Social Marketing Plan to Decrease the COVID-19 Vaccine Hesitancy among Senior Citizens in Rural India

Abstract

Social marketing is a set of activities aimed at changing people’s behavior for good. COVID-19 vaccine hesitancy is a significant concern in rural India. This article introduces a comprehensive social marketing plan to address this social issue among senior citizens of rural India. The model described in the study uses social marketing principles and practices such as environmental analysis, STP strategies, strategies for formulating behavioral objectives and goals, examining the barriers, benefits, competitions, and influential others, strategies for integrated marketing mix, evaluation and monitoring strategies, strategies for establishing budgets, raising funds and implementation plan. The plan’s objective may help the professionals to develop an action plan to counter vaccine hesitancy.

1. Introduction

COVID-19 vaccines were developed in a short amount of time worldwide. Countries that have created vaccines have thoroughly examined them for safety. Vaccine side effects are only transient and do not indicate that a person is ill. Getting vaccinated against COVID-19 variations can prevent us from significant sickness and death. The more vaccinated people, the less likely the virus will spread and change into new strains [1]. Studies have found vaccines to provide additional protection for people infected with COVID-19 [2]. Vaccination, despite all of this information, is a personal choice.

As per the World Health Organization, vaccine hesitancy is a delay in accepting and refusal of vaccines despite the availability of its services [3]; it is primarily caused by complex and context-specific factors that differ across time, place, and vaccine brands. Vaccine hesitancy is influenced by anxiety, convenience, confidence, and various sociodemographic factors such as age, sex, ethnicity, and religious beliefs [4]; it is also caused by misinformation/infodemic [5] and different conspiracy theories, mostly circulated online, mainly by social media [6]. The drivers for low confidence in COVID-19 vaccines are also related to socioeconomic and healthcare inequalities/inequities, structural racism, lower level of education, poor access to correct information, ineffective public health campaigns [7].

India dispensed 12.8 billion COVID-19 vaccine doses in a day in August 2021 [8]. The central government is also accelerating the pace of vaccination in the country [9]; however, vaccine hesitancy is a primary concern before the government. India so far has reported many cases concerning vaccine hesitancy [10]. Although many people in India take the vaccines at the recommended schedule, the campaign’s success is challenged by individuals who delay or hesitate to take these shots for various reasons [11]. Further, people turning up for COVID-19 vaccinations in local health centers of rural areas are found to be very low or even no takers. In contrast, urban areas have witnessed increased demand [12].

Social marketing is a technique that focuses on changing the behavior of the consumers for good [13]. Social marketing is found to be effective in the health sector. From the beginning of the planning process, it has guided the public, improved the management, implementation, and intervention programs, and prepared and broadcasted the campaign’s messages through media appropriate to the target audience. Social marketing in the health sector has also improved public satisfaction and helped the market analysts figure out which health problem demands a behavioral change [14].

Previous studies have shown social marketing techniques influencing immunization rates [15]. Although studies have been conducted to understand COVID-19 vaccination apprehensions in India [16,17,18], there have been virtually no efforts to dispel the “myths” linked with COVID-19 vaccines, especially in rural India. Hence, a planned social marketing campaign requires research around the internal and external environment, marketing research, setting behavioral objectives and goals, examining the barriers and benefits of the consumers, developing a strategic marketing mix, and a plan for monitoring, evaluation, and implementation.

The rural sector occupies 65% of the Indian population. Since India’s urban population has a higher population density, it accounts for many COVID cases compared to rural India. An increase in vaccine hesitancies is a major concern in rural India. The widening gap in vaccine registrations between rural and urban India is increasing vaccine inequity. Out of 176 million people living in India’s least developed districts (114), only 23 million doses of vaccines have been administered so far [16]. It is worth mentioning that rural India has a lesser number of testing facilities. If the issue of vaccine hesitancy continues, India might find it difficult to decrease the infection rates; this calls for an urgent marketing campaign to educate the rural population. The purpose of such a campaign may focus on educating the public about taking COVID vaccines. The drive may focus on creating awareness of COVID-19 vaccinations, thereby improving the nation’s public health. The proposed plan uses the framework by Lee and Kotler [13] and may be implemented by any social marketing organisations, government, Non-Governmental Organisations (NGOs) for the considerable benefit of the health and well-being of the nation. The infographic of the proposed plan is shown in Figure 1.

1.1. Stage 1: Environmental Analysis

Before rolling out a social marketing plan, it is imperative to study the marketing environment [17]. A quick audit of the organisation’s strengths, weaknesses, opportunities, and threats will impact the subsequent planning decisions. The organinsation proposing the social marketing effort may scrutinize the microenvironment [18] related to the social marketing plan. The organisation may check the levels of funding, its adequacy, the expertise to tackle this social issue, support of decision-making units, the priority of the problem within the organinsation, the likely support of the stakeholders, the potential alliances and partners, the success rate of similar projects carried out in the past and so on. These microenvironment components are controllable. Hence, organisations should maximize the strengths and minimize the weaknesses associated with the above-mentioned microenvironmental factors.

In the macro-environment [19], the uncontrollable forces may be appropriately studied by social marketing organizations to minimize the failure rate of campaigns. The firm may take advantage of opportunities and prepare for any threats coming out of these uncontrollable factors. A scrutiny of the consumers’ cultural factors like their values, lifestyle preferences, and behaviors may be monitored to leverage the best possible marketing campaigns. Demographic characteristics such as education level, income, trends affecting the problematic behavior (vaccine hesitancy), perception of people etc., may also be studied. In the case that the campaign is taken up by an NGO or any private social marketing firm, the governments’ laws, rules, and regulations that could potentially affect the campaign may also be studied.

1.2. Stage 2: Segmenting, Evaluating, and Targeting the Audience

Segmenting, Targeting, and Positioning (STP) is a three-stage process that scrutinizes products or services and examines ways to communicate the benefits to target consumers [20]. Segmenting the target audience, assessing the chosen segment, and targeting the right segment are important in social marketing. The primary target audience may be chosen based on several segmentation variables such as age, sex, the size of the family, geographical location, the intensity and severity of the problem-related behavior, the stage of change in the change model [21].

Senior citizens are found to have maximum vaccine hesitancy in rural India [22]. The author suggests tapping these individuals who are in the pre-contemplation stage of the change model. Senior citizens are the decision-makers in typical Indian households. The likelihood of the campaign’s success to be rolled out to other age groups is mainly dependent on this age group. Picking one senior citizen (preferably traditionalists) from every house of various rural areas in a phased manner may become the trump card for the social marketer. The marketer may approach different religious heads, and community leaders for help.

The chosen segment, i.e., senior citizens, may be evaluated using a nine-point criteria [23]. The segment so chosen can be compared with another potential segment. A list of these criteria follows (

Table 1. Evaluation of the chosen segment (senior citizens).

Sr.No	Criteria	Details	Evaluation
1.	Segment	Number of people in this segment	How many senior citizens are yet to take the COVID-19 vaccine?
2.	Problem incidence	Number of people engaged in problem-related behavior	What percentage of senior citizens are reluctant to take the COVID-19 vaccines?
3.	Problem severity	The level of consequences of problem-related behavior in this segment	What is the incidence of COVID-19 infections among senior citizens?
4.	Defenselessness	The number of people who can take care of themselves versus those needing help	What percentage of senior citizens have easy access to vaccination camps?
5.	Reachability	The extent to which this audience can be identified and reached.	Are there media channels and other options that can be used for promoting vaccination messages targeted explicitly for senior citizens?
6.	General responsiveness	The readiness, willingness, and ableness to respond to the social marketer	How concerned are senior citizens with COVID-19 infections? How do they compare with Generation Y? Which group has been responsive to similar campaigns in the past?
7.	Incremental costs	Estimated cost to reach and influence this segment	Are there free or inexpensive channels to reach the target audience? How does this compare to Generation Y? Are there similar campaigns from neighboring states that have worked well with senior citizens, or will the social marketer need to start from scratch?
8.	Marketing mix	The likeliness of this segment to respond to social marketing strategies	What are the most significant influences on senior citizens’ decisions relative to their vaccine hesitancy? How concerned are their relatives with potential programs and messages?
9.	Organisational capabilities	Availability of staff expertise to handle the social issue	Are the social marketers’ experience and knowledge in handling senior citizens as strong as Generation Y?

), along with probable questions that can be asked to establish each measure. To illustrate each criterion, a situation is described in which the social marketer may decide whether senior citizens would be the most attractive segment to mitigate COVID-19 vaccine hesitancy; this segment may then be compared with a similar evaluation of Generation Y (between 25 and 40 years old). The feasibility of proceeding ahead with senior citizens can be evaluated with these criteria by quantitatively assigning a score to each segment and then creating a rational way of ranking them to interpret the results.

Once the evaluation is complete, the social marketer may prefer concentrated marketing strategies [24] for targeting. Such a strategy is ideal because it will involve directing all the efforts and resources to develop a social marketing campaign for the specific segment of the target audience, i.e., senior citizens.

1.3. Stage 3: Formulating Behavioral Objectives and Goals

Having selected the target audience for a campaign, the next stage establishes campaign objectives and goals. The primary aim will be to influence the behavior of the senior citizens to accept the desired behavior (take vaccination) or modify, reject or abandon the problematic behavior (vaccine hesitancy). A social marketer may fix three objectives: behavioral, knowledge, and belief [25].

The campaign may have a behavioral objective, but if the social marketer determines that the target audience needs to know or believe for them to “act,” these objectives can also be incorporated into the social marketing plan (

Table 2. Hypothetical objectives and goals.

Purpose	Behavior	Knowledge	Belief
Reduce vaccine hesitancy	What does the social marketer want the target audience to do?	What does the target audience need to know before they act?	What does the target audience need to believe before they act?
Objective	Get vaccinated	To know that vaccinated people have fewer complications if affected with COVID-19	Believing that postponing vaccination can risk one’s health and deteriorate nation’s health index
Target goal	Increase the percentage (from 20% to 70% in 3 months) of senior citizens who take vaccination	Increase the percentage of people (from 20% to 70% in 3 months) who become aware of the fact that vaccination brings fewer complications	Increase the percentage of people (from 20% to 70% in 3 months) who believe that postponing vaccination is a risk to one’s health and nation’s health.

).

Once the campaign objectives are set, the social marketer must set a robust goal. SMART [26] is a well-established pattern to fix the target goals, and the social marketer may ensure that the criteria used in SMART goals are attainable within a specific time frame (

Table 3. Hypothetical SMART Goals.

SMART	Details	Action
Specific	Goals need to be and clearly defined. The marketer must know what to accomplish	To educate the senior citizens in rural India to get vaccinated
Measurable	The goal set to be achieved. How can it be assured that the goal will be completed?	The marketer may request the audience to furnish the vaccination certificate provided by the COWIN * app/web portal. The social marketing firm may seek the help of the government to capture this measurement. The report may furnish the list of people who are getting vaccinated after the campaign
Attainable	Goals to be realistic. The social marketer may scrutinize what is possible with the availability of resources, time, and knowledge. The marketer must ascertain the likelihood of the campaign being successful	How likely were the senior citizens’ responses to similar marketing campaigns in the past
Realistic	The importance of creating a material impact on achieving the objectives	To examine if the target audience is ready to listen to the marketer. Do they want to be physically fit and stay immune?
Time-based	Locking the goals to a specific time frame	The marketer can lock the target to be achieved, such as few months

* CoWIN is a web portal for COVID-19 vaccination registration in India. It is owned and operated by the Ministry of Health and Family Welfare; it shows booking slots of COVID-19 vaccines available in nearby places. Booking can be made on the website as well as in the app.

).

1.4. Stage 4: Understanding the Barriers, Benefits, Competitions, and Influential Others

A social marketer must understand the barriers, benefits, competing behaviors, and groups influencing the target audience. Barriers can be internal, such as a lack of proper skill to carry out an activity, or external, such as structural changes that may be needed for the behavior to be more convenient. Barriers may be associated with various factors, such as beliefs, skills, knowledge, abilities, culture, perception, economic status, etc. Few obstacles that social marketers may confront from the perspective of senior citizens may be linked to perceptions such as adverse effects of vaccines, fear, vaccine ineffectiveness, ‘I am immune’ fallacy, lack of motivation to get vaccinated, lack of opportunity, lack of education, and lack of capability.

The benefits of vaccinations are multi folds. The marketer may emphasize the success stories of people who are protected by vaccinations. Vaccinations elevate the health index of the country. People should realize that getting vaccinated is a license to go out without worry, reconnect with loved ones, less risk of getting severe complications, and a tool to protect oneself and the community.

Competition in social marketing is behaviors that the target audience would prefer over the one we are promoting. When the target audience considers our offering as pain and their behavior as pleasure, this results in competing behavior. In this case, competing behavior will primarily be using immunity booster medicines/diets, believing stereotypes, staying indoors, praying, etc. The audience may consider these competing behaviors to be safe and cost (non-monetary costs such as effort, time, physical discomfort, etc.) of performing this behavior to be less than the desired behavior of the social marketer. The social marketer may blend the ratio of benefits to barriers to make the target behavior more attractive. Four tactics [25] to do this follow.

(a).

Increasing the benefit of target behavior: e.g., An appreciation certificate (if vaccinated) from a high-rank government official.

(b).

Decrease the target behavior’s barriers (and or expenses): e.g., Free pick and drop to vaccination camps and back to home.

(c).

Decrease the benefits of the competing behavior: e.g., Restricted supply of immunity booster drugs if not vaccinated.

(d).

Increase the barriers (and or expenses) of the competing behavior: e.g., Audience to pay a heavy price for immunity booster drugs if not vaccinated.

Social marketers must also find out the midstream audiences [27] that the target audience looks up to. The opinion of the midstream audiences are regarded as trustworthy, credible, and likable by the target audience. Knowing what these midstream audiences (influential others) are saying and doing concerning the desired behavior will have major implications, especially for marketing strategies, perhaps warranting an additional target audience for the social marketing plan.

1.5. Stage 5: Crafting a Positioning Strategy

Positioning is not what we do to the product or service, but the prospect’s mind. Positioning creates a unique impression in the minds of the consumers [28]. Positioning in social marketing is similar to commercial marketing. Keeping the target audience’s profile in mind, we may craft a positioning statement considering the respondents’ related behavioral characteristics. One way of developing a positioning statement can be done from the lists of barriers and benefits identified in the social marketing plan. A typical positioning statement against vaccine hesitancy may take the following shape.

“We want the senior citizens to see COVID-19 vaccinations as a life vest to guard against coronavirus as more important and beneficial than abstinence”.

This positioning statement can be the motto of internal staff carrying out the campaign.

Positioning vaccine hesitancy towards the target audience can take up the following shapes:

(a).

Behavior-focused positioning—How do we want the target audience to behave? (e.g., to take vaccine shots at the earliest to combat COVID infections)

(b).

Barrier-focused positioning—Focus on the social marketers offering to help overcome perceived barriers such as fear, self-efficacy, and perceived high cost associated with performing the desired behavior (e.g., free pick up and drop off to vaccination camps and back to home)

(c).

Benefits focused positioning—The focus here should be on the benefits that the target audience wants (e.g., free health checkup once a month if vaccinated).

(d).

Competition focused positioning—Focus on removing the competing behavior of the target audience (e.g., Positioning vaccine hesitancy as a severe threat to life).

1.6. Stage 6: Developing an Integrated Marketing Mix

After devising strategies for positioning, it is time to decide how the marketer will influence the target audience to perform the desired behavior. Tools like the product, price, place, and promotion (commonly known as 4Ps of the marketing mix) help make this happen [29]. Proper strategies for the 4Ps will help reduce the barriers and create an environment to deliver value that senior citizens expect in exchange for the new behavior.

Table 4. Marketing mix to combat vaccine hesitancy.

4Ps	Description	Strategies for Targeting Senior Citizens
Product
Core	Benefits of performing the behavior	By taking vaccine: Peace of mind. Stay protected
Actual	Special features	Vaccination camps
Augmented	Additional features put forward to perform the behavior	Counseling, support at home
Price	Monetary and non-monetary incentives/ disincentives	Monetary incentives: People who come forward to take vaccines be given some coupons and rebates when they visit hospitals for medical checkups for subsequent visits. Other options are free food packages for lower-income families, free lodging in private hospitals, free drugs, etc. Non-monetary incentives: Recognition, felicitation by the government if vaccinated. Monetary disincentives: Fines and increased taxes on availing medical facilities if not vaccinated Non-monetary disincentive: Negative visibility of the non vaccinated people
Place	Access to the goods and services	Extended clinical hours for vaccination Home visits for vaccinations A separate queue for senior citizens for vaccination Free transport to get the vaccination
Promotion	Key messages	“All vaccination services are free.” “Vaccination for everyone is prevention for all.” “Privileges for vaccinated senior citizens”
	Key messengers	Health care workers Social marketers Government ASHA * workers Community volunteers NGOs
	Key media channels	Mass media: TV, radio, print media, internet, hoardings/billboards, wall painting, bus/auto panels, LED scrolls Print materials: Posters, pamphlets, factsheets, banners Special events: Flashmobs, street plays, drama, local folk songs, story telling Videos: At health center waiting areas, banks, public library Personal communications: Use of health workers and peer groups Community mobilisation: Use of surveillance groups Advocacy: Local teams targeting families and political leaders

* An accredited social health activist (ASHA) is a community-focused health worker under the Ministry of Health and Family Welfare as a part of India’s National Rural Health Mission.

describes the marketing mix to combat vaccine hesitancy of aging adults.

1.7. Stage 7: Monitoring and Evaluation

Once the marketing strategies are laid, it is suggested to develop a plan to monitor and evaluate the social marketing strategies. Monitoring directs to the measurements conducted once the social marketing campaign is launched but before it is completed. On the other hand, evaluation directs to the final measurement and reports on what happened, answering questions like has the goal to change the behavior, knowledge, and attitude reached? The evaluation stage may also check the time and budget of the plan, unintended consequences (that may arise now or future), check which strategies worked well and which did not, find out the missing elements, and scrutinize an option to do differently next time. From a broader perspective, it addresses the following areas. A proper plan for the following areas will help prioritize and allocate the optimum use of the resources; it will also help to take corrective actions if needed.

Why is the measurement being conducted, and who will be the audience for the results?

The motive of this measurement will help to do the campaign better next time if rolled out to other age groups. A successful campaign may even pay the way for funding by third parties. This stage also checks to prioritize and allocate the available resources to move forward and may also alert the social marketer to midcourse correction needed to achieve the goals.

What will be measured?

A logic model [30] can guide what a social marketer will measure to achieve the evaluation. The model that follows (

Table 5. What will be measured: A Logic model.

Input	Output	Outcome	Impact	ROI
Resources allocated to the social marketing campaign	Activities conducted to influence the behavior of the audience	Response to output by the target audience	Indicators showing the level of impact on the social issue	Rate of return associated with the effort
Money, Social marketers, Man-hours, Existing material used	The number of senior citizens targeted/met, Events (camps) held, Reach and frequency of social marketing communications, Media coverage (free and paid), Implementation of the social marketing programs (Whether conducted on time, budget, etc.)	Change in behavior, belief, and value of the senior citizens, No. of vaccinations completed, Response to the social marketing campaign, Campaign awareness etc.	Improvement in health, Lives saved	Cost to change the behavior, For every money spent, money saved or generated calculating ROI

) is a visual schematic that helps to organize the social marketing program evaluation measures into various categories that can be measured and reported by a logical flow starting with inputs, outputs, outcomes, impacts, and return of investments (ROI).

How will the measurements be conducted?

Quantitative surveys [31] will help understand the percentage increase in vaccination levels. These surveys can be administered using telephone, online, as a self-administered questionnaire [32], or as in-person interviews [32] with the senior citizens. Qualitative surveys [33] such as Focus Group Discussions [34], informal interviews (Robert Woods Johnson Foundation, 2019) [35], capturing the anecdotal comments given by senior citizens, observational research [36] such as monitoring people wearing masks, maintaining social distancing, using soaps and sanitizers may also aid the measurements. Keeping track of records and databases (such as the number of visits to the COVID helpline website, toll-free numbers dialed, comments on social media promoting vaccination, number of visits to health centers, etc.) are also suggested. If needed, using technical surveys and control group experiments may better help the evaluation process.

When will it be measured?

Before the campaign, during the campaign, and post-campaign are the three options to do this.

How much will the cost be?

The recommended cost for monitoring and evaluation may vary from simple costs (checking records and database and anecdotal comments) to moderate costs (surveys and observational research) to significant costs (scientific or technical surveys). The decision to fund these activities can be judged on their value to the social marketing plan. It will be a wise investment if such activity helps get support and funding for the social marketing program. Further, if such activities help refine the social marketing effort in the future, payback is more specific in terms of ROI.

1.8. Stage 8: Establishing Budgets and Raising Funds

The strategies and activities identified in earlier stages should now be allocated with price tags. Once the number is totaled, the social marketer may evaluate these probable costs by linking it to the anticipated benefits from the targeted behavioral change level, comparing it with current funding, and identifying additional resources if needed.

Commercial and non-profit marketing suggests three strategies for raising a budget: affordable, competitive parity, and objective and task methods [37]. For the proposed campaign, the most logical approach might be the objective and task method. In this scenario, the marketer may identify the cost related to the marketing mix and the evaluation and monitoring efforts.

Product-related costs may be directed in developing or enhancing associated services needed to support the behavior change. These may include the direct cost of giving services and indirect costs such as social marketers’ time. Product-related costs related to vaccine hesitancy may involve the need to lease vehicles to transport senior adults to vaccination camps, counseling costs, opportunity costs, administrative costs, etc. Price-related costs may include incentives, recognitions, and rewards for senior citizens in performing the desired behavior; these costs may also have the losses associated with performing the services. Price-related costs for vaccine hesitancy may include incentives for vaccination, reduced rate for immunity booster drugs if vaccinated, free bus passes, free monthly health checkups, government-certified vaccination badges to “feel good,” and spread the word to other senior citizens etc. Place-related costs may include providing enhanced access to new/improved locations (such as separate waiting rooms and a separate queue for senior citizens) at vaccination camps, extended hours for vaccination, separate window for online vaccination registrations, etc. Promotion-related cost is related to developing, producing, and disseminating communications related to vaccinations. These costs may include developing posters, brochures, fact sheets, banners, performing street plays, dances, mass media promotions, etc. Evaluation-related costs may consist of expenses incurred in follow-up surveys and related costs. The social marketer may source additional funds to start the campaign from crowdfunding, requesting government grants, seek the help of other NGOs, advertisement and media partners, coalition and other partners, corporations, etc.

1.9. Stage 9: Implementation Plan

The implementation plan is the final stage in the social marketing plan; it should reflect all prior decisions and is a significant step in the social marketing planning process. This stage serves as a working document to track all planned efforts. The social marketing team must ensure that they do what they want to do within time and budget. Marketing implementation must ensure that the marketing strategies and plans are transferred into marketing actions to accomplish strategic marketing objectives [38]; thus, a comprehensive implementation plan may include clear strategies on what will be done, who will be responsible, what will be done, and associated costs related to vaccine hesitancy campaigns.

2. Conclusions

A social marketing plan to decrease vaccine hesitancy may be considered as a systematic and strategic planning process. A proper environmental analysis, judiciously planning strategies for segmenting, targeting, positioning, and 4Ps, understanding barriers, benefits, competing behaviors, a formal evaluation and monitoring strategies, anticipating budgets, and raising funds will help implement a robust social marketing plan against vaccine hesitancy. The benefits of such a marketing campaign are multi-fold. Well-run campaigns may boost vaccination coverage and reduced disease morbidity and death; such campaigns may increase the public’s confidence, reduce stress and allow family and friends to connect with the community. The limitations of such a campaign are the outreach (India being a highly populated country) and the myths associated with vaccines. Assessment of new vaccination efficacy, safety, storage, and dispensing, technical requirements, acceptance, publicity, and maintaining the records are among the other issues; however, the comprehensive plan developed in this paper may be used as a framework to help the policymakers, social marketers, and NGO’s in devising a behavior change not just for senior citizens but also for other age groups. The proposed plan may also be used to guide any vaccination campaigns, not just COVID-19. Such plans, if properly executed, may benefit the community and stakeholders at the largest.