This commentary offers 8 promising approaches forming a framework known as PANDEMIC to address COVID-19 vaccination hesitancy.
After sufficient doses are manufactured and logistical barriers are reduced, convincing an overwhelming majority of people to receive a COVID-19 vaccination may be the next major challenge during this pandemic. A group of experts recently proposed strategies that have compelling rationales and are well grounded in behavioral science. However, their approaches may sometimes be unacceptable, impractical, and/or unsuccessful. Therefore, other strategies will be greatly needed to address vaccine hesitancy. The present commentary offers 8 additional promising approaches forming a framework known as PANDEMIC. This acronym stands for the following strategies: presumptive language, asking for advice, norms on an anonymous level, description of favorable attributes, emphasizing clinicians’ own experiences, mandated choice, images, and communication of risk. Each of the strategies is discussed in turn. Many of the proposed strategies have empirical support for achieving desired outcomes in other domains. However, the PANDEMIC framework is untested in regard to increasing the uptake of COVID-19 vaccinations. Therefore, the strategies should be carefully evaluated before they are widely disseminated through public health announcements, email distribution lists, electronic health record messages, and other outlets.
Am J Manag Care. 2021;27(5):e137-e140. https://doi.org/10.37765/ajmc.2021.88605
This commentary offers 8 promising approaches forming a framework known as PANDEMIC to address COVID-19 vaccination hesitancy.
After sufficient doses are manufactured and logistical barriers are reduced, convincing an overwhelming majority of people to receive a COVID-19 vaccination may be the next major challenge during this pandemic. According to a December 2020 national survey, just 56% of Americans were likely to get a COVID-19 vaccination once available to the general public.1 Black individuals and people with lower educational backgrounds had even lower intentions to become vaccinated.1
Volpp, Loewenstein, and Buttenheim recently proposed 5 strategies for a national COVID-19 vaccine promotion program.2 Their strategies have compelling rationales and are well grounded in behavioral science. However, their approaches may sometimes be unacceptable, impractical, and/or unsuccessful (see the Table2-4).
Therefore, other strategies will be greatly needed to address vaccine hesitancy. The present commentary offers 8 additional promising approaches forming a framework known as PANDEMIC. This acronym stands for the following strategies: presumptive language, asking for advice, norms on an anonymous level, description of favorable attributes, emphasizing clinicians’ own experiences, mandated choice, images, and communication of risk. Each strategy is discussed in turn.
This style of communication has been successfully used by primary care clinicians regarding past vaccinations. Training practitioners to use presumptive announcements (eg, “There are some shots we need to do today”), as opposed to more neutral messages (eg, “What do you want to do about shots today?”), increased human papillomavirus (HPV) vaccination rates for younger adolescents.5 Of course, parents encountering the former communication style could still decline the HPV vaccination for their children. Nevertheless, a similar statement implying that a COVID-19 vaccination is standard clinical practice may enhance the credibility of these shots.
Asking for Advice
Liu and Gal found that a business might increase future transactions after informing potential customers, “We are interested in what advice you might have for our organization.”6 In contrast, these researchers concluded that asking solely for opinions or expectations did not produce the same effect. Although the mechanism for this finding is not fully understood, the research team speculated that asking for advice engenders feelings of greater perceived closeness.
This strategy could be adapted for COVID-19 vaccinations by having organizations (eg, local agencies, places of worship) ask for advice regarding ways to encourage future vaccination uptake among its local reluctant members. This approach would be consistent with community coalition–driven interventions, which have some evidence for reducing disparities in other health domains.7 This approach would also be compatible with motivational interviewing, a nonconfrontational communication style in which patients are asked about their own ideas regarding how healthy changes can be facilitated. Some experts have suggested that motivational interviewing is particularly beneficial for minority populations.8
Norms on an Anonymous Level
Volpp et al proposed that individuals publicize their COVID-19 vaccinations.2 Highlighting the worthwhile activities (eg, better food choices, energy conservation) of peers has increased desired behavior by target individuals.9-11 The greater the similarity between the peers and the target person, the more likely that the social norms led to the desired outcomes in those studies. Social influences can demonstrate the acceptability and feasibility of the desired action to ambivalent individuals.
However, in those aforementioned empirical studies, social norms were presented in a deidentified fashion. There would be multiple ways to convey comparable information regarding COVID-19 vaccinations. Describing the sociodemographic heterogeneity of the phase 3 vaccination trial participants (eg, “Thousands of Caucasians and thousands of individuals from racial/ethnic minority groups volunteered for those studies”) may encourage diverse populations to receive vaccinations. Similarly, as members of the general public receive vaccinations under emergency use authorizations, summary statistics about local recipients could further the same objective.
Description of Favorable Attributes
Kreps and colleagues found that people reported being more willing to receive COVID-19 vaccinations if (1) efficacy rates were 90% (as opposed to 50%) and (2) the products were developed by US companies.12 Therefore, a statement like “These vaccinations, which were developed by Pfizer (from New York) and Moderna (from Massachusetts), reduced cases by 95%” may be persuasive to target individuals.
Emphasizing Clinicians’ Own Experiences
Patients often view their own health care providers as more trustworthy relative to other informational sources (eg, government officials).13 Clinicians could mention their own healthy choices, including personal receipt of COVID-19 vaccinations, to help convince reluctant patients.14
Mandated Choice (“active choice”)
Many opportunities reflect “opt-in,” which necessitates neither engagement in a target behavior nor explicit notification of one’s decisions. Similarly, mandated choice—which is more commonly known as active choice—preserves freedom by allowing people to decide if they wish to follow a recommended course of action. However, unlike opt-in, active choice requires people to indicate explicitly an affirmative decision or a negative decision. Active choice may help overcome procrastination and signal the importance of the present opportunity. Relative to opt-in, active choice has been shown to increase intentions for influenza vaccinations.15
Under an opt-in approach to COVID-19 vaccinations, employers would inform employees about the availability of shots and invite them to a scheduling website. Under an active choice approach, employers would require employees to visit a website within a brief time frame to formally indicate their decision—yes vs no—regarding receiving a vaccination. Organizations could justify active choice for not only maximizing vaccinations but also obtaining prompt, accurate estimates of the demand for these shots.
Active choice could be even more impactful by highlighting the benefits of the target behavior and the drawbacks of the opposite behavior.15 Enhanced active choice for COVID-19 vaccinations would go beyond presenting people with an “agree” option and a “decline” option. Enhanced active choice could feature 2 more strongly worded options from which each person must select, such as “YES! I agree to receive the COVID-19 vaccination to reduce my chances of getting this disease” and “I do not agree to receive the vaccination. I realize that my decision may increase my chances of getting COVID-19.”
Verbal messages may lack the vividness to capture someone’s attention. Salient images have resulted in positive outcomes ranging from increasing intentions to quit cigarette smoking to discouraging littering.16,17 Distinctive visual images that are not typically encountered in everyday life may be more effective in facilitating desired behavior vs text-only approaches.18 Media coverage of long lines of cars containing people seeking COVID-19 vaccinations is one potential image that would convey these shots’ popularity. Subsequently, other strategies (eg, widespread dissemination at local pharmacies and scheduled appointments) could be implemented to convince people about the relative ease of obtaining the high-demand vaccinations.
Communication of Risk
Informing potential recipients of the adverse effect profiles of the vaccinations may engender feelings of trustworthiness. Mentioning small weaknesses may enhance the credibility of the message/messenger and increase uptake of the vaccination. Nevertheless, an undue emphasis on adverse effects may dissuade individuals from vaccination although benefits greatly outweigh harms. Presentation of risk information may influence acceptability of vaccinations. Previous research suggests that presenting the likelihood of adverse effects as percentages (eg, “1% of people experienced a high fever”) rather than frequencies (eg, “1 in 100 people experienced a high fever”) may promote more favorable views of the vaccinations.19 The latter presentation may lead people with less numeracy to more easily envision other patients with adverse effects. In addition, positive framing (eg, “99% of individuals did not experience a high fever” vs negative framing (eg, “1% of individuals had high fever”) might enhance willingness to receive vaccinations.19
Although many of the proposed strategies have empirical support for achieving desired outcomes in other domains, the PANDEMIC framework is untested in regard to increasing the uptake of COVID-19 vaccinations. Therefore, the strategies should be carefully evaluated before they are widely disseminated through public health announcements, email distribution lists, electronic health record messages, and other outlets. The large number of people who are not highly interested in vaccinations, combined with calls to ease informed consent requirements for minimal risk research,20 would facilitate the empirical evaluation of these approaches.
The strategies proposed in this commentary may not be appropriate for all individuals. At one extreme, these strategies may be unnecessary for people who are extremely motivated to receive vaccinations. At the other extreme, these strategies would likely fail to convince those individuals who are adamantly opposed to these shots. Therefore, these strategies may have the greatest impact for those who are unsure about receiving vaccinations. The phrasing of these strategies should be pilot tested, refined, and tested with these ambivalent individuals. For those skeptics questioning if a single strategy would have a demonstrable impact on vaccination rates, multiple strategies could be combined into an overall communication plan.
In conclusion, persuasive messages that increase COVID-19 vaccination rates by even a few percentage points could help the country move closer toward herd immunity. Considerable resources have been devoted to develop, test, and manufacture biological interventions for this pandemic. Assuming that data continue to indicate that COVID-19 vaccinations are safe and efficacious, optimal behavioral strategies to encourage these shots deserve substantial attention, as well.
Author Affiliation: Nationwide Children’s Hospital/The Ohio State University Department of Pediatrics, Columbus, OH.
Source of Funding: There was no external funding for this work. Internal support from Nationwide Children’s Hospital was utilized to support the author’s time in writing this commentary.
Author Disclosures: The author reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.
Authorship Information: Concept and design; drafting of the manuscript; critical revision of the manuscript for important intellectual content; and literature review.
Address Correspondence to: Jack Stevens, PhD, Nationwide Children’s Hospital/The Ohio State University Department of Pediatrics, 700 Children’s Dr, NEOB 3rd Floor, Columbus, OH 43205. Email: Jack.Stevens@nationwidechildrens.org.
1. Szilagyi PG, Thomas K, Shah MD, et al. National trends in the US public’s likelihood of getting a COVID-19 vaccine—April 1 to December 8, 2020. JAMA. 2021;325(4):396-398. doi:10.1001/jama.2020.26419
2. Volpp KG, Loewenstein G, Buttenheim AM. Behaviorally informed strategies for a national COVID-19 vaccine promotion program. JAMA. 2021;325(2):125-126. doi:10.1001/jama.2020.24036
3. Largent EA, Persad G, Sangenito S, Glickman A, Boyle C, Emanuel EJ. US public attitudes toward COVID-19 vaccine mandates. JAMA Netw Open. 2020;3(12):e2033324. doi:10.1001/jamanetworkopen.2020.33324
4. Hamel L, Kirzinger A, Muñana C, Brodie M. KFF COVID-19 vaccine monitor: December 2020. Kaiser Family Foundation. December 15, 2020. Accessed January 6, 2021. https://www.kff.org/coronavirus-covid-19/report/kff-covid-19-vaccine-monitor-december-2020/
5. Brewer NT, Hall ME, Malo TL, Gilkey MB, Quinn B, Lathren C. Announcements versus conversations to improve HPV vaccination coverage: a randomized trial. Pediatrics. 2017;139(1):e20161764. doi:10.1542/peds.2016-1764
6. Liu W, Gal D. Bringing us together or driving us apart: the effect of soliciting consumer input on consumers’ propensity to transact with an organization. J Consum Res. 2011;38(2):242-259. doi:10.1086/658884
7. Anderson LM, Adeney KL, Shinn C, Safranek S, Buckner-Brown J, Krause LK. Community coalition–driven interventions to reduce health disparities among racial and ethnic minority populations. Cochrane Database Syst Rev. 2015;(6):CD009905. doi:10.1002/14651858.CD009905.pub2
8. Lundahl B, Burke BL. The effectiveness and applicability of motivational interviewing: a practice-friendly review of four meta-analyses. J Clin Psychol. 2009;65(11):1232-1245. doi:10.1002/jclp.20638
9. Goldstein NJ, Cialdini RB, Griskevicius V. A room with a viewpoint: using social norms to motivate environmental conservation in hotels. J Consum Res. 2008; 35(3):472-482. doi:10.1086/586910
10. Miranda JJ, Datta S, Zoratto L. Saving water with a nudge (or two): evidence from Costa Rica on the effectiveness and limits of low-cost behavioral interventions on water use. World Bank Econ Rev. 2020;34(2):444-463. doi:10.1093/wber/lhy025
11. Otto AS, Davis B, Wakefield K, Clarkson JJ, Inman JJ. Consumer strategies to improve the efficacy of posted calorie information: how provincial norms nudge consumers to healthier consumption. J Consum Aff. 2020;54(1):311-341. doi:10.1111/joca.12272
12. Kreps S, Prasad S, Brownstein JS, et al. Factors associated with US adults’ likelihood of COVID-19 vaccination. JAMA Netw Open. 2020;3(10):e2025594. doi:10.1001/jamanetworkopen.2020.25594
13. Quinn SC. African American adults and seasonal influenza vaccination: changing our approach can move the needle. Hum Vaccin Immunother. 2018;14(3):719-723. doi:10.1080/21645515.2017.1376152
14. Frank E, Breyan J, Elon L. Physician disclosure of healthy personal behaviors improves credibility and ability to motivate. Arch Fam Med. 2000;9(3):287-290. doi:10.1001/archfami.9.3.287
15. Keller PA, Harlam B, Loewenstein G, Volpp KG. Enhanced active choice: a new method to motivate behavior change. J Consum Psychol. 2011;21(4):376-383. doi:10.1016/j.jcps.2011.06.003
16. Gibson L, Brennan E, Momjian A, Shapiro-Luft D, Seitz H, Cappella JN. Assessing the consequences of implementing graphic warning labels on cigarette packs for tobacco-related health disparities. Nicotine Tob Res. 2015;17(8):898-907. doi:10.1093/ntr/ntv082
17. Ernest-Jones M, Nettle D, Bateson M. Effects of eye images on everyday cooperative behavior: a field experiment. Evol Hum Behav. 2011;32(3):172-178. doi:10.1016/j.evolhumbehav.2010.10.006
18. Rogers T, Milkman KL. Reminders through association. Psychol Sci. 2016;27(7):973-986. doi:10.1177/0956797616643071
19. Peters E, Hart PS, Fraenkel L. Informing patients: the influence of numeracy, framing, and format of side effect information on risk perceptions. Med Decis Making. 2011;31(3):432-436. doi:10.1177/0272989X10391672
20. Asch DA, Ziolek TA, Mehta SJ. Misdirections in informed consent—impediments to health care innovation. N Engl J Med. 2017;377(15):1412-1414. doi:10.1056/NEJMp1707991