Optimizing COVID Vaccination Rates

Welcome to Phase 1 of our lab’s project. This is a draft, and we welcome your feedback.

-- BJ Fogg, PhD  bjfogg@stanford.edu

Introduction

Our lab is investigating the challenge of getting billions of people vaccinated for COVID-19. In this phase of the project, we use some tools of Behavior Design to analyze the potentials and pitfalls of this global challenge. We hope our work will optimize efforts around the world to vaccinate people safely and efficiently. 

What type of behavior is vaccination?

In this project we assume that vaccination for COVID-19 will be a one-time behavior. You do the behavior once -- for example, you get a shot in the arm -- and you are done. In Behavior Design, we call this a DOT Behavior (“done one time”). DOT behaviors are different from other behavior types, such as a habit that is done repeatedly. (For more on behavior types, see https://behaviorgrid.org/ )

In the traditional academic literature, people have long studied how to influence people to do behaviors one time. Decades ago two sets of compliance-gaining strategies emerged (Marwell & Schmitt, 1967; Kellerman & Cole, 1994). Some strategies, such as appealing to altruistic motives strike our lab team as good to use, while other strategies, like threatening punishment, are less noble. The most influential work related to compliance is Robert Cialdini’s book Influence, which explains six compliance-gaining strategies. 

Vaccination is a compliance challenge. Psychological factors for vaccine acceptance and hesitancy have been studied for decades. In our current project, we use Behavior Design for the first time to analyze research from the past, as well as the new research emerging about COVID-19 vaccination behaviors. 

(A note of clarification: The word compliance can be ambiguous. In our project we use the word compliance as it was used in decades of psychology research: getting people to do a behavior one time. This meaning is not the same as “medication compliance” e.g., take your heart medication daily. Unfortunately, the word compliance has both meanings.)

What factors matter for vaccination?

All human behaviors are a function of three components: Motivation, Ability, and Prompts. These comprise the Fogg Behavior Model. 

Like all behaviors, the one-time behavior of getting vaccinated against COVID-19 is a function of Motivation, Ability, and Prompts.  

A graphical version of the Behavior Model offers additional insight by showing Motivation and Ability are continuous variables, as well as providing an Action Line that shows the compensatory relationship between Motivation and Ability.

If someone has enough Motivation and Ability to get vaccinated at the moment they are prompted, they will get vaccinated. In contrast, if Motivation or Ability (or both) are lacking, then people will not get vaccinated when prompted. The graphic below shows these two scenarios mapped to the Behavior Model. 

All three components must be present at the same moment for the vaccination behavior to occur. The person must have sufficient Motivation, the Ability to get vaccinated, and a Prompt. All at the same moment. 

Below we discuss these three components in reverse order. 

A Prompt for vaccination is anything that tells a person to get vaccinated now. Prompts can come from friends, doctors, TV news, billboards, text messages and more. Sometimes people can prompt themselves: “Oh, I need to get vaccinated.” 

When it comes to vaccination for COVID-19, our lab anticipates that Prompts will be plentiful. Once a vaccine is ready, people around the world will read and hear this message a lot: “Get vaccinated!”  As such, our lab does not anticipate Prompts to be lacking. 

Another component of any behavior, including getting vaccinated, is the Ability to do the behavior. In this case, Ability means how easy or hard it is to get vaccinated. 

One model in Behavior Design segments Ability into five aspects. We believe four of these five are relevant to the vaccination challenge: 

• Time

• Money

• Cognitive Effort, and 

• Physical Effort. 

In this lab project, we assume that getting vaccinated will require little time and that vaccinations will be free (or very affordable). That means we anticipate Time and Money will not be barriers to getting vaccinated.

In addition, in this project we assume that to get vaccinated people won’t need to think much or expend lots of physical effort. That means we anticipate Cognitive Effort and Physical Effort will not be barriers to getting vaccinated. 

(Despite what we’ve written above, we know our assumption about Ability will not be true for many people and many parts of the world. Yes, we realize that for some people the vaccination may be costly. Or it could take long travels to get to a vaccination clinic. In addition, when a COVID-19 vaccination is first introduced, the supply might be limited. In these scenarios and others, Ability will be a challenge to address. We might tackle these issues in a later phase of our project.)

Motivation is the remaining component of a behavior. And this -- Motivation -- has become the focus of our project in this phase. 

For the behavior of getting vaccinated against COVID-19, we believe motivation will be the most critical and variable component. Simply put, if someone lacks motivation for getting vaccinated, they won’t do this behavior, even if vaccination is really easy to do (high Ability) and Prompts are plentiful. 

In brief: The lower the motivation level, the less likely someone will be to get vaccinated.

How to think clearly about motivation for getting vaccinated

Motivation is not a simple construct. For performing any given behavior, motivation is usually a combination of forces: pleasure, pain, hope, fear, social acceptance, and social rejection.

For the behavior of getting vaccinated, multiple motivational forces will be at work. Some factors, such as hope, will motivate the vaccination behavior. Some factors, such as fear, will de-motivate the vaccination behavior. In some cases, an individual may even be required by work or school to get the COVID-19 vaccine—which would greatly increase motivation. 

For example, the hope of protecting your spouse from contracting COVID-19 is a motivator for many people to get vaccinated. In contrast, the fear that a vaccine will have terrible side effects on your health is a de-motivator. 

These two forces, hope and fear, conflict with each other. They press against each other like vectors in physics. In Behavior Design, these are called conflicting motivations. Part of you wants to do the behavior; another part of you does not want to do the behavior. 

As you combine the hope motivator with the fear de-motivator, you can view the overall level of motivation for getting vaccinated.

The graphic below shows a person who is experiencing hope and fear in equal amounts. As a result, this person is undecided about getting vaccinated. 

In the graphic below, the overall motivation level is relatively high because hope is stronger than fear. In this scenario, the person will get vaccinated when prompted. 

In the last graphic below, the overall motivation level is relatively low because fear is stronger than hope. In this scenario, the person will not get vaccinated when prompted. 

Identifying Motivators and De-Motivators for getting vaccinated

In our research we set out to identify the most important Motivators and De-Motivators for getting vaccinated. We approached this in two ways.

First, we analyzed the most recent and prominent research studies about vaccine adoption and vaccine hesitancy. From those articles we identified the strongest Motivators and De-Motivators for getting vaccinated.

Next, we did some research of our own to find what people say would motivate or de-motivate vaccination. 

What the Published Research Says

Drawing from recently published research about motivational factors for getting vaccinated for COVID-19, we put together our findings (so far):

What Motivates People to Vaccinate for COVID-19?

• Other people with shared backgrounds and identities are being vaccinated (Abrams, D., Wetherell, M., Cochrane, S., Hogg, M. A. & Turner, J. C. 1990)


• People they know or admire are cooperating (Fischbacher, U., Gächter, S. & Fehr, E. 2001)


• Trusted local leaders and community members are encouraging them (Bavel, J.J.V., Baicker, K., Boggio, P.S. et al 2020)


• The vaccine is made in their country in a trusted facility (Morning Consult + Politico National Tracking Poll 200797)


• The altruistic idea of getting vaccinated to protect other people who may be more vulnerable (Reiger 2020)


• Feeling informed about vaccine benefits, risks, and supply (Schoch-Spana M, Brunson E, Long R, Ravi S, Ruth A, Trotochaud M 2020).


• Feeling confident that vaccine allocation and availability are evenhanded (Schoch-Spana M, Brunson E, Long R, Ravi S, Ruth A, Trotochaud M 2020).


• Receiving meaningful, relevant, and personal information about the vaccination that has crowded out the misinformation (Schoch-Spana M, Brunson E, Long R, Ravi S, Ruth A, Trotochaud M 2020).


• Independent representative bodies have instilled public ownership of the vaccination program in a person’s own community (Schoch-Spana M, Brunson E, Long R, Ravi S, Ruth A, Trotochaud M 2020).

What De-Motivates People to Vaccinate for COVID-19?

• Feeling that a rushed process of finding a vaccine makes it seem less trustworthy (Hallsworth, Buttenheim; 2020)  (Schoch-Spana M, Brunson E, Long R, Ravi S, Ruth A, Trotochaud M 2020).

• Ardent belief in alternative remedies over traditional science and views (Sommer, W. 2020)

• Feeling the amount of suffering that has already been caused by the pandemic makes any intervention like a vaccine feel like a futile effort now (Hallsworth, Buttenheim 2020)

• Historical and contemporary experiences of discrimination dissuading minority communities to distrust vaccination efforts  (Hoffman 2020)

• Feeling unsure about the optimistic projections for vaccine development timelines (Schoch-Spana M, Brunson E, Long R, Ravi S, Ruth A, Trotochaud M 2020).

• Believing that the unprecedented emphasis on speed has fostered unrealistic expectations about availability of the vaccine (Schoch-Spana M, Brunson E, Long R, Ravi S, Ruth A, Trotochaud M 2020).

• Belief that there are massive conspiracies relating to COVID-19  (Jolley, D. & Douglas, K. M.  2014)

Primary Research on COVID-19 Vaccination

In addition to drawing on outside studies, we conducted our own small research project to find out what would motivate or demotivate people to get vaccinated. From a survey of 51 people (a convenience sample), we identified these to be the top five motivators for getting vaccinated (with the most common motivators listed first):

What Motivates People to Get Vaccinated—COVID-19

1. The side effects are shown to be minimal (or nonexistent).

2. The vaccine is shown to be effective.

3. The vaccine is recommended by trusted people or organizations.

4. The perception that “COVID-19 is a big threat where I live.”

5. Vaccine sales and distribution are free of political or profit motives.

From the same survey of 51 people people, we derived the top five de-motivators for getting vaccinated (with the most common demotivators listed first):

What De-Motivates People to Get Vaccinated -- COVID-19

1. Fear the vaccine safety and research process was rushed

2. Belief that the vaccine is not effective

3. Conflicting guidance from Trump and scientists

4. Concern the vaccine will have significant side effects

5. Distrust of “big pharma” and a vaccine profit motive

Visualizing Conflicting Motivations for Getting Vaccinated

The Fogg Behavior Model is uniquely suited to help visualize conflicting motivations. The arrows pointing upward are Motivators. They drive people toward getting vaccinated. The arrows pointing downward and de-Motivators. They drive people away from getting vaccinated.

For example, we can place the motivational forces from the research literature on the Fogg Behavior Model.

The motivational forces from our lab’s primary research can also be placed on the Fogg Behavior Model. Two such examples are below. 

Motivation is Variable and Dynamic

Motivators and De-Motivators vary by individual, by region, and by culture. In addition, they also vary over time for individuals, regions, and cultures.

To be clear, these motivational forces/vectors are not static. They shift day by day, and even minute by minute. 

Some motivational forces are more dynamic than others. In other words, someone’s hope may be weakened quickly after reading a Facebook post about the ineffectiveness of a vaccine in a friend’s life. In addition, some motivation forces are stronger than others: A parent’s fear that vaccination will cause autism in her child may be a very strong demotivator, overwhelming other motivators, like protecting a grandparent.

The graphic below shows how multiple motivational forces can be mapped to the Behavior Model. This illustrates how the overall motivation level is a result of the various motivational forces. 

To increase the overall level of motivation, you can decrease fear. For example, a trusted medical source can guarantee that you won’t get COVID-19 from the vaccine. Another way to increase the overall level of motivation is to increase hope. For example, here’s an additional hope component: “Getting vaccinated will protect me and the people I love.”

The graphic below illustrates how a person’s overall motivation level can change when fear is reduced and hope increases. 

In some cases it will be easier to reduce fear. In other cases, the best approach will be to increase hope. Most interventions will need to do both to influence a broad audience. 

Designing to Increase the Overall Motivation Level

To be clear: At this phase of the project, we are not prescribing how to most effectively increase the overall motivation level for vaccinations against COVID-19. Instead, we’ve focused on analyzing the problem. 

In the next phase we may shift focus from analysis of the problem to the design of various solutions. In this way we hope to contribute our expertise and insight to optimize the global adoption of a safe and effective COVID-19 vaccination. 

We welcome your feedback. This will guide future phases of our project. 

Please send comments and questions to BJ Fogg, PhD—bjfogg@stanford.edu

References

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