A COMMUNICATOR’SGUIDE TO COVID-19
VACCINATION
Research, Theories, Models, and Recommendations
Communicators Should KnowTABLE OF CONTENTS
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EXECUTIVE SUMMARY AND KEY FINDINGS ................................... 1
INTRODUCTION ...................................................................... 4
a. Why This Topic is Importantb. Limited Health Literacyc. Importance of Theories and Models
VACCINE HESITANCY AND CONFIDENCE ....................................... 8
a. Vaccine Hesitancyb. The Anti-Vaccination Movementc. Determinants of Vaccine Uptake
UNDERSTANDING AUDIENCES ................................................... 14
a. The Role of Influencers
b. At-Risk Populations
c. Health Inequalities
TRUST IN INFORMATION .......................................................... 18
a. The Role of Trust and Mistrustb. Misinformation and Disinformation
LEVERS AND EVIDENCE-BASED PRINCIPLES FOR APPLICATION ...... 23
a. Optimism Biasb. Confirmation Biasc. Inoculation Theory
THEORIES AND MODELS TO CONSIDER IN A FRAMEWORK .............. 26
a. Heuristics
b. Theory of Planned Behavior (TPB)c. Protection Motivation Theory (PMT)d. Common Sense Model (CSM)
e. COM-B Model of Behavior
f. Diﬀusion of Innovations Theory
GUIDELINES AND STRATEGY RECOMMENDATIONS ........................ 31
a. Key Guidelines
b. Recommendations About Information Sources (including federal agencies)
c. Recommendations from Theories and Models
d. Recommendations for Communicating About the Vaccine (including Messaging Strategies)
CONCLUSION ......................................................................... 33
INSTITUTE FOR PUBLIC RELATIONS RESOURCES ......................... 33
RECOMMENDED EXTERNAL RESOURCES .................................... 35
REFERENCES ......................................................................... 37
CONTRIBUTORS ..................................................................... 42

EXECUTIVE SUMMARY
AND KEY FINDINGSUNESCO (2020) has termed this COVID-19 period to be a “disinfodemic,” filled with anover-abundance of information and disinformation. With the staggered rollout around theworld of the COVID-19 vaccine, compelling and targeted communications are central toincreasing vaccine uptake. Employees and external audiences are increasingly depending on
companies to be trusted sources for providing credible information and resources.
The purpose of this guide is to highlight research, theories, models, and research-driven
recommendations that will help ensure eﬀective communication strategies for organizations
worldwide. The Institute for Public Relations has reviewed more than 100 research articles toassemble this guide.
Below are 17 Key Findings, which are all backed by research discussed in more detail within
the guide

1

Vaccine hesitancy is not due to a lack of information. Vaccine hesitancy, or the
reluctance or refusal to vaccinate despite vaccine availability, is a threat to global
health. Attitudes toward vaccines typically fall on a continuum (rather than being only“pro” or “anti” vaccinations). Vaccine hesitancy is not due to a lack of information,and sending out information about vaccines alone does not increase vaccine uptake(or taking the vaccine). People who are vaccine-hesitant should be treated withcompassion, sensitivity, and respect. Perceptions of risk and safety are two of themain concerns people have about vaccinations. People more willing to be vaccinatedare more likely to believe that they are at risk of contracting COVID-19, that the impact
can be severe, and that the vaccine is safe and eﬀective.

2

Transparency is key. Being transparent and keeping audiences updated is criticallyimportant for building trust and confidence. People are concerned about the“rushed” vaccine process so these concerns need to be addressed. Additionally,
people should be given Vaccine Information Statements (VIS) as well as Vaccine
Adverse Event Reporting System (VAERS) summary data. The potential adverse eﬀects
of a vaccine should be disclosed to patients. Keep it simple or detailed analyses andjargon will dissuade people.

3

Tailoring communication with each audience is critical. Attitudes andperspectives on vaccinations can vary widely depending on demographics, at-riskfactors, religion, psychographics, culture, political views, news consumption,
geographic locations, technographic factors, among others. A one-size-fits-all
approach will not be as eﬀective. Communicators should conduct research about
their specific audiences to better understand them. Messaging should be pre-tested
and made available in multiple languages. Deploying insights should be done
responsibly and ethically.

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Use theories and models to guide communication planning as well as
strategies and tactics. Understanding behavioral intentions, how people think
and feel, and the determinants of behavior change can make or break acampaign’s success. For example, using the COM-B model of behavior by applying
the Behavior Change Wheel can increase vaccine uptake.

5

Marginalized groups have lower vaccine confidence. Communities of color
have lower confidence in vaccines due to historic and systemic racism,discrimination, and inequities within the healthcare system and government.
Messaging and education related to COVID-19 vaccinations must specifically focus
on these communities with input from people within those communities. Cultural
humility is important.

6

Trust doctors and nurses. Healthcare providers (HCPs) are the most importantsource for many to increase vaccine uptake. Research shows that HCPs must be
confident in the vaccine and have the resources, knowledge, and tools toeﬀectively communicate with their patients and communities.

7

Opinion leaders for target audiences should be defined. Just as audiences andtheir needs vary widely, so do their opinion leaders. Identifying and employing
eﬀective opinion leaders and influencers increases uptake. Vaccinate credible
influencers within defined communities to demonstrate vaccine confidence. Per
social contagion theory, people have a tendency to think and act like their friends
and family, which encourages adoption of behaviors. Family and friends are one of
the most trusted sources of information.

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The anti-vaccination movement should not be ignored. While communicators
are unlikely to change the minds of those in the anti-vaccination movement, theanti-vaccination community is influential to those who are undecided about
vaccinations. This could decrease vaccine confidence within thecritically-important, undecided community.

9

Tell stories, not statistics. Stories and anecdotes about those aﬀected positively
by vaccinations are more likely to be eﬀective than statistics. First-person
testimony can help increase confidence. The COVID-19 vaccination should beframed as another important action to take with hand washing, mask-wearing,and physical distancing to prevent COVID-19. Oﬀicial communications about
vaccines should have a clear take-home message, tell a memorable story, andelicit feelings.

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Agencies must be aligned. All agencies (government, the healthcare community,
federal agencies, companies, etc.) must provide clear and consistent messaging toincrease public trust and confidence.

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Misinformation should not be repeated. Communicators must be careful to notamplify misinformation when they are rebutting or correcting it. Multiple sources
providing accurate information is better than a single source. While research
about the impact of the backfire eﬀect has seen mixed results, communicators do
not want people to reject credible information presented to them and strengthen
their original stance on an issue. Also, do not respond to trolls.

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Inoculate people against misinformation. Inoculation theory suggests false
claims should be debunked before people encounter them. Inoculating against
misinformation, or “prebunking,” by warning people about potential
misinformation can be eﬀective.

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Understand biases. Omission bias indicates a strong preference for inaction evenwhen taking action is more beneficial. Optimism bias means people believe they
have a lower chance of contracting COVID-19 than they actually do. Confirmationbias, or seeking information that only confirms one’s beliefs, may lead topolarization and echo chambers. Understanding biases can equip communicatorswith strategies for overcoming them.

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Help encourage health literacy. Cultivate critical thinking by increasing theknowledge of employees and the community about health information to help
them make appropriate health decisions. Low health literacy is more prevalent
among older adults, minority populations, those with low socioeconomic status,and medically underserved people. Oﬀer programs and workshops to help
employees become more health literate. It also helps protect against
misinformation.

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Language matters. Avoid using loaded terms that can turn people oﬀ. Some ofthese include “conspiracy theories” or “anti-vaxxers.” Also, “Operation Warp
Speed” or a “rushed” vaccine approval process may impact people’s perception of
the vaccine’s safety. “Public health agencies” is better than “federal” or“government” to not elicit a feeling of red tape.
Listen. Listen to people’s and HCP’s concerns about the vaccine to increasevaccine uptake. Listening to rumors also can help identify deeper issues.
Technology can help increase uptake. Digital push technologies, such as text
messaging, have been eﬀective at increasing uptake (including for a series
vaccination like the COVID-19 vaccine) for some audiences. Gamification is also
eﬀective for changing attitudes and behavior, such as identifying and dismissing
disinformation. Also, do not forget to track and measure communication eﬀorts.

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INTRODUCTION
models,This guide outlines research, theories,
thatand research-driven recommendations

ted toorganizational leaders should know relaitancy,COVID-19 vaccines, including vaccine hes
vaccine uptake (defined as the use of thest, andvaccine), understanding audiences, tru
aredisinformation. While additional topics

dibility,
critical to understand, such as source creused ondue to space and time limitations, we foc
ncertain key areas from a communicatio
perspective. Finally, research-based
recommendations are included.

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Why This Topic Is Important
Organizations play an important role in vaccine uptake even if they are not in thehealthcare space. Employees and external audiences are increasingly depending on
companies to be trusted sources for providing credible information and resources.
Attitudes to and perspectives on vaccinations can vary widely depending on
demographics, religion, psychographics, culture, political views, news consumption,
geographic locations, technographic factors, among others. Brewer et al. (2017)
suggested one of the ways that employers can help increase uptake is to promote
vaccinations to employees and oﬀer convenient, free vaccines to employees. To be
successful, an understanding of eﬀective behavioral influence and communication
strategies are needed. Also, to increase vaccine uptake, tailored plans are critical,
especially for at-risk populations and those aﬀected by health inequities.
In a peer-reviewed article in the      , French and colleagues (2020) oﬀer key guidelines for developing aproactive COVID-19 Pro-Vaccination Strategy that can benefit organizations (fordetails of each section, please see French et al., 2020):
1.

Behavior Change Planning

2.

Audience Targeting and Segmentation

3.

Competition and Barrier Analysis and Action

4.

Mobilization

5.

Vaccine Demand Building

6.

Community Engagement

7.

Vaccine Access

8.

Marketing Promotions Strategy

9.

Media Relations and Outreach

10.

Digital Media Strategy

In 2019, before the outbreak of COVID-19, the World Health Organization (WHO)
named “vaccine hesitancy” as one of the top 10 threats to global health. Vaccine
hesitancy is defined by WHO (2019) as the “reluctance or refusal to vaccinate
despite the availability of vaccines.” WHO research found inconvenience and lack5

of confidence as two oft-cited reasons why people might be vaccine-hesitant. Vaccine
hesitancy is a complex and context-specific issue that varies across time, place, and thevaccines (MacDonald, 2015).
In early December 2020, the Pew Research Center reported that 75% of Americans
reported having “a fair amount” or “a great deal” of confidence that the “research anddevelopment process in the U.S. will produce a safe and eﬀective vaccine for COVID-19.”
This was a 10 percentage point increase from September 2020. Those respondents who
said they would not get a COVID-19 vaccine said they were skeptical of the vaccine R&D
process and were less concerned about getting a serious case of COVID-19.
Other concerns about vaccinations relate to disinformation campaigns against vaccines.
Watts (2020) said vaccine disinformation in the United States has the potential to be more“potent” than COVID-19 disinformation due to two sources: legacy anti-vaccination
communities and maligned actors (e.g., Russian, Chinese, and Iranian state media).

Limited Health Literacy
Another likely barrier to vaccine uptake is a lack of health literacy, which is the “degree towhich individuals have the capacity to obtain, process, and understand basic healthinformation needed to make appropriate health decisions” (Health Resources andServices Administration, 2020, p. 1). Nine-out-of-10 adults in the U.S. lack the ability
to “understand basic medical information and engage in self-care and chronic
disease management” (Liu et al., 2019, p. 2).
According to the Health Resources and Services Administration (2019), low health literacy
is more prevalent among older adults, minority populations, those who have low
socioeconomic status, and medically underserved people.
When people are searching for information online, algorithms will direct more healthliterate users to more reputable sources while those with less health literacy will besteered toward fake cures or misleading medical advice (Susarla, 2020). Moreover, ananalysis of top COVID-19-related videos screened on YouTube in March 2020 found more

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than one-quarter contained misleading or inaccurate information (Li et al., 2020).
Evidence indicates that health misinformation is prevalent on social media, especially as
it relates to public health situations with limited or novel scientific information (Bolsover& Tizon, 2020).

Importance of Theories and Models
Theories, models, and guidance from psychology, behavioral science, andcommunication studies can help enhance the understanding of people’s perceptions
toward vaccination. According to Corcoran (2007), models and theories are useful inexplaining influences and factors that impact health decisions and elements important to
influencing attitude and behavior change. Even though theories and models may not
explain every factor eﬀecting behavior change, having a theoretical grounding can aid indesigning, planning, and executing health promotion strategies.
For example, researchers examined how to increase vaccination rates by using
communication strategies and psychological science. Brewer et al. (2017) found thatperceptions (both cognitive and emotional) can impact motivation. Their research foundthat risk beliefs (e.g., perceived risk, worry, anticipated regret, fear) also influence
motivation (intentions, hesitancy, willingness), which correlates reliably with getting
vaccinated or not. Low confidence in safety correlates reliably with not getting vaccinated(Brewer et al., 2017). Therefore, the perception of risk and safety is a significant
factor in vaccination uptake.
Increasing vaccine adoption and uptake is a complex problem, and the promotion of aneﬀective vaccine is a significant undertaking (Schiavo, 2020). An integrated approach is
key among clinicians, universities, employers, professional organizations, policy
advocates, policymakers, journalists, scientists, and government agencies. She
emphasizes that, “Empathy, respect, cultural humility, and genuine concern in discussing
any doubts or fears people may have, and providing them with evidence-based
information to positively shape immunization decisions, should inform all our eﬀorts.” (p.
74). Sunstein (2020) adds that ensuring information is salient and simplified is also
critical.

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VACCINE HESITANCYAND CONFIDENCE
This section explores research related to vaccine hesitancy, vaccine confidence, and thedeterminants of vaccine uptake. Parents are an oft-studied audience for vaccinations so
lessons learned in these studies may be applied to the COVID-19 vaccine as well.

Vaccine Hesitancy
Vaccine hesitancy is not a novel phenomenon—widespread community resistanceto vaccinations drove a Supreme Court ruling in 1905 that set a precedent for publichealth law in the U.S. (Harrison & Wu, 2020). Vaccine hesitancy, though, is notnecessarily the same as being anti-vaccination, even though some use these terms
interchangeably. The term “vaccine hesitancy” emerged to depolarize the “pro”
versus “anti” vaccination groups to show that people’s perceptions towardvaccinations typically fall on a continuum (Larson et al., 2014). A working group of
experts on vaccine hesitancy identified vaccine-hesitant individuals as:
A heterogeneous [or diverse] group who hold varying degrees of indecision
about specific vaccines or about vaccinations in general. Vaccine-hesitant
individuals may accept all vaccines but remain concerned about them, they
may refuse or delay some vaccines but accept others, or they may refuse all
vaccines (as cited in Larson et al., p. 2151).
To understand the diversity among groups in terms of vaccine confidence,researchers mapped 149 countries to find out perceptions of the safety, importance,
eﬀectiveness, and religious compatibility of vaccines. For more information about
this study, please see the de Figueiredo et. al study in the Recommended External
Reading and Resources section.

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Conceptualized by WHO, the “Three Cs” model of vaccine hesitancy includes complacency,
confidence, and convenience. MacDonald (2015) defines these as:• Confidence: Trust in the eﬀectiveness and safety of vaccines, the health system andproviders, and the motivations of policy makers who decide they are needed.
• Complacency: Degree to which people believe in the risk of the perceived disease andwhether a vaccine is needed to prevent it.
• Convenience: Resources and barriers include availability, costs, accessibility, and the ability
to understand the vaccine (language and health literacy)
The Sage Working Group on Vaccine Hesitancy developed a Matrix outlining factors that should beconsidered when dealing with vaccine hesitancy (MacDonald, 2015). These include (p. 4163):
1. Contextual influences: communication and media environment; influential leaders;
historical influences; religion; socio-economic status; culture; gender; politics; geographies;
and perceptions of the pharmaceutical industry
2. Individual and group influences: personal, family or community experiences withvaccinations; health beliefs; level of knowledge/awareness; healthcare providers;
perceptions of immunizations
3. Vaccine considerations: perceived risks/benefits; mode of administration, design ofprogram, reliability of vaccine source, vaccine schedule, costs, strength of therecommendations for the vaccine
Biases can also lead to vaccine hesitancy. One such bias is omission bias, which indicates a strong
preference for inaction even when taking action is more beneficial to the individual. Harmful
actions or “commissions” may be perceived to be more detrimental than inactions or “omissions”—
preference for the status quo in some circumstances (Ritov & Baron, 1992). This applies tovaccination in that people become more concerned with the perceived harms of receiving avaccination rather than the significant harms that may result from not being vaccinated (Ritov &Baron, 1990). Therefore, understanding individual reasons for vaccine hesitancy is critical(Habersaat & Jackson, 2020).
Vaccine hesitancy should not be blamed on a lack of information. Rather, Kata (2010) contended
that vaccine hesitancy may be attributed to alternative understandings of health, diﬀerent
perspectives of parental responsibility, and questioning the legitimacy of traditional authorities. She
concluded that, “labeling the other as ‘wrong’—as has been the status quo—is ineﬀectual” (p. 1715).

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9Much research exists investigating vaccine hesitancy related to parents and their children’svaccinations. One study investigated lessons learned about vaccine hesitancy in relation to parents
and administering Vitamin K in their newborns (Shah et al., 2020). The researchers found that
medical organizations typically cite statistics and warn people about the dangers of not vaccinating
while failing to recognize the importance of personal stories. Additionally, they failed to take into
consideration the impact of communities on skeptical college-educated parents. In this case, thecommunity had a falsely high assumption risk associated with immunization (Shah et al.). Shahand colleagues recommended those who are vaccine-hesitant should be treated withcompassion and sensitivity, rather than attempting to defiantly invalidate their views.
In an article about COVID-19 vaccine hesitancy with parents, Taylor et. al (1997) said the single mostimportant factor in getting parents to accept vaccinations is one-on-one contact with an informed,
caring, and concerned pediatrician. In this case, the rationale should be made for the importance ofthe vaccination. Vaccine Information Statements (VIS) also should be given before vaccine
administration or referrals to authoritative sites, such as the Centers for Disease Control andPrevention (CDC), to increase vaccine confidence. Stories and anecdotes about those aﬀected
are also more eﬀective than statistics.
Vaccine hesitancy also is caused by a lack of trust in how well vaccine harms are documented andreported (Scherer et al., 2016). In an experimental study on information eﬀectiveness related to
uptake of Human Papillomavirus (HPV) vaccines, participants were divided into three groups: those
who received only the CDC’s VIS, those who received both VIS and VAERS (Vaccine Adverse Event
Reporting System) summary data, and those who received both the VIS and VAERS full detailed
reports (Scherer et al.). Those who received the VIS alone saw increased perceptions of vaccine
benefits and decreased personal risks. Those who received the VIS and VAERS summary data
displayed more trust in the CDC and greater vaccine confidence. However, those who received VIS
and full detailed VAERS reports saw a significant decline in trust and confidence. This could be
attributed to several possibilities such as the presence of medical jargon or the increase in thevividness of adverse events. Research indicates that potential vaccine candidates should be
informed of the potential adverse events associated with vaccines, but not overwhelm withoverly complex jargon and information.

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The Anti-Vaccination Movement
The anti-vaccination movement has been around for as long as vaccinations themselves, datingback to the early 1800s (College of Physicians of Philadelphia, 2018). People who strongly oppose
vaccinations have been termed “anti-vaxxers,”* but as that term has been debated, we will refer tothem in this guide as the “anti-vaccination community.” One challenge for medical experts isdealing with those strongly opposed to vaccinations. Viswanath (as cited in Burki, 2020) has
suggested that the dogmatic views of anti-vaccination clusters won’t change so it’s more important
to go after those who are undecided about vaccinations. However, the anti-vaccination community
is an important audience as Johnson et al. (2020) determined in a study of Facebook pages. While aminority, they can become “highly entangled with undecided clusters” on the network (Johnson etal., 2020, p. 230).
Some research has investigated attitudes of the anti-vaccination community toward medical
experts in shaping their policy positions. One cognitive bias is the Dunning-Kruger eﬀect, in whichpeople with a low level of knowledge think they know more than they actually do. Specificallyapplied to the debate surrounding vaccinations and autism, research has found that those whoknow the least about the causes of autism are more likely to think they know more than medical
professionals about the causes of autism, perpetuating the claim that vaccines cause autism (Motta
et al., 2018). The researchers concluded that “overconfidence has important implications for
vaccine policy” (p. 280). Additionally, these individuals are more likely to elevate the role of“non-experts.”
Vaccine opposition has been linked to the polarized political environment in the United States. A
study investigated how the current polarized political climate and a lack of scientific consensus has
an eﬀect on public support for the HPV vaccine. The researchers found that a greater understandingof politization is imperative, especially how the political setting at the state level can undermine
public confidence and have an impact on vaccine uptake (Saulsberry et al., 2019).
Some of the anti-vaccination community has been successful at telling first-person stories of those
who say they have been harmed by vaccinations, eﬀectively co-opting experts and research (Brewer
et al., 2017). The stories typically capitalize on fear, anger, and emotion, and promote messages that

*People against vaccinations have been campaigning unsuccessfully
to replace the term “anti-vaxxer” with “vaccine risk aware.”11are memorable and interesting. Oﬀicial sources tend to be more clinical, data-driven, and“forgettable.” (Brewer et al.) Novelty stands out and attracts people compared to pro-vax messaging(Kofler, 2019). First-person testimony can help encourage vaccine confidence.

Determinants of Vaccine Uptake
Specific to COVID-19, Guidry et al. (2020) conducted a survey of 788 people with quota matching on
gender, race/ethnicity, and identifying factors that influence vaccine uptake intentions. The factorsthat lead to a higher likelihood of taking a vaccine include:• Higher education levels• Having insurance• High subjective norms (extent to which an important person or group of people will approveand support a particular behavior)• Positive attitude toward vaccines• High perceived susceptibility to COVID-19• High perceived benefits of the vaccine• High self-eﬀicacy for getting the vaccine• Low barriers to the vaccine
In addition to the aforementioned, the same research found that willingness to take the vaccine
under emergency use authorization (EUA) was also correlated with:• Younger Age• Race/ethnicity (White respondents were more likely compared to Black respondents)• High perceived behavioral control
In a research essay on vaccine confidence, Harrison and Wu (2020) argued the reason people opt outof vaccination programs might not be due to biomedical considerations and risks, but rather thatthe social, cultural, economic, religious, or moral outcomes outweigh the risk from the disease.
There are many reasons why people may choose not to be vaccinated, and these may depend on
several factors related to the population and their communities. In a 2020 study in China,
researchers sampled parents from pediatric immunization clinics in all districts of Shanghai except
Chongming. Many parents expressed concerns about vaccine side eﬀects (73%), vaccine safety(63%), and vaccine eﬀectiveness (52%) (Wagner et al., 2020).

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Understanding how education influences attitudes about vaccination in various countries isimportant as one of the more recent phenomena is people with higher levels of education refusing
vaccinations. A study of 30 countries by Makarovs and Achterberg (2017) about the H1N1
vaccination found (in a general sense) that some highly-educated people oppose getting
vaccinations more so than others with less education. The authors noted, “While the inclination ofpeople with lower socioeconomic status to refuse vaccination may reflect their misinformation,
ignorance and perceived vulnerability, the tendency of more educated ones to avoid H1N1
immunization may be attributed to their overall distrust in science and suspicion of all kind of
manufactured risks that are intrinsic to the modern world” (p. 8).
However, the impact of education levels on vaccination uptake cannot be applied universally. Whilesome studies in certain countries (e.g., The Netherlands, Nigeria, Greece) have found those withhigher education are more likely to vaccinate, research in other countries (e.g., China, Israel, USA)
have found this is not the case (Larson et al., 2014). Less education is also a barrier in somecountries (e.g., India, Kyrgyzstan, Nigeria), including illiteracy and anti-vaccination attitudes.
Some studies found that disseminating vaccination information alone is insuﬀicient to overcome
vaccine hesitancy. Rather, the perceived susceptibility to, and severity of the disease in question, as
well as the perceived eﬀectiveness and risks of vaccinations, are important determinants inpredicting uptake.

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nCoV 19

UNDERSTANDING
AUDIENCES

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To increase vaccine uptake, strategies must be tailored to specific stakeholder groups
based on their demographics, psychographics, geographic locations, technographics,
community, cultural considerations, and other factors. A one-size-fits-all approach will
not work. This section discusses some of the audiences and considerations of vaccine uptake.

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Influencers
Research indicates influencers can improve or lower vaccine uptake. A study of thenCoV 19

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impact of social media influencers on flu vaccinations found that individuals will
engage in positive ways with vaccine promotion messaging on social media if

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presented by individuals they admire or follow (Bonnevie et al., 2020). But someresearch suggests that the most important influencers can be found closer to home.

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The role of interpersonal networks can be closely related to the concept of social
contagion, meaning people have a tendency to think and act like their friends

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and family, which encourages adoption of behaviors (Vaidyanathan, 2020).
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Repeatedly, though, research has found healthcare providers (HCPs) are themost critical influencers and trusted advisors on vaccine confidence. HCPs

nCoV 19with more knowledge about vaccines’ safety and eﬀectiveness are more likely torecommend vaccinations than HCPs with less knowledge (Paterson et al., 2016).

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One of the strategies outlined to increase vaccine confidence is to equip HCPs withtools and guidance to communicate with their patients. This includes

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communicating with respect and empathy to understand the patient’s position
regarding vaccinations (Thomson et al., 2018).

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It should be noted that HCPs often have time constraints, inadequate information

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given to them, and increased workloads, so it’s important to consider this and oﬀer
HCPs more support and resources (Paterson et al., 2016). Additionally, HCPs should

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be included more often in establishing vaccine recommendations (Paterson et al.). However, not all
HCPs globally are fully supportive of vaccinations. In Israel, parents, nurses, and medical workers
not caring for COVID-19 patients expressed higher levels of vaccine hesitancy, especially regarding
the safety of a rapidly-developed vaccine, than those who did care for COVID-19 patients (Dror et al.,2020).
Special consideration should be given to how health oﬀicials and healthcare professionals, including
nurses and ancillary healthcare staﬀ, communicate with communities of high-risk groups, low-income
groups, and people of color. HCPs are critical in terms of encouraging overall vaccine uptake.
However, who is considered an influencer depends on the culture so communicators must have astrong understanding of the audiences and who they perceive as opinion leaders. In 1956, Elvis
Presley received a polio vaccine on “The Ed Sullivan Show,” which resulted in a significant uptake
among teens and young adults (Perry, 2020). Journalists and historian David Perry said regarding
the COVID-19 vaccine, “Celebrity leadership and activism can be overrated, but there are moments inwhich famous and trusted people can sway mass opinion in ways vital to the public good” (para. 9).
In a study of HPV vaccine uptake of college students in Kentucky, parents were found to be the mostsignificant influencer, while doctors were not very influential (LaJoie et al., 2018). Influencers can be
critical to vaccine uptake—the challenge is determining the best influencer for each stakeholder
group. Consistently across research studies, though, including the past two years of the IPR
Disinformation in Society Report (2020), family and friends are the most trusted source for providing
accurate information.

At-Risk Populations
Additional considerations must be taken for at-risk populations when it comes to messaging,including HCPs and immunocompromised patients (Doornekamp et al., 2020). Consistently acrossall at-risk groups, greater knowledge levels increased vaccination uptake in most cases, but
knowledge alone is not suﬀicient. At-risk populations should not be treated the same as othergroups; rather, campaigns should be targeted to a specific audience.
For example, extensive research has been conducted on vaccine hesitancy among pregnant women,
an at-risk population. A meta-analysis of 50 studies found that beliefs that vaccines could cause

315congenital disabilities or general harm were strong deterrents to flu vaccinations, while perceptionsof vaccine utility had a strong influence on uptake (Kilich et al., 2020). One of the greatest factors,
though, was a healthcare professional (HCP) who recommended the flu shot as a routine
vaccination, which resulted in 10 times greater odds of being vaccinated compared to those who
didn’t receive a recommendation from an HCP (Kilich et al., 2020).
In a U.K. survey of 527 older adults (aged 65+) and young-middle-aged adults with chronic
respiratory diseases, researchers found a reluctance to receive the COVID-19 vaccine was associatedwith the respondents’ perceptions that the media have exaggerated the risks and that COVID-19
would be short-lived (Williams et al., 2020). Four key themes emerged from this study that should beconsidered relating to potential COVID-19 vaccine adoption by respondents:•

Personal health and susceptibility to COVID-19•

Perceptions of the seriousness of the illness•

Perceived health consequences to others and loved ones•

Vaccine safety and the “rushed” process (as a barrier)Health Inequalities
COVID-19 has disproportionately impacted people of color. According to the APM Research Lab(2020), Black and Indigenous Americans have suﬀered the greatest loss of life with a death toll of
one in 1,000 in the United States. Research found that “prior research on attitudes towardvaccination across ethnic and racial groups suggests that this may in part be attributable to greater
mistrust of government and health information possibly due to historical and present-day medical
and structural racism” (Jamison et al., 2019, p. 93).
COVID-19 is not the first healthcare challenge that has aﬀected people of color. Certain agents ofpower have been influential in contributing to racial injustice and inequity in healthcare over a long
period of time. The Tuskegee Syphilis Study is one of the most well-known “experiments,” butothers have been conducted in prisons, hospitals, and in the military, according to Washington (1995).
In an essay in Harvard’s Bill of Health, Campbell (2020) contends, “reducing African Americans’
skepticism to anxieties resulting from the U.S. Public Health Service Syphilis Study is a misguided
and myopic rhetorical ploy that obscures the very long arc of medical racism in the U.S.” (para 9).
Mistrust can have significant consequences. In a study applying disinformation and163inequality-driven mistrust from AIDS denialism to COVID-19, researchers wrote that disinformation
promoted from institutions and the federal government to “preserve power” and “undermine
already marginalized groups” in the current COVID-19 environment has an impact on communities whoalready are vulnerable due to “historical and ongoing structural inequities” (Jaiswal et al., 2020, p. 2776).
Jaiswal and colleagues (2020) suggest public health responses must address the “complex
dimensions of mistrust” by paying attention to the “issues of structural racism andsystematic discrimination which create, perpetuate, and sustain mistrust and influence people’s
acceptance or rejection of misinformation or disinformation” (p. 2777). Similarly, Marmot (2005)
outlined the importance of addressing the “causes of the causes: the social conditions that give rise
to high risk of non-communicable disease whether acting through unhealthy behaviours or throughthe eﬀects of impossibly stressful lives” (p. 1102).
Factors of inequality can also play a role in vaccine uptake. Brewer and colleagues (2017) said
context determinants must be considered related to vaccine confidence. Social determinants (howpeople grow up and work), social, economic status, education, and ethnicity also play a role.
Outside of the population groups, how healthcare systems services are provided, designed, andfinanced are important as well. Costs, convenience, and lack of time are other noted barriers.
Wilkinson and Marmot (cited in Marmot, 2005) in a report for the World Health Organization
outlined the evidence for 10 factors on the social determinants of health:
•
•
•
•
•
•
•
•
•
•

The Social Gradient (inequalities in population health are related to disparities in social status)
Stress
Early life
Social exclusion
Work
Unemployment
Social support
Addiction
Food
Transportation

Messaging and education related to COVID-19 vaccinations must specifically focus on high-risk
groups, including low-income individuals and communities of color (Malik et al., 2020). Within thesemessages is a need for cultural humility* and community engagement. Again, this researchemphasizes the need for healthcare professionals and health oﬀicials to be involved in this process.

*Cultural humility is the “ability to maintain an interpersonal stance that isother-oriented in relation to aspects of cultural identity that are mostimportant to [that person]” (Hook et al., 2013, p. 2).

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3

TRUST IN
INFORMATIONThe Role of Trust and Mistrust
According to Macnamara (2020a), corporations, political organizations, and theiragents must be trustworthy. To do so, strategic communication serves as a trustintermediary between an organization and the public. Trust plays a key role in rates ofvaccine uptake. There have been multiple studies investigating the recent role of trust
in institutions during the COVID-19 pandemic. Here are some of the top-line findings:

75%

of respondents said they believe“Americans’ trust in the federal
government has been shrinking.”(Pew Research, July 2020)20%of respondents trust thefederal government(Pew Research, Sept 2020)

62%of respondents said the government
does a “very good” or “somewhat
good” job “ensuring safe food andmedicine” (Pew Research, Sept. 2020)

73%

72%

71%

(The Harris Poll, August 2020)(The Harris Poll, August 2020)(The Harris Poll, August 2020)of respondents said they trust
the Centers for Disease Control
and Prevention (CDC).

of respondents said they
trust the U.S. Food andDrug Administration (FDA).

40%

64%

(The Harris Poll, May 2020)(Pew Research, July 2020)of the American public said pharma’s
reputation has improved since thebeginning of the COVID-19 outbreakof respondents said they
believe “Americans’ trust ineach other has been shrinking”

of respondents said they trust
drug makers actively working on
COVID-19 vaccines.

62%

Trust in businesses increased to 62%(+4 percentage points), but respondents
still hold deep concerns aboutbusinesses (Edelman, May 2020)

38%

80%

67%

September 2020)

May 2020)(Edelman, May 2020)of Americans have “a lot” of trustin scientists (Pew Research,

93%of U.K. adults trust nurses and 91%
trust doctors (Ipsos, November 2020)

trust doctors to “tell the truth
about COVID-19” (Edelman,

16%of U.K. adults trust
government ministers(Ipsos, November 2020)

trust online health experts to “tellthe truth about COVID-19.”+8%

The healthcare industry has seen oneof the “greatest trust gains to date,”with trust increasing by 8 percentage
points (Edelman, May 2020)

VACCINE
10 ml

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In a review of Heidi Larson’s book, “Stuck: How Vaccine Rumors Start—and Why They Don’t Go Away,”
Gellin (2020) emphasizes the critical role trust plays in the vaccine process:“The foundation that underpins vaccination acceptance is trust. Trust in the processes, practices,and policies of vaccine development, licensure, and manufacturing; in the policymakers who set
vaccine recommendations; and in the healthcare system—the doctors, nurses, and community
immunisers who administer vaccines as part of routine care and during mass vaccination
campaigns. Without understanding and addressing trust, eﬀorts to improve vaccine confidence
will be a steep climb. That will certainly be the case when COVID-19 vaccines arrive, especiallygiven the many new vaccine technologies that are being tested and the speed at which they arebeing developed” (p. 1).
In a meta-analysis of HPV vaccination mistrust in Europe, studies found, depending on the country, an
increased mistrust of health authorities, pharmaceutical companies, doctors, and new vaccines(Karafillakis et al., 2019). In Italy, the willingness to get the COVID-19 vaccine is correlated with trust inscientific research as well as general attitude toward vaccine eﬀicacy (Palamenghi et al., 2020). Whilesome may trust vaccinations and the process, others have varying degrees of mistrust or distrust.
Some scholars have diﬀerentiated between the definitions of distrust and mistrust. Lenard (2008) defines
distrust as “a suspicious or cynical attitude towards others” while mistrust is “a cautious
attitude towards others” (p. 313). While there may be distinctions, for this purpose, this guide willview these definitions as being similar, as the literature testing mistrust or distrust uses these terms
interchangeably.
Mistrust of the medical profession has a negative impact on vaccine uptake. Hornsey et al. (2020) found
the reasons why some people prefer complementary or alternatives medicines (CAMs) over vaccines canbe attributed to distrust of conventional medicine rather than trust in CAMs.
In a study investigating the demographic and attitudinal predictors of parental vaccine hesitancy,
Reuben et al. (2020) found less trust in the medical profession played a role as did younger age, lower
levels of education, greater religiosity, and greater disgust sensitivity. Establishing and reinforcing trust inagencies is critical for vaccine uptake, though, this is easier said than done.
Jamison et al. (2019) caution that enhancing the trustworthiness of agencies will require consistentattention to agency actions, including those beyond influenza vaccination with sensitivity to concerns ofminority groups who often have diﬀerent experiences with government agencies.

*Disgust sensitivity has been studied in relation to disgust towardcertain political and social attitudes, such as ethnocentrism or
disapproval of gay people (Reuben et al., 2020).

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Misinformation and Disinformation
The World Health Organization (WHO) has classified the COVID-19 pandemic as a “massive infodemic”
characterized by an over-abundance of information, including disinformation, that makes it diﬀicult forpeople to find trustworthy sources (2020, p. 2). Due to the vast amount of disinformation, UNESCO
has termed this COVID-19 period to be a “disinfodemic” and has created two guides to help
decipher and dissect disinformation (Posetti & Bontcheva, 2020a; Posetti & Bontcheva, 2020b).
According to Macnamara (2020b), part of the strategy for organizations is deciding how or even whether
to challenge and correct misinformation or disinformation. Disinformation is defined as deliberately
misleading or false information, with emphasis on the “deliberately,” meaning there areintentions on the part of the sender to deceive (Institute for Public Relations, 2020). Misinformation,or false or leading information, is more the result of ignorance, carelessness, or a mistake.
Misinformation and disinformation can be found in discussions relating to vaccines in both online andoﬀline channels.
One important area of misinformation is related to the confidence of information disseminated byperceived authorities or experts (in some cases, due to their authority in a position rather than their levelof knowledge). All agencies must be aligned, including government oﬀicials, the healthcare community,and federal agencies; otherwise, vaccine confidence may be reduced. Misinformation by the U.S.
government released in 2020 relating to the COVID-19 pandemic included a downplay of the severity ofthe disease, the level of testing capacity, the eﬀicacy and safety of pharmacological interventions, andthe speed of vaccine development. (Malik et al., 2020). These eﬀorts diminish public trust andconfidence.
Regarding online channels, a 2020 study (conducted pre-COVID-19) estimated that 84% of Americans
visit a vaccine-related webpage annually, with only 18.5% of people encountering vaccine-skepticalcontent, which is more likely to be published by untrustworthy websites (Guess et al., 2020).
Furthermore, searches originating on Google were more likely to generate non-skeptical content thanemail and, to a lesser extent, Facebook.
People may fall for misinformation when engaging in “cognitive laziness,” because they are not careful or
do not care deeply enough about the information they are exposed to (Pennycook & Rand, 2018). Those
who have a stronger tendency to engage in analysis and evaluation of information are less susceptible tomisinformation, even if it aligns with their ideology.

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3

So, what should communicators do? Within the field of behavioral science, there is information about
the best strategies for combatting misinformation. People typically reduce their belief in
misinformation if multiple “expert” sources (as opposed to one) correct the misinformation(Vraga & Bode, 2017). However, when correcting misinformation online, communicators must be careful
to prevent the backfire eﬀect. Therefore, they should be aware that those with deeply held beliefs canuse fact-based information to counter their claims (Wood & Porter, 2018).
Results have been mixed as to the evidence and strength of the backfire eﬀect. Nyhan and Reifler (2010)
define the backfire eﬀect as, “Individuals who receive unwelcome information may not simply resist
challenges to their views. Instead, they may come to support their original opinion even more strongly”(p. 307). While Nyhan and Reifler’s research consistently found evidence of the backfire eﬀect, others
have found its impact to be more elusive. In a series of five experiments testing the backfire eﬀect on 52
polarized issues, Wood and Porter (2017) did not find evidence of the backfire eﬀect. They concluded,“By and large, citizens heed factual information, even when such information challenges theirideological commitments” (p. 1).
Regardless, research does support that rebuttals and corrections of disinformation need to focus onproviding scientific, factual, or other credible information relevant to the issue (Macnamara, 2020b).
False statements should not be repeated as doing so increases familiarity.
While trolls and bots are sources of disinformation, research indicates it may be counterproductive toengage with bot-driven narratives directly as it may “feed the trolls.” (Jamison et al., 2019). Further, “thisrequires profound understanding of how epistemic and ideology beliefs act as obstacles to accepting
scientific evidence” (Wang et al., 2019, p. 8). Research found that increasing “oﬀicial” health narratives is
not enough to counter disinformation (Jamison et al.). Instead, improving social media literacy may be
more successful.
In terms of conspiracies, researchers investigated the extent of this in healthcare, including COVID-19.
Grimes (2020) outlined three motivations for perpetuating health conspiracies:•

Epistemic: Health conspiracies oﬀer simple narratives to complex phenomena, which provides asense of security.

• Egotistic: Narcissistic individuals may be more likely to ascribe to conspiracies, granting them an“illusion of special knowledge.”• Political: Health conspiracies can be damaging to “enemies” by undermining public trust.

21
3

He concluded, “The dark irony is that such conspiratorial narratives induce an inherent distrust of
conventional medicine, providing a cloak for charlatans to operate under” (p. 2).
Macnamara (2020b) summarized some of the flawed argumentation methods and ways to spreaddisinformation, as reported by Cook et al. (2017):• False balance strategy: exploitation of the widely followed media convention of giving equal space
and time to alternative views• Fake experts: people without relevant qualifications• Lack of consensus: even through citing a single dissenting voice, it can create confusion.
When participants were educated in Cook et al’s study (2017) about some of the faulty techniques used
to spread misinformation, they became more resistant to misinformation and disinformation. Thishighlights that media literacy, including applying inoculation theory (discussed in the next section), canmake a diﬀerence.
The framing of messages can impact how information is received. Messages that evoke negative
emotions such as fear, anger, or disgust, can be extremely eﬀective and powerful, even if they are false(Vaidyanathan, 2020). Anti-vaccination content on the internet also has contributed to broader and faster
dissemination of rumors, myths, and inaccurate beliefs regarding vaccines, which negatively impacts
vaccine uptake (Dubé et al., 2013). Additionally, due to the success of vaccines, vaccine-preventablediseases are becoming less visible, and often, the risks or alleged risks of a vaccine are more highlighted
than the risk of the disease itself.

22
3LEVERS AND EVIDENCEBASED PRINCIPLES FORAPPLICATIONThis section includes behavioral science levers and considerations that can be deployed acrosstactical design, key messages, and strategies to influence attitude and behavior change.

Optimism Bias
Optimism bias can present challenges in healthcare. Optimism bias is defined as“the diﬀerence between a person’s expectation and the outcome that follows. If
expectations are better than reality, the bias is optimistic; if reality is better than
expected, the bias is pessimistic” (Sharot, 2011, p. R941). Applied to COVID-19,
people who believe they have a lower chance of contracting the virus thanthey do in reality have an “optimism bias.” Overall, people typicallyoverestimate the likelihood of positive events happening to them andunderestimate the likelihood of negative events. Research found that excessive
optimism can “reduce precautionary behavior” through the underestimation of risk
(Sharot, p. R944).
Researchers conducted studies about the influence of optimism bias relating to
COVID-19. Kuper-Smith and colleagues found individuals tested in three countries(U.K., Germany, and the U.S.) all appeared to share an optimism bias regarding theirchances of getting infected and infecting others (Kuper-Smith et al., 2020). In asimilar vein, researchers also found that risk perception could “become moreaccurate, as the unrealistic optimism belief updating is dampened down” (p. 3). Thismeans that the more people believe in the risk of COVID-19, the more likely they will
engage in behaviors to lessen the spread of COVID-19 (Bottemanne et al., 2020).

Confirmation Bias
Confirmation bias is the seeking or interpreting evidence that aligns withexisting beliefs and expectations (Nickerson, 1998). This can be especially

23

challenging in health contexts as studies in healthcare have found people will selectively expose
themselves to information that is consistent with their beliefs when they seek information. For
example, those who are anti-vaccination may look for information only on anti-vaccination
websites to confirm their viewpoint that vaccinations are bad. One study of early-childhood
vaccinations found that people find information more credible, useful, and convincing when in linewith their ideas, including individuals with high health literacy (Meppelink et al., 2019).
Confirmation bias is similar to “selective exposure.” Selective exposure has been applied to many
genres thanks to Leon Festinger, the father of cognitive dissonance theory. Festinger theorized thatthose who seek out information consistent with their beliefs are doing so to help reduce their
cognitive dissonance, or the mental uneasiness they feel when their perceptions do not align withother information or beliefs (Festinger, 1957). Exposing oneself to information that only aligns
with one’s beliefs can create “homogeneous clusters” or echo chambers. When this happens,
as one study found, this “fosters confirmation bias, segregation, and polarization. This comesat the expense of the quality of the information and leads to a proliferation of biased narratives
fomented by unsubstantiated rumors, mistrust, and paranoia” (Del Vicario et al., 2016, p. 558).

Inoculation Theory
One theory that has limited application to vaccines but studied in other healthcare areas where
misinformation and skepticism may be encountered is inoculation theory. Inoculation involves
debunking false claims before people encounter them. Then, their first encoding of
misinformation is strongly tied with the notion that it is false, equipping people witharguments that can be used to refute and dismiss it. The two main elements of inoculation are
explicit warnings that there are attempts to mislead people and refutations of misinformation(Betsch et al., 2015).
Research indicates countering misinformation once it’s already in society can increase the potentialof a backfire eﬀect (or strengthening one’s existing position). Inoculation theory proactively
counters “potential misinformation by exposing some of the logical fallacies inherent in misleading
communications a priori” or before people encounter it (also called “prebunking”) (Cook et al.,2017, p. 4). Similar to the role of vaccinations, this “inoculates” people to misinformation.
A series of experiments applied to climate change found combining accurate information with an
inoculation was eﬀective in neutralizing misinformation, while simultaneously increasing

24

consensus around climate change (Cook et al., 2017, p. 15). An important note in these experiments
relating to climate change is that the specific misinformation was not presented, but rather awarning about misinformation by explaining the “general technique” being used to create doubt.
This way, generally-framed inoculations could “potentially neutralize a number of misleadingarguments that employ the same technique or fallacy” (Cook et al., 2017, p. 15). While more
research needs to be done in health contexts, the inoculation theory has been applied successfully
to underage drinking, smoking, and vaccines (Compton et al., 2016).
In a study testing how well inoculation theory works concerning the HPV vaccine, Wong (2016)
found two diﬀerent types of messages—those providing reassurances of the safety and eﬀicacy of
the HPV vaccine and those providing reassurances for vaccines in general—were both eﬀective ininoculating against misinformation. Thus, he concluded that “inoculating against negative
messages about vaccinations may be an eﬀective strategy to bolster vaccination rates” (Wong, p.
135).

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THEORIES AND
MODELS TO CONSIDER
IN A FRAMEWORK

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This section highlights theories and models to include as part of a framework to help explainor predict people’s perceptions and subsequent adoption or refusal of vaccinations.

nCoV 19

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Heuristics
Heuristics are mental shortcuts people use to help make decisions and solve
problems. Several types of heuristics have been investigated in the vaccination literature, but only two will be addressed here.

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nCoV 19

Psychologists Amos Tversky and Daniel Kahneman (1973) developed the concept of anavailability heuristic. “When faced with the diﬀicult task of judging probability or
frequency, people employ a limited number of heuristics which reduce these judgments
to simpler ones” (Tversky & Kahneman, p. 207). People use availability heuristics during
a problem-solving process. This is what people can recall when thinking and making
decisions in terms of examples, information, and perceptions about a topic that are justone piece of the broader landscape of available information. News consumption (andrecall) and experiences can influence this as well. For example, if a person knows someone who has died of the COVID-19, this information may come to them more readily.
Perhaps, they also recall the number of people who have been aﬀected or died of thedisease because those statistics are frequently mentioned in the media. At the sametime, they could forget, not know about, or not recall helpful or important informationthat can help them make a decision. Familiarity or salience/importance of the issue
plays a role and, in some cases, can lead to biased decisions due to the type and scopeof information available or recall (or not available) from an individual during the decision-making process (Siegrist & Árvai, 2020).

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The availability heuristic has been applied to risk-related studies. Research found that people
who experience an event have higher risk perceptions than those who have not had such an
experience. Similarly, the aﬀect heuristic represents how people make a decision based

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on their current emotions and how they feel—their “gut” feeling. This can have positive or negative
consequences on the decision-making process, depending on the situation (Tversky & Kahneman, 1973).

Theory of Planned Behavior (TPB)
The Theory of Planned Behavior (TPB) by Icek Ajzen investigates how attitudes, norms, and perceived
control of behavior could impact behavioral intentions and, therefore, behavior. According to
Ajzen (1985), behavior is guided by three types of considerations:• Personal factors: an individual’s positive or negative evaluation (or attitude) of performing this behavior.
• Subjective norms: an individual’s intention to perform a behavior when they evaluate it positively and when
they believe the extent to which “important others” should perform it.
• Perceived behavior control: the perceived ease or diﬀiculty in performing a particular behavior. High

perceived control includes internal factors such as competence, willpower, and determinations andexternal factors such as resources (time, money, tools, and equipment), depending on other people
as well as laws, rules, and regulations (Fishbein & Ajzen, 2011).

TPB has been applied in more than 2,000 studies and in 30 meta-analyses (Hagger et al., 2019). In one
meta-analysis of nearly 100 studies, certain factors were found to be more important than others invaccination intentions. While not focused specifically on COVID-19 vaccinations, some of these include
improving cognitive attitude (thoughts, beliefs, ideas) rather than aﬀective attitude (feelings and emotions) and increasing perceived susceptibility belief. However, it should be noted, that research has foundthat a greater intention to vaccinate does not always translate into people getting vaccinated. Regardless, TPB can help guide large-scale interventions and improve intentions, according to Xiao and Wong (2020).
Anticipated regret may be one of the primary motivators for vaccine confidence in TPB. Sandberg
and Connor (2008) defined regret as a “negative, cognitive-based emotion that is experienced when werealize or imagine that the present situation could have been better had we acted diﬀerently” (p. 590).
Anticipated regret is anticipating that regret before the behavior occurs, so a person avoids it. In ameta-analysis of anticipated regret, scholars found a strong anticipated regret-intention relationshipwith this factor being more significant than all others. (Sandberg & Connor, p. 590.)

Protection Motivation Theory (PMT)
Developed by Ronald Rogers, the Protection Motivation Theory (PMT) examines an individual’s intention to protect oneself from a potential threat, in this case, a vaccination. PMT posits that based on
one’s perception of a threat, people are more or less likely to protect themselves through vaccinations(Makarovs & Achterberg, 2017).

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Rogers (as cited in Makarovs & Achterberg, 2017) oﬀers three components of a fear appeal:• Magnitude of noxiousness (associated with the threat)• Probability of occurrence (associated with the threat)• Eﬀicacy of recommended response (associated with the coping response)
According to Makarovs and Achterberg (2017), people translate this “objective” information provided by
the three components of the fear appeal into their subjective perceptions. The protection motivation isthen their intention to adopt (or not adopt) the recommended coping response (e.g., a vaccination).
Those people who are more likely to believe that they are at risk, that the impact of COVID-19 can besevere, and that the vaccine is safe and eﬀective will be more willing to be vaccinated (Makarovs &Achterberg). In a study of 30 countries with the H1N1 vaccine, the study confirmed that “belittling apandemic's danger and being not sure about vaccination eﬀectiveness and safeness results into an
unwillingness to get vaccinated, fully underscoring the relevance of the protection motivation theory” (p. 7).
Looking at the impact of theories of behavior change on emergency response in infectious disease
outbreaks, the application of PMT yielded support in key outcomes and conclusions. However, alongwith TPB, one of the criticisms of this theory is it does not adequately allow for emotional factors indecision making (even though PMT does consider emotion) (Weson et al., 2020).

Common-Sense Model (CSM)
The Common-Sense Model of Self Regulation, also known as “the Common Sense Model” (CSM), hasbeen applied to vaccine and medicine adoption to explain the process of how patients become aware ofa health threat, navigate their aﬀective responses to it, formulate perceptions of it, and create actionplans for addressing it (Leventhal et al., 2016). The model is a multi-level process that incorporates how
people view certain illnesses based on symptoms they may experience, observation, discussions withothers, and in some circumstances, the mass media and the environment. Perception can influence
response. The theory also diﬀerentiates prototypes (memory structures) and representations (mental
model activated in a specific instance in time).
In a study relating to HPV vaccinations, those who perceive themselves as low risk may decide a vaccine
is not needed. Those who have higher illness coherence (or a personal understanding of an illness) may
be more likely to engage in preventative behaviors, or in this case, a vaccination (Sherman et al., 2017).
However, this is not always the case. A study of the pertussis vaccination applied the CSM model to lookat how parents use their perception of pertussis (whooping cough) and their emotional representation to
make sense of the pertussis symptoms and their vaccination decision. Those who had a greater awareness of the pertussis symptoms were less likely to vaccinate or plan to do so in the future. Also, the ability28
3to control the illness representations, or the perception that vaccines are ineﬀective and antibiotics arean eﬀective treatment, was important. The researchers concluded that educational eﬀorts in West
Virginia to help people identify pertussis (through its characteristic cough) may be a double-edged
sword, decreasing vaccine uptake among more educated mothers (Garg et al., 2018).
The Common-Sense Model is a complex, multi-level model. For more reading about this model, please
see Levanthal (2016).

COM-B Model of Behavior
The COM-B model of behavior was developed to help identify what is needed for an intervention or
behavior change to be eﬀective (West & Michie, 2020). Michie et al. (2011) constructed a “behavior
system” framework synthesized from 19 behavior-change intervention frameworks (that included nineintervention functions and seven policy categories). This COM-B system comprises three essentialconditions for behavior change: capability, opportunity, and motivation that form the hub of a
Behavior Change Wheel (BCW) (see Figure 1).
Moving out, forming a layer around the centerof the wheel are intervention functions. These
are sets of activities designed to change behavior
patterns to address deficits in the three behavior
change conditions. These intervention functions
include education, restrictions, persuasion,
incentivization, coercion, training, enablement,
modeling, and environmental restructuring. The
Figure 1.
final or outside layer of the wheel includes broad
Source: Michie et. al (2020).
Behavioral Change Wheel (BCW)
policy categories that may enable the interventions
to occur. These policy categories may include
guidelines, planning, communication, legislation, service provision, regulation, and fiscal measures. The
researchers recommend the intervention and policy categories should be used to ensure important
options are not ignored in the behavioral change process.
Using the BCW in the COM-B model as a guide, Williams et al. (2020) studied the barriers and facilitators
as identified by high-risk individuals in the U.K. for receiving a COVID-19 vaccine. They found that education and persuasion are most useful, specifically to improve knowledge of the susceptibility andseverity of COVID-19 and vaccine eﬀectiveness. Persuasion could be used to change beliefs andencourage attitudes. Finally, the researchers recommended a unified traditional media and social
media presence to ensure consistent messaging (focused on concerns for oneself and others).

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Diﬀusion of Innovations Theory
Developed by Everett Rogers (2013), the diﬀusion of innovations theory looks at how an innovation(anything perceived as new – in this case, a COVID-19 vaccine) is diﬀused among a social systemover a period of time. The theory posits that the media influences awareness and knowledge of an
innovation, while interpersonal networks impact its adoption. Those who are considered “innovators” are the ones who are the first to adopt the innovation. Following innovators, the early adopters,
early majority, late majority, and laggards follow an S-curve of adoption in that order. Each innovation
may have a diﬀerent set of innovators.
Innovators and early adopters may be opinion leaders and influence adoption among the rest of the
population. However, some innovators, if not perceived as “opinion leaders” or trusted within a community, can create a backfire eﬀect and make people less likely to adopt an innovation. This outcome wasexperienced in a public health eﬀort in a Peruvian village to encourage the boiling of water. The intervention failed due to its inability to consider the influence of opinion leaders and cultural norms and values.
Important in the diﬀusion of innovations theory are the five main factors that influence adoption (Rogers,
2003):• Relative advantage: the degree to which an innovation is perceived as better than the idea it supersedes• Compatibility: the degree to which an innovation is consistent with existing values, past experiences, andneeds of potential adopters• Complexity: the degree to which an innovation is relatively diﬀicult to understand and use• Trialability: the extent to which can be tested, experimented with, or tried before adoption• Observability: the degree to which the results are visible to others

A study of H1N1 investigating the impact of mass media and personal networks on vaccine willingness
found personal information sources were more eﬀective than mass media sources in influencing attitude
and intention (Sengupta & Wang, 2014). Social networks are crucial for vaccine uptake, as are healthcare
providers. “Healthcare providers who are embedded in large networks tend to be more exposed toinnovations, and if they [the networks] are suﬀiciently dense, more inclined to adopt these” (Wensing etal., 2020, p. 3).
Some studies, though, have seen mixed results with the diﬀusion of innovations theory. For example, a
study on the diﬀusion of influenza vaccine found diﬀusion of innovations theory had greater application
to younger adults than to older adults, possibly attributed to the latter’s long-term exposure to vaccination messaging (Chun et al., 2016).

30

GUIDELINES & STRATEGYRECOMMENDATIONS
The following section includes additional research-driven recommendations for a
vaccine-related communication strategy and messaging based on the literature.

Information Sources (including federal agencies)
This section
includesbehavioral
sciencelevers and considerations
that canbetransparent
deployed acrossThe
FDA could
enhance
its trustworthinessby providing
more

informationon theandprocessof influenza
vaccineproduction,
approval,
tactical design,
key messages,
strategies
to influence
attitudeand behavior
change.and regulation(Jamison et al., 2019).

The CDC could potentially improve trust in the agency by acknowledging andexplaining how vaccine eﬀectiveness is assessed and what those measures ofeﬀectiveness mean for the public (Jamison et al., 2019).
Transparency and clear information from regulatory authorities and pharmaceuticalcompanies on the COVID‐19 vaccine development, approval, and safety monitoring
will be pivotal in enabling such trust (Cohen et al., 2020).
Healthcare providers who make a vaccine recommendation are likely to influencevaccine uptake than those who do not (Kilich et al., 2020).
The ideology or aesthetic identity of the messenger makes a diﬀerence. What mattersmost varies across time and communities (Harrison & Wu, 2020).
Behavioral science can inform both empirical work to understand behavior, and thedesign and implementation of interventions to aﬀect behavior (Weston et al., 2020).
Health workers, especially those in communities, remain the most trusted advisor
and influencers of vaccination decisions, and they must be supported to provide
trusted, credible information on vaccines (WHO, 2019).

Theories and Models“The messenger eﬀect” and a credible, similar, likeable messenger (for pro-vaccine, i.e.,a high school student who is getting himself vaccinated) can be beneficial (Kofler, 2019).
In line with "the Theory of Planned Behavior (TPB), helping people form intentions andreducing their vaccine hesitancy may be the first and most critical step to increase theirvaccine acceptance. Additionally, research should explore whether a “strong
vaccination intention” has been formed. If so, resource-based interventions are key; if
not, persuasion-based interventions are more eﬀective (Xiao & Wong, 2020).

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In line with TPB, strengthening perceived control (oﬀering resources to make it easier tobecome vaccinated) among parents or health providers is particularly important (see“perceived behavior control under TPB) (Xiao & Wong, 2020).
The content of mass media interventions to improve vaccine uptake should focus on the
Behavior Change Techniques of health, emotional, social, environmental consequences,and salience of consequences. These techniques should be pitched concerning both self,
and most importantly, others (Williams et al., 2020).
An inoculation message designed to protect a person’s generalized attitude toward a
topic or behavior may be able to provide a blanket of protection for a person’s attitudes
toward specific issues that all fall within the same broad content domain (Wong, 2016).

Communicating About the Vaccine (including messaging strategies)
Being transparent about the adverse eﬀects of a vaccination is essential (Cohen, 2020).
Concerns about side eﬀects or bad reactions should be incorporated in vaccine
communication campaigns and interventions (Guidry et al., 2020).
Cultivate critical thinking and improve health and media literacy by equipping individuals
with the faculty to critically assess information credibility (Wang et al., 2019).
Oﬀicial communications about vaccines should have a clear take-home message, tell amemorable story, and elicit feelings (Shelby & Ernst 2013).
People are concerned about the rushed vaccine development process, so concerns andeducation about the process need to be addressed (Guidry et al., 2020).
Frame the intervention so it aligns, so it aligns with existing compliance and messaging
about hand washing, mask-wearing, and physical distancing. Also, collective support isdrawn from messaging such as, “we’re in this together,” and the protective discourse
implied within phrases like “shielding” (Williams et al., 2020).
Listening to people's concerns will be fundamental to any successful approach, including
thorough engagement with the general public, intended recipients of the vaccine, consumers,
and healthcare professionals in discussions on COVID‐19 vaccines (Cohen, 2020)
Listen to these rumors and recognize what people are saying. These analyses can reveal
deeper issues such as the feeling of being disenfranchised and not being heard (Gellin, 2020).
Avoid the term “conspiracy beliefs” which risks “obscuring and denying meaningful
aspects of people’s lived experience, particularly regarding inequality-mistrust, and is an
ethical and strategic mistake for public health” (Jaiswal, 2020, p. 2777).
Digital push technologies (e.g., text messaging) have a modest, positive impact on vaccine
uptake and series completion compared to non-digital interventions (Atkinson et al., 2019).

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Conclusion
Understanding what people know, how they think, their behavioral intentions, and subsequent
behavior can help increase vaccine uptake with the hope of managing the COVID-19 pandemic.
Theories and models are critical guides to help companies on their journeys. But the topic ofvaccinations can be complicated. Employees, communities, and other external audiences depend oncommunicators to provide them with consistent, clear, and accurate information that fosters trust andconfidence. This guide aims to help companies reduce uncertainty for their employees and to design
tailored, research-driven plans, strategies, tactics, and messaging to increase vaccine confidence, andultimately uptake.

Institute for Public
Relations Resources
The Institute for Public Relations has resources available on its website, including in its Research
Library and Behavioral Insights Research Center.
IPR COVID-19 Vaccine Resources Page

This page provides research relating to the COVID-19 vaccination, including topics such as vaccine hesitancy, vaccine
confidence, multidisciplinary theories and models for frameworks and planning, levers and evidence-based principles
for application, the role of disinformation, and recommendations/strategies for vaccine uptake.

IPR Behavioral Insights Research Center (BIRC)
The mission of the BIRC is to research the factors that influence attitude and behavioral change to enable eﬀective
communication. BIRC can help professionals understand how and why people think and behave the way they do inthis ever-changing business environment.

COVID-19 Resource Center For PR Professionals
IPR has compiled a list of resources beneficial for public relations and communication professionals to better
understand and prepare strategies for COVID-19.

10 Ways To Combat Misinformation: A Behavioral Insights Approach
Misinformation, the unintentional dissemination of false, incorrect, or erroneous information, can lead people to holdinaccurate beliefs and make misguided decisions. To help fight against misinformation, the IPR Behavioral Insights
Research Center has published this guide.

2020 IPR Disinformation in Society Report
The second annual study examines and tracks how disinformation — deemed as deliberately misleading or biased
information — is spread in U.S. society. The poll of 2,200 Americans conducted March 25-27, 2020 by Morning Consult,
explores the prevalence of disinformation in the U.S., the parties most responsible for sharing disinformation, the levelof trust the American public has for diﬀerent information sources, and whose job it is to combat disinformation.

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10 Ways to Identify Disinformation – A Guide and Checklist
How can we stop the spread of disinformation? One way is to take additional steps to find out more about the information or
articles or posts we may share with others via word-of-mouth or through technology. Advancements in technology have made itdifficult for people to discern real posts, sites, or videos from fake ones. To help, IPR has created this guide to help people think
before they link.

Why Debunking Myths About Vaccines Hasn’t Convinced Dubious Parents by Chris Graves
This blog post by Christopher Graves leverages the day-to-day challenges faced by internal and external communicators andwhat can be learned from the vaccine wars.

What You Need To Know About Incorporating Behavioral Science Into Public Relations: A Primer
This primer helps organizations deliver more research-based, theoretical insights driven by behavioral science. Behavioral
science aims to understand human behavior and decision-making. It encompasses disciplines examining the psychologicalunderpinnings of behavior, such as cognition, neuroscience and social psychology.

IPR Research Letter
This letter is a weekly digest connecting you to noteworthy actionable academic and applied research in public relations,
corporate communication, and beyond. We send out a new edition every Wednesday to keep you updated on the latest
research in the PR industry.

About the Institutefor Public Relations
Founded in 1956, the Institute for Public Relations is an independent, nonprofit foundation
dedicated to the science beneath the art of public relations™. IPR creates, curates, and promotes
research and initiatives that empower professionals with actionable insights and intelligence they
can put to immediate use. IPR predicts and analyzes global factors transforming the profession andamplifies and engages the professional globally through thought leadership and programming. All
research is available free at www.instituteforpr.org and provides the basis for IPR’s professional
conferences and events.
Follow Us On Social Media
Twitter | Facebook | Instagram | LinkedIn

34

RECOMMENDED EXTERNALREADING AND RESOURCES
The Public's Role in COVID-19 Vaccination: Planning Recommendations Informed by Design
Thinking and the Social, Behavioral, and Communication Sciences
Monica Schoch-Spana, Ph.D., Emily K. Brunson, MPH, Ph.D., and colleagues
Johns Hopkins Center for Health Security; Texas State Anthropology (2020)
This report examines implications of social and behavioral science on uptake of the COVID-19 vaccine. Several
recommendations for US policymakers and communicators are included in the report, such as:
1. Understand and inform public expectations about vaccine benefits, risks, and supply.
2. Earn the public’s confidence that vaccine allocation and availability are evenhanded.
3. Make vaccination available in safe, familiar, and convenient places.
4. Communicate in meaningful, relevant, and personal terms, crowding out misinformation.
5. Establish independent representative bodies to instill public ownership of the vaccination program.

The Vaccine Confidence Project
Based in the U.K., The Vaccine Confidence Project (VCP) monitors public confidence in immunization
programs, determines the risk level of public concerns in the implementation of vaccine programs, andprovides analysis and guidance for sustained public confidence in vaccines. The VCP has several
current research initiatives underway to evaluate current attitudes surrounding the COVID-19 vaccine
in the U.K. The project website also houses current resources and latest news for vaccines and
COVID-19.
Mapping Global Trends in Vaccine Confidence and Investigating Barriers to Vaccine Uptake: A
Large-Scale Retrospective Temporal Modelling Study
Alexandre de Figueiredo, Ph.D., Clarissa Simas, MSc, Emilie Karafillakis, MSc, Pauline Paterson,
Ph.D., Heidi J. Larson, Ph.D. (2020)
This study mapped vaccine confidence across 149 countries between 2015 and 2019. Findings suggestthat confidence in the importance, safety, and eﬀectiveness of vaccines fell in Afghanistan, Indonesia,
Pakistan, the Philippines and South Korea during this time. However, confidence in vaccines improved
between 2018 and 2019 in some EU member states including Finland, France, Ireland, and Italy.
Confidence in the importance of vaccines (rather than their safety or eﬀectiveness) had the strongest
association with vaccine uptake.
Combating the Disinfodemic Part One: Deciphering COVID-19 Disinformation
UNESCO (2020)
UNESCO developed a policy brief detailing main themes and dominant forms of COVID-19
disinformation based on research that is currently being conducted by the ITU-UNESCO Broadband
Commission. The four dominant forms of COVID-19 disinformation are:1. Emotive narrative constructs and memes
2. Fabricated websites and authoritative identities353. Fraudulently altered, fabricated, or decontextualized images and videos
4. Disinformation infiltrators and orchestrated campaigns
The brief also explains nine main themes that are present in COVID-19 disinformation, such as
false and misleading statistics, discrediting journalists and credible news outlets, andpoliticization, among others.

Combating the Disinfodemic Part Two: Dissecting Responses to COVID-19 Disinformation
UNESCO (2020)
This policy brief assesses the responses used to combat the prolific spread of COVID-19 disinformation.
Four main types of responses to COVID-19 disinformation are:
1.
2.
3.
4.

Responses that focus on identifying COVID-19 disinformation.
Responses governing the production and distribution of COVID-19 disinformation.
Responses within the production and distribution of COVID-19 disinformation.
Responses aimed at supporting the target audiences of COVID-19 disinformation campaigns.

Guide to COVID-19 Vaccine Communications
Emily K. Brunson, MPH, Ph.D., and colleagues
Center for Public Interest Communications at the University of Florida; Purpose; The United Nations
Verified Initiative (2020)
This guide, prepared by the Center for Public Interest Communications at the University of Florida,
outlines a set of research-backed principles for sharing vaccine information that can help increase
trust, acceptance, and demand for vaccination. Key principles include, but are not limited to:•••Make content concrete, supply a narrative, and provide value.
Recognize that communities have diﬀerent relationships with vaccination.
Evoke the right emotions.

A Jab for Elvis Helped America Beat Polio. Now Doctors Have Recruited Him Again…
Robin McKie
The Guardian (2016)
This article reflects on campaigns used to combat polio vaccination hesitancy among teens in the
1950s. Elvis agreed to get his polio shot on air during the Ed Sullivan Show in an eﬀort to persuade
teens to get vaccinated – the eﬀort worked, but not overwhelmingly. A grassroots organization called
Teens Against Polio actually made a bigger diﬀerence in convincing other teens to get vaccinated. The
takeaway is that hard-to-influence groups can still be reached by tapping into new forms ofcommunication.
Vaccine Hesitancy: Definition, Scope, and DeterminantsNoni E. MacDonald
Vaccine (2015)
This article defines vaccine hesitancy as “delay in acceptance or refusal of vaccination despite
availability of vaccination services.” Vaccine hesitancy is complex and context-specific, as it varies
across time, place, and vaccine. Findings suggest that the three determinants of vaccine hesitancy arecomplacency, convenience, and confidence.

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PRIMARY AUTHOR
Dr. Tina McCorkindale
Institute for Public Relations

CONTRIBUTORS

Mike Kuczkowski
Orangefiery
Jasmine Lubin
Institute for Public Relations

Ian Bailey
QurateDr. Jim Macnamara
University of Technology Sydney

Michael Cherenson
SCG Advertising + Public Relations

Frank Ovaitt
Institute for Public Relations

Dr. Marcia DiStaso
University of Florida

Diane Schwartz
Ragan

Dr. Terry Flynn
McMaster University

Michael Schoenfeld
Duke University

Bret Galloway
Communication Consultant

Kerry Sette
Voya Financial

Paul Gennaro
Voya Financial

Stacey Smith
Jackson Jackson & Wagner

Jerilan Greene
Yum! Brands

Chris Talley
Talley Communication Strategies

Erica Hall
Institute for Public Relations

Stephen Thomas
AIA

Brittany Higginbotham
Institute for Public Relations

Dr. Natalie Tindall
Lamar University

Sarah Jackson
Institute for Public Relations

Dr. Jennifer Vardeman
University of Houston

Nikki Kesaris
Institute for Public Relations

Ame Wadler
Zeno GroupMark Klein
Dignity Health

Chuck Wallington
Cone Health

Lilly Kofler
H+K

DESIGNED BY:

Olivia Kresic
Institute for Public Relations

Britt Buzan
Hamburger Creative

For questions about this guide, please contact Dr. Tina McCorkindale at tina@instituteforpr.org
For the report, please visit, https://instituteforpr.org/a-communicators-guide-to-vaccines/

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