Why won’t they just take the vaccine?

?A behavioral science approach to driving uptake of the HPV vaccine in India.?

By Kriti Chouhan

In early 2021, India saw one of its largest vaccination drives when it released the COVID vaccine and set out to vaccinate about 300 million priority groups against the virus. It has been over three years since then and Manju devi, a part time domestic help in the capital city of Delhi still believes that the vaccine is unsafe and also unnecessary. Despite numerous studies that have shown the vaccine to be safe and effective, she believes that natural immunity is better as the vaccine may also cause serious long term effects such as infertility. Similar perspectives are shared by Rahul Khanna, a middle aged working professional from the cosmopolitan city of Mumbai who believes that the vaccine was developed in a rush and is associated with long term heart diseases. Such myths and misconceptions are not uncommon when a new vaccine is launched or when an existing vaccine is brought to the forefront and pushed by the government.

In the latest budget announcement, the finance minister of India made its intentions of putting a concentrated effort to encourage the uptake of the HPV vaccine, which has been in the country for a decade, by adolescent girls very clear. The vaccine uptake has been particularly low due to its cost, which the government now intends to bring down by including it in its immunisation programme. While this is a positive move towards making India cervical cancer free, these efforts by the government can be undermined if misinformation and disinformation, as well as other behavioral biases that can affect uptake of the HPV vaccine persist.?

Underinvestment in preventive health is a growing area of research which demonstrates that individuals deviate from the standard economic principle of rationality and under invest in high-return opportunities. In other words, research from behavioral science has shown that people significantly under-value or ignore the life-changing benefits of preventive health products like vaccinations, bed nets, prenatal care or water chlorination, and over exaggerate the short-term costs of effort and inconvenience, leading to low uptake. However, their willingness to pay for curative healthcare when their child is sick is exponentially higher. This intention-action gap is often a product of incorrect mental models, biased beliefs, present bias and procrastination. For public health response plans to be effective, the heuristics and biases of the target population need to form the crux around which social mobilisation efforts are planned.

As the government gears up its efforts to encourage the uptake of the HPV vaccine, following are some of our learnings from applying behavioral science research and conducting studies and literature reviews around the HPV vaccine across the global south that can ensure that the government campaigns, especially communications campaigns around the vaccine are the most effective in driving intentions of parents and caregivers to get their daughters the HPV vaccine:

Use positive or aspirations framing: Parents have a sense of responsibility for their children throughout their lives and want to do everything in their power to protect their children and their future. Leveraging this sentiment, the vaccine promotion initiatives should frame messages targeted to parents in accordance with the aspirations framing linking the HPV vaccine to the aspirations of parents for their daughters’ future.

Use of social norms framing: Individuals tend to look at the behavior of their peers to inform their decision making, and have a tendency to conform to the same behavior their peers are engaged in. This can be leveraged to promote the uptake of the HPV vaccine by highlighting positive social norms or emphasising high vaccination rates within communities, using social proofs such as testimonials and endorsements from respected and trusted community members and leveraging social networks.

Debunking myths and misconceptions: Myths and misconceptions are often to be expected when a new vaccine campaign is launched. Some of the common myths around the HPV vaccine from around the world are that it is associated with infertility, it is unsafe, it is a family planning method and that there are adverse reactions to the vaccine. It is thus imperative that the government understands the most prevalent myths around the vaccine in different communities and addresses them by providing accurate information and clarifying common myths that can also help align social norms with the scientific consensus on the safety and effectiveness of the vaccine.

Use visual communication of a doctor’s support for the HPV vaccine: Doctors and other health workers including community health workers are often reported as the most trusted sources of health related information. They are seen as experts in the health field and thus, at times, even more trusted than the government. This immense trust in health workers should be leveraged by HPV promotion initiatives targeting parents.

Understand the audience and their contexts: It is imperative that practitioners understand the context and environment of their audience as not all channels of communication will work for all kinds of audiences. For example, in one of our studies in Kenya, we found that owing to busy schedules, the SMS campaign did not work very well with only a minority of parents texting back to learn more about the vaccine. This suggests that sending too many messages via SMS may not work in promoting the vaccine in the low income Kenyan context. Thus, the government should leverage only the most appropriate channels of communication that may differ by communities or regions within India.

Framing of vaccine as “cancer preventing”:? Another potentially impactful way of advertising the vaccine to improve take up is to make the link between the vaccine and cancer very clear due to the prevailing fear of cancer. This would involve framing the vaccine as a cancer-preventing rather than a HPV-preventing vaccine. By advertising it as a cancer prevention tool, parents might feel more intrinsically motivated to vaccinate their daughters.

Behavioral science offers valuable insights into understanding human behavior and decision-making processes, which can be leveraged to improve the HPV vaccine uptake. By understanding the context and the cognitive barriers associated with vaccine decision making, health campaigns can include targeted interventions and strategies to address barriers, motivate behavior change, and ultimately improve vaccine uptake rates within communities by closing any intention-action gaps.