Background

Malawi is a low-income country with a population of approximately 20 million. The first COVID-19 cases were confirmed in April 2020, amidst political uncertainty and denial of the COVID-19 pandemic’s existence in Malawi. This may have contributed to mistrust in the Malawi government, resulting in low-risk perception, low adherence to preventive measures and low uptake of the vaccine (Kayode et al. 2022).

Malawi received the first shipment of 360,000 doses of the Oxford-AstraZeneca vaccine from COVAXFootnote 1 on 5 March 2021, and an additional 102,000 doses from the African Union (Kayode et al. 2022). The first phase of vaccinations prioritised high-risk populations, including health workers, the elderly and those with comorbidities. The segmentation and prioritisation of these groups created many rumours, including fears that the government wanted to eliminate the elderly and those with chronic illnesses. Rumours, as they pertain to COVID-19 origin, prevention, COVID-19 vaccines and vaccination processes, are unverified claims that circulate, including on online platforms, which verification processes may find to be false, misleading or exaggerated (Zubiaga et al. 2016). The term ‘misinformation’ refers to inaccurate or false information shared by someone without realising the information is false or intended to cause harm (Islam et al. 2021; Zubiaga et al. 2016). In this chapter, we use ‘rumours’ and ‘misinformation’ interchangeably. In April 2021, the vaccine rollout was scaled up to include people aged 18–59 years, pregnant women and marginalised populations such as prisoners and refugees (Sethy et al. 2022). In this first phase, 300,000 doses were administered by 14 April 2021, but 16,400 doses of the vaccines donated by the African Union expired before they could be used and were disposed of, causing rumours to arise around the out-of-date doses and the quick vaccine development process. This disposal of the vaccines contributed to mistrust of the Malawi Government and further increased vaccine hesitancy, as people questioned why the Malawi Government had accepted vaccines that were close to their expiration dates (Kayode et al. 2022).

Malawi ran out of its supply of AstraZeneca in June 2021, resulting in delays for those scheduled to receive their second dose. This caused confusion and, for some, validated rumours that the vaccines were experimental due to the initial Ministry of Health (MOH) communication that there should be a 12-week interval between the first and second doses of AstraZeneca, followed later by communication that the vaccine was more effective when the second dose was delayed beyond 12 weeks. By January 2022, the Malawi Government started administering the Pfizer and Johnson and Johnson (J&J) vaccines to children aged 12 years and above who were eligible to receive the vaccine. The three different vaccine types required different intervals between doses (AstraZeneca and Pfizer) and number of doses (one for J&J and two for AstraZeneca and Pfizer). This further compounded community mistrust towards the Malawi Government. Based on risk communication and community engagement (RCCE) rumour-tracking reports, some people believed that additional vaccine types pointed to the low efficacy of AstraZeneca and the experimental rollout of vaccines, while others argued that the government was being pushed by COVID-19 vaccine manufacturers and Western governments to administer vaccines.

By August 2022, the Ministry of Health (MOH) Daily Update reported that Malawi had recorded 87,865 COVID-19 cases and 2675 deaths, with only 16.3 per cent of the eligible population fully vaccinated. The many rumours about COVID-19 vaccines have contributed to low vaccine uptake and high rates of vaccine hesitancy among Malawians (Government of Malawi 2021). Vaccine hesitancy, defined as the ‘delay in acceptance or refusal of vaccination despite the availability of vaccination services’, has been listed as one of the top ten threats to global health by the World Health Organization (WHO) (Kayode et al. 2022; Puri et al. 2020).

To address the rampant rumours, the MOH established rumour-tracking systems supported by various partners, including Breakthrough ACTION. These systems document rumours and misinformation about COVID-19 vaccines. The rumours collected and analysed showed that many believed vaccine manufacturers were using the government to fulfil their ‘ulterior motives’ to make profits and depopulate Africa; such rumours suggested that vaccines killed after two years of receiving a dose and that they affected fertility, particularly among youth. Malawians affected by rumours also questioned the purpose of the vaccines in the context of religious beliefs, pointing to those that accept and promote vaccines as being ‘satanic’ or of low faith. Many Malawians believe that the vaccines are not fully researched, and they assert that the need for booster doses proves the experimental nature of the vaccines. Analysis of the rumours clarified that mistrust of both the vaccines and the Malawi government’s role in administering vaccines was compounded by various sociocultural beliefs, affecting vaccine uptake.

The Role of Social Media, Celebrities and Religious Leaders in Health Communication

Evidence shows that social media platforms are a popular source of information-seeking and discussing COVID-19; information shared online influences people’s perceptions, attitudes and intentions regarding vaccination (Kostygina et al. 2020; Obi-Ani et al. 2020; Stellefson et al. 2020; Zubiaga et al. 2016). With the increased use of social media in recent decades, internet users are increasingly at risk of accessing and sharing misinformation online. The United Nations has referred to the spread of false or misleading information linked to COVID-19 as an ‘infodemic’, requiring consistent monitoring and vigilance (Global Infectious Hazard Preparedness 2021). Therefore, educating the public, ensuring fact-based health messaging, dispelling myths and countering misinformation are critically important (Malik et al. 2021). Celebrities and religious leaders have for years been engaged to influence behaviour change in public health (Abdulaev and Shomron 2020; Baker et al. 1992; Matobobo and Bankole 2021; Ruijs et al. 2013). In an anti-tobacco campaign by the ‘Truth Initiative’, and in messaging around HIV prevention, the use of celebrities such as Lady Gaga, Rihanna and Magic Johnson to call attention to public health issues has had documented success (Baker et al. 1992; Kostygina et al. 2020).

In Malawi, commercial firms, non-government organisations and other social marketing agents have used celebrities as brand ambassadors. Examples include UNICEF Malawi’s use of a popular hip-hop artist, Penjani Kalua, to champion children’s rights in 2018. The 2014 Moyo ndi MpambaFootnote 2 (Life is Precious!) campaign in Malawi also used several celebrity musicians to disseminate an array of health messages through their music; the brand still resonates with audiences and continues to underpin various MOH campaigns to date. The popularity and influence of celebrities can thus serve as an entry point to reach followers with factual health communication messages. Social media has provided celebrities with a platform to amplify their influence as the content can be received by many individuals simultaneously (Abdulaev and Shomron 2020).

Religious leaders are also important influencers, as religion plays a significant role in influencing beliefs and behaviours. In Malawi, the response to the HIV pandemic included strategic engagements with religious bodies in coordination and facilitation of faith-based responses, which gave birth to umbrella bodies such as the Malawi Interfaith AIDS Association. In a study that examined the relationship between religion and HIV risk behaviours in rural Malawi, engagement of religious leaders in disseminating health messages was influential for the AIDS-related behaviours of their members (Trinitapoli 2009). Religious leaders are gatekeepers and respected members of the community in Malawi and are well positioned to enhance health promotion and influence behaviour change.

To counteract the infodemic, Breakthrough ACTION supported the Malawi MOH in rolling out a social media campaign to provide correct information, working through celebrities and religious leaders.

The Intervention

As part of the Osayidelera COVID-19 campaign, Breakthrough ACTION, in partnership with the Malawi MOH RCCE subcommittee and media agency Applied Development Communication and Training Services (ADECOTS), commenced social media engagement on WhatsApp and Facebook platforms in September 2021. The project introduced the social media component in cohesion with other social and behaviour change (SBC) approaches to provide messages that address rumours contributing to COVID-19 vaccine hesitancy. This section focuses on how we designed and implemented the intervention and outlines some of the key outcomes and lessons learnt from the interventions. The social media component of the Osayidelera COVID-19 campaign included several phases, as described below.

Identification of Celebrities and Religious Leaders

We selected 11 celebrities based on an assessment and ranking of the celebrities’ popularity, reach, influence, history of active involvement in health campaigns and willingness to take part in the engagement. For the purposes of this chapter, celebrities included musicians, comedians, poets, activists and social commentators. The project selected prominent religious leaders from existing networks of two national coordinating faith bodies: the Public Affairs Committee and the Malawi Interfaith AIDS Association. The selection criteria were based on active participation within the networks.

Orientation

Orientation involved the MOH working with celebrities and religious leaders to strengthen their capacity to understand and share correct messages on COVID-19 prevention measures and vaccines through a series of workshops. The workshop facilitators included MOH staff from the Health Education Services, which is the mandated lead for health SBC in Malawi, the Community Health Services Section and Breakthrough ACTION staff. Eleven celebrities and 144 Christian and Muslim leaders (high-ranking leaders, including women, and youth leaders) were trained through presentations and plenary sessions.

The workshop objectives were to:

  • provide correct information on COVID-19 prevention measures and COVID-19 vaccines;

  • highlight and discuss the influential role of celebrities and religious leaders in reducing vaccine hesitancy;

  • demonstrate the need to promote vaccine uptake;

  • set the agenda for celebrities’ and religious leaders’ interaction with audiences; and

  • discuss the role of celebrities and religious leaders in documenting rumours through their pages.

Positioning of Messages

We premised positioning of the messages by celebrities and religious leaders on a comprehensive creative brief developed by various stakeholders, led by the Ministry of Health’s Health Education Section (MOH-HES), with support from Breakthrough ACTION in August 2021. The creative brief identified specific problems related to the COVID-19 vaccine that could be addressed through a communication campaign, identifying barriers and facilitators of the intended behaviours/desired behaviours, development of overarching messages and identification of preferred channels of communication. We developed a message matrix based on the creative brief presented to celebrities and religious leaders during the orientation.

The Campaign

In consultation with Malawi’s MOH, on a weekly basis, we provided key focus areas and messages to the celebrities based on the message matrix and emerging issues. Breakthrough ACTION encouraged celebrities to craft messages to suit their individual styles of engaging audiences. For example, a celebrity soccer commentator, Robert Chiwamba, talks about soccer on his social media pages and integrates the vaccine messages into his soccer commentary to his followers so they can easily relate to the message (Fig. 19.1

Fig. 19.1
A tweet from Robert Chiwamba has a text in a foreign language. On the right, the text begins with, as we are waiting to lose to the soccer team of the blue, here is an important message. The COVID-19 Pfizer vaccine available and being administrated to those that are 12 years of age and above.

Excerpt from Robert Chiwamba’s social media

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).

Celebrities with wide reach and influence were engaged to share correct messages on the benefits of COVID-19 vaccines to address rumours and misinformation. The celebrities frequently sought technical guidance from health education specialists and Breakthrough ACTION staff before responding to the rumours and questions that came through their pages.

Support for Celebrities and Religious Leaders

We provided celebrities and religious leaders with ongoing technical support, which included data bundles to facilitate posting, sample messages and materials for posting, including video clips and digital posters featuring religious leaders, job aids and regular check-in meetings.

Celebrities and religious leaders were provided with COVID-19 messages, including frequently asked questions and factsheets as a source of standardised information on COVID-19 and COVID-19 vaccines. The religious leaders shared correct messages with their congregants and community members through WhatsApp groups and other social media platforms, and interpersonal communication during routine religious gatherings. WhatsApp groups included the religious leaders who had been oriented on the project, Health Education specialists and Breakthrough ACTION staff to strengthen two-way communication for sharing daily MOH COVID-19 updates such as new infections, hospital admissions, deaths, vaccination status and mass media print, audio and audio-visual materials for onward sharing through the religious leaders’ social media platforms. In turn, the religious leaders used the same groups to share new rumours from the communities that needed addressing.

Celebrities and religious leaders came together periodically during review meetings to discuss successes and challenges. During one of the review meetings, the celebrities reported receiving many technical questions and religion-oriented comments, which they felt ill-equipped to respond to. To resolve this, Breakthrough ACTION engaged health promotion specialists from the Malawi MOH/HES and youth religious leaders to support celebrities in responding to both highly technical and religious questions. The choice to link youth religious leaders to celebrity Facebook pages was strategic because younger leaders were more frequent users of Facebook.

Data Collection and Analysis

Lessons learnt were drawn from observations and celebrity self-reports during review meetings, as well as audience reactions and comments to celebrity and religious leaders’ posts on Facebook. Seven out of the 11 celebrity pages between March and April 2022 were sampled. A total of 125 comments that were classified as ‘most relevant’ were analysed to represent audience responses to celebrity COVID-19 prevention and vaccine posts on Facebook. A web-based data collection form was created to capture celebrity messages and audience responses. A simple analysis of the comments was conducted using Microsoft Excel categorised into seven thematic areas related to the COVID-19 vaccines. These themes were established through an inductive coding process. Table 19.1 provides the definitions of each thematic area.

Table 19.1 Thematic descriptions from Facebook posts
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Lessons Learnt Through Implementation

We collected the following outcomes through observations of interactions with the celebrities and religious leaders through review meetings, as well as audience reactions to and comments on celebrity and religious leaders’ posts on Facebook and WhatsApp. This section highlights key outcomes and lessons learnt from the intervention.

Reach of Messages Shared by Celebrities and Religious Leaders

The celebrity posts reached millions of people with COVID-19 preventive measures and vaccine messages. Within the first three months of the campaign, the celebrities posted 176 Facebook COVID-19 vaccine messages, reaching approximately five million Malawians. Campaign staff observed differences in levels of reach and engagements for the different types of celebrity posts noted above. Individualised celebrity messages tended to reach the most followers and attracted more engagements, followed by celebrity posters and then opinion leader short videos. However, celebrities reported that the opinion leaders’ short videos did not resonate with their followers because the videos did not feature the celebrities themselves. As one participating celebrity commented, ‘Our followers are interested in our lives and our actions, so featuring other people does not pull audiences.’ The celebrities added that the videos and the celebrity posters, which featured donor and partner branding logos, contributed to audience mistrust.

When asked what they thought would attract increased reach, engagements and audience reactions, the celebrities suggested removing logos from materials and having action-oriented posters that depict the celebrities role modelling the recommended COVID-19 prevention behaviours themselves and their family members getting vaccinated.

Campaign staff primarily used WhatsApp to disseminate COVID-19 messages to the religious leaders. These leaders then forwarded the messages to their respective audiences through various individual WhatsApp groups and religious gatherings. We determined the reach of these messages from monthly reports compiled by religious leaders, representing a combination of face-to-face gatherings and messages disseminated through WhatsApp. Cumulatively, religious leaders reached approximately 43,668 people; however, the reporting templates did not disaggregate approximate reach through WhatsApp alone. Data verification was difficult since the religious leaders come from separate locations, so conducting quality data checks became difficult logistically.

Behavioural Change Among Celebrities and Religious Leaders

Several celebrities and religious leaders self-reported through reports and other project activities that the orientation increased their knowledge and self-efficacy to practise COVID-19 preventive measures and personally accept COVID-19 vaccines. They also reported feeling more confident and empowered to post messages and interact with their audiences on COVID-19 vaccines. For example, a religious leader said in the post-orientation interview: ‘The training was an eye-opener. Since then, I have addressed my fellow women during our meetings, and most of them have been convinced and gone for the vaccine.’

Many testimonials received from religious leaders involved in the campaign point to capacity strengthening as a key component to changing individual attitudes and perceptions as well as empowering them to promote positive behaviours among other community members. A youth religious leader pointed out through the WhatsApp coordination group forum that, due to the orientation sessions, they now understood COVID-19 and vaccines, but they also mentioned that other religious leaders did not, resulting in those leaders providing misleading information and discouraging their congregations from getting vaccinated. This underscored both the need for a strategy to reach out and orient more religious leaders and the challenges posed when rumours are shared by people in positions of trust.

Through the WhatsApp coordination groups, religious leaders shared their progress in promoting vaccine uptake within their religious communities. Within two months of the orientation, one of the youth religious leaders reported reaching 1200 youth with COVID-19 vaccine messages. Upon follow-up with individuals reached, as well as with those who self-reported, more than one-half of them were indeed vaccinated. A youth leader reported that during his interaction with fellow youth, their reluctance to be vaccinated was evident due to the lack of correct information; however, when given the correct information, young people demonstrated willingness to access COVID-19 vaccines.

Celebrities also reported feeling more confident to post COVID-19 prevention and vaccine messages after the orientations. Despite the backlash received, several celebrities said they were continuing to be part of the intervention because they saw it as their social responsibility to disseminate correct information on COVID-19 prevention and vaccines.

Involvement of Health Promotion Specialists

Health promotion specialists were helpful in supporting the celebrities and religious leaders and received many technical questions, especially in the first three months of the intervention. Questions mainly focused on the efficacy of COVID-19 vaccines, manufacturers of the different vaccines, whether mixing types of vaccines harmed or enhanced immune response, and the logistics of accessing the vaccines. However, from the fourth month of implementation, celebrities forwarded fewer questions to the specialists, and those they sent often focused on availability of and access to the vaccines. This was because celebrities had become more conversant with technical information of the COVID-19 vaccines and more confident in responding to their audiences.

Lessons Learnt from Audience Responses in Terms of How They Received the Intervention

Most audience responses were negative (80 per cent), mostly towards the intervention itself (59 per cent), towards the vaccine (20 per cent) and towards both the intervention and vaccines (16 per cent). The negative responses were predominantly under the following thematic categories: religious, traditional and cultural factors (24 per cent); trust, norms and role modelling (20 per cent); and other negative feedback (13 per cent). The positive responses came up to 20 per cent, half of which were under trust, norms and role modelling (10 per cent). This section provides the audience responses under the dominant themes established from the data analysis of celebrity Facebook posts (Fig. 19.2).

Fig. 19.2
A 3-D pie chart presents the data in percentages. Purpose or authorization, 6. Religious or traditional, 24. Characteristics or efficacy or benefits or comparisons, 10. Distribution or eligibility or access, 10. Trust and norms and role modeling, 30. Other comments, 14. Side effects or outcomes, 6.

Coded comments under the stated thematic areas illustrated in percentages

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Religious, Traditional and Cultural Factors

All the comments under this theme were negative and mostly oriented towards religion with suggestions that the acceptance of COVID-19 vaccines was indicative of a lack of faith in God and that God, rather than vaccines, was the protection people needed:

We don’t need vaccines to be protected, we need God.

The great physician is God.

There was also a strong perceived association between the vaccine and Satanism:

COVID-19 vaccine is the beginning of 666 only that people don’t know yet.

Religious leaders featured in posters and short videos faced similar backlash. They were accused of not having enough faith:

Pastor, where is your faith? We are in the last days and can see the fake pastors.

What kind of pastor advocates for COVID-19 vaccine?

Trust, Norms and Role Modelling

Many comments showed mistrust in the celebrities and religious leaders, with several accusing them of receiving monetary benefits from the government and international organisations:

In Malawi, when someone starts talking about this, it is because they have been paid to do it.

Has the president given you money to be discussing this COVID-19 vaccine nonsense?

When the celebrities shared posters and videos of well-known religious leaders delivering the campaign messaging, audience members also accused the religious leaders of receiving money:

I don’t trust Bill Gates. I don’t trust celebrities. I don’t trust sheikhs. I don’t trust these vaccines. I don’t trust you.

Sheikhs in Malawi have stopped fearing Allah and are more concerned about money.

There were others who voiced their appreciation and admiration of the celebrity’s artistry but cautioned them for accepting money and threatened to stop following them if they continued talking about COVID-19 vaccines on their pages. We also observed that some audiences followed more than one of the 11 celebrities and were able to point out similarities among the different celebrity posts, which was interpreted as proof that they had been recruited and were paid to post COVID-19 messages.

The positive responses positioned the celebrities as role models and praised them for sharing COVID-19 messages:

Messages like this are messages that people need to hear from people like you. Guys get vaccinated, be smart, be safe.

I got vaccinated already, I got both doses of AstraZeneca and J&J as a booster. I am doing what you are advising.

Characteristics, Efficacy, Benefits or Comparison

There were comments that questioned the efficacy of COVID-19 vaccines. Some audiences claimed that the vaccines and booster doses did not work because those vaccinated were still getting sick with COVID-19. Audiences also did not understand why people were expected to continue observing prevention measures even if vaccinated.

There is no benefit at all in getting the vaccine since people have to still wear masks, wash their hands and keep distance.

All these boosters and second doses are there to only show that this is not working.

Other Feedback

Here we refer to other feedback including other themes not mentioned above.

There were doubts about the purpose of the COVID-19 vaccines, with claims that the vaccine was developed to depopulate Africans. Other comments reflected concerns that COVID-19 vaccines weakened the immune system rather than strengthening it. Some claimed that the vaccine would cause impotence or impact sexual function.

COVID-19 vaccine affects the human reproductive system thereby making men and women unable to bear children.

These vaccines are not working, yet here you are encouraging people to get vaccinated.

There were several questions around eligibility, particularly for the Pfizer vaccine being administered to children as young as 12 years of age as well as changes from only one J&J dose to two. Others questioned the authority and expertise of celebrities in talking about COVID-19 vaccines:

My fellow Malawians, we should not be influenced by these what we call icons of the nation or famous people. Their lives are not ours; moreover, they have no idea or knowledge of what is involved in developing a drug and a vaccine. Most of them don’t know what a clinical trial is but if they had known or studied, they wouldn’t be here posting this. In fact, ask them questions about the vaccine, they wouldn’t know what to answer, they are just being used as a tool of influence.

You are not a medical person so stop talking about COVID-19 vaccines.

Key Observations and Recommendations

The approach of using celebrities to disseminate COVID-19 prevention and vaccine messages through social media reached many people. However, based on the audience response, the celebrity influence in this instance was limited. Celebrities were accused of being money hungry and satanic, and faced the risk of losing their followers, resulting in a few celebrities dropping out in the first three months of the intervention. Celebrities who continued with the intervention and newly recruited celebrities reported viewing the intervention as their social responsibility. Despite their commitment, many comments were left unanswered, creating room for further spread of rumours and misinformation as well as the loss of potential clients willing to get vaccinated had their questions been answered. Self-reported reasons for not consistently responding to audience comments included limited time to review all the comments and questions due to their busy schedules, and avoiding conflict with audiences. Health promotion specialists and religious leaders who were engaged to support responses to technical and religious-based comments also cited similar challenges. To mitigate this, investment in personnel with the specific role of managing and facilitating responses would potentially address this gap. Also, sociodemographic factors such as age, gender and local context should be carefully considered in selecting celebrity influencers for public health social media campaigns.

According to social influence theory, behaviour is influenced by information, observation and social norms (Kaplan and Miller 1987; Wood 2000). Additional emphasis could be placed on showing examples of how to role-model (such as pictures of the celebrities quarantining at home) to adapt social norms.

Training the celebrities and religious leaders equipped them with correct information on COVID-19 prevention measures and vaccines and even influenced the celebrities’ own behaviours; however, they needed additional training in persuasive health communication. Additionally, the intervention workshops trained celebrities to use correct information from the creative briefs and encouraged them to use these messages creatively to give the post an authentic and story-driven voice.

More careful consideration needs to be placed on how the intervention sequences topics and messages among the celebrities, as the audience could pick out similarities between the posts, as such perceiving the celebrities to be part of a campaign driven by international donors whose agenda was not to be trusted. Additionally, audiences questioned the technical authority of celebrities in providing COVID-19 vaccine messages, suggesting that a more visible presence and voice of health promotion experts is required.

Religious leaders did not report receiving backlash on WhatsApp posts. This could be due to the intrinsic differences between WhatsApp and Facebook in terms of their use and experience. Such differences include WhatsApp being a more intimate form of communication and more controlled than Facebook, where one can express opinions more freely (Karapanos et al. 2016) and posts are made by people who are followers but strangers. However, as indicated above, a more robust system is needed for data capture and verification to better understand these engagements.

Conclusion

Overall, this intervention demonstrated both the potential and limitations of utilising celebrities and religious leaders in COVID-19 messaging on social media. The use of social media, particularly Facebook engagements, provided an opportunity to reach large groups of people, document people’s perceptions and counteract rumours related to COVID-19 and its related vaccines; however, many challenges existed with this approach. While the orientations were effective in equipping celebrities and religious leaders with correct information, additional training was needed in persuasive health communication and adapting messages into creative and story-driven posts within their individual skill sets. Reactions to information posts were mixed, and celebrity social media videos or digital posters showing examples of appropriate behaviour for preventing transmission may be more effective; removing donor and government logos may promote authenticity. Additionally, investments in health promotion personnel are needed to intensify response rates to questions and rumours from audiences, to ensure posts and misinformation do not go unaddressed. Finally, a more robust data-reporting and verification system was needed to better capture sociodemographic characteristics, reactions and engagements, and changes in attitudes and perceptions of the audiences on both WhatsApp and Facebook. The lessons learnt from this intervention could be applied to projects or programmes in other sociocultural contexts to strengthen the impact of the COVID-19 SBC response.