An invited presentation to the National Vaccine Equalities Steering Group on work on behavioral sciences contributions to vaccine uptake

1. Public Health Covid Briefings
Jim McManus, Director of Public Health,
Hertfordshire County Council
Jim.mcmanus@hertfordshire.gov.uk
Behavioural Sciences Contributions to Vaccine
Uptake - Hertfordshire
www.hertfordshire.gov.uk/behaviouralscienceresources
14th May 2021

2. Public Health Covid Briefings
Jim McManus is Director of Public Health for Hertfordshire.
Jim is Vice-President of the Association of Directors of Public Health and
Past Chair of the Behavioural Science and Public Health Network
www.bsphn.org.uk
Jim is a registered Public Health Specialist, a Chartered Psychologist,
Chartered Scientist and a Fellow of the British Psychological Society
This presentation and all materials associated with it are Copyrighted ©
Hertfordshire County Council, 2020-21. Use may be made with
acknowledgement

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Who is in our Behaviour Change Unit?
Dr Michelle
Constable,
Head of BCU
Wayne Bateman,
Behavioural Science
Specialist
Roshni Deo,
Behavioural Science
Specialist
Ludovico Nocco,
Behavioural Science
Specialist
Catherine Haylock,
Evaluation Officer
Khadija Mohamud,
Evaluation Officer

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The 30 second version
 Following our research on what works in increasing vaccine uptake, we produced a
review of research and identified several sets of issues
 We then developed recommendations and tools to enable people to systematically
engage with local populations and to explicitly link barriers and issues people identify
with interventions then determine what impact they had
 Our suite of tools includes: Detailed review on uptake, engagement process briefing
with links and tips, templates for engagement and links to key behavioural science tips
and tools within it
 We have used it locally – Gypsies and Travellers, BAME communities, Homeless
 All can be found at www.hertfordshire.gov.uk/behaviouralscienceresources

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Our uptake strategy
 Joint Public Health, NHS and Districts Inequalities Group
 Monitoring Daily through dashboard
 Countywide uptake strategy
 Locality by locality strategy to target MSOA level uptake – eg Watford business case
 Work with community agencies – wide coalition
‒ Herts&BedsAfroGPs, Mosques, Serbian Mosque, Dioceses and London Boroughs
 Get the balance right in targeting – target too much and you can worsen
inequalities (eg hyper targeting of one cohort of 60 people versus an entire ward of
8,400)
‒ We are trying to do both – eg homeless population AND the Watford Business
case

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Examples

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Behavioural Science Background
 Scientific evidence on behavioural and social
science contributions to public health
 National Strategy 2018
https://tinyurl.com/s4uermdt
 Read strategy on www.bsphn.org.uk
 Public Health Problems are complex problems
from social and structural to biological. Most PH
problems require action at multiple levels
 Vaccine uptake – over 45 years of knowledge on
this in PH

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Hertfordshire Evidence and Impact Plan
 From a commitment to Outcomes and Impact we created an Evaluation
Unit (whose purpose is to support Local Authority and Vol Sector
projects develop effective interventions from design to delivery)
‒ Real world evaluations for real world projects
‒ Toolbox and Library of evaluation Reports
https://www.hertshealthevidence.org/evaluation.aspx
 We also created a Behaviour Change Unit in 2019

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Scientific Partnerships

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Herts Behaviour Change Unit
 August 2019
 6 Behavioural Scientists working on everything from whole school conduct strategies to
designing new recycling facilities
 Support corporately with Theories of Change and behavioural analyses using Behaviour Change
Wheel (Michie et al, 2011)
 Covid struck - unit has been applied to support preventative behaviours positive mental health
and resilience, disease prevention, and reducing vaccine hesitancy.
 www.hertfordshire.gov.uk/behaviouralscienceresources .
 One campaign toolkit PlayYourPart here https://www.hertfordshire.gov.uk/about-the-
council/news/campaign-toolkits/play-your-part-campaign.aspx

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Covid work
 Public Mental Health - Created and supported a public mental health cell and national MH
collaborative with LGA on Knowledge Hub
 Lockown – health, coping and compliance
 Behavioural sciences for NPIs - design of communications to design of social distancing measures in
town centres. Evaluated impact of social distancing measures in town centres to support ongoing
suppression strategies
 Vaccine Confidence - behavioural skills and components of “being vaccine confident” in staff and
volunteers promoting vaccine uptake. Research on vaccine hesitancy and strategies. Engagement
tools for populations with low uptake
 Exit the Pandemic - “skills for living and working in a covid endemic environment” to inform
interventions as part of the Roadmap to re-opening
‒ Undertook research on vaccine hesitancy identifying strategies to improve vaccine uptake.

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12
Willingness to accept a vaccine falls on a continuum
The SAGE Working Group on Vaccine Hesitancy:
"Vaccine hesitancy refers to delay in acceptance
or refusal of vaccination despite availability of
vaccination services. Vaccine hesitancy is
complex and context specific, varying across
time, place and vaccines. It is influenced by
factors such as complacency, convenience and
confidence."

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WHO Determinants of Uptake (2014)
• Confidence – the level of trust in a vaccine’s safety and/or effectiveness. (Note – we have
STOPPED talking about just hesitancy). Acceptability (multiple aspects)
• Complacency – the perception of risk regarding how likely someone is to contract COVID-19
and the severity of the implications it would have upon their health if contracted.
• Convenience – how easy it is for someone to get the vaccine.
Most dimensions of vaccine uptake can be
conceptualised in these domains
World Health Organization. (2014).
https://apps.who.int/iris/bitstream/handle/10665/111548/9789241506892_eng.pdf?sequence

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Vaccine Equity Plan - the Big 4 to Fix
 Access and Structural Barriers
 “Hesitancy” is not complex enough
‒It’s really an Acceptability - Confidence spectrum
 Data
 Misinformation
Most dimensions of vaccine uptake can
be conceptualised in these four domains
from call and recall systems to cultural
and faith norms about vaccines

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Behavioural Science Vaccine Work to date
 LGA Webinar here, quick LGA Article here
 Podcasts 8 and 9 in the BSPHN series
 Review of What Works
 Out of this review came guiding principles of Engagement and
tools to help teams improve uptake
‒ Example of one focus -Social Care (Vaccine Hub)
https://www.hcpa.info/covid-19-vaccinations/
‒ One strand of a multi-component plan

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Built around Engagement Principles
 You will only get uptake if you understand and engage with
communities about the multiple issues in take up
 They will be different for each population and community
 You need to do this work properly
‒ Pre-engagement Analysis
‒ Engagement
‒ Implement and Evaluate

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Pre Engagement Analysis
 What do you know about the population or
community already?
 Saves time and is a mark of respect for the
community by not expecting them to do
work you should do yourself
 Understand the population, barriers and
enablers, what interventions have worked
 Impact of Covid
 Uptake of vaccine
 An initial statement to re-iterate

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Principles of Engagement

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Engage to Understand
 Understand barriers and facilitators
 Clarify areas for further work
 Agree best way to engage with communities
 Identify key influences and messengers
 Identify which sources of information people trust
 The COM-B Model
‒ Capability, Opportunity, Motivational Barriers
‒ Includes example questions for each area

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Engage to Empower
 Apply insights from previous stage to
co-produce solutions
 Ensure interventions are culturally
sensitive, appropriate, acceptable
and accessible
 Link solutions EXPLICITLY to
identified barriers, influencers and
enablers
 Iterate with feedback

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Engage to Evaluate
 Conduct a process of evaluation
‒ what actually happened against the stated plan
‒ what impact did it have? (Did Vaccine uptake increase? What other
impacts positive or negative?)
 Follow up and confirm with community what has changed
 The tools you used throughout this process form the basis of your
evaluation conversation
 Influences on vaccination intentions fluctuate over time so strategies
and communications will need to reflect changes to ensure they are
still relevant.

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Examples
 Social Care
 Mosques
 Homeless
 Black Majority Churches
 Black Community Centre
 Unregistered Portuguese
 Unregistered Romanian
 Community Free Transport Watford
https://www.qni.org.uk/resources/a-county-
wide-approach-to-vaccination-in-hertfordshire/

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Lessons
 Simplify or collapse the multiple dimensions of Uptake at your peril – peoples concerns are very real
and should not be dismissed
 Get the balance right in targeting – target too much and you can worsen inequalities (eg hyper
targeting of one cohort of 60 people versus an entire ward of 8,400)
‒ We are trying to do both – eg homeless population AND the Watford Business case
 Work with levels of hesitancy and take time to understand the issue
 Behavioural Sciences are WAY MORE than behavioural insights or “nudge”.
‒ EG Meaning and motivation (which means sociological and social psychological perspectives.
Community Identifiable Reference Persons are every bit as important, for example)
‒ Its not just the message but the messenger and the communication channels that are important
 Lessons from HIV Prevention

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Thank You!
Further Reading Links are in the appendices slides below

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Appendix: where do I learn more?
Some materials on vaccine hesitancy here
 Short read https://www.local.gov.uk/our-support/guidance-and-resources/comms-hub-
communications-support/covid-19-communications/covid-8
 Longer reads
‒ https://www.hertfordshire.gov.uk/services/health-in-herts/professionals/covid-19-behavioural-
science-resources.aspx
‒ https://www.ecdc.europa.eu/en/immunisation-vaccines/vaccine-hesitancy
 A podcast here https://www.bsphn.org.uk/719/Coronavirus-Mini-Series-8---Behavioural-Science-to-
Increase-Vaccine-Uptake-Jim-McManus-Wayne-Bateman-Paul-Chadwick

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Where do I learn more?
Some good reads
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)30218-1/fulltext
Catalogue of hesitancy reduction requirements
https://www.ecdc.europa.eu/sites/default/files/documents/Catalogue-interventions-vaccine-
hesitancy.pdf
https://www.ecdc.europa.eu/en/publications-data/catalogue-interventions-addressing-vaccine-
hesitancy
https://www.mayoclinicproceedings.org/article/S0025-6196(20)31487-7/pdf
https://www.who.int/immunization/sage/meetings/2014/october/3_SAGE_WG_Strategies_addressing
_vaccine_hesitancy_2014.pdf