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.

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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

POSITIVE PATHWAY

POINTS OF DIVERGENCE

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Vaccine enters
consideration set

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Seeking Mitigation Strategies

How can I cope with the
COVID-19 risk?

More Details

Confidence in current mitigation measures

 

Vaccine decision avoidance

Perceived need for vaccine

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COVID-19 Vaccine Appraisal

How do I feel about the COVID-19 Vaccine?

More Details

Unfavorable vaccine appraisal and favorable status quo appraisal

 

Selective engagement with 

Acceptance of vaccine

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Coping with Vaccine Risk
 

How can I cope with vaccine risk?

More Details

Unfavorable vaccine and favorable status quo appraisal

 

Procrastination and reappraisal

Getting 1st 
vaccine jab

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Vaccination Uptake

How can I get this vaccine?

More Details

Ability/access gaps

 

Inaction and rationalization

Complete

COVID-19/boosters vaccine

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Vaccination Adherence

Should I get the second dose?

More Details

Lack of coping expectation discrepancy or poor intent

 

Second dose avoidance

Internalization of COVID-19 Risk

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COVID-19 Disease Appraisal

What do I feel about the COVID-19 disease?

More Details

Negligible 
COVID-19 risk

 

Vaccine information and decision avoidance

Qualitative Insights

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:
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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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. 

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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. 

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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.

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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.

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Vaccine mandates are a much needed push towards vaccination for some, and cause for concern and skepticism for others.

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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.

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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.

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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.

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The ‘moveable middle’ considering vaccination but uncertain about adverse effects may procrastinate taking the vaccine.

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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.

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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.

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