--- title: Variables determining COVID-19 vaccine uptake tags: live-v0.2, behaviour permalink: https://c19vax.scibeh.org/pages/vaxuptake --- {%hackmd 5iAEFZ5HRMGXP0SGHjFm-g %} {%hackmd GHtBRFZdTV-X1g8ex-NMQg %} # Changing Behaviour: Increasing COVID-19 Vaccination Uptake ::: warning This page summarises the specific variables that have been associated with uptake of the COVID-19 vaccines so far, including research that has been conducted since the publication of the handbook in January 2021. **These determinants of COVID-19 vaccine uptake are also linked to many other factors, which we cover in greater detail on separate, dedicated [pages](https://hackmd.io/@scibehC19vax/home#Table-of-contents-for-the-wiki-grouped-by-topic)**. We provide additional links in the green boxes to relevant pages that provide more in-depth material to the points on this page. ::: [TOC] ## Intentions do not always predict behaviour * The factors influencing any behaviour are [complex](https://implementationscience.biomedcentral.com/articles/10.1186/1748-5908-6-42) and [not always predicted](http://eprints.whiterose.ac.uk/107519/3/The%20Intention-Behavior%20Gap%20R1.pdf) 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. :::success See our page on [attitudes and intentions related to COVID-19 vaccines](https://c19vax.scibeh.org/pages/publicattitudes) for more information. ::: * In the [United States](https://www.kff.org/coronavirus-covid-19/poll-finding/kff-covid-19-vaccine-monitor-in-their-own-words-six-months-later/), 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)](https://www.nature.com/articles/s41586-021-03843-2?utm_source=twt_nat&utm_medium=social&utm_campaign=nature) 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](https://www.medrxiv.org/content/10.1101/2021.01.25.21250356v2), [UK SAGE](https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/952716/s0979-factors-influencing-vaccine-uptake-minority-ethnic-groups.pdf)). * 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](https://www.medrxiv.org/content/10.1101/2021.02.11.21251548v2.full.pdf)). :::success See our page on [cultural differences in vaccine uptake](https://c19vax.scibeh.org/pages/vaxculture) for more information. ::: * In England, **younger age groups** are showing lower levels of vaccination uptake and [larger gaps in uptake](https://twitter.com/chrischirp/status/1382725119773134848?s=12) between those from the most and least deprived groups ([Osama et al., 2021](https://blogs.bmj.com/bmj/2021/10/14/covid-19-vaccination-in-children-adolescents-and-young-adults-how-can-we-ensure-high-vaccination-uptake/?utm_source=twitter&utm_medium=social&utm_term=hootsuite&utm_content=sme&utm_campaign=usage)). * In the [United States](https://www.axios.com/covid-vaccines-low-income-poor-workers-58698275-0451-4158-a967-37189dbf673c.html), 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](https://psyarxiv.com/z6kxm/)). * <span style = 'color:green'> A key issue now, in many countries, is encouraging uptake of boosters (see e.g., [CDC](https://www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html)). 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](https://www.thelancet.com/action/showPdf?pii=S2589-5370%2822%2900362-5)). The fact that, for many, the pandemic is now perceived as less of an immediate threat (see also, [Lazarus et al., 2022](https://www.nature.com/articles/s41467-022-31441-x])) means that efforts to increase uptake will likely be necessary. The recommendations for increasing uptake detailed next extend to booster campaigns. </span> ## Recommendations for increasing uptake Ensure the target population has the [capability, opportunity and motivation](https://www.bps.org.uk/sites/www.bps.org.uk/files/Policy/Policy%20-%20Files/Optimising%20vaccine%20uptake.pdf) to get vaccinated. * Increase public **understanding** of vaccine safety, benefits, side-effects and requirements for full vaccination ([BPS, 2021](https://www.bps.org.uk/sites/www.bps.org.uk/files/Policy/Policy%20-%20Files/Optimising%20vaccine%20uptake.pdf)). Use mass media campaigns but ensure messages are tested first ([Chevalliere et al., 2021](https://www.cell.com/trends/cognitive-sciences/pdf/S1364-6613(21)00033-4.pdf)). :::success See our pages on [facts about COVID-19 vaccines](https://c19vax.scibeh.org/pages/c19vaxfacts) and [potential side effects](https://c19vax.scibeh.org/pages/sideeffects) for more information. ::: * Provide **evidence for the effectiveness** of vaccinations ([BPS, 2021](https://www.bps.org.uk/sites/www.bps.org.uk/files/Policy/Policy%20-%20Files/Optimising%20vaccine%20uptake.pdf)). :::success See our page on the [success of vaccines](https://c19vax.scibeh.org/pages/vaxsuccess) for more information. ::: * Use **short, clear messages** that can be easily understood and remembered. Avoid scientific and vaccine-related jargon ([BPS, 2021](https://www.bps.org.uk/sites/www.bps.org.uk/files/Policy/Policy%20-%20Files/Optimising%20vaccine%20uptake.pdf); [Lawes-Wickwar et al., 2021](https://www.mdpi.com/967546); [Wood & Schulman, 2021](https://jamanetwork.com/journals/jama/fullarticle/2780792?resultClick=1)) . * Use **trusted messengers and communications channels** and honest information ([BPS, 2021](https://www.bps.org.uk/sites/www.bps.org.uk/files/Policy/Policy%20-%20Files/Optimising%20vaccine%20uptake.pdf); [Chevalliere et al., 2021](https://www.cell.com/trends/cognitive-sciences/pdf/S1364-6613(21)00033-4.pdf); [Lawes-Wickwar et al., 2021](https://www.mdpi.com/967546); [Razai et al., 2021](https://www.bmj.com/content/373/bmj.n1138); [Kushel et al., 2021](https://blogs.bmj.com/bmj/2021/03/22/bringing-covid-19-vaccines-to-high-risk-populations-like-those-who-are-homeless-requires-a-tailored-approach/)). 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](https://jamanetwork.com/journals/jama/fullarticle/2780792?resultClick=1)). :::success See our pages on [trust in scientists](https://c19vax.scibeh.org/pages/trust_scientists) and the importance of [health care professionals](https://c19vax.scibeh.org/pages/healthpros) for more information. ::: * **Personalise messages** to meet the specific needs of individuals and groups. Include target populations in the design and delivery of messages ([BPS, 2021](https://www.bps.org.uk/sites/www.bps.org.uk/files/Policy/Policy%20-%20Files/Optimising%20vaccine%20uptake.pdf); [Lawes-Wickwar et al., 2021](https://www.mdpi.com/967546)). Where needed, translate material into appropriate languages or produce in a more accessible format ([Razai et al., 2021](https://www.bmj.com/content/373/bmj.n1138)). * 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](https://jamanetwork.com/journals/jama/fullarticle/2780792?resultClick=1)). * Have readily available **online material** on vaccine safety and effectiveness for both healthcare workers and vaccine recipients ([Razai et al., 2021](https://www.bmj.com/content/373/bmj.n1138)). * 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](https://www.bps.org.uk/sites/www.bps.org.uk/files/Policy/Policy%20-%20Files/Optimising%20vaccine%20uptake.pdf); [Chevalliere et al., 2021](https://www.cell.com/trends/cognitive-scences/pdf/S1364-6613(21)00033-4.pdf); [Hamel et al., 2021](https://www.kff.org/coronavirus-covid-19/poll-finding/kff-covid-19-vaccine-monitor-april-2021/)). Where needed, offer appointments in the evenings and weekends and offer to arrange transport or use home visiting facilities ([Razai et al., 2021](https://www.bmj.com/content/373/bmj.n1138)). Give people paid time off work to get vaccinated and to recover from any side effects ([Hamel et al., 2021](https://www.kff.org/coronavirus-covid-19/poll-finding/kff-covid-19-vaccine-monitor-april-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](https://www.cell.com/trends/cognitive-sciences/pdf/S1364-6613(21)00033-4.pdf)). Ensure the method of delivery is appropriate to the target population ([Lawes-Wickwar et al., 2021](https://www.mdpi.com/967546)). * 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](https://www.cell.com/trends/cognitive-sciences/pdf/S1364-6613(21)00033-4.pdf)). ## 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](https://www.nature.com/articles/s41586-021-03843-2?utm_source=twt_nat&utm_medium=social&utm_campaign=nature)). * In [rural Turkey](https://www.theguardian.com/world/2021/apr/27/covid-vaccination-persuasion-teams-reap-rewards-in-turkey?CMP=Share_iOSApp_Other), 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](https://www.theguardian.com/society/2021/aug/03/savings-bonds-lotteries-and-cheap-food-do-vaccine-incentives-work?CMP=Share_iOSApp_Other), [baseball game tickets, museum admission](https://www.theguardian.com/us-news/2021/may/07/new-york-city-vaccines-tourists-johnson-and-johnson?CMP=Share_iOSApp_Other), and [travel cards](https://www.rollingstone.com/culture/culture-features/vaccine-reward-incentive-lottery-bond-1170692/) (see [Higgins et al., 2021](https://www.sciencedirect.com/science/article/pii/S0091743521000050) 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](https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3912786)). * **Vaccine passes/passports** and **COVID-19 health certificates** [have been introduced in some countries](https://www.theguardian.com/world/2021/aug/01/leaders-tackle-global-question-of-how-to-persuade-unvaccinated-to-get-covid-jab?CMP=Share_iOSApp_Other). 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](https://www.cbc.ca/news/canada/british-columbia/why-hesitant-people-now-getting-vaccinated-1.6210266), but their use is [controversial](https://inews.co.uk/opinion/vaccine-passports-covid-dont-make-sense-for-our-health-or-society-encouraging-self-isolation-is-more-effective-1179458) with other evidence suggesting they might lead to lower vaccination uptake ([Drury et al., 2021](https://link.springer.com/article/10.1186/s12889-021-11166-0)). <!--Should also add newer references on mandates and vaccine passports--> :::success See our page on [vaccination mandates](https://hackmd.io/@scibehC19vax/vaxmandates) for more information. ::: * [Bateman et al. (2021)](https://www.thelancet.com/journals/lanrhe/article/PIIS2665-9913(21)00148-X/fulltext) 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](https://twitter.com/MKushel/status/1415109211969638407) of people with community roots ([Kushel et al., 2021](https://blogs.bmj.com/bmj/2021/03/22/bringing-covid-19-vaccines-to-high-risk-populations-like-those-who-are-homeless-requires-a-tailored-approach/)). * [The Conversation](https://www.greaterthancovid.org/theconversation/) 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. * <span style = 'color:green'> Finally, for expert advice specifically on improving booster uptake see [Bohm et al., 2022](https://www.thelancet.com/action/showPdf?pii=S2589-5370%2822%2900362-5). </span> # Vaccination Rates Around the World [Our World in Data](https://ourworldindata.org/covid-vaccinations) tracks vaccination rates around the world. Differences between countries will reflect both vaccine availability and uptake. <iframe src="https://ourworldindata.org/explorers/coronavirus-data-explorer?zoomToSelection=true&time=2021-11-16&facet=none&pickerSort=asc&pickerMetric=location&Metric=People+vaccinated+%28by+dose%29&Interval=7-day+rolling+average&Relative+to+Population=true&Align+outbreaks=false&country=ARE~PRT~CUB~CHL~ESP~SGP~KHM~URY~KOR~CAN~CHN~IND~USA~IDN~PAK~BRA~NGA~BGD~RUS~MEX~JPN~ETH~PHL~EGY~VNM~TUR~IRN~DEU~THA~GBR~FRA~TZA~ITA~ZAF~KEN~OWID_WRL&hideControls=true" loading="lazy" style="width: 100%; height: 600px; border: 0px none;"></iframe> ---- Source: [Our World in Data](https://ourworldindata.org/covid-vaccinations) <iframe src="https://ourworldindata.org/grapher/covid-vaccine-booster-doses-per-capita?country=BGD~BRA~CHL~IND~ITA~PAK~RUS~SGP~USA~OWID_WRL" loading="lazy" style="width: 100%; height: 600px; border: 0px none;"></iframe> Source: [Our World in Data](https://ourworldindata.org/covid-vaccinations) ## 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](https://www.sciencedirect.com/science/article/pii/S2590136221000310)). :::success See also our page on [cultural differences in vaccine uptake](https://c19vax.scibeh.org/pages/vaxculture). ::: <sub>**Page manager:** Katy Tapper **Other contributors:** Dawn Holford</sub> {%hackmd GHtBRFZdTV-X1g8ex-NMQg %} {%hackmd TLvrFXK3QuCTATgnMJ2rng %} {%hackmd oTcI4lFnS12N2biKAaBP6w %}
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SciBeh C19 Vax
Team web space for the covid-19 vaccine Wiki
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Argument quality and fallacies

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Vaccine Deniers

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Politics of COVID-19 Misinformation

The politics of misinformation related to COVID-19 In many countries, COVID-19 and measures to address it, including vaccination, have become heavily politicized with important negative effects in the public's willingness to be vaccinated and follow the WHO and government relevant guidelines. In this unit, we present findings that illustrate the politicization of Covid-19 and its disastrous effects (vaccine hesitancy, disobedience in measures like mask wearing etc.), as documented in research from all around the world. Then, we discuss the most significant factors that have contributed to this phenomenon (psychological characteristics of people, motivated misinformation by malevolent agents, conflicts of interest between countries and companies etc.). The politicization of COVID-19: evidence and effects A clear factor that affects beliefs and attitudes regarding Covid-19 is political ideology and partisanship. In a multi-country study conducted before Covid-19 vaccines were available, significant differences were found between countries, indicating that trust in government was a strong predictor of vaccine acceptance (Lazarus et al., 2021): people who trust their government are much more likely to accept getting vaccinated than those who do not. Many more studies have investigated the effect of partisan differences and epistemological attitudes on vaccine hesitancy in specific countries. After more than two years since the pandemic struck, a clear consensus has been formed: political partisanship significantly affects people's beliefs regarding Covid-19 and their attitudes towards vaccine and behavioral measures, often leading to science denialism and believing in conspiracy theories. America Beliefs In the United States, a worrisome partisan gap in perceptions regarding COVID-19 and responses to relevant government measures emerged between conservatives / republicans and progressives / democrats. For example, an analysis of over 1.1 million survey responses collected daily between April and September of 2020 found that levels of concern have come to deviate sharply between Republicans and Democrats over time, regardless of the incidence of the disease in respondents' local areas, as has individuals’ willingness to stay-at-home and reduce mobility in order to help contain the pandemic (Clinton et al., 2020). Similarly, Calvillo et al. (2020) found that U.S. conservatives tended to view the virus as less severe, and often believed that the spread of the virus was a conspiracy. Similarly, a longitudinal study on COVID attitudes identified a decrease in the willingness to vaccinate among Republicans, while Democrats attitudes remained stable (Fridman et al., 2021).

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Conspiracy theories

Pandemics have always been a fertile breeding ground for conspiracy theories, and the COVID-19 pandemic is no exception. When people suffer a loss of control or feel threatened, they become more vulnerable to believing conspiracies.

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