Novel Strategies to Support Global Promotion of COVID-19 Vaccination

"By providing a validated global framework for communication efforts, we can better develop promotional campaigns that 'travel' across regions, and know which efforts require local adaptations before being implemented."

By 2021, many countries had begun distributing COVID-19 vaccines but were hampered by significant levels of vaccine hesitancy or apathy. In that light, experts have recommended that standard health communication campaigns be expanded to include behaviourally-oriented strategies. Thus, the researchers constructed a Delphi panel of 92 marketing and behavioural science university faculty to assess 12 vaccination promotion strategies described in previous United States (US)-based research, asking respondents to assess applicability and potential efficacy of the strategy in their country and to make recommendations for local adaptations. Separately, the researchers sought to determine whether strategies based on cognitive mechanisms (e.g., "nudges") are more readily generalisable than strategies based on social identity.

Developed using consumer behaviour and behavioural economics research, the 12 strategies were based on either cognitive mechanisms (relying primarily on underlying mental functions) or social mechanisms (relying primarily on interpersonal effects). Based on responses to the email survey, which was open to the university faculty from February 16 2021 to March 11 2021, all 12 behavioural strategies were validated for use in the 7 major world regions (as categorised by the World Bank), meaning that a majority of respondents reported they would or could work well in their country. However, the surveyed experts indicated the need for regional adaptation and predicted variance in efficacy, due in part to potential cultural differences - e.g., individualism/collectivism.

The strategies, with selected findings in brackets from the survey and suggested adaptations, are:

1. Segment by identity barriers: Because vaccination attitudes are influenced by a person's self-identity or membership in a group, gear messages towards different identities and use group leaders or celebrities. [Panel validation: 83.3%. One suggestion: Adapt the characteristic by which populations are segmented - e.g., affiliative groups based on sports, entertainment, and social activities (Europe and Central Asia; sub-Saharan Africa), urban versus rural residence and age groups (Middle East and North Africa), professions (East Asia and the Pacific), religion and attitudes toward modern medicine (Latin America), or the intersection of affluence and perceived health (South Asia).]
2. Identify a common enemy: Unite highly polarised groups by framing vaccination as defeating a common enemy that both strongly dislike. [Panel validation: 82.4%. One suggestion: While common enemies can be used to unite a highly polarised area, for more homogeneous or collective communities, it is beneficial to reframe this strategy as a common goal (e.g., create an anthropomorphised goal-oriented mascot such as Brazil's readapted Zé Gotinha (Droplet Joe) mascot, originally created to promote polio vaccination campaigns in the 1980s and 1990s.)]
3. Use analogy: Explain processes (how the vaccine works) and risks (the odds of getting sick) with accurate analogies. [Panel validation: 94.2%. One suggestion: analogies should be relevant and sensitive to different cultures. Many regions benefit from the use of emotion-based analogies (e.g., the vaccination protects you like a mother's loving arms), based on local proverbs, or tied to local mythologies (Latin America, sub-Saharan Africa, Middle East and North Africa, South Asia and East Asia and the Pacific).]
4. Increase observability: Make vaccinated persons a walking advertisement for vaccine popularity by making the # of vaccinated observable. [Panel validation: 87.2%. One suggestion: shift the framing from the individual focus to the community. Making vaccinated individuals observable may be non-normative in collective communities or may cause unwarranted attention where vaccination is viewed with suspicion or where it might trigger perceptions of status/corruption. Here, a preferred approach might be a billboard with an electronic counter with the number of people vaccinated.]
5. Leverage scarcity: Leverage the natural scarcity of the vaccine to frame it as highly precious. [Panel validation: 83.5%. One suggestion: Use this strategy to prompt different patterns of vaccine distribution. For example, in Mali, it may be best to offer scarce vaccines first to the highest-status members of a community because associating vaccinations with power emphasises their value. In Uganda, it may be best to offer scarce vaccines equitably to citizens and immigrants alike, where associating the shots with strict fairness emphasises their value.
6. Predict and address negative attributions: Monitor and directly address incorrect negative attributions made about the vaccine or its delivery. [Panel validation: 92.9%. One suggestion: Determine the channel of misinformation most damaging in the community - often, social media. In some regions, social media regulation is seen as a critical tool (Europe and Central Asia, North America); in other regions, social media counter-campaigning was seen as more practical and effective. Panellists noted that the foundational challenge in implementing this strategy is the need to build trust. One common suggestion is to find, educate, empower, and incentivise trusted local community-influencers.
7. Prompt anticipated regret: Ask people to consider what would happen and how they would feel if they or someone they loved were to get sick. [Panel validation: 84.9%. Suggestion: Use this strategy only where the vaccine is widely available or when the patient can get vaccinated at that moment so that guilt and fear may be avoided. Also, in more communal regions, focusing on the possible illness of a loved one (not oneself) will be more effective. Finally, some subpopulations may feel that such a question is too emotionally manipulative (Europe and Central Asia); in such instances, this strategy is not recommended.]
8. Beware the danger of piecemeal risk info: Be aware that people see greater risk when information trickles out over time and thus changing info about vaccine roll-out may increase anxiety. [Panel validation: 84.7%. One suggestion: Emphasise how new information is a positive sign and indicates that scientists/doctors are not just resting on their laurels after developing the vaccine. (Overall, this strategy was seen as the least easily applicable of the 12.)]
9. Promote compromise options: Considering that, when uncertain, people feel more confident about compromise options, frame their vaccination "choice" as the middle of three options. [Panel validation: 74.7%. Suggestion: Used this strategy in limited situations for COVID-19 communication: For many regions, people may be required to be vaccinated. Even if they can choose, the idea of having an array of options may feel false or suspicious in communities where this is not often the case. Finally, in some cultures, choosing a middle option can be a very negative signal of ambivalence or weakness.]
10. Create fear of missing out (FOMO) motivations: Trigger loss aversion by mentioning incentives that people may miss out on by not vaccinating now. [Panel validation: 85.2%. One suggestion: Ensure that in areas with rampant economic, health, or security crises, the "fear" should be taken out of FOMO so that a positive tone is employed. The panel further expressed that it is critical that promises be fulfilled if this strategy is implemented.
11. Combat uniqueness neglect: Look for hesitant people who see the vaccine as a "one-size-fits-all" solution but see themselves as "not average", and offer small special accommodations to them. [Panel validation: 73.8%. One suggestion: Exercise care in regions that may be more attracted by the sameness of the treatment and be suspicious of inconsistencies (South Asia, sub-Saharan Africa).]
12. Neutralise the case versus base-rate heuristic: Note that people often underweight base-rate statistics and overweight anecdotal cases (stories) in judging probability, a decision heuristic known as the base-rate fallacy. [Panel validation: 96.5%. One suggestion: Counter a hesitant person's fear of unlikely bad outcomes with positive stories first and statistics second (if at all). This approach can be especially powerful in countering negative stories that are shared on social media.

(For more concrete suggestions and examples for adapted use of the 12 strategies globally, see table 2 in the paper; examples of how the panellists agree these might be applied for selected countries are shown in table 3.)

To understand why some strategies are more easily applicable to cross-national use, the researchers categorised the original 12 into 3 categories based on mechanism: cognitive mechanisms to increase perceived net benefits, cognitive mechanisms to leverage implicit "nudges", and social mechanisms to increased perceived affiliation or affect. Taken together, the data suggest that mechanism matters. Strategies that use cognitive mechanisms to promote net benefits are highly transferable and need only superficial adaptation. Strategies that use social mechanisms to promote affiliation and emotional appeal are highly transferable, but they need careful adaptation to local culture. Finally, strategies that use cognitive mechanism to prompt implicit nudges are not as easily transferable and also need significant adaptation regionally; thus, health organisations must be careful with how "nudges" are used across global contexts.

Open-ended responses suggested the addition of 3 emergent strategies to a global effort:

• Use "coupling" strategies that encourage people to achieve multiple prohealth behaviours (COVID-19 vaccination plus other treatments/protections, especially those that occur regularly like annual check-ups, influenza vaccines, or cancer screenings), thereby increasing the likelihood of achieving both rather than by raising the likelihood of one at the expense of the other.
• Focus on recent "wins": Even when "success" is relative to other more catastrophically hit areas, a basis of pride can prompt new efforts in an effort to avoid losing that pride. While positive and encouraging, this strategy also subtly prompts loss aversion, which describes the asymmetric attention to and motivation for avoiding losses compared with achieving gains.
• Convey vaccination as ritual artifact, such as by timing (e.g., the Navaho Nation decided to first vaccinate against COVID-19 their members who can fluently speak Navaho, irrespective of age) or by ceremony (e.g., first vaccinating leaders in ceremonial dress at a community event). The meaning stems from or is enhanced by the symbolic narratives promoted by community leaders such as religious elders or matriarchs/patriarchs; the ritual meaning of vaccines must evolve naturally but can be shared to inspire other communities.

Figure 2 outlines a phased framework by healthcare role to deploy applicable strategies as part of a multifaceted vaccination promotion campaign. The researchers stress that "successful campaigns will use a combination of many strategies in the effort to reach the heterogeneity of vaccine attitudes even within the same community, such as those who are vaccine hesitant versus those that are vaccine apathetic."

They conclude by suggesting that: "The use of behaviourally oriented persuasion techniques, that go beyond standard health communication practices, will also benefit future healthcare initiatives and campaigns."