How can behavioural insights boost malaria vaccine uptake?

Behavioural science has extraordinary potential to supercharge malaria vaccine rollouts currently underway across Sub-Saharan Africa. 

Almost 20 countries across the African continent are embarking on one of the most significant public health initiatives of our time – implementing the rollout of the malaria vaccine. With vaccines such as RTS, S and R21 now in play, we have a powerful new tool in the fight against a disease that still claims over 600,000 lives each year. 

It is an essential addition to the existing prevention toolkit, which includes indoor residual spraying, chemoprevention, preventive treatment, and insecticide-treated nets – the latter having already contributed to a nearly 70% decline in malaria cases in Sub-Saharan Africa. 

Despite its effectiveness, recent international aid budget cuts put sustainable funding for the malaria vaccine at risk. The solution could be closer than we think: redirecting the equivalent of just one year of U.S. Halloween spending—about $3.5 billion—could fully vaccinate every child under three in the highest-risk countries over the next five years, preventing roughly 500,000 deaths. 

But with limited resources, every dose must count, so we must ask: will people get the jabs? 

In the rush to secure supply chains and train frontline health workers, there’s a risk we overlook the other side of the equation: demand. And without it, scarce vials could go unused, and the opportunity to save lives could slip through our fingers.

At BIT, we believe this is where behavioural science can play a crucial role. Our work in global health tells us that even modest, well-designed behavioural changes can unlock big gains in vaccine uptake. 

The barriers to malaria vaccine uptake

As life-changing as the malaria vaccine could be for the region, it presents a unique set of intriguing behavioural challenges, including:

• Mistrust in new vaccines: Unfamiliarity or misinformation can create hesitation. Building knowledge and trust with health workers and community advocates, beyond the routine (and more familiar) vaccinations, is essential. Early evidence from Burundi and Kenya shows that while misinformation is currently low, it could easily become an essential factor in vaccine uptake. 

• Incomplete protection: The Mosquirix (RTS,S) vaccine reduces malaria cases by about 40%, and the newer R21/Matrix‑M vaccine reduces them by about 70–75%. This is a big improvement, but because the vaccines aren’t perfect, some children will still get sick, which could affect caregiver trust.

• Reduced use of other prevention methods: The effectiveness of this vaccine depends on its integration with, and continued use of, staple malaria prevention methods, such as bed nets, chemoprevention, testing, and treatment. Caregivers of vaccinated children may assume they are sufficiently protected and use these methods less often. 

• High drop-out rates: RTS, S and R21 require four doses over 12 months. Routine programmes already lose about 8–18% of children between the first DTP shot and later doses globally, and malaria-vaccine recipients see a fourth-dose fall to 54–72 % of third-dose coverage.

Using behavioural insights to supercharge malaria vaccine effectiveness 

We have a unique opportunity to pre-emptively address these barriers. Behavioural interventions have been shown time and time again to increase vaccine uptake. 

In an evidence review we undertook for the Wellcome Trust, we identified several high-potential, low-cost interventions, including: optimising vaccination schedules, redesigning immunisation cards, using visual aids, providing planning prompts, offering incentives, sending timely reminders and engaging social networks.

Over the years, BIT has led nearly 30 vaccination projects across the globe, partnering with governments, NGOs and international agencies to identify and overcome the behavioural barriers that limit vaccine uptake. Our work consistently shows how behavioural science can unlock practical solutions that drive results.

In the UK, we worked with NHS England and Public Health England to trial a small tweak to a standard Covid-19 vaccine reminder text. Simply telling people they had “reached the top of the queue” led to an estimated 42,000 additional vaccinations across the country. It’s one of the largest individual-level randomised trials ever run in behavioural science, and a striking example of how thoughtful communication can shift behaviour at scale.

In Georgia, we partnered with the Ministry of Health and UNICEF to improve uptake of the HPV vaccine, which protects against cervical cancer. Our behavioural interventions, which were tailored to local attitudes and delivery systems, doubled vaccination rates among adolescent girls, strengthening long-term protection for thousands of young people.

In Argentina, we collaborated with the government’s Behavioural Science Unit and the Ministry of Health in Chaco Province to address a drop in Covid-19 booster uptake. We designed a WhatsApp-based chatbot that helped people book appointments and overcome barriers to follow through, resulting in a threefold increase in booster uptake.

These examples show what’s possible when behavioural insights are embedded into vaccine delivery. Investing in malaria vaccines is a vital step forward, but without strategies to ensure high uptake, their full potential won’t be realised. Now is the time to apply what we know to ensure these vaccines protect as many lives as possible.

If you are a public health official, implementer, or funder interested in learning more about our approach and current proposals, please don’t hesitate to reach out.