COVID-19 Vaccine Deployment: Behaviour, Ethics, Misinformation and Policy Strategies

"Vaccines and vaccination are two very different things. To achieve the estimated 80% of uptake of the vaccine required for community protection, we need a serious, well-funded and community-based public engagement strategy." - Professor Melinda Mills, Director of the Leverhulme Centre for Demographic Science at the University of Oxford

Created in anticipation of a vaccine against COVID-19, this rapid review from the British Academy and the Royal Society for the SET-C (Science in Emergencies Tasking: COVID-19) group focuses on the historical, ethical, and socio-behavioural factors related to vaccine uptake. The report draws on scientific evidence to aid policymakers in the United Kingdom (UK) and globally to plan effective and equitable vaccine deployment, with a focus on communication through dialogue and understanding rumours and misinformation.

First, the report outlines the public health and economic benefits of vaccinations. It then draws lessons from historical vaccination efforts, explores reasons for variation in immunisation coverage, and considers vaccination hesitancy across countries and over time. Evidence from other countries indicates that widely published safety scares can have deep, long-lasting influence on vaccine confidence. In the case of COVID-19, around 36% of people in the UK say they are either uncertain (27%) or very unlikely (9%) to be vaccinated against the virus. Drawing on examples of vaccine deployment in past outbreaks, the report then explores behavioural and socio-demographic factors underlying vaccine uptake, including:

• Complacency of the perception of risk - For example, as with COVID-19, previous pandemics were initially met with scepticism and the belief that the virus was akin the seasonal flu.
• Lack of confidence in the efficacy and safety of the vaccine - As noted here, what is unusual for COVID-19 compared to previous vaccines is that dialogue and communications about the safety and efficacy of the various vaccines must be developed under conditions of uncertainty. Also, multiple media reports and individual scientists have discussed the speed at which the COVID-19 vaccine has been developed and tested, raising safety concerns. In light of the fact that COVID-19 reveals structural inequalities, there has also been concern that COVID-19 clinical trials have underrepresented certain populations, such as minority groups.
• Convenience of access - A well-planned distribution chain that builds on successful vaccination structures has been found as crucial for vaccine uptake.
• Sources of information and knowledge deficits - For example, a growing strand of literature claims that internet users are more likely to believe that healthy individuals do not need to be vaccinated and that it is harmful.
• Socio-demographic characteristics (education, sex, ethnicity, religion, etc.) - For example, a systematic review of H1N1 vaccination uptake found that one of the strongest predictors for vaccination was past behaviour.

This analysis is followed by a discussion of ethics and equity in vaccine allocation, including the need to consider vulnerable populations . Four fundamental ethical principles have been suggested with regard to the allocation of scarce resources during a pandemic:

1. Maximise benefit - Save the greatest number of lives, focusing on those with the best prognosis.
2. Treat people equally - A first-come, first-served system, or one offering vaccination to those who can pay, is not fair. (If individuals have similar prognoses, vaccine access should be randomised.)
3. Promote and reward instrumental value - Reward those such as health care or frontline workers who put themselves at risk but also save others.
4. Give priority to the vulnerable or worse off - This includes those who will become the most sick or die as a result of infection or to the young who will lose the most life years.

In outlining interim advice for a phased approach that accounts for priority groups for COVID-19 vaccination in the UK, the report stresses the importance of clarity and open engagement to manage expectations of the general public. It also discusses certain factors that are essential to take into account, given past experiences. For instance: "When planning a vaccination campaign with priority groups, it is essential to develop a clear and transparent rationale to explain why these target groups have been chosen and the reasoning behind any ranking or phasing. Attention should be placed not only on priority groups, but also the 'excluded' to clarify the reasoning behind allocation with clear and targeted dialogue strategies."

The report then turns to the rise of misinformation, focusing on the history of anti-vaccination sentiments tracing back to the 19th century, the contemporary anti-vaccination movement, and the producers of the information in the present COVID-19-related "infodemic" (e.g., influencers on social media). Propagators of misinformation tend to draw on: distrust of science and selective use of expert authority; distrust of pharmaceutical companies and government; straightforward, simplistic explanations that are difficult to distinguish from truth; use of emotion and individual anecdotes to impact rational decision-making; and polarised communities (gatekeeping, information bubbles, and echo chambers).

That said, as explored here, social anthropologists who have studied vaccine anxieties and uptake across multiple global contexts argue that the focus on misinformation is distracting. These researchers focus on how risk, trust, and rumour underpin vaccine anxieties and resistance. Rather than viewing parents or individuals as easily influenced by the anti-vaccination movement, they argue that individuals make decisions based on their personal and local experiences and that their concerns are valid and need to be understood via dialogue.

To illustrate this concept, the report looks at the distrust and boycott of polio vaccines in northern Nigeria in 2003, which emerged from a longer contextual history and subsequent spread of rumours that led to the rejection of the oral polio vaccine (OPV). "The central policy recommendations from this Nigerian experience were to understand first why people have concerns and fears about the vaccination and then to actively debate and discuss these concerns. Communication is therefore not passive, uni-directional, or providing detailed information on a webpage, but rather a dialogue that is participatory, iterative and sensitive to local politics."

Other policy recommendations that conclude the report include, but are not limited to:

• Start an open, transparent dialogue over vaccine deployment with the general public to address uncertainties about efficacy and safety and provide clarity on the longer timescale of vaccination roll-out to build support and understanding.
• Make vaccinations convenient, such as by ensuring they are available at weekends and evenings at physicians' offices and other appropriate sites; centralised mass sites and roving teams are likely to be less effective.
• Implement a decentralised local vaccination programme, with toolkits to support local authorities in community engagement, including tailored, appealing, visual, and multi-language messages to reach diverse populations and mobilise local communities. Some of the elements that have found to be central to good, evidence-based community engagment include:
  • Balanced messaging about risks that match everyday experience;
  • Enhanced public understanding of the uncertainty of COVID-19 vaccinations, ethical principles, expected barriers, safety and efficacy, including expectation management with regard to any potential changes in the response due to new scientific knowledge and potential adverse effects;
  • Active monitoring of the public's concerns, beliefs, and debates through multiple channels;
  • Active work on dialogue with the public, more than uni-directional communication and information;
  • Management of expectations about the timing and roll-out of the vaccine, anticipating potential supply and distribution problems;
  • Engagement in coordinated policies and communications through all nations and local communities to avoid public confusion and avoidance of doubt;
  • Work with diverse stakeholders to reach communities and individuals with a history of vaccine hesitancy or exposure to misinformation;
  • Engagement at the places where people frequent that counters perceived and actual barriers to vaccination; and
  • Efforts that build on successful vaccination strategies by international organisations that have experience of communicating risk in emergency situations.
• Implement phased and ethical vaccine deployment, adopting transparent principles of priority groups and ensuring these are sufficiently debated with the public to build understanding - starting with age- and comorbidity-based priority groups and healthcare workers and then looking to high-risk occupations (e.g., teachers, bus drivers, retail workers) and vulnerable groups in crowded situations (e.g., homeless and incarcerated persons).
• Counter misinformation and fill knowledge voids by empowering the public to spot and report misinformation, monitoring nefarious misinformation spread by local and foreign actors, ensuring accountability for media companies to remove harmful information, and punishing those who spread misinformation.

Professor Melissa Leach, a member of the World Health Organization (WHO) Roadmap Social Science Expert Group for COVID-19 and British Academy COVID-19 Steering Group that helped to inform the report says, in conclusion: "In short, vaccine hesitancy is set to be a huge issue for Covid-19; building vaccine confidence is a massive priority, and social science insights are vital to support this."