Beyond Politics — Promoting Covid-19 Vaccination in the United States

Medicine frequently segments patients by demographic or socioeconomic traits, but a striking aspect of the public response to the pandemic has been the association of anti-Covid efforts with personal identity, especially political identity.¹¹ Some groups have incorporated masks into their self-image as a symbol of community responsibility and respect, while others see wearing masks as a sign of weakness or cowardice. Some mask-protest leaders represent masks as an attack on freedom and thus democracy. Yet we must be careful not to inadvertently reinforce the identity drivers behind mask wearing; for example, labeling vaccine-hesitant people as “conservative” or “Covid-hoaxers” tells political conservatives that vaccines are a liberal concept and open to skepticism. And it tells people who are vaccine-hesitant for other identity-related reasons (e.g., distrust of medical research by some people of color) that their concerns are not being heard or respected by the medical community.

This is not a simple case of red-state/blue-state duality. Some elderly Republicans, for example, are quietly worried by their party’s failure to take the pandemic seriously, but are afraid to rock the boat; other elderly Republicans are defiant in their assertion of fearlessness. No common persuasive message will work for both groups: highlighting the virus’s danger would scare the former group but might reinforce the latter’s defiance. Such segmentation suggests that we need different messages targeted not according to such demographic characteristics as age, but according to barriers created by self-identity, in-groups, or social beliefs.¹² In this case, campaigns could address the first group’s fear of social censure and promote the idea that the best good works are done quietly, known only to oneself, while assuring the second group that their legacy of rebellion should include dying on some fearless adventure, not alone, locked in tubes, wheezing through a plastic straw.

Uniting two polarized groups often depends on finding a third, more hated common enemy that can be used to build community across differences.¹³ The obvious common enemy here is the virus, but demonizing it will work only if both groups see it as real and dangerous. Currently, some groups view the virus threat as inflated or a hoax,¹² though uncontrolled spread across communities may make it harder to dismiss as the winter progresses. For now, appropriate common enemies may be downstream effects: we can focus on “battling” poverty by getting people back to work or on “racing” other countries to return to normal.

Analogies used in communication harness understanding of some familiar concept to elucidate a complex new concept.¹⁴ Many attitudes toward the pandemic are responses to complex medical information being communicated at a troubled time. Analogies can communicate rich information in a single image or phrase. For example, “the war against Covid” may connote coming together, making sacrifices, doing tough things, and emerging on the other side with new improvements and inventions in hand.

Or consider the difficulty of conveying statistical information. According to the National Center for Educational Statistics, more than half of Americans score 2 or lower on the 5-point numeracy scale developed by the Program for the International Assessment of Adult Competencies, and even highly educated people can make errors in understanding risk. People may ask whether the vaccine “guarantees” that they won’t get Covid-19, and of course it can’t, but an analogy to some extremely rare event may help: we can say, “The likelihood is about the same as being killed in a car crash,” rather than simply “no.”

The introduction of the Apple iPod was one of the most successful product launches ever. Although there were other MP3 players, the iPod dominated the market and the mental schemas of consumers. One reason was its white earphones: even if the device itself was hidden in a pocket, observers knew that the wearer had an iPod. iPod owners became walking advertisements. An innovation known as Rogers’ concept of observability suggests that consumers’ ability to observe others’ choices can increase an innovation’s rate of adoption.¹⁵

Imagine how vaccination status could be made observable. Perhaps wearable tokens, such as Livestrong-style bracelets or stickers or pins similar to those given to voters, would work for in-person environments. Digital badges (such as frames or banners for one’s social media profile photo) are easy to create and effective in virtual environments.

In consumer markets, scarcity often signals exclusivity and prompts greater interest or desirability.¹⁶ Because of a natural attentiveness to negative outcomes, we’re attuned to goods that might run out or opportunities we might miss.¹⁷ Although it would be wrong to create an artificial scarcity of vaccines to boost the attractiveness of securing one, we should not ignore natural scarcity’s effect on attitudes toward vaccines as they’re rolled out. We should frame early access to vaccines as a mark of honor or respect for people we want to protect, whether they’re older Americans or people with chronic illnesses, first responders (police, firefighters, and emergency medical technicians), medical staff, schoolteachers, or essential workers. For healthy people who identify as “tough” (such as first responders), we can frame priority access as a sign of respect “awarded” to them. Leveraging scarcity may help counteract guinea pig metaphors and hesitancy to “go first.” At the same time, the unexpected initial scarcity and early demand for the vaccine should not provide a false sense of security that we will not need to address resistance as we strive to achieve our population vaccination goals.

“Attribution theory,” from social psychology, explores how people confronted with something unexpected or troublesome develop explanations for it.¹⁸ For new products, consumers’ attributions can help or hurt adoption. For example, if a product launch occurs later than initially announced, people might attribute the delay to a problem with the product (even if the delay was caused by bad weather slowing a shipment). If a product runs out quickly, people might assume it’s highly desirable and popular (even if, really, poor supply-chain planning led to a stock-out).

The need for trust and transparency demands that vaccine promoters not fabricate positive attributions. But given attributions’ power (and the ability of unconfirmed information to spread on social media), effective promotion will involve predicting negative attributions and combating them directly. For example, policymakers may choose to make vaccines available first in historically disadvantaged neighborhoods, aiming to get protection early to people who can least afford a setback. But a possible negative attribution is that these people are being treated as “lab rats” to test the vaccine’s safety before it’s given to wealthier people. Anticipating and combating negative attributions requires listening openly to the vaccine-hesitant, building trust, and addressing false attributions directly and consistently. There is also a clear need to work with social media platforms to limit dissemination of false information.¹⁹

Research on insurance suggests that many people overinsure themselves for highly unlikely occurrences such as flooding in areas that are not floodplains.²⁰ One major reason is anticipated regret: emotions, such as regret, are powerful motivators of decisions, and they can motivate us even before they’re experienced.²¹ Vaccination can prevent a specific anticipated regret: the fear that someone we love will die from the illness. People may be especially persuaded by a fear for their loved ones. We may also be motivated by others’ anticipated regret (e.g., “Do it so your mother can stop worrying and get some sleep.”)

One challenge for the pandemic response is the slow release of information about the scientific milestones in vaccine development. Although this information flow is a well-intentioned effort to improve transparency for the scientific community, it could backfire with the public. Again, consider how our evolving knowledge of the benefits of masks has sown confusion when it appears that experts are not clear on the issue.

Current research²² suggests that piecemeal risk — risk information that trickles out over time — can be especially dangerous for uptake of pharmaceutical innovations. People are more sensitive to the risk of side effects and significantly less likely to try a new drug when risk information is presented piecemeal over time than when a single news source presents a final risk assessment. Though the efficacy and safety of Covid-19 vaccines are highly newsworthy, policymakers should recognize that negative trends that “trickle out” can disproportionately influence the public. Vaccine news cannot be covered up, but it can be presented in total, rather than with incremental updates.

Coffee shops’ practice of offering three serving sizes builds on consumer research suggesting that people seek easy rules of thumb in making uncertain decisions like how much coffee we need; one robust example is our tendency to look for normal or nonextreme choices and thus choose middle, or compromise, options.²³ At the coffee shop, a tally of drink-size selections would probably follow a bell-shaped distribution, with most customers choosing the middle option.

In medicine, patients are often offered only two choices — to get or not get some recommended treatment. But the compromise effect suggests that we can nudge people to a desired choice and increase their confidence about it by making it the compromise option. To make vaccination decisions a three-option rather than two-option choice, we could allow people to get the shot now, sign up for a later date, or not get it at all. Or all three options could include the vaccine (get the shot now and donate plasma, just get the shot now, or get the shot later). The key is to avoid depicting vaccination as the most extreme action in a range of choices.

People dislike missing out on fun things, but vaccination is not normally a fun experience — we get an injection and may incur unpleasant side effects, and some Covid vaccines require a second shot weeks after the first. Though the public health benefits are clear, there is no immediate individual reward for completing the vaccination sequence — nothing to miss out on. One possibility is to create a desirable reward so people feel an urgency to act lest they miss out on a limited opportunity.²⁴

Immediate rewards could be tied to getting vaccinated and even to the potential for greater side effects of the second shot in a two-dose sequence.¹⁹ For example, employers could offer a day off to reward an employee’s contribution to a safe workplace. A public messaging campaign could create a narrative about families staggering their vaccinations so one “vaccine hero” at a time can stay on the sofa and be coddled with snacks and movies. Universities could offer students and staff tickets to future sports or cultural events. Financial incentives such as insurance rebates and tax benefits could also be considered.

Uniqueness neglect is a phenomenon recently conceptualized as one reason patients are resistant to having artificial intelligence diagnose or treat them.²⁵ Some people believe they are unique or different from the average person (e.g., more sensitive, more prone to side effects). They may see vaccines as one-size-fits-all options for the average person — but not for them. Clinics may be wise to develop some variations in vaccine delivery (e.g., topical numbing of the injection site for sensitive patients) that cater to such patients. As more vaccines are approved and specific indications, such as pediatric labeling, are developed, we can address this tendency with more specific matching of patients to characteristics of different vaccines.

Although medical school emphasizes communication using facts and statistics, people often underweight base-rate statistics and overweight anecdotal cases — stories — in judging probability, a decision heuristic known as the base-rate fallacy or case versus base-rate effect.²⁶

The first patient with a rare side effect from a vaccine, anaphylaxis from the Pfizer-BioNTech vaccine,²⁷ was heavily profiled in the media. Such a story is more emotionally evocative and will go more “viral” than a numerical statistic. Unfortunately, experts will probably respond by citing statistics showing that such cases are rare. But when a vaccine-hesitant patient repeats side-effect stories, clinicians can counter with their own stories, rather than elaborate statistical explanations. Furthermore, vaccine communications teams should proactively spread their own “cases” in addition to statistics. News briefings or websites could include real individual success stories — a Georgia family going out for ice cream after being vaccinated, perhaps, or Indiana retirees joyfully visiting neighbors 10 days after receiving the vaccine. Such stories, however banal, can help counteract the shock value of a few bad-effect stories.

The development of Covid-19 vaccines is an amazing scientific achievement. Adoption of vaccines by the U.S. public will require a similar level of achievement. Vaccine promotion demands a multifaceted behavioral approach if it is to succeed.