Building Confidence in the COVID-19 Vaccine in India
UNICEF India Insights for Impact Project with Facebook
As the coronavirus pandemic continues to unfold, billions of people across the globe are still waiting to receive their first dose of the COVID-19 vaccine. To meet this need, UNICEF is leading the global distribution of lifesaving COVID-19 vaccines as the key delivery partner of the COVAX Facility — a groundbreaking partnership between the World Health Organization (WHO), the Global Alliance for Vaccines and Immunizations (GAVI), UNICEF, and Coalition for Epidemic Preparedness Innovations (CEPI) to address the multiple facets of the pandemic. To date, COVAX has secured more than 5 billion vaccine doses and, of these, UNICEF has already shipped over 236 million across 138 countries. However, significant challenges in vaccine distribution remain. Not only does vaccine hesitancy continue to grow around the world, the pandemic has also disrupted routine vaccination services that are critical for protecting children against preventable diseases in more than 70 countries.
To better understand constraints to vaccine adoption, Facebook’s Data for Good team is leveraging its Insights for Impact program to help equip UNICEF and its key partners with information and tools to build public confidence in both routine and COVID-19 vaccines. Beginning as an eight-country pilot in 2020, this collaboration has expanded to include broader support for UNICEF’s vaccine messaging efforts in more than 100 countries with the help of Facebook’s Health Partnerships team. This case study explores how Facebook worked with UNICEF India to address vaccine hesitancy and increase COVID19 vaccine adoption in India.
Defining the Problem
Official statistics in India have counted over 34 million COVID19 cases since the onset of the pandemic and over 450,000 deaths from the disease. At the same time, the number of tests conducted per capita in India remains low and only 30% of the eligible population has been vaccinated from COVID19. Alongside the operational challenges in delivering vaccines to a country of 1.38 billion people, vaccine hesitancy remains a barrier, with health workers facing resistance from people who believe that vaccines aren’t effective, and cause serious side effects.
Insights from Public Posts and COVID19 Trends and Impacts Survey in India
To better understand trends in vaccine hesitancy in India, Facebook’s Data for Good team analyzed thousands of public posts about the topic on Facebook. The research team also included insights on hesitancy from Facebook’s COVID19 Trends and Impact Survey (CTIS), which tracks information on vaccine acceptance at a local level in over 200 countries and territories worldwide.
At the time of analysis, the COVID19 Trends and Impact Survey found that India had one of the highest rates of vaccine acceptance in the world with almost 77% of respondents indicating that they would like to receive the vaccine. While concerns about side effects are typically the main reason for hesitancy, the top factor contributing to hesitancy in India was that people stated that they want “to wait and see if [the COVID19 vaccine] is safe and get it later” which was indicated by 45% of respondents who said they did not want a COVID-19 vaccine. The second most common reason for not wanting the vaccine was “I think other people need it more than I do right now,” which was indicated by 37% of respondents.
Qualitative assessment of the public posts around the COVID19 vaccine in India demonstrated generally positive feelings, with many posts expressing national pride that India produced its own vaccine and, at the time, was distributing its vaccine to other countries. The posts included undertones of social cohesion and a strong national momentum to vaccinate. Many users also shared personal stories of being vaccinated, encouraged others to get vaccinated and showed appreciation for health workers. Lastly, public posts about the vaccine revealed that many people had questions about their availability, about potential side effects and when/how they would be eligible to receive their first dose.
The Importance of Message Testing
Using these insights, the Yale Institute for Global Health, UNICEF and Facebook worked to develop a series of eight campaigns -- four in English and four in Hindi -- all of which targeted both men and women aged 18 years and older in India and had the goal of increasing the public’s confidence in the COVID-19 vaccine. With content designed by the Public Good Projects, the campaigns linked out to the Government of India’s COWIN website which provided more information on vaccines, registration for appointments, and getting their vaccination certificate.
1. Filling Information Gaps with Emphasis on Safety and Efficacy [English/Hindi]: Given that the CTIS and public post data indicated a mostly positive attitude about vaccination, this campaign approach aimed to fill the information deficit and answer people’s questions about vaccine safety and efficacy. This campaign emphasized vaccine safety by outlining the rigorous testing by scientists and promoted efficacy by outlining that vaccines are the best way to limit the spread of COVID-19.
2. Countering the “Wait and See” Approach [English/Hindi]: Given the high proportion of hesitancy being driven by those choosing to “wait and see” if the vaccine was safe, this campaign sought to counter this position with fact-based messaging highlighting the urgency of vaccination using messages like, “Every day you wait to get vaccinated is another day that you could be spreading COVID-19 in your family and community.” This campaign aimed to reassure people, despite the perceived rush to develop and distribute vaccines, that the time for them to be vaccinated is now.
3. National Pride [English/Hindi]: This campaign also sought to capitalize on the social approval expressed in public posts, as well as the national pride that people were expressing at India’s ability to develop its own vaccine and share with other countries (deploying messages like, “Make India #1 in COVID-19 vaccination” and “Don’t let India down, get vaccinated against COVID-19.” This messaging positioned India as a leader in the global fight against COVID-19 and motivated Indians to join the fight by getting vaccinated.
4. Testimonials/Messengers [English/Hindi]: The analysis of public posts revealed that many people were sharing vaccination testimonies and encouraging their friends to get the vaccine and explaining why they chose to get it. Moreover, public posts often expressed appreciation for healthcare workers. Leveraging these insights, this campaign focused on personal stories of successful vaccination through trusted peers, family members and healthcare workers. The content emphasized minimal side effects and desire to return to normal life.
UNICEF, Yale and Facebook tested the effectiveness of these four approaches, in both languages, over a three week period in July-August 2021. Viewers of each ad set were randomly divided into two groups – those that saw the ads and those that did not. Upon completion of the campaign, viewers from both groups were randomly surveyed to help determine whether the ads had successfully influenced attitudes on vaccination. The post-campaign survey for all eight campaigns tested five different messaging elements, including recall of the campaign itself, the perceived importance of vaccination to prevent COVID-19, and likelihood of advising others to get vaccinated against COVID-19. Of the five questions asked, we asked two custom questions for each campaign.
The eight campaigns reached a combined total of over 98 million people in India. A statistically significant lift was observed in ad recall for four of the eight campaigns, three of which were in English, which indicates that the content was engaging and memorable for English-speaking audiences. Overall, the most successful campaign was the “National Pride” campaign that attained a statistically significant lift for four out of the five awareness and attitude questions for both English and Hindi campaigns. This campaign was particularly effective in increasing the likelihood that Hindi-speakers would advise a close friend or relative to get vaccinated against COVID-19. Meanwhile, the “Testimonials/Messengers” campaign attained an especially strong lift around perceived social approval for COVID-19 vaccination and the “Filling Information Gaps with Emphasis on Safety and Efficacy” worked particularly well in shifting attitudes on the perceived effectiveness of COVID-19 vaccines among English-speaking audiences. The “Countering the “Wait and See” Approach” campaign was the only campaign that did not attain a statistically significant lift for any of the non-ad recall questions.
In terms of language performance, results were mixed across Hindi and English campaigns, with English campaigns achieving higher recall, but Hindi campaigns moved attitudes more significantly. The research team also examined the campaign click-through rates to the India COWIN website and found that the Hindi campaigns had higher click-through rates than the English campaign, indicating this content was more effective in getting people to seek more information.
Overall, the campaigns improved attitudes among the Indian public towards COVID-19 vaccines, including their effectiveness and whether people would recommend COVID-19 vaccines to friends or family. Campaigns emphasizing social norms such as national momentum and content depicting testimonials with diverse messengers including health care workers and parents achieved the greatest lift in attitudes, showcasing the importance of leveraging credible voices in the quest to address vaccine hesitancy.
Influencing Vaccine Decision-making Moving Forward
Vaccine decision-making is complex and influenced by individual observations, experiences, knowledge, and even values and beliefs. Changing vaccine attitudes and behaviors often requires multiple nudges at multiple levels to be effective, including programs that target individuals, communities and even the policy landscape.
Observing statistically significant outcomes as a result of a digital campaign is a substantial accomplishment, showcasing how online outreach can influence complex decision-making at a low cost per person reached, as well as providing valuable insights to UNICEF that can be applied to future vaccine outreach.
Learnings that can be applied to future vaccination campaigns include:
- Consider content leveraging national momentum to vaccinate. In the India context, highlighting social norms and promoting cohesion can be a powerful strategy for building confidence in vaccines. This campaign worked particularly well for increasing the likelihood that Hindi-speaking audience members would advise a close friend or relative to get vaccinated against COVID-19.
- Use Trusted Messengers and Testimonials. Campaign results confirmed that doctors continue to be trusted and effective messengers in the Indian context, aligning with broader research and consensus within the field of vaccine acceptance and behavior change. Furthermore, the campaign results also demonstrated that personal stories about why people chose to vaccinate may be compelling.
- Share practical information and answer common questions. Given the high vaccine acceptance in India and generally positive sentiment from public posts, a campaign may link people to online resources for vaccination information (including safety and efficacy), registration and site locations may be an effective strategy to make it easier for people to get their shot and alleviate their concerns.
- Consider content in local and/or multiple languages. In a country as large and diverse as India, it is important to consider content in the language which will resonate with local populations. Our research found that results were mixed across Hindi and English campaigns, however, the Hindi campaigns had higher click-through rates and were more likely to move attitudes.
Yale and UNICEF plan to leverage these insights in a number of additional countries to increase vaccine acceptance across the many countries in which they work.
“We knew from our social listening reports that there was a high level of vaccine hesitancy amongst the public. There were concerns about the safety and efficacy of the vaccines being given in India, on their availability and lack of access to getting vaccinated. After the second wave in India, there was an urgency and necessity to vaccinate the public. This campaign allowed us to reach a significant audience with important messages, encouraging the public to get vaccinated as soon as possible and measure the impact of our messaging on the audience.” said Brian Alfred Boye, Communication Officer, Communication, Advocacy and Partnerships at UNICEF India.
"This is an incredible opportunity to learn from the power of social media for health promotion. In recent years, my research group and others have found promising leads on how to influence people’s health behavior and these insights provided us the opportunity to evaluate at scale.
The major strength of this effort is the collaboration - particularly with Facebook, UNICEF country offices, and other partners - where we bring together all our unique strengths to address one of the most pressing issues facing global health, vaccine confidence,” said Dr. Saad Omer, Director of the Yale Institute for Global Health.
"Being able to use insights from public posts on Facebook to inform outreach in India showcases the power of digital platforms to increase vaccine awareness and uptake," said Steve Satterfield, VP of Privacy and Public Policy at Meta. "We look forward to continuing the partnership with UNICEF to increase adoption of both childhood immunizations and the COVID-19 vaccine across countries."