Promoting COVID-19 Vaccine Acceptance through Community Engagement: An Ethnographic Study in Ghana

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Introduction
Vaccine hesitancy has increased steadily in over 90% of countries since 2014 [1], while it has been estimated that countries need at least 60 to 70% of the population to have immunity to really break the chain of transmission, as a measure to contain the SARS-CoV-2 virus, which is a highly transmissible virus [2].If allowed to occur naturally, herd immunity will occur over an extended period of time, during which the health and economies of countries will have sufered extensively [2].Terefore, to facilitate and attain the level of vaccination required to achieve early herd immunity, countries need to extensively engage citizens in order to build public trust, which could promote vaccine acceptance [3,4].Consequently, the WHO and other bodies have increasingly advocated for strong community engagement using available opportunities and creating more avenues to inform and prepare communities for acceptance of health interventions such as COVID-19 management as well as to promote vaccine acceptance [4][5][6][7].
Tere have been large-scale communication and engagement campaigns all over the world to raise awareness of the virus and its preventive measures.As of 1 st October 2020, 90% of countries reported having a national risk communication and community engagement (RCCE) plan.Tis indicates that the crucial role of RCCE is understood and prioritized by many countries [7].Ghana recorded its frst case of COVID-19 in March 2020 [8] and by 1 st September 2022, a cumulative fgure of 168,580 cases had been confrmed, with 167,080 recoveries and 1,459 deaths and 41 active cases [9].Since the advent of the virus, the government has instituted new structures, committees, advisory bodies, and lines of communication to promote COVID-19 vaccine acceptance and vaccination [8].Te government used the following strategies to engage the public on COVID-19 prevention, management, and vaccination: radio programmes, regular presidential address to the nation, and mass education.Four key government institutions that are mandated to carry out community engagement activities in Ghana are the Information Services Department (ISD) under the Ministry of Information [10], the National Commission for Civic Education (NCCE) (National Commission for Civic Education) [11], the district/municipal assemblies, and the Ghana Health Service (GHS).Te ISD is mandated to disseminate government policies, programmes, and activities to the general public [10].Te NCCE was created to sustain societal awareness of the principles and objectives of the 1992 fourth Republican Constitution of Ghana, as the fundamental law of the people of Ghana (National Commission for Civic Education) [11].Te district or municipal assemblies were established to deepen decentralized governance and improve access to services at the district or municipal level [12].Te GHS, which is the health service delivery arm of the Ministry of Health, provides a majority of health services to the general public in Ghana [13].
Ghana was the frst African country to receive 600,000 COVAX vaccines from the COVAX Facility in February 2021 as part of an initial tranche of deliveries of the AstraZeneca/Oxford vaccine licensed to the Serum Institute of India [14].Te vaccines were administered among key public fgures including the Ghanaian president and vice president, chiefs, religious leaders, and essential workers (health workers and security personnel, among others) [15].Tis strategy was aimed at promoting public acceptance of vaccination and also to ensure that essential workers were protected to promote the delivery of essential services.
Ghana's target is to vaccinate 22.9 million people and by 1 st September 2022, only 36.1% (8,251,886) of the target population were fully vaccinated, while 49.8% (11,371,567) had received at least one vaccine dose [9].Te situation is direr in the Volta Region of Ghana, which registered the lowest rate of vaccine uptake of 18.2% as of the stated data.Te country leveraged on the experience of its successful existing EPI vaccination programme such as the National Polio Immunization Day to establish a National COVID-19 Immunization Day [16].Te success of previous immunization programmes has been largely due to efective community engagement and risk communication programmes, so the COVID-19 programme adopted this strategy.Te approach contributed to successfully administering 14,944,182 doses of COVID-19 vaccine as of 10 th May 2022 [16].
It has been reported that the vaccination momentum is subsiding in some parts of Ghana and the rest of the African continent [17].A study in Ghana noted that 40.7% of radiologists, who were prioritized in the administration of the frst consignment of vaccines, were unwilling to vaccinate [15].Botwe et al. [15] noted that the reasons accounting for vaccine hesitancy include clinical safety concerns, lack of education or information, and religious beliefs among some that God will protect them, so they do not need to be vaccinated.A national survey of the sixteen regions of Ghana reported that about half (51%) of mostly urban adult Ghanaians over the age of 15 years were likely to take the COVID-19 vaccine, if made generally available [18].Te North East Region recorded the highest vaccine acceptance (65.10%), while the Volta Region recorded the lowest vaccine acceptance (32.50%) [18].Te high vaccine hesitancy in the Volta Region has created the urgent need to intensify and prolong community engagement.Yet, currently, there is no information on how the government institutions such as the Ghana Health Service, the district/municipal assemblies, the National Commission for Civic Education, and the Information Services Department are engaging communities in order to achieve the national goal.Tis qualitative study contributes to the literature by exploring and describing how government institutions engaged communities to facilitate vaccine acceptance and uptake in the Volta Region of Ghana.Te fndings will help to inform policy and intervention eforts.
1.1.Community Engagement Defned.Tis study adopted community engagement as has been defned by the World Health Organization as ". ..developing relationships that enable stakeholders to work together to address health-related issues and promote well-being to achieve positive health impact and outcomes" [19].Te World Health Organization's [19] defnition presents three main components, which are actors/stakeholders, developing the process, and purpose of engagement.Stakeholders are perceived as different parties that have an interest in the process, which comprises multiple communities that could include community members, patients, health professionals, policymakers, and other sectors [20].Te process suggests that the 2 Advances in Public Health diferent stakeholders strive to create a relationship that is based on respect, trust, and a sense of purpose [19].Te current study adopted the WHO's defnition of community engagement to expore how government entities engaged communities in two Ghanaian municipalities in the management of COVID-19 and vaccine acceptance.Te Ghana Health Service operates a decentralized administrative system with ofces at the national, regional, municipal levels, sub-district ofces, hospitals, health centres, and community-based health planning and service (CHPS) facilities in each region (Ghana Statistical Service [22].To ensure that the study was refective of the diferent levels of health service delivery, a multi-stage random sampling technique was used to select a sub-municipality, and a CHPS facility was selected for the study.In the frst stage, the names of all the sub-municipal health directorates in each study municipality were obtained from the respective municipal health directorates.Tey were written on pieces of paper, which were folded and an observer was invited to select one sub-municipality for the study.In the second stage, all CHPS compounds under the selected sub-municipality were written on pieces of paper, which were folded and the observer randomly picked one.To ensure that community experiences were also captured in the study, a third stage was included, which included writing down the names of communities under each selected CHPS facility and folding it, and one was randomly selected to participate in the study.

Selection of Study Participants and Sampling.
From each of the study sites, one municipal health service manager, one sub-municipal health manager, two health providers from the selected CHPS facility, one ofcial from the municipal assembly, NCCE, and ISD, respectively, and some of the community elders were purposively sampled to participate in IDIs (Table 1).A cross section of women, men, and migrants from diferent age groups who were available and willing to participate in the study was conveniently sampled to participate in FGDs consisting of 6 to 13 participants.Te interviews sought to understand how the municipal assembly, GHS, NCCE, and ISD engaged communities towards the COVID-19 vaccination rollout and uptake.Saturation was attained when no new information was obtained from study participants, which is in accordance with qualitative enquiry [23].
Participation was voluntary, and those who were not interested were automatically excluded, as well as those who were mentally challenged.
Te three components of the WHO's defnition of community engagement (categories of stakeholders, processes used to engage communities, and the purpose of the engagement) were used to guide the selection of the stakeholders, design the IDI and FGD guides, and determine the focus of the study, which was on COVID-19 interventions.Tis manuscript is drafted from a larger study, and the other aspects of the study have been reported in an upcoming paper.

Training of Data
Collectors and Quality Control.Four graduate data collectors were trained by the frst author, MA, a medical and organizational anthropologist, on qualitative data collection methods including interviewing and writing feld notes and also seeking informed consent, which equipped them with the needed skills for data collection.Te IDI and FGD guides for community members were translated into the native language Ewe during the training, and research assistants were trained in English and the local language.
To ensure rigour, the study guides were pretested among eligible participants from a municipality similar to the municipalities selected for the study.Te pretesting process also guided in the revision of the guides to ensure its validity and reliability.

Data Collection, Management, and Analysis.
In-person interviews were conducted in English with the government ofcials and in Ewe with the community members.Migrants were interviewed in French, as majority of them are from Togo and cannot speak English nor Ewe.Interviews were recorded using a digital audio recorder and later transcribed verbatim to preserve respondents' views and experiences.Te average duration of IDIs was 50 minutes, and that of FGDs was one hour.Meetings were held between MA and the data collectors every week to ensure trustworthiness of data.
Transcribed data (IDIs and FGDs) were uploaded onto a computer and transferred onto a qualitative software NVivo 12, to support data coding.Te data were triangulated and analysed thematically, which formed the basis for reporting study results.Tis article reports on how government institutions conducted engagement activities in the two study municipalities, challenges, gaps, and future plans.Other aspects of the study have been reported in a forthcoming paper.

Results
Te study used the WHO defnition of community engagement to understand how government institutions engaged communities in the two study municipalities.Te study found that government institutions engaged communities through public educational programmes and radio talk shows.Tey held meetings with chiefs and community elders, opinion leaders, and religious bodies.Tey also held community durbars with a cross section of community members.Another approach utilized was to meet pressure groups and occupational groups such as drivers' unions and traders' associations to educate them and encourage them to get vaccinated.Health ofcials also used routine programmes such as Child Welfare, Antenatal, and Postnatal clinics and Reproductive and Child Welfare clinics as platforms to educate community members about COVID-19 vaccines and the vaccination process.Such initiatives contributed to the acceptance of vaccines and helped to prepare some communities towards the vaccine rollout.

How Government Institutions Engaged Communities in the Vaccine Rollout. Te health directorate of Municipality
A reported that they engaged the communities through radio discussions focusing on vaccines and their benefts.Tey also used the community centres (most communities have specially designed places within the community installed with communication equipment for important announcements) to announce COVID-19 activities and to educate community members.Te community members accepted the message and were willing to take the vaccine.Tis helped to reduce vaccine hesitancy among the community members.A health manager stated: Municipality B health directorate reported that it had engaged the various communities within its catchment area by holding community durbars (open air meetings) with chiefs and community members (in spite of the existence of COVID-19, which discouraged large gatherings).Tey informed the community of the COVID-19 vaccine availability and benefts.So, the chiefs agreed, took the frst dose, and several of the community members also took the dose.
". . .we used the radio stations to propagate information about the vaccine, and we also did community engagements such as organizing durbars even though we are in COVID-19 era.We met the chiefs.We gathered about fve chiefs together and told them the vaccine was available and we needed to take it to help prevent the disease and they agreed to it and came out to have the frst dose" (Health manager, Municipality B).Municipality B's Information Services Department reported that it had engaged and educated communities within the municipality.Tis had resulted in the acceptance of the vaccine and the communities were waiting to take the vaccine, whenever it was made available."For us, we have educated them about the vaccine.So, what they are waiting for is for the vaccine to come, so that they will go and take it" (ISD ofcial, Municipality B).

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Te Municipality B CHPS facility reported sensitizing the community members within its catchment area through community durbars, prior to the arrival of the frst vaccine into the country.Tey also used routine healthcare programmes such as child welfare clinic (CWC), antenatal care (ANC), and reproductive and child health (RCH), to educate clients on the vaccine.A nurse explained: "We educated our community members (on COVID-19 vaccines), especially those who came for community durbars and CWC, ANC, and RCH 2.2.How Government Institutions Addressed Myths, Misconceptions, Misinformation, and Rumours.All government ofcials interviewed in the two municipalities reported that there were myths, misconceptions, and misinformation in the communities about COVID-19 vaccines.Some of the community members believed that the vaccine was manufactured to kill Africans; others believed that it is intended to cause sterility in African men and infertility in women in order to reduce the African population and wipe out the current generation of Africans, so that western countries can take Africa's natural resources.Other misconceptions were the vaccine will shorten the lives of those who will be vaccinated and the belief that COVID-19 vaccines are a new sort of 666 mark (666 mark refers to the mark of the devil) on those who get vaccinated.Tus, some refused to take the vaccine; others delayed in taking it and were waiting for others to get vaccinated frst and if nothing happened to them, then they will get vaccinated.
One strategy that was adopted by the government ofcials was to take the COVID-19 vaccines in the full view of community members.Others flmed the process of taking the vaccine and showed it to others from nearby communities.Tey explained to the communities that since they are the frontline health workers and they know the vaccine is safe, they were the frst to take it.Ofcials from the district assembly reported that they allayed the fears of community members with regard to the myths and referred them to some of the staf of the GHS for information and education.Such initiatives helped to dispel fears and myths about the vaccine.
"From the information given to us by the health experts and government itself, we have to go to the feld telling them the truth and that if it were true that the vaccine is made to kill Africans, then government ofcials will not take it.Big men will not take it.So, they have to take it to protect themselves" (ISD ofcial, Municipality B).

"When I took my jab, I had to make a video and show it to the elders to show that I myself have taken my jab" (Health worker, Municipality A CHPS facility).
"Some people who had fears and came to me in this ofce that they heard that if they take the vaccine, their manhood would not work.I allayed their fears and again, and I referred them to the Municipal Director [of health] to talk to them" (Municipality B Assembly ofcial).
Another strategy adopted by health workers in CHPS facilities in both municipalities in dealing with misinformation was to hold meetings with community elders including chiefs and queen mothers to refute misinformation.Tey also took advantage of routine health programmes such as child welfare clinics (CWCs) to educate parents who brought their children for CWCs.Tey countered false information by comparing the vaccine to the existing childhood vaccines such as polio and measles among others given to children under fve years, which are more widely known and accepted in Ghana.Tey also compared the COVID-19 vaccines to the history of successful childhood vaccination programmes in Ghana in order to assure adults that it was safe.Tey refuted misconceptions about COVID-19 to community members by educating them on the importance of the vaccine and vaccination.Also, health workers who had taken the vaccine took videos of the process, which they showed to their clients in order to allay their fears and to build trust.". . .We also showed them our cards, which showed that we have also been vaccinated and that anytime the vaccine comes, they should champion their members to take it up" (Health manager, Municipality B).

"We frst engaged the opinion leaders and gave them education. Vaccines that are coming are just like vaccines given to children. So, during CWC, we compare what has been given to us [COVID-19 vaccines] and what has been given
to children [vaccines for under fve-year-old].We hold the bottles and show them the origin of the vaccine.So, if India is giving this to your children and you accept it, then it should be easy for you to accept what is going to be given to you, as you are even mature and you can withstand some of the things.So when I took my jab, I took a video and showed it to the elders" (Health ofcial, Municipality A CHPS facility).

Challenges and Gaps in Government-Community
Engagement.Interactions with the government ofcials revealed that some community members continued to have reservations about COVID-19 vaccines and were unwilling to take it, despite the government institutions having provided information.
Te NCCE ofcials in the two municipalities attributed vaccine hesitancy to late initiation of community education due to having to wait for directives from their superiors before they could embark on community education.Another crucial challenge was that the agency lacked logistics such as vehicles and funds from the central government to carry out engagement activities.
Te GHS, which carried out more engagement activities in comparison to the other government entities, reported vaccine stockouts at the onset of the vaccination exercise as an obstacle to their engagement process.Health ofcials in Municipality A and ofcials from Municipality A assembly reported that they had informed and prepared communities for the frst consignment of vaccines, unknowing that it was meant for government leaders, essential workers, the aged, and persons with underlying health conditions.As a result, community members were disappointed.Te Municipality A health directorate on the other hand reported that it Advances in Public Health engaged only essential workers such as health workers and the security services because the initial vaccines were meant for them.
"We did a lot of work, so by the time we started, people were ready to take it.When some even got to know that the frst dose was only for health workers, they were not too happy" (Health manager, Municipality A). ". . . the frst batch that came was for targeted institutions, the health personnel, and the security.So, the frst engagement was directed towards those institutions.So, the health personnel, security, and banks were engaged before the vaccine was rolled out.But for the general public, no such engagement has been done yet" (Municipality A assembly ofcial).
Te unavailability of the second dosage of the COVID-19 vaccine after the community had accepted the frst dose was another challenge experienced by the Municipality B health directorate during the community engagement on the vaccine.Te district directorate reported that the second dosage had delayed, but they had remained in contact with the communities, and currently, the chiefs who took the frst dose are making calls to the directorate for the second dosage of the vaccination.
"We met the chiefs . ..and they agreed to it and came out to have the frst dose.Tey are even worrying me about the second dose.Some of the chiefs keep calling me every now and then.Te interval between the frst dose and now is over twelve weeks.We told them from the onset that twelve weeks is the longest period to receive. . . the second dose and they were calculating it themselves and started calling me when it was twelve weeks.Tey keep calling me every now and then to ask about the second dose" (Health manager, Municipality B).
Te ISD in Municipality B indicated that it had informed and educated communities in the Municipality B township, which is the municipal capital, but they were yet to develop a plan to engage the various communities outside the municipal capital, due to the unavailability of vehicles.Te Municipality B ISD equally reported that they had been trained in disseminating information on the vaccine; however, they lacked a vehicle to carry out community engagement activities.An interview with an ISD staf revealed the following.
ISD ofcial: We were trained.We had a workshop on the vaccines.But for the vaccines, we have not been able to go to the communities.We mostly do that in Municipality A itself [only carried out in the capital of the municipality].
Interviewer: Why not the other communities?ISD ofcial: "It is our information van because that is our biggest tool.You know, our work is not an ofce work.We need to be on the feld 24/7 giving information to the public on all aspects of government information.But our main challenge is information van, they are all broken down. . . .

if we have at least the information van, we can go to the community for at least education. ... But our main challenge, especially during this COVID is our van" (ISD offcial, Municipality B).
Te NCCE ofces in the two municipalities reported that they are not well-resourced, so they experienced fnancial challenges, such as inadequate funding, vehicles, and fuel to visit the various communities within their catchment area on a regular basis.Te NCCE ofces in Municipality A reported that community members expected them to visit the communities frequently.Municipality B ofce added that the community members expected them to provide them with COVID-19 protective materials such as nose masks and sanitizers, which they lacked.Municipality A NCCE rated their community engagement performance as bad because the lack of resources contributed to the delay in community engagement towards the vaccination rollout.Tey attributed the proliferation of misinformation such as the belief that the vaccine is meant to kill Africans and community refusal to take the vaccine was due to their inability to provide information and education early.

"We did our best here in Municipality A, but if I want to rate our performance in engaging with communities on vaccines, it is not good because we should have started this education earlier, before the vaccine came. But because the resources are not available, we were not able to carry out any serious public education before the vaccine came in. So, it created a lot of problems. If you listen to radio, you would hear people saying they would not take the vaccine because it is a plan by the western world to kill Africans and they'll never take it and they are urging the public never to get vaccinated" (NCCE ofcial, Municipality A).
Another gap identifed by Municipality B health directorate was community members' consistent demand for snacks and transportation because they believed the directorate was fully resourced by the government.However, the directorate did not have the fnancial resources to fund such demands.So, the directorate began to experience low turnout whenever they called for community engagement on the COVID-19 vaccine.Municipality B municipal health directorate also reported that community members demanded items such as nose masks and sanitizers from them whenever they visit the communities to carry out educational activities.Tey indicated that since they do not have funds to purchase such items, they were unable to visit the communities frequently.Municipality B, which shares boundaries with Togo reported that they faced a challenge in carrying out community engagement in migrant communities.Te migrant community is made up of persons from Togo and Nigeria, among others, some of who come from diferent religious backgrounds such as Christianity and Islam.Te cultural diferences among the migrants and the Ghanaian ofcials and language barrier contributed to the difculty in the engagement process.". . . the cultural diference is one of the big gaps.You know, it is a mixed breed of Muslims, Nigerians, and a whole lot of people who have inhabited the border community. ...It is difcult to actually convince them because of their cultural diferences. .., language is also another gap"(Health manager, Municipality B).

Community Experiences in Government Engagement
Process on Vaccination.IDIs with community leaders and FGDs with community members in Municipality A and B revealed that government ofcials had provided them with information and had been educated on COVID-19 prevention, management, and the need to take COVID-19 vaccines.Tey reported that most of the information that they received was from health professionals at the CHPS facilities.Majority of the study participants noted that the health workers provided them with information and education on COVID-19 but made little efort to promote other components of community engagement such as planning, collaborating, consulting, and empowering the community members to deal with COVID-19.Study participants further reported that another important source of information to them was the traditional media such as the radio.Migrants reported that announcements were made through the radio and the information van; however, it was in the native language of the area, which is Ewe, which they did not understand, so they were not well informed on COVID-19 issues.Community members further attested that they believed in information provided through the radio and believed that that was the truth.About half of the community members confrmed that they believed in the misconceptions and rumours that were spreading and that the vaccine was not right and indicated that they were not willing to take the vaccine.Others also reported that those who had taken the vaccine had become ill, so they were afraid to get vaccinated.

Government Institutions' Plans towards Engaging Communities with regard to COVID-19
Vaccines.Te study sought to fnd out the plans that the institutions had towards future community engagement eforts concerning vaccine acceptance in the two study municipalities.
Municipality B reported that based on the directive from the central government, they had included COVID-19 activities in the municipality's immediate and medium-term plans and they were partnering with the municipal health directorate to carry out community engagement activities.Te municipal assembly reported that previous engagement with migrant communities suggested that they did not have pipe-borne water to enable them to observe hand washing and other forms of hygiene, so as part of the plan they had started drilling a borehole in the migrant community.Municipality A assembly further indicated that the Public Health Emergency Management Committee (PHEMC) planned to engage community members in the municipality through existing community structures such as traditional leaders, traders, and drivers' associations.However, they are waiting for permission from the central government to start.
Municipality A health directorate indicated that they planned to continue education on COVID-19 to prepare the communities towards vaccination and to maintain community enthusiasm, as the vaccine was currently not available.However, Municipality A CHPS facility revealed that there was no plan to engage the communities towards the vaccine rollout in their catchment area."We will continue with the education and make sure the information gets down well and we will maintain their enthusiasm in how to be able to counteract some information that contributes to the hesitancy.So the education will continue until we make sure everybody gets the vaccine.Of course, the vaccine is not available, but we will do our part to make sure they are ready when it comes" (Health manager, Municipality A).
Municipality A sub-district health directorate reported that they did not intend to carry out education prior to the availability of vaccines.Tey planned to carry out education to communities once vaccines became available for the communities.Tey believed that constant announcement during such periods would facilitate acceptance and willingness to get vaccinated.A manager explained that his plan for Municipality B was that the health directorate will begin to announce to communities the importance of getting vaccinated, whenever the directorate received vaccines to vaccinate them.
Municipality B health directorate revealed that it had stopped its engagement activities because the community members who had the frst dose of the vaccine but not the second dose had started mounting pressure and demanding for the second dose, which was unavailable.Tey did not want to raise community members' expectation, since there was currently no vaccine to meet the demand.Tey added that once the health directorate receives doses of the vaccine, they will inform the communities to come for it.Similarly, Municipality B NCCE indicated that they started community engagement but had stopped, awaiting further instructions to proceed with the second phase of COVID-19 vaccination campaigns to the various communities.

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Municipality A NCCE reported that they had planned to continue carrying out community education; however, they were facing fnancial constraints.Tus, they were praying that they will get the needed funds to continue with the educational activities."Our plan is to continue education.We are praying to get the funds, so that we can continue" (NCCE Ofcial, Municipality A).
Municipality A ISD indicated that they had engaged and educated the various communities within the municipality; however, they were yet to draw an itinerary to carry out engagement activities in the communities outside the capital of Municipality A township "We have planned to draw an itinerary, so that we can also get outside Municipality A [the municipal capital].To tell them the benefts that they will derive when they take the vaccine" (ISD ofcial, Municipality A).Similarly, Municipality B CHPS facility revealed that they were yet to educate the communities about the safety and benefts of the COVID-19 vaccines.
Municipality A NCCE indicated that they intended to continue educating communities on vaccine acceptance, despite not having the needed funds.Consequently, they were considering an alternative plan of collaborating with the Ghana Health Service in the municipality to carry out community engagement activities.

Discussion
Tis qualitative research study used a focused ethnographic approach to explore how government institutions engaged communities to prepare them for COVID-19 vaccine acceptance and uptake.Te results suggest that all the government institutions carried out community engagement activities in the two municipalities.Te Ghana Health Service, which has a decentralized health system, was better positioned in terms of having more structures and opportunities to carry out community engagement at various levels of society compared to the other agencies (the municipal assembly, ISD, and NCCE) in vaccine preparedness.It is therefore not surprising that the community members identifed them as a key source of information and education.
Te government institutions used existing resources such as chiefs and elders, community information centres, and durbars as well as radio stations to engage communities on vaccine acceptance and uptake.Specifcally, in Municipality B, chiefs were encouraged to take the vaccine in public in order to build trust in communities to motivate them to access vaccination opportunities.Such measures contributed to some community members developing trust in the vaccination process leading to acceptance and willingness to take the vaccine.Te positive outcome suggests that when community trust in leadership and institutions is high, the fear of COVID-19 and vaccine hesitancy could lessen.However, when there is distrust of leaders and institutions, the fear of COVID-19 and vaccine hesitancy could be high [24].Similarly, Adhikari et al.'s [25] review of literature found that community structures such as existing organizations, physical infrastructure, and health service centres as well as human resources such as health workers boosted community engagement eforts in Asian and African countries.Also, other studies have noted that community trust in government institutions and health service delivery promotes the acceptance of healthcare interventions [3,26,27].Additionally, another study reported that trusted sources of information are crucial for community acceptance of vaccines [28].
Te study noted that the government institutions used an instrumental engagement approach, and they focused on informing communities on vaccines and vaccination with little input from the communities.Tey did not engage communities much in planning and empowering them to deal with COVID-19.Similarly, other studies on health and development interventions have noted that governments in other contexts tend to do more of instrumental engagement such as providing information to communities but do not engage them in planning and empowering them to participate in the engagement processes [29].Also, Afolabi and Ilesanmi [30] noted that community involvement was lacking in African governments' decision and implementation of COVID-19 interventions.Ojikutu et al. [31] suggested that eforts to end the pandemic through vaccination will be hampered because of an overemphasis on short-term strategies, such as community outreach, delayed community engagement, and absent investment in at-risk communities.
Government agencies especially the ISD and the NCCE faced challenges such as lack of funds and transport to travel to distant communities to carry out engagement activities; thus, they limited their engagement activities to the municipal capital and did not carry out engagement activities in distant communities, most of which are rural.Te GHS on the other hand was able to carry out engagement activities in both the capital of their municipalities and in distant rural communities.Tis is not surprising, since the GHS has a decentralized structure, with CHPS facilities situated in rural communities.Te concentration of community engagement activities in the capital towns starves rural communities of crucial information, which can hamper vaccine acceptance, as earlier surveys in Ghana suggest that rural communities and the uneducated were less likely to vaccinate [18,32].
Te GHS indicated that they had not received adequate doses of vaccines, yet they had aroused community interest in the vaccination and had successfully facilitated chiefs to take the AstraZeneca vaccine.Yet, they were not able to get the second dose to them in time, which had led to disappointment for some.Tus, some of the institutions had chosen to wait till vaccines were available before they resumed engagement eforts Similarly, a study in Somalia reported that challenges to the rollout of the vaccine included limited supply of vaccines, logistical and security challenges, lack of adequate awareness, and limited community mobilization and outreach services [33].Another study found that in the early stages of vaccine discovery, optimism around rapid vaccine delivery in some European countries turned to distrust among some people when vaccine delivery was delayed [34].Tus, it is important to Advances in Public Health manage expectation considering that new variants of COVID-19 are increasingly being identifed and campaigns for vaccine booster doses are being carried out [34].Similarly, Nachega et al. [6] reported that challenges in vaccine acquisition are not limited to Ghana, and the whole African continent is sufering from insufcient supply and distribution within countries.Some of the institutions admitted that delays in carrying out community engagement had resulted in communities depending on informal sources such as the radio, some of which had contributed to the spread of misinformation about COVID-19 vaccines, leading to vaccine hesitancy.Similarly, another study has reported that one of the factors accounting for public distrust in the COVID-19 outbreak response on the African continent is the delayed response by many African governments and public health experts [30].Also a study in France reported that earlier public health engagement with the French public on diseases, such as mumps and measles, helped them to build confdence in the French public health system, which made it easy for the public to accept COVID-19 vaccines [34].
Earlier studies in two other districts in Ghana equally revealed that misconceptions, myths, and lack of trust in the government's efort towards managing the pandemic contributed to poor attitudes towards COVID-19 prevention and management [35,36].Other studies have noted that the problem of COVID-19 vaccine hesitancy is not limited to the Ghanaian population but to African populations [37,38].Te hesitancy in COVID-19 vaccine uptake among African populations has been attributed to the history of colonial medical and vaccine research abuse in Africa and among persons of African origin.Recent comments attributed to two French doctors in early April 2020 with regard to conducting COVID-19 vaccine trials in Africa further increased the level of distrust for vaccines being brought to Africa from the West [37].Additionally, an absence of nuanced and culturally informed understanding of vaccine hesitancy and misinformation are major contributing factors to vaccine hesitancy in the continent.Other studies have reported that factors contributing to vaccine hesitancy in Africa include the lack of political will and frm commitment from the government on vaccine rollout.Others are the concern about vaccine safety, misinformation, religious myths and beliefs, myths about the vaccines, and the lack of information and education [15,30,32,37,39].A study in Cameroon also noted that inconsistent information and anti-vaccine campaigns warning Africans to refuse COVID-19 vaccines on social media and concerns about the reliability or source of vaccines served as barriers to COVID-19 vaccine acceptance [6].
Government institutions designed messages that countered myths and misconceptions such as taking their vaccines in public for the community members to see and recorded their vaccination process to share with distant communities, comparing COVID-19 vaccination to the under-fve vaccinations as well as touting the benefts of COVID-19 vaccination.Most of the institutions made eforts to counter myths and misinformation through strategies such as workers taking the vaccine in public and capturing it on video to share it with communities.Also, health workers assured community members of the safety of the COVID-19 vaccines by comparing them to the child vaccinations that Ghana has been embarking on for decades.Municipality B health directorate also ensured that chiefs set examples by taking the vaccine in public.Such measures helped to improve public trust and willingness to be vaccinated.Other studies have found that interventions are taken when there is public trust in vaccines and government information sources [30].Te WHO has equally noted that while COVID-19 is the frst pandemic in history in which technology and social media are being used on a massive scale to keep people safe, informed, productive, and connected, the same tools are being used to amplify infodemic that continues to undermine the global response and jeopardize measures to control the pandemic [40].It has consequently initiated the formation of the Africa Infodemic Response Alliance (AIRA) to coordinate infodemic response, conduct research, and to prevent misinformation among others [41].
While some community members believed and cooperated with the government institutions who engaged them and were willing to vaccinate, others distrusted them and continued to believe in misinformation and myths about COVID-19 and vaccination, which contributed to vaccine hesitancy.Similarly, Lazarus et al. [42] found that respondents who reported higher levels of trust in information from government sources were more likely to accept a vaccine and take their employer's advice to do so compared to those who were distrustful of government sources.A study on Twitter users equally revealed that more Twitter users in London and New York perceived high risk of getting COVID-19 which indicated a lack of confdence in vaccine safety, distrust in governments and experts, and belief in widespread misinformation or rumours.Teir counterparts in Mumbai, Sao Paulo, and Beijing rather worried more about vaccine production [43].Our fnding confrms the earlier study which found that the Volta Region recorded the lowest rate of COVID-19 vaccine acceptance (32.50%) in Ghana [18].

Limitations of the Study
Te study, as is typical of qualitative research studies, selected government ofcials, community leaders, and a cross section of community members, who had knowledge of the matters of discussion.Tis introduces some level of subjectivity into the study and thus cannot be generalized.

Conclusion
Tis qualitative study is one of the few studies or the frst in Ghana to the best of our knowledge to focus on government engagement with communities on COVID-19 vaccine preparedness and acceptance.Te fndings suggest that government institutions' engagement activities were centred in the urban communities, which are municipal capitals.Challenges and gaps that hampered extensive engagement in Advances in Public Health the municipalities included limited funding, bureaucracy that contributed to late initiation of engagement eforts, and proliferation of infodemic, among others.For the country to achieve the target of vaccinating 20 million people, recommendations have been suggested.
Government institutions need to continue to devise strategies to counter the spread of infodemic in order to maximize the impact of community engagement eforts.Diferent government organizations need to improve on collaboration in sharing information, logistics, and other resources to enable them reach rural and distant communities with the needed information and education to boost vaccine acceptance.
Te circulation of infodemic is still high in urban and rural communities, and the main source of such information is the social media.Government institutions need to be ahead of time to counter misinformation.Leveraging on existing community resources would help counter the spread of myths and misconceptions as well as promote the acceptance of COVID-19 vaccines.
Te government needs to devote more resources in the engagement efort such as providing the NCCE, the ISD, and the GHS with adequate funds to enable them to carry out their constitutional duty of engaging communities in distant communities.Te use of existing platforms such as the CHPS facilities and routine health programmes such as child welfare clinics to inform and encourage community members to accept COVID-19 vaccination is commendable.However, majority of community members who attend such programmes are women and children, so to reach out to men, the elderly, and the youth, health workers need to carry out more community reach programmes.

Table 1 :
List of data collection methods and categories of respondents.
* Municipality A does not have migrant settler communities; thus, no interviews were conducted for such a category.

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Te community members see us as people who are getting all the monies for the job.Tey see us as people who are government's people.Tere is a detachment.Tey see us as people who are the government's people who have the monies and things like that.And in engaging the community, money is involved.When you call meeting once and you don't serve them snacks during the frst one, they 6 Advances in Public Health would not come for the second one when you call them.So, from the initial stages, the enthusiasm was there and they were very smart.When the money was not there for snacks, you call them and they don't come but if you call for a meeting and you tell them there would be snacks and refund of T&T, they'll come in numbers" (Health manager, Municipality B).