Ending the Pandemic: How Behavioural Science Can Help Optimize Global COVID-19 Vaccine Uptake

"Combining knowledge on the determinants of vaccine acceptance with established frameworks for behaviour change, the behavioural sciences are well-positioned to support a coordinated approach to vaccine acceptance that can serve as a guide for multi-level stakeholders."

Vaccination is an individual choice and requires acceptance of the need to be vaccinated in light of any risks. Over the past two decades, behavioural scientists have been developing strategies to increase vaccine acceptance. Promoting behaviour change to increase vaccine uptake involves multiple influences on individual decision making that require coordinated actions by people who function at several ecologic levels. This paper presents a behavioural sciences framework to promote COVID-19 vaccine acceptance. "Such a framework is essential, as the interplay between individuals at the various levels is inherently complex, and complicated by the fact that information about vaccine efficacy and safety is emerging and evolving, resulting in the need for rapid adaptation..."

Based on the conviction that effective promotion of vaccine uptake requires understanding the context-specific barriers to acceptance, the paper presents the AACTT (Action, Actor, Context, Target, Time) framework to identify the action needed to be taken, the person needed to act, the context for the action, and the target of the action within a timeframe. Table 1 in the paper illustrates how the AACTT framework could guide the behaviours of policymakers, organisational leaders, and individuals/families in achieving optimal vaccination acceptance. It does so by providing a guide to identify multi-level problems and specific solutions, including what needs to be done by whom, for whom, when, and how. For example, individuals/families need to take actions including attending a vaccination appointment as opportunities arise, promoting vaccination amongst their personal social network, talking favourably about vaccine scheduling and dosing among family and friends, and being mindful to dispel vaccine-related misinformation and rumours.

Having defined the behaviour(s) to change using AACTT, the paper explores the processes by which behaviour change occurs (in this case, vaccine acceptance). Recent work on the integration of various behaviour change theories and methods has led to a listing of the necessary ingredients to effectively promote behaviour change, resulting in the Capability-Opportunity-Motivation-Behaviour (COM-B) model. COM-B posits that behaviour change is influenced by: (i) capability, the physical and psychological abilities to engage in the behaviour; (ii) opportunity, the physical or social opportunities to engage in the behaviour; and (iii) motivation, the psychological processes that energise and direct behaviour, such as the belief that a behaviour is important and/or socially desirable. "Identifying which COM-B domains are relevant for specific AACTTs can form the foundation for selecting fit-for-purpose tailored strategies to promote vaccine acceptance."

Case examples are offered to help the reader understand how to implement the AACTT and COM-B frameworks in the context of optimising vaccine acceptance. The authors consider the situation where, despite the availability of vaccines, there has been disproportionately low vaccine uptake in a particular neighbourhood in a large urban city. Using the COM-B assessment at the individual level would first involve knowing the extent to which citizens in that neighbourhood believe getting the vaccine is important and worthwhile. The authors walk the reader through an analysis of what should be done once the assessment is complete, based on the AACTT framework.

Another of the examples provided here concerns COVID-19 vaccine uptake among Indigenous communities in Canada. As reported here, colonialism, structural racism, and contemporary tensions between Indigenous nations and the government contribute to mistrust, skepticism, and fear of vaccines promoted by the Canadian government. In this case, addressing capability factors would entail strengthening culturally relevant knowledge and educational events that affirm pre-colonial realities (Action, Target, Context). Addressing opportunity factors would require addressing racism in health systems, leveraging trustworthy sources of information (e.g., Knowledge Keepers), and administering vaccines in culturally sensitive ways, such as allowing communities to determine when and where activities occur (Action, Target, Context, Time). Ideally, these strategies would be endorsed by respected elders or community leaders, not government officials (Actor). Finally, addressing motivation-related factors might mean acknowledging past mistreatment of Indigenous populations, discussing fears of continued discrimination, and taking steps to tackle broader health issues such as food insecurity (Action, Actor, Target).

The authors conclude that AACTT and COM-B can be used to facilitate action that is fluid in light of changing COVID-19 realities and that involves policymakers, organisational leaders, and citizens and families in the effort. Looking ahead, they call for the systematic assessment of both population- and local-level data within the context of these two behavioural frameworks, which would "inform evidence-based care to those with vaccine hesitancy, and determine the uptake rate of COVID-19 vaccines. The collection of such data in real-time will ultimately generate practice-based evidence that can improve public health outcomes....Together, these frameworks can help maximize vaccination rates by capitalizing on decades of behavioural science research."