Nudging Vaccination Uptake in Low Coverage Areas in Lebanon: Evidence from a Randomized Controlled Trial

Summary:

With a rapidly growing population and a rise in poverty levels, measles has reemerged in low-coverage areas across Lebanon. As a strengthening strategy and preventative mechanism against future outbreaks, the MoPH, in collaboration with UNICEF Lebanon, launched the Accelerated Immunization Activities (AIA) program in 2017 to provide quality immunization for every child through the primary healthcare system in Lebanon. To complement this effort, in 2018, UNICEF Lebanon partnered with Nudge Lebanon to design, implement and evaluate a behavioral insights intervention to improve the delivery of the AIA program in order to increase the uptake of vaccination among households with unvaccinated children. The intervention, which was piloted as a clustered Randomized Controlled Trial in seven urban communities over a period of two months, consisted of a behaviorally-informed calendar that combined five nudges designed to address some of the most common challenges identified through in-depth interviews, focus group discussions and field observations. Data collected from 16 healthcare centres, revealed that the calendar resulted in a 6.8 percentage points increase in the probability of a household vaccinating at least one child (95% CI = [0.049, 0.087], p < 0.01), compared to a control group (proportion vaccination at least on child: control group = 13.5 ppts; treatment group = 20.3 ppts). Overall, the increased uptake of vaccination reveals a substantial increase compared to standard procedures, lending support to the use of behavioral insights and nudging as one of the social and behavior change techniques to identify and address behavioral barriers.

Background/Objectives:

With a rapidly growing population and a rise in poverty levels, measles has reemerged in low-coverage areas across Lebanon. As a strengthening strategy and preventative mechanism against future outbreaks, the MoPH, in collaboration with UNICEF Lebanon, launched the Accelerated Immunization Activities (AIA) program in 2017 to provide quality immunization for every child through the primary healthcare system in Lebanon. To complement this effort, in 2018, UNICEF Lebanon partnered with Nudge Lebanon to design, implement and evaluate a behavioral insights intervention that aimed to increase the uptake of vaccination among households with unvaccinated children.

Description of Intervention and/or Methods/Design:

The intervention consisted of a behaviorally-informed calendar that combined several nudges designed to address some of the most common challenges identified through in-depth interviews, focus group discussions and field observations. More specifically, the calendar consisted of statements revealing support for the AIA program by others (social norms); a non-binding commitment by parents to vaccinate their children (commitment); an intention-implementation plan, in which parents would specify the date and location in which they will vaccinate their children (implementation-intention plan); the Ministrys guarantee of the quality and effectiveness of the vaccine (effect of the messenger); and a request to place the calendar somewhere visible (salient reminder). The intervention was evaluated using a clustered randomized controlled trial (RCT) at the level of outreach teams, with community-level stratification. A total of 37 trained outreach teams reached 12,332 children, in 6,160 households, across seven communities.

Results/Lessons Learned:

Data collected from 16 healthcare centres, revealed that the calendar resulted in a 6.8 percentage points increase in the probability of a household vaccinating at least one child (95% CI = [0.049, 0.087], p < 0.01), compared to a control group (proportion vaccination at least on child: control group = 13.5 ppts; treatment group = 20.3 ppts). Adding covariates revealed additional insights and associations between household characteristics and uptake of vaccination. For instance, the probability of a household vaccinating increased by 2.3 percentage points for every additional unvaccinated child. Nationality also played an important role such that non-Lebanese households were significantly more likely to vaccinate at least one child (Non-Lebanese HH: 18.2% vs Lebanese HH:13.8%). However, there was no significant difference in the treatment effect between Lebanese and non-Lebanese households and no significant gender effects.

Discussion/Implications for the Field:

Overall, the increased uptake of vaccination reveals a substantial increase compared to standard procedures, lending support to the use of behavioral insights and nudging as one of the social and behavior change techniques to identify and address behavioral barriers such as neglect, forgetfulness and misconception around social norms, especially in urban settings. Moreover, this results of this intervention shows that reaching out to households more than once could amplify the effectiveness of the outreach program, but only when the follow-up visits are coupled with the behaviorally-informed calendar.

Abstract submitted by:

Ali Osseiran - Nudge Lebanon
Andrew Saab -  Nudge Lebanon
Joanne Yammine - UNICEF