Building Confidence to Continue Routine Immunization During COVID-19

As the COVID-19 pandemic continues to unfold, millions of people eagerly await a coronavirus vaccine.  UNICEF is leading the global distribution of lifesaving COVID-19 vaccines as the key delivery partner of the COVAX Facility — a groundbreaking partnership between WHO, GAVI, UNICEF, and CEPI to address the multiple facets of the COVID-19 pandemic. To date, COVAX has secured 4.06 billion vaccine doses and, of these, UNICEF has already delivered 59 million doses across 122 countries. However, as these efforts lead to unprecedented achievements, significant challenges still remain. Not only does vaccine hesitancy continue to grow around the world, the pandemic has disrupted routine vaccination services in more than 70 countries during the past year.

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 108 countries with the help of Facebook’s Health Partnerships team. This case study explores how Facebook worked with UNICEF Ukraine to address vaccine hesitancy that was driving a drop in routine vaccination rates across the country.

Defining the Problem

In 2020, the UNICEF Ukraine team began to observe a sharp decrease in routine vaccination rates. “As the pandemic started, we faced an alarming decline in the number of children receiving life-saving vaccines,” said Anna Sukhodolska, Communication for Development Section Chief at UNICEF Ukraine. “As of June 2020, only 28% of one-year-old children received the first dose of the measles, rubella, and mumps (MMR) vaccine due at that age. On the same date in 2019, this number was 42.” As the pandemic continued, more and more parents and caregivers were choosing to delay or selectively complete scheduled routine vaccinations for their children because parents were unsure about the safety of visiting health clinics during COVID-19.

The UNICEF team decided to launch a national awareness campaign to remind parents and caregivers of the importance of completing all routine vaccinations on time as well as highlight the new safety measures that local health centers were using to keep health workers and families safe from COVID-19. UNICEF knew that how they delivered these messages was key — beyond just sharing information, the campaign needed to shift negative perceptions about the continued safety of vaccination to ultimately reduce hesitancy and increase vaccine uptake.

Deciding on a Winning Strategy

In a context where trust in public health authorities is not uniformly high, UNICEF Ukraine recognized that the campaign’s success depended on crafting messages that mitigated public concerns about vaccination safety during COVID-19. In order to figure out the most effective messaging, UNICEF partnered with the Yale Institute for Global Health and Facebook to test two message framings to determine how well the messages resonated with the target audience that included parents and caregivers between the ages of 18 and 65.

The first framing, dubbed the “rational” campaign, focused on sharing fact-based scientific information in a clear and compelling way and featured a well-known Ukranian doctor — UNICEF’s health expert — as the key messenger. The second, “emotional” campaign was designed to appeal to caregivers’ desire to minimize disruptions to the lives of their children during COVID-19. It highlighted the many things that have changed for children during COVID-19, from playdates to spending time with grandparents, and contrasted them with one thing that hasn’t changed: the importance of completing all childhood vaccinations on time.

Both campaigns, however, communicated the same core messages: the importance of timely and complete childhood vaccination and the safety of continuing routine vaccination during the COVID-19 pandemic.

The Importance of Experimentation

The Yale team helped UNICEF adapt the messages to the different approaches, both of which took the form of 30-second video ads that were optimized for mobile viewing and comprehension without sound. Both drew on the same child-friendly visual style that incorporated animations and real-life photography but used different color schemes — deep royal blue and purple for the “rational” campaign and yellow and green pastels for the “emotional” campaign.

The “rational” video incorporated healthcare-related imagery and featured a trusted, well-known doctor who used authoritative, evidence-based language. She communicated facts like “vaccines teach immune systems to fight infections” to convey the importance and safety of continuing routine vaccinations.

• Link to “rational” video

The “emotional” video used playful images of children to reference changes to important childhood experiences that the pandemic has brought. Those experiences were juxtaposed with the unchanging importance and safety of vaccination: The pandemic has turned childhood upside down. But vaccination remains unchanged,” the ad said.

• Link to “emotional” video

UNICEF and Facebook tested how well the two different approaches performed with the target audience over a two-week period. Both viewers who saw the ads (the test groups) and those who didn’t (the control groups) were randomly surveyed to see whether the ads shifted attitudes on the safety of continued vaccination during COVID-19. The survey also helped UNICEF gather important information on how to better tailor future vaccination campaigns.

Measuring and Comparing Impact

The campaigns reached a combined total of over 7.9 million people across Ukraine. Survey results showed that the approach featuring science-based messaging from an authoritative health messenger successfully increased both knowledge of new COVID-19 safety measures and confidence in the safety of continuing routine vaccination. The “emotional” approach, however, showed no statistically significant effect on attitudes toward vaccination.

Campaign Results Highlighting Where Ad Exposure Caused a Positive Shift in Attitudes Between Test and Control Groups

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. This often involves various communication approaches and program activities that target both individuals and their networks, as well as the broader community and even the policy landscape. Given the multifaceted nature of these decisions, observing positive influence or “lift” in vaccine attitudes (outcomes that meet an 80% replication threshold) as a result of a digital campaign on its own is a significant accomplishment and showcases how digital outreach can be a powerful tool for influencing complex decision making at a low cost per person reached.

The post campaign  survey tested four elements: ad recall, knowledge of new safety measures, the safety of continuing routine vaccinations, and the importance of continuing routine vaccinations. Statistically significant lift was found in all four elements as a result of the “rational” campaign and in ad recall for the “emotional” campaign:

Campaign performance reflects: *Chance of brand lift 90% or greater; ^Chance of brand lift 80% or greater

Applying Learnings to Future Campaigns

This case study illustrates how thoughtfully-designed and well-tested campaigns can be used to rebuild public confidence in the safety of routine vaccination during the COVID-19 pandemic.

“While the project helped us establish that, amidst the pandemic, a rational appeal should be used for further demand generation on routine immunization, we also learned something new about our own audience,” Sukhodolska said. “For instance, older adults showed surprisingly high interest in vaccination-related content. Hence, more grandparents should be mobilized as advocates for child immunization in their households.”

While these insights are context specific, in the months ahead UNICEF Ukraine and Facebook will continue to explore and compare other approaches to vaccine messaging as part of a broader, multi-country impact evaluation led by the Yale Institute for Global Health.

“Ukraine has made great strides in public health, but also has unique challenges including lower public trust of key stakeholders and decision makers in the vaccine landscape, “ said Dr. Saad Omer, Director of the Yale Institute for Global Health. “Communication based on behavioral science is the way forward, and we are excited to work with colleagues from UNICEF Ukraine in this mission.”