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What would persuade South Asians to get vaccinated against covid-19?

New research suggests a way to change minds.

Pakistani people receive a dose of the Chinese-made Sinopharm coronavirus vaccine in Islamabad on Thursday. (Sohail Shahzad/EPA-EFE/Shutterstock)

The current coronavirus wave in India, with case rates topping 4,500 in a day, threatens to spill over into the neighboring countries of Pakistan and Bangladesh. As in India, those countries’ pandemic response is complicated by a low rate of compliance with public health orders intended to control the pandemic, including wearing masks and staying home under lockdown. And Pakistani citizens are wary of being vaccinated because of the CIA-run fake vaccination campaign purportedly against hepatitis B in the early 2010s — although, in fact, it was collecting DNA evidence to help locate al-Qaeda leader Osama bin Laden.

Once the CIA’s campaign was exposed, vaccination rates of all kinds dropped in Pakistan. The Taliban issued a fatwa against women working to vaccinate citizens against polio. This leftover mistrust threatens to suppress coronavirus vaccination rates — and acceptance of protective health behaviors more generally.

But new research from Bangladesh and Pakistan offers some hope for the region’s willingness and ability to fight the virus and its disease, covid-19. In Bangladesh, researchers tested interventions and found effective ways to encourage mask-wearing. And in Pakistan, my research found evidence of what helps Pakistanis comply with public health orders. Here’s what you need to know.

Social norms in South Asia prove effective in promoting mask-wearing

A team of Yale and Stanford researchers recently studied what works to normalize mask-wearing in Bangladesh. They ran an experiment with 600 rural villages in Bangladesh, in which different villages received different approaches in different combinations to see which worked most effectively. Those included distributing free masks; having local mosque leaders or imams encourage masking; promoting mask-wearing through videos and posters; and having community monitors explicitly encourage neighbors to wear masks.

By itself, distributing free masks did increase mask-wearing rates, although by a small amount. The most effective approach, however, came from mixing all four different interventions. Together, these four interventions increased mask-wearing, compared to the control group, from 13 percent to almost 42 percent.

The researchers claim that the critical ingredient was having social monitors establish and enforce norms. These monitors stopped unmasked people with questions as simple as, “We distributed masks here — why aren’t you wearing one?” They then offered a mask on the spot. This prompted a feeling of shame that people wanted to avoid — and stayed effective after the experiment ended.

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Other nations’ reputations can influence Pakistani citizens’ behavior

In October 2020, I fielded a telephone-based survey experiment as part of Gallup Pakistan’s Coronavirus Attitude Tracker Survey, Wave 8. The survey informed a nationally representative sample of 2,100 respondents that Pakistan had initiated Ehsaas, an emergency-cash program for people below a certain poverty threshold. Launched at the cusp of the pandemic, the Ehsaas program was intended to increase economically vulnerable Pakistanis’ lockdown compliance rates by supplementing their incomes.

After survey respondents learned about the Ehsaas program, one-third were told that the program had received fiscal support from the U.S. government. Another third were told that Ehsaas had received fiscal support from the Chinese government. The remaining third received no information during the survey about foreign donor support.

Compared to those who received no information about foreign donor support, Pakistani respondents who heard that China helped fund the program were more likely to believe that the Pakistan’s reporting on covid-19 cases is credible. They also self-reported as being more willing to comply with the government’s lockdown orders for a longer time.

But I found no evidence that respondents became less willing to comply when told about U.S. support. Previous research suggests that Pakistani men were willing to forgo the payments, worth about one-fifth of their daily wages, as an indirect way of expressing their opposition to the United States. However, in my study, respondents who learned that the U.S. government helped fund the Ehsaas program were no more or less likely to say they would comply with lockdown than others in the study.

Generally, Pakistanis perceive China as a stable and reliable ally, unlike the United States. This suggests that China’s positive reputation boosted willingness to comply with public health orders, but that the U.S.’s negative reputation didn’t reduce compliance.

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So how could Pakistan and Bangladesh effectively encourage vaccination?

Combined, these two research efforts suggest a possible approach to overcoming South Asians’ vaccine skepticism. As the pandemic rages in South Asia, any intervention aimed at promoting healthy behavior will rely on citizens’ choices.

To address vaccine hesitancy, the Pakistani government might consider launching a social norms campaign that includes encouragement from local leaders and highly reputed public figures such as imams, athletes or entertainment celebrities. The government could also provide more explicit information about where the vaccines are being manufactured and imported from. Pointing out that vaccines come from the international Covax program, which receives direct funding from reputable donor countries, could boost interest.

These interventions could improve public trust in the government-run vaccination campaign and increase compliance with public health orders. In the early days of the pandemic, similar efforts nudged people toward mask-wearing. They might now encourage them toward the next necessary step: getting the jab.

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Syeda ShahBano Ijaz (@shahbano_ijaz) is a PhD candidate in political science at the University of California at San Diego and does research on the comparative political economy of development with a regional focus on South Asia.

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