Following the approval of two vaccines by the drug regulator, the prime minister has reiterated that India is on the threshold of the largest vaccination programme in the world. In that context, an editorial in this newspaper (‘Turning Point’, IE, January 4) rightly pointed to the need “to follow the science and for public communication messages to be framed accordingly”. Similar sentiments were expressed by the PM and the Union health minister recently. Contrarian views to both vaccine approval and the programme have included debates around institutional processes, pure politics, anti-vaccine sentiments and, of course, conspiracy theories.
Recently released data from a survey in India of approximately 11,000 respondents revealed that 53 per cent were unsure about taking the COVID-19 vaccine. A citizen-survey platform in Delhi found that about 69 per cent of respondents saw no urgent need to get immunised and noted that key reasons for hesitancy included limited information about side-effects, efficacy levels and perceived high immunity levels. This resonates with a global survey (in collaboration with the World Economic Forum) conducted in October 2020 of more than 18,000 adults from 15 countries that reported confidence being down by 4 points compared to the previous round in August 2020. Vaccination intent declined in 10 of the 15 countries, most of all in China, Australia, Spain and Brazil. Globally, 10 per cent reported they were against vaccines in general, including 14 per cent in India and South Africa. Other key reasons included perceptions that the vaccine will not be effective (up to a sixth of the respondents in Germany) and that the risk of their getting COVID-19 is low (up to a fifth of all respondents in China and Australia).
The WHO’s SAGE (Strategic Advisory Group of Experts on Immunisation) Working Group on Vaccine Hesitancy defines hesitancy as a behavioural phenomenon that is vaccine and context specific and measured against an expectation of reaching a specific vaccination coverage goal, given that immunisation services are available. They also recognise that demand and hesitancy are not completely congruent, and that an individual or a community may fully accept vaccination without hesitancy but may not demand a specific vaccine.
The WHO EURO Vaccine Communications Working Group proposed the 3Cs model to unravel layered challenges: Complacency, confidence and convenience. Vaccine confidence encompasses trust in the effectiveness and safety of the vaccine; the system that delivers, including the reliability and competence of the health services and professionals and the perceived motivations of policy-makers making decisions on the vaccine. Vaccination complacency exists where perceived risks of the disease in question are low and vaccination is not deemed a necessary preventive action. Vaccination convenience is a significant factor that entails physical availability, affordability and willingness-to-pay (for those who would not be eligible for, or would not like to avail of, the government programme).
Communication strategies are critical for tracking, negotiating and shaping perceptions around the vaccines and the programme. Since it is a new disease against which several candidate vaccines are being developed and licensed in a fast-tracked manner, communication strategies and responses need to be shaped around four key themes: Product development, prioritisation strategies, programme rollout activities, and AEFI (Adverse Effects Following Immunisation) and AESI (Adverse Effects of Special Interest). There are reasonable questions and concerns in popular discourse and will shape perceptions around the vaccine, including demand and hesitancy. These require not just clear proactive sharing of information to build trust and confidence but also real-time responses as vaccination progresses.
With the programme rollout around the corner, both vaccine optimism and vaccine scepticism co-exist. Indeed, each one of us is a believer and a non-believer in parts, not quite unlike deciding on whether or not to vote for a new party in a critical election. Communication challenges around the COVID-19 vaccine acceptance and hesitancy are unique and it would be of limited relevance to fall back on the conventional wisdom of anti-vaccine lobbies and vaccine hesitancy where the point of reference is with childhood vaccines and eradication/elimination campaigns such as polio or measles-rubella. Significantly, childhood vaccines are 90 to 99 per cent effective in preventing the respective diseases, and a myriad efficacy figures of candidate COVID-19 vaccines are shaping the perceptions game.
A study of 149 countries during 2015-19 noted that perceptions about vaccines in general had grown to be more volatile than earlier and that scepticism about the safety of vaccines tended to grow alongside political instability and religious extremism. As is well recognised, online misinformation is an increasing threat to public trust in vaccines and vaccination programmes. An example in the early phase of the pandemic: The poultry sector in India suffered an estimated loss of $ 1.5 m per day erroneously linking consumption of chickens to the disease.
Longer and wider views need to be taken beyond demand generation for the COVID-19 vaccination programme. The challenge lies in being able to frame and co-create credible communication and community engagement strategies, with blended content both around the vaccine as well as sustained emphasis on key preventive behaviours that will continue to be relevant — respiratory etiquette, hand hygiene and physical distancing. The programme leadership shall need to act in congruence with communication teams, backed by social and behavioural sciences research inputs. Effective messaging strategy shall need both a compelling story and a storyteller; credible voices will be crucial, going beyond celebrity status or political popularity. For a task such as this, belief in good science is essential but not sufficient; the risk is in being confined to the professional domains while not being adequately connected to the ground.
This article first appeared in the print edition on January 5, 2021 under the title ‘Communicating the vaccine’. The writer is chairperson, Centre of Social Medicine & Community Health, Jawaharlal Nehru University