Vaccination, effective self-isolation, and adequate socioeconomic support are key public health measures that are proven to reduce the impact of COVID-19. Vaccination is safe,1 and scientifically shown to reduce death, hospitalisation, and severe health issues arising from COVID-19. Vaccination is currently available to everyone in Australia aged over 16; from 13 September 2021, it will be extended to 12 to 15 year olds. I’m very lucky, and thankful, to be fully vaccinated. Vaccination itself was quick, easy, and painless. Health staff delivered excellent service. In particular, the clinicians who carried out the vaccine were compassionate, warm, patient, and good humoured. I urge everyone who is medically able to get vaccinated as soon as possible.
Vaccination efforts have been radically advanced in the state of New South Wales (NSW), due to the current Delta outbreak. As of today, 4 September 2021, vaccination doses have already reached 7.3 million in NSW alone.2 Mass vaccination sites are producing extraordinary results given current constraints, including a strict lockdown in Southwestern Sydney.3
Nevertheless, there is a pressing need to rapidly increase vaccination. To date,4 62.1% of people over 16 years have received one vaccine dose in Australia, and only 37.8% are fully vaccinated. Health inequities undermine vaccine efforts. I’ve previously detailed that policing patterns are unfairly targeting racial minorities in working class suburbs, illustrating how race and class impact the management of vaccination.5 As I show below, there has been a lack of vaccine supply and outreach to priority groups at high-risk of COVID-19, including Aboriginal and Torres Strait Islander communities, people living in aged care and disability group homes, and rural and remote regions.
Many countries are struggling to entice people to return for their second vaccination. For example, in early April 2021, five million Americans6 had not gotten their second dose. By early August Britain is lagging behind France on second doses.7
Systemic support could improve vaccination, especially through federal funding to support people who are unemployed or precariously employed, so they are not forced to keep struggling until they are fully vaccinated. Alongside institutional responses, small physical and behavioural tweaks could improve the public experience at mass vaccination sites.
Today, I present a visual ethnography of my experience at a mass vaccination site in Sydney, which took place from late-July to mid-August 2021. Ethnography is the study of people’s behaviour and organisations in their everyday setting. My analysis draws on two ethnographic methods: participant observation and visual sociology.
Participant observation involves watching people, objects, a physical environment, and texts in their natural setting (that is, outside of a lab).8(pp109-120) Researchers can assume various roles to carry out this analysis, from a complete participant who joins in, and records, all activities, to complete observer (someone who watches, but does not join).9 Since I reflect on my own vaccination here, I am closer to the complete participant end of the spectrum. I documented my impressions of the environment, and the procedures used to organise the public through their vaccination.
I also used visual sociology; a methodology for collecting visual data to analyse social phenomena.10 In this case, I took photos and short videos of my experience in line while I waited to be vaccinated, but I did not directly film other people or staff. I did not record audio, personal data, or any other material that would be identifying.
The aim of this visual ethnography is to provide behavioural insights on how the mass vaccination process might be improved. Behavioural insights is the application of social and behavioural sciences to improve delivery of policy, programs, and services. I discuss some of the behavioural barriers in the mass vaccination process, especially things that could potentially contribute to people delaying coming back for their second dose. I also discuss how improved behavioural cues and messages could enhance the vaccination experience.
Summary of findings
- Wait times for bookings at the Sydney mass vaccination site are up to two months for non-priority groups
- Despite holding pre-scheduled appointments, on the day, the public lines up outdoors for up to two-hours. This makes for a physically uncomfortable and de-motivating experience
- Behavioural barriers during the mass vaccination experience may impact people’s willingness to return for their second dose in a timely way. For example:
- the line-up system is confusing
- it’s hard to hear staff directions
- inadequate accessibility
- lack of social distancing outdoors
- few signs and instructions
- lacking cultural safety for Aboriginal and Torres Strait Islander people
- poorly promoted multilingual services for migrants
- insufficient communication about extended wait times mean people may not be properly prepared to stand in line for so long
- Behavioural science evidence could be used to improve the customer service experience, by:
- improving physical cues, to encourage COVID-19 safe behaviours, and
- using behavioural messages to motivate customers to return for their second vaccination dose on time.
The rollout and management of the vaccination program in Australia has been lacking. With the aim to vaccinate four million Australians by April 2021, the federal Government quickly fell behind schedule.11 Poor leadership,12 ongoing mismanagement of vaccine supply13 and lack of access for Aboriginal people,14 people living in aged care homes,15 and disabled people in group homes16 has contributed to vaccine hesitancy.
This has forced states and territories to take over vaccination in rapid timeframes.
On 21 August 2021,17 New South Wales (NSW) exceeded the highest number of COVID-19 within a 24-hour period, for any Australian state or territory (with 825 cases). Numbers continued to climb. Five days later,18 we exceeded 1,000 daily cases; a trend which has continued daily. Today, on the 04 September, we reached 1,533 daily cases,2 with increasing number of deaths. The number of people being hospitalised due to COVID-19 is up to 15%, with the intensive care capacity at 80% capacity in NSW.19 In this context of alarmingly high Delta variant cases, getting COVID-19 cases down, and vaccination up, is paramount to slowing the spread of infection.
As of today,20 72% of people over 16 years in New South Wales have received one vaccine dose, and 39% are fully vaccinated. However, vaccine availability and access vary.
Vaccination is especially needed in rural and remote regions in NSW, particularly in Western Sydney, which is currently battling a concerning rise in COVID-19 cases. For example, Wilcannia is in crisis21 due to government failure. The small town, which has a population that is 69% Aboriginal, is battling 97 COVID-19 cases (13% of the town is infected to date),22 a lack of food and medical services, and inadequate access to vaccination.23 While two-thirds of the town has now received its first vaccine dose, this only happened in the past two weeks, after cases made national headlines.
Aboriginal communities were identified as a priority vaccination group by the federal Government in February 2021, but less than 20% are vaccinated across the country. In nine local health districts in NSW,24 the vaccination rate of Aboriginal and Torres Strait Islander people is at least half that of non-Indigenous people.
Multicultural suburbs across Southwestern Sydney and Western Sydney are experiencing especially tough conditions,25 with harsh curfews, stricter restrictions, and the additional expectation that these locals should get vaccinated as soon as possible. As these suburbs comprise up to 80% of authorised workers (people who cannot work from home),26 they represent the biggest groups who are mandated to be vaccinated by their industry (including aged care, health, construction, and education).27
Health professionals are doing an exemplary job of delivering vital care and services under such challenging circumstances. What follows is not a comment on healthcare workers, or the healthcare system, but rather an analysis of how behavioural science could enhance mass vaccination, given the current constraints.
The focus of my discussion is solely on the physical environment and behavioural messages at the mass vaccination site.
This analysis does not typify all vaccine contexts, and it captures sociological and behavioural observations at one site at a particular point in time. I do not deal with the lack of vaccine doses, and confusion about eligibility, or other issues, such as vaccine hesitancy. For my research methods and ethics, see the end of this post. For broader issues on vaccination, see my other research;28 and for structural dynamics and inequality of COVID-19, please see my recent writing.5,29,30
The steps to vaccination
1. Pre-registering and booking
I pre-registered my interest to be vaccinated as soon as this was possible in New South Wales, in early June 2021. At this time, only one vaccine type was available to my age group.
As I am not in a priority group, the earliest booking I could make meant waiting two months.
Thankfully, now, in Sydney, anyone over 18 years31 can now receive AstraZeneca (AKA Vaxzervria) from pharmacists, their medical practitioner and walk-in clinics without any wait time.32 It’s safe for almost everyone, including people who are breastfeeding,33 and pregnant.34 Pfizer will now be available to all Australians over the age of 16 years.35 Soon, vaccination will open up to 12 to 15 year olds.36,37 Either way, people should not wait; everyone should take whichever vaccine is available as soon as possible.38
The booking form takes five minutes. The questions ask about pre-existing health conditions, disability, pregnancy and allergies. You can put in your Medicare details, but it’s not required. Vaccines are free for everyone in Australia, including undocumented people. You are shown vaccine availability dates and times; the system does not allow you to book the second dose any sooner than three weeks after the first dose.
Textbox 1: Tips for your vaccination
- Make your booking with other household members, if possible, to make the experience easier. You can add household members on the same booking, to ensure you go together
- If possible, book in early in the morning, as it is even busier from 4pm onward
- At time of booking, tick the box for disability assistance, if you have injuries or have trouble standing for long periods
- Plan for a two-hour visit. Bring jackets, snacks, and water
- Download your vaccination certificate from the MyGov/ Medicare website or app. If you are undocumented or don’t have a Medicare card, ask the staff to print your certificate on the day
2. Getting vaccinated
I was vaccinated at a mass vaccination site in Greater Sydney, in a metropolitan location. My first dose was in late July 2021, and my second dose in mid-August 2021.
I received a reminder SMS the day before each of my appointments. The content was perfunctory (time, date, and link to a PDF with extra information – see below).
This text misses an opportunity to use behavioural messaging to increase commitment to show up for the appointment, especially the second dose. For example, the SMS reminders could say:
Dose 1: Thank you for booking. You’re helping to get our lives back on track
Dose 2: A vaccine has been reserved for you.
(For discussion, see the textbox below)
For my first appointment, I arrived 25 minutes early, at 4.20pm. I was vaccinated at 6.47pm, andI left after 7.00pm. It had been quicker for me to walk to the vaccination site, rather than take multiple buses and trains. However, not knowing I would be standing for two hours, this aggravated my knee injury and led me to seek physiotherapy. My physiotherapist noted I was the fourth person they’d treated because of long wait times at mass vaccination sites. I tried to call the mass vaccination site ahead of my second appointment to see what help was available, but after a 30-minute wait, I gave up. The link to my booking and the information link sent in my reminder text had no other way for me to contact the site other than via phone.
For my second appointment, I arrived on time, at 9.30am. I was vaccinated at 10.15am and I left at 10.35am. Following the advice of my physiotherapist, I spoke to clinic staff about my injury, and I had a note from my physio stating that I should not stand for longer than 15 minutes at a time. There was a little confusion, but I was then given a coloured sticker and I was able to go straight in. There was still some lining up once indoors (around 15 minutes, plus a 30-minute wait while seated). Once inside, but before entering the building, a nurse asked me questions about my injury, pain and whether I was on medication. I was told that due to my injury, I could have gone straight in through another entrance, but there was no way for me to know, as no staff I asked outside mentioned this.
Both times, the lines went around the block both ways. Throughout the hours I was there, there were at least two to three hundred people at any given time, but it seemed slightly less crowded in the morning.
Inside the building, check in kiosks were swift and efficient, printing out a QR code and customer vaccination number.
You’re directed into different seated waiting areas (e.g. general public, and people with special requirements). Both times, I waited 30 minutes while seated. Monitors show people’s QR code number when their vaccine is ready. You get a text message when it’s your turn to be vaccinated.
The vaccination took less than two minutes each time, including reviewing the health questionnaire I filled in at time of booking. Each person was seated with a nurse at a desk. The nurse checks that the information and your contact details are up to date. The needle is painless, and it takes two seconds to receive the vaccine. You’re given a sticker with the time of your vaccination, so staff can let you know when it’s safe to leave (15 minutes later). The staff were kind, engaged and provided an opportunity to ask questions.
After you receive each dose, you’re taken to an observation area that was well-staffed. You wait for 15 minutes, in case you have an adverse reaction. Staff responded quickly and with compassion when a customer said they felt unwell (e.g. faint). When your time is up, staff ask if you feel okay, and if you do, you hand in your stickers and leave.
There are monitors in the observation section. This visual real estate could be used effectively to leverage reciprocity and pro-social messaging (see Textbox 2).
During my first visit, I received two flyers in the observation area. There was too much text (information overload), and no call to action to motivate people to come back for their second dose. Behavioural insights best practice shows that people are more likely to change their behaviour, or comply with a message, if they understand in plain language exactly what they must do and when.39
On my second visit, we received no health literature.
The flyer (and lack thereof) are missed opportunities to use behavioural messages, and boost commitment to return, as well as promote vaccination to friends and family.
For both doses, there were no verbal instructions about maintaining COVID-19 safe behaviours post-vaccination. The flyer includes a list of ways to ‘stay COVID safe;’ however, it doesn’t explain why it matters. It takes two-to-three weeks after the second dose for the vaccine to be fully effective. In a forthcoming study, we found that simple and salient instructions, repeated visually and verbally, increases compliance with COVID-safe behaviours. Given the NSW Public Health Order currently restricts travel and mandates mask-use, it may seem okay not to explain how the vaccine works. However, behavioural research suggests risk compensation could lead to people becoming lax in observing social distancing and other rules.40 This is especially a problem in between the first and second dose, where protection from the vaccine is lower.
To improve outcomes, behavioural message could say:
Thank you for getting vaccinated. It takes three weeks for the vaccine to be fully effective. Keep following COVID-safe rules, or you could still get sick:
1. Wear a mask every time you leave home
2. Get tested as soon as you have symptoms. Self-isolate until you get a negative result
3. Use QR codes to check-in at venues
4. Wash your hands regularly
Textbox 2: Using behavioural messages
Reciprocity and pro-social messaging are context-specific and vary across culture and religion. What works for one health issue may not apply in other settings; this is why we must test behavioural messages with specific communities.
Behavioural studies on reciprocity show we are more likely to comply with public health if we’re reminded of how others have helped us.41 For example, in the USA, people are more likely to register as organ donors when they’re told they might need an organ transplant.42
A behavioural study of over 47,300 people in the USA (70% white) shows that a SMS saying a vaccination “is waiting for you” led to increased flu shots.43 The message is more effective than telling people the vaccine helps protect family members. It works because it invokes loss aversion (people prefer to keep what they own), as well as a sense of reciprocity: “the provider has gone to the trouble of setting aside the vaccine dose, and it would be rude not to take it.”44 This might be effective with COVID-19 vaccination reminders, especially for white people.
As racial minorities have stronger collectivist values, it is possible that reciprocity messages might be more appropriate when coupled with social norms and personalisation about their local communities E.g. “At least 60% of your neighbours in Parramatta are vaccinated. They’re helping to keep your community safe. Join them by booking your vaccine via this link.”
Pro-social messaging is when we take personal action to benefit others, over our own self-interest.45 In an Israeli study, people were significantly likely to support pro-social measures to prevent COVID-19 (e.g. filling a pre-commitment to self-isolate), and were less supportive of self-interest measures (e.g. reminders about washing hands, or an alert when approaching a person who is COVID-19 positive).46 Minorities (Arab people who are predominantly Muslim, and Ultra-Orthodox-Jewish people) were less likely to support pro-social messages that weren’t about COVID-19; from seemingly innocuous issues (setting double-sided printing as the default) to other health issues (being asked to register for organ donation when getting a driver’s licence).
A large study in Sydney provided a “rule-of-thumb” behavioural message in COVID-19 negative result SMS (“come back as soon as you have symptoms again”). This significantly increased people’s willingness to get retested.47 However, a pro-social message was less effective (“you have helped prevent deaths in New South Wales”).
Yet in an USA study of 20,000 people, four pro-social behavioural messages increased willingness to get vaccinated.48 Messages were tested in English and Spanish. Messaging about helping loved ones was especially effective among hesitant groups (“Your loved ones need you. Get the COVID-19 vaccine to make sure you can be there for them”). The other pro-social messages included “let’s get our lives back again,” “the vaccine was tested with 70,000 people,” and a trusted messenger (“approved by healthcare workers”). Similar pro-social messages could be used, so that people who are vaccinated at the mass vaccination site feel good about doing good for their loved ones and community, as well as the service they received, and spread positive word of mouth.
I did not have painful side effects, other than a mildly sore arm after the first dose, and a little redness and itching after the second dose. Both times, these symptoms were gone after a couple of days.
Side effects are normal.49 Most people who experience side effects only have mild symptoms. Over 99% of people who get a COVID-19 vaccine do not experience any major side effects. Only rarely (1% of cases), will people who are at-risk of developing a rare blood clot (thrombocytopenia syndrome, or TTS) will be affected if they take AstraZeneca. Everyone else, including others at-risk of blood clots, are safe to receive AstraZeneca and should not delay vaccination.50 All other major vaccines available in Australia do not carry this risk which affects a minority of people.
I received two post-vaccination surveys. The first was about immediate side effects after the vaccination. The second was about lingering side effects a week after the second dose. Both surveys were exclusively focused on physical reactions. There were no questions about mental health, COVID-19 safe behaviours (e.g. did you maintain self-isolation?), and the customer service experience.
My vaccination certificate was not available two weeks after my second dose. I followed the instructions on the flyer I had previously received and logged onto the MyGov website. This showed my general immunisation record, with my second vaccination dose only, but not a separate COVID-19 certificate. I downloaded the Medicare app, as the flyer alternatively suggested. This was a bureaucratic pain, as I would otherwise prefer not to use this app. Still, it did not have the certificate. I contacted Services Australia publicly on Twitter, and the next day received an email saying my certificate was ready.
This process should be easier. Individuals should receive an automated alert when the certificate is ready. The delay did not impact me, but timely delivery is especially important for workers who have a requirement to be vaccinated. Soon, it will be necessary for the broader public, given that NSW is exploring options to provide additional freedoms to people who are fully vaccinated, once the state reaches the 70% and 80% double dose targets.
The following physical barriers led to a protracted waiting process and may impact people’s prompt return for their second dose.
Reduce friction costs for families
Friction costs—the direct and indirect hurdles to healthcare and other assistance—put off some people from accessing services. The booking reminder email says you shouldn’t bring children.51 This is a barrier to people with primary care responsibilities (especially single parents), Aboriginal and Torres Strait Islander people, and migrants. This is even tougher when people are being actively encouraged not to use childcare services (100 centres are closed in NSW alone),52 and the Public Health Order rules prevent having family members from outside the household babysit.
On the days I was vaccinated, a couple of people brought kids or elderly family members and they were forced to wait across the road or in cars. There was nowhere for them to sit.
Reducing the hassle for parents and other carers would increase vaccination take-up.
Simplifying the lining up system
There were no signs on where to line up. There is no way to understand how lines correspond to appointment times. There was only a small sign at the entrance, which is hard to see from around the corner. Coordination of lines is confusing – lines go both ways around the park.
Making the lines easier to follow with better signs and physical cues would reduce this otherwise disorienting experience.
Signs to boost COVID-19 compliance
Adverse choice architecture opens potential for transmission.Choice architecture describes how the organisation of information, including a physical environment, impacts our decisions.53 Because there are no physical cues, people line up as they would normally, without applying the 1.5 metre social distancing rule. Due to poor signs, new arrivals must ask other people in line what to do. Because we’re in masks, everyone leans into one another to hear. Even with masks, this creates potential for the spread of infection, as we cannot maintain social distancing (customers may be infectious even if they are asymptomatic and unaware they’re sick).
Signs and other environmental cues would help social distancing compliance.
Remove ambiguity for AstraZeneca patients
Occasionally, staff will call for people who have “AZ” at the end of their booking confirmation. It’s not clear that this is for AstraZeneca, and why this is being done, and so people were confused. Staff rarely stopped to explain. It’s hard to hear these calls.
Make it clear before arrival that AstraZeneca patients are prioritised in line.
Eliminate vaccination inequity
At the time of booking, patients can tick if they have accessibility requirements. However, some people may not feel comfortable, especially if they are used to be being denied opportunities. Disabled people can enter through another door, but you may not know if you didn’t pre-book. People who are hard of hearing would be unable to hear staff shouting directions outside, especially from long distances. Deaf people who use hearing aids cannot hear shouting, no matter how loud someone thinks their voice is; they require hearing loops.
The inside waiting area has large screens showing which customer numbers are ready to be vaccinated; however, the numbers are tiny and vision impaired people would find this difficult to read. People with mobile phones receive a SMS but some older people may not be checking their phones.
Accessibility should be built into every step of the customer journey.
Provide culturally safe services
Aboriginal people experience racism in healthcare. Lack of access to vaccination is in itself a sign of institutional racism. It is unsurprising that First Nations people currently have low vaccination rates. At the mass vaccination site, there was an Acknowledgement of Country sign at the entrance, and an Acknowledgement of Country occasionally flashed on screen inside. These signs are the bare minimum given we are on First Nations’ land, and do not go far enough to create a welcoming environment.
Provide a culturally safe service for Aboriginal and Torres Strait Islander people.
Provide multilingual services
At the time of booking, you can tick a box if you need a translator, but it’s easy to miss. On the day, staff have stickers they can give customers who ask for interpreters, but there’s no way to know this unless you find a staff member to ask. Generally, people with low English proficiency are reticent to ask for help unless they see someone who they think speaks their language.
I saw a man speaking Mandarin ask several staff for assistance and various staff asked one another if they knew anyone who could help. They were evidently eager to help, but there was no easy process to request a translator on the ground.
Before entering the mass vaccination building, a multilingual sign at the entrance says “Welcome” in many languages. There are no other multilingual signs, even though the mass vaccination site and surrounding suburbs are 78% overseas-born, predominantly from non-English speaking countries.
Many migrants have lost family members to COVID-19. Many of us are cut off from family and friends due to lockdown in a way that impacts us differently than other Australians (e.g. due to cultural and religious obligations). Getting vaccinated is an emotional rollercoaster as a result. The need to have culturally and linguistically relevant services is paramount.
Increasing multilingual services on the ground would help migrants feel welcome.
Reduce negativity bias
Negativity bias measures how, in Western cultures, negative memories often outweigh positive ones.54 The mass vaccination site is currently vaccinating over 10,000 people daily. They are under-staffed. Staff work long hours and are on their feet all day. Understandably the few staff on site stand together near the entrances and exits. While some staff float around, and occasionally yell instructions, they cannot cover the full length of the massive lines. As a result, new arrivals invariably walking to the entrance, only to be told to line up elsewhere. A poor customer experience may disincentivise the public from coming back promptly for their second dose.
Creating a better customer service experience outdoors will ensure people aren’t put off from returning.
The notion of time is culturally mediated; societies value time differently, and this has material consequences for some workers over others.55 The “choice” to be vaccinated is not as simple as making vaccines available. Research shows that when people in Western cultures weigh up two options, they will prefer to reap immediate rewards.56 They will delay investing in costs today, even if it means foregoing a bigger benefit in the future. A long wait time now still means being fully protected sooner. This is especially pertinent with Delta cases rising daily. After all, it takes two-to-three weeks from the second dose for the vaccine to be effective. The longer you put off getting vaccinated, the greater the risk of contracting COVID-19.
Yet with a two-hour wait time in line, it’s understandable that people would delay the second dose, because you must set aside so much time to get vaccinated, even with an appointment. Some people may delay vaccination, in order to wait for crowds to thin out, and get speedier service when there is less demand. Others might be afraid to lose so much time off from work: four hours to a casual or precariously employed worker can impact whether or not you can pay your rent. While the NSW Government gives public servants and council workers paid time to be vaccinated,57 other workers are not currently eligible, not even disability residential care workers who work with a priority group at-higher-risk of COVID-19 (noting they are federal Government employees).58 Even though there are appointments in evenings and weekends, waiting hours in line (especially for workers who are on their feet all day) is not an enticing experience.
Speeding up the wait times and making the experience more pleasant would ensure people don’t put off their second dose.
Promote effective planning
Anchoring is a cognitive bias, where people are heavily influenced by the first piece of information they receive, impacting our future decisions.59 By anchoring patients to an appointment time, there’s inadequate planning. Many people arrive early and end up standing for hours. There’s nowhere to sit. I was vaccinated in Autumn; it gets pitch black at 5.30pm. It was very cold and uncomfortable outdoors. The people in front of me left at the one-hour mark. Having arrived in the afternoon, and not realising the wait would be so long, I missed dinner. There was nowhere to purchase food nearby (plus I would have lost my spot on the line).
Anchoring could be better managed by telling people what to expect before they arrive, and giving people updated wait times on arrival.
Easy instructions with timely reminders
- Make it easier to get there. Increase trains and buses. Introduce shuttle buses from community centres. Reduce traffic congestion with better directions for people arriving by car.
- Help people plan. Vaccine hesitancy partly stems from people not knowing what to expect on the day. Make clear in the booking reminder email/ SMS that AstraZeneca bookings go in a different line and provide a clear map of the entrances, to show them where to go. Telling the public about the excellent customer service they can expect before they arrive would be highly motivating. (“Speak to our staff if you have questions on the day.”)
- Manage expectations. Tell people to come on time, and that early arrivals will only be seen at their allocated time. Give people indication that wait times can be up to two hours. Tell people to dress accordingly, and to bring water and snacks.
Improve the customer experience outside
- Boost customer service. Roster more staff and spread them out along the line to provide clear instructions and answer customer questions.
- Improve accessibility. Introduce hearing loops and provide microphones for staff giving instructions.
- Employ Aboriginal and Torres Strait Islander liaison officers. E.g. with a badge saying their role.
- Employing more Aboriginal and Torres Strait Islander health practitioners and staff, and following cultural safety protocols, could make customer experience more welcoming to Aboriginal and Torres Strait Islander people.60
- There could be specific days that are dedicated to First Nations people’s vaccination, just as there has been to essential workers, construction workers, and Year 12 students from the 12 multicultural “suburbs of concern.” Organise community buses to pick up families. Collaborate and fund Aboriginal community-controlled health organisations (ACCHOs) to promote to communities.
- Employ staff from multilingual backgrounds. E.g. badges saying they speak a specific language. More multilingual signs and bilingual staff could make the vaccination process easier.
- Enhance comfort and safety.
- Provide seated waiting area for vulnerable community members. E.g. Staff to be on the lookout for older people, disabled people, and pregnant people.
- Use social distancing markers on the ground. There are stickers inside, but not for the long queues outdoors
- Lights along the street from 5.30pm. Set up portable street heaters for night-time
- Make it social. At least half of customers came alone. Promoting sign up of households would help to alleviate the prolonged line up experience
- Place reciprocity messages outdoors, to keep customers in good spirits, and stay motivated to wait in line. Include messages in different languages. E.g. “Thank you for getting vaccinated. You’re helping to protect your loved ones and your community.”
- Visible instructions for lines around both directions. E.g. arrows and signs “4.30pm follow this sign.” Use different colour signs and stickers for different times.
- Directions for AstraZeneca appointments. Use coloured signs/ stickers so these customers can speed ahead. Separate line/ entrance for AZ customers to speed up process.
- Automate wait time indications. E.g. On arrival, tell people what they’re in for, such as “Your wait time is 1 hour.” Moving check-in to outdoors while in line would facilitate this.
- Provide outdoor check in to speed up lines, give people a clear indication of how long the wait time is, and allow people to seek shelter instead of standing in line for hours.
- Once checked in, send customers a SMS telling them their wait time, and when to start lining up (so customers can find a place to sit while waiting).
Maximise commitment once inside
- Improve accessibility. Introduce hearing loops inside, and audibly announce customer vaccination numbers. Show customer vaccination numbers larger on screen.
- Provide a simplified flyer to urge people to return for their second dose.
- Reinforce importance of second dose in observation area. Monitors can include behavioural messages using reciprocity and pro-social messaging to motivate people to return for second dose.
The table below summarises the behavioural barriers and solutions.
|Not family friendly||Reduce the hassle for parents and carers. Encourage household sign-ups|
|Lack of cues for long lines||Simplify the lining up system with salient colours and better signs|
|Insufficient signs, so the public leans in to talk||Better signs to enforce social distancing. Stickers outdoors to show 1.5 metre rule. Use reciprocity messages outdoors|
|Unclear process for AstraZeneca bookings||Ensure booking reminder shows AZ is prioritised in line and where to line up|
|Staff yell instructions, but it’s hard to hear. There are no hearing loops||Build in accessibility. E.g. hearing loops, microphones for staff|
|Not especially welcoming to Aboriginal and Torres Strait Islander people||Provide culturally safe services. Employ more Aboriginal and Torres Strait Islander staff. Collaborate with, and pay, Aboriginal community controlled health services to co-host community vaccination days|
|Not especially welcoming to migrants||Increase multilingual services and signs. Employ more bilingual staff|
|Under-staffed||Improve customer experience. Hire more staff, spread them out along the line outdoors. Enhance comfort and safety with seated waiting areas, better lighting, and heating. Encourage people to book in at same time as household members|
|Long wait times||Enhance timeliness of service. Check in outdoors. Give people wait time indication over SMS|
|Poor planning advice||Promote effective planning by telling customers what to expect. Make it easy to get to vaccination site via increased public transport. Manage wait time expectations|
|Ineffective use of SMS reminders, flyers and monitors||Provide a simplified flyer with behavioural messages. Reinforce importance of coming for second dose via reminder SMS and monitors in waiting area|
|No behavioural questions in post-vaccination survey||Include follow-up survey about mental health, COVID-safe behaviours such as social distancing, and customer service experience at the mass vax site|
|Delayed vaccination certificate||Automate delivery of certificate|
Infographic: COVID-19 mass vaccination behavioural process
I attended my vaccination as an ordinary citizen, not as a researcher intending to carry out analysis. However, upon arrival, the layout and coordination of the vaccination site soon piked my sociological imagination. I have been conducting visual sociology since 2009, including on this blog and on my social media. I often take notes, photographs, and videos of my everyday life. Like most sociologists, I walk through the world as a sociologist, meaning that I do not ever switch off from critical reflection. Even as I documented my experience, I did not originally expect to publish this analysis. I was motivated to write this post after my second vaccination, seeing that the process had not improved.
I am trained as a qualitative researcher. My professional expertise is in improving outcomes on social policy issues. In recent years, I have worked on public health (including COVID-19), education, equity, and justice, with a focus on disadvantaged groups. I am generally interested in making services more accessible for the public, particularly marginalised people.
My analysis of the mass vaccination centre was opportunistic. Once I arrived at the vaccination site, I quickly assessed that the process could be enhanced with behavioural insights.
I took observational notes on my mobile phone, noting:
- the physical surroundings, such as posters and signs, and physical cues (such as social distancing stickers)
- the times when we were moved from one area to another
- length of waiting periods
- behavioural barriers (e.g. examples where it was difficult to follow instructions, or where coordination led to adverse behaviours, such as when strangers were forced to ask for help because there were no other signs)
- behavioural enablers (e.g. examples of good practice, such as stickers for people needing translators)
- ideas of how the environment and process could be improved
I did not take notes or collect other data about specific staff or the public, nor did I record or analyse conversations of staff or others around me. I did not collect data, or otherwise evaluate, the job performance of staff. I did not collect, nor did I have access to, any medical records other than my own.
I also took photographs and short videos of the environment, and my reflections on my progress through the line. I only captured images of objects in my path, but did not record notes, visuals, voice or other data about other people. I followed staff directions and did not go out of my way to photograph or film other people, rooms, or events outside of my immediate view, nor did I walk into unauthorised areas.
Visual data I collected included:
- Images of text message and emails related to my appointment
- Signs and posters at the vaccination centre
- Flyers provided to me during vaccination
- Stickers and other markers on the ground
There are no research participants involved in this analysis, and so this work does not require ethical review. However, I would still like to reflect on the ethics of my participant observation methods.
The National Statement on Ethical Conduct in Human Research is organised around the four sets of values outlined below. My analysis falls under ‘negligible risk research,’ as there is no foreseeable risk of harm or discomfort to others.61
- Research merit and integrity: I share my reflections to demonstrate the value of using behavioural insights to improve the coordination of mass vaccination. The perceived benefits of this analysis is to demonstrate to other practitioners how vaccination efforts might be bolstered with simple behavioural cues and messages.
- Justice: there were no participants recruited. By publishing my observations on my blog, I hope my analysis is available to the public, in a timely way. The COVID-19 pandemic is dynamic, and the Public Health Order changes constantly. As such, opportunities to improve the vaccination process, or public understanding of vaccination issues, has potentially strong value.
- Beneficence (do no harm): human research must justify any risks to participants, as well as the benefits to participants or the wider community, or to both. Again, there are no direct participants included in my analysis, outside of myself. The topic of vaccination is potentially fraught, due to ongoing public debate about misinformation, mandated vaccination of some workers, lack of access to vaccines by groups at-higher-risk of COVID-19, and other issues. My analysis has not collected data on these, or other, sensitive topics.
- Respect: research must address the rights and dignity of participants, including their privacy, confidentiality, and cultural sensitivities. I did not elicit participation of other people in research, nor do I incorporate any private information, or other data about other individuals.
My recommendations on how to improve mass vaccination are drawn from observations of a public space. My presence did not impact staff, nor other members of the public. As this is an unobtrusive observation of a public place, and I draw on non-identifiable reflections, my analysis is unlikely to cause harm.
1. Australian Government Department of Health. Australia’s COVID-19 vaccine rollout. Australian Government Department of Health. https://www.health.gov.au/initiatives-and-programs/covid-19-vaccines/australias-covid-19-vaccine-rollout. Published August 24, 2021. Accessed August 25, 2021.
2. NSW Health. COVID-19 (Coronavirus) statistics 4 September 2021. News. https://www.health.nsw.gov.au/news/Pages/20210904_00.aspx. Published September 4, 2021. Accessed September 4, 2021.
3. Davies A. Vaccination blitz targets south-west Sydney under-40s as NSW reports 452 new coronavirus cases. The Guardian. https://www.theguardian.com/australia-news/2021/aug/17/nsw-covid-update-vaccination-blitz-targets-south-west-sydney-under-40s-as-state-reports-452-new-cases. Published August 17, 2021. Accessed August 22, 2021.
4. Australian Government Department of Health. COVID-19 Vaccine Rollout Update – 4 September 2021. Canberra; 2021. https://www.health.gov.au/sites/default/files/documents/2021/09/covid-19-vaccine-rollout-update-4-september-2021.pdf Accessed September 4, 2021.
5. Zevallos Z. Policing Public Health. The Other Sociologist. https://othersociologist.com/2021/08/02/policing-public-health/. Published August 2, 2021. Accessed September 4, 2021.
6. Robbins R. Millions Are Skipping Their Second Doses of Covid-19 Vaccines. The New York Times. https://www.nytimes.com/2021/04/25/business/covid-vaccines-second-doses.html. Published April 25, 2021. Accessed August 18, 2021.
7. Henley J. Six EU states overtake UK Covid vaccination rates as Britain’s rollout slows. The Guardian. https://www.theguardian.com/world/2021/aug/06/six-eu-states-overtake-uk-covid-vaccination-britain-rollout-slows. Published August 6, 2021. Accessed August 18, 2021.
8. Waller V, Farquharson K, Dempsey D. Qualitative Social Research: Contemporary Methods for the Digital Age. London: Sage; 2016.
9. Gold RL. Roles in sociological field observations. Soc Forces. 1958;36(3):217-223. doi:10.2307/2573808
10. Zevallos Z. Visual Sociology as Public Outreach. The Other Sociologist. https://othersociologist.com/2013/11/14/visual-sociology-as-public-outreach/. Published November 14, 2013. Accessed August 29, 2021.
11. Jackson E, Curran S. Australia’s COVID vaccine rollout is well behind schedule — but don’t panic. The Conversation. https://theconversation.com/australias-covid-vaccine-rollout-is-well-behind-schedule-but-dont-panic-157048. Published March 16, 2021. Accessed August 18, 2021.
12. Tingle L. Senior business figures turned to former PM Kevin Rudd to intervene in bringing forward Australia’s Pfizer vaccine supply. ABC News. https://www.abc.net.au/news/2021-07-11/kevin-rudd-australia-covid-pfizer-vaccine-supply-senior-execs/100284902. Published July 11, 2021. Accessed August 1, 2021.
13. Schultz A. No national stockpile? Australia has 6.8m vaccine unused doses in storage. Crickey. https://www.crikey.com.au/2021/07/29/national-stockpile-australia-6-million-vaccine-unused-doses/. Published July 29, 2021. Accessed August 18, 2021.
14. Gooley C, Thompson A. Calls for more Western Sydney vaccine hubs as COVID cases soar. The Sydney Morning Herald. https://www.smh.com.au/national/nsw/calls-for-more-western-sydney-vaccine-hubs-as-covid-cases-soar-20210818-p58jsg.html. Published August 18, 2021. Accessed August 18, 2021.
15. Knaus C. Covid outbreaks threaten 34 aged care facilities across NSW. The Guardian. https://www.theguardian.com/australia-news/2021/aug/18/covid-outbreaks-threaten-34-aged-care-facilities-across-nsw. Published August 18, 2021. Accessed August 18, 2021.
16. Shorten B. Less than half of all Australians living with disabilities in care are fully vaccinated. Twitter. https://twitter.com/billshortenmp/status/1424900473400696832. Published August 10, 2021. Accessed August 25, 2021.
17. NSW Health. COVID-19 (Coronavirus) statistics 21 August. NSW Health News. https://www.health.nsw.gov.au/news/pages/20210821_01.aspx. Published August 21, 2021. Accessed August 29, 2021.
18. NSW Health. COVID-19 (Coronavirus) statistics – News. NSW Health News 26 August. https://www.health.nsw.gov.au/news/Pages/20210826_00.aspx. Published August 26, 2021. Accessed August 28, 2021.
19. Morton R. Exclusive: Covid-19 hospitalisations three times higher than reported. The Saturday Paper. https://www.thesaturdaypaper.com.au/news/politics/2021/09/04/exclusive-covid-19-hospitalisations-three-times-higher-than-reported#mtr. Published September 4, 2021. Accessed September 4, 2021.
20. Kontominas B. NSW records 1,218 new locally acquired COVID-19 cases, six deaths. ABC News. https://www.abc.net.au/news/2021-08-29/nsw-records-1218-new-covid-19-cases-six-deaths/100416170. Published August 29, 2021. Accessed August 29, 2021.
21. Smee B. Indigenous Australians ‘going through hell’ as Wilcannia Covid outbreak worsens. The Guardian. https://www.theguardian.com/australia-news/2021/aug/21/indigenous-australians-going-through-hell-as-wilcannia-covid-outbreak-worsens. Published August 21, 2021. Accessed August 22, 2021.
22. Daniel S. NSW records 1,533 new COVID-19 cases, four deaths as total infections in Wilcannia near 100. ABC News. https://www.abc.net.au/news/2021-09-04/nsw-records-1-533-new-covid-19-cases-four-deaths/100434218. Published September 4, 2021. Accessed September 4, 2021.
23. Brennan B, Archibald-Binge E. COVID-19 was never supposed to get into Indigenous communities. Now it’s at the “doorstep” . ABC News. https://www.abc.net.au/news/2021-08-26/covid-delta-unvaccinated-indigenous-communities-outbreak/100406682. Published August 26, 2021. Accessed August 28, 2021.
24. Allam L, Evershed N. Indigenous communities being left behind in NSW vaccine rollout, leaked figures show | Indigenous Australians | The Guardian. The Guardian. https://www.theguardian.com/australia-news/2021/aug/28/indigenous-communities-being-left-behind-in-nsw-vaccine-rollout-figures-show. Published August 28, 2021. Accessed September 4, 2021.
25. Visontay E, Taylor J. Tougher Covid restrictions for western Sydney criticised for threatening wellbeing of ste’s poorest | . The Guardian. https://www.theguardian.com/australia-news/2021/aug/20/tougher-covid-restrictions-for-western-sydney-criticised-for-threatening-wellbeing-of-states-poorest. Published August 21, 2021. Accessed August 25, 2021.
26. Zevallos Z. Disproportionate policing and individual blame belies race and class inequality. Twitter. https://twitter.com/OtherSociology/status/1428189758761562120. Published August 19, 2021. Accessed August 29, 2021.
27. NSW Government. COVID-19 vaccination for workers. COVID-19. https://www.nsw.gov.au/covid-19/health-and-wellbeing/covid-19-vaccination-nsw/covid-19-vaccination-for-workers. Published August 27, 2021. Accessed August 29, 2021.
28. Zevallos Z. Sociology of the anti-vaccination movement. The Other Sociologist. https://othersociologist.com/2016/02/28/sociology-of-anti-vaccination-movement/. Published February 28, 2016. Accessed July 21, 2020.
29. Zevallos Z. Pandemic, race and moral panic. The Other Sociologist. https://othersociologist.com/2020/07/05/pandemic-race-and-moral-panic/. Published July 5, 2020. Accessed July 25, 2020.
30. Zevallos Z. Race, Class and the Delta Outbreak. The Other Sociologist. https://othersociologist.com/2021/07/25/race-class-and-the-delta-outbreak/. Published July 26, 2021. Accessed September 4, 2021.
31. Lowrey T. ATAGI urges all adult Sydneysiders to “strongly consider” the AstraZeneca vaccine amid NSW COVID outbreak. ABC News. https://www.abc.net.au/news/2021-07-24/atagi-says-anyone-over-18-should-get-astrazeneca/100321056. Published July 24, 2021. Accessed August 18, 2021.
32. NSW Government. AstraZeneca vaccine for people aged 18 and over. NSW Government. https://www.nsw.gov.au/covid-19/health-and-wellbeing/covid-19-vaccination-nsw/astrazeneca-18-years-and-over. Published 2021. Accessed August 18, 2021.
33. Willis O. AstraZeneca COVID vaccine safe for breastfeeding women, health experts say, after official advice causes confusion. ABC News. https://www.abc.net.au/news/health/2021-08-19/astrazeneca-covid-vaccine-safe-for-breastfeeding-women/100388964. Published August 19, 2021. Accessed August 25, 2021.
34. Dahlen H. Should pregnant women have a COVID vaccine? The evidence says it’s safe and effective. The Conversation. https://theconversation.com/should-pregnant-women-have-a-covid-vaccine-the-evidence-says-its-safe-and-effective-165192. Published July 29, 2021. Accessed August 25, 2021.
35. Masters R. Coronavirus update: Pfizer vaccine to be made available for 16-39 year olds by next month. 9News. https://www.9news.com.au/national/coronavirus-update-pfizer-vaccine-to-be-available-for-australians-aged-16-39-by-august-30-covid-19-news-update/0bb30448-268f-410b-be0c-2537cf1e18f6. Published August 19, 2021. Accessed August 25, 2021.
36. Karp P. Australia to open Covid vaccinations to 12- to 15-year-olds from 13 September | Australian politics. The Guardian. https://www.theguardian.com/australia-news/2021/aug/27/australia-to-open-covid-vaccinations-to-12-to-15-year-olds-from-13-september. Published August 27, 2021. Accessed August 28, 2021.
37. Macmillan J. ATAGI decision on opening COVID vaccine rollout to 12- to 15-year-old children expected soon. ABC News. https://www.abc.net.au/news/2021-08-18/atagi-decision-12-15-year-olds-pfizer-vaccine-covid/100387662. Published August 18, 2021. Accessed August 25, 2021.
38. Sydney Institute for Infectious Diseases. Should I wait for Pfizer? The case for Astra Zeneca – now. The University of Sydney. https://www.sydney.edu.au/infectious-diseases-institute/news-and-events/news/2021/08/05/should-i-wait-for-pfizer-the-case-for-astra-zeneca-now.html. Published August 5, 2021. Accessed August 25, 2021.
39. Jones A, Vlaev I, Herbert F, Richardson S. RESPONSE: A Behavioural Insights Checklist for Designing Effective Communications. Practitioners’ Playbook.; 2019.
40. Trogen B, Caplan A. Risk Compensation and COVID-19 Vaccines. Ann Intern Med. 2021;174(6):858-859. doi:10.7326/M20-8251
41. Oliver A. Do Unto Others: On the Importance of Reciprocity in Public Administration: https://doi.org/101177/0275074016686826. 2017;48(4):279-290. doi:10.1177/0275074016686826
42. O’Carroll R, Haddow L, Foley L, Quigley J. If you needed an organ transplant would you have one? The effect of reciprocity priming and mode of delivery on organ donor registration intentions and behaviour. Br J Health Psychol. 2017;22(3):577-588. doi:10.1111/BJHP.12248
43. Milkman KL, Patel MS, Gandhi L, et al. A megastudy of text-based nudges encouraging patients to get vaccinated at an upcoming doctor’s appointment. Proc Natl Acad Sci. 2021;118(20). doi:10.1073/PNAS.2101165118
44. Berger M. Behavior Change for Good unveils effective strategies to boost vaccination rates | Penn Today. Penn Today. https://penntoday.upenn.edu/news/Penn-Behavior-Change-for-Good-strategies-boost-vaccination-rates. Published February 18, 2021. Accessed August 28, 2021.
45. Wittek R, Bekkers R. Altruism and Prosocial Behavior, Sociology of. Int Encycl Soc Behav Sci Second Ed. January 2015:579-583. doi:10.1016/B978-0-08-097086-8.32158-4
46. Tikotsky A, Sahar-Inbar L, Peer E. Minorities’ Support for Pro-Social Nudges Increases for COVID-19 Prevention Nudges. SSRN Electron J. May 2020. doi:10.2139/SSRN.3597346
47. Behavioural Insights Unit. How behavioural insights can help improve responses to COVID-19 | NSW Government. Behavioural Insights Unit Blog. https://www.nsw.gov.au/behavioural-insights-unit/blog/improving-responses-to-covid-19. Published November 30, 2020. Accessed August 28, 2021.
48. The Behavioural Insights Team. Four messages that can increase uptake of the COVID-19 vaccines. The Behavioural Insights Team. https://www.bi.team/blogs/four-messages-that-can-increase-uptake-of-the-covid-19-vaccines/. Published March 15, 2021. Accessed August 25, 2021.
49. Groch S, Clun R. COVID vaccines: What are the AstraZeneca, Pfizer and Moderna side effects? The Sydney Morning Herald. https://www.smh.com.au/national/why-do-vaccines-cause-side-effects-and-what-should-you-watch-for-20210818-p58ju9.html. Published August 19, 2021. Accessed August 25, 2021.
50. Pasricha S-R, Monagle P. A history of blood clots is not usually any reason to avoid the AstraZeneca vaccine. The Conversation. https://theconversation.com/a-history-of-blood-clots-is-not-usually-any-reason-to-avoid-the-astrazeneca-vaccine-161889. Published June 10, 2021. Accessed August 22, 2021.
51. Koopmanschap MA, Rutten FFH, van Ineveld BM, van Roijen L. The friction cost method for measuring indirect costs of disease. J Health Econ. 1995;14(2):171-189. doi:10.1016/0167-6296(94)00044-5
52. Martin S. ‘Immediate risk’: nearly 150 childcare centres closed across Australia over Covid threat. The Guardian. https://www.theguardian.com/world/2021/aug/19/immediate-risk-nearly-150-childcare-centres-closed-across-australia-over-covid-threat. Published August 19, 2021. Accessed August 28, 2021.
53. Thaler RH, Sunstein CR. Designing better choices. Los Angeles Times. https://www.latimes.com/archives/la-xpm-2008-apr-02-oe-thalerandsunstein2-story.html. Published April 2, 2018. Accessed August 18, 2021.
54. Rozin P, Royzman EB. Negativity Bias, Negativity Dominance, and Contagion: http://dx.doi.org/101207/S15327957PSPR0504_2. 2016;5(4):296-320. doi:10.1207/S15327957PSPR0504_2
55. Zevallos Z. Samoa Loses a Day: Sociology of Time. The Other Sociologist. https://othersociologist.com/2011/12/30/samoa-time/. Published December 30, 2011. Accessed August 28, 2021.
56. O’Donoghue T, Rabin M. Doing It Now or Later. Am Econ Rev. 1999;89(1):103-124. doi:10.1257/AER.89.1.103
57. Visontay E. NSW government quietly announces two hours of Covid vaccine leave for public workers. The Guardian. https://www.theguardian.com/australia-news/2021/jul/26/nsw-government-quietly-announces-two-hours-of-covid-vaccine-leave-for-public-workers. Published July 26, 2021. Accessed August 29, 2021.
58. National Disability Services. COVID-19 Vaccine rollout for the Disability Sector. NDS. https://www.nds.org.au/item/covid-19-vaccine-rollout-for-the-disability-sector. Published August 23, 2021. Accessed August 29, 2021.
59. Wilson TD, Houston CE, Etling KM, Brekke N. A New Look at Anchoring Effects: Basic Anchoring and Its Antecedents. J Exp Psychol Gen. 1996;125(4):387-402. doi:10.1037/0096-3422.214.171.1247
60. CATSINaM (Congress of Aboriginal and Torres Strait Islander Nurses and Midwives). National Summit on Cultural Safety in Nursing and Midwifery: Background Paper. Canberra; 2014. http://catsinam.org.au/?page_id=495. Accessed August 25, 2021.
61. National Health and Medical Research Council (NHMRC). National Statement on Ethical Conduct in Human Research (2007) – Updated 2018. Canberra; 2018. https://www.nhmrc.gov.au/about-us/publications/national-statement-ethical-conduct-human-research-2007-updated-2018#toc__95. Accessed August 29, 2021.