Objective To assess the accuracy of seven commonly used Global Positioning System (GPS)-based geolocation techniques, including a handheld GPS device and smartphones using Google Maps, Open Data Kit (ODK) and Research Electronic Data Capture (REDCap) with and without internet connectivity, for measuring distances between houses in a field epidemiology setting.Design Cross-sectional study conducted in February–March 2024.Setting Field study in a village in the Comoros where leprosy is endemic.Participants 55 randomly selected house pairs, of which 50 were included in the analysis.Primary outcome measure Measurement error, defined as the difference in straight-line distance between house pairs measured by each index test (GPS-based geolocation technique) and the reference standard (surveyor map).Results Three index tests showed substantial shortcomings, including indeterminate results (one technique), outliers (two techniques), systematic underestimation (mean measurement error −3.0 m for one technique) and high variability (SD of measurement error ranging from 9.4 m to 16.6 m). The remaining four index tests showed little bias (mean measurement error ranging from −1.7 m to 0.4 m across techniques) and low variability (SD of measurement error ranging from 5.7 m to 7.4 m). For the most precise technique, 95% of measurements were estimated to fall between an underestimation of 11.9 m (95% CI 8.9 to 17.5 m) and an overestimation of 10.5 m (95% CI 8.4 to 13.7 m). Even this narrowest range was two to three times wider than the claimed accuracy.Conclusions GPS-based geolocation techniques may show substantial variability under field conditions and may give rise to misplaced confidence in their accuracy when this is assumed rather than empirically assessed. Careful selection and testing of techniques in context, along with transparent data handling and consideration of uncertainty, are needed to improve the reliability of geospatial data in public health research and practice.

Progress in malaria control has stalled since 2015, highlighting the need for new control tools. The R21/Matrix-M (R21) malaria vaccine, a pre-erythrocytic vaccine recently approved by WHO for small children, may be one of these tools. This trial aims to assess whether seasonal mass vaccination with R21 reduces malaria transmission in The Gambia and Burkina Faso, two countries at the extreme of the transmission spectrum. This is a multi-centre open cluster-randomised controlled trial to assess the impact of mass vaccination with R21 on malaria transmission and morbidity. The trial will be implemented in eastern Gambia (low to moderate transmission) and Central Burkina Faso (intense transmission). Thirty medium-sized villages in The Gambia and 24 in Burkina Faso will be randomised (1:1) to either intervention or control arm. All eligible residents in intervention villages will receive R21 vaccinations in three-monthly rounds, from May to July 2024, prior to the malaria transmission season. A booster vaccine dose will be administered the following year, in June 2025. The primary outcome is malaria prevalence at peak transmission (November 2024). Secondary outcomes include safety and tolerability, incidence of clinical malaria, vaccination coverage and community acceptability, cost and cost-effectiveness of the intervention. This is the first trial on seasonal mass vaccination aiming at reducing malaria transmission. Strengths of the study include its design as an adequately powered cluster-randomised trial and the inclusion of study sites with differing transmission intensity which will also provide safety and efficacy data for different age groups. Key challenges remain vaccine hesitancy and vaccination coverage. If successful, R21 seasonal mass vaccination will be an innovative intervention to accelerate malaria elimination efforts and reach the goal set in the Global Technical Strategy for malaria 2016–2030. Clinical trials.gov, NCT06578572. Registered on 27 March 2024.

BACKGROUND:The concept of "ownership" in global health policymaking broadly assumes that external donors and advisors expect recipient countries to actively steward their national programmes when assistance is provided. This study specifically explored country ownership of national policy decision-making for Plasmodium vivax malaria using three case studies: Laos, Pakistan and the Solomon Islands. METHODS:Yin's comparative case study model, Kingdon's Multiple Streams policy theory guided this analysis. From 2021 to 2024, interviews were undertaken with 29 national stakeholders, external partners and relevant global stakeholders. RESULTS:There were four main findings: firstly, national malaria programme respondents expressed strong ownership of internal antimalarial policy processes but acknowledged nuanced influence of external donors on the national policymaking space. Second, in countries relying on external funding, antimalarial policy change is mainly triggered by the World Health Organization's (WHO) recommendations and WHO national support was identified as a key enabler of policy change. Third, external donors often influence, or outline policy directions aligned with WHO recommendations, but policy change is also driven by antimalarial tools procurement constraints. Fourth, timing of updated WHO recommendations may not align with countries' needs. Yet many malaria endemic countries face pressure from external funders, that resource national policy decision-making, to adhere to WHO recommendations, although the WHO considers its recommendations as advisory only. Overall, these external influences moderate country ownership of national policy change. CONCLUSIONS:This study indicates that there is potential to strengthen country ownership of national antimalarial policymaking. This may require application of targeted policy acceleration levers such as better alignment of timing of global guidance with country needs and an understanding between external donors and national stakeholders that WHO guidance is advisory only and should be understood as one perspective relative to country needs.

Women with reproductive desires and needs face various health system constraints in the Global South. Certain biomedical practices, such as C-section, are also perceived by women as risky. In this paper, we explore how women in one of the Susu villages in western Guinea use their agency to navigate health system-related constraints and risks. This was a twelve-month ethnography using focus group discussions, individual in-depth interviews, informal conversations, direct observations, carried out between April 2020 and August 2022 in the Maferinyah village of Guinea. Using the concepts of reproductive navigation, collective agency, street-level bureaucracy, and trust, we showed that women in labor creatively navigate these constraints and risks, relying in different ways and degrees on their social networks, including midwives. Woman’s social relationships are an important part of a collective agency to navigate her reproductive trajectory. We also found that reproductive navigation is structured by women’s relationships with individual care providers, their ability to mobilize social resources, their perception of risks associated with medical practices, and the health system constraints they face. This calls for political actors and healthcare providers to prioritize actions to mitigate health system constraints and build trust in that system.

Syndemics theory has been applied to study interactions between biomedical and social factors leading to the clustering of diseases. Because syndemics theory focuses on interactions that enhance risk, the concept of vulnerability is central to this approach. We conducted a scoping review to better understand how this theoretical framework helped to define, operationalize, and tackle issues of vulnerability during the COVID-19 pandemic. Original research, reviews, and opinion pieces elaborating on syndemics, vulnerability, and COVID-19, published between December 2019 and October 2022 and available from PubMed, were eligible. We analyzed 40 records and identified three framings of syndemics operating during this period: (1) interactions between COVID-19, diseases/health conditions, and specific social factors; (2) interactions between COVID-19 and social determinants of health; and (3) impacts of COVID-19 on specific populations. Emerging conceptualizations described vulnerability to COVID-19 as a systemic issue, explained the impact of COVID-19 control measures on increased vulnerability, and presented COVID-19 as a syndemic on its own. However, this theory’s potential for deepening our understanding of vulnerability during this pandemic was constrained by superficial explorations of the interactions between biomedical and social spheres, and insufficient theoretical and methodological support from the social sciences.

Health policy processes should be evidence-informed, transparent and timely, but these processes are often unclear to stakeholders outside the immediate policymaking environment. We spoke to 36 international malaria stakeholders to gain insights on the processes involved in the World Health Organization’s Global Malaria Programme’s recommendations for their treatment guidelines of P. vivax malaria. Four key themes which drew on the 3i policy framework and Shiffman’s four factors that influence global and national policymaking were identified to understand these processes. Triggers for policy change and change prioritisation, evidence types that inform policy, effects of funding on decision-making processes, and transparency and communication of these processes to external stakeholders. Results indicate that more clarity is needed on what triggers global malaria policy change processes, a clearer justification of evidence types used to inform policymaking, better understanding of the impact of the WHO’s funding model on policymaking and further transparency and improved communication of these processes to external stakeholders is also needed. We suggest that global malaria policymaking could be improved by using the following strategies: ensuring that identified triggers actually initiate the policy change process, expediting decision-making timelines by developing a priority framework for assessing new evidence, adopting suitable frameworks to assess contextual evidence, and increasing the transparency of the role of non-state funders in policy decision-making processes and when publishing new recommendations.

Background Recently, global health has been confronting its visual culture, historically modulated by colonialism, racism and abusive representation. There have been international calls to promote ethicality of visual practices. However, despite this focus on the history and the institutional use of global health images, little is known about how in practice contemporary images are created in communities, and how consent to be in photographs is obtained. Methods We conducted semi-structured interviews with 29 global health photographers about the ethical and practical challenges they experience in creating global health images, and thematically analysed the findings. Findings The following themes were identified: (1) global health photography is undergoing a marketing transformation and images are being increasingly moderated; (2) photographers routinely negotiate stereotypical and abusive tropes purposefully sought by organisations; (3) local scenes are modified, enhanced and staged to achieve a desired marketing effect; (4) ‘empowerment’ is becoming an increasingly prominent dehumanising visual trope; (5) consent to be photographed can be jeopardised by power imbalances, illiteracy, fears and trust; (6) organisations sometimes problematically recycle images. Interpretation/Discussion This research has identified practical and ethical issues experienced by global health photographers, suggesting that the production cycle of global health images can be easily abused. The detected themes raise questions of responsibility and accountability, and require further transdisciplinary discussion, especially if promoting ethical photojournalism is the goal for 21st century global health.

Global health photography has historically been commissioned and, therefore, dominated by the gaze of Western photographers on assignments in the Global South. This is changing as part of international calls to decolonise global health and stimulate ‘empowerment’, spawning a growing initiative to hire local photographers. This article, based on interviews with global health photographers, reflects on this paradigm shift. It highlights how behind the laudable aim of ‘empowerment’ of local global health photography there is a simultaneous exploitation of precarious photographer labour and the emergence of ‘glocal’ photography elites. The paper argues that empowerment of local photographers can become a euphemism for reducing image production costs and maintaining control over the image content, while extending the scope of mainstream global health visual culture without challenging it. Finally, the article amplifies the growing concern that uncritical engagement with institutionalised empowerment becomes a warrant for the reproduction of local inequalities behind the fashionable façade of cooperation and care.

Despite the global threat of antimicrobial resistance (AMR), evidence on the use and quality of medicines at community level is limited, particularly in impoverished, rural areas where prevalence of (bacterial) infections is high. To better understand the processes that drive vulnerability to AMR' effects, this study aimed to assess social factors underpinning access to-and use of-medical products and healthcare, among people from the Raglai ethnic minority in Ninh Thuan Province, Vietnam. We conducted ethnographic research in eight villages in 2018-2019, using interviewing and participant observation methods for data collection. Different types of informants (including community members and healthcare providers) were selected using purposive sampling strategies and analysis was retroductive. Our findings show that, despite the existence of a government-funded health insurance scheme, Raglai people's flexible therapeutic itineraries did not systematically start with formal healthcare. Different types of care (private/informal, public, shamanic) were combined in parallel or in alternation, determined by distance to the provider, cost, workload, perceived diagnostic capacity, perceived severity and aetiology of the illness, and trust in the provider. Available medicines were often tablets dispensed in plastic bags containing labelled tablets, unlabelled tablets (in bulk) or tablets ground to powder. Treatment was often considered effective when it relieved symptoms, which led to abandonment of the treatment course. When symptoms did not speedily abate, the illness aetiology would be reinterpreted, and "stronger" medicines would be sought. The precarious socio-economic status of some Raglai drove them in cycles of severe poverty when additional unforeseen factors such as illness, animal disease or loss of crops arose, hampering access to (in)formal healthcare providers and/or appropriate diagnosis and treatment. We conclude that Raglai communities are structurally unable to buffer themselves against the threat and consequences of AMR. Despite this vulnerability, they are among the least targeted by efforts to optimize antibiotic use, which are concentrated in secondary and tertiary healthcare facilities targeted at urban populations.

In Burkina Faso, there is lack of awareness of antibiotic use at the community level. This study aims to generate information on the commonly used antibiotics along with the reasons for which they have been used in rural Burkina Faso. The drug bag method was employed to collect information from 423 households in the health district of Nanoro. Descriptive analyses were performed using R software version 4.2.1. Of the 33 antibiotics inventoried, amoxicillin tablets and oxytetracycline were the most recognized and used antibiotics. This study indicated that antibiotics were used for a range of health problems in the community, some of which were administered as painkillers. While primary healthcare facilities constituted the primary source of drugs for households (76.8%), informal drug sellers constituted an additional option (61.5%) for community members. This is a significant concern, given that some antibiotics classified as “Watch”—such as norfloxacin—were readily available in these outlets, despite not being included on the country’s Essential Medicines List. This study underscores the necessity of considering the role played by formal providers in the inappropriate use of antibiotics and the importance of understanding the circumstances and logical reasoning underlying communities’ access to and use of antibiotics.

The goal of this qualitative research study, part of an interdisciplinary project, was to understand the overlapping geographical distribution of COVID-19 and tuberculosis burden in Lima. Using an ethnographic approach, we applied the concept of disease situations to explore how inhabitants’ social and spatial situatedness affected their capacity to respond to the pandemic. Our results show that for some populations in Lima, the risk to develop COVID-19 did not emerge suddenly; it could be traced back to situations of living under subsistence models, relying on unstable sources of income, facing food insecurity, depending on certain mechanisms of social protection, residing in precarious living environments and lacking access to quality health care. These populations did not only have less resources to adjust to changes in daily life induced by the pandemic; they were also forced to constantly weigh the risk of COVID-19 against other pressing needs and potentially face increased risks when control measures were actually followed. Pre-existing social networks played fundamental roles as sources of emotional and material support. The lens of disease situations can help to identify and explain spatial and social configurations that enhance vulnerability, as well as resilience mechanisms that are in place to deal with crises. This perspective could inform the design of contextualised prevention and response strategies around health risks in cities as diverse as Lima, whilst building on existing resources at local levels.

Dialogue with people who are vaccine hesitant has been recommended as a method to increase vaccination uptake. The process of cultivating dialogue is shaped by the context in which it occurs, yet the development of interventions addressing vaccine hesitancy with dialogue often overlooks the role of context and favors relatively fixed solutions. This reflexive paper shares three key lessons related to context for dialogue-based interventions. These lessons emerged during a participatory research project to develop a pilot intervention to create open dialogue among healthcare workers in Belgium about COVID-19 vaccination concerns. Through a mixed methods study consisting of in-depth interviews, focus group discussions, and surveys, we engaged healthcare workers in the design, testing, and evaluation of a digital platform featuring text-based and video-based (face-to-face) interactions. The lessons are: (1) what dialogue means, entails, and requires can vary for a population and context, (2) inherent tension exists between helping participants voice (and overcome) their concerns and exposing them to others' ideas that may exacerbate those concerns, and (3) interactional exchanges (e.g., with peers or experts) that matter to participants may shape the dialogue in terms of its content and form. We suggest that having a discovery-orientation-meaning to work not only inductively and iteratively but also reflexively-is a necessary part of the development of dialogue-based interventions. Our case also sheds light on the influences between: dialogue topic/content, socio-political landscape, population, intervention aim, dialogue form, ethics, researcher position, and types of interactional exchanges.

Background: Polarized debates about Covid-19 vaccination and vaccine mandates for healthcare workers (HCWs) challenge Belgian HCWs ability to discuss Covid-19 vaccine sentiments with peers and patients. Although studies have identified drivers of HCWs vaccine hesitancy, they do not include effects of work-place interactions and have not addressed consequences beyond vaccine coverage. Methods: Interviews and focus group discussions with 74 HCWs practicing in Belgium addressed Covid-19 vaccine sentiments and experiences of discussing vaccination with peers and patients. Results: Most participating HCWs reported difficulties discussing Covid-19 vaccination with peers and patients. Unvaccinated HCWs often feared that expressing their vaccine sentiments might upset patients or peers and that they would be suspended. Consequently, they used social cues to evaluate others' open-ness to vaccine-skeptical discourses and avoided discussing vaccines. Surprisingly, some vaccine -confident HCWs hid their vaccine sentiments to avoid peer and patient conflicts. Both vaccinated and unvaccinated HCWs observed that unvaccinated patients occasionally received suboptimal care. Suboptimal care was central in unvaccinated HCW unwillingness to express their vaccine sentiments to peers. Both vaccinated and unvaccinated HCWs described loss of trust and ruptured social relations with peers and patients holding divergent vaccine sentiments.Discussion: Belgian HCW perceived Covid-19 vaccines as a risky discussion topic and engaged in "strate-gic silences" around vaccination to maintain functional work relationships and employment in health institutions. Loss of trust between HCW and peers or patients, along with suboptimal patient care based on vaccination status, threaten to weaken Belgium's, and by implication, other health systems, and to cat-alyze preventable disease outbreaks.(c) 2022 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC license (http://creativecommons.org/licenses/by-nc/4.0/).

Background Reducing the risk of recurrent Plasmodium vivax malaria is critical for malaria control and elimination. Primaquine (PQ) is the only widely available drug against P. vivax dormant liver stages, but is recommended as a 14-day regimen, which can undermine adherence to a complete course of treatment. Methods This is a mixed-methods study to assess socio-cultural factors influencing adherence to a 14-day PQ regimen in a 3-arm, treatment effectiveness trial in Papua, Indonesia. The qualitative strand, consisting of interviews and participant observation was triangulated with a quantitative strand in which trial participants were surveyed using a questionnaire. Results Trial participants differentiated between two types of malaria: tersiana and tropika , equivalent to P. vivax and Plasmodium falciparum infection, respectively. The perceived severity of both types was similar with 44.0% (267/607) perceiving tersiana vs. 45.1% (274/607) perceiving tropika as more severe. There was no perceived differentiation whether malaria episodes were due to a new infection or relapse; and 71.3% (433/607) acknowledged the possibility of recurrence. Participants were familiar with malaria symptoms and delaying health facility visit by 1–2 days was perceived to increase the likelihood of a positive test. Prior to health facility visits, symptoms were treated with leftover drugs kept at home (40.4%; 245/607) or bought over the counter (17.0%; 103/607). Malaria was considered to be cured with ‘blue drugs’ (referring to dihydroartemisinin-piperaquine). Conversely, ‘brown drugs,’ referring to PQ, were not considered malaria medication and instead were perceived as supplements. Adherence to malaria treatment was 71.2% (131/184), in the supervised arm, 56.9% (91/160) in the unsupervised arm and 62.4% (164/263) in the control arm; p = 0.019. Adherence was 47.5% (47/99) among highland Papuans, 51.7% (76/147) among lowland Papuans, and 72.9% (263/361) among non-Papuans; p < 0.001. Conclusion Adherence to malaria treatment was a socio-culturally embedded process during which patients (re-)evaluated the characteristics of the medicines in relation to the course of the illness, their past experiences with illness, and the perceived benefits of the treatment. Structural barriers that hinder the process of patient adherence are crucial to consider in the development and rollout of effective malaria treatment policies.

Wellcome Centre for Ethics and Humanities. Ethox Centre, University of Oxford, Nuffield Department of Population Health, University of Oxford, UK Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia School of Public Health, University of the Western Cape, Cape Town, South Africa

The Health Policy paper of Esmita Charani and colleagues,1Charani E Shariq S Cardoso Pinto AM et al.The use of imagery in global health: an analysis of infectious disease documents and a framework to guide practice.Lancet Glob Health. 2023; 11: e155-e164Summary Full Text Full Text PDF PubMed Scopus (0) Google Scholar showed how stereotypical global health tropes (such as the so-called suffering subject and white saviour) can be perpetuated through the images chosen to illustrate publications on global health. We propose that generative artificial intelligence (AI), which uses real images as a basis for learning, might further serve to show how deeply embedded the existing tropes and prejudices are within global health images. This in turn can perpetuate oversimplified social categorisations and power imbalances. Using the Midjourney Bot Version 5.1 (released in May, 2023), we attempted to invert these tropes and stereotypes by entering various image-generating prompts to create visuals for Black African doctors or traditional healers providing medicine, vaccines, or care to sick, White, and suffering children. However, despite the supposed enormous generative power of AI, it proved incapable of avoiding the perpetuation of existing inequality and prejudice. Although it could readily generate an image of a group of suffering White children or an image of Black African doctors (Figure 1, Figure 2), when we tried to merge the first two prompts, asking the AI to render Black African doctors providing care for White suffering children, in the over 300 images generated the recipients of care were, shockingly, always rendered Black (figure 3).Figure 2Prompt—a group of Black African doctors in the style of photojournalismView Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Prompt—African doctors administer vaccines to poor White children in the style of photojournalismView Large Image Figure ViewerDownload Hi-res image Download (PPT) Occasionally the renderings for Black African doctors presented White people, effectively reproducing the saviour trope that we were trying to challenge (figure 4). This was also the case for traditional African healers prompts that often showed White men in exotic clothing (figure 5), also posing the question of gendered biases in such AI-generated global health images.Figure 5Prompt—Traditional African healer is helping poor and sick White childrenView Large Image Figure ViewerDownload Hi-res image Download (PPT) Eventually we were able to invert only one stereotypical global health image, by asking the AI to generate an image of a traditional African healer healing a White child; however, the rendered White child is wearing clothing that could be understood as a caricature of broadly defined African clothing and bodily practices (figure 6). When requested to produce images of doctors helping children in Africa, the AI generated images of doctors and patients with exaggerated and culturally offensive African elements such as wildlife (figure 7). In further probing the rendering bias, we discovered that AI couples HIV status with Blackness. Nearly all rendered patients for an HIV patient receiving care prompt (150 of 152) were rendered Black (figure 8).Figure 8Prompt—an HIV patient receiving care, photojournalismView Large Image Figure ViewerDownload Hi-res image Download (PPT) In summary, we were unable to achieve our initial goal of inverting stereotypical global health images, and instead we unwittingly created hundreds of visuals representing white saviour and Black suffering tropes and gendered stereotypes; these images were created despite the AI developers' stated commitment to ensure non-abusive depictions of people, their cultures, and communities.2MidjourneyTerms of service.https://docs.midjourney.com/docs/terms-of-serviceDate: July 21, 2023Date accessed: July 21, 2023Google Scholar This case study suggests, yet again, that global health images should be understood as political agents,1Charani E Shariq S Cardoso Pinto AM et al.The use of imagery in global health: an analysis of infectious disease documents and a framework to guide practice.Lancet Glob Health. 2023; 11: e155-e164Summary Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 3Alenichev A Encountering semiotic misdirection in COVID-19 etiquette guides.Sci Technol Stud. 2022; 35: 97-111Crossref Google Scholar and that racism, sexism, and coloniality are embedded social processes manifesting in everyday scenarios, including AI.4WHOEthics and governance of artificial intelligence for health: WHO guidance. World Health Organization, Geneva2021Google Scholar In unpacking this bias, it is essential to mention that AI learns by absorbing existing images available online, which, in the case of global health, have historically been considered as disrespectful and abusive. In contrast, AI is seen as a way of generating universal knowledge and products devoid of contexts and social meanings. This view reinforces AI-produced global health imagery as a so-called neutral visual genre, thereby misdirecting attention away from the context of the emergence of the original images,5Grietens KP Friesen P Gerrets R Kuhn G Kingori P Douglas-Jones R Misdirection in global health: creating the illusion of (im)possible alternatives in global health research and practice.Sci Technol Stud. 2022; 35: 2-12Crossref Google Scholar and the system through which they are now reproduced. Global health actors are already using AI for their media, reports, and promotional materials, making this an urgent, complex, and extremely relevant problem for science and society. A promotional marketing image in a photojournalistic style was shared on behalf of the WHO in May, 2023. The AI-generation detection tool Hive suggests a 99% likelihood that this image is AI-rendered, and the picture shows visible compositing artefacts and irregularities common among heavily edited or AI-generated images. This discovery leads to a sharp question for the international global health community: what is our responsibility in reinforcing or challenging visual stereotypes regarding socially enacted markers of similarity and difference, and the symbolic violence they might entail? And who is accountable for generating these visuals and potential transgressions? An extensive version of this case study was presented at the Oxford Global Health and Bioethics International Conference in June, 2023. Even though we helped create these problematic images by running prompts, and are displaying them for a wide diverse audience, we do not endorse the content of these biased AI-generated images, nor the counterparts from which AI draws from, and we hope to facilitate a conversation about the history, present, and future of global health and its visual culture. This research was funded in whole by the Wellcome Trust (grant numbers 221719 and 209830/Z/17/Z). We declare no competing interests.

The COVID-19 pandemic has disrupted societies globally. Public health institutions were tasked with responding to the pandemic in a dynamic and uncertain context. This paper sheds light on the experiences of COVID-19 response actors as they navigated multi-dimensional crises associated with the pandemic in general and vaccine hesitancy in particular. This research was conducted during the initial phase of the COVID-19 vaccine rollout in Flanders, Belgium. Participants included informants across all levels of the COVID-19 vaccination strategy including but not limited to those producing scientific knowledge, providing policy input, or implementing public health directives locally. ‘Crisis’ was identified as a recurring theme in interviews with informants. The paper highlights multi-dimensional crises experienced by informants such as the: (i) crisis of prioritization, (ii) crisis of communication, (iii) crisis of the changing image of science, (iv) crisis of epistemic agency and autonomy, and (v) crisis of trust.