SARS-CoV-2 Vaccine Acceptance: We May Need to Choose Our Battles
Authors: Alison M. Buttenheim
Journal: Annals of Internal Medicine (2020)

Editorials4 September 2020SARS-CoV-2 Vaccine Acceptance: We May Need to Choose Our BattlesFREEAlison M. Buttenheim, PhD, MBAAlison M. Buttenheim, PhD, MBASchool of Nursing, Center for Health Incentives and Behavioral Economics, and Leonard Davis Institute, University of Pennsylvania, Philadelphia, Pennsylvania (A.M.B.)Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M20-6206 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail A vaccine against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is widely considered a key strategy to ending transmission of the virus and getting our social and economic lives "back to normal." All eyes are on Operation Warp Speed and other rapid vaccine development initiatives, with optimistic projections for a safe and effective vaccine being approved in the next few months. But as Fisher and colleagues (1) note in their analysis of attitudes toward a potential SARS-CoV-2 vaccine, approval of a vaccine is just the starting line of a long and challenging race to achieve widespread acceptance of 1 or more novel coronavirus vaccines.In an April 2020 survey of around 1000 adults representative of the U.S. population, Fisher and colleagues (1) found that only about 6 in 10 respondents said "yes" when asked whether they will get vaccinated when a vaccine for coronavirus becomes available. Consistent with other similar surveys fielded later in 2020, about 1 in 10 said "no" and 3 in 10 said "not sure." It is clear from past vaccine promotion efforts that different strategies will be needed for each of these groups. Given long-standing underfunding of public health infrastructure and programs, it is also clear that we may need to choose our battles in terms of which groups we focus on to achieve SARS-CoV-2 vaccine coverage.It is tempting to focus on the most resistant group—the 10% in Fisher and colleagues' study who reported they would not get the vaccine. The study's capture of open-ended responses explaining a "no" or "not sure" answer is helpful here: Respondents in the "no" group most commonly explained their stance with responses about not believing in vaccines, not wanting the vaccine, or not feeling comfortable with vaccines. Concerns about safety and side effects and general distrust were also common. Unfortunately, prior research on vaccine acceptance suggests that this group may be very difficult to persuade to vaccinate. Targeted messaging campaigns that seek to change attitudinal or belief-based antecedents of existing vaccine hesitancy have not shown much efficacy (2). Mandates, scare tactics, and even simple information provision efforts can backfire (3, 4). Given a strengthening antivaccine movement, continued politicization and polarization of vaccines, and limited public health research and programmatic funds, this may be a battle we choose not to fight.The "not sure" group (about 30% of Fisher and colleagues' respondents) is one we cannot afford to lose but is also hard to influence. Although this group's stated reasons for not being sure about vaccinating overlap with those of the "no" group, the safety, efficacy, and newness of the vaccine rank higher in importance, with a strong need for more information. Distinct from garden-variety vaccine hesitancy, the hesitancy around the SARS-CoV-2 vaccine appears to be driven by the unprecedented speed of the vaccine development process and uncertainties about the U.S. Food and Drug Administration approval process and allocation of a limited vaccine supply. This group might well be called the "wait and see" group—they may sit out the early months of vaccine rollout until more safety and efficacy data accumulate. This form of vaccine hesitancy makes the "not sure" group particularly susceptible to misinformation about SARS-CoV-2 vaccines, which is likely to increase as we get closer to approval and in the early months of rollout.A promising strategy to counter and build "resistance" to misinformation is psychological inoculation. Inoculation theory–based interventions expose people to a weakened "dose" of a pathogen—in this case, misinformation—and also offer preemptive rebuttals or refutations of the weakened arguments, for example by pointing out logic flaws or malicious intent (5). The goal is to build resistance to these persuasive techniques so that they can be recognized when encountered on social media or in a personal appeal. Research efforts are already under way to build inoculation theory–based interventions to counter SARS-CoV-2 vaccine misinformation, but they are not shovel-ready.The "not sure" group may also be engaging in some rationalization. As my colleague Dr. Michael Hallsworth and I recently described (6), people may feel that they do not need a SARS-CoV-2 vaccine because they believe they have already had coronavirus disease 2019 (COVID-19)—a particularly easy belief to adopt, given high rates of asymptomatic cases and chronically low availability of COVID-19 diagnostic testing. Or, uncertainty about future vaccine acceptance (on the grounds of not needing it) may reflect a desire to rationalize risky behaviors that some people want to engage in (such as travel or socializing) or must undertake (such as going to work). Interventions to counter these rationalizations involve replacing faulty or biased mental models (for example, overestimating the probability of prior infection) with salient, personalized risk communication. Like inoculation theory–based interventions, they are complex and time-consuming to design and trial.The leaves the "yes" group. Counterintuitively, this majority group that already asserts their intention to vaccinate will also need focused interventions to ensure high rates of vaccine coverage. Fisher and colleagues (1) note that although 60% of respondents stated an intention to get vaccinated, the percentage that will actually get vaccinated is likely to be much smaller. Why? We know from studies of annual influenza vaccination campaigns (7) that even persons who plan to get a flu vaccine often procrastinate, forget, or balk at seemingly small logistic or financial barriers. Fortunately, interventions to close the intention-to-behavior gap for vaccines already exist, and they are often easy and inexpensive to implement. Getting the vaccine must be as easy and hassle-free as possible. It should be free at the point of service—there should be no copays for the vaccine or a vaccine administration fee. Vaccine services should meet people where they are: at a gym, at school, at a retail pharmacy, or in an Uber. Other well-tested strategies—reminders, commitment devices, social comparisons, incentives—can be easily adapted for SARS-CoV-2 vaccine. Efforts to adapt and scale interventions such as these should start now.Ideally, the public health community will be ready to go on day 1 (approval of one or more vaccines) with a national plan for SARS-CoV-2 vaccine communication, demand creation, promotion, and delivery. In the absence of national investments in such a plan, state and local health departments, health systems, and health insurance plans will have to forge their own paths and may need to pick and choose where to focus their efforts given resource constraints. Closing the intention-to-behavior gap for most U.S. residents who appear willing to get a SARS-CoV-2 vaccine is likely to have the greatest payoff for vaccine coverage, disease mitigation, and population health.References1. Fisher KA, Bloomstone SJ, Walder J, et al. Attitudes toward a potential SARS-CoV-2 vaccine. A survey of U.S. adults. Ann Intern Med. 2020;173:964-73. doi:10.7326/M20-3569 LinkGoogle Scholar2. Brewer NT, Chapman GB, Rothman AJ, et al. Increasing vaccination: putting psychological science into action. Psychol Sci Public Interest. 2017;18:149-207. [PMID: 29611455] doi:10.1177/1529100618760521 CrossrefMedlineGoogle Scholar3. Omer SB, Betsch C, Leask J. Mandate vaccination with care. Nature. 2019;571:469-72. [PMID: 31332351] doi:10.1038/d41586-019-02232-0 CrossrefMedlineGoogle Scholar4. Nyhan B, Reifler J, Richey S, et al. Effective messages in vaccine promotion: a randomized trial. Pediatrics. 2014;133:e835-42. [PMID: 24590751] doi:10.1542/peds.2013-2365 CrossrefMedlineGoogle Scholar5. Basol M, Roozenbeek J, van der Linden S. Good news about bad news: gamified inoculation boosts confidence and cognitive immunity against fake news. J Cogn. 2020;3:2. [PMID: 31934684] doi:10.5334/joc.91 CrossrefMedlineGoogle Scholar6. Hallsworth M, Buttenheim A. Challenges facing a COVID-19 vaccine: a behavioral science perspective. Behavioral Scientist. 11 August 2020. Accessed at https://behavioralscientist.org/challenges-facing-a-covid-19-vaccine-a-behavioral-science-perspective on 1 September 2020. Google Scholar7. Milkman KL, Beshears J, Choi JJ, et al. Using implementation intentions prompts to enhance influenza vaccination rates. Proc Natl Acad Sci U S A. 2011;108:10415-20. [PMID: 21670283] doi:10.1073/pnas.1103170108 CrossrefMedlineGoogle Scholar Comments0 CommentsSign In to Submit A Comment Jo G SweetRetired4 September 2020 Covid Immunization As an internist of about 50 years I am strongly pro-immunization and maintain personal recommended immunizations. I am in my late 70's and have co-morbid conditions. I also remember the swine flu immunization and Guillain-Barré. Given the haste of development and testing of the Covid immunization and perceived political involvement in the development, even I will have second thoughts about being in the first weave of recipients. I think this sort of hesitation will be important to address in the "maybe" group. John L. Friedman, MD, FACPRetired Pulmonologist4 September 2020 Our Terrible President Will Scare off Many From getting the COVID-19 Vaccine I've taken all of the recommended vaccines over 90 years since I was a child, but I may not accept the COVID-19 vaccine right off because of my fears that Trump is ramming it through for political reasons. It may result in an ineffective and side-effect ridden injection because it has been rushed through development to aid the president's re-election efforts. I'll wait and see what happens as I remain isolated at home, washing my hands, and wearing a mask. I'll see what happens to Dr. Fauci if he takes it right away. Raminder S Dhadli MDRetired19 January 2021 COVID-19 vaccine acceptance I am a strong proponent of vaccinations. I retired from VA Hospital in 2015 as a staff Physician. I always took the flushot on the first day when it was available to the empolyees. That was the only way I could convince my veterans to take the flu shot, leading by example. I took Shingrex two doses last year. 2nd shot gave me some side effects. I am assured that it gives me 95% protection from Herpes Zoster. I plan to take COVID-19 vaccine whenever it is available. It is worth it to suffer some minor side effects of the vaccine than risking infection with this horrendous virus and its serious side effects. The rewards of getting the COVID-19 vaccine are too many than risks of not taking it. Author, Article, and Disclosure InformationAuthors: Alison M. Buttenheim, PhD, MBAAffiliations: School of Nursing, Center for Health Incentives and Behavioral Economics, and Leonard Davis Institute, University of Pennsylvania, Philadelphia, Pennsylvania (A.M.B.)Disclosures: The author has disclosed no conflicts of interest. The form can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M20-6206.Corresponding Author: Alison M. Buttenheim, PhD, MBA, University of Pennsylvania School of Nursing, 416 Fagin Hall, 418 Curie Boulevard, Philadelphia, PA 19104; e-mail, abutt@nursing.upenn.edu.This article was published at Annals.org on 4 September 2020. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoAttitudes Toward a Potential SARS-CoV-2 Vaccine Kimberly A. Fisher , Sarah J. Bloomstone , Jeremy Walder , Sybil Crawford , Hassan Fouayzi , and Kathleen M. Mazor Annals On Call - Vaccine Hesitancy: Choosing Our Battles Robert M. Centor and Kimberly D. Manning Metrics Cited byWillingness to accept COVID-19 vaccine among the elderly and the chronic disease population in ChinaPreprocedural Viral Load Effects of Oral Antiseptics on SARS-CoV-2 in Patients with COVID-19: A Systematic ReviewThe effect of training with the Pecha Kucha method on the attitudes of chronically ill women toward COVID-19 vaccinationWillingness of Older Adults with Chronic Diseases to Receive a Booster Dose of Inactivated Coronavirus Disease 2019 Vaccine: A Cross-Sectional Study in Taizhou, ChinaMouthrinses against SARS-CoV-2 – High antiviral effectivity by membrane disruption in vitro translates to mild effects in a randomized placebo-controlled clinical trialScarcity in COVID‐19 vaccine supplies reduces perceived vaccination priority and increases vaccine hesitancyFrom COVID-19 Vaccination Intention to Actual Vaccine Uptake: A Longitudinal Study Among Chinese Adults After Six Months of a National Vaccination CampaignPredictors of intention to get COVID‐19 vaccine: A cross‐sectional studyChanges in COVID-19 Vaccine Intent From April/May to June/July 2021Equitable allocation of COVID-19 vaccines in the United StatesThe role of health managers in community prevention and control of Corona Virus Disease 2019Monitoring COVID-19 Vaccine Acceptance in Kuwait During the Pandemic: Results from a National Serial StudyConfidence and Receptivity for COVID-19 Vaccines: A Rapid Systematic Review 15 December 2020Volume 173, Issue 12Page: 1018-1019KeywordsCOVID-19Health insuranceInoculationPrevention, policy, and public healthRacial and ethnic issuesResearch fundingSafetyVaccine developmentVaccine hesitancyVaccines ePublished: 4 September 2020 Issue Published: 15 December 2020 Copyright & PermissionsCopyright © 2020 by American College of Physicians. 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