The Drum Beat 831 - Behavioural and Social Insights to Drive Vaccination Uptake

• 1.Declining Trends in Vaccine Confidence across Sub-Saharan Africa: A Large-Scale Cross-Sectional Modeling Study
  by A. de Figueiredo, E. Temfack, R. Tajudeen, and H. J. Larson
• This study examines trends in vaccine confidence across 8 sub-Saharan countries, measuring perceptions of the importance, safety, and effectiveness of vaccines, with the former of these 2 metrics now used in the BeSD framework as the major elements of vaccine confidence. The study highlights declining vaccine confidence trends across many sub-national regions in sub-Saharan Africa - notably, in the Democratic Republic of Congo (DRC). [Jun 2023]
   
• 2.Uncovering the Drivers of Childhood Immunization Inequality with Caregivers, Community Members and Health System Stakeholders: Results from a Human-Centered Design Study in DRC, Mozambique and Nigeria
  by Jessica C. Shearer, Olivia Nava, and Wendy Prosser, et al.
• Human-centred design (HCD) has been used in global health programmes to better understand the challenges and potential solutions from the perspective of end-users, which this study sought to do. In addition to using HCD tools, the research team drew on 3 analytical frameworks: the United Nations Children's Fund (UNICEF)'s Journey to Health and Immunization framework; the BeSD framework; and the determinants of childhood vaccine coverage model. Across all the countries (DRC, Mozambique, and Nigeria), most of the caregivers interviewed expressed the desire for their child to be vaccinated, but gender, social factors, and structural inequalities intersected and interacted to produce a variety of barriers. Presentation of caregivers' stories in community-level workshops built empathy and enabled co-design of locally relevant solutions. [Mar 2023]
   
• 3.The Behavioural Drivers Model: A Conceptual Framework for Social and Behaviour Change Programming
  by Vincent Petit
• Why do people do what they do? How can we influence it? These questions animate UNICEF's Behavioral Drivers Model (BDM), which offers a common reference and language for the study and practice of social and behaviour change (SBC). "The thinking is simple: one must investigate a behaviour to understand why it is happening, and then try to figure out what may influence these drivers no matter what they are. This problem-solving mindset is the key to moving away from pre-conceived ideas and go-to communication interventions, and instead approach behaviour change as a holistic effort addressing all possible psychological, social and structural factors that the diagnosis puts forward." [Sep 2019]
   
• 4.Strengthening Polio Vaccine Demand in Ghana: Understanding the Factors Influencing Uptake of the Vaccine and the Effectiveness of Different Message Frames
  by Anna-Leena Lohiniva, Anastasia Nurzhynska, and Abdul Mueed, et al.
• This cross-sectional study explores factors influencing the uptake of the type 2 novel oral polio vaccine (nOPV2) vaccine among Ghanaian mothers with children younger than 5 years old, as well as their intention to vaccinate in the future. The BDM was used as a conceptual framework for the study. The BDM categorises factors influencing behaviour into individual factors, social factors, and environmental factors, which in turn are divided into a number of dimensions. Those who received support from health workers and those who felt satisfied with the information provided by vaccinators were each 12% more likely to intend to vaccinate their child in the next polio vaccination campaign. The study also includes an experiment with short polio vaccine voice message "nudges" to identify the most effective message frames for encouraging vaccination. [Feb 2023]
   
• 5.Strengthening Immunization Service Experience: Global, Regional and Country Insight Gathering
• In order to move toward a more positive, people-centred immunisation service experience, John Snow Research & Training Institute, Inc. (JSI), in collaboration with Gavi, the Vaccine Alliance, and members of the Demand Hub Service Experience Workstream, consolidated existing knowledge and learning around immunisation service experience at the global and regional levels (January-April 2020) and in 4 countries (April-July 2020). Results were then shared at a Service Experience Co-Creation Workshop. This document summarises key outputs of the gathering. Among the recommendations: (i) collaborate with the Demand Hub BeSD group to conduct a systematic review of existing indicators that could be used to measure immunisation service experience; and (ii) conduct operational research in prioritised countries - documenting lessons learned about the immunisation service experience and its link to demand and improved immunisation coverage and equity. [Dec 2020]
   
• 6.What We Gain from More Behavioral Science in the Global South
  by Pauline Kabitsis and Lydia Trupe
• From the blog: "...There are several ways more work in the Global South can improve the field of behavioral science, including...by providing opportunities to solve system-level issues that often lie at the root of our most pressing challenges.....Our work at Common Thread focuses on improving behaviors related to health, like encouraging those persistently left behind to get vaccinated....We use a behavioral model that considers not just the individual biases that impact people's behaviors, but the structural, social, interpersonal, and even historical context that triggers these biases and inhibits health seeking behaviors....Because behavioral science applied in the Global South encourages us to consider the individual, along with the overarching political, economic, historical, social, and technological context, it forces practitioners to develop more complex frameworks and models for behavior change..." [Mar 2023]
   
• See also:
  Determinants of Immunisation Dropout among Children under the Age of 2 in Zambézia Province, Mozambique: A Community-Based Participatory Research Study Using Photovoice

• 7.Understanding the Behavioural and Social Drivers of Vaccine Uptake WHO Position Paper - May 2022
• This WHO position paper summarises the development of tools and indicators, published by WHO in 2022, to assess the BeSD of vaccine uptake for childhood and COVID-19 vaccination. The 4 BeSD domains include: (i) thinking and feeling about vaccines, (ii) social processes that drive or inhibit vaccination, (iii) motivation (or hesitancy) to seek vaccination, and (iv) practical issues involved in seeking and receiving vaccination. The paper also reports the main findings of a scoping review that examined existing systematic reviews and meta-analyses on interventions to improve vaccine uptake. It makes recommendations for using the tools and resulting data to prioritise local interventions and suggests future research directions. [May 2022]
   
• 8.A User-Centered Approach to Developing a New Tool Measuring the Behavioural and Social Drivers of Vaccination
  by K.E. Wiley, D. Levy, and G.K. Shapiro, et al.
• This prospective, descriptive, multi-country study illuminates the challenges faced by immunisation programme managers, partners, and stakeholders in obtaining and utilising good-quality BeSD data. For example, cultural and political sensitivities hindered how vaccine-related data are reported and used, which impeded advocacy for change. Also, capacity for conducting BeSD studies was lacking in some jurisdictions. To address this issue, some interviewees reported, for example, training local researchers to deploy surveys in a culturally acceptable way. When asked about what they felt the BeSD tools should include, among other things, participants highlighted the importance of awareness of the different ways that vaccine decisions are made in various cultures, as well as the fact that individual-centred questions might not be useful in all settings. [Sep 2021]
   
• 9.Using the Journey to Health and Immunization (JTHI) Framework to Engage Stakeholders in Identifying Behavioral and Social Drivers of Routine Immunization in Nepal
  by Nicole Castle, Surakshya Kunwar, and Leela Khanal, et al.
• UNICEF Nepal, JSI, and the Dhulikhel Hospital-Kathmandu University School of Medical Sciences established a Behavioral Science Center (BSC) to engage a diverse group of stakeholders in increasing the capacity of practitioners to use behavioural science in immunisation programming. The team decided to use the Journey to Health and Immunization (JTHI) framework, a model and journey mapping tool developed by UNICEF and its partners in 2017, as well as the BeSD approach. This paper describes the BSC's Behavioral Science Immunization Network, arguing that this type of engagement model is effective for generating demand for and strengthening capacity to use behavioural science approaches. [Nov 2023]
   
• 10.Behavioral Interventions for Vaccination Uptake: A Systematic Review and Meta-analysis
  by Amyn A. Malik, Noureen Ahmed, and Mehr Shafiq, et al.
• This systematic review and meta-analysis of the literature on behavioural-insights-based interventions to increase vaccine uptake includes 613 studies published between 1990 and 2020 that represent 64 countries globally, 27 of them low- and-middle income countries. The paper describes the BeSD domains in detail and highlights some studies across different countries as examples of how different techniques have been used to increase vaccine uptake. All domains they examined improved vaccine uptake, with the highest effect size associated with provider recommendation (odds ratio (OR): 3.4); BeSD domain: motivation) and on-site vaccination (OR: 2.9); BeSD domain: practical issues). [Sep 2023]
   
• 11.How Behavioral Economics Can Inform the Next Mass Vaccination Campaign: A Narrative Review
  by Ratnalekha V.N. Viswanadham
• The field of behavioural economics draws on psychological insights into human behaviour to analyse decision-making. It can explain why people hesitate to vaccinate and what strategies can encourage vaccination. This article argues that vaccination campaigns need to deliver processes and information necessary to help people decide to vaccinate, employing "nudges" (promoting action) and removing "sludge" (breaking down blockers) to influence decisions. For example, messaging from relatable figures in a community, such as local leaders or midwives, can motivate behaviours like vaccine uptake, as seen in the successes of polio vaccination. [Jan 2023]
   
• 12.Using Behavioral Insights to Increase the Demand for Childhood Vaccination in Low Resource Settings: Evidence from a Randomized Controlled Trial in Lebanon
  by Ali Osseiran, Fadi Makki, and Aya Haidar, et al.
• This randomised controlled trial investigates the barriers that prevent households in Lebanon's low-coverage areas from vaccinating their children, and it evaluates a behaviour change intervention that was designed to offset them. The most prevalent barriers identified were forgetfulness and neglect, as most beneficiaries lived in poverty, and therefore had diverted priorities. In response, a visual planning aid in the form of a calendar featuring 5 nudges was designed and distributed. The average vaccine uptake among households receiving the intervention (visual planning aid + outreach) was 20.2% (vs. 13.5% in the control group). The demand for vaccination increased 1.8 percentage points for every additional unvaccinated child in the household. [Oct 2023]
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• See also:
  Increasing Vaccine Acceptance Using Evidence-Based Approaches and Policies: Insights from Research on Behavioural and Social Determinants Presented at the 7th Annual Vaccine Acceptance Meeting

• The year 2024 marks 50 years of the Expanded Programme on Immunization (EPI), which helped set up essential infrastructure and standardised processes to universalise access to immunisation. However, inequalities persist in the coverage of immunisation globally and across the life course. This special issue of the journal Vaccines will include research and review articles that deepen our understanding of immunisation inequalities and highlight entry points or modalities to reduce them. Submit your manuscript by April 30 2024. Click here for details.
   

• 13.Prevention against Emerging Infectious Diseases: An Opportunity for Inclusive Health - Understanding the Behavioural and Social Drivers (BeSD) of COVID-19 Vaccination among Persons with Disabilities in Internally Displaced Camps in Somalia/Somaliland
  by Davide Ziveri and Hawaa Abdullahi
• Handicap International - Humanity & Inclusion adapted and piloted BeSD of vaccination tools to understand and analyse the perception of COVID-19 vaccines, as well as the barriers to and drivers of immunisation, among persons with disabilities in internally displaced person camps in Somalia/Somaliland. This study's hypothesis is that the drivers of and barriers to vaccination are shaped in specific ways by the experience of living with a disability in a given socio-cultural context. The inclusive use of the BeSD tools allows for the identification of these barriers at different levels and appropriate steps to address them before launching a risk communication and community engagement (RCCE) or SBC communication campaign. [Jul 2023]
   
• 14.Measuring Behavioral and Social Drivers of COVID-19 Vaccination in Health Workers in Eastern and Southern Africa
  by Helena Ballester Bon, Symen A. Brouwers, and Jenna Mote, et al.
• In 2021, 20 out of 21 countries in the Eastern and Southern Africa (ESA) region introduced COVID-19 vaccines. Health workers (HWs) were established as one of the priority groups for the first phase of COVID-19 vaccine roll out. HWs have heightened risk of COVID-19 infection and transmission, are one of the most trusted sources of information on COVID-19 vaccines, and can be a partner in the identification and implementation of (community) acceptable demand promotion strategies. Yet, with variable willingness to uptake vaccines across ESA countries, UNICEF conducted this study to better understand factors that impact BeSD by collecting data on 27,240 HWs in Kenya, Malawi, Mozambique, South Africa, and South Sudan. Practical Issues was found to be a critical dimension to consider: Despite working in healthcare settings, many HWs reported perceived lack of ease to access vaccination services for themselves. [Jul 2023]
   
• 15.Community-Based Approaches to Increase COVID-19 Vaccine Uptake and Demand: Lessons Learned from Four UNICEF-Supported Interventions
  by Kathryn L. Hopkins, Talya Underwood, and Iddi Iddrisu, et al.
• This article shares lessons learned from 4 UNICEF interventions that supported governments to generate acceptance and demand for COVID-19 vaccines in Zambia, Iraq, Ghana, and India. For example, UNICEF, in collaboration with Zambia's Ministry of Health, employed the BeSD of vaccination framework to identify population-wide personas that similarly represent the vaccination-related constructs of "thinking and feeling", "social norms", and "levels of motivation". Viamo developed and administered a mobile survey via interactive voice response to glean insights into demand for COVID-19 vaccines. The findings informed: (i) the development of tailored strategies to improve vaccine acceptance and demand for the different personas, and (ii) the revision of the national Advocacy Communication Social Mobilization strategy. [Jun 2023]
   
• 16.Defining Drivers of Under-immunization and Vaccine Hesitancy in Refugee and Migrant Populations
  by Anna Deal, Alison F. Crawshaw, and Jessica Carter, et al.
• Refugees and migrants may face a range of personal, social, and physical barriers to accessing health and vaccination services. This paper summarises key BeSD of vaccination among these communities, as well as solutions and strategies for tackling drivers of under-immunisation and vaccine hesitancy in the context of COVID-19 roll-out. Communication-related lessons learned to date suggest a focus on fostering meaningful community engagement, improving patient/provider interactions and building trust, providing strong risk communication, and designing and delivering tailored information that is context- and audience-specific. Multiple communication strategies will be needed to address the different motivations and social and cultural practices behind vaccine acceptance and preferred communication channels. It is important to do robust research prior to future vaccination campaigns to identify key BeSD of vaccination and to design appropriate strategies. [Jun 2023]
   

• 17.Behavioural and Social Drivers of Vaccination: Tools and Practical Guidance for Achieving High Uptake
  by Lisa Menning and Francine Ganter-Restrepo
• From WHO, this guide follows a 3-step process (plan, investigate, and act) and includes: a quick start guide, which provides an overview on how to gather, analyse, and use BeSD data; an explanation of each step and best-practice recommendations; and tools to measure the drivers of vaccine uptake. [2022]
   
• 18.Human-Centred Design for Tailoring Immunization Programmes
• This guide leverages UNICEF's Human Centred Design 4 Health (HCD) and WHO's Tailoring Immunization Programmes (TIP) to create a consolidated and simplified strategy for evidence-based co-design suited to low-resource settings: HCD-TIP. Through a series of steps detailed in each of 4 stages - Diagnose, Design, Implement, and Evaluate - this guide outlines a cyclic process to overcome hurdles to vaccination. Guided by the BeSD framework, the process is designed to be people focused, community centred, applicable to immunisation across life stages and all public health campaigns, and adaptable to new situations, such as emerging needs during emergencies. [2022]
   
• See also:
  Vaccination Demand Hub

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