The “Improving Vaccine Uptake Project” is a collaborative effort that focuses on identifying and targeting the range of barriers and behavioral drivers that underlie vaccine hesitancy within different populations.
Vaccine Decision Journey
Our study indicates that COVID-19 vaccination decision is a journey progressing through a set of micro-decisions. The decision journey consists of decision stages with desired outcomes. Sewed together, all the desired outcomes collectively create a positive pathway for vaccine uptake action. But in this journey at the decision stages, evaluation also leads to unfavourable assessment of COVID-19 vaccine causing drop offs.
In the vaccine decision journey there are enablers that facilitate a person to move forward in their COVID-19 vaccine uptake journey through the different decision stages. And there are barriers that impede the forward movement of a person through the decision stages resulting in either regression to previous stage(s) or lead them to drop out of their COVID-19 vaccine uptake journey.
The journey framework exists within the larger dynamic COVID-19 context. There are triggers, arising within the context, which can result in non-linear and iterative movements within the journey, and they can:
Push an individual forward towards uptaking the COVID-19 vaccine (e.g., during a pandemic peak, the high case load leads to higher risk perception and a more favorable vaccine appraisal).
Move an individual back towards avoiding the COVID-19 vaccine (e.g., a lower case load leads to lower risk perception, or a high ‘“viral” vaccine adverse event leads to a higher vaccine risk).
Lead an individual to skip some stages and move directly to uptake (e.g., extreme symptoms).
Journey to COVID Vaccince Uptake Framework
POINTS OF DIVERGENCE
Seeking Mitigation Strategies
How can I cope with the
Confidence in current mitigation measures
Vaccine decision avoidance
Perceived need for vaccine
COVID-19 Vaccine Appraisal
How do I feel about the COVID-19 Vaccine?
Unfavorable vaccine appraisal and favorable status quo appraisal
Selective engagement with
Acceptance of vaccine
Coping with Vaccine Risk
How can I cope with vaccine risk?
Unfavorable vaccine and favorable status quo appraisal
Procrastination and reappraisal
How can I get this vaccine?
Inaction and rationalization
Should I get the second dose?
Lack of coping expectation discrepancy or poor intent
Second dose avoidance
Internalization of COVID-19 Risk
COVID-19 Disease Appraisal
What do I feel about the COVID-19 disease?
Vaccine information and decision avoidance
Phase 1 of the study has been completed. The initial findings from the qualitative data confirm the presence of a number of behavioral enablers and barriers affecting vaccine confidence and thereby the uptake behavior surrounding COVID-19 vaccines. The behavioral complexity surrounding vaccinations involve factors such as vulnerabilities, contextual anchors, risk perception and information seeking. We identified the following themes contributing to the COVID-19 vaccination behavior:
With the vaccine having been available for almost a year and 50% of the population in Pakistan already vaccinated, the ‘moveable middle’ is rapidly shrinking. Most people have already decided whether the vaccine is favorable or unfavorable.
Low COVID-19 case burden leads to a feeling of low risk and the belief that COVID-19 disease is not relevant in Burkina Faso. In this context, vaccine is not considered as an active decision to be made.
With less than 20% of the population vaccinated in African countries, the majority of the population in Kenya and Cote D'Ivoire is still contemplating the vaccination decision, creating a large movable middle who have not yet made their final decision.
People are unable to make sense of inconsistent and contradictory information around vaccine, resulting in a pursuit of lived and heard experience from 'trusted' people around them.
With radio, ‘community criers’ and community bodies as the dominant channels of information, together with low COVID-19 information seeking behaviour, limits their exposure to COVID-19 reporting and misinformation.
Even though individuals may harbour favourable vaccine beliefs, lack of engagement on the topic of vaccines and COVID-19 within the community and low signalling of vaccination status by those who have been vaccinated does not create necessary social proof needed for vaccine action.
For people who trust and engage with mainstream information channels and the health system, COVID-19 vaccination uptake is more likely. Those who remain on the margins of these institutions, in terms of access and trust, feel alienated from the vaccination process.
European dynamics play a central role in influencing beliefs around COVID-19 disease and COVID-19 vaccine. Europe’s experience with the pandemic and vaccine provides points of comparison, often leading to negative COVID-19 vaccine intention.
There is deep rooted distrust towards any kind of external intervention due to colonial history. ‘Us’ vs ‘Them’ mental model is used to view the vaccines.
There is high trust in the health system to treat extreme symptoms and conditions. Hesitancy among HCWs with respect to COVID-19 disease and the perceived trivial nature of symptoms impedes trust in vaccination and health information seeking behavior.
Experiences of living with other epidemics and endemic diseases (like HIV, Malaria, Yellow fever, Ebola, Meningitis) act as reference points to evaluate COVID-19 symptoms, severity, and the ability to cope with COVID-19.
Vaccine mandates are a much needed push towards vaccination for some, and cause for concern and skepticism for others.
While mandates can be the much needed push for the unvaccinated, mandates create a perception that those vaccinated have done so due to only the mandate overshadowing vaccine relevance and benefits.
People will default to staying unvaccinated, unless a felt need and urgency for vaccines are created, as vaccination is seen as a disruption to their current ‘healthy’ state.
Even though individuals may believe the vaccine is favorable, prolonged vaccine inaction due to various barriers leads to a disconnect between their beliefs and actions. This disconnect eventually leads to a belief that the vaccine is unfavorable.
The ‘moveable middle’ considering vaccination but uncertain about adverse effects may procrastinate taking the vaccine.
Women are at risk of remaining unvaccinated, given their limited decision autonomy, high fear from dominant misinformation themes regarding infertility, and limited exposure to information and mandates.
People suffering from other illnesses and pre-conditions, fear the ‘strong’ vaccine and adverse effects therefore avoid vaccination altogether, alienating a critical high risk population.