How vaccine fatigue in Uttar Pradesh could be addressed with Behavioural Science

As the threat of the new Omicron Covid-19 variant sends the world into a panic, our recent research about vaccine uptake and hesitancy in Uttar Pradesh shows that significant numbers of residents have failed to get fully vaccinated. This could pose a significant threat.

This research has helped us at Ashoka University’s Centre for Social and Behaviour Change to formulate some suggestions for how officials could deploy a set of nudges and prompts to get Uttar Pradesh residents to take their vaccinations.

From mass communication strategies to using personalised messages, officials could use Behavioural Science – which studies decision-making and human actions – to address the doubts, fears and lethargy of those who are not fully vaccinated.

High uptake of first dose

The first finding from our data analytics team is that both independent survey data and government data confirm that the uptake of the first vaccination dose is high in Uttar Pradesh.

We analysed data from the Global Covid-19 Trends and Impact Survey, or CTIS, conducted by the University of Maryland Social Data Science Center in partnership with Facebook. Facebook users were asked to complete a survey related to Covid-19 worries and taking the vaccine each month starting in January. A total of 52,776 people in Uttar Pradesh took the survey from January to November.

In November, over 93% of Uttar Pradesh respondents reported having taken at least one dose of the vaccine, according to the CTI Survey.

As of December 3, according to the Indian government’s Co-WIN app, 11.13 crore first doses had been given in Uttar Pradesh. This represented approximately 76% of eligible adults in Uttar Pradesh. The increase of first dose takers is significant in terms of absolute numbers (1.42 crore new first doses in November) and in percentage points (up 10 percentage points from the end of October).

While the gap between the 93% of first dose takers reported in the CTI Survey versus the 76% coverage reported on Co-WIN may seem significant, most of it could likely be accounted for by the differences in samples. The CTI Survey attracted Facebook users who are younger, more educated, more urban and more likely to be male than the overall population of the state – making them more likely to be vaccinated.

Hesitancy is low

According to the CTI Survey, the reasons mentioned by completely unvaccinated respondents for not being immunised were that others needed it more, they plan to wait and see if it is safe, or that they were concerned about side effects.

In November, only a small number of unvaccinated respondents, 27, mentioned “no vaccines or appointments available” as a barrier to getting vaccinated.

Only 9% of the respondents were against the vaccine and said they definitely would not take it. These people said they do not believe vaccines are needed, do not know if the vaccine will work, don’t like vaccines, or do not trust the government.

We believe that they need to be influenced by trusted messengers and influencers – people who are like them or people they look up to. These people may need to understand that one stark negative consequence of their inaction could be death. Their resistance could also be overcome by emphasising that nearly everyone around them has taken the vaccine and they are all safe.

The 15-percentage point gap between the 24% unvaccinated people in Uttar Pradesh (according to Co-WIN) and the 9% who definitely will not take the vaccine (according to the CTI Survey) represents about two crore eligible adults in UP who should be ready to take the first dose. The state probably has another six weeks to go – at average rates of delivery – before adults who are willing to take the first dose become very hard to find.

Behavioural explanations for vaccine fatigue

Finally, we found a problematic delay in second doses being taken. As of December 3, over 43 lakh people in Uttar Pradesh were overdue by at least two weeks for their second dose. These people took the first dose, so why do they not go for the second dose on time?

As individuals, despite our best intentions, it can be hardest to follow through on plans when a behaviour needs to be repeated. Data on child immunisation from the National Family Health Survey show a similar pattern for childhood immunisations as we see for Covid-19 vaccinations.

According to the NFHS-5 for Uttar Pradesh released in November, the first vaccine on the schedule – BCG – has coverage of 93.2%, while the proportion of young children who have gotten all three polio vaccinations on time stands at 74.3%. This comparison allows us to see Covid-19 vaccination rates in the context of broader vaccination success and of human behaviour.

Behavioural Science also tells us that the dramatically lower Covid-19 infection rates now being recorded compared to the second wave will have reduced people’s sense of the risk of contracting the virus. CTI Survey respondents from Uttar Pradesh expressed extreme worry about catching Covid-19 peaked in May (46%), which was followed by a drop in the following months (33% by November).

On top of this, the average person cannot tell that their first dose has been protective because most do not know if they have been exposed to coronavirus after vaccination. And, as vaccine coverage steadily increases, it becomes easier for us to find examples of people who have only received one dose and stayed uninfected by Covid-19 – because they are gaining protection from the immunised people around them.

These are a few examples of common beliefs and expectations that might hold someone back from finishing the vaccination course, or even taking a booster dose once they are offered.

Increasing second dose uptake

Mass communication strategies to improve second dose uptake could start with emphasising the most local social good: protecting our loved ones from hospitalisation and death. Further, people often respond to social proof, in this case, messages that most people who got the first dose have taken the second dose and are better off for it.

Finally, emphasising the small cost (temporary side effects) for the large remaining benefits (stronger and longer-lasting protection) could help people put the trade-off in perspective.

Behavioural Science also gives suggestions beyond mass communication. In fact, one of the central ideas is that personalised tactics are more effective. In this case, the SMS reminders for the second dose sent by Co-WIN could include people’s names and perhaps the names of other people registered on the same phone number.

Researchers have also found that setting appointments for vaccines and informing people about them increases the uptake. Proactive appointments are a promising move because it would require people to justify cancelling the second-dose appointment. These people have already shown that they personally had a good reason to take the first dose, so it is unlikely they can justify refusing the appointment for the next dose.

One final human foible relevant for understanding complete vaccination is our preference for immediate rewards. As noted, vaccination has immediate costs and long-term gains, and most humans overvalue what happens in the short term. Recently, some governments in India have launched lotteries offering those who take the second dose rewards like smartphones or refrigerators to help tip individuals back to opting for the long-term benefits of the second dose over the immediate hassle.

Gautam Patel is the lead of the UP Behavioural Insights Unit at the Centre for Social and Behaviour Change at Ashoka University.

Simran Saraf is a Data Associate at the Centre for Social and Behaviour Change at Ashoka University.