To evolve an eye a species must first develop light-sensitive cells. Then slowly, over hundreds of thousands of years and continuous natural selection — the species will finally have a functioning complex “camera” eye. This half a million year long process will give the species the evolutionary advantage as a hunter and survivor in the environment.
Evolution is slow. Changing takes time as the change itself is modified through the process of interacting with a society. However, when it came to the COVID-19 pandemic, cultural evolution was placed under stress and had to happen quickly and decisively. Governments across the world were forced to act quickly by setting up mitigating measures and laws which significantly changed our way of living from the economic to social milestones like weddings and funerals. When this article was written Kenya had recorded over 4,000 deaths from COVID-19 with over 200,000 positive cases (Ministry of Health). The government responded by taking several controlling measures to limit the spread of the virus which have been tightened or relaxed depending on infection rates. These measures include ordering the closure of some businesses, curfews and the banning of social and religious gatherings among others (Ministry of Health). They were instituted to “flatten the curve” to prevent health facilities from being inundated while buying time for the development of a vaccine, but have also had significant economic and social costs.
How social norms can be used to eradicate vaccine hesitancy in Kenya.
Instituting change on this level needs cooperation between individuals and their governments to drive compliance. Several factors influence whether citizens will comply with government regulations on preventive health practices in times of crisis.
At an individual level, institutional trust (Thaker, 2021), risk/threat perceptions (Fridman, 2021), and the propensity to believe in misinformation/rumors (Thaker, 2021) have all proven to be important in influencing compliance.
At the community level, individuals who have neighborhood support or are members of community associations are more likely to adopt preventive health behavior. In particular, members of religious groups, and religiosity were associated with higher rates of preventive health behavior. However, certain religious practices (such as physical gatherings for worship and burial rites) and beliefs (such as that in the superiority of spiritual healing over modern medical care in symptomatic cases) could possibly be a barrier to compliance with national directives during epidemics, or at least slow the transition from disbelief to compliance/ acceptance (Pelcic et al., 2016).
While we know that vaccine uptake, particularly with regard to essential vaccines, is relatively high in Kenya (the Bacillus Calmette Guerin (BCG) vaccine stood at 95% in 2019 WHO); we also know that there can be some hesitancy when significant resistance comes from the right places, such as religious leaders, as it happened with the Human Papillomavirus (HPV) vaccine (CatholicPhilly). We were curious about whether this would be the case with the COVID-19 vaccine. In fact, shortly after our experiment, the Oxford AstraZeneca vaccine — the only brand officially being used by Kenya — was linked to a very rare possibility of blood clots, which caused some debate on the vaccine’s safety in the country.
To find out whether the individual and community level factors listed above influence the COVID-19 vaccine uptake, we designed an experiment using Juma, a hypothetical character who lives in Nairobi and hears a presidential directive on radio announcing the availability of the vaccine and instructing that citizens get vaccinated. We then grouped our 594 respondents (mainly christian, highly educated, low and middle income people in Nairobi) into 3 groups — a control and two treatments. In the control group: respondents’ responses were about his compliance to the directive. In the first treatment Juma receives anti-vaccination information from his religious group and in the second treatment from a village elder, respondents in these treatments also responded on Juma’s compliance to the directive.
What did we find?
Both the community and religious contradictions lead to declines in the levels of agreement on getting vaccinated in accordance with a government directive.
A majority of respondents agreed or strongly agreed that Kenyans should get vaccinated when asked about it before the study. However, after the treatment, significantly more respondents in the community and religious contradiction groups indicated that they didn’t think Juma would get vaccinated when compared to the control group.
Another interesting takeaway from this is that the community serves as a stronger reference group than religion when it comes to deciding whether to get vaccinated against COVID-19. While the differences here are statistically significant, they are small on the individual level with most of the changes happening when respondents were switching from agreeing to disagreeing, as opposed to one extreme or another.
Both the community and religious contradictions lower perceptions of individual willingness to get vaccinated.
We asked respondents to give an indication around how many people out of 10 near Juma they thought would get vaccinated. The control group indicated a higher average number of people they thought would get vaccinated compared to the religious and community intervention groups (p<0.01). Moreover, the community contradiction group had a significantly higher number of respondents who indicated that fewer people around Juma would get vaccinated, particularly those who said only 1, 2 or 3 would get vaccinated (p<0.001).
This finding also indicates that respondents believe that others in the community reference group are less likely to get vaccinated compared to the religious reference group, while those in the control (which could represent government/ national interest) believe that more people would comply with vaccination. These both point to community and religious contradiction both having a significant role in lowering perceptions of government/ national interest when it comes to vaccine hesitancy.
However, recent research into the potential role that descriptive norms (social norms that describe how people typically act, feel, and think in a given situation) can play in increasing COVID-19 vaccine uptake among young adults has also found them to be “rather limited” in comparison to standard information based appeals to young people to accept a new vaccination. (Sinclair & Agerström, 2021)
Well, what if we ask them to report non-compliance?
With both the community and religious contradiction, people thought that others would be less likely to be sanctioned for failing to comply with government directives.
While sanctions will help overcome the free rider problem where an individual believes that others will follow protective behaviors on their behalf, both community and religious contradiction led to more people believing fewer people would be reported for not getting vaccinated while more people in the control group indicated that everyone would report someone for not getting vaccinated compared to the treatment groups (p<0.001). Moreover, those who completed the study after the announcement of the vaccine’s availability in the country thought fewer people would report someone for not getting vaccinated (p<0.1).
Summary
In order to accelerate the capacity of humans to rapidly adapt and survive in the face of the COVID-19 pandemic, the following strategies should be adopted to positively leverage the findings from this research towards increase the COVID-19 vaccine uptake:
- Use positive community and religious leaders as figureheads for vaccine roll-out: The study has established that community and religious leaders can be influential in reducing vaccine uptake. However, using community and religious leaders (who are not controversial) as public figureheads for the vaccine roll-out can also be influential in increasing uptake.
- Tailor messaging based on past vaccine hesitancy behavior: Acknowledging that vaccine hesitancy cuts across different vaccines enables health practitioners to design messaging that targets individuals who have refused other vaccines in the past (particularly for their children). This strategy should acknowledge that vaccine hesitancy is based on personal beliefs and experiences as well as the opinions and actions of others within their communities. As such, it should seek to engage and understand the concerns and past experiences the individual might have had and understand their interactions with others who share the same views with the aim of convincing them to change their position rather than to lecture or ridicule with the aim of getting them to submit. The aim should be not only to convince individuals to get vaccinated, but to also create advocates for vaccine within networks of people who might be opposed to getting vaccinated.
- Story telling rather than scientific evidence might be more convincing: Evidence based communication about vaccines is difficult because of the relatively high degree of scientific literacy required to understand, internalize and pass the message. Story telling, however, is much more effective at making a message salient and transmissible. Sharing stories of how the vaccine changes lives is more effective than explaining how it works.
These lessons clarify some of the approaches that can be taken to do away with vaccine hesitancy, however, it is important to acknowledge that other factors – such as an individuals’ relationship with their government – might also be at play and are worth investigating as an area of future research. Meanwhile, COVID-19 remains a major health threat, and research on further strategies to drive compliance on the vaccines that at this point in time form our best fight against it, are necessary.
