listening by UNICEF), the Federal Ministry of Health launched three national gender-oriented social media campaigns in both the digital and interpersonal communication space in partnership with UNICEF:

• The first campaign ran on social media from September 16-22 2021, addressing four major gender-specific concerns around COVID-19 vaccines (fertility, breastfeeding, pregnancy, and menstruation).
• The second campaign, carried out from the January 20-28 2022, used social media in combination with home visits and community dialogues engaging face-to-face with approximately 270,000 individuals country wide. This effort was aided by the dissemination of 11,000 copies of factsheets with gender-oriented messages.
• The third campaign (February 19 - March 1 2022), involved use of the hashtag "Says who?" and "Your story matters" and aimed to encourage the public to question information received by word of mouth, helping to counter misinformation and rumours. Testimonies and advice from medical experts, broadcast on television and radio as well as on social media, supplemented this third campaign. Moreover, about 52,000 community members across Sudan were engaged in face-to-face interpersonal communication approaches like home visits and community dialogue.

In addition to the above, UNICEF and the Ministry of Health conducted nationwide community engagement activities such as community dialogue by community leaders and home visits by trained health promoters (who were mostly female) to reach those less served by the social media campaign and to reinforce messages for those who may have limited internet access. Orientation sessions for women were also conducted at the health centres and in communities.

Within one week of the campaign's onset, UNICEF observed a 144% increase in women's COVID-19 related social media engagement. Subsequent campaigns further enhanced women's engagement from 31% to between 35% and 47%. Women's vaccination rates increased by 9% while the first 2 campaigns were live. System constraints hindered data linkages for the third campaign.

Analysis of the posts revealed that some posts were much more effective in driving the volume of interactions than others. Seven social media posts attracted over 1,000 comments during the gender-sensitive campaigns. These 7 posts were broadly categorised into 4 major themes (i) women sharing positive experiences with COVID-19 vaccination during pregnancy and lactation; (ii) the ability to conceive; (iii) the availability of vaccines and the nearest vaccination sites; and (iv) a still-hesitant group who wanted more reassurance from the health authorities and from other women engaged online.

Per UNICEF, "social listening informed gender-responsive messaging, provided a space for women's concerns to be voiced, addressed low vaccine acceptance, and resulted in enhanced female engagement on social media. Crucially, the questions and fears were shared in close-to-real time, and authorities were able to respond to this feedback, thus increasing trust and confidence in the services." For example, women online were requesting more female vaccinators and greater privacy, leading the Ministry of Health to take action to address these concerns. "Social listening has the potential to provide invaluable insights into other dimensions of people's lives, addressing their multiple roles, broader gender norms and harmful practices - beyond public health concerns alone, which is particularly relevant for emergency situations."

UNICEF recommends that social listening be used not only passively, but also proactively. With passive application, social listening platforms are used to gather and organise existing public attitudes towards key health behaviors or to monitor what public health information is being shared. Proactive application can include approaches such as using social listening data systematically as part of formal programming monitoring of planned interventions, which may allow sentiment analysis. These approaches can help to mitigate misinformation and shape more relevant and effective public health action.

In conclusion, these findings demonstrate the value of integrating real-time feedback with large-scale social media campaigns and the potential of linking online and offline strategies to further refine interventions. "Responses should be tailored, contextualized, and person-centered, particularly in addressing concerns unique to women."