Public Trust and the Politics of Pakistan’s COVID-19 Vaccination Program

Abstract

The capacity to implement effective public health policies relies crucially on public trust. Without trust in governments, science and institutions, support for necessary public health programs is difficult to mobilize, particularly where individual sacrifices are necessary and personal gains might be uncertain. A trust-gap existed between the public and government entities in Pakistan even before Coronavirus, but has been exacerbated since and the gap is even wider in certain segments of the population. This trust-gap has crucial implications for how the COVID-19 vaccine will be received by the public and raises questions about what the best channel (public or private) is to distribute the vaccine and what social marketing messages should be associated with it. Through focus group interviews and a survey of a random sample of 1,000 households in Lahore, Pakistan, this study will examine how perceptions of who is developing and administering the vaccine affects vaccine willingness/hesitancy.

Background

Research in international contexts suggests that citizen perception regarding the quality of public health services and trust in government play a crucial role in how citizens select various health service providers. For instance, the role of citizen trust in the government is recognized in public health and it is considered essential to the legitimacy of the health system. Previous studies have found that trust shapes both acceptance of and compliance with preventive and curative health services. Fear and perception of risk can deter citizens from seeking health services in a particular domain. By contrast, confidence in the importance of vaccines (rather than in their safety or effectiveness) has been found to have the strongest univariate association with vaccine uptake compared with other social and demographic determinants. We hypothesize that endorsement by different actors regarding the COVID-19 vaccine will encourage uptake. We further hypothesize that positive framing of the COVID-19 vaccine will encourage uptake. Consequently, we propose a three-arm randomized controlled trial (RCT) to understand vaccine uptake among individuals.  Results from the trial will inform the following specific questions:  Does endorsement by various actors shape COVID-19 vaccination uptake?  Does positive framing of the COVID-19 vaccine shape vaccine uptake? How do various individual and household level characteristics shape uptake of the COVID-19 vaccine? The three experimental arms are: endorsement by the Prime Minister of Pakistan; endorsement by a Religious Cleric; and framing effects.

Research Design

This study will conduct a three-arm randomized controlled trial (RCT) to understand COVID-19 vaccine uptake among individuals in Lahore, Pakistan. The sample size of 2100 individuals will be split across the three experimental arms and the control group. We intend to use the results of this study to generate evidence which can be used for further exploration in a larger study.  The three experimental arms are:

Treatment 1- Endorsement by the Prime Minister of Pakistan: The first treatment will consist of a video which shows the Prime Minister getting vaccinated. Respondents will be told that he has received his vaccination shots and is doing okay. 

Treatment 2 – Endorsement by a Religious Cleric: The second treatment will consist of a video in which the religious cleric is asking people to get vaccinated and is informing them that getting vaccinated is safe and effective.

Treatment 3 – Framing effects: The third treatment will comprise a series of positive messages regarding the impacts of the COVID-19 vaccination. These include, return to normality and especially employment; minimal short term side effects; and higher likelihood of not falling very sick if vaccinated.

Pure control group: The pure control group will not receive any treatment.

Hypotheses

We will test the following sets of hypotheses.

H1: Endorsement by the Prime Minister of Pakistan will lead to a higher intent to vaccinate/willingness to register for the COVID-19 vaccine

H2: Endorsement by a Religious Cleric will lead to a higher intent to vaccinate/willingness register for the COVID-19 vaccine

H3: Framing effects will lead to a higher intent to vaccinate/willingness to register for the COVID-19 vaccine.

Findings

• We find high levels of vaccine hesitancy with nearly 35% of participants reporting that they will not vaccinate.

• Exposure to any of the three treatments, in comparison with the control group, was not linked with an increased likelihood of accepting help for immediate registration for the vaccine.

• There was a statistically significant relationship between willingness to pay for the vaccine and exposure to all treatments.  Exposure to a positive endorsement from the Prime Minister was associated with an increased likelihood of being willing to pay for the vaccine (coefficient 1.912, 95% CI 1.54 – 2.28). Endorsement from a religious cleric (coefficient 0.895, 95% CI 0.50 – 1.30) and endorsement from doctors (coefficient 0.459, 95% CI 0.042 – 0.88) were also associated with an increased likelihood of being willing to pay for the vaccine.

Implications

• Endorsement of the COVID-19 vaccine by the government, a prominent religious figure, or doctors, does not lead to an increased willingness to be assisted in immediate registration for our study sample.

• The finding of greater willingness to pay suggests that for resource constrained countries such as Pakistan, there might be room for some cost reallocation to ensure wider coverage.

Access the powerpoint slides from Hina Khalid’s presentation on the preliminary findings of the project here.