Designing Behavioural Strategies for Immunization in a Covid-19 Context

"Within the new COVID-19 context, people across the world are experiencing new government guidelines to reduce the spread of the pandemic....These experiences, and the way people perceive and trust government guidelines and services, public and other sources of information and assess their risk of COVID-19 and other diseases, will determine whether or not they are going to demand and seek out immunization services..."

On May 21 2020, the Learning Network for Countries in Transition (LNCT) held a webinar to review the current context for immunisation amidst the COVID-19 pandemic, with a focus on behavioural strategies for increasing public trust and demand for immunisation to ensure global gains do not unravel. The 52 participants from 25 countries also heard from 4 LNCT countries - Côte D'Ivoire, India, Sri Lanka, and Vietnam - on key challenges and lessons learned from their experiences with reintroducing and managing routine immunisation in the context of COVID-19. The following summary outlines the major themes that the webinar covered, provides access to the video recording, and includes links to resources that emerged from it.

The webinar focused on the potential of behavioural science to help governments and organiations understand how and why people are reacting the way they are in this new context, including sometimes in seemingly "irrational" ways. Through applying behavioural science, we can understand some of the key reasons behind these behaviours, and how to utilise behavioural levers to increase and/or maintain demand for immunisation. These levers include trust, transparency, fear, and social norms.

Trust: LNCT stresses that trust is a key cornerstone to successful behaviour change strategies, in that trust in government or other organisations can help build people's compliance to policies they need to act upon. COVID-19 has presented an opportunity for governments to gain the trust of their populations and communities. Building trust requires understanding who people in your country and various communities trust or distrust, and why, in order to leverage these people and organisations. Trust in people and organisations is fluid and often localised - varying from community to community, which means that leveraging people or organisations in one area may not be effective in another.

Example from Vietnam - Dang Thi Thanh Huyen (Vice Head of National Expanded Programme on Immunization (EPI), Ministry of Health (MoH), Government of Viet Nam) spoke on what Vietnam has learned from recently resuming immunisation services and shared advice for others; Nam Tong (Associate Director, Viet Nam, Clinton Health Access Initiative) spoke on how trust in government can help achieve compliance with COVID-19 policies, even with few cases.

According to the presenters, the government responded to COVID-19 quickly, intervening in January 2020 with a variety of measures (e.g., quarantining high-risk groups, closing inessential services, expanding testing services, providing financial aid for citizens, and preparing for different health scenarios and needs). This proactive and robust response included wide engagement from all levels of government and the private sector, along with transparent and widespread communication.

In Vietnam, many facilities stopped providing immunisation services in mid-March 2020. In the intervening months, Vietnam slowly resumed services, based on the release of technical guidelines from the EPI. Immunisation services had completely resumed by May 2 2020; however, parents were hesitant to bring their children to immunisation centres out of fear of being infected with COVID-19. As a result, immunisation rates fell in the first quarter of 2020 compared with 2018. The MoH has directed health facilities to conduct more outreach and increase the number of days that immunisation is offered to close the coverage gap. However, having re-launched immunisation activities nationwide, there have been signs in some localities of community reluctance to seek services due to fear of COVID-19 infection.

Transparency: Transparency is another lever for behaviour change that can be considered a subcomponent of trust. Particularly in times of uncertainty and fear, if people do not feel they are receiving honest and reliable communication, they may fill the void with false information or rumours. The Centers for Disease Control and Prevention (CDC)'s Crisis and Emergency Risk Communication (CERC) programme offers 6 principles of transparency: Be first, Be right, Be credible, Express empathy, Promote action, and Show respect.

Example from Sri Lanka: Dr. Ravi Rannan-Eliya (Institute for Health Policy) and Dr. Anuji Gamage, MBBS, MSc. MD (Consultant Community Physician, Management Development and Planning Unit, MoH, Government of Sri Lanka) spoke on how the government and other players can manage public communication with transparency, especially amongst the most vulnerable populations.

As they explain, Sri Lanka developed a communication plan before the first case was reported. As part of that plan, they launched a hotline aimed at explaining possible symptoms and providing advice and a dashboard on the Health Promotion Bureau (HPB) website, which provided status updates on the number of cases, deaths, and recoveries. To help the population comprehend the risks, the Sri Lankan government also began delivering situation reports and media briefings that promoted preventative behaviours and outlined the government response to COVID-19. As the government started to consider a gradual exit from lockdown, the HPB released a risk communication plan, instituted at the subnational level, which focused on strengthening the risk communication system, including communication internally and between partners, communication with the public and affected communities, and rumour monitoring and management.

Though the Sri Lankan government acted swiftly, instituting a country-wide lockdown, there were some challenges with the policy. The government initially responded to this challenge by blaming the public for not following instructions; since then, MoH officials have worked to bolster trust by opening more clinics, working longer hours to treat more people, and following up with caregivers to confirm they will attend needed appointments. At the moment, according to the presenters, vaccine hesitancy does not seem to be an issue, and caregivers generally have a good relationship with the MoH, which plays the main role in communicating with caregivers and ensuring they come to appointments.

Example from Côte D'Ivoire: Dr. Daniel Ekra (Directeur Coordonnateur PEV, Maître de Conférences Agrégé en Santé publique - Épidémiologie, UFR Sciences Médicales, Université FHB) spoke on the spread of rumours and their source.

The government of Côte D'Ivoire instituted policies to limit the spread of COVID-19 and support management of over 2,000 cases of the disease; however, these policies were undermined by the spread of rumours. The rumours related mainly to the proper treatment of the virus, with some treating symptoms with garlic, neem leaves, or other unproven traditional medicines or treatments. Some of the most persistent rumours also surrounded vaccination.

After a European doctor on foreign television proposed testing of the vaccine in Africa, a rumour started that a purported vaccine for COVID-19 that would spread the virus was being tested on the population in Côte D'Ivoire. Anti-vaccine movements took advantage of this fear and distrust to spread rumours, including that vaccines are a money-making scam by manufacturers and vaccine-funding organisations. These rumours resulted in a call for vaccinations offered in health centres to be refused. A telephone poll conducted among 55,291 respondents in mid-April 2020 showed that half the population were planning to discontinue vaccinating their children, either because of the rumours circulating or because they do not believe in vaccination. Consequently, Côte D'Ivoire saw decreased attendance at vaccination centres and increased vaccine refusal, leading to lower immunisation coverage overall. If this situation persists, it may risk the resurgence of vaccine-preventable diseases.

To combat the effects of these rumours, the Minister of Health gave an address to the population that was disseminated to the media and to regional, departmental, and local authorities. The government also posted an informational interview related to vaccines on social networks and has continued to monitor and respond to false information. Finally, civil society partners, paediatricians, and other experts have participated in radio and television broadcasts to spread credible information.

Fear: LNCT holds that fear, if used appropriately, can lead to rational behaviour that we want to see. However:

• Too much fear may lead to irrational decision making or paralysis, whereby people: shut down in helplessness, believing their actions will be ineffective in reducing the threat; fail to act due to defensive denial, that is, willfully denying a threat to maintain a sense of safety and control; find the threat unbelievable and be unmotivated to take preventative action; have difficulty responding rationally and overreact; and/or downplay future "threats" and distrust government sources if dire warnings fail to materialise.
• On the other hand, a too-low level of fear can lead people to be unmotivated to take the preventative health actions that might reduce disease spread by, for example, going against government advice and going outside. This can happen when a government underplays a public health threat because they don't want people to panic, the economy to suffer, or to draw attention to policies or missteps that, in retrospect, reduced preparedness or made things worse. This can contribute to disease spread and undermine their credibility as a source of public health information.

LNCT explains that getting fear "right" is challenging. To motivate desired health behaviours, the threat has to be scary enough to motivate, yet realistic. People have to believe that it could affect them, and they also have to believe that the recommended actions will reduce the threat. Politics have to be put aside for the sake of public health so as not to overplay, or underplay, the health threat.

Social norms: Two subsets of social norms include:

• Social proof - using "what other people do" as a mental shortcut to decide on what the appropriate behaviour would be if we are unsure. For example, if the media shows images of empty streets, this might encourage those watching to stay at home, as it looks like others are doing the same.
• Social approval or disapproval - doing what you believe others think you should do. For example, some countries have adopted this tactic around wearing masks, with some leaders stating that not wearing a mask is "disrespectful" to others, including frontline health workers.

Example from India: Dr. Kapil Singh (National Project Officer, Gavi Secretariat, Health System Strengthening Project, Immunization Division, Ministry of Health and Family Welfare, Government of India) spoke on how the government has used fear and social norms to enforce compliance with COVID-19 measures and improve confidence in immunisation services.

By the time COVID-19 reached India, the media had already covered its impacts in other countries. This helped citizens understand the scale of the pandemic. The government took advantage of this caution by issuing frequent appeals to follow social distancing guidelines, providing evening updates on COVID-19 from the MoH, and establishing social norms around wearing masks, handwashing, and lockdown, etc. Furthermore, the media highlighted instances the Prime Minister and other leaders were seen complying with those norms. This was further complemented by the leveraging of social disapproval at those not following social distancing norms through speeches. Finally, health officials have been capitalising on population's fear of COVID-19, and their desire for a COVID-19 vaccine, to encourage people to get vaccinated against diseases that already have vaccines. As the lockdown eases, the government has begun zoning districts, and healthcare officials are modifying outreach to deliver immunisation safely to non-hotspot districts.

Editor's note: On April 30 2020, LNCT organised a peer learning discussion group for countries to discuss the COVID-19 pandemic's impact on immunisation programmes and responses across countries. Several LNCT countries - Georgia, India, and Indonesia - shared their experiences and concerns for the immunisation programme, changes that have been made to immunisation activities how services are being delivered as a result of the pandemic, and any impact already seen on the use of immunisation services. Gavi also joined the discussion to describe its programmatic commitments to help countries respond to the pandemic. Click here to access the webinar recording and resources associated with this event, "COVID-19 Impact on Immunization Programs".