Behavioral insights for COVID-19 vaccine uptake in the Caribbean: rapid surveys from Belize, Haiti, and Jamaica Amy Margolies Ellen Moscoe Daniel Pinzón Micaela Mussini Phillis Kim Laura Di Giorgio Behavioral insights for COVID-19 vaccine uptake in the Caribbean: rapid surveys from Belize, Haiti, and Jamaica World Bank Mind, Behavior and Development Unit Ellen Moscoe Daniel Pinzón World Bank Health, Nutrition, and Population Global Practice Amy Margolies Micaela Mussini Phillis Kim Laura Di Giorgio August, 2023 © World Bank. Health, Nutrition and Population Global Practice. 1818 H Street NW, Washington DC 20433 Internet: www.worldbank.org Telephone: 202 473 1000 Some rights reserved This work is a product of the staff of the World Bank. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of the Executive Directors of the World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. Rights and Permissions The material in this work is subject to copyright. Because the World Bank encourages dissemination of its knowledge, this work may be reproduced, in whole or in part, for noncommercial purposes, as long as full attribution to this work is given. Attribution Please cite the work as follows: Margolies, Amy Elliott; Moscoe, Ellen; Pinzon, Daniel; Mussini, Micaela; Kim, Phillis; Di Giorgio, Laura. 2023. Behavioral insights for COVID-19 vaccine uptake in the Caribbean: rapid surveys from Belize, Haiti, and Jamaica. Washington, D.C. : World Bank. © World Bank.” All queries on rights and licenses, including subsidiary rights should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC, 20433, USA; fax: 202-522-2625; e-mail: pubrights@worldbank.org All queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: pubrights@worldbank.org Cover image and graphic design - David Lloyd Contents Contents Acknowledgements02 Abstract03 Introduction04 Methods07 Results11 Vaccination coverage among respondents 11 Vaccine intentions 12 Risk behaviors and vaccine access 14 Vaccination concerns 16 Vaccination information and messengers 18 Intentions to be boosted among older adults 21 Experiment on vaccine messaging: can behavioral framing affect vaccination intention? 21 Limitations27 Discussion28 Recommendations32 Annexes35 Annex 1. EMBeD social media surveys 36 Annex 2. EMBeD questionnaire 37 Annex 3. EMBeD Facebook messenger advertisements for survey participation 46 Annex 4. Predictors of vaccination status by country 47 References49 Behavioral insights for COVID-19 vaccine uptake in the Caribbean: | 01 rapid surveys from Belize, Haiti, and Jamaica Acknowledgements Acknowledgements This report was produced by a team from Practice, the Development Impact Evaluation the World Bank’s Health, Nutrition, and (DIME) Department, and country government Population Global Practice. The team was led partners. by Dr. Laura Di Giorgio (Senior Economist, Latin America and Caribbean region). This study was partially funded by the Advancing Dr. Amy Margolies (World Bank Consultant) led Health Online (AHO) Initiative, an initiative to the preparation of the report under technical advance public understanding of how social guidance of Dr. Di Giorgio. Micaela Mussini (World media and behavioral sciences can be Bank Health Specialist, Latin America and leveraged to improve the health of communities Caribbean region) and Phillis Kim (World Bank around the world, the Canada Caribbean Senior Health Specialist and Behavioral Scientist, Resilience Facility (CRF) which supports Global Engagement Unit) provided technical countries’ recovery to disasters, and by the inputs. Tim Johnston (Program Leader for the Primary Health Care (PHC) Transformation Caribbean region) provided high-level guidance. Trust Fund, a global health partnership to achieve Ellen Moscoe and Daniel Pinzón led the PHC transformation for better health and human preparation and implementation of the social capital. The findings, conclusions, and media surveys and supported data analysis and recommendations expressed in this article are findings interpretation. those of the authors and do not necessarily reflect the views of the collaborators.  Additional contributing team members include Renos Vakis, Zeina Afif, Laura Zoratto, Mohamad The team would like to extend its sincere Chatila, JungKyu Rhys Lim, Haena Kim, Michelle gratitude to counterparts from Government Dugas, and Corey Cameron at the Mind, Behavior officials from Belize, Haiti and Jamaica, who & Development (eMBeD) Unit in the World Bank’s shared or assisted with data acquisition and Poverty and Equity Global Practice. The authors provided inputs to the findings. express their gratitude to all collaborators who contributed to this project, including the World Bank’s Health, Nutrition and Population Global Behavioral insights for COVID-19 vaccine uptake in the Caribbean: 02 | rapid surveys from Belize, Haiti, and Jamaica Abstract Abstract In the wake of the pandemic, the greatest COVID-19 vaccine. Further, surveys tested the obstacle to COVID-19 vaccination in the impact of different behaviorally informed Caribbean is vaccine acceptance and uptake messages on vaccine intention. Each country rather than supply. Social media surveys were presented unique vaccination uptake challenges conducted in three Caribbean countries to better which required specific interventions or outreach understand the socio-behavioral drivers of strategies to change vaccination attitudes and vaccine acceptance and uptake to address behaviors. The responses of the movable middle ongoing vaccination challenges to prevent provide insights into how this group could be morbidity and mortality. Behavioral science made targeted for improving uptake. Knowledge of this critical contributions to global COVID-19 group can aid in targeting messaging, selection vaccination campaigns. We wanted to of trusted messengers and channels.  understand vaccine intentions, behavioral biases and barriers limiting vaccine uptake to better target vaccination efforts and inform health communication campaigns. Surveys were administered via Facebook messenger chatbot, with data drawn from a non-probability sample of both vaccinated and unvaccinated respondents. Surveys were conducted in April-May 2022, with respondents from Belize (n=2,657), Jamaica (n=4,096), and Haiti (n=10,419). We focused on the ‘movable middle’, i.e., people who are still undecided about whether they wanted the Behavioral insights for COVID-19 vaccine uptake in the Caribbean: | 03 rapid surveys from Belize, Haiti, and Jamaica Introduction Introduction Early in the pandemic the greatest challenge Organization’s (WHO) initial COVID-19 vaccination with COVID-19 vaccination was creating, target of 70 percent coverage, and many are still producing, and distributing vaccines. Across below 50 percent coverage5. The WHO’s revised the Latin American and Caribbean region, COVID-19 vaccination strategy redoubled efforts vaccine availability is no longer a primary to reach populations most at risk (WHO 2022). constraint. Two years later, the greatest obstacle The new target aims for 100 percent coverage is vaccine acceptance and uptake rather than of health care workers and 100 percent coverage supply. This challenge is particularly acute in the of the highest-risk populations with both the Caribbean. National governments, the Pan- primary series and booster doses. Despite the American Health Organization (PAHO) and the new strategy, the challenge of vaccine COVID-19 Vaccines Global Access initiative acceptance and uptake persists in the (COVAX) aided in the distribution of vaccines in Caribbean, testing national capacities to protect Latin America and the Caribbean (LAC) region. populations against the virus. Jamaica was the first country in the Caribbean to receive donations of COVID-19 vaccines from The World Bank undertook social media COVAX1 for primary vaccinations2. Booster doses surveys to better understand the socio- first became available in many countries in LAC behavioral drivers of vaccine acceptance and by August of 2021. By July 15, 2022, COVAX uptake to address ongoing vaccination distributed 149 million doses in the Americas3. challenges to prevent morbidity and mortality Despite these efforts, the variation in vaccination from COVID-19 in the region. Due to the global coverage in the region is breathtaking - over 90 nature of the problem, concerns about percent of Chileans are fully vaccinated with the vaccination must be addressed at scale. Social primary series as compared to barely two and behavior change communication (SBCC) percent of Haitians4. Further, most Caribbean interventions and campaigns are a strategy countries fall well below the World Health employed by governments, non-profit  ttps://www.paho.org/en/news/15-3-2021-jamaica-becomes-first-country-caribbean-receive-covid-19-vaccines-through-covax. 1h  rimary vaccination refers to the full vaccination series for one vaccine type (i.e., two vaccinations for Pfizer, one for Johnson 2P & Johnson, etc.). The primary vaccination series is completed prior to receiving a booster dose. 3 https://www.as-coa.org/articles/timeline-tracking-latin-americas-road-vaccination. 4 Our World in Data, October 20, 2022.  rinidad and Tobago, Dominica, Bahamas, Saint Lucia, Grenada, Saint Vincent and the Grenadines, Jamaica, Haiti 5T (Our World in Data, October 20, 2022). Behavioral insights for COVID-19 vaccine uptake in the Caribbean: 04 | rapid surveys from Belize, Haiti, and Jamaica Introduction organizations, and others to help shift attitudes individual-level factors that influence proximate on vaccination. During the pandemic, SBCC determinants of vaccination intentions. Epidemic campaigns were deployed via social media to level factors include prevalence, severity, and reach audiences while avoiding the risk of transmission dynamics of COVID as well as the transmitting the virus through in-person events. effectiveness and safety of vaccines. Community More than 4.1 billion adults use social media and level factors cover the health system and social instant messaging services across the globe, and norms, and individual factors encompass health participation is rapidly growing in low and middle- status and history, health system experience and income countries which provides an opportunity education and income status. While epidemic, for communication-based strategies for public community and individual level factors are health-based socio-behavioral interventions. important and influence the proximate This underscores the power of social media determinants of vaccine intentions, the eMBeD as a platform to deliver important behaviorally approach focuses on socio-behavioral informed messages. It also raises the question of determinants. These include the role of which messages are more salient and effective. behavioral biases and barriers that influence The vaccine acceptance and uptake surveys in those proximate determinants as well as those the Caribbean were designed to leverage this that directly affect vaccine uptake. social media platform and to test messaging using different behavioral approaches to identify Behavioral science has made critical the most effective framing. The WHO Technical contributions to global vaccination campaigns Advisory Group on behavioral insights decided for COVID-19. We wanted to understand vaccine that strategies to improve vaccine acceptance intentions, behavioral biases and barriers limiting should focus on ‘creating a conducive enabling vaccine uptake so we can better target environment, harnessing social influencers and vaccination efforts and lead successful taking measures to increase the motivation of communication campaigns. The challenges people to get fully vaccinated’ (WHO 2020). faced by policymakers in addressing barriers to vaccination such as the intention-action gap and The eMBeD approach is a three-step process building vaccine confidence require and is based on a conceptual framework for recommendations rooted in data based on how vaccine uptake founded in the vaccine people think, act and feel in regard to COVID-19 acceptance literature (eMBeD 2021). This vaccination (The World Bank/UN 2021). Detailed framework outlines epidemic, community and data collection was required to gather these Behavioral insights for COVID-19 vaccine uptake in the Caribbean: | 05 rapid surveys from Belize, Haiti, and Jamaica Introduction perspectives from countries in the Caribbean The movable middle is highlighted, as this group region. This work was part of a portfolio of provides valuable input into how vaccine surveys developed by the Poverty and Global acceptance and uptake could be improved among Practice Mind, Behavior, and Development group those who have not made up their minds. The (eMBeD), in collaboration with the Development moveable middle is significant as this represents Impact Department (DIME), Health, Nutrition the remaining portion of the current population & Population Global Practice (HNP), Poverty & that can still be persuaded to vaccinate, with the Equity Global Practice (POV), and External least required effort. This survey approach was & Corporate Relations (ECR) of the World Bank designed by the eMBeD behavioral unit at the and supported financially by the World Bank and World Bank and aims to use COVID-19 diagnostics the Alliance for Advancing Health Online. to inform communication strategies and support country partners in improving vaccine uptake. The eMBeD approach involves using behavioral The evidence from these studies informs country diagnostics to inform COVID-19 communication interventions. In Belize, it set the groundwork strategies, including measuring vaccine for technical assistance work to develop new intentions, beliefs, norms, access, trust, and outreach strategies and to adapt current vaccine behaviors. This is followed by testing the impact campaigns. of different message framings to promote vaccination on vaccine intentions. The final step, where applicable, is to design customized support to aid country partners in improving vaccination campaigns, including technical assistance on communication strategies, capacity building and other behavioral solutions. The objective of this report is to synthesize the results of three social media surveys that measured COVID-19 vaccine attitudes and acceptance in the Caribbean (Haiti, Jamaica, Belize) in the first half of 2022 to provide insights into improving vaccine outreach and uptake in the Caribbean. We focused on the results of the ‘movable middle’, i.e., people who were still undecided about whether they wanted to receive a COVID-19 vaccine. Further, the surveys tested the impact of different behaviorally informed messages on vaccine intention, whose results are reported here. We present the results of recent rapid social media surveys in these countries that explore COVID-19 vaccine attitudes and acceptance rates, including experiments with vaccine messaging to explore country specific constraints and opportunities to improve vaccine outreach. Behavioral insights for COVID-19 vaccine uptake in the Caribbean: 06 | rapid surveys from Belize, Haiti, and Jamaica Methods Methods Surveys were administered via Facebook across countries and to characterize and messenger chatbot and the data was drawn describe the responses of the ‘movable middle’, from a non-probability sample. In each country, or the segment of the population that was still the survey sample was drawn from all Facebook unsure about vaccination. We undertook a accounts for users over 18 years of age, users process to adapt the questionnaires beginning self-selected by clicking the survey link to the with a literature review and followed by a questionnaire in a Facebook advertisement. comparative analysis of the questions asked in Survey weights were used to aid in representing the major surveys focused on COVID-19 vaccine each country’s population across demographic hesitancy at the time; including the UNICEF indicators using the population distribution from Vaccine hesitancy survey, the Johns Hopkins the Demographic and Health Surveys or other COVID dashboard/UMD CITS, and the study of nationally representative data. The Facebook ads PAHO healthcare workers and categorized and targeted pre-defined demographic groups compared survey questions with the eMBeD (based on age, gender, and geographic region) to survey across thematic domains: 1) vaccine mirror the country’s populations. To incentivize status and intention; 2) social norms and participation, entered respondents could win a behaviors; 3) reasons for hesitancy or gift card. The total sample was composed of acceptance (motivation); 4) knowledge, opinions both vaccinated and unvaccinated respondents and attitudes; and 5) structural and practical who opted to take the survey. barriers to vaccination (access). We used this process to identify gaps and to adjust the The Caribbean eMBeD surveys were adapted wording of survey questions to our needs. from vaccine hesitancy questionnaires developed by the Mind, Behavior and In each country, clusters were selected based Development Unit at the World Bank. These on demographic characteristics such as age, surveys were designed to better understand sex and region and appropriate population vaccine acceptance and hesitancy and to test weights were applied. In Belize, 24 clusters were behavioral messages to improve uptake of sampled based on age, gender, and region. COVID-19 vaccines. The questions also covered Population weights were based on region, age vaccine attitudes, trust in institutions and and gender from the Statistical Institute of Belize messengers and issues of vaccine access. Annex through the Facebook ads. The survey in Belize 2 contains the complete eMBeD questionnaire. ran from April 21 to May 9, 2022. The final sample This allowed us to describe levels of intention of completed surveys was 2,657 respondents Behavioral insights for COVID-19 vaccine uptake in the Caribbean: | 07 rapid surveys from Belize, Haiti, and Jamaica Methods from a total of 3,142 that started the survey. that started filling out the surveys through the In Jamaica, the sample was composed of 16 messenger app, 10,419 completed their data. clusters based on age, gender and region. Population weights were based on region, age Generally, in all three countries the surveys and gender from the Statistical Institute of attracted more young people (18-39 years of Jamaica. As in Belize, the survey was age) than older people (age groups of 40 years administered via Facebook messenger chatbot and above). This is to be expected as social and respondents were recruited with Facebook media users tend to be younger (see Limitations ads with a voucher incentive. The final sample section). Survey respondents in these countries had 4,096 completed surveys of 5,155 that were also tended to have higher levels of education, started. The survey ran from April 21 through May secondary education or above. In Belize and 23, 2022. The survey in Haiti sampled 4 clusters Jamaica, respondents were more likely to be based on gender and region. Population weights female, in contrast with Haiti where more men were based on region and gender from the responded to the survey. Further information on Institut Haïtien de Statistique (IHSI) through the samples by age, education, gender, and region Facebook ads6. The survey was conducted from for each country surveyed can be found in Box 1. April 21 through May 4, 2022. Of 12,685 people Descriptive and inferential statistical analyses were conducted in Stata 17. Box 1. Survey samples by country Age 8,000 8,034 6,000 4,000 2,015 2,000 1,364 1,060 973 941 748 640 555 512 243 54 0 18 30 40 50 18 30 40 50 18 30 40 50 Belize Haiti Jamaica t is important to note that the survey in Haiti was conducted at a time of political disruption, growing insecurity, and deteriorating 6I socio-economic situation. Behavioral insights for COVID-19 vaccine uptake in the Caribbean: 08 | rapid surveys from Belize, Haiti, and Jamaica Methods Gender 6,000 6,377 3,969 4,000 2,671 1,657 2,000 1,366 1,099 0 Male Female Male Female Male Female Belize Haiti Jamaica Education 4,535 5,000 3,617 4,000 3,000 1,879 1,829 2,000 1,039 978 896 788 1,000 671 289 190 172 86 92 76 0 No education Primary Secondary Tertiary Vocational No education Primary Secondary Tertiary Vocational No education Primary Secondary Tertiary Vocational Belize Haiti Jamaica Behavioral insights for COVID-19 vaccine uptake in the Caribbean: | 09 rapid surveys from Belize, Haiti, and Jamaica Methods Region 5,000 5,271 5,075 4,000 3,000 2,525 2,000 1,512 1,096 986 1,000 674 0 Belize Other Regions Other Regions Ouest Other Regions Cayo Surrey Belize Haiti Jamaica The ‘movable middle’, or those who were unsure vocational school education (37 percent versus 25 or had not yet decided whether to receive a percent) than the entire population of the surveys. COVID-19 vaccine, are a key group to Across the three countries, this group was slightly understand as they are potentially persuadable less vaccinated against diseases other than to be vaccinated. The movable middle was COVID-19 (-5 percent). defined in our analysis as those respondents who self-declared as ‘undecided’ or ‘unsure’ to whether they would receive the COVID-19 Ethical approval vaccine/s. This definition excluded individuals who were against vaccination in general, as the Protocols for the protection of human subjects assumption is those people may not be interested were obtained from a research ethics review in changing their minds about the COVID-19 by Health Media Lab Institutional Review Board vaccines. This group had slightly different on October 20 – 22, 2021. Data from the demographics than the full sample of the social Facebook messenger survey was sent to Google media surveys. The movable middle had a similar Cloud. Data was deidentified and kept in secure sex composition but was younger (63 percent servers. Ownership of the data is retained by the were in the 18-30 age group as compared to World Bank and is managed following World Bank 49 percent) and more respondents had a policies on data management and privacy. Behavioral insights for COVID-19 vaccine uptake in the Caribbean: 10 | rapid surveys from Belize, Haiti, and Jamaica Results Results Vaccination coverage among Maya and Mestizo respondents had higher respondents vaccination rates than the Garifuna ethnic group. A small number of respondents in Jamaica Survey respondents were more vaccinated self-identified as healthcare workers (HCWs) than the rest of the population. In Belize, 90 took the survey (n=95) while a larger sample percent of respondents had received at least one did so in Haiti (n=1,204). In Haiti, HCWs were dose of a COVID-19 vaccine as compared to 60 slightly more vaccinated than non-healthcare percent of the Belizean population at the time of workers. Thirty-three percent of these the survey. In Jamaica, 54 percent of survey respondents reported being vaccinated against respondents were vaccinated as compared to 26 COVID-19 as compared to 23 percent of those percent of the rest of the Jamaican population. who were not in the healthcare sector. By In Haiti, the general population is only 2 percent healthcare profession, doctors were most vaccinated as compared to 26 percent of the vaccinated (44 percent) in contrast to survey sample7. Vaccination status showed little community health workers and pharmacists variation by demographic characteristics such (36 percent) or nurses (34 percent). as region, sex, age or education in Belize. In Jamaica, vaccination rates varied by age and Booster coverage among survey participants education. A higher percentage of older adults was very low despite booster doses becoming (61 percent for adults 40-49 years of age, 68 available in Belize and Jamaica as early as late percent for those 50+ years of age) were 2021. A third of vaccinated respondents in Belize vaccinated as compared to younger adults (43 had received a booster. Among the vaccinated percent for 18-29 years, 45 percent for 30-39 in Jamaica, only 13 percent reported receiving years). Respondents in Jamaica with primary or a booster dose. In Haiti, only 5 percent of survey tertiary education were more vaccinated than respondents had received 3 shots. those with no education, vocational or secondary education. There were small but not meaningful Access to specific vaccine types may have differences by demographic characteristics in influenced vaccination uptake among Haiti. Ethnic differences in vaccination status respondents. In Jamaica and Belize, 2 in 10 only varied in Belize, where the self-identified vaccinated respondents said the type of vaccine 7 Our World in Data, October 20, 2022. Behavioral insights for COVID-19 vaccine uptake in the Caribbean: | 11 rapid surveys from Belize, Haiti, and Jamaica Results influenced whether they got vaccinated. a surprising number of people did not think they The principal reasons for interest in a specific were eligible for the second shot, particularly in vaccine type varied, including perceived safety Haiti and Jamaica (Haiti – 31 percent, Jamaica of the technology (17 percent in Belize and – 20 percent, Belize – 9 percent). Some avoided Jamaica), effectiveness (16 percent in Jamaica) a second shot due to previously experienced side and recommendation by a healthcare worker effects (Belize - 19 percent, Haiti – 14 percent, (16 percent in Belize). However, many of these Jamaica – 6 percent). Overall, most respondents respondents did not have a choice of vaccine knew how to get the second dose, as only small type when they were vaccinated (1 in 3 in Belize percentages were unsure how to receive it did not have a choice of vaccine type, and 1 in (Jamaica – 8 percent, Belize – 5 percent, Haiti – 5 in Jamaica did not choose a vaccine type). 1 percent). Only a few respondents did not receive the second dose because they thought they were already protected (Haiti – 9 percent, Belize – 8 percent, Jamaica – 3 percent). Vaccine intentions Most respondents vaccinated with one or two The vaccine intention was examined for doses of a vaccine did not intend to receive a 1) primary vaccination and 2) boosters. booster dose. Among this vaccinated but not The survey also allowed for a breakdown boosted group, less than half planned to get a of vaccination intention by demographic booster (49 percent in Belize, 47 percent in characteristics such as region, age, gender, Jamaica, 44 percent in Haiti). These differences and education and profession. For the primary varied by education level, but the trends across vaccination series, intention to vaccinate in Haiti countries were not consistent. In Haiti, was the lowest among the three countries – only respondents with no education had low intention 17 percent of unvaccinated Haitians in the survey to boost – 57 percent did not plan to get a third said they planned to get vaccinated, and another shot once it became available, as compared to 35 percent were unsure about vaccination. those with secondary education (23 percent). This was the opposite in Jamaica, where those Among those who received only one shot of with no education were more likely to plant to get the primary vaccination series8, the main a booster shot (59 percent). Generally, the reasons to not get the second dose of the younger ages reported lower intention to boost vaccine showed a consistent pattern across than older cohorts, the 18-30 group reported the countries: missing appointments, previously lowest intention in Belize, Jamaica, and Haiti (45, experienced side effects and perceived lack 44 and 43 percent). There were very small of eligibility. Missing the appointment for the differences by sex in booster intentions in Belize second shot was a notably common problem and Jamaica, but in Haiti men had higher booster (Belize – 39 percent, Jamaica - 34 percent, intentions than women (48 percent as compared Haiti - 24 percent). However, the reason for to 37 percent). Healthcare workers in Haiti survey missing the appointment was not because reported only slightly higher intention to be people were too busy (Haiti – 9 percent, Jamaica boosted than those not in the healthcare sector – 9 percent, Belize – 8 percent). In addition, (46 percent versus 42 percent).  ote that the sample sizes for the respondents who received only one dose and not a second dose were small (Jamaica=114, 8N Haiti=364, Belize=133) as compared to those who had two doses but were not boosted (Jamaica=1698, Haiti=872, Belize=1503). Behavioral insights for COVID-19 vaccine uptake in the Caribbean: 12 | rapid surveys from Belize, Haiti, and Jamaica Results There were different reasons for not getting their minds about the vaccine (Haiti – 78 the booster as compared to the second shot – percent, Jamaica – 69 percent, Belize – 54 people were more likely to think they were percent). The most common reasons across the already protected and did not need a booster. three countries that people who were unsure Others did not think they were eligible for the about vaccination gave that could affect their booster yet. Respondents were more likely to decision were if the vaccine was necessary for believe they were already protected against social activities, if health workers recommended COVID if they were vaccinated but had not it or if they had a sick family member. received the booster (Belize – 32 percent, Jamaica – 29 percent, Haiti – 29 percent). This is Most people who did not plan to vaccinate said notably higher as compared to those who had not nothing will change their minds about completed the primary series and only received a vaccination (Belize – 96 percent, Jamaica – first vaccination dose but not the second. In Haiti 72 percent, Haiti – 52 percent). In contrast, a and Jamaica, more than a quarter of respondents smaller percentage of the movable middle (Belize did not believe they were eligible for a booster – 41 percent, Jamaica – 28 percent, Haiti – 22 (28 percent and 24 percent), while in Belize only percent) was intransigent about vaccination. 14 percent had this impression. A small but not insignificant number of people in each country There were also notable differences in relation were avoiding the booster due to previous side to what could potentially change their minds effects (Haiti – 10 percent, Belize – 9 percent, about vaccination between the movable Jamaica – 6 percent). middle compared those of respondents who did not plan to vaccinate. Overall, a quarter of Many parents - even parents who are the movable middle said they would change their vaccinated themselves - do not intend to plans if vaccination was necessary for social vaccinate their younger children. There was activities (Belize – 12 percent, Haiti – 26 percent, particularly low intention to vaccinate children in Jamaica - 25 percent), as compared to Haiti. In Jamaica and Belize, parents’ vaccination respondents who did not plan to vaccinate beliefs were aligned with parental vaccination (Belize – 1 percent, Haiti – 14 percent, Jamaica status. More than half of vaccinated parents – 7 percent). Health worker recommendations intended to vaccinate their children in Jamaica were not important motivating factors for those and Belize (Jamaica - 51 percent, Belize - 56 without vaccination intention (Belize – 0 percent, percent). Among unvaccinated parents in Haiti – 9 percent, Jamaica – 3 percent), while the Jamaica, only 17 percent would vaccinate their movable middle was potentially more influenced children and in Belize, only 13 percent. This trend by the opinion of healthcare workers (Belize – contrasted with data from Haiti, which showed 13 percent, Haiti – 15 percent, Jamaica - 12 few parents wanted to vaccinate children under percent). 12 even if the parents were vaccinated. Among unvaccinated, only 19 percent plan to vaccinate Among the vaccinated in Belize and Jamaica, their children. While the rate for vaccinated approximately one fifth of respondents said parents was higher, at 34 percent, it is still low. the vaccine type affected their decision to vaccinate. This is even though many of them There was a group of people in each country, did not have a choice of vaccine (33 percent the movable middle, who were unsure about in Belize, 20 percent in Jamaica). Safety of the vaccination and who are open to changing vaccine technology was the second most Behavioral insights for COVID-19 vaccine uptake in the Caribbean: | 13 rapid surveys from Belize, Haiti, and Jamaica Results common reason for choosing a vaccine type vaccine first” (81 percent). The discrepancy in (17 percent in both countries). these responses between the movable middle and those who did not intend to vaccinate was The most noted benefit of the vaccine was largest in Belize, where 76 percent of the self-protection among both unvaccinated and movable middle supported the statement on vaccinated people. Among the vaccinated in the need to protect others in contrast to only Jamaica, Belize, and Haiti, close to two-thirds 27 percent of those without vaccination of respondents believe protecting themselves is intention. the most important benefit of the vaccines. The unvaccinated feel similarly (Haiti – 50 percent, Jamaica – 30 percent, Belize – 22 percent), as do older adults over 50 (Jamaica - Risk behaviors and 62 percent, and Belize - 63 percent). However, a significant portion of unvaccinated people do vaccine access not believe there are any benefits of the vaccine at all (Belize – 48 percent, Jamaica - 38 percent, Mask wearing behaviors were most Haiti – 28 percent). Few of the unvaccinated consistent in Jamaica, while in Haiti and see the vaccine as a critical way to resume Belize a quarter to a third of respondents interactions (Jamaica – 16 percent, Haiti – decreased masking after vaccination. 13 percent, Belize – 12 percent). Masking intention was examined to explore the persistence of risk mitigation behaviors and The movable middle, however, was more to see whether vaccination would alter these interested in self-protection and was less likely practices. In Jamaica, vaccination status did to report that they did not see any benefit not affect mask wearing. Most people of vaccination. The largest difference was seen continued with same masking behavior as in Belize, where only 38 percent of the movable before being vaccinated. Vaccinated middle felt there were no benefits to the respondents overwhelmingly continued to wear vaccines as compared to only 78 percent of masks after vaccination, revealing strong risk those who did not intend to vaccinate. In terms mitigation practices among this group (74-86 of self-protection, in Belize 23 percent of the percent continued as before, depending on how movable middle noted this vaccination benefit, many shots they received). In Haiti, a quarter of while only 9 percent of those without vaccination people reduced mask wearing after vaccination. intention felt similarly. In Haiti, 44 percent of the In Belize, it was more common to reduce mask movable middle emphasized the need to protect wearing after vaccination, only half of vaccinated themselves as compared to 27 percent of those respondents maintained the same mask wearing who did not intend to vaccinate and in Jamaica, as before. A third of Belizean respondents 26 percent of the movable middle valued self- reduced mask wearing after vaccination. protection as contrasted with 8 percent of those In broader context, however, face mask use lacking vaccination intention. Likewise, most of and frequency of use has been documented the movable middle agreed with the statement to be on the decline in some countries due that “everyone should get a vaccine to protect to ‘pandemic fatigue’ and decreased perception others” (83 percent) but were also highly likely to of risks of disease (MacIntyre 2021). agree that they would “wait for others to get the Behavioral insights for COVID-19 vaccine uptake in the Caribbean: 14 | rapid surveys from Belize, Haiti, and Jamaica Results Photo: Dominic Chavez / World Bank Behavioral insights for COVID-19 vaccine uptake in the Caribbean: | 15 rapid surveys from Belize, Haiti, and Jamaica Results A portion of the unvaccinated reported issues first (81 percent) and believe there will be other with accessing vaccines, particularly among effective treatments soon (85 percent). individuals who intended to get vaccinated. Haiti had the largest group of people reporting access issues. Thirty-three percent of unvaccinated people who intended to be Vaccination concerns vaccinated had problems with vaccine access. The most common reason reported for issues Health risks were the overwhelming vaccine with access was the vaccination location or concern across all three countries (Figure 1). problems with registration, a busy vaccination Following this, low trust in government was a site or vaccine preference. Some of the more common response in Haiti (18 percent) unvaccinated in Belize and Jamaica had problems than in Jamaica or Belize (8 and 7 percent accessing vaccines, the most common issues respectively). Between 15-20 percent of people being: they were too busy to get vaccinated, in each country said “something else” as their they preferred a specific vaccine type, the concern. Unfortunately, due to the structure vaccination site was overcrowded and other of the survey we do not have further information logistical issues. In Belize and Jamaica, the age about those other concerns. Very few people group 50+ and older was the most likely to said they were anti-vaccination or against experience barriers to the vaccine and the most vaccines in general. There were similar concerns common reason was that personal commitments about vaccines among the unvaccinated who prevented from accessing the vaccination site. were unsure about vaccination or who did not want to be vaccinated. The primary In terms of access problems for the vaccine, concern of the unvaccinated were also potential the movable middle was less likely to say health risks, and the secondary concerns varied being too busy was a problem (Belize – 24 by country. percent vs 45 percent, Haiti – 31 percent vs 33 percent, Jamaica – 20 percent vs There were few notable differences in vaccine 51 percent). Overcrowding was an issue concerns by age, sex, region, or education in in Jamaica and Belize (Belize – 27 versus the three countries. A greater portion of men in 0 percent, Jamaica – 20 percent versus Belize were concerned about health risks than 11 percent). Vaccine preference was less of women (55 versus 44 percent) and had vaccine a deciding factor among the movable middle concerns related to low trust in government as compared to those without vaccine intention, (12 percent versus 3). There were no geographical except for Jamaica where nearly a third of differences by region except for Belize. Concerns the movable middle (28 percent) cited vaccine about health risks were higher in Belize City than preference as an issue as compared to only Cayo province (55 and 42 percent respectively). 12 percent of those who did not plan to The only difference by educational background vaccinate. A significant percentage of the was that a greater portion of those in vocational movable middle believed that getting sick school were concerned about health risks (Belize was outside their locus of control and it was – 73 percent, Haiti – 54 percent, Jamaica – 69 inevitable they would get COVID (59 percent). percent) as compared to those with no education, Additionally, most of the movable middle said primary, secondary, or tertiary education. they would wait for others to get the vaccine Behavioral insights for COVID-19 vaccine uptake in the Caribbean: 16 | rapid surveys from Belize, Haiti, and Jamaica Results Figure 1. Vaccination concerns by country 70 Belize Haiti Jamaica 60 50 40 30 20 10 0 Health Something Not concerned Low trust in Someone Generally not risks else because already government I trust told supportive had COVID-19 me not to of vaccines get the vaccine Vaccine concerns among the movable middle percent of those who didn’t intend to vaccinate). showed a higher percentage reporting health In Jamaica, this difference was 69 percent of the risk as a concern. The largest difference movable middle as compared to 59 percent of between the movable middle and the rest of those who didn’t intend to vaccinate, while in the population in health concerns was in Belize Haiti – 51 percent of the movable middle noted (62 percent movable middle compared to 53 health concerns, slightly higher than 47 percent Behavioral insights for COVID-19 vaccine uptake in the Caribbean: | 17 rapid surveys from Belize, Haiti, and Jamaica Results of those who did not intend to vaccinate. To this People who do not intend to vaccinate express end, the movable middle was most interested in lower trust in the authenticity and/or knowing more about the safety (side effects) of effectiveness of vaccines than the movable the vaccines (41 percent), followed by vaccine middle. Those who did not intend to vaccinate efficacy (25 percent) and length of effectiveness were more likely to agree with the statement that (17 percent). COVID vaccines may be fake or not work than the movable middle (Belize – 78 percent versus 55 percent, Haiti – 49 percent versus 30 percent, Jamaica – 66 percent versus 47 percent). Vaccination information and messengers Social media is the primary source of COVID-19 information among survey respondents (Figure Across the three countries, health workers 3). Belize is the country with the greatest were the most trusted messengers for percentage of respondents using social media as COVID-19 information (Figure 2). Scientists are their primary source for COVID information (53 the second most trusted while others rely on percent). In Jamaica, more people rely on family to provide advice. Health workers were television (27 percent) than in Belize or Haiti (13 most trusted in Jamaica (49 percent), then Haiti and 5 percent), while radio is more popular in (42 percent), followed by Belize (38 percent). Haiti than in the other countries. For older people Forty-one percent of the movable middle trusted (50 years of age and above), TV was the most health workers. Scientists are trusted by more popular communication source about COVID-19 people in Haiti (29 percent) than in Jamaica (21 in Jamaica (36 percent) and social media was percent) or Belize (19 percent). In Belize, nearly more common in Belize (45 percent). There were a third of respondents trust family as few differences by vaccination status, but in Haiti messengers for COVID information, whereas and Jamaica a larger portion of unvaccinated much fewer do in Jamaica and Haiti (15 and respondents relied on social media sources for 11 percent). Trust in other messengers, such as COVID-19 information than the vaccinated. It is religious leaders, friends, community leaders and important to note that these percentages may celebrities was low across the three countries. be higher percentage than in the rest of the population as the survey respondents were Concerningly, among all respondents, the identified through social media. Thus, they may government is not universally trusted as a be more likely to rely on social media for messenger (Haiti – 13 percent, Belize and COVID-19 information. Jamaica – 10 percent). Those who did not plan to vaccinate generally did not agree that the The movable middle had similar preferences on government response to COVID was effective preferred sources of COVID-19 information as (Belize – 29 percent, Haiti – 27 percent, Jamaica the rest of the survey population. There was – 50 percent). The movable middle was slightly some variation by country, for example, in Belize more supportive of the effectiveness of the where a greater percentage of the movable response (Belize – 56 percent, Haiti – 26 middle reported using social media (57 percent) percent, Jamaica – 64 percent). Haiti had the as compared to those who didn’t intend to lowest level of support for an effective vaccinate (48 percent). government response. Behavioral insights for COVID-19 vaccine uptake in the Caribbean: 18 | rapid surveys from Belize, Haiti, and Jamaica Results Figure 2. Trusted messengers by country 50% Belize Haiti Jamaica 40% 30% 20% 10% 0 Family Health worker Scientists Government Religious leaders Friends Community leaders Celebrities and social media influencers Behavioral insights for COVID-19 vaccine uptake in the Caribbean: | 19 rapid surveys from Belize, Haiti, and Jamaica Results Figure 3. COVID-19 Information sources by country 60% Belize Haiti Jamaica 50% 40% 30% 20% 10% 0 Social media Television Radio In-person Message Newspaper Behavioral insights for COVID-19 vaccine uptake in the Caribbean: 20 | rapid surveys from Belize, Haiti, and Jamaica Results Healthcare workers were as vaccinated or - 42 percent). However, 41 percent in Jamaica more vaccinated than the general population9. reported that nothing will change their mind Healthcare workers in the Haiti survey were more about getting vaccinated, while in Belize this vaccinated than respondents with other figure rose to 75 percent. Seventeen percent of professions (67 percent versus 26 percent). Belizean and Jamaica older adults who had However, there was no difference in vaccination completed the primary vaccination series did not coverage between Jamaican healthcare workers plan to be boosted. This change in vaccination and non-healthcare workers (55 percent and 54 decisions shows how vaccination preferences percent respectively). Despite generally higher are mutable. vaccination coverage among healthcare workers in Haiti, the unvaccinated in this group mirrored Booster uptake was also challenged by the the vaccination intentions of the general fact that many vaccinated older adults did not population (54 percent unsure about vaccination feel at risk of severe disease from COVID-19. and 15 percent did not plan to be vaccinated). Moreover, there was also confusion about In Jamaica, among unvaccinated healthcare booster eligibility among older people. The most workers, 1 in 2 plan to vaccinate - slightly higher common reason for not getting boosted among than the rest of the population. However, 1 in 3 older adults in Jamaica and Belize (30 percent) healthcare workers in Jamaica are unsure about was that they already feel protected against vaccination. COVID-19. In addition, a portion of older adults incorrectly believe they are not yet eligible for boosters yet (Jamaica - 23 percent, Belize - 14 percent). Intentions to be boosted among older adults Experiment on vaccine Only half of older adults 50 years of age and above who were vaccinated planned to get a messaging: can behavioral booster shot10. Further, many older adults in framing affect vaccination Belize and Jamaica were unwilling to change their intention? minds about vaccination. Fifty percent of vaccinated older adults in Jamaica and 53 The survey also explored the impact of percent in Belize intended to get the booster message framing on unvaccinated shot. Those that were unvaccinated but would participants’ intention to vaccinate. consider vaccination wanted more information Unvaccinated participants in all three countries on vaccine efficacy (Jamaica – 44 percent, Belize were randomly assigned four messages to test  ealthcare workers made up 29 percent of the sample in Haiti and 12 percent of the sample in Jamaica. The sample in Belize did not 9H include enough healthcare workers.  lder adults are defined as those over 50 years of age and was only reported on in Jamaica and Belize where the survey sample of 10 O this group was sufficiently large. However, it is important to note that these individuals are only a small sample of the overall elderly population in each country (Annex 1). Detailed results from the elderly population can be found in the World Bank publication ‘Redirecting Efforts to the Most Vulnerable and Documenting Lessons from COVID-19 for Future Pandemics — Evidence from the Caribbean (2022)’ . Behavioral insights for COVID-19 vaccine uptake in the Caribbean: | 21 rapid surveys from Belize, Haiti, and Jamaica Results which one was most effective. Each message treatment message. The endemic message is had a specific behaviorally informed approach framed around the inevitability of the COVID-19 that addressed different motivations to receive virus becoming regularly found in that country the COVID-19 vaccine: 1) control framing, 2) (i.e., becoming endemic). This messaging endemic framing, 3) variant framing, 4) prosocial approach on endemicity helps make continued framing (Annex 2). In the control framing, there risks more salient. The framing of the variant was no behavioral angle, rather this message message emphasized the likelihood of new served as a “control group” for comparison with COVID-19 variants but continued effectiveness the other experimental messages. In Belize and and protection from vaccines against them. Haiti, 62.5 percent of respondents were The variant message framing places emphasis on randomly assigned to the control group and 12.5 efficacy, even against new variants of the virus. percent to each treatment message, whether in The prosocial message framed the importance Jamaica 50 percent were randomly assigned to of protecting yourself, your friends, family, the basic framing and 16.6 percent to each and others around you through vaccination. Behavioral insights for COVID-19 vaccine uptake in the Caribbean: 22 | rapid surveys from Belize, Haiti, and Jamaica Results Box 2. Experiment on framing vaccine messaging to encourage vaccination intention For unvaccinated respondents, the survey respondents to consider the risks for others then generated distinct messages framed if they do not get vaccinated (Annex 2). towards increasing vaccine uptake. This The survey also asked questions on vaccine experiment on message framing randomly behaviors and intentions, role models and generated one of three treatments or a trust, concerns and hesitancy, social norms control message. The control message was and COVID-19 knowledge and behaviors. basic framing, while treatment 1 was framed The surveys were launched April 21, 2022. around how COVID will become an endemic disease, treatment 2 was focused on the risks Table 1 details the framing approaches of virus variants and treatment 3 had a delivered in this experiment as well as the pro-social framing that encouraged text for each message used in the survey. Table 1. COVID-19 Information sources by country Framing approach Message text in survey Control framing Do you plan to get the COVID-19 vaccine? Endemic framing As we learn to live with COVID-19, it is likely we will all be exposed to the virus eventually. The best way to protect yourself is to get fully vaccinated because it greatly reduces the risk of hospitalization and death. Do you plan to get the COVID-19 vaccine? Variant framing New variants of the COVID-19 virus can be worrying, but the best evidence so far indicates that vaccines are still highly protective against serious illness and death from COVID-19. Do you plan to get the COVID-19 vaccine? Pro-social framing The latest studies from around the world confirm that the COVID-19 vaccines are safe and protect you, your friends and family from COVID-19 by reducing hospitalizations and death. Do you plan to get the COVID-19 vaccine? Behavioral insights for COVID-19 vaccine uptake in the Caribbean: | 23 rapid surveys from Belize, Haiti, and Jamaica Results The results from the experiment on behavioral messaging for COVID-19 vaccination are shown in Box 3. Box 3. Experimental behavioral messaging I will take the COVID-19 vaccine when it’s available, by treatment status 1. Belize (n=258) * Statistically significant 40% +65%* 30% +24%* +11%* 20% 10% 0 Basic Framing Endemic Variant Pro-social 2. Haiti (n=7,672) * Statistically significant 40% +42%* +29%* +22%* 30% 20% 10% 0 Basic Framing Endemic Variant Pro-social Behavioral insights for COVID-19 vaccine uptake in the Caribbean: 24 | rapid surveys from Belize, Haiti, and Jamaica Results 3. Jamaica (n=489) * Statistically significant +18%* 25% +4%* 20% -7%* 15% 10% 5% 0 Basic Framing Endemic Variant Pro-social The messages that emphasized that the virus percent as compared to the control message. would become endemic were the most The larger unvaccinated sample in Haiti reflects effective in improving vaccination intentions lower levels of vaccination coverage among the in Haiti and Belize. Other messaging approaches general population (n=7,672). As in Belize, the such as protection against variants and endemic framing – which emphasizes that emphasizing the need to protect yourself everyone will eventually be exposed – was the and others through vaccination were also most effective, increasing vaccination intentions successful in Haiti. None of the messages by 42 percent. Other messaging was also significantly impacted vaccination intention in impactful in Haiti. Variant framing increased Jamaica, although the pro-social messaging was vaccination intentions by 29 percent and more successful than the other messages11. prosocial framing by 22 percent. In Jamaica, targeted advertisements reached the unvaccinated (n=489), with 50 percent of Finally, we developed vaccination personas or respondents randomly assigned to the control characterizations to better understand the group and 16.6 percent to each treatment concerns of survey participants. Survey message. Unfortunately, despite this targeted respondents were grouped into categories such approach, none of the messages were effective as early adopters (those who got vaccinated as in increasing vaccine intention. Messages in soon as vaccines became available), emerging Belize reached a smaller sample of people champions, those who had safety concerns (n=258) as there were fewer unvaccinated (issues with vaccine side effects), uninformed/ participants in the survey. People who received had covid, individuals expressing low trust, and messages with endemic framing significantly those against vaccines generally (Figure 4). increased their vaccination intentions by 65 These categorizations represent how vaccine 11 We refer to impacts on messaging when the results are statistically significant at least at the 90% confidence level. Behavioral insights for COVID-19 vaccine uptake in the Caribbean: | 25 rapid surveys from Belize, Haiti, and Jamaica Results beliefs exist on a continuum according to the educated individuals who believe in COVID specific concerns of individuals. Belize had the but think that better treatments will become highest percentage of early adopters – or people available. In Jamaica, predictors of vaccination who were already vaccinated (91 percent), status for those concerned about safety included followed by Jamaica (54 percent) with Haiti far higher education, waiting for others to vaccinate behind (26 percent). The unvaccinated or unsure fist, and believing in other effective treatments group could be primarily categorized as those being available soon. In Belize, predictors of with safety concerns (19 percent in Jamaica, 24 vaccination status were more education, percent in Haiti, 4 percent in Belize). We also older age, vaccinating to protect others, belief analyzed the predictors of vaccination status in the efficacy of vaccines, having a household and concerns by country (Annex 4). In Haiti, member hospitalized and wearing a mask. predictors of safety concerns were older, more Figure 4. Vaccination personas 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Haiti Belize Jamaica Early adopters Safety concerns Low trust Emerging champions Uninformed/had covid Against vaccines generally Behavioral insights for COVID-19 vaccine uptake in the Caribbean: 26 | rapid surveys from Belize, Haiti, and Jamaica Limitations Limitations The surveys had limitations, including sample choice answers. The findings do not capture the composition and survey design constraints. full range of vaccine beliefs in each context, Respondents were Facebook social media users, rather they provide a rapid view of the current and their distribution was not nationally state of vaccine attitudes among a sample of representative. Facebook users tend to be respondents. This information can be very useful younger and more educated than the general to feed into country-led vaccination campaigns population and are more likely to be vaccinated. to improve uptake. The survey results show a This is potentially problematic as less educated snapshot of vaccine attitudes and uptake; and older people may be harder to reach through however, these beliefs can change over time. social media surveys as well as through Finally, the surveys were launched in April of vaccination outreach; they may also be less likely 2021, a period when some countries were still in to be vaccinated. Reports show that while older the process of rolling out vaccines. Thus, some populations are prioritized in the latest WHO vaccine uptake might have been from early vaccination target, vaccination coverage within adopters who would have gotten vaccinated this group is well below the desired level in most anyway, not necessarily due to exposure to countries in the Caribbean (Margolies, Mussini, messaging. On the other hand, phased Kim, & Di Giorgio, 2022). More research is vaccination – i.e., prioritizing vaccination to needed to better understand the socio- specific groups in phases, may have restricted behavioral motivations of those populations in some groups from vaccinating early. these countries. That said, these surveys provide important insights into vaccine intentions for many others in the population, and these people may also hold sway over vaccination decisions of older members of their households. Additionally, each survey was able to capture unvaccinated respondents and gain key information on their decision-making in regard to questions such as message framing and trusted messengers. Other limitations to the survey were due to design constraints of the chatbot. For example, vaccine beliefs and behaviors were self-reported and were restricted to single Behavioral insights for COVID-19 vaccine uptake in the Caribbean: | 27 rapid surveys from Belize, Haiti, and Jamaica Discussion Discussion Each country presented unique vaccination percent, Belize – 39 percent). This is an uptake challenges which required specific opportunity to analyze and address problems or interventions or outreach strategies to obstacles with scheduling or rescheduling shots change vaccination attitudes and behaviors. and making shots more easily available. Our synthesis of results from the three Caribbean countries, i.e., Belize, Haiti, and Jamaica, Despite the WHO recommendation to provides insights about the vaccinated and reprioritize vaccine allocation and coverage, unvaccinated populations, highlights coverage among high-risk groups such as commonalities and differences as well as older adults in the Caribbean was still low. opportunities for outreach and communication. Most Caribbean countries have not achieved the The results of these rapid social media surveys new WHO target of vaccinating 100 percent of provide evidence for the need for tailoring the highest risk populations; their priority groups targeted efforts to each context to affect are not being reached adequately with full vaccination behaviors. We highlighted the primary vaccination and booster doses. As of movable middle as a group that is ripe for mid-2022, out of eleven countries and territories messaging efforts, as they are still open to in the Caribbean, only one territory (Cayman be vaccinated and have not yet made up Islands) reported achieving 100 percent primary their minds. We excluded anti-vaxxers as immunization coverage of their elderly population this group is small and is often resistant to and booster coverage is even lower among this receiving messages on vaccination. group (7 of 9 countries had coverage below 50 Understanding context-specific vaccine percent) (Margolies et al., 2022). Our surveys in behaviors can also aid in tackling more general Belize and Jamaica provided timely insights into concerns related to vaccination. There is concern the older population’s behavioral and social that backsliding may be occurring or could occur motivations. The share of older people in with routine immunizations due to new vaccine Jamaica and Belize who intend to get a booster concerns and vaccine hesitancy issues that or are unsure offer a window of opportunity emerged with the COVID-19 vaccine. to increase booster coverage. However, the number of older adults that say nothing will Completing the primary vaccination series is change their minds about vaccination is still an issue for a portion of the population. concerning. This reflects the need to refocus Missing the appointment for the second shot vaccination efforts on vulnerable groups such was common (Haiti - 24 percent, Jamaica - 34 as the elderly – which entails improving monitoring Behavioral insights for COVID-19 vaccine uptake in the Caribbean: 28 | rapid surveys from Belize, Haiti, and Jamaica Discussion Behavioral insights for COVID-19 vaccine uptake in the Caribbean: | 29 rapid surveys from Belize, Haiti, and Jamaica Discussion of vaccination coverage of priority groups as well While there was low intention to vaccinate as targeted outreach to these populations children, parental vaccination aligned with (Margolies et al., 2022). their own vaccination status in Jamaica and Belize. This opens a potential opportunity to Boosters are a priority that must be addressed engage or opening to encourage under- with focused and intensified efforts, and it is vaccinated parents or those without the particularly important to target those groups complete series to get their children vaccinated that are most vulnerable, like the elderly. The when they get their remaining vaccines. In Haiti, booster dose vaccination rate was very low in our the challenge is greater as adults are generally survey. Approximately a third of people across less vaccinated and even those who are the three countries who already received the vaccinated are reluctant to vaccinate their primary vaccination series believed they were children. A broader outreach campaign on the already protected with the primary vaccination benefits of the under-12 vaccines and safety series and did not need the boosters. This is a information is warranted in the more challenging common problem with the boosters which has context of Haiti. been reported among vulnerable priority groups such as the elderly and others (Margolies et al., Healthcare workers are key actors in risk 2022). The highest vaccination rate was in Belize, communication and in community but only 27 percent of respondents were engagement. A contribution of this work is boosted. That said, 53 percent of the sample of testing messages and messengers before older adults in Belize intended to get the booster implementing targeted communication shot. This is a challenge and an opportunity for strategies. Insights from harmonized data countries to focus on increasing progress in the collected in 25 countries also confirmed vaccine series and ensure continued protection. healthcare workers were the most trusted The necessity of boosters is a communication sources of information (eMBeD, 2021). challenge for countries as risk perception is lower Healthcare worker intention to vaccinate was once the primary vaccination series is similar to the rest of population as it was in Haiti completed. Understanding the behavioral drivers and Jamaica – but a significant portion are still of vaccination can help craft messaging that unsure about vaccination (Haiti - 54 percent, address the motivations of different populations. Jamaica and Honduras - 30 percent). Surveys are one way to gather this information, focus group discussions and social listening can In the Latin American and Caribbean region, also provide these insights. As the only one other country – Honduras - received communication strategies and information on an eMBeD COVID-19 social media survey. vaccines have evolved over time in response to The results show similarities with themes from changing science and vaccination priorities, it is the recent Caribbean countries, such as concern difficult for many in the public to understand why over vaccine health risks and trusting health additional vaccination doses are needed. In low workers for medical information. The Honduras and middle-income countries, the focus is still on survey had the same methodology, using the the initial booster. However, this problem is also Facebook messenger but was conducted earlier seen in high-income countries such as the United in the pandemic (March 19 – April 8, 2021). States where the new bivalent Omicron booster Only half of respondents were willing to get has seen low uptake despite evidence of its vaccinated and 3 of 10 people are unsure about efficacy against the variant. vaccination. As in the Caribbean counties, health Behavioral insights for COVID-19 vaccine uptake in the Caribbean: 30 | rapid surveys from Belize, Haiti, and Jamaica Discussion risks are also the most common concern with the intention aligned with community norms – COVID-19 vaccines, but in Honduras there also whether family and friends consider it important was low trust in health institutions (eMBeD, to get the vaccine or whether family and friends 2021). Despite this low trust in health institutions, will get vaccinated. Recommendations from this as in the Caribbean countries, people in survey aimed at improving trust and Honduras trusted healthcare workers such as transparency around vaccines, using religious doctors and nurses for medical advice. However, leaders and focus on local community norms fewer healthcare workers in Honduras said they instead of national institutions. Nuanced would not get vaccinated as compared to the differences of which messages or messengers Caribbean countries (Jamaica – 22 percent, Haiti are most effective serve as an important – 15 percent, Honduras – 8 percent). In reminder of the diversity in the LAC region and Honduras, those that did not plan to vaccinate the need for focused socio-behavioral research trusted family and friends more. In Honduras, to identify sub-groups to target to increase there was a different framing experiment that vaccine acceptance and uptake. focused more on messengers rather than messages. The messengers were grouped The movable middle is aptly named – this together in different formulations to see if the group is more likely change their minds about combinations of messengers affected vaccination. They specifically noted they would vaccination intention. In this case, experts and change plans if vaccination was necessary for religious leaders (19 percent), experts (15 social activities or by recommendation of a percent), and celebrities (14 percent) increased health worker. The movable middle is younger vaccine intention. This trust in religious/ (63 percent in the 18-30 age group) and slightly community leaders and/or celebrities less vaccinated against diseases other than contrasted with Haiti, Belize, and Jamaica COVID-19 (-5 percent) than the rest of the where trust in these messengers was low. Even survey population. The movable middle is also among people with no plan to vaccinate in more interested in self-protection and less likely Jamaica, only 8 percent considered religious to believe there are no benefits to vaccination. leaders a trusted source of medical advice. In The responses of the movable middle as Honduras, targeting people who are concerned compared to those without vaccination with vaccine safety saw the highest increase in intention provide insights into how this group vaccine intention (29 percent). Also, vaccination could be targeted for improving uptake. Behavioral insights for COVID-19 vaccine uptake in the Caribbean: | 31 rapid surveys from Belize, Haiti, and Jamaica Recommendations Recommendations i. National targeting may not be the most feature local leaders or stories of fellow effective means to reach the ‘movable community members who have been middle’, or people who are undecided vaccinated. There was low trust in about vaccination. Large-scale national government as a messenger for medical vaccination campaigns have not proved advice or in conducting the COVID successful in reaching priority populations response, so Ministries of Health should or in convincing the undecided population not be relied upon for communication of to vaccinate. Effectively identifying who is vaccine messages. Despite the higher level in the ‘movable middle’, targeting their of skepticism by Haitians for an effective concerns and understanding their government response to COVID, it was motivations is key to engaging them in Jamaicans and Belizeans who expressed discussions about vaccination. the least trust in the government to provide medical advice. HCWs were still ii. Knowledge of the movable middle as a the most trusted messengers, but also a group can aid in targeting messaging, third of the movable middle also trusted selection of trusted messengers and scientists. Scientists could be used as channels. Variation in their responses by communicators particularly to speak on country is informative for the development safety and benefits of vaccines. of context-specific strategies targeted to this group. The lack of concern with self- iii. Ensure immediate, constant, and easy protection and the perceived lack of availability of second doses particularly benefits of vaccine indicate there is a on-site where people receive other messaging or information gap targeted to health services. Reinforcing messaging, this population. Messaging should focus on reminders, mobile clinics or prompts and/ health risks/safety issues followed by or opportunities to receive second doses information on efficacy – which were could aid in improving completion of the greater concerns for the movable middle. full series. The same approach can work for As this group was more likely to agree to boosters, however, more education and wait to see if others got the vaccine first, outreach are needed to convince the messages could emphasize how many vaccinated that boosters are necessary. people have already gotten vaccinated or The exception is in Haiti, where access Behavioral insights for COVID-19 vaccine uptake in the Caribbean: 32 | rapid surveys from Belize, Haiti, and Jamaica Recommendations to vaccination sites to receive first doses booster for those that do not seek it out is the priority due to very low vaccination but are not against it. Many respondents coverage. emphasized the importance of self- protection as a motivation for vaccination; iv. Address specific access issues for the communication efforts should focus on the movable middle for vaccination in each short and long-term protective benefits of country. In Belize, a third of the movable the shot to those that are unsure or believe middle complained of overcrowded they are already protected. vaccination sites. In Haiti, they struggled with the vaccination locations and vi. Behavioral approaches to messaging can registration process. Vaccine preference aid in the development of targeted risk became an obstacle to receiving a communication and vaccination vaccination in Jamaica in addition to outreach. However, each context is overcrowding. distinct – in Haiti and Belize, endemic framing was successful in increasing v. Improved booster availability must be vaccination intention while in Jamaica none reinforced by concerted outreach and of the tested messages had a positive educational information (especially impact although the pro-social framing regarding protective benefits and appeared to work better than other eligibility) delivered by trusted messaging. In Haiti, there also needs to messengers such as healthcare workers be follow-up for missed appointments and or others identified in each country. to clarify confusion about eligibility – for This information should also be delivered example, text reminders, automating through communication mediums including follow-up appointments, providing social media to reach those who are unsure information on walk-in sites. Sending (i.e., “movable” in their opinions) or have multiple vaccination reminders has been low motivation to seek out information. found to be effective in a variety on One example of a clear opportunity to contexts (Lim et al., 2022). Messages in intensity uptake efforts is in Belize, where Haiti and Belize should be tailored to be the movable middle was more likely to use more effective towards the unvaccinated, social media, and the Government was for example, using the endemic approach already utilizing the medium for health tested in the survey. Trusted healthcare communication. People that are ready for workers can also be leveraged to respond a booster are presumably not completely to concerns at the community level, to against vaccination in general as they have emphasize how COVID-19 is here to stay already received the primary series. (i.e., endemic) and the protective role However, there is still a large group that is vaccines and boosters play. Unfortunately, not getting the booster: some which in Jamaica, none of the different messages believe it is not needed or are too busy, positively impacted vaccination intention. others who think they are not eligible or are This suggests the need for further research not prioritizing it as the pandemic shifts to better understand what other messages into a different phase. Countries can or issues would best appeal to Jamaicans. facilitate rapid and easy access to the Behavioral insights for COVID-19 vaccine uptake in the Caribbean: | 33 rapid surveys from Belize, Haiti, and Jamaica Recommendations vii. To address the low interest in child institution-wide vaccination campaigns and vaccination against COVID-19, discussions on vaccine concerns (Peterson, governments can work with pediatricians Lee, & Nugent, 2022). to engage parents to communicate COVID risks and vaccine safety (Lim et al., ix. Social media is a key medium that can 2022). Education workers such as teachers disseminate vaccine information as well can also be important partners to share as misinformation. Because of its ubiquity information with families. Collaborating with and popularity, it is necessary to use the healthcare professionals can help leverage same social media tools to combat vaccine the trust and relationships they have with misinformation spread through those local communities, as many people do not platforms. Techniques to address this view government as a trusted source of include pre-bunking, de-bunking, and COVID-19 information. Working with reminders to check information before families could also have ripple effects to sharing on social media. Tools such as other relatives, for example, in Belize where the eMBeD WhatsApp chatbot or family are seen as trusted messengers of misinformation video clips or games can COVID-19 information. Identifying influential support these efforts (Basol et al., 2021; parents to be communicators within their Lim, Vakis, Cameron, & Dugas, 2022). networks can expand those impacts. Messages should focus first on the primary concerns of parents – vaccine safety and efficacy and self-protection but can also reinforce learning loss due to COVID-19 and community protective benefits. viii. Develop multi-component interventions to provide healthcare workers of different professions – such as frontline workers and nurses - with materials, capacity building opportunities such as trainings and advice on how to communicate with patients. This engagement should also target unvaccinated healthcare workers to provide more information about COVID-19 vaccination and to address their own vaccine concerns confidentially. Interventions to increase healthcare workers COVID vaccination uptake have already shown some effect, such as providing different forms of information (leaflets, lectures), non-monetary incentives, vaccination reminders, Behavioral insights for COVID-19 vaccine uptake in the Caribbean: 34 | rapid surveys from Belize, Haiti, and Jamaica Annexes Behavioral insights for COVID-19 vaccine uptake in the Caribbean: | 35 rapid surveys from Belize, Haiti, and Jamaica Annexes Annex 1. EMBeD social media surveys EMBeD social media surveys are part of a knowledge product series that the World Bank is leading to collect global information on COVID-19 vaccine attitudes. The main trends are based on data collected from social media using stratification techniques that allow population weighing. The data includes information on respondents’ current beliefs and attitudes towards COVID-19 vaccination. The social media surveys on COVID vaccine perceptions and uptake in the Caribbean were conducted through Facebook in three countries (Jamaica, Belize and Haiti) from April 21-May, 2022. Sample sizes from each country including samples by vaccination status are included in Table 1: Table 1. eMBeD survey sample sizes Country Total sample Unvaccinated Vaccinated Haiti 10,346 7,643 2,703 Jamaica 4,037 1,864 2,173 Belize 2,756 261 2,495 Sample sizes for the elderly (50+) for from each country including samples by vaccination status are included in Table 2: Table 2. eMBeD survey sample sizes for people aged 50+ Country Total sample Unvaccinated Vaccinated Haiti 54 41 13 Jamaica 973 314 659 Belize 555 40 515 The eMBeD surveys are limited by a small sample among this age category. In addition, the fact that the survey was delivered via social media may limit its applicability to the wider elderly population. eMBeD uses COVID-19 diagnostics to inform communication strategies. This approach measures intentions, beliefs, norms and trust and creates a typology of vaccine intention personas. The eMBeD team then assesses the impacts of message framing on vaccine intentions. This leads to expanded tests of vaccine messaging applying survey insights, such as applying insights to message framing for each vaccine intention persona identified in Phase 1. Ultimately, the eMBeD team provides customize support Behavioral insights for COVID-19 vaccine uptake in the Caribbean: 36 | rapid surveys from Belize, Haiti, and Jamaica Annexes to country partners on vaccination uptake efforts including technical assistance on communication strategies, capacity building for communication approaches and for frontline staff as well as behavioral solutions beyond communication (e.g., registration and appointments). This work was part of a portfolio of surveys developed by the Poverty and Global Practice Mind, Behavior, and Development group (eMBeD), in collaboration with the Development Impact Department (DIME), Health, Nutrition & Population Global Practice (HNP), Poverty & Equity Global Practice (POV), and External & Corporate Relations (ECR) of the World Bank and supported financially by the World Bank and the Alliance for Advancing Health Online. For more information on eMBeD’s global vaccine hesitancy work using social media surveys, see the blog post “Vaccine hesitancy: 10 lessons from chatbotting about COVID-19 in 17 countries.” More information about eMBeD can be found at: https://www.worldbank.org/en/programs/embed Annex 2. EMBeD questionnaire Question Question (English) Number 1 Which language would you like to conduct this survey in? A- English B- French C- Spanish 2 Thank you for agreeing to participate in this chat-survey around the COVID-19 vaccination efforts. This survey will take 5 minutes. By agreeing to participate, you agree to Facebook’s privacy policy. This survey is conducted by the World Bank. If at any point there are any questions you do not feel comfortable answering, you can choose not to answer them and may withdraw from the survey at any time, without consequence. Your answers will be stored securely and kept confidential, they will only be seen by the research team. If at any time you wish to see your personal data or request that all your personal data be deleted, you can write an email to embedresearch@worldbank.org. You can delete this thread after you have finished the survey, to keep your answers private from anyone else using your phone. … table continues next page Behavioral insights for COVID-19 vaccine uptake in the Caribbean: | 37 rapid surveys from Belize, Haiti, and Jamaica Annexes Question Question (English) Number 3 To thank you for your participation, once you complete the chat-survey, you will be automatically enrolled to a chance of winning a [$100 USD] voucher. Do you agree to participate? A- Yes, I want to do the survey B- No, thanks 4 What is your gender? A- Male B- Female C- Other D- Don’t want to answer 5 Have you been vaccinated with any of the COVID-19 vaccines? A- Yes B- No 6 Which vaccine did you start your vaccination with? A- Johnson & Johnson (Jansen) B- Moderna, AstraZeneca, Pfizer, or Sinopharm C- I don’t know 7 If Q5=A = vaccinated How many COVID-19 shots have you received to date? A- One shot B- Two shots C- Three shots D- Four shots E- I don’t know 8 Do you plan to vaccinate your children (under 12 years) against COVID-19? A- Yes B- No C- I haven’t decided yet D- I do not have children under 12 years old 9 If Q5=A vaccinated but no booster (Q6 / 7 : Johnson & Johnson (1 dose), mRA (<=2 doses Do you plan to get a third shot (booster shot) when you are eligible? A- Yes B- No C- I haven’t decided yet … table continues next page Behavioral insights for COVID-19 vaccine uptake in the Caribbean: 38 | rapid surveys from Belize, Haiti, and Jamaica Annexes Question Question (English) Number 10 If Q5=A vaccinated but no booster ( Q6 / 7 : Johnson & Johnson (1 dose), mRA (=2 doses)) What is the main reason you haven’t you recieved your “additional” shot (booster) yet? A- I am waiting to be eligible for the next vaccine dose B- I missed the date/time and have not rescheduled C- It is too difficult to arrange with my work schedule D- I think one dose is enough protection E- I felt sick with one dose and didn’t want to take another F- I’m not sure when or where to get my second dose G- Other 11 If Q5==A=Yes Now that you have recieved at least one COVID vaccine, have you changed when and where you wear a mask? A- No, I wear masks the same as before my vaccine B- Yes, I wear a mask less often than before C-Yes, I wear a mask more often than before, D-Not applicable (I did not wear a mask before my vaccine) 12 If Q5=A vaccinated but no booster ( Q6 / 7 mRA (=1 doses)) Why haven’t you taken the next dose? A- I am waiting to be eligible for the next vaccine dose B- I missed the date/time and have not rescheduled C- It is too difficult to arrange with my work schedule D- I think one dose is enough protection E- I felt sick with one dose and didn’t want to take another F- I’m not sure when or where to get my second dose G- Other 13 If Q5= Yes, vaccinated Did the vaccine type available to you affect your intention to take the second or booster shots? A-Yes B-No … table continues next page Behavioral insights for COVID-19 vaccine uptake in the Caribbean: | 39 rapid surveys from Belize, Haiti, and Jamaica Annexes Question Question (English) Number 14 If Q13=Yes Why did you choose a particular vaccine type? A- I feel the vaccine technology is safer B- I feel more confident because of the country where the vaccine was produced C- I wanted fewer shots D- I think the vaccine I chose works better than others E- The vaccine I chose has less side effects F- Someone I knew took that vaccine G- A healthcare provider (Doctor, nurse, community health worker) recommended it 15 If Q5= No, not vaccinated Are you facing any problems with accessing the COVID-19 vaccine? A-Yes B-No 16 If Q15=Yes What is the main problem preventing you from accessing the COVID-19 vaccine? A- Vaccine location or time didn’t work for me B- I lack access or had technical difficulties with website or phone line C- I was unable to provide a required document D- Personal commitments prevented me accessing vaccine site (work, childcare, school) E- Too crowded or long waits for vaccination F- Vaccine type I want is not available G- I did not know where to go to get vaccinated Randomized message testing 17 if Q3=No: Do you plan to get the COVID-19 vaccine? A- Yes B- I am not sure yet C- No 17A if Q5=No: Unvaccinated only As we learn to live with COVID-19 it’s likely we will all be exposed to the virus eventually. The best way to prepare yourself is to get fully vaccinated because it greatly reduces the risk of hospitalization and death. Do you plan to get the COVID-19 vaccine? A- Yes B- I am not sure yet C- No … table continues next page Behavioral insights for COVID-19 vaccine uptake in the Caribbean: 40 | rapid surveys from Belize, Haiti, and Jamaica Annexes Question Question (English) Number 17B if Q5=No: Unvaccinated only New variants of the COVID-19 virus can be worrying, but the best evidence so far indicates that vaccines are still highly protective against serious illness and death from COVID-19. Do you plan to get the COVID-19 vaccine? A- Yes B- I am not sure yet C- No 17C If Q5=No: Unvaccinated only The latest studies from around the world confirm that the COVID-19 vaccines are safe and protect you, your friends and family from COVID-19 by reducing hospitalizations and death. Do you plan to get the COVID-19 vaccine? A- Yes B- I am not sure yet C- No 18 If Q5=No, Not vaccinated What is the main reason you have not been vaccinated? A- Someone I trust told me not to get the vaccine B- Vaccines are against my beliefs or religion C- Had side effects or bad experience from another vaccine D- I don’t think I am at risk or think the risk of side effects from the vaccine is higher than the risk from COVID-19 E- I already had COVID-19 and don’t think I need the vaccine F- I do not trust the government G- I am unsure about the long term side effects of the vaccine H- Something else 19 If Q5=No and Unsure/No. Don’t intent to get vaccinated (after treatment) Which of the following is most likely to change your beliefs or plans about getting the Covid - 19 vaccination? A- If I or someone from my family gets very sick B- My relatives/friends or someone I know gets the vaccine first C- Doctors/health workers recommended the vaccine to me D- If I received a financial incentive to get the vaccine E- If my employer or school requires me to get vaccinated F - If it will be necessary in order to return to social activities (eat out at restaurant/cafe, shops, public events, travel) H- Nothing can convince me to get the vaccine … table continues next page Behavioral insights for COVID-19 vaccine uptake in the Caribbean: | 41 rapid surveys from Belize, Haiti, and Jamaica Annexes Question Question (English) Number 20 What is the main benefit/advantage of taking the COVID-19 vaccine, in your view? A- Protecting myself B- Protecting others C- Resuming work/school and in-person social interactions D- Something else E- None, I don’t believe the vaccine has any benefits 21 Who of the following do you trust the most to give you health and medical advice? A- Family B - Friends C- Religious or traditional leaders D- Doctors/nurses/pharmacists E- Community leaders F- Scientists and epidemiologists/public health experts G- Celebrities and social media influencers H-Government/Ministry of Health 22 Think of the last time you got information about COVID-19 vaccines. Where did you get it? A- I saw it on social media (ex. Facebook, Instagram, Twitter, and/or YouTube). B- It was sent to me on a messaging service (ex. WhatsApp, FB Messenger, SMS, etc.) C- I heard it on the radio. D- I saw it on television E- I read it in a newspaper F- I saw the information in-person (ex. notice board or billboard) G- Someone told me about it in-person 23 Thank you for your answers so far, you are 50% done. To what extent do you agree with the following statements: When you get vaccinated, it is not only to protect yourself but also to protect others A- Agree B- Disagree 24 When a new vaccine is available, I would prefer to wait to see what other people do rather than get the vaccine right away A- Agree B- Disagree 25 I believe that most of my friends and family members will get the COVID vaccine A- Agree B- Disagree … table continues next page Behavioral insights for COVID-19 vaccine uptake in the Caribbean: 42 | rapid surveys from Belize, Haiti, and Jamaica Annexes Question Question (English) Number 26 No matter what I do, if I am going to get sick, I will get sick A- Agree B- Disagree 27 The government has generally responded effectively to the COVID-19 pandemic. A- Agree B- Disagree 28 I don’t believe COVID exists A- Agree B- Disagree 29 I think COVID vaccines offered may be fake/not work A- Agree B- Disagree 30 I am confident there will be other effective COVID treatments soon A- Agree B- Disagree 31 I feel I am not at risk for severe COVID. A- Agree B- Disagree 32 The process for getting vaccinated is easy for people like me. A- Agree B- Disagree 33 Which of the following is the most important thing you want to know about the COVID-19 vaccines available in the country? A- How effective it is in preventing severe COVID or death B- How safe it is (side effects) C- Whether my doctor thinks I should get it D- What my friends and family think E- Whether national health authorities recommend taking it F- Whether local officials recommend taking it G- Whether celebrities/bloggers recommend taking it H- How long the effectiveness lasts … table continues next page Behavioral insights for COVID-19 vaccine uptake in the Caribbean: | 43 rapid surveys from Belize, Haiti, and Jamaica Annexes Question Question (English) Number 34 In the last 7 days, did you always wear a mask when in public indoor spaces? A- Yes B- No 35 Have you ever been vaccinated against diseases such as polio or rubeola, or flu? A- Yes B- No C- I don’t know 36 Was your child vaccinated with the recommended vaccines (e.g, polio, measles) A-Yes B-No C-I don’t have children 37 Has anyone in your household been hospitalized or died from COVID-19? A- Yes B- No C- I don’t know 38 Including you, how many people live in your household and regularly share meals together? A- 1-2 B- 3-4 C- 5-6 D- 7+ 39 Are there any of the following people in your household? A- Older adults age 65 and over B- Children under 18 C-Children under 12 D-Children under 5 E- People with underlying conditions such as diabetes and cardiovascular disease F- At least two of the previous five groups G- None 40 Do you work in the education sector in any capacity (teacher, administrator, other staff)? A- Yes B- No … table continues next page Behavioral insights for COVID-19 vaccine uptake in the Caribbean: 44 | rapid surveys from Belize, Haiti, and Jamaica Annexes Question Question (English) Number 41 Do you work in the health sector in any capacity? A- Yes, doctor B- Yes, nurse C- Yes, pharmacist D-Yes, community health worker E-Yes, other F- No 42 What is the highest level of education that you have completed? A- No education B- Primary C- Secondary (high-school) D- Higher education (Bachelor’s degree or higher, any post-secondary) E-Vocational school 43 What ethinic group do you belong to? A- option 1 B- option 2 44 How would you describe the area where you live? A - Big city B - Small town C - Village or rural area 45 Thank you for your responses! To thank you for your participation, you are now enrolled to a lottery with a chance of winning a voucher. … table ends. Behavioral insights for COVID-19 vaccine uptake in the Caribbean: | 45 rapid surveys from Belize, Haiti, and Jamaica Annexes Annex 3. EMBeD Facebook messenger advertisements for survey participation Behavioral insights for COVID-19 vaccine uptake in the Caribbean: 46 | rapid surveys from Belize, Haiti, and Jamaica Annexes Annex 4. Predictors of vaccination status by country a) Belize Intend to Already Unvaccinated, don’t intend to vaccinate, vaccinate: 2% vaccinated: unsure: 7% (n=171) (n=65) 91% (n=2,495) Other reasons: 0% Behavioral insights for COVID-19 vaccine uptake in the Caribbean: | 47 rapid surveys from Belize, Haiti, and Jamaica Annexes b) Haiti Intend to Already Unvaccinated, don’t intend to vaccinate, vaccinate: 23% vaccinated: unsure: 41% (n=4,167) (n=2,376) 26% (n=2,703) Other reasons: 10% c) Jamaica Intend to Already Unvaccinated, don’t intend to vaccinate, vaccinate: 16% vaccinated: unsure: 26% (n=1,040) (n=632) 54% (n=2,173) Other reasons: 4% Behavioral insights for COVID-19 vaccine uptake in the Caribbean: 48 | rapid surveys from Belize, Haiti, and Jamaica References References Basol, M, Roozenbeek, J, Berriche, M et al. 2021. Towards psychological herd immunity: cross-cultural evidence for two prebunking interventions against COVID-19 misinformation. EMBeD. 2021. Behaviorally informed interventions for COVID-19 vaccine take- up: updates and preliminary insights from Honduras. Washington, DC: The World Bank. Lim, J, Vakis, R, Cameron, C, Dugas, M. 2022. Behavioral science and COVID-19: an interactive solutions guide for better policy design. Washington, DC: The World Bank. MacIntyre, C. R., Nguyen, P. Y., Chughtai, A et al. 2021. Mask use, risk-mitigation behaviours and pandemic fatigue during the COVID-19 pandemic in five cities in Australia, the UK and USA: A cross-sectional survey. International Journal of Infectious Diseases, 106, 199-207. Margolies, A, Mussini, M, Kim, P and DiGiorgio, L. 2023. Redirecting Efforts to the Most Vulnerable and Documenting Lessons from COVID-19 for Future Pandemics — Evidence from the Caribbean. Washington DC: The World Bank. Peterson, CJ, Lee, B, and Nugent, K. 2022. Covid-19 vaccination hesitancy among healthcare workers – a review. Vaccines, 10(6), 948. The World Bank/United Nations. COVID-19 Vaccination confidence, access and roll-out: global lessons from the field using behavioral science. World Health Organization. 2022. Global COVID-19 Vaccination Strategy in a Changing World. Geneva: World Health Organization. World Health Organization. 2020. Behavioural considerations for acceptance and uptake of COVID-19 vaccines: WHO Technical Advisory Group on Behavioural Insights and Sciences for Health, meeting report, 15 October 2020. Geneva: World Health Organization. Behavioral insights for COVID-19 vaccine uptake in the Caribbean: | 49 rapid surveys from Belize, Haiti, and Jamaica ECO-AUDIT Environmental Benefits Statement The World Bank Group is committed to reducing its environmental footprint. In support of this commitment, we leverage electronic publishing options and print- on-demand technology, which is located in regional hubs worldwide. 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