1. Understand your challenge
It is important to take some time to reflect on the behaviour(s) you are trying to change and the contexts in which they take place. More specifically it can help to begin by narrowly defining your behaviour(s) of interest. These can be ‘ultimate’ (i.e., the behaviours that you ultimately want to change) or ‘proximate’ (i.e., behaviours that influence the likelihood of the ‘ultimate’ behaviour occurring).
You can then move on to identifying the groups whose behaviour you want to influence, and to undertaking research that uncovers key barriers to change. For those under time pressure this can be completed relatively quickly through desk research. For those who have more time and resources, it may also be valuable to undertake some primary research (e.g., surveys or interviews).
This guide focuses on the work councils can undertake to improve vaccine uptake. However, you can use the steps outlined below to change other behaviours related to COVID-19.
1.1. Determine which behaviours to change
When designing a behavioural solution, it is crucial to define the behaviour(s) that you are trying to change. For example, do you want to:
Increase the number of residents who get vaccinated?
- Change perceptions about vaccinations?
- Increase the number of people who adhere to social distancing after getting vaccinated?
- Reduce the number of missed vaccination appointments?
The final ‘behaviour’ you are looking to change, increasing vaccine take-up, can be thought of as the ‘ultimate’ behaviour. To understand how to achieve this it can be useful to break down this outcome into constituent ‘proximate’ behaviours which influence your ‘ultimate’ behaviours. When doing so, it is important to outline a clear Theory of Change that shows the relationships between ‘proximate’ behaviour(s) causally affects the ‘ultimate’ behaviour.
An example of this approach would be to try to encourage vaccinations (‘ultimate’) by first changing attitudes toward vaccines (‘proximate’). However, while changing attitudes is likely to causally affect vaccine uptake, it may not be sufficient. For example, individuals may not know how to get vaccinated. Thus, in this case, it may be worthwhile to design solutions that also provide residents with information.
This process is also linked to how you might evaluate the impact of your work. Understanding what behaviour(s), proximate or ultimate that you can measure. This is covered in section 3 ‘Evaluate your solution’.
1.2 Identify your target audience
Once you have defined the behaviour(s) you want to change you then need to identify your target audience. You can follow the two-step process below.
1.2.1. Review evidence on vaccine hesitancy
Conducting a quick literature review on vaccine hesitancy can be very insightful. It can help you identify the socio-demographic groups that are more likely to be vaccine hesitant.
Once you’ve identified key groups, check whether you have any local data to challenge or support your assumptions. Draw on local vaccination data if available or feedback from your community. You will need to continuously reassess your target groups as more data becomes available. Questions to consider include:
- Are there any socio-demographic groups or communities that have lower vaccination rates in your area?
- Are the groups you identified lagging in terms of vaccination rates? Are there other groups that you have to consider?
- What is the feedback from community representatives or public health teams?
1.2.2. Prioritise target groups
After having identified groups that are more likely to be vaccine hesitant you should prioritise them based on the national vaccine delivery plan, your area’s socio-demographic composition and your own local knowledge. Doing so will help you form an achievable target.
- Which cohorts are due to be vaccinated? Are there any groups within these cohorts that are more likely to be vaccine hesitant?
- What are the socio-economic and demographic characteristics that are most represented in your area?
- Are there any other groups you should consider based on your local knowledge? Are there communities that are particularly isolated?
Other councils have adopted strategies which first identify a set of challenges or groups that are likely to be vaccine hesitant in the future. They construct this list by reviewing the vaccine priority lists and reviewing local data and insights. They then look to address the three or four most pressing problems. By addressing three or four challenges instead of trying to tackle all of the challenges they are facing this ensures the workload is reasonable and not overwhelming. Doing so allows the council to be forward looking and agile.
1.3 Understand group-specific barriers to vaccine take-up
It is important to work with communities to understand what their concerns and barriers to take up are. To do this you need to both engage with your target audience and to try to map and identify their specific needs and challenges. We have expanded on these below.
1.3.1. Engage with your target audience
During the pandemic councils are using a range of tools to engage with, and gain insight from, specific groups or populations. The most common methods used include social media monitoring, organising FAQ sessions, webinars, meeting with community forums, as well as using surveys and focus groups.
It’s important to consider the strengths and weaknesses of the different approaches as well as the time and resources needed to carry them out.
1.3.2. Identity barriers to vaccine take up
To help you structure your thinking, we present two helpful behavioural science frameworks. You can use these frameworks to identify barriers to vaccine take-up. Note that you will need to adjust these frameworks to fit your local context.
Once you have identified the key barriers to take-up, move on to the next step and start developing your behaviourally informed solutions.
Confidence, complacency, convenience model of vaccine hesitancy
Vaccine hesitancy is a complex issue. The ‘3C model’ is a useful tool to understand the main reasons that drive vaccine hesitancy. It breaks them down into three main factors:
- Confidence: People are vaccine hesitant because they have low confidence in the vaccine’s effectiveness and safety and distrust scientists, policymakers and health professionals.
- Complacency: People are vaccine hesitant because they don’t perceive themselves to be at risk and view the vaccine as not necessary.
- Convenience: People are vaccine hesitant because there are a number of barriers (physical, logistical or economical) that hinder them from getting a vaccine.
We developed a template based on this model to help you understand the reasons driving vaccine hesitancy among your target audience. You can use it when conducting interviews, focus groups or surveys.
The COM-B model is a behaviour change model and is a useful tool when identifying barriers and opportunities for behaviour change. It suggests that any behaviour is the result of three main factors. These can be used as levers to achieve behaviour change:
- Capability: People have the skills, ability and knowledge to perform in a behaviour
- Opportunity: There are external factors which make a certain behaviour possible, these can be provided by the social or physical environment (social norms, peer support, resources).
- Motivation: People have the desire, impulse, habit or the intention to perform a behaviour.
Numerous councils use the COM-B model to identify barriers to vaccination and to develop solutions to address these barriers. We developed a template to help you apply the COM-B model.
2. Apply Behavioural Insights
After you have mapped the barriers to the takeup of vaccines, you can begin developing solutions that either remove––or push people to overcome––these barriers.
Councils have a range of tools that they can use to support vaccine uptake, such as communications, policies, and programmes. The following sections provide concrete recommendations that you can take into account when designing your solutions.
2.1. Design your behavioural solution
In this section, we list a set of behavioural insights and recommendations that councils can use to try and change or shift behaviour.
The first set of behavioural insights help to encourage individuals to form intentions to vaccinate. These can be applied specifically when designing communications.
The second set of behavioural insights help to get people who have the intention to get the vaccine to take action and go and get the vaccine. This is called bridging the intention-action gap. These insights can be applied to communications, or to designing services, the physical environment or be linked with how you enforce policies.
You do not need to apply all of the recommendations at once; instead, choose the ones that best suit your context.
2.1.1. Encourage vaccination intentions
2.1.2. Bridge the intention-action gap
2.2. Find the right messenger
If your solution is to send a communication or to provide information, consider who delivers the message. People are not only influenced by the content of a message, but also by the individual or organisation that conveys it.
Consider whether your council would be an influential messenger to communicate to your target audience. If the council is not the most influential communicator, consider working with partners.
- Who might be most effective at delivering the message?
- Councils have access to individuals in a range of roles. Are there any specific figures within your council that would be more influential (e.g. public health leads or councillors)?
- Are there any influential external figures that could support or endorse council communications (e.g., local GPs or community leaders)?
- Are there any influential external figures that could become direct messengers (e.g., community leaders or third sector organisations)?
Below are some recommendations on how to identify influential messengers: (Martin & Marks, 2019).
- Recommendation: Use figures that are perceived to have authority or expertise to deliver vaccine communications, such as faith leaders, community leaders, or local GPs.
- Why: Hard messengers are influential because they possess some sort of status relative to the audience. They have authority, expertise, a high socio-economic status, or physical attractiveness.
- Example: To encourage vaccine uptake among Hounslow’s ethic community, the council designed communications that featured quotes from local GPs from ethnic backgrounds. Read the full case study: London Borough of Hounslow: Used the messenger principle to address vaccine misinformation
- Recommendation: Leverage community ties and relatable figures to disseminate vaccine communications, such as community champions, volunteer organisations, social media influencers.
- Why: Soft messengers are influential because they have similar characteristics to the intended recipient and are seen to be trustworthy.
- Examples: Wirral Council is using its existing ‘community connectors’ programme to encourage vaccination. Community connectors are a group of local residents with strong links within their community. They regularly engage with their network to understand and address their concerns about the vaccine. Read the full case study: Wirral Council: Listened to the ‘voice of the resident’ and engaged with hard-to-reach communities. Similarly, several councils are working with sports clubs, ambassadors and other organisations to promote social distancing and vaccine uptake.
Things to avoid:
Avoid involving figures that can be politicised. They can create resistance among part of the population, undermining vaccination intentions.
2.3. Choose your channel
If your solution is communication-based, consider the channel(s) that can most effectively deliver your message to your target audience.
In some cases, the most effective communication channel will be dependent on the ‘messenger’ you choose. In other cases, you won’t need to find a channel as the ‘messenger’ will deliver the message through their network. For example, community leaders can work as messengers and channels to disseminate messages.
The channel you choose will affect your ability to evaluate your solution. Consider whether there are any outcome metrics you can record to assess the impact of your solution. For example, if you are sending out bulk emails you will be able track whether recipients open them or click on links.
Here are a few examples of channels used by other councils:
Social media (Twitter, Facebook, TikTok, Instagram)
Example: The London borough of Hounslow launched a series of messages via Facebook that address concerns about vaccine trials being rushed. Using Facebook, they were able to track engagement and determine the effectiveness of their messages.
Read the full case study: London Borough of Hounslow: Used the messenger principle to address vaccine misinformation
Similarly, the Hertfordshire council posted videos on TikTok to reach younger generations. The videos they designed received over 40,000 views.
Example: Stockport Council organised a webinar with care home staff and the council’s public health team. The goal was to have a wider conversation about vaccination. They used this channel to engage directly with their target audience and address their concerns.
Example: The London Borough of Havering organises online FAQ sessions on vaccination for its residents, working with local health authorities. They leveraged their existing links to different community forums and specifically used this channel to engage with BAME residents and women. Read the full case study: The London Borough of Havering: Using the COM-B framework to develop a vaccine take up strategy
One to one - personal networks
Example: Wirral Council use ‘community connectors’, which are local residents with strong community ties, to disseminate vaccine communications within the community. Before COVID-19 they operated door to door in neighbourhoods. During lockdown they have shifted their work online but continue to build on local networks. Read the full case study: Wirral Council: Listened to the ‘voice of the resident’ and engaged with hard-to-reach communities
Example: The London Borough of Hackney designed a series of physical posters to encourage vaccine take up
Example: To reach out to its South Asian community, Sandwell Council has leveraged its community links and transmitted messages via the Punjab Radio. Local radio with specific groups and demographics is an excellent way to communicate with those where English is a second language. Read the full case study: Sandwell Council: Creating an army of vaccine advocates
Direct messaging (email, letters, flyers)
Direct messaging that utilise behavioural science principles––such as personalising texts and using commitment devices (e.g., asking individuals to pledge to get vaccinated or asking people to set up a booking)––have been effective in many contexts.
Example: The behaviour change consultancy Ideas42 designed emails aimed at encouraging vaccination that combine various behavioural techniques: social norms, loss framing, and an ‘enhanced active choice’, which prompts people to consider the consequences of their actions.
Read the case study: Behavioral emails increase flu vaccine uptake among city employees
3. Evaluate your solution
The importance of evaluation cannot be understated. Where possible we would advise you to dedicate some time to tracking the outcome(s) of your work.
Evaluating the impact of your solutions enables you to understand if you have achieved your goals, lets you build on what works, and helps you direct resources to activities with maximum impact. Furthermore, it is particularly valuable to share these learnings across the LGA network.
That said, it is not always feasible (or desirable) to conduct a full-scale evaluation. Most councils are working with limited resources and are having to adapt to changing policies and circumstances. The following section will help you to set a reasonable evaluation plan and choose appropriate methods at this time.
3.1. Define your outcomes and metrics
3.1.1. Set your outcomes
When setting up an evaluation, first identify your desired outcomes. Earlier in the guide [1.1. Determine which behaviour to change] we outlined the difference between an ‘ultimate’ outcome, which is the final behaviour you wish to change and the intermediate or ‘proximate’ outcomes. We suggest drafting or using a Theory of Change to help understand how you expect your solution will remove barriers, address proximate behaviours to change your solution.
Think about the ultimate outcome that you aim to achieve: Are you looking to increase vaccination rates within a specific group? Correct misinformation around vaccines? Encourage people to take their second dose? Or prompt them to maintain social distancing once they have got their vaccine?
Once you have identified your ultimate outcome, think of any intermediate outcomes that you need to change in order to achieve your main goal. Your solution might lead to an increase in vaccine take-up, but might do so by first changing attitudes, beliefs, or intentions around vaccines.
There are a number of factors that are strongly associated with vaccination that can be considered as intermediate outcomes: 1) having positive attitudes towards vaccination, 2) perceiving that its a social expectation, 3) feeling anticipated regret if they were not to vaccinate, and 4) believing that COVID-19 is serious and that they are at risk of contracting it (Godinho et al., 2016; Bish et al. 2011).
Read more about How to develop a Theory of Change.
3.1.2. Determine your metrics
Once you have defined your outcomes identify metrics that allow you to track them.
First consider whether you can measure your ultimate outcome. Then examine whether you can measure any other proximate or intermediate outcomes. In order to assess the impact of your solution, keep in mind that you should be able to directly link your solution to the outcome.
- Are you able to measure behaviour, such as actual vaccination?
- Are you able to measure attitudes, intentions, beliefs or self-reported vaccination through surveys?
- Can you directly link your solution to the outcome? In other words, can you determine whether the person who was exposed to your solution later went on to get vaccinated?
- At what level can you capture your metrics? At an individual-level? household-level? Neighbourhood-level?
- Can you capture repeated measures of your outcomes to monitor change overtime?
Using proxy metrics
When tracking your ultimate or intermediate outcomes is not possible, consider finding proxy metrics. Proxy metrics are data points that can be used to represent other metrics.
Examine the extent to which your proxy metric provides data specifically about your target audience. Consider whether it is granular or representative enough to be meaningful.
Below are some examples of proxy metrics that could be used as substitutes for tracking vaccination intentions:
- Click through rates on links providing information on vaccines
- Social media reactions to posts (likes, comments, shares, views)
- Number of downloads or delivered leaflets.
- Number of people attending to vaccine related online events.
- Number of scheduled vaccination appointments
Example: The London Borough of Hounslow tested different behaviourally informed messages on Facebook. Their goal was to address concerns about the vaccine trials being rushed and ultimately encourage vaccination among minority groups. They added links to the Facebook posts that directed residents to the council’s COVID-19 webpage. They tracked click throughs and used them as a proxy metric to evaluate the effectiveness of their messaging.
Read the full case study: London Borough of Hounslow: Used the messenger principle to address vaccine misinformation
3.2. Choose your evaluation method
Deciding on what evaluation method to use will largely depend on your time, resources, and practical feasibility. Below you will find a list of commonly used methods that you can use to evaluate your interventions:
A/B tests (also known as randomised controlled trials)
About: A/B tests are a robust evaluation method. They rely on randomly assigning people to either a control group or one or more treatment groups and then comparing outcomes between these groups. People in the treatment group(s) will receive the solution that you have designed, whereas people in the control group will not.
Strengths: It provides accurate results. If done well, they ensure that any impact you record will be directly attributable to the effectiveness of your solution and not to external factors.
Limitations: Setting up A/B tests can require resources and planning. You will have to ensure that you can control who receives your solution in order to randomly assign them into either group. However, most social media platforms have in-built tools to do this.
Example: The London Borough of Hounslow has conducted an A/B test on Facebook to test the effectiveness of different messages aiming at addressing people’s concerns about the vaccine being rushed. They targeted people within a 10 mile radius from Hounslow and used click through rates as a metric for engagement.
Read the full case study: London Borough of Hounslow: Used the messenger principle to address vaccine misinformation
About: You can measure the impact of your solution by getting your target audience to respond to a survey before and after rolling-out the solution. By comparing outcomes before and after you will be able to assess the effectiveness of your solution. You can track different outcomes in the survey, such as self-reported vaccinations, intentions to vaccinate, attitudes or beliefs.
Strengths: It is an effective method to use when you cannot randomise who will be exposed to your communication or solution.
Limitations: It is less accurate than an A/B test or randomised control trial. There might be other external factors that explain changes in outcomes before and after the implementation of your solution.
Example: Wolverhampton Council have developed an online survey to track changes in attitudes. They deliver the survey before and after launching campaigns to understand which messages work and with which groups.
Read the full case study: Wolverhampton City Council: Applying behavioural science principles as quick wins to COVID work
One-off survey experiments
About: You can launch one-off surveys where you randomly assign survey participants into a number of groups. Each group will be shown a different communication. You can record respondents’ beliefs, attitudes or intentions as outcome metrics. Doing so will allow you to compare the effectiveness of different types of communications and identify the most impactful ones.
Strengths: One-off survey experiments require less planning than an A/B test can can provide accurate results.
Limitations: Getting your target audience to take the survey might be challenging. Consider using incentives to ensure participation.
About: You can conduct a focus group to test your behavioural solution or communication. Gathering qualitative feedback from residents can help you understand if it might work and fine tune your solution before a full roll-out.
Strengths: Qualitative feedback provides rich input that can help to answer why a particular solution might (not) work.
Limitations: Feedback based on qualitative data is hard to quantify and organising focus groups might be time consuming. This method might be best used during the solution development phase but not as a means of conducting a final evaluation.
Example: The London Borough of Hackney conducted a series of focus groups with residents to test the effectiveness of a set of COVID-19 communication. This allowed them, to improve their design and pick the best one.
Read the full case study: Hackney Council: Used resident focus groups to test vaccine hesitancy messaging
Monitoring clickthroughs, downloads, or queries
About: You can monitor how your target audience interacts with your solution. For example, you can track the number of views, clicks, or downloads of a social media post or a an online resource.
Strengths: Often quick and easy to implement (the data are readily available).
Limitations: Unless the data you monitor closely represents your ultimate or intermediate outcomes, the ability to evaluate the impact of your solution is limited.
Example: Norfolk Council developed a behaviourally informed COVID-19 prevention tool-kit for small businesses. They were able to estimate the impact of their solution by monitoring the number of times the tool-kit was downloaded from the council’s website.
Read the full case study: Norfolk County Council: Designed toolkits for small businesses to encourage preventative behaviours
3.3 Learn, adapt and scale
Once you have selected your evaluation method and analysed your data, you should be able to tell which of the solutions you implemented worked particularly well and which were low performers.
You might have also collected valuable feedback throughout the evaluation phase. For example, if you engaged in focus group discussions, you might have received comments from residents when they reacted to your proposed solutions.
Use these learnings to improve your solutions and, once you have the capacity, evaluate them again. This iterative process will ensure that you systematically build on what works and implement behavioural solutions that have the strongest positive impact.
Scale and disseminate
If you have conducted research and found relevant learnings, it is immensely valuable to share these internally within your council and with practitioners across the LGA network.
Please share your learnings with us! We would like to promote and disseminate them across our network.