Improving COVID-19 vaccine acceptance: Including insights from human decision-making under conditions of uncertainty and human-centered design

As of the time of this writing, more Americans have died due to COVID-19 in the last 11 months than all the Americans who died in WWI and the Vietnam, Korean, and Middle East conflicts combined. More than 135,000 Americans are currently hospitalized with COVID-19, and one out of every 744 Americans has now died of this disease. Worldwide, over 2 million people have died, and many more millions sickened and hospitalized. Despite daily news reports providing witness to this tragedy, many deny the reality of the pandemic and its severity; they reject wearing masks, maintaining physical distancing, and other non-pharmaceutical interventions. Critically, the definitive answer to the management of this pandemic lies in safe and effective vaccines widely used among the population. Despite this, vaccines are likely to be rejected by a significant minority of Americans, based on recent polls. Rejection of evidence-based recommendations has been observed across nations, governments, and institutions—despite ongoing evidence of the continuing carnage due to the SARS-CoV-2 virus and definitive evidence of the value of masking and distancing and of vaccines. Why? What motivates some people to take precautions for themselves, their families, and their communities, and others to reject such evidence-based measures? In attempting to understand what leads to acceptance or rejection of a health measure (in this case, the COVID-19 vaccine), it’s critical that healthcare providers (HCPs) understand the beliefs of their patients, while understanding that a common attribute of humans is a determination to defend and hold to their beliefs; to do this, they often reject data and arguments that don’t fit with their previously determined beliefs (i.e., belief-dependent realism). Additionally, it is important to understand the context under which an individual is making decisions. Likely, due to the nature of this ongoing global pandemic (and understanding the context of how the brain makes decisions within conditions of uncertainty and within the context of traumatic events, which this pandemic qualifies as), there will be individuals who are in survival mode, focused on only what is necessary for immediate survival, or engaging in more emotion-based decision-making. This will be different for each individual and understanding this context may be helpful when progressing through the decision-making process with the patient. In the healthcare realm, success in healthcare decision-making by patients is often founded on the HCPs ability and skill in adapting information-sharing and educational efforts to the particular needs of the patient—based on how the patient thinks, synthesizes information, and makes decisions. In a previous set of articles, one of us (CMP) outlined the major tenets of the Preferred Cognitive Style and Decision-Making Model (PCSDM), which has great value for HCPs in improving communication and success in achieving the desired goal of improving vaccine uptake [2], [3], [4], [5]. In one of these articles, we noted that “current vaccine educational efforts, particularly those developed by governmental and public health authorities, invariably adopt a unimodal fact-based, left-brain cognitive style. This reflects the preferential cognitive style used by the developers and approvers of such materials—a style that may not be favored by the intended recipients—and quite obviously not a style that has changed vaccine acceptance behavior in the population. Instead, we believe it is worthwhile to identify preferred cognitive decision-making styles at the individual and group level and adopt educational strategies and message framing specific to each style. Critical to our approach is the idea that an individual’s preferred cognitive style, emotional baseline, and subsequent behavior, are all intertwined” [2]. The PCSDM outlines six representative and common cognitive styles that individuals employ to make decisions (see Table 1 ); in this case, decisions surrounding whether to accept or reject a COVID-19 vaccine. It is critical for HCPs to accurately determine the preferred cognitive style of the patient, adapt this style in regard to educational efforts and conversations, and present information in a style that is within the primary and secondary preferred cognitive styles of the patient. If an HCP communicates facts and data in line with his/her own cognitive style, but that is not the preferred cognitive style of the patient, the healthcare provider has missed communicating in a style that facilitates information processing as they engage in decision-making processes. It is a missed opportunity to educate effectively. Table 1 Cognitive Style Main Effect Verbal Expression Approach Denialist Disbelieves accepted scientific facts, despite overwhelming evidence. Prone to believe conspiracy theories “I don’t care what the data show, I don’t believe the vaccine is safe” Provide consistent messaging repeatedly over time from trustworthy sources, provide educational materials, solicit questions, avoid “hard sell” approach, use motivational interviewing approaches Innumerate Cannot understand or has difficulty manipulating numbers, probabilities, or risks “One in a million risk sounds high, for sure I’ll be the 1 in a million that has a side effect, I’ll avoid the vaccine” Provide nonmathematical information, analogies, or comparators using a more holistic “right brain” or emotive approach Fear-based Decision making based on fears “I heard vaccines are harmful and I’m not going to get them” Understand source of fear, provide consistent positive approach, show risks in comparison to other daily risks, demonstrate risks of not receiving vaccines, use social norming approaches Heuristic Often appeals to availability heuristic (what I can recall equates with how commonly it occurs) “I remember GBS happened in 1977 after flu vaccines, that must be common, and therefore I’m not getting a flu vaccine” Point out inconsistencies and fallacy of heuristic thinking, provide educational materials, appeal to other heuristics Bandwagoning Primarily influenced by what others are doing or saying “If others are refusing the vaccine there must be something to it, I’m going to skip getting the vaccine” Understand primary influencers, point out logical inconsistencies, use social norming and self-efficacy approaches Analytical Left brain thinking, facts are paramount “I want to see the data so I can make a decision” Provide data requested, review analytically with patient Open in a separate window Table from Poland CM, Poland GA. Vaccine education spectrum disorder: the importance of incorporating psychological and cognitive models into vaccine education. Vaccine. 2011 Aug 26;29(37):6145–8.