Changing Behaviour: Increasing COVID-19 Vaccination Uptake

• Changing Behaviour: Increasing COVID-19 Vaccination Uptake
  • Intentions do not always predict behaviour
  • Factors associated with lower uptake
  • Recommendations for increasing uptake
  • Interventions shown to increase uptake
  • Initiatives aimed at increasing uptake
• Vaccination Rates Around the World
  • Country-level variables associated with higher uptake

Intentions do not always predict behaviour

• The factors influencing any behaviour are complex and not always predicted by a person's attitudes or intentions. Vaccination uptake is therefore likely to be lower than the rates of people expressing a willingness or intention to be vaccinated.

• In the United States, 92% of those who, in early 2021, intended to get vaccinated “as soon as possible” had received at least one dose of a COVID-19 vaccine 6 months later. Of those who said they would “definitely not” get vaccinated or would “only get vaccinated if required”, 76% remained unvaccinated.
• Dai et al. (2021) obtained different results when assessing vaccination intentions in an online study versus vaccination uptake in a field study, highlighting the need for caution in relation to research examining intentions.

Factors associated with lower uptake

• Studies reporting on England’s National Health Service, in the preliminary weeks of vaccine roll-out, identified lower vaccination rates among ethnic minorities, people living in areas of higher deprivation, and those with severe mental illness or learning disabilities (MacKenna et al., 2021, UK SAGE).
• This pattern of lower uptake among ethnic minorities and those from more deprived areas was also found among healthcare workers offered vaccinations (Martin et al., 2021).

• In England, younger age groups are showing lower levels of vaccination uptake and larger gaps in uptake between those from the most and least deprived groups (Osama et al., 2021).
• In the United States, most unvaccinated people have low incomes.
• In the United States, there are lower vaccination rates in counties where residents prioritise moral concerns about bodily and spiritual purity and higher vaccination rates in counties where residents show stronger endorsement of values relating to fairness and loyalty to the group (Karimi-Malekabad et al., 2021 preprint).
• A key issue now, in many countries, is encouraging uptake of boosters (see e.g., CDC). At present, even countries that achieved high coverage with their initial vaccination campaigns may struggle with booster uptake (see e.g., [CDC]((see e.g., Bohm et al., 2022). The fact that, for many, the pandemic is now perceived as less of an immediate threat (see also, Lazarus et al., 2022) means that efforts to increase uptake will likely be necessary. The recommendations for increasing uptake detailed next extend to booster campaigns.

Recommendations for increasing uptake

Ensure the target population has the capability, opportunity and motivation to get vaccinated.

• Increase public understanding of vaccine safety, benefits, side-effects and requirements for full vaccination (BPS, 2021). Use mass media campaigns but ensure messages are tested first (Chevalliere et al., 2021).

• Provide evidence for the effectiveness of vaccinations (BPS, 2021).

• Use short, clear messages that can be easily understood and remembered. Avoid scientific and vaccine-related jargon (BPS, 2021; Lawes-Wickwar et al., 2021; Wood & Schulman, 2021) .
• Use trusted messengers and communications channels and honest information (BPS, 2021; Chevalliere et al., 2021; Lawes-Wickwar et al., 2021; Razai et al., 2021; Kushel et al., 2021). Consider the target audience when selecting a messenger; for those with less interest in vaccination, the likeability of the messenger may be more important than their expertise (Wood & Schulman, 2021).

• Personalise messages to meet the specific needs of individuals and groups. Include target populations in the design and delivery of messages (BPS, 2021; Lawes-Wickwar et al., 2021). Where needed, translate material into appropriate languages or produce in a more accessible format (Razai et al., 2021).
• Create novel messages using bright color, emotion, humor, sensory information and memorable catchy slogans. Present these where people are likely to encounter them in their daily lives (Wood & Schulman, 2021).
• Have readily available online material on vaccine safety and effectiveness for both healthcare workers and vaccine recipients (Razai et al., 2021).
• Make vaccinations free and easy to access with no prescription. Identify and remove barriers to access and factors known to make vaccination inconvenient. Make vaccines available at doctors' surgeries, worksites and other places that are familiar to local residents (BPS, 2021; Chevalliere et al., 2021; Hamel et al., 2021). Where needed, offer appointments in the evenings and weekends and offer to arrange transport or use home visiting facilities (Razai et al., 2021). Give people paid time off work to get vaccinated and to recover from any side effects (Hamel et al., 2021).
• For priority populations, send reminders and prompts in a timely manner, for example using text messages, emails, postcards and/or phone calls (Chevallier et al., 2021). Ensure the method of delivery is appropriate to the target population (Lawes-Wickwar et al., 2021).
• Exploit social norms by helping people communicate to others about their decision to be vaccinated, for example by giving away badges or ribbons (Chevalliere et al., 2021).

Interventions shown to increase uptake

• Research conducted in the United States showed that text-based reminders delivered one day after notification of vaccine eligibility increased uptake by 3.57 percentage points. The reminders were designed to make vaccination salient (to curb forgetfulness) and easy (by including a link to the appointment scheduling website). These reminders were more effective when the wording was designed to induce psychological owernship ('…been made available for you', '…claim your dose'). Follow-up reminders delivered 8 days after notification further increased uptake by 1.06 percentage points. However, there was no evidence that combining reminders with video-based information addressing vaccine hesitancy increased their effect (Dai et al., 2021).
• In rural Turkey, uptake among those who have declined a vaccination has reportedly been increased by nearly 30% by teams of doctors and healthcare workers telephoning individuals and visiting them at home, sometimes accompanied by a community leader.

Initiatives aimed at increasing uptake

• Many governments have used incentives to increase uptake. These have included cash, goods, food, alcohol, lottery tickets, baseball game tickets, museum admission, and travel cards (see Higgins et al., 2021 for a review of the use of incentives). However, an analysis of state incentive programmes in the US showed they were not associated with any significant change in vaccination rates (Thirumurthy et al., 2021 preprint).
• Vaccine passes/passports and COVID-19 health certificates have been introduced in some countries. These allow individuals access to certain activities or venues, such as places of work, education or entertainment. Some have suggested they can increase vaccination rates, but their use is controversial with other evidence suggesting they might lead to lower vaccination uptake (Drury et al., 2021).

• Bateman et al. (2021) sent mobile SMS messages to patients with rheumatic disease (an at-risk group for COVID-19 complications). The messages contained a link to an 8-min interactive web-based educational video.
• In San Francisco, those experiencing homelessness have been reached using mobile teams of people with community roots (Kushel et al., 2021).
• The Conversation is an American website where Black and Latino health care workers provide information about COVID-19 vaccines and users can find their nearest vaccination centre.
• Finally, for expert advice specifically on improving booster uptake see Bohm et al., 2022.

Vaccination Rates Around the World

Our World in Data tracks vaccination rates around the world. Differences between countries will reflect both vaccine availability and uptake.

Source: Our World in Data

Country-level variables associated with higher uptake

Some of the factors that influence vaccination uptake can be viewed as broader sociocultural variables that emerge slowly over extended periods of time. Such factors would point to the need for longer term investment in initiatives aimed at social and cultural change.

• High rates of COVID-19 vaccination uptake in Chile have been linked to a history of public trust in vaccines and an awareness of their benefits alongside high uptake of other vaccinations (Castillo et al., 2021).

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