The pandemic has been central to our lives for the past 2 years and the context has been ever dynamic and it still continues to evolve. From high caseloads, prolonged peaks and gradual tapering, high fatalities, lockdowns, quarantine we are now at a stage where we are seeing a burst of cases, quick peaks and sudden tapering, lower fatalities, removal of covid appropriate behavioral mandates etc. And then there are the COVID-19 vaccines. Developed at a breath-taking speed, vaccines have provided a sense of hope and control over a seemingly ravenous disease.
Dr. Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization, has said that “Vaccine inequity is the world’s biggest obstacle to ending this pandemic and recovering from COVID-19”. Though there is no denying that vaccine inequity exists and the same was evident in the way vaccines were rolled out predominantly in the high income economies first, yet vaccine inequity is largely seen as only a supply-focussed problem rooted in the delivery aspect of the vaccine. Achieving vaccine equity requires both the availability of the vaccine and also the uptake of the vaccine. Hence, for a more holistic action plan to tackle the ‘biggest obstacle’ may require efforts to address both the supply-side barriers as well as the demand-side barriers.
Hesitancy…the demand-side obstacle
Individual decision-making and actions in relation to COVID-19 vaccine uptake are more complex than commonly appreciated. In spite of vaccine availability, social security support and better health delivery systems, the United States (66%) and the European Union (73%) have not been able to vaccinate the desirable percentage of population. The problem of less desirable vaccination rates hence is not only because that vaccines are unavailable but there is inconsistent uptake behavior within the population. For Africa, the percentage of the population fully vaccinated is just 16%. We should be cautious not to be under the impression that the low numbers seen around vaccination can be resolved by supplying the necessary resources.
The demand-side obstacle that impedes positive vaccine action is low confidence and low willingness, resulting in hesitancy to take up the COVID-19 vaccine. Vaccine hesitancy is a delay in acceptance, or refusal, of vaccination despite the availability of vaccine services. Hesitancy is complex, contextual, and varies across time, place and vaccine type. Though COVID-19 has brought the spotlight over hesitancy behavior, pockets of hesitancy have been observed with respect to other vaccines like DPT, MMR, and Polio which have seen less than optimal level of uptake in recent years resulting in unwanted outbreaks of Rubella, Polio, and Measles. Vaccine hesitancy exists in the realm of human behavior and impacts demand for vaccines. Human behavior is affected by internal factors rooted in psychological underpinnings as well as external factors rooted in the environmental landscape. Exploring behaviors, attitudes and beliefs supporting hesitancy and impacting the demand for COVID-19 vaccination, and not just supply focussed environmental landscape, can enable a more nuanced understanding needed for policymakers and governments for demand mobilization and improving vaccination numbers.
Psycho-Behavioral Segmentation Approach
In our ongoing study a key objective is to identify population segments who are more likely to be hesitant or averse towards COVID-19 vaccination, but with targeted intervention and confidence building measures have the potential to have their beliefs and behaviors moved towards desirable vaccine attitude and action.
Segmentation is a popular go-to tool for targeted solutioning. Segmentation is defined as a statistical method of classifying people into groups based on their characteristics and is used to tailor products and services to sub-sections of the targeted populations. Often segmentation leads to clustering of observables based on revealed preferences, demographic factors and one that uses the ‘What’ aspect more than the ‘How’ aspect to define the segments. A ‘What’ type segmentation focuses on questions to unearth observable such as - ‘what is the age’, ‘what is the kind of choice made (or expected to be made or has been made), ‘what is the gender’, ‘what are the benefits’ etc. But identifying segments on just the ‘what’ aspects can leave efforts of targeting half baked. A ‘How’ segmentation can augment segment definition by asking questions that help unearth the unobservables, seated in the minds of individuals as well as inexplicit contextual and environmental dynamics - ‘how is a choice made’ , ‘how does gender impact outcome’, ‘how are the benefits evaluated’, ‘what are the different decision context’ etc. The psycho-behavioral approach we have adopted in this project tries to capture clear, discrete, and relevant differences within the population, based on perceptions, motivations and affective cognition driving individual behaviors behind the vaccine decision. This helps us capture behavioral decision heuristics and also biases involved, paving the way for addressing the behavioral barriers and leveraging the behavioral enablers towards positive vaccine action and improving vaccination program efficacy.
Decision to take or avoid the vaccine requires one to appraise different parameters surrounding the decision such as rewards, risks, ability, and motivation. Decision making thus is more of a journey involving different milestones (sub-decisions) than just the mere action of vaccination or inaction of it. Each decision consists of an elaborate evaluation process involving multiple behavioral components such as
Relevance (‘does the vaccine help achieve my health/economic/social/survival goals?’)
Coping ability (‘how will i deal with the risks or stresses?’)
Risk perception (‘Is COVID-19 dangerous enough? and/or Is COVID-19 vaccine risky?’)
Risk-reward trade-off (‘What are the short term risks and long term rewards? Do the risks outweigh the rewards?’ )
Mental models (‘COVID-19 does not affect people with strong immunity’; ‘if i don’t see cases around me, I dont think there is any cause for concern’),
Social norms ( ‘what would others in my locality think if I decide to take the vaccine?’; ‘are others in the neighbourhood also taking up the COVID-19 vaccine?’) etc.
In understanding an individual’s vaccination decision, segments are often created using decision outcomes (choice and preferences) and not the decision process (motivations, beliefs, and attitudes). Sizing populations based on the the different elements and stages of the decision process layered over the individual actions can help create more nuanced segments which can be better targeted.
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Ali, M., Khan, J., Ahmad, N. et al. COVID-19 vaccination gives hope to eradicate polio. Nat Med27, 1660–1661 (2021). https://doi.org/10.1038/s41591-021-01518-z