Behavioural segmentation of hesitancy to assist India’s vaccination program

By: Namiya Jain, and Nishan Gantayat

The COVID-19 pandemic is anything but over. Drawing lessons from the experiences of other countries, it is essential to design a robust & adaptive vaccination program. In this article, we use our learnings and experiences from our field research in India to present our viewpoint on how a behavioral understanding of hesitancy is important to cater to both demand and supply issues being experienced in the vaccination program. And thereby designing a robust vaccination program in the days to come.

Credits: IndiaSpend

Developing a safe and efficacious vaccine against COVID-19 in record time has been a challenging task by itself and to some extent can be seen a success as well. But now India as well as other countries are grappling to ensure vaccine supply and vaccine demand are kept at an optimum to tackle the pandemic. Massive vaccination drive is underway in India, with the goal of vaccinating the entire population by the end of 2021. The major challenges to successful roll-out of the COVID-19 vaccine has been delay or refusal in vaccine uptake, the differential nature of vaccine supply in terms of ordering, allocation, and to some extent vaccine utilization.

Vaccine hesitancy, as defined by WHO is a delay in acceptance, or refusal, of vaccination despite the availability of vaccine services. Hesitancy is a complex and a context-based behavior, varying across time, place and type of vaccine. While a certain level of vaccine hesitancy in the population is to be expected, indications of its scale for COVID-19 is a concern. Initial data from India shows that the national average for vaccination coverage among frontline workers and health care professionals stands at 82% for first dose and 56% for the second dose. The differences also vary between states which adds to the problem. Currently, only 12.4 % (as of August 13,2021) of the population is fully vaccinated.

Can exploring inconsistencies in micro-behavioral aspects like vaccine confidence become one of the factors that help moderate demand and also vaccine allocation? Can a better understanding of hesitancy help us to better prepare the vaccination program in coming months when covering the hard-to-reach and hard-to-convince population segments?

Context driven hesitancy

India unlike other economies, has a public health mandate on vaccination restricted to child immunizations and not adult vaccines, and also does not face any major ideological opposition to vaccination. In India, where conventional assumptions in health-seeking behaviors around care management, therapeutics, service delivery etc. are constantly challenged, looking at vaccine decision as a simple Yes or No can prove to be ineffective.

Final Mile has undertaken two separate qualitative studies exploring vaccine demand in India. One of the studies, with a sample representative of end-users as well as healthcare workers, was conducted to understand drivers of hesitancy. The second research was conducted in the states of Maharashtra and Punjab aimed at exploring and identifying the key enablers and barriers to COVID-19 testing along with conscious and non-conscious drivers of hesitancy or refusal towards COVID-19 vaccine for the first and second shot.

During these researches, we found that the dynamic nature of the context fuels vaccine uptake attitudes. Context includes circumstances surrounding a user/individual. The context within which an individual operates shifts continuously where at one moment one can see reduction in cases and opening up of the economy without a vaccine, and in the other there is rise of cases, closure of economy and launch of a vaccine. The experience of stressors like lockdown, income loss, and fatalities can create a high willingness to get vaccinated, but the strength of these stressors varies because of the changing context accompanying vaccination, and subsequently impacts willingness. An individual’s perception of risk around COVID changes continuously due to changing context’s impact on the relevance of these stressors. There is no single context in which the long-drawn-pandemic has been experienced. Instead, it is a mix of different periods characterized by their own set of infection rates, fatality rates, personal experiences, adaptations and information. The context has been tenuous, and individuals seem to have experienced the pandemic in stages, each with its own unique goals, risk perception, trade-off parameters, and mitigation strategies. For instance the pandemic can be seen as a set of the following statges:

Lockdown → Unlocking 1 → Vaccine Discovery → Unlocking 2 + Vaccination Drive → Second Wave + Lockdowns → Unlocking 3

Along each such stage and the corresponding context, individuals adopt separate sets of goals which influences what action one decides to take. These goals may include staying away from infection, returning to economic normalcy, seeking social freedom, concentrating on immunity and compliance measures, or just plain survival.

During the early months of 2021, when the COVID-19 vaccine was being introduced and made available to the healthcare staff, general sentiment towards the vaccine in India was positive with an action tendency of wait and watch. While the vaccine was being considered as an important step towards returning to normal, diverse information regarding its efficacy and long-term side-effects did not help in moving people from “wait and watch” to a more vaccine confident zone. During our study conducted in Punjab and Maharashtra, majority of the respondents shared stories of vaccinated individuals suffering with severe side-effects also cases of fatalities within their community while we explored their willingness towards COVID vaccines. Though any causal linkage is yet to be established within the scientific circles regarding the severe side-effects of vaccine, such local stories create negative narratives around the COVID vaccines making them scary and a costly alternative. Local community-based social-proof has started playing an important role in midst of the trust deficit accompanying the deluge of information and misinformation. As people trust their social networks and strong ties the most, such stories become increasingly relevant and very impactful and get anchored deeply. With the unlocking of the country, reduced restrictions and lowered COVID cases, the perceived risk of COVID may reduce and result in lower-than-expected uptake of COVID vaccine in coming months. The data on daily registrations on Co-Win, if taken as proxy for willingness has shown a lot of variability in this respect.

During our qualitative studies the vaccine decision has appeared to be one that involves a series of tradeoffs between cost elements (lack of complete knowledge of the vaccine, potential side-effects, losing control over the situation) and the benefits (prevention of COVID, returning to normalcy, community welfare, family health etc.), as individuals continue to have varied experiences.

Demand Variability and Vaccine Allocation

From late march onwards, when the COVID cases shot up exponentially, India found itself needing a disproportionate number of medical supplies including vaccines. Understanding hesitancy as a non-binary phenomenon and where context can create different kinds of hesitancy can help social planners forecast demand more closely. Though at an aggregate level there is an absolute number of total shots that needs to be purchased for the population to see this pandemic off, the infrastructural constraints warrant local officials to manage order and allocation based on consumption patterns, wastage, and expected demand. At any point of time, there exist cohorts who are vaccine confident, those who are fearful and waiting for some kind of definitive assurances, those who think vaccines are not relevant right now, those against the inconvenience vaccine registration/uptake brings with itself, and those who are not willing to take up the vaccine. Target population moves between these boundaries depending upon the context within which they find themselves at that instance. Someone who is willing and confident of vaccine might delay their appointment and move into the category who feel vaccines are not relevant now. For instance, when 65+ age group was opened up in January, understanding hesitancy could have led to anticipation of lower-than-expected uptake leading either to a more focused communication campaign to mitigate fears for the senior citizens or opening up of 45+ age group to channel the available supply towards their unmet demand.

As the 2nd wave of COVID cases in India seems to be on the decline, the context has shifted again. In addition to the declining country level figures, some states are seeing high number of positive cases like Kerala, and some continue to have high R-value like Meghalaya, Mizoram, Sikkim, Maharashtra, and Tamil Nadu. With this the risk perceptions and need for vaccine will shift and in absence of a stressors like high fatality the demand will not be as high as one experienced during the month of April-May. But it should not also be considered that the demand patterns will revert to February-March numbers. Since we are still in the early stages of the vaccination drive with a significant portion of the population remaining to be vaccinated, the assumption that we will achieve vaccination targets by producing numbers equal to the demand may not work. Thinking two steps ahead, demand management will become essential in presence of an optimal supply. Different set of narratives like those of the new variants might drive uptake whereas fears surrounding re-infection, mucormycosis etc. or the need for third booster dose can create trust deficit and subdue the demand. Demand patterns in coming months where size of different segments (vaccine confident, wait and watch, vaccine as irrelevant, vaccine refusal) are not constant, understanding vaccine uptake from behavior sceince lens can help identify better understanding of population segments beyond just demographics.

Hesitancy at the heart of vaccination program

What we have been seeing is a conventional demographic based vaccination program. Such an approach does not recognize the nuance of confidence and hesitancy between and within the demographic segments which leads to a sub-optimal program where programmatic efforts are not fine-tuned to the needs and fears of the population. As a result leading to a failure to drive demand and also give rise to supply side problems where allocation cannot be ascertained effectively.

Demand can be better segmented with a more intricate understanding of it and explored using the hesitancy lens. Hesitancy understanding can pave path for a behavioral science led segmentation of population where segments are characterized by emotions and attitudes, and coupled with demographic sizing could be beneficial for the program going ahead. When the government is sponsoring incentives and designing communication plans to spur the demand, exploring hesitancy can help make such incentives and communication more effective. Normalising demand will also help plug in the supply side issues we are experiencing today.







Final Mile brings unique and proven capabilities in addressing complex behavioral challenges. As one of the first Behavioral Science & Design consultancies, Final Mile has had the opportunity to bring these to practice in a wide variety of sectors and contexts. We have executed highly complex behavior change projects across a wide variety of areas covering Global Health (HIV, TB, Maternal Health, WASH), Financial Inclusion, Safety across Africa, Asia, Europe, and the US.

Final Mile is also building a pandemic playbook that can be used as a potential toolkit by policymakers and implementors in mitigating Covid19 and future such pandemics.

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Final Mile is a research and consulting firm solving tough and relevant behavioral problems across the globe