Boosting COVID-19 vaccination rates for the hesitant

By Sarah Thomas, managing director, Deloitte Center for Health Solutions, Deloitte Services LP, and Greg Szwartz, managing director, Life Sciences data science practice lead, Deloitte Consulting LLP

A safe and effective vaccine against COVID-19 may be humanity’s best bet for neutralizing the novel coronavirus and recovering our economic, social, and mental health. Yet, surveys show that 25% to 50% of Americans have said they would be hesitant to get a COVID-19 vaccination due to concerns about safety and the unprecedented speed of development.^1,2,3 What can public health officials and other stakeholders do to encourage enough people to be both willing and committed to getting inoculated?

Consider this:

• Each year, most American adults (55%) do not even get a “normal” vaccine like that for the seasonal flu shot.
• A subset of the population is actively resistant to vaccination, but many more people don’t get vaccinated for other reasons (estimates vary, but one poll put this at 7% for the measles vaccine).⁴
• Although Blacks, Hispanics, and indigenous populations have been disproportionately impacted by COVID-19, it may be a challenge convincing them to get vaccinated. The vaccination rate for the seasonal flu is 48.7% for non-Hispanic white adults and 39.4% for Black adults.⁵
• Researchers found a drop-off for vaccines that require multiple shots. For Hepatitis A, only 27% adhere to the 2-dose schedule.⁶ 

Assuming we need to achieve 60% to 70% immunity to arrive at—and maintain over years—herd immunity, we should organize the strategy to address specific population segments, understanding each group's motivations and the potential opportunity to shift them from hesitation to immunization. Such a strategy should also address how to overcome hesitation if the vaccination has side effects (e.g., fever).

Governments, businesses, and other stakeholders should pull out all the stops to develop strategies that provide accurate information to people in creative, effective, and ethical ways. Lessons learned from other public health campaigns are an important start, but we should approach this topic like any other marketing effort. We should use social media and technology where appropriate. Messages should be tailored to meet people where they are and from the sources they trust, using behavioral economics and decision science.

For even greater impact, these steps can be paired with other incentives and strategies.

Use public health information to spur action

Past public health campaigns have motivated people to wear seatbelts and bicycle helmets (requiring an action to start), and to quit smoking (requiring an action to stop).

One of the biggest challenges with vaccine hesitation is the vast amount of information available to the public that is not based on scientific evidence. A public health framework with potential for this particular issue is the Health Belief Model, developed by Godfrey H. Hochbaum in 1958. This model breaks down people’s thinking (the perceived threat and the net benefits of a health-related decision) into perceived susceptibility, perceived severity, perceived benefits, and perceived barriers. These make up a person’s “readiness to act,” which is otherwise known as the “reality-to-intention gap.” Cues to action activate that readiness and close the intention-to-action gap; this will need to be activated twice if the vaccine requires a booster. 

Health Belief Model

The reality-to-intention gap

Behavioral economists and decision scientists have contributed enormously to our understanding of how people make decisions, including how they decide to do (or not do) something that makes rational sense and benefits themselves and society.

A research paper on adult acceptance of influenza vaccinations outlined multiple applications of behavioral economics and several relevant concepts and implications:  

• Use storytelling to help people visualize a situation: People tend to believe that an event is more likely to occur if they can easily recall vivid examples. Real-life examples can be particularly powerful.
• Use credible information to dispel misconceptions: Some people avoid vaccines because they either don’t think they are effective, or they believe they won’t get sick. An outreach campaign should provide credible information about vaccine effectiveness and the risk of infection to people who don’t get vaccinated.
• Ask people to take a more distant perspective: A campaign should encourage people to act like an outside observer and consider the vaccination decision of someone like themselves. 
• Harness regret: Paint a picture of how a person would feel if they didn’t get the vaccine and ended up in the hospital or infected their parents or grandparents.

Risk and severity perception will likely vary by geography and demographics. Public health agencies and others might consider using what we call precision engagement to more precisely target outreach and messages. Precision engagement involves the use of analytics to map risk levels by county, neighborhood, and even at the individual level. This type of analysis can create a personalized behavior-change strategy based on needs and resources instead of a one-size-fits-all approach.

Engender trust, work with trusted sources, and be trustworthy

We live in an era where consumer trust isn’t a given. Hospitals and academic medical centers are among the most trusted organizations, but only 50% of people trust them, according to Deloitte's annual survey of consumers. Only about one-third of surveyed consumers say they trust government health organizations, and only about one-quarter of people trust pharmaceutical companies and health plans.

Critical to addressing vaccine hesitance will likely be communicating information through channels consumers trust and allowing others to be the ambassadors of the information and message. These could include celebrities, social influencers, and non-profit membership organizations. Marketing and consumer-experience experts have deep experience in rating content and formats for their trustworthiness, according to a report from Deloitte Digital that looked at trust across various consumer industries. 

Any outreach strategy should recognize the valid historical reasons for lower use of vaccines among Black Americans. The strategy should recruit trusted sources of information and arm them with valid, balanced, and complete information. Historically Black Colleges and Universities (HBCUs) with medical schools might, for example, be good partners. Sharing information with organizations like churches is another possible strategy (even if they are holding online services, they still are a trusted source for their congregations). Church leaders might help convince parishioners that a vaccine could mean a quicker return to more traditional services and activities.

Physicians can be another critical avenue for sharing scientific information, reminding (even pestering) their patients to get vaccinated, but they may need some help with targeted messaging to different audiences rather than a “one-size fits all” message. Medical professionals who are vaccinated early could help model the safety of a vaccine. Recent polls show physicians are rising in people’s trust given their roles on the front lines of caring for people with COVID-19; nurses tend to be an even more trusted source of information.

Community pharmacists are another potential source of information, especially if vaccines are available and easy to get in retail pharmacy settings.

Regulators and manufacturers also have roles in explaining—in a clear and transparent way—the processes that they use to make drugs safe and effective, documenting any shortcuts (including the potential implications of these), and providing rigorous scientific data.

Leverage social media and social networks to help get the message out

Many public health campaigns have not successfully used social media as they have been resistant to segmenting the audience and tailoring messaging beyond pure demographics. Social media has been used to work against vaccination and scientific evidence about COVID-19 (e.g., potential health risks, consequences, therapies, and benefit of mask wearing and social distancing). Consumers can tap into the internet to confirm almost anything, whether it’s true or not. This does not mean the internet can’t also be used to support a goal of higher uptake.

Analysis of social networks and identification of key influencers are necessary for a successful public health campaign; these influencers can help amplify the pro-vaccination message.

There are several steps to doing this work. One step starts with identifying potential influencers on the COVID-19 vaccine topic, and then determining which ones stand out and connect to the most people. From there, one can analyze messages to see what those influencers are talking about, how they are using their social media platforms, and which of their messages (words and hashtags) gain the most traction. Persona analysis can help translate this information into outreach messages aimed at various audience segments. This strategy can help tailor messages to meet people where they are in terms of their concerns, expectations, and circumstances.

Data from social networks and online purchases also has potential to identify which messages resonate with certain people.

Incentives can help

While messaging and outreach can help convince many (if not all) people to become vaccinated, other incentives can also be effective. Some examples include:

• Requirements: Employers, state and local governments, schools and other entities might require demonstration of the COVID-19 vaccination in order to participate in certain riskier activities, like work travel, coming into the office, large meetings or classes, or large social events. It could be a condition of employment.
• Financial penalties: Insurers might be allowed to provide discounts to those who show they are vaccinated or charge higher premiums for those who are not, like they do for using tobacco.
• Financial bonuses: Employers, governments, or businesses could provide rewards to those who get vaccinated, such as tax breaks, prizes, or discounts on travel.

Incentives have helped to support public health initiatives in the past, but they should be designed carefully to take advantage of accurate information and not inspire resistance or perverse behaviors despite best intentions.

Other strategies and incentives might be needed

Even if a public marketing campaign proves successful in addressing hesitations and concerns about a COVID-19 vaccine, other elements of a program are likely needed to help ensure people follow through on their intention. Some people make excuses for avoiding the flu shot if it’s not convenient. Making a COVID-19 vaccine available through a wide range of channels and places could make it more difficult to put off. Pharmaceutical companies also might consider whether different formulations of vaccines might help with follow through. For example, some individuals might be more willing to accept a vaccine provided nasally than an injection.

Technology can support tailored messaging through social media as well as patient groups, affinity groups, and other trusted sources. It also can help close the intention/action gap by helping individuals find a place and time to get vaccinated or set reminders, including for a second dose if that turns out to be needed. Technology that incorporates gamification or rewards for getting vaccinated could also be effective.

As we wait for the first part of the vaccine strategy (clinical trials and supply chain) to show results, we also should work on the second part (awareness, trust, and getting vaccinated). That will require:

• Establishing public and private collaboration to drive vaccination
• Leveraging “precision engagement” to determine channel, message, timing, and frequency to improve vaccination rates, while also using plain language to engage people in a trusting and simple manner
• Aligning incentives (consumers, providers, payers, and pharmaceutical companies)

Endnotes

^{1. 64% of Voters Say U.S. Should Prioritize Thorough COVID-19 Vaccine Testing Over Speed, Politico, July 29, 2020}

^{2. Just 50% of Americans plan to get a COVID-19 vaccine. Here’s how to win over the rest, Science, June 30, 2020}

^{3. A quarter of Americans are hesitant about a coronavirus vaccine, Reuters/Ipsos poll, May 21, 2020}

^{4. The average anti-vaxxer is probably not who you think she is, Quartz, March 4, 2015}

^{5. Influenza (general population vaccination coverage), US Centers for Disease Control and Prevention, September 26, 2019}

^{6. Adherence with and completion of recommended hepatitis vaccination schedules among adults in the United States, ScienceDirect, August 23, 2018}

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