How to convince Americans to get the COVID-19 vaccine

The coronavirus pandemic has exposed fatal flaws in every aspect of America’s response to a public health crisis — the knack of our political leaders to polarize simple yet effective precautions, the vulnerability of our social media bubbles to misinformation, the fragility of our supply chains for testing and protective equipment and the inadequacy of federal support for workers and small businesses.

But perhaps the most consequential challenge facing the country has been behavioral. How do you persuade people to make the small personal decisions that will help keep them and others safe, from wearing masks to staying 6 feet apart to eventually getting vaccinated?

Behavioral scientist Katy Milkman is a professor at the Wharton School of the University of Pennsylvania, where she co-directs the Behavior Change for Good Initiative. She is also the president of the Society for Judgment and Decision Making and the host of the podcast Choiceology; her book “How to Change: The Science of Getting From Where You Are to Where You Want to Be” will be published in 2021.

Milkman is not surprised that many Americans have resisted masking up — and she is not surprised that many remain wary of the COVID-19 vaccines. “Behavior change is really, really hard,” she tells Yahoo News. “There’s no playbook for the behavioral part of of a pandemic. That was a failure.”

Milkman’s job is to harness insights from economics and psychology in order to nudge people to make better choices, and she is convinced that we can get the COVID-19 endgame right — from surviving a dangerous winter to maximizing vaccine uptake early next year — if we follow the latest behavioral science. She spoke to Yahoo News about what that science says — and why she is optimistic about the difficult months ahead.

(Katy Milkman via Twitter)
Katy Milkman. (Katy Milkman via Twitter)

YAHOO NEWS: How quickly did you realize the pandemic would be a big challenge in terms of individual decision making and behavior?

KATY MILKMAN: Pretty quickly it was clear that human behavior was going to be the key to keeping this thing at bay. I study health decision making, and everyone in my community was immediately focused on how we could help. In early March, behavioral scientists were talking about how to get people to stop shaking hands. I was already studying flu shots, and by late March, early April, we realized we should scale it up and think about it as a pilot opportunity for encouraging COVID-19 vaccination.

Did you sense how messy the behavioral piece of this would get?

Behavior change is really, really hard. There’s a reason that we have an obesity crisis, and it’s not because nobody knows that you have to exercise and eat the right things. I mean, people are still smoking. And those are all things that are really selfish. Now you want us to do things that are not only good for us, but actually a lot of them are mainly going to save other people’s lives? That’s tricky. There’s no playbook for the behavioral part of a pandemic. That was a failure. I hope in the future we’ll get better at that.

What has surprised you about the U.S. response?

I didn’t anticipate that there would be a political element to it, and I still am dismayed that there has been. That obviously made it even harder. We could certainly imagine that our leadership had immediately endorsed masks and been seen wearing masks and that there didn’t need to be an argument over that. The research shows that one of the most powerful predictors of behavior is perceived social norms — what we think everyone else is doing. And leaders often convey that in their behavior, their symbols. We goofed on that. That’s one reason I was really thrilled to see that three of our former presidents have said they’re going to be vaccinated publicly: George W. Bush, Bill Clinton and Barack Obama, all teaming up to put their weight behind vaccination and making it visible that this is a safe thing to do.

Should Trump join them?

Well, he’s already had COVID, of course. But even if you’ve already had it, there’s no reason you can’t get vaccinated (that I know of). So maybe Trump could get it just to show it’s safe. It would be great if he were helpful in encouraging people to get vaccinated.

Black Lives Matter counter protester chants slogans during an 'Anti-Mask' rally, Black Lives Matter protest at Ohio Statehouse.(Megan Jelinger/SOPA Images/LightRocket via Getty Images)
An "anti-mask" rally at the Ohio Statehouse in Columbus on July 18. (Megan Jelinger/SOPA Images/LightRocket via Getty Images)

Let’s talk about vaccines. Are you worried about the numbers you’re seeing in the polls showing that a large percentage of Americans won’t get a COVID-19 vaccine?

I was worried before anyone did a poll. Actually, I’m relieved to see that we’re trending upward from our low point in September in terms of vaccine hesitancy. It was down to only 50 percent saying they would take it. Now we’re back up to 60 percent. The team I’m directing is bringing together a whole bunch of different groups that are thinking about the behavioral science around vaccines. We’re making a game plan so we nail it. There’s a lot of thought and, frankly, also a lot of money being invested in goofing less on this than we have on other things.

What about the people who say they’ll never take it?

True hard-core anti-vaxxers are actually a really small population — about 15 percent of all Americans.

Are they a lost cause?

Totally. I write them off. I don’t even waste any effort on them. So while I’m worried that we’re at 60 percent, I think we can get closer to 85 percent if we play our cards right.

You’ve identified two problems going forward: persuasion and follow-through. Can you describe each of those challenges?

Persuasion is “What do I say when asked if I’m going to get vaccinated?” So that’s about intention, and it requires changing people’s minds. The second thing is follow-through. Sometimes I say I intend to do something and don’t. In fact, anywhere from 40 to 70 percent of the things we say we’ll do, we don’t. That’s everything from saying “I’m going to vote” to saying “I’m going to get this health screening.” I say, “I’m going to exercise,” and then I don’t actually get around to it. That follow-through challenge is huge.

People wearing protective masks cross a street in Midtown on December 6, 2020 in New York City. (John Lamparski/Getty Images)
People wearing protective masks in New York City on Sunday. (John Lamparski/Getty Images)

Let’s break those down. Persuasion: What do we have to get right over the next few months?

So there’s the obvious stuff, which is total transparency about the testing and approval process, so that people don’t feel like it was done behind closed doors, or was political, and so they understand how rigorous the evaluation is and how safe this actually is. Another thing, again, is building social norms. Conveying that lots of other people are doing this is critical to building comfort. “Well, Bob and Sally down the street did it. So did Joe down the street. If everybody I know is doing it, it can’t be that unsafe. They’re all fine.” This is especially true among low-risk groups, like college students who might not think, “I need it personally,” and among underrepresented minority groups, many of which are more vaccine-hesitant than others because there’s a really ugly history of government mistreatment there.

So it’ll be important to highlight members and leaders of these groups getting vaccinated, and it should be easy to make it visible. Like the “I voted” stickers — we should get “I got vaccinated” stickers. Facebook made it possible to post “I voted” and see all your friends who voted. We want to do the same kind of thing on social media. Celebrities, too. When Elvis got vaccinated [for polio], it had a huge effect on young people. We’ll need Taylor Swift or Justin Bieber or — I don’t even know who’s popular —

Someone on TikTok.

[Laughs] Yes, yes, whatever that is. TikTok will be important.

And then for the second piece of the puzzle: How do you actually get people to follow through?

This is what I’ve studied forever, and to me it’s the low-hanging fruit, because you’re already on board. We just have to get your arm out for the shot. And it’s going to be an especially big deal with COVID because many of these vaccines will require two shots weeks apart. So it’s not just that we have to get you in the door of your pharmacy or doctor’s office once, when you said you wanted to be there. Now you’ve got to do it twice — and on a schedule. I’m very concerned about that. But we have tools to help us get it right.

What are those tools? What looks the most promising?

Follow-through has a bunch of components, and we’re doing a big trial to try to find some new answers. Walmart is our partner, along with two local health systems, Penn Medicine and Geisinger Health. We’re testing lots of different messaging: jokes with humor; asking people to make a commitment; just-in-time reminders 15 minutes before your appointment; even a message that actually tells you there’s a vial reserved with your name on it at the doctor’s office … so come get your vial!

I find that very comforting for some reason.

I do too. I really love that one. Another one that’s been tested elsewhere: sending people letters from their employers saying we’re having a free on-site vaccination clinic at your workplace and we scheduled you for an appointment. Come at this time for your appointment, or reschedule it if you can’t. And even though it was really just walk-in hours, no appointment needed, that message increased vaccination 36 percent. The more we can give you a sense of, like, “This has already been taken care of and you don’t have to think about it. Just show up” — it really helps. We should be building these insights into our plan.

U.S. President-elect Joe Biden put on a mask after he spoke on November job numbers at the Queen theater December 4, 2020 Wilmington, Delaware. (Alex Wong/Getty Images)
President-elect Joe Biden puts on a mask after speaking at the Queen theater in Wilmington, Del., on Friday. (Alex Wong/Getty Images)

So you’ll be testing these messages against each other and looking for “winners”?

Exactly. It’s like a big horse race. And also, it’s a very large trial, like hundreds and hundreds of thousands of people. So not only can we say, “Telling people that they have a vial with their name on it works really well on average,” we can actually look and see what works best for different subgroups. And it may be that messaging about how valuable this is for your community works for one group and asking you to dedicate your flu shot to someone you love and automatically texting them your dedication works better for another group. We’ll be able to personalize this. I think it’s going to be really valuable.

When do you expect to get data back?

In the next couple of weeks.

What happens then?

At some point the expectation is that we’ll be in pharmacies and doctor’s offices. We’re going to create a bunch of toolkits. Obviously, Walmart will be using these tools, but we want CVS and Walgreens and large health systems and mayors to know about them too. We have a pretty good network of connections, and we’re going to be spending a lot of time communicating with all the key players involved in encouraging uptake.

How about the incoming Biden administration?

The Biden administration is so all over this. They’ve got two great people on their pandemic task force: Zeke Emanuel, who’s actually a member of our team, the Behavior Change for Good Initiative, and is at Penn in the department where I’m the secondary; and Atul Gawande, who wrote “The Checklist Manifesto” and thinks a lot about behavioral science and encouraging better decisions. I feel really good about the fact that behavioral science will be at the table when the Biden team is thinking about the pandemic response.

A traffic sign reads, "Mask up!" above a road in Westchester as the city continues the re-opening efforts following restrictions imposed to slow the spread of coronavirus on December 06, 2020 in New York City. (Noam Galai/Getty Images)
A sign over a road in Westchester County, N.Y., on Sunday. (Noam Galai/Getty Images)

But before that, we need to get through what’s looking like a very dark winter, with the holidays in full swing and with Americans increasingly impatient about returning to their pre-pandemic lives. Why are we still having such a hard time making good decisions about COVID-19?

The term now in the media is “pandemic fatigue.” I think that’s a bunch of things that psychologists would give other names to. One is hedonic adaptation, which is this idea that fairly quickly, within six months, we can get used to anything. From losing a limb to winning a lottery, we adapt back. Part of the reason we all took preventative measures in March is that we were on high alert. Our emotions told us, “This is an emergency. I need to do something different.” But that high-alert state doesn’t last forever, and it’s definitely been trailing off.

There’s also some really interesting research on differences in the way we react to described versus experienced risk. A researcher named Ido Erev in Israel got interested by observing the different levels of risk tolerance around terrorism in people who are outsiders and not living with the risk of, say, boarding a bus and worrying it could blow up, versus people who are insiders and experience it each day. He recognized that when we live through a high-risk event, it feels really different and we react differently than we would if someone just gave us the statistics.

So a year ago, if someone had said, “I will plop you into this pandemic on Dec. 4, and this is what the risk profile will look like. If you don’t wear a mask, you’ll face this kind of risk. If you don’t socially distance, then your risk will look like this.” We probably would be like, “I’ll lock myself at home,” or more people would. But it’s different when you experience the arc of a pandemic over time and the risk is normalized. All of this contributes to lax behavior.

So how do we better nudge people to wear masks and distance now? Do mandates work, for example?

They’re good. Even if you’re not going out and slapping $200 tickets on people like they did in Australia. When I hear that this is the law, I assume some degree of enforcement if I break it. So it changes, in my mind, the choice and the trade-off — even if in reality it’s never really enforced.

What else should we try?

I do think we’ve entered a new level of emergency mode and we should be blasting that from the mountaintops. We need to do everything we can to activate that original fear response to kill complacency. I got a high-alert message from the city of Philadelphia the day before Thanksgiving that came over the Amber Alert channels: “Hey, things are really bad. Things are ticking up. It’s not June, it’s November. Things are really different.” And I think that was really smart. We need to help people realize that this is not month nine, this is peak month.

We want to suppress disinformation as much as possible as well. That’s going to be true for vaccines. But for anyone who is out there arguing, “We don’t need masks. Fauci originally told us we didn’t need them,” we have to just wipe that out of the conversation. To the extent we can get social media companies and news organizations to assist, that will be valuable.

Another is emphasizing the personal benefit of masks as well as the shared responsibility. Masks were initially framed as a selfless act: “You’re doing this for your neighbor.” And while there is some research on the benefits of feeling like I’m doing things for others, self-interest is normally the biggest motive in our actions.

Finally, we really need to emphasize that the majority of people are doing this and that it’s trending up. Lots of research suggests that’s one of the most effective ways to get other people to conform — getting them to think they’re going to be the weirdo if they don’t.

I know we’re all dismayed that everyone isn’t wearing masks. But I’m actually impressed by how far we have come. Knowing how behavior changes, I think it’s amazing how many people are complying — how many people have radically altered their lives. I think that’s good news, even if I wish it were 100 percent.


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