Behavioural Considerations for Acceptance and Uptake of COVID-19 Vaccines: WHO Technical Advisory Group on Behavioural Insights and Sciences for Health

"Learning can be increased by engaging with target populations in local communities to listen and respond to their perspectives, concerns and expectations in relation to vaccination..."

Recent years have seen a great deal of research on vaccination uptake and its behavioural drivers. While evidence on promoting vaccination in general is useful, the acceptance and uptake of COVID-19 vaccines present an unprecedented challenge. In an effort to support targeted efforts to achieve high and equitable COVID-19 vaccine uptake, the World Health Organization (WHO) Technical Advisory Group (TAG) on Behavioural Insights and Sciences for Health and WHO Department of Immunization, Vaccines and Biologicals held a meeting on October 15 2020 to share behavioural insights and make recommendations. This report summarises the guidance that emerged.

The TAG identified 3 categories of drivers of vaccine uptake, based on existing behavioural research:

1. Enabling environment - Multiple groups influence uptake of vaccination, including political decision-makers, immunisation programme managers, community and religious leaders, health workers, civil society organisations, media outlets, and digital platforms. These actors can facilitate or discourage vaccination by creating more or less enabling environments. For example, one component of the environment is information: Have people been given timely, easy-to-understand and relevant information about what they are supposed to do, how they are supposed to do it, and how they might benefit? Strategies for creating an enabling environment include, for example, designing services and policies to support people's intended behaviours and circumstances. For instance, the TAG indicates that making vaccines available from familiar and convenient locations can encourage uptake. It also noted, however, that fears of contracting COVID-19 in a health facility might impede immunisation efforts, and so safety measures should be implemented visibily. An enabling environment is necessary but not sufficient; what is also needed is targeted, credible, and clear communication from trusted sources demonstrating that getting vaccinated is important, beneficial, easy, quick, and affordable (or free).
2. Social influences - Barriers to vaccine acceptance and uptake can be the product of unfavourable social influences and/or insufficiently favourable ones. Such influences can include beliefs about what others in one's social group do, or what they approve and disapprove of (social norms). Media reports can intensify and skew these beliefs, for better or for worse. For example, anti-vaccine sentiments expressed by relatively small but vocal groups may be highlighted heavily in the media, so that they are erroneously seen as capturing a widespread or even majority view. The TAG asserts that harnessing social influences can be used to promote favourable behaviours of both health professionals and the general population. This can be achieved by:
   • Making social norms in favour of vaccination more salient: Making uptake visible, either via social media or by enabling ways for people to signal they have been vaccinated, can normalise vaccination.
   • Highlighting new and emerging norms in favour of vaccination: Communication that spotlights the development of new norms is especially important given that efforts to distribute the COVID-19 vaccine will be focused on groups in which vaccination may not be the common or the expected behaviour.
   • Leveraging the role of health professionals: Targeting efforts to facilitate the vaccination of health professionals can in turn lead to greater acceptance and uptake by the general population.
   • Supporting health professionals to promote vaccination: Conversations guided by motivational interviewing, a collaborative method of interaction aimed at exploring people's real reasons for hesitancy and strengthening their own motivation for change, have been found to facilitate vaccination. Recommendations from providers have also been shown to be more effective when the opportunity to get vaccinated is presented as an expectation (the default) rather than an option.
   • Amplifying endorsements from trusted community members: If endorsers share similar values and characteristics with the relevant group (such as religious or ethnic identity), they are more likely to be influential.
3. Motivation - Some groups may believe they are at low risk, and so are reluctant to be vaccinated; others may be wary of the safety of the vaccine; and still others may be hesitant because of religious values or lack of trust in the health system. Key strategies to remove motivational barriers include:
   • Building timely trust in vaccines: This could involve using trusted messengers to help navigate the COVID-19 information landscape and build confidence in the vaccine development process. Communities should be engaged early on to listen to concerns, respond to questions, and address misinformation. Communicating consistently, transparently, empathetically, and proactively about uncertainty, risks and vaccine availability can contribute to building trust.
   • Leveraging anticipated regret in communications: Anticipated regret - when people expect that an unpleasant future outcome would lead them to wish they had made a different decision - has been shown to be a strong predictor of vaccination, and there is potential promise in evoking it to encourage vaccination. For example, asking people during consultations with health professionals how they would feel if they did not get vaccinated and ended up contracting COVID-19 or transmitting it to loved ones may encourage vaccination.
   • Emphasising the social benefits of vaccination: Communicating the fact that vaccination protects others in the community has been found to increase vaccination intention, particularly when the risk associated with vaccination is low and getting vaccinated involves little effort.

A common theme to emerge from the above is engagement with local communities in developing and implementing tailored strategies to support vaccination uptake. The TAG suggests that working in partnership with communities, building trust, and ensuring that messages come from trusted endorsers are key strategies. Furthermore, "As local circumstances change over time, drivers of people's behaviour will shift as well; it is important to monitor and respond to these changes in as timely a manner as possible."

While this report seeks to extract evidence-based principles that can be considered relevant across a wide range of populations and settings, the TAG recommends that the behavioural considerations be further researched locally, including in underrepresented low- and middle-income settings, to inform targeted and context-specific interventions.

In conclusion: "New evidence relevant to increasing COVID-19 vaccine acceptance and uptake will emerge over time, which means that obtaining and using up-to-date evidence is critical. This report is designed to provide a framework within which to consider new knowledge as it emerges and to help to shape forthcoming policies."