The Indian district of Raigarh (population 1.6m) has achieved 100% first-dose vaccination of all eligible citizens, without financial incentives or a governmental mandate, writes a group of medical specialists from that country.
The Raigarh success story shows the power of behavioural and motivational strategies, write Ravi Mittal, Dr Surbhi Jain, Christopher Myers, Tinglong Dai, and Dr Amit Jain in Health News Express.
They write:
COVID-19 vaccination efforts have decelerated or plateaued in developing and developed nations alike. To deal with vaccine holdouts, leaders across the world have proposed concrete benefits such as monetary compensation and lotteries, as well as punitive strategies such as barring unvaccinated people from restaurants, flights, and public places.
However, leveraging such reactive techniques broadly may be viewed as coercion, trigger legal and political challenges, and even fuel public distrust toward authorities and harden anti-vaccination beliefs. Furthermore, by shying away from intrinsic motivation, health leaders miss an opportunity to leverage an array of behavioural, motivational, and organisational strategies that are supported by decades of management research.
While full vaccination may seem like a lofty goal, it is not completely out of reach. The Indian district of Raigarh, with a population of approximately 1.6m (in the state of Chhattisgarh, where mean per capita income is $1,400 per year), was able to achieve 100% first-dose vaccination of all eligible, adult citizens without financial incentives or a governmental mandate.
This made national headline news across India. Raigarh achieved this success despite severe resource limitations (including the sharp vaccine shortages throughout India in early 2021), and heterogeneity in geographical, ethnic, linguistic, social, and religious attributes, which added to the mission's complexity.
We share five actionable strategies learned from the Raigarh case study, which can help bolster vaccination rates in both resource-poor and well-resourced settings.
Target a broad and diverse set of local leaders
Given the sheer scale of the vaccination effort, reaching everyone individually is infeasible. Local leaders carry the trust of their respective communities and serve as central nodes sitting between various sub-community networks, allowing them to spread information and influence behaviour faster and effectively.
Moreover, systematically recruiting local leaders across the spectrum of political, communal, social, and religious strata is instrumental in influencing all groups, as diverse communities have differing viewpoints with diverse sets of leaders. For instance, in Raigarh, local agricultural leaders were strategically recruited to influence the farming communities, and religious clergy were appealed to motivate the religious communities. Genuine respect and open dialogue can turn local leaders into powerful allies for mobilising the population.
Confront information asymmetry
In addition to having a trustworthy messenger, the consistency and relatability of the message about vaccination are critically important. A clear message (“Get vaccinated”), presented through an influential messenger (e.g., local community leaders or a local celebrity’s vaccination selfie) crafts a powerful narrative that can overcome alternative sources of (often incorrect) information, particularly when presented in an appropriate local medium.
Stories of peers’ successful experience can help dispel common vaccine myths (e.g., infertility, paralysis, migraines) and enhance individuals’ motivation to learn more about that experience (consistent with research on the motivating effects of exceptional success).
Transparency and public confidence are also important. The team released information on vaccine stocks, allocation plans, and accomplishments through daily press releases, which were issued through the district health departments. Echoing research on operational transparency in various business and societal contexts, this strategy imbues a sense of positivity and confidence in the public and the media. It also removed policy opacity and promoted public trust.
Motivate through celebration
Echoing research on the importance of recognising “small wins”, the vaccination team made it a rule to celebrate early successes throughout the vaccination effort. Celebrating the first 10% of vaccinators was seen as much more crucial than lamenting the 90% of non-vaccinators. For instance, communities who were early-adopters and first to participate in the vaccination campaign were publicly lauded. Similarly, to celebrate community milestones, the team deployed “gamification” strategies (which have been increasingly used to motivate health behaviours), including merit badges and leaderboards, to both celebrate successes and motivate under-performers.
Mega vaccination drives in certain localities were another effective strategy to break inertia and reach the maximum number of people in the minimum amount of time. For instance, on June 26, 14% of the target population was vaccinated on a single day through a mega-vaccination event, an achievement that fuelled the team’s efforts and pushed the district toward the “critical mass”.
Focus on convenience
A one-size-fits-all approach often does not work for motivating behaviour in large, diverse populations. However, one exception to this rule is the paramount importance of simplicity and convenience in driving consumer decisions and behaviour. For example, the Raigarh vaccination team employed a strategy of “No banker hours” in offering vaccination appointments. The team customised service hours to the needs of the target community (e.g., more evening sessions for labourers and farmers). Similarly, resonating with studies showing that the proximity of vaccination networks contributed to higher vaccination rates, locating vaccination sites close to peoples’ place of work or residence was particularly effective.
Robust monitoring and rapid course correction
Finally, the Raigarh team focused on continually measuring and monitoring progress to make rapid adjustments if their efforts were not working as planned. Monitoring local-level data allowed the team to maintain constant awareness of frontline, “on the ground” challenges and allocate resources on the fly, in a way not unlike the Lean philosophy that emphasises that problems should be resolved at the lowest level and close to when and where they arise.
Haven’t we tried these strategies before?
While certain strategies outlined above have been used across the US and elsewhere, we have seen considerable variability and inconsistency in how these are used, which could contribute to ongoing vaccination challenges. For instance, vaccinations rates continue to lag in some historically underserved black and Hispanic communities, which may be due to a failure to engage leaders from racial and ethnic minority groups at a local level, as well as broader failures to dispel misinformation through social media and stick to a consistent federal narrative. Indeed, mixed-messages from the CDC, government officials, and organisational leaders throughout the pandemic may also have spilled over into vaccine adoption and hurt confidence among the undecided.
Though these five strategies are not a magic recipe for vaccination success, and there is certainly an important role for tools like the vaccine mandates implemented by some hospitals or corporations, the Raigarh success story highlights the incredible power of basic behavioural and motivational strategies in achieving success in vaccinating the population against COVID-19.
The authors: Ravi Mittal, MBBS, is an Indian Administrative Services officer currently posted as the CEO of the District Council in Raigarh, India. He serves as the district COVID-19 nodal officer charged with planning and executing all aspects related to the COVID-19 pandemic in the district.
Dr Surbhi Jain is a consultant physician of internal medicine at the Fortis OP Jindal Hospital and Research Centre in Raigarh. She serves on the Raigarh District COVID Management Team.
Christopher Myers, PhD, is an associate professor of management at the Johns Hopkins University Carey Business School and School of Medicine and core faculty of the Hopkins Business of Health Initiative.
Tinglong Dai, PhD, is a professor of operations management and business analytics at the Johns Hopkins University Carey Business School and School of Nursing and core faculty of the Hopkins Business of Health Initiative.
Dr Amit Jain is an associate professor of orthopaedic surgery and neurosurgery at the Johns Hopkins University School of Medicine, a practicing adult and paediatric spine surgeon, and core faculty of the Hopkins Business of Health Initiative.
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