Assessing Community and Individual Drivers of Vaccination- Adapting and Applying the Besd Framework to Identify Enablers and Barriers to Covid-19 Vaccination in India

Background: Universal immunization coverage is critical if countries are to achieve Sustainable Development Goals and the Immunization Agenda 2030 (IA 2030) strategy to leave no one behind. Vaccines save lives by preventing disease, limiting outbreaks, and combating anti-microbial resistance. The unprecedented objectives to vaccinate entire populations with COVID-19 vaccines, including in India, required local data on individual and community demand for COVID-19 vaccines and vaccination services. To analyze vaccination-specific beliefs, processes, and practical issues, the World Health Organization developed a tool called 'Behavioural and Social Drivers of Vaccination (BeSD)'. The tool adapts existing evidence-based behavior change theories to provide a framework for measuring and developing targeted strategies for overcoming barriers to vaccination. This study presents the findings from the application of the BeSD survey in diverse communities across India. Method: Using a quantitative study design and multistage sampling, the study surveyed 768 potential COVID-19 vaccination clients across six Indian states.Findings: Using multiple regression analysis informed by the BeSD framework, the study confirms the relationship between behavioral and social factors such as ‘family and religious norms’ and ‘concerns about COVID-19 disease’ with ‘intention and uptake of the COVID-19 vaccine’. Factors such as ‘lack of awareness of COVID-19 vaccines’, ‘family resistance’, and ‘fear of adverse events following immunization’ emerged as key reasons for low intent to vaccinate. Implications: Integrating the BeSD framework into routine immunization data collection activities can offer insights into how to continually improve program implementation. The study findings manifest the importance of a multilevel intervention in mitigating vaccine hesitancy. While top-down communication through mass media still stands relevant, ‘interpersonal communication’ via health workers and faith-based organizations is needed to establish positive religious, community and family norms.