Behavioural and Social Drivers of Vaccination: Tools and Practical Guidance for Achieving High Uptake

"To increase vaccination coverage, it is vital to know why uptake is low. Immunization programmes should collect data on what people are thinking and feeling, their motivation, and the social processes and practical issues that drive or hinder vaccination to develop evidence-informed strategies that increase uptake."

Understanding the reasons for low vaccine uptake, tracking trends over time, and reducing coverage inequities requires tools for gathering and using data. This guidebook from the World Health Organization (WHO) supports the use of the behavioural and social drivers (BeSD) of vaccination tools - including surveys and in-depth interview guides for both childhood and COVID-19 vaccinations - to understand what drives uptake of vaccines. It is intended for immunisation programme managers, research advisors, and others who are collecting, analysing, and using data for immunisation programme planning and evaluation. Routine tracking of BeSD data can foster the systematic design, implementation, and evaluation of tailored interventions to increase vaccine uptake.

The BeSD of vaccination can be grouped and measured in four domains:

1. Thinking and feeling about vaccines: Cognitive and emotional responses to vaccine-preventable diseases (VPDs) and vaccines
2. Social processes that drive or inhibit vaccination: Social experiences related to vaccines, including social norms about vaccination and receiving recommendations to be vaccinated
3. Motivation (or hesitancy) to seek vaccination: Readiness to vaccinate, including vaccination intentions, willingness and hesitancy, but not reasons for vaccination
4. Practical issues involved in seeking and receiving vaccination: Experiences people have when trying to get vaccinated, including access barriers

While many factors affect uptake, the BeSD tools focus primarily on proximal factors that are measurable in individuals, specific to vaccination, and potentially changeable by programmes. The BeSD surveys are formatted for verbal administration; the in-depth interviews are traditionally carried out in-person with one individual at a time.

WHO considers 4 broad intervention areas to be foundational to any immunisation programme: (i) community engagement; (ii) communication and education; (iii) service quality (e.g., provider recommendation, reminder/recall, inclusive services); and (iv) supportive policies (e.g., requirements, incentives). The BeSD priority indicators, which represent the domains in the BeSD framework and are framed around immunisation programme gains, support tracking how these foundational interventions are working, where, and for whom. Where interventions are not working, BeSD assessments can support understanding why that is - particularly through use of the qualitative interview guides. At a subnational level, these assessments can be conducted as part of a human-centred design or tailoring immunisation programme process to diagnose the reasons for low uptake, choose tailored interventions, and evaluate their effectiveness.

The guide follows a 3-step process (plan, investigate, and act) and includes:

• A quick start guide, which provides an overview on how to gather, analyse, and use BeSD data;
• An explanation of each step and best-practice recommendations; and
• Tools to measure the drivers of vaccine uptake:
  • Childhood vaccination surveys and interview guides (Annex 1); and
  • Adult COVID-19 vaccination surveys and interview guides (Annex 2).

Also, guidance is offered for adapting the BeSD tools (Annex 3), for Global Positioning System (GPS) data collection (Annex 4), and for collecting vaccination status (Annex 5). Example report templates and charts and provided in Annex 6, and Annex 7 describes WHO policy on data collected in Member States.

The tools in this guide were developed, tested, and validated through an evidence-based process with support from a global, multidisciplinary working group. See Related Summaries, below, for additional details on the process.