Building Confidence in Routine Childhood Vaccines in India

The evidence-based initiative began with a literature review to identify the context-specific barriers and enablers of vaccine uptake in India. As the next step in the process, the collaborators aggregated and analysed publicly available posts about vaccines on high-traffic social media platforms (Facebook, Twitter, online video sites, news sites, and blogs) in both Hindi and English over a 3- to 12-month period. In parallel, they examined the 100 posts about childhood vaccines that received the most engagement across multiple platforms. Of these, 95% were pro-vaccine, suggesting positive public sentiment around routine vaccination. Among these posts, conversations focused largely on polio, referencing the success of past vaccination drives and current efforts to vaccinate children. Conversations not centred around polio largely celebrated India's ability to develop vaccines domestically against a variety of diseases.

Analysis of the online content revealed the following key trends:
 

• Over-indexing of men on posts across all topics: In India, men tend to post more than women, representing 78% of discussions, on average, across topics. Within vaccine-related discussions, men were found to be overrepresented in Hindi discussions around measles and polio but relatively under-represented in these discussions in English.
• National momentum and collectivism: Collectivism was often used to advocate for and communicate around childhood vaccination, including posts around National Vaccination Day and the successful national eradication of polio.
• Stories of healthcare workers providing remote care: Posts were found celebrating healthcare workers going to remote locations to ensure all children are vaccinated. One such post, depicting a healthcare worker standing with her daughter in a river carrying vaccines, went viral, suggesting healthcare workers may be effectively used as messengers within future campaigns.

Finally, the collaborators reviewed select online vaccine campaigns launched with UNICEF India during previous years of this collaboration as the last step of the foundational analysis. (For one example, see Related Summaries, below.)

Next, they identified behavioural insights for strategic messaging based on insights collected during the first phase, selecting five messaging strategies:
 

1. Amplify social responsibility and connectedness alongside national pride narratives.
2. Reinforce the social norm of vaccination, given the pro-vaccine conversation in the majority.
3. Prioritise fathers as messengers and priority audiences in vaccine messaging campaigns.
4. Leverage healthcare worker heroes as messengers.
5. Reach out to audiences in low immunisation coverage areas (Bihar, Rajasthan, Madhya Pradesh, Uttar Pradesh, and the cities of New Delhi and Mumbai) to encourage vaccine uptake with pragmatic information about how to catch up children with missed doses and information about vaccination cards.

All the online campaign ads were designed to convey on a casual, engaging tone and peer-to-peer communication style, using a local photo library provided by the UNICEF India Country Office team and building a colour palette based on local key visual cues. The collaborators used a creative design process, including visual research, to develop assets for India by examining local art and popular media for shapes, colours, and patterns to be incorporated into the designs. The ads, which featured links to more information on the UNICEF India website, were branded by UNICEF and deployed at the same time within state- and city-level campaigns.

The collaborators then launched two rounds to test these materials. In the first round, they tested the communication campaign "social cohesion and national pride" versus "social norming", which ran for four weeks in August 2022. In the second round, they tested the campaigns "vaccination card" and "prioritising fathers", which ran for four weeks in September 2022. Together, these four campaigns reached a combined total of more than 277 million people in India across both rounds. More than 3.4 million people clicked through to the landing page, highlighting a widespread demand for additional information on vaccination. Ads featuring pictures of children with their parent(s) reached the highest number of users in all areas. Also, national pride ads with an illustration of the Indian flag consistently generated high reach, impressions, and clicks.

Context:
India continues to be home to the largest number of un- and underimmunised children in the world and faces coverage barriers that are multi-level and complex. At a structural level, multiple access barriers make vaccination more challenging for those living in rural areas as well as densely populated urban slums. Demographic and socio-behavioural factors introduce additional barriers at individual, family, and community levels. Lack of family support and living in minority religious communities also correlate with lower vaccination rates, as does low information access (which creates knowledge gaps around the importance and timing of routine vaccinations and the risks posed by vaccine-preventable diseases).

Recommendations:
 

• Highlight positive social norms: The social norming campaign performed the best of the tested messaging strategies in Madhya Pradesh and the rest of the country (excluding high-priority regions).
• Feature parents and children together to encourage vaccination: Depicting children with their parents, especially fathers, performed well within campaign testing.
• Use local languages: In Mumbai, the collaborators recommend developing campaigns in both Marathi and Hindi. Hindi, rather than English - although an official language - was used exclusively for all campaigns in other regions given higher engagement with this content from past campaigns.
• Incorporate the vaccination card to encourage timely and complete vaccination: Based on the results of the two rounds of testing, the collaborators propose featuring the national vaccination card in campaign assets in most high-priority regions across India (apart from Madhya Pradesh). This campaign performed well and likely indicates a need for basic information in high-priority regions.