Psychological science will be at the forefront of combating vaccine hesitancy brought on by misinformation now that several vaccines have proven to be safe and effective against COVID-19.
Right now, more people want a vaccine than can get one, due to low supply. But as a long pandemic winter eases into spring and summer, it will be important to ensure that everyone who could benefit from the vaccine actually rolls up their sleeve to get it. The politicization of COVID-19, messaging about masks, and the mental health impact of social distancing have all made clear how important psychology is during a pandemic. Vaccination is no different.
Psychologists will play an important role in ensuring vaccine uptake by determining the best way to fight back against misinformation, along with smoothing logistics and communicating benefits and risks.
“It doesn’t matter how great your biomedical innovation is, if people aren’t convinced to use that innovation, then the innovation has no impact at all,” says Gregory Zimet, PhD, a clinical psychologist at the Indiana University School of Medicine who studies vaccine decision-making.
Vaccine uptake
Psychologists have been tracking vaccination attitudes since spring 2020, trying to understand who is hesitant to receive a COVID-19 vaccine and why. National surveys painted a promising picture as the vaccine rollout began: After a low point of only 50% of Americans saying they were willing to be vaccinated in September, 63% expressed willingness in a national poll taken in late November (Gallup, 2020opens in new window). Gallup researchers speculated that reports of side effects in the AstraZeneca vaccine trials and fears of a politically driven approval process were the reason for the September slump. A Henry J. Kaiser Family Foundation survey taken in December put willingness to be vaccinated at 71% (KFF COVID-19 Vaccine Monitor, 2020opens in new window), also up from September’s numbers.
However, research also suggests that acceptance is unevenly distributed. Kaiser’s ongoing COVID-19 Vaccine Monitor project finds consistent gaps between groups. Those most likely to be hesitant are Republicans, people ages 30 to 49, rural Americans, and Black Americans. Those most likely to be enthusiastic are Democrats, people over 65, the college-educated, and those with major health issues. Reasons for hesitancy vary among these groups, with Republicans less likely to believe COVID-19 is a risk than other hesitant groups, and hesitant Black Americans more worried that the vaccine might have dangerous side effects or give them COVID-19.
It’s not clear how many people need to be vaccinated to achieve community immunity, in which the coronavirus pandemic fizzles out because the virus can’t find vulnerable hosts. National Institute of Allergy and Infectious Diseases director Anthony Fauci, MD, gave a range of 70% to 85% in December. But if some groups are less likely to be vaccinated than others, pockets of vulnerability could still persist even if overall acceptance is high. Thus, vaccine acceptance is an important part of equity in the fight against COVID-19.
Vaccine communication
Psychologists and other behavioral scientists are working to inform the communication efforts around the vaccine. A recent report from the National Academies of Sciences, Engineering, and Medicine on equitable vaccination allocation calls for drawing on the established research in risk communication to drive outreach (NASEM Framework for Equitable Allocation of COVID-19 Vaccine, 2020opens in new window). The National Institutes of Health also released a report in December calling for evidence-based strategies, including tailored messaging and framing vaccination as a beneficial, apolitical decision (COVID-19 Vaccination Communication: Applying Behavioral and Social Science to Address Vaccine Hesitancy and Foster Vaccine Confidence, 2020opens in new window). “It shouldn’t be amateur hour with the stakes so high,” says Baruch Fischhoff, PhD, a psychologist at Carnegie Mellon University and a member of the committee which wrote the report. “We should rely on psychological science, not intuition about what people think.”
For example, many of the vaccine-eager may be tempted to shame those who have questions or are hesitant. But research shows that positive emotional messages, such as altruism and hope, are more effective than negative ones in encouraging vaccination (Chou, W. S., & Budenz, A., Health Communication, Vol. 35, No. 14, 2020opens in new window).
It’s also important to know that the Mayo clinic notes that people with certain health conditions are not currently advised to get the vaccine and encourages people to talk to their health care provider if they have questions. Psychologists need to be sensitive to those who are desperate for the relief of a vaccine but aren’t medically advised to receive one.
Many who are hesitant to get vaccinated have deeply personal reasons to feel that way. Mistrust of the medical community among Black Americans, for example, is often rooted in historical events such as the Tuskegee Syphilis Study, in which the United States Public Health Service misled and withheld treatment for syphilis from poor Black men between 1932 and 1972. Personal experiences with racism may also foster mistrust; a Kaiser Family Foundation survey in 2020 found that 20% of Black Americans reported personally experiencing racism while seeking health care in the previous 12 months (KFF Survey on Race and Health, October 2020opens in new window).
Tailoring messaging to specific communities is thus very important, Fischhoff says. For historically marginalized communities, it’s particularly crucial to open up two-way lines of communication, he says. One way to do this might be to leverage the power of professional organizations such as APA and the American Public Health Association, which have members in diverse communities all over the country. “They can get the word out and listen to what’s on people’s minds, and they can also get the content and tone right in a way that somebody sitting at a major advertising agency just can’t do,” Fischhoff says.
Some collaborations already exist. The Johns Hopkins Bloomberg School of Public Health Center for Health Security is addressing vaccine equity and hesitancy with five multidisciplinary local teams in Alabama, southern California, Idaho, Baltimore, and Prince George’s County, Maryland. Neil Lewis Jr., PhD, a social psychologist at Cornell University, is working with a multidisciplinary group to help the New York City health department respond to questions that people ask the doctors administering the COVID-19 vaccine. Often, these concerns contain a kernel of truth, Lewis says. After all, early in the pandemic, experts warned the public that safe vaccines take years to develop. It’s not surprising, then, that people have worries about the safety of a vaccine developed in less than a year. “People have concerns,” Lewis says, “and we have to acknowledge that those are legitimate concerns, let them ask their questions, and respond to them.”
The CDC’s Vaccine Adverse Event Reporting Systemopens in new window gives a sense of the types of adverse reactions reported, ranging from benign and expected (headache, soreness) to serious (anaphylactic shock and heart attack). However, psychologists using this data should be aware that anyone can enter a report, and the system is not designed to show that an event was caused by the vaccine.
Personal experience may also be a powerful tool for vaccine communication. Many doctors and nurses—especially doctors and nurses of color—have been sharing their own vaccine experiences on social media, including any common side effects they may experience. “The slow rollout might end up having this unintended benefit of creating enough time that the broader public can see that yes, the vaccine is working, the people who are getting it are doing well, so that could help to increase trust in it over time,” Lewis says.
For those who are strongly opposed to vaccines based on emotion or ideology, the messaging is more difficult—but not impossible. These strong anti-vax, anti-mask attitudes appear driven by a phenomenon called psychological reactance, says Steven Taylor, PhD, a clinical psychologist at the University of British Columbia in Canada, which is a motivational state driven by the feeling that someone is trying to curtail one’s freedom. For this group, any messaging suggesting that authorities want people to get vaccinated is aversive. Instead, Taylor says, it’s best not to frame vaccination as an obligation. “The best message could be, ‘Getting vaccinated is a right you have, don’t let people take that away from you,’” he says. “That’s not a disingenuous message; it’s an accurate one.”
Intent versus action
Even among the willing, vaccination intent does not equal vaccination behavior. There are many people who are not ideologically against vaccines who still don’t get around to getting their annual flu shot. With COVID-19 case rates high this winter, motivation to get the vaccine is also high for many. As spring and summer begin, case numbers and deaths may begin to decline due to virus seasonality and the vaccination of high-risk individuals. With the danger less immediate, people may be less motivated to make vaccination appointments, says Gretchen Chapman, PhD, a professor of social and decision sciences at Carnegie Mellon University.
Another complication is that the Pfizer and Moderna vaccines require two doses, administered three or four weeks apart, to be most effective. Getting people to come in for the second dose at the right time is a separate problem from getting them to come in for the first dose, Chapman says: “In the first round, you’ll take whoever shows up, but in the second round you need the exact people who were there the first time, exactly 3 weeks later.”
However, while intervening to change people’s vaccination beliefs can be difficult, there are proven methods for changing vaccine behavior, Chapman says. These include reminders, automatically scheduled appointments, and strategies to make logistics for the patient as seamless as possible. Health systems or pharmacy chains could capitalize on winter’s vaccine enthusiasm by having people sign up to be notified when vaccines are available for their risk group, Chapman says. People may also need paid time off from work to get the vaccine and recover from mild side effects, including localized and temporary pain, swelling or redness at the injection site, Lewis says. “If people don’t have the time or have other logistical hurdles in the way, we’re in trouble,” he says.
Behavioral science can help smooth the logistics of vaccination for underserved populations. University of California, Los Angeles, psychologist Vickie Mays, PhD, has developed a model of neighborhood vulnerability to COVID-19 in Los Angeles County, based on indicators like pre-existing health conditions of residents and social exposure to the virus (Brite Center, 2020opens in new window). Similar models could be used across the country to open vaccination sites and focus outreach for the most vulnerable.
Natural incentives may also encourage vaccination even among people who are not worried about the coronavirus and their own health. Incentives might include airlines requiring proof of vaccination for international travel, or sports venues requiring proof of vaccination for entry to events, Chapman says. However, such incentives might also deepen inequities for groups who are less able to access the vaccine. Direct monetary incentives are likely to backfire. Research led by psychologist and marketing professor Cynthia Cryder, PhD, of Washington University in St. Louis, found that paying people to participate in potentially risky research studies made the participants believe that the studies were more risky than if they weren’t paid ( Social Science & Medicine, Vol. 70, No. 3, 2010 opens in new window). The money “conveys that this is a risky thing that you don’t want to do unless we’re paying you,” Chapman says.
Such results highlight the importance of field studies going forward during the COVID-19 vaccine deployment, she says. Interventions need to be tested in a real-world context. At the Behavior Change for Good Initiative at the University of Pennsylvania, economist Katy Milkman, PhD, and colleagues have tested nearly two dozen text message reminder strategies for flu vaccinations with real patients at health systems and customers at Walmart pharmacies. Preliminary results from doctors’ offices, currently being prepared for publication, suggest that a variety of messages can boost vaccination, with 21% of messages tested significantly boosting vaccination rates. The most successful, a two-part reminder that told patients that a flu vaccine had been reserved for them at their upcoming well-check visit, boosted vaccination 10% at essentially zero cost, Milkman said in a Jan. 6 webinar hosted by the Science of Behavior Change Research Networkopens in new window. Milkman and her colleagues plan to release results from more than 500,000 Walmart pharmacy customers in late January.
Building the knowledge and capacity to enact COVID-19 vaccination will pay off long after the pandemic is over, Taylor says. “Now, having lived it, we all know how important psychology is,” he says. “We need to keep these platforms up and running. We shouldn’t dismantle them after the pandemic is over, because they’re going to be important for preparing for the next pandemic.”
