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Reluctant men: reaching South Africa’s most hesitant groups with the Covid-19 vaccine

·9-min read
 (AFP via Getty Images)
(AFP via Getty Images)

A car carrying Jacob Mamabolo pulls into a popular truck stop parking lot. Mamabolo is wearing a bright yellow, reflective safety jacket and blue surgical mask — not the outfit one might expect from a provincial transport minister but perhaps fitting for the occasion.

Although the petrol station sits less than 30 minutes’ drive north of South Africa’s capital Pretoria, the landscape here shifts quickly from tall city buildings to fields dotted with acacia trees. In the parking lot, men in yellow and orange vests guide lorries into available bays.

Mamabolo gets out of his car. He’s here to support a team running a pop-up Covid-19 vaccination site in hopes of persuading truck drivers to take the jab.

Today, about seven out of 10 South African adults say they’d take a Covid-19 vaccine, recent national surveys show, but only about a quarter of adults — or almost 10 million — have been fully vaccinated, as of mid-October. Certain groups, including men, have lagged behind in South Africa’s national vaccine program.

The clock is ticking. Scientists say the country must vaccinate 70 per cent of adults by year-end to avert an additional 20,000 deaths from the virus. Experts estimate that at least 200,000 South Africans already have died from Covid-19.

Gauteng transport minister Jacob Mamabolo inspects vaccination efforts (Laura Lopez Gonzalez)
Gauteng transport minister Jacob Mamabolo inspects vaccination efforts (Laura Lopez Gonzalez)

With a black notebook and pen in hand, Mamabolo approaches a pair of healthcare workers seated at a folding table in the shade not far from the truck stop’s chain of fast-food restaurants.

“How many people have you seen?” he asks.

“Five,” a healthcare worker replies sheepishly. A few metres away, nurses waiting to vaccinate people sit under blue canopies beside empty chairs, scrolling through their mobile phones.

Noticeably underwhelmed, Mamabolo sets off towards the lorries. He spots a trio of truck drivers around a picnic table near the petrol station’s convenience store. One of the men, Tsiko Fhedzi, is wearing a face mask branded with the logo of a beloved local football team, the Kaiser Chiefs.

Amakhosi,” shouts Mamabolo, using the IsiZulu nickname for the football club. Fhedzi begins to chuckle. The minister sees his “in”: Have they been vaccinated, he asks?

No, replies Fhedzi. Mamabolo explains that the pair can be vaccinated just a few meters away. It will take only about 20 minutes.

Fhedzi agrees, and as Mamabolo walks off to chat to another driver who has just pulled his lorry into the lot, a healthcare worker emerges to register Fhedzi on a national electronic vaccination database using a small electronic tablet.

With the administration complete, Fhedzi turns to walk away — but not to the vaccination tents.

“First,” he chirps, “lunch.”

Whether you get a vaccinate depends on three factors, according to behavioural models used by agencies like the World Health Organisation: You, your community and, lastly convenience.

Our motivation to get a vaccine is often a mix of both how we feel about immunisation and how those around us speak or act about it, explains Peter Benjamin, co-founder of the digital health organisation Health Enabled. Benjamin also sits on a South African task force aimed at increasing the demand for jabs.

But whether even a highly motivated person actually gets a vaccine depends on the third component, convenience — just how many hurdles you have to overcome to get a shot. For instance, can you afford to skip a day’s work without pay to queue for a jab? Or do you have money to pay for transport to a clinic?

And in a country where more than four out of every 10 people are unemployed, hurdles abound, says David Harrison, CEO of the non-profit DG Murray Trust. He leads the South African government’s Covid-19 vaccine demand creation task team.

In South Africa, men make up just four out of every 10 vaccinated people in the country. Meanwhile, the 22 worst-performing districts for Covid-19 immunisations are a mix of rural areas known for poor healthcare services and big cities that must vaccinate large numbers of people to reach coverage targets.

In response, the country has changed how it offers Covid-19 jabs. In the rural areas, non-profit organisations are sending vaccinators out in 4x4 trucks, while rail and shipping company Transnet has added Covid-19 vaccines to trains to reach remote communities. The country has also invested huge resources recently to run weekend vaccination sites.

Still, Harrison says it’s not yet clear whether it’s a lack of motivation or logistical challenges that are standing between many people and vaccines.

“Understanding how much of it is a real demand issue and how much of it is access is very complex because, how close is close enough for a vaccination site? We’ve been trying to get a handle on that,” Harrison explains. “Some spatial analysis …shows that sites have to be within a three-kilometre radius of their home.”

He continues: “We’ve also got to be asking, what will persuade people in the next outer radius, or the next three kilometres to come to that site?”

Ultimately, Harrison believes South Africa will reach about half of South African adults with relative ease, but the next 20 per cent needed to reach the national target of 70 per cent will be tough.

“Material incentives will play an important role,” he says. “In the context of such an unequal society as South Africa, we’re going to actually have to put money on the table.”

A man  receives a jab of the Johnson and Johnson vaccine inside the Transvaco Covid-19 vaccine train stationed at the Springs Train Station outside of Johannesburg, on August 25, 2021. (AFP via Getty Images)
A man receives a jab of the Johnson and Johnson vaccine inside the Transvaco Covid-19 vaccine train stationed at the Springs Train Station outside of Johannesburg, on August 25, 2021. (AFP via Getty Images)

At the truck stop, Bobby Mohanoe takes a break by the small, blue vaccination tents. He usually works supporting HIV-positive men in Johannesburg clinics to stay on treatment.

Today, however, Mohanoe has spent the morning trying to convince truckers to come forward for the jab with little success.

Instead, line cooks and cashiers from the truck stop’s fast food outlets fill the vaccination tents. Working 12-hour shifts, these employees have not been able to access most of the country’s more than 3,000 vaccination sites that, until recently, only operated between about 8 am and 4pm on weekdays.

Mohanoe is used to dealing with men who are, generally, much more hesitant to access healthcare, partly because they don’t want to be seen as being “weak” but also because seeking out healthcare comes at a cost.

“Many men are busy trying to find some way to earn an income,” he says. “They must choose between hustling to find something that will put bread on the table, or going to queue at a health facility.”

But today, he says, different concerns are making truckers wary of getting immunised.

“Ninety percent of them want to vaccinate because they say to us they listen to a lot of radio and they know about Covid-19 and the importance of vaccines,” Mohanoe says. “But they’re sceptical of the side effects. They’re worried they get dizzy or feel unwell and they won’t be able to drive long distances.”

Covid-19 vaccines have been shown to be overwhelmingly safe and effective. Still, short-lived headaches and fatigue can be common side effects of both the Pfizer and Johnson & Johnson immunisations, the US Centers for Disease Control and Prevention explain.

Mohanoe continues: “They’ve already made a decision that they will take the Covid-19 vaccine when they’re off work and most of the time, that’s Saturday or Sunday.”

Anti-vax demonstrators at a protest march against Covid-19 vaccinations and wearing of masks, in Pretoria on August 30, 2021. (AFP via Getty Images)
Anti-vax demonstrators at a protest march against Covid-19 vaccinations and wearing of masks, in Pretoria on August 30, 2021. (AFP via Getty Images)

About 50 kilometres south, the country’s largest health insurer Discovery Health has turned a popular Johannesburg convention centre into a mass vaccination open seven days a week.

Today, almost 60 per cent of Discovery Health members are fully vaccinated. Still, the health and life insurance scheme is using incentives to encourage even more to get the jab, including offering points as part of its Vitality rewards programme. It will also begin factoring vaccination into premiums for new customers seeking life cover.

The South African government may have to follow suit, handing out perhaps R100 (£5) vouchers for mobile phone airtime or groceries to help overcome country’s gaping inequalities.

“Incentives aren’t bribery — they’re an acknowledgement that people face an uphill battle to get to a vaccination site and that’s a very steep uphill for people with very little money,”Harrison explains. Similar incentives have already been used in countries such as the United States to increase vaccination rates.

“It’s perhaps easy to criticise incentives if you can just climb into your car and go down the road to your local pharmacy to get vaccinated,” he says, “But there are massive opportunity costs for somebody living in a [township] like Khayelitsha who needs to get on a taxi and has to make a trade-off between literally between food in the mouth today or that taxi fare.”

As of August, more than 13 million people in South Africa applied for a monthly Covid-19 social grant of just £17.

“We’re trying to level the playing fields,” Harrison adds. “We’re trying to reduce the actual costs [of Covid-19 vaccination] so the calculus in people’s minds swings in the right direction.”

 (Gauteng Health)
(Gauteng Health)

Back at the truck stop north of Pretoria, driver Tsiko Fhedzi has just finished sharing a plate of steamed cornmeal and meat with friends.

“When we heard about Covid-19, we thought it was a simple thing that would be over in a few months,” says Fhedzi, wiping his hands on some paper napkins. “Instead, it’s continuing. I was retrenched because of this thing.”

He walks to the nearby vaccination tents. Only he and his new co-worker are in the queue. Fhedzi has been driving lorries for four years. Still, he’s only been with his current company for about three months after becoming one of the nearly 650,000 South Africans who lost their jobs during the national Covid-19 lockdown earlier this year.

A nurse calls him forward and he takes a seat.

Within minutes, the jab is administered and he joins two women, a pair of fast-food workers, in the observation tent laughing and looking at their phones. Soon, health department officials ask if they can interview him on camera. They’re hoping to use the video on social media to convince other men to be vaccinated.

“My mother and my father have both been vaccinated, and I was glad they got the vaccine,” he says. “I was thinking about getting vaccinated earlier but because of work sometimes it’s just hard.”

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