GLEAN: Using BVM to Increase COVID-19 Vaccination in Rural Pakistan
Each year, CUBIC picks 2-3 major projects to write up a publication called GLEAN: Gathering Learning, Evidence, Analysis and News. This blog post is based on the GLEAN Issue #4 publication about using BVM in Pakistan to increase vaccine uptake.
Throughout 2021 and 2022, Pakistan’s Expanded Program on Immunization (EPI) administered millions of doses of COVID-19 vaccinations. This systematic rollout campaign operated at scale – by August 2021, one million doses were being administered a day. However, at a district level, statistics from EPI showed that the rollout was not penetrating equally in all areas. 50 districts in the provinces of Baluchistan, Sindh, and Khyber-Pakhtunkhwa were identified as having the lowest COVID-19 vaccination rates across all districts in Pakistan. These districts are predominantly rural, have lower digital access and lower literacy levels.
Save the Children hypothesized that the population may have been missed by previous COVID-19 communication efforts, due to the identified digital, literacy, and language barriers.
In early 2022, CUBIC and Save the Children Pakistan worked together to design solutions that could extend outreach effectively to the targeted districts. This took the form of a Bulk Voice Messaging (BVM) trial. BVM involves pushing a prerecorded voice message to people’s phones; from the recipients’ perspective, their phone rings and when they answer it, they hear a pre-recorded message. The advantage of BVM, compared with SMS messaging, is that it does not rely on people’s reading ability. BVM was chosen over SMS messages because of the low digital access and lower literacy levels in the target districts.
The developed intervention used BVM to test three variations of messages encouraging people to get vaccinated against COVID-19. Each of the three BVM variations focused on tackling an important barrier to vaccination in Pakistan:
1. Addressing common worries about side effects and different vaccine brands
In the first variation, two students discuss traveling home for the holidays, but one of them is worried because their parents have yet to get vaccinated due to their hesitancies. The students emphasize the protection offered by the vaccine, how each available vaccine has been approved and is better than no protection, and include a social norm on how many people have already been vaccinated safely.
2. Addressing beliefs that the vaccines are not suitable for pregnant or breastfeeding women
In the second variation, a pregnant woman tells her husband that she wants to get vaccinated before her next prenatal checkup. Although the husband initially has doubts, he is convinced by her argument that her doctor recommended it and that getting vaccinated can help protect her as well as pass some protection on to the baby. The message also aimed to showcase that women should have a voice in their vaccine decision.
3. Addressing religious concerns about vaccines not being aligned with Islamic belief and misconceptions of vaccine ingredients not being halal
In the third variation, utilizing a pre-recorded message, an influential religious leader encourages Muslims to get vaccinated and highlights that preventative medicine has a long history in Islamic culture; that the vaccines have been approved by both health and religious institutions; and that the Hajj pilgrimage to Mecca already requires some mandatory vaccines.
To analyze the impact of the messages, we looked at engagement (percentage of the message people listened to before hanging up) and self-reported intention to get vaccinated (using survey response data). Against these measures, we found that:
The religious testimony had the highest impact on vaccine intention.
The messages focused on pregnancy led to higher engagement and higher intention to get vaccinated, compared to the message focusing on side effects.
The behavioral science behind the religious testimony of an influential figure:
Research suggests that influential figures can have a significant impact on shaping their followers’ beliefs and prosocial behaviors, particularly in early stages, by capitalizing on their voice of authority and social influence. Serving as role models, these figures exhibit exemplary behavior and embody qualities and skills that inspire others to follow suit. When it comes to matters of health, faith leaders have demonstrated the ability to influence the health behaviors of their congregants and broader community. In fact, a study underscored that these leaders not only influence health decisions on the individual level, but on a socio-cultural and environmental level as well. This influence was found to be primarily achieved through the power of social influence and by setting an example as role models. Moreover, the effectiveness of religious leaders in shaping health outcomes can also be attributed to the authority principle and the messenger effect.
Looking ahead, it is advantageous to harness the potential of influential figures, especially faith leaders that are trusted and looked up to by a community, in order to effectively convey timely messages and adapt their communication to resonate with their audience. Through leveraging the power of social influence, these leaders can help their followers stay informed and make better decisions.
By Erica Phiansunthon
To read more about the intervention, visit: https://resourcecentre.savethechildren.net/document/glean-gathering-learning-evidence-analysis-and-news-issue-4-using-bulk-voice-messages-to-increase-covid-19-vaccination-uptake-in-rural-pakistan/
NOTE: As this project was a small component of our wider ACTIVATE COVID-19 vaccination program, we did not conduct additional formative research. Instead, we relied on pre-existing information, including Save the Children's ACTIVATE campaign, previous social listening sessions through digital focus groups, and publicly available data, such as the John Hopkins COVID-19 Behaviors Database.