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What drives vaccine uptake?

Thinking and Feeling

Perceived disease risk

Vaccine confidence �(includes perceived benefits, �safety and trust)

Vaccination �Uptake of recommended

vaccines

Motivation

Intention to get�recommended

vaccines

Social Processes

Social norms (includes support of family and religious leaders)

Health worker recommendation

Gender equity

Practical Issues

Availability

Affordability

Ease of access

Service quality

Respect from health worker

The Behavioural and Social Drivers (BeSD) Framework. Source: The BeSD working group. Based on Brewer et al. Psychol Sci Public Interest. (2017)

Behavioural and social drivers

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Tools and guidance on BeSD

Childhood vaccination tools

Survey: for parents of children under 5 years
Qualitative tools: 1) parents, 2) health workers, 3) community stakeholders, and 4) authorities

Practical implementation guidance

COVID-19 vaccination tools

Surveys: for 1) adults, 2) health workers
Qualitative tools

Access all tools and guidance here: https://apps.who.int/iris/handle/10665/354459

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Summary �of the �development process�(2019-2021)�

Literature review
Identification of constructs
Qualitative interview questions
Survey items and iterative reduction
Demographic items and survey instructions

Tool

development

Tools for childhood vaccination
Tools for COVID-19 vaccination

🗹 Guidance for data collection and use

Finalisation of all tools and guidance

PHASE

KEY ACTIVITIES

END-USER INPUTS

Key informant interviews

IVIR-AC consultations (two)

🗹 Validation study protocol

🗹 Translations and data-gathering

Data analysis
Working group review and indicator selection

Psychometric validation and indicator selection

Validation sites:

Angola, Ethiopia, DRC, India, Nigeria, Pakistan

Implementing end-user feedback on guidebook

🗹 Languages and countries selected

🗹 Study protocol and scripts

Translation of all materials (& translator feedback)

Surveys:

Cognitive interviewing
Analysis spreadsheet: item, results, revisions

Qualitative tools:

🗹 Draft qualitative guides

🗹 Interviewer debrief form and analysis framework

Field testing

Testing sites:

Indonesia, Sierra Leone, Guatemala, Australia

Regional and Country Offices feedback

EPI programme and implementer feedback

Continue to gather end-user feedback

SAGE recommendations on systematic gathering and use of data on BeSD, October 2021 (WER report)

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Summary of all topics measured:�Childhood vaccination survey

⬤ Main survey question. �✪ Priority question in main survey. �🞆 Optional question.

Thinking and feeling	Motivation	Social processes	Practical issues
✪ Confidence in vaccine benefits	✪ Intention to get child vaccinated	✪ Family norms	✪ Know where to get vaccination
⬤ Confidence in vaccine safety		⬤ Health worker recommendation	✪ Affordability
🞆 Confidence in health workers		⬤ Peer norms	⬤ Took child for vaccination
		⬤ Community leader norms	⬤ Received recall
		🞆 Religious leader norms	⬤ Ease of access
		🞆 Mother’s travel autonomy	⬤ Reasons for low ease of access
			⬤ Vaccine availability
			⬤ Service satisfaction
			⬤ Service quality

Demographics
Age
Gender
Parent/caregiver
Number of children under 5
Relationship to child
Age of child
Gender of child
Vaccination status

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DOMAIN/ construct	Childhood vaccination survey
DOMAIN/ construct	Priority question	Indicator
THINKING AND FEELING Confidence in vaccine benefits	How important do you think vaccines are for your child’s health? Would you say… Not at all important A little important Moderately important, or Very important?	% of parents/caregivers who say that vaccines are “moderately” or “very” important for their child’s health
SOCIAL PROCESSES Family norms	Do you think most of your close family and friends want you to get your child vaccinated? NO YES	% of parents/caregivers who say most of their close family and friends want their child to be vaccinated
MOTIVATION Intention to get vaccine	[COUNTRY NAME] has a schedule of recommended vaccines for children. Do you want your child to get none of these vaccines, some of these vaccines or all of these vaccines? NONE SOME ALL	% of parents/caregivers who want their child to get “all” of the recommended vaccines
PRACTICAL ISSUES Know where to get vaccination	Do you know where to go to get your child vaccinated? NO YES	% of parents/caregivers who know where to get their child vaccinated
PRACTICAL ISSUES Affordability	How easy is it to pay for vaccination? When you think about the cost, please consider any payments to the clinic, the cost of getting there, plus the cost of taking time away from work. Would you say… Not at all easy A little easy Moderately easy, or Very easy?	% of parents/caregivers who say vaccination is “moderately” or “very” easy to pay for

Priority indicators for monitoring: childhood vaccination

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Summary of all topics measured:�COVID-19 vaccination survey

⬤ Main survey question. �✪ Priority question in main survey. �🞆 Optional question.

Thinking and feeling	Motivation	Social processes	Practical issues
✪ Confidence in COVID-19 vaccine benefits	✪ Intention to get vaccinated	✪ Family norms	✪ Know where to get vaccination
⬤ Confidence in COVID-19 vaccine safety	⬤ Vaccine confidence – brand	⬤ Peer norms	✪ Affordability
⬤ COVID-19 vaccine –see friends and family	⬤ Willingness to recommend vaccine to others	⬤ Religious leader norms	⬤ Received recall
🞆 Perceived risk – self		⬤ Community leader norms	⬤ Ease of access
🞆 Confidence in health workers		⬤ Health worker recommendation	⬤ Reasons for low ease of access
		🞆 Workplace norms	⬤ Service satisfaction
		🞆 Gender equity – travel autonomy	⬤ Service quality
			🞆 On-site vaccination

Demographics
Age
Gender
Occupation
*Health worker role
COVID-19 risk
COVID-19 diagnosis

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Priority indicators for monitoring: COVID-19 vaccination

DOMAIN/ construct	COVID-19 vaccination survey
DOMAIN/ construct	Priority question	Indicator
THINKING AND FEELING Confidence in vaccine benefits	How important do you think getting a COVID-19 vaccine will be for your health? Would you say… Not at all important A little important Moderately important, or Very important?	% of adults/health workers who think a COVID-19 vaccine is “moderately” or “very” important for their health
SOCIAL PROCESSES Family norms	Do you think most of your close family and friends want you to get a COVID-19 vaccine? NO YES	% of adults/health workers who think most of their close family and friends want them to get a COVID-19 vaccine
MOTIVATION Intention to get vaccine	Do you want to get a COVID-19 vaccine? Would you say… You do not want to, You are not sure, You want to, or You are already vaccinated?	% of adults/health workers who want to get a COVID-19 vaccine
PRACTICAL ISSUES Know where to get vaccination	Do you know where to go to get a COVID-19 vaccine for yourself? NO YES	% of adults/health workers who know where to get a COVID-19 vaccine for themselves
PRACTICAL ISSUES Affordability	How easy is it to pay for vaccination? When you think about the cost, please consider any payments to the clinic, the cost of getting there, plus the cost of taking time away from work. Would you say… Not at all easy A little easy Moderately easy, or Very easy?	% of adults/health workers who say vaccination is “moderately” or “very” easy to pay

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Moving from data to action:

Promising interventions by BeSD domain to guide planning

Domain where problem is identified	Interventions shown to increase vaccination
Thoughts and feelings and Motivation	Campaigns to inform or educate the public about vaccination Dialogue-based interventions, including one-to-one counseling to encourage vaccination
Social processes	Community engagement Positive social norm messages Vaccine champions and advocates Recommendations to vaccine from health workers
Practical issues	Reduced out-of-pocket costs Service quality improvements Reminder for next dose /recall for missed dose Onsite vaccination at home, work and school Default appointments Incentives School and work requirements (mandates)

NB: Multi-component interventions more effective than single – and M&E always needed

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SAGE conclusions and recommendations:�Behavioural and social drivers (BeSD) of uptake

“SAGE recommended the systematic gathering and use of data on behavioural and social drivers to assess the reasons for low uptake, for routine tracking of trends, and monitoring and evaluation of interventions.”

SAGE, October 2021

MORE INFORMATION:

SAGE October 2021 meeting conclusions and recommendations (WER, 17 Dec 2021):

https://apps.who.int/iris/handle/10665/350649

SAGE October 2021 meeting agenda, background documents, presentations and highlights:

https://www.who.int/news-room/events/detail/2021/10/04/default-calendar/sage_meeting_october_2021

Final tools and guidance:

https://www.who.int/teams/immunization-vaccines-and-biologicals/essential-programme-on-immunization/demand

WHO Position Paper on BeSD, May 2022:

https://apps.who.int/iris/bitstream/handle/10665/354458/WER9720-eng-fre.pdf

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WHO Position Paper – May 2022:��Understanding the behavioural and social drivers of vaccine uptake

Outline of contents:

Summary of the development and validation of BeSD tools, indicators, and guidance
Findings of a scoping review: interventions to increase vaccine uptake
Recommendations on use of BeSD tools and resulting data to prioritize local interventions
Future research directions

Example of recommendations

National and Regional Immunization Technical Advisory Groups are recommended to:

analyse and use data from BeSD surveys and in-depth interview guides (in conjunction with other programme data, including digital listening insights) to guide planning and prioritization; and,
include individuals with social sciences expertise and representatives from civil society to their membership to strengthen work on vaccination.

Access the Position Paper here: