It's time to apply some people science to the vaccine hesitancy problem
Let's being by getting the family doctor involved
For many decades, economists wandered around in the dark, confused that their elegant formulas about consumer behavior failed again and again. They'd yell at their calculations in dark rooms, frustrated that people didn't actually move through the world as rational actors, like the data they fed into those formulas. Then a band of rogue economists started integrating behavioral psychology into their formulas and -- boom! -- it turned out that people were Predictably Irrational. It's time we shoved a lot more of their behaviorism into our thinking about the pandemic. Since I spent a few years writing a series of essays on cognitive biases for PeopleScience.com, I've been thinking a lot about this, and here are my thoughts. I'd be interested in yours.
Like you, I'm really concerned that the U.S. is losing the variant vs. vaccine race. So there's a lot of talk about racing to shots into the arms of the nearly 100 million Americans who haven't taken a vaccine yet. We've focused a lot on strident anti-vaxxers; that's probably a waste of time. It's easy to see people who still haven't been vaccinated as monolithic -- hey, that's the point of cable TV news! -- but it's pretty far from reality. There are plenty of reasons people haven't taken a shot yet, from perfectly reasonable to perfectly crazy. We should start with the easy problems and work our way towards the difficult (or impossible) rather than the other way around.
In Gretchen Rubin's model of human behavior, the Four Tendencies, strident anti-Covid-vaxxers are rebels. They don't like being told what to do, period. Don't confuse rebels with what she calls Questioners, however. These are people who ask a lot of irritating questions -- more than most people can stomach -- but in the end, if you satisfy their questions, they can be persuaded. True rebels are actually a pretty small percentage of the population, and they will be the last to be vaccinated, if ever. It's hard to say how large that group is but Ipsos puts this "hard pass" group at 15%.
Meanwhile, the chart above from CommonwealthFund.org suggests there is a wide swath of people -- opportunity targets -- who are unsure or hesitant about getting vaccinated, but they aren't strident. The underlying data come from this CDC survey, which is interesting to explore. It suggests there are 10s of millions of Americans who are just waiting to hear the right answers to their questions before they get vaccinated. We should work hard to produce these answers for them.
Even still, this model still assumes rational acting, and we know that's not how people behave. We also know what people say and what people do often diverge dramatically. I know plenty of folks who talk like anti-vaxxers who've taken the vaccine, for example. I also know people who say they are anti-vaccine who are really afraid of needles, or afraid of doctors in general. Don't you? Then there is that very large percentage of people who just don't get around to things. Roughly one-third of Americans don't pay their credit cards in full on time every month, even though many of them could. People forget to show up for dentist appointments. They get busy at work. They just...forget.
Then there are all kinds of mechanical reasons people might not get the shot. They are, legitimately, afraid of potential side effects and perhaps how that might impact employment or child care. Plenty of parents are worried the vaccine hasn't been tested enough against the complex systems of growing human bodies -- another rational fear, which is currently shared by global health organizations for children 12 and under. One survey I found said that many parents were waiting until the beginning of the school year to get their over-12 kids vaccinated, another understandable choice. That’s usually when kids have to get medical checkups for sports, etc.
But I think the biggest obstacle of all is that most Americans still have to receive the vaccine from a strange person in a strange place. Primary care doctors were mostly cut out of vaccination plans initially; in part because cold storage requirements and other mechanical factors made administration by doctor's offices practically impossible. But in May, Pfizer got permission from the FDA to dramatically simplify cold storage rules, making it far easier for small practices to administer the vaccine. This is an incredibly important step. Many people don't trust a strange person at a strange facility, just like they don't trust a talking head on TV -- but they do trust the family doctor. Kaiser says that half of “wait and see” unvaccinated Americans would get the shot if it were offered to them during a routine medical visit.
So why aren't people going to see their family doctor to get a Covid vaccine? Some are. But it's still incredibly burdensome, and expensive, for local offices to give out the jab. Commonwealth Fund talked to some doctors who tried. Their good-faith laments were long. Keeping track of patients for two-shot visits required purchase of new software; the application to become a provider was laborious (“One question: What brand is your refrigerator”). And of course, the time required to deal with hesitancy questions is a real barrier to giving all the other required care in the 12.5 minutes or so that docs get with each patient.
Still, getting shots into the hands of family doctors should be the next big push for state and county health officials and the CDC (the CDC says it's trying; perhaps not hard enough). That's because the most powerful concept of all behavioral principles is the default bias. A huge percentage of people didn't enroll in 401(k) plans at work until they were enrolled by default. Critically, there is an opt-out option, but auto-enrollment tends to double participation. We need to make Covid vaccination the default choice. Some of this is happening organically -- every time a workplace creates a vaccine mandate or a bar requires vaccination. But the best method is for family doctors to check vaccination status with every visit and ready a jab as if it's perfectly normal and standard, forcing patients with true objections or healthcare concerns to voice them. The opt-out option must be robust, but the default option is our best way to quickly lift vaccination rates.
Here are a few other behavioral concepts to consider that might be at play in vaccination rates (linked to my more detailed essays on each bias)
The truth is we trust people we like, and we distrust people we dislike. This is called Affect Heuristic. That's why it would help a lot for Donald Trump to forcefully, dramatically, emotionally plead with his supporters to get vaccinated. That's probably the biggest single thing that could happen to increase vaccination rates in America today. People who like him dislike so many government officials they are unlikely to believe anything the current administration says. This is also why family doctors matter so much. People may distrust Doctors in general, or Big Pharma. But they often like the doctor they know, who they would trust to give them a jab.
Whenever we are in a new situation, we all look around at others to see what to do. Even if you rarely take off your shoes when you enter a home, you'll do it if you go to a party and you see a pile of shoes in the entryway. Vaccine messaging should include the idea that "everyone is doing it." All the emphasis on vaccine objectors right now is having the opposite effect, exaggerating the size of the group that isn't doing it.
One optimistic note: Ipsos says 9 out of 10 people now say they know someone -- a family member or friend - who has been vaccinated. At the same time, 80% know someone who has tested positive for Coronavirus, a record, and 35% say they know someone who has died. That should also help with the "everyone should get vaccinated" message.
In a related way, social proof fights back against "false consensus" and groupthink. The world is full of examples that people will believe the wrong thing if the people around them do -- the failed launch of the Space Shuttle Challenger being the most famous example. The problem runs deep. Studies show people assume those groups who disagree have something wrong with them. More likely, they are suffering from availability bias: They are more scared about the vaccine than about Covid if everyone around them feels the same way. And groups tend to take up bunker mentalities when they feel threatened. I have some strategies to fight against groupthink in this piece.
Social proof also helps fight against confirmation bias, perhaps the strongest of all cognitive biases. We let in information that confirms our worldview and block out information that would cause cognitive disconnect. It's very hard -- nearly impossible -- to talk someone out of confirmation bias, so there's very little point in trying. That's why I wrote the rest of this piece =)
People have a bad tendency to see two or three examples of something as a trend – or worse, as a full dataset. So when we hear about a few breakthrough cases of Covid in people who are fully vaccinated, it's incredibly hard not to jump to conclusions that the vaccines don't work. It's hard to talk your way out of this, too, but anyone who has invested money in the stock market knows it's a bad idea to sell all your holdings based on today's bad day. Make a plan based on facts and logic, and stick to it unless new facts and logic come your way
One of the most powerful behavioral tricks is to have a dialog with your future self about some important decision. What will 60-year-old-Bob who wants to retire early think about 50-year-old-Bob who blows $50,000 on a red convertible? This construct can help with persuasion: Ask people to imagine themselves on a ventilator, haunted by the thought that it was entirely preventable with one or two jabs of a needle.
People naturally "kick" when they are close to the finish line, inspired to complete a task. Instead of dwelling on how many unvaccinated people there are in America, it would help to talk about how close we might be to herd immunity. That's not a hard number, of course. But getting a jab into all those vaccine-hesitant types might be enough, even without the strident opponents. Imagine if you were the last person to tip the scales in your community? Your vaccination was the one that put Covid on the run in your town or your school? That would be a powerful incentive.
I think it's possible that people who have yet to get vaccinated don't want to surrender their holdout in part because ... they've invested so much time in the idea, like a stock that's losing value. This is a hard emotion/cognitive bias to overcome. But all that matters is the future. Someone who isn't vaccinated in a place where Covid cases are rising is basically living in March 2020, and will be until they are vaccinated.
When restaurant-goers see chefs prepare their food, their evaluation of food quality goes up dramatically – that’s operational transparency at work. The CDC has failed to gain public trust through transparency throughout the pandemic. Plenty has been written about this already, but it requires mentioning. Questioners (from Gretchen Rubin's model) will not do what they're told without radical transparency, and the CDC has so far failed to deliver that.
One death is a tragedy; “a million deaths” is a statistic. At this point, it should be obvious that case count numbers aren't persuading people to get vaccinated. But stories of individual cases, particularly those involving real suffering and sadness, do have an impact. They light up our emotional limbic system rather than our stuffy prefrontal cortex. I see more of these in local media now; particularly folks who were vaccine-hesitant and now regret it. I don't think we can tell enough of those stories.
Websites trick consumers all the time into “panic buying” by telling them, "Only three left!" Scarcity, when in the middle of a life and death situation, is a fairly easy case to make. See those red counties in Alabama? See those ICU beds filling up? Better get vaccinated, or there will be no bed for you. Something I've pondered, but so far rejected, is a hard deadline to end free vaccinations. It's easy to imagine folks might drop what they are doing and get a shot if time was about to run out. There might be a less-brutal way to accomplish this, like ending a $100 gift card giveaway. But the idea that the vaccine can be available in perpetuity might be a contributing reason for folks to put it off. Rising Covid cases, particularly as school opens and the weather turns cold, offer a sad deadline.
Tell someone to lose weight, they'll likely fail. Give them step-by-step instructions and they're much more likely to succeed. That's the power of concrete planning. Don't just tell people to get a vaccine. Work with them to promise they'll take off Tuesday morning and go to the CVS that's five minutes away. Behaviorists call this "implementation intentions" or "trigger action plans." One company that offered a flu shot clinic on-site found uptake rose by 10% merely by instructing workers to write down a date and time to get it. Concrete plans are essential to getting anything done, especially something as important as vaccination against a pandemic.