5 Questions: Kevin Schulman on encouraging COVID-19 vaccination in a politically polarized country

COVID-19 vaccination rates must reach 80% to achieve herd immunity, but only about 60% of Americans are willing to be vaccinated, according to the Pew Research Center. Stanford physician and economist Kevin Schulman suggests marketing tactics to boost compliance.

- By Krista Conger

The COVID-19 vaccine developed by Pfizer was granted emergency use authorization by the Food and Drug Administration.

More than 300,000 Americans have died of COVID-19 — about 1 in every 1,000 people in this country. But will people agree to be vaccinated against the virus that causes the disease?

In November, only about 60% of Americans were willing — far short of the 80% believed necessary to stop the disease from spreading, according to a survey from the Pew Research Center. On Dec. 31, the Los Angeles Times reported that about 50% of Riverside County’s frontline workers declined the injection. 

In an article published Jan. 6 in The New England Journal of MedicineKevin Schulman, MD, MBA, professor of medicine, and Stacy Wood, PhD, professor of marketing at Duke University, note the strong correlation that has been observed between a person’s political views and his or her willingness to comply with social distancing, mask wearing and other efforts to keep the virus in check. This correlation, they suggest, calls for different communication strategies in upcoming vaccine launches and coronavirus vaccination campaigns. They also explore principles of marketing that could help health care professionals and policymakers frame their messaging to encourage vaccine participation. Recently, science writer Krista Conger spoke with Schulman about their recommendations.

1. Why is it important to consider lessons from marketing when framing important public health messages? 

Schulman: Encouraging 80% to 90% of people in this country of over 300 million people to be vaccinated with not one but two doses of vaccine is one of the largest communications challenges any of us have seen in our lifetimes. We need people across the political spectrum to pull together and get vaccinated. But we learned early in the pandemic that our communications strategies about prevention weren’t working. In many cases, masks haven’t been used effectively, for example. So how do we learn from that and adopt new strategies now? 

As clinicians, we’re comfortable dealing with patients in front of us in the exam room, but populationwide questions, like who should be vaccinated, require us to pivot from one-to-one conversations to one-to-many. That’s where marketing and good messaging come in. 

We all want this pandemic to end. We want the economy back and functioning well. We want everyone’s lives to be back to normal. Some piece of this message should resonate with everyone, regardless of who you voted for. 

2. What can health care providers do to encourage vaccination? 

Schulman: It’s important to understand human nature. When faced with three choices — like three possible cup sizes at your favorite coffee shop — most people will choose the one that is less extreme. Moderation feels safe. Framing a health care decision in similar terms can make people feel more comfortable. For example, rather than asking whether someone will get the vaccine, ask whether they are going to get it today, next week or wait until summer, emphasizing that summer is a less recommended option. Make getting the vaccination the normal, rather than an extreme, choice. 

Kevin Schulman 

Another critically important piece is the power of personal stories to demonstrate the safety and importance of vaccination. If someone feels the vaccine is unsafe, tell them about someone in a similar situation who took the vaccine and is doing well. Frame the availability of the vaccination to certain groups as a mark of respect for their service to society, and use visible badges or bracelets to indicate to the public that you’ve been vaccinated because you’re a first responder, or a patient-facing employee, or an essential worker. Celebrate and normalize vaccination. 

A former student of mine was the leader of the polio eradication efforts in Nigeria. To build confidence in rural villages, he would first take the vaccine himself in front of everyone. Then the village elders would take it, and then the elders’ children. Only then would the rest of the villagers take it. Our personal stories and examples are really important.

3. What are other things to keep in mind when speaking with someone who isn’t planning to be vaccinated? 

Schulman: Be careful with numbers and statistics. It can be very challenging for many people to truly understand risks, odds ratios and other statistics that physicians are taught throughout medical school. Instead of talking about the rare risk of side effects, for example, convey concepts with analogies. If they want a guarantee that the vaccination will protect them from the disease, describe how the risk of contracting and dying from COVID-19 after receiving the vaccine is about the same as dying in a car crash. It’s not zero, but it’s very unlikely. 

Another strategy in framing the need for vaccination is to find a common enemy, such as poverty, unemployment or the lockdowns we are now experiencing. Regardless of our political views or our beliefs about the virus, we all want those to end. Don’t talk down to them, or belittle them. Try to find a common ground.

Finally, it’s important to realize, as medical care providers, that we can’t be falsely reassured that everyone out there feels the way we do about the availability of vaccination. There are a lot of people who say they probably won’t or definitely won’t get the vaccine. But we need these people too. How can we reach and reassure these folks as well? 

4. What can medical institutions like Stanford Medicine do to help in this effort?

Schulman: Creating a visible symbol of vaccination, like a wearable badge or a digital stamp for social media or Zoom meetings, can help spread awareness and excitement about the vaccine. It’s also important to gather and spread success stories on websites and across social media promoting the relief and increased freedom experienced by vaccine recipients. It’s clear that misinformation and reports of adverse events spread rapidly over platforms like Twitter and Facebook, so it’s important to actively combat those with positive, personal stories. 

Finally, we also need to be aware of the many different communities we serve, and choose analogies and stories that are statistically appropriate and resonate with each audience and their cultural background. Taking note of what is most successful for each group, and sharing that information among our physicians, would provide a valuable resource when speaking to patients about vaccination. 

5. Are efforts to achieve adequate vaccination rates for COVID-19 likely to be an ongoing challenge? 

Schulman: Absolutely. It’s vital to be clear that we need to vaccinate somewhere between 80% and 90% of our population to stop the spread of this virus. Those rates may even be higher as the virus mutates and spreads more quickly. Until we get to that last mile, we are not done. This is not just a persuasive challenge but a logistical one. Even some people who are eager for the vaccine will not follow through unless it is easy and convenient to do so. As time goes on, we are going to have to do even more, not less. The last time we had a similarly urgent public messaging campaign was World War II, when we pulled out all the stops in terms of engagement of the whole population. Eradicating COVID-19 is going to take a communication effort of that scale to be successful. 

About Stanford Medicine

Stanford Medicine is an integrated academic health system comprising the Stanford School of Medicine and adult and pediatric health care delivery systems. Together, they harness the full potential of biomedicine through collaborative research, education and clinical care for patients. For more information, please visit med.stanford.edu.

2024 ISSUE 1

Psychiatry’s new frontiers