Regardless of whether the Covid-19 end-game is eradication, or containment in a way we can live with it, we will need a vaccine that works and, just as importantly, one that the majority of us are willing to take.

While clinical trials aimed at creating a safe and effective vaccine charge ahead, far less is being done to ensure the take-up rate is high enough to deliver potential benefits. Without both, it is possible that we face a protracted period of extreme disruption to our personal lives, the organisations that sustain our economies, the societies to which we belong and the world we live in.

In a recent article by Hallsworth and Buttenheim, called Challenges Facing a COVID-19 Vaccine:  A Behavioural Science Perspective, the authors conclude that even after a suitable vaccine is developed, there is a strong probability most people will choose not to take it. They cite a US poll showing one in three will not try to get vaccinated and one in five will actively refuse. To the majority of us this is hard to comprehend, but to a sizable minority it is a legitimate position to take. Behavioural science provides ways to understand why someone might chose not to engage in Covid-19 vaccination and what we can do to increase participation rates.

Hallsworth and Buttenheim describe three behavioural phenomena which, if not addressed, could negatively impact the take-up rate for a Covid-19 vaccine: rejection, rationalisation and habituation. Each of these involves some assessment and processing of perceived risk.

Rejection occurs when the cost of actions designed to mitigate risks are deemed to be too burdensome or restrictive. As the negative impact of protracted lockdown on livelihoods increases, more people are likely to reject measures aimed at reducing the risk of infection, including vaccination. We are seeing this tension play out daily in the media as pro-libertarian sentiments clash with those primarily focused on bringing infection rates under control.

Rationalisation is when we know an action increases our risk, but we do it anyway, and resolve the mental tension by changing our beliefs.  When we engage in a known risky activity, but don’t experience any negative consequences, we are likely to modify our belief and conclude that the activity does not pose substantial risk. There are certain features of Covid-19 that increase the probability of rationalisation. For example, studies to date suggest 50% to 70% of people who contract the virus experience no symptoms at all.  Awareness of this could lead us to believe we have already had it, so no need to worry anymore or, even if we get it, there is a high probability there will be little negative impact. This may be particularly true for young people who, as a cohort, appear to experience less detrimental effects than others.

Habituation occurs when we passively accept the current state in a fatalistic way and believe we can’t do anything about it.  Phrases like ‘we are all going to get it eventually’ are indicative of habituation and, paradoxically, the more infectious we perceive the virus to be, the more likely is this response. In this case, the perceived inevitability of contracting Covid-19 renders any action aimed at mitigating risk pointless.

Each of these personal behavioural responses are having a very real-world, material impact on our ability to collectively and effectively respond to this pandemic. Their degree of influence differs greatly depending on factors such as age, culture, personal circumstances and political affiliation.   More precisely understanding how such personal factors interact with rejection, rationalisation and habituation, and taking appropriately targeted action, rather than a ‘one size fits all’ approach, will help increase vaccine take-up rates.

The work of Robert Kegan, a psychologist, Harvard academic, and the author of Immunity to Change, sheds further light on why many may push back on embracing a Covid-19 vaccine.  He found that only one in seven patients living a life threatening, unhealthy life-style actually made the positive changes advised by their doctors and to which they had committed. Without significant targeted effort and help, deciding to change behaviour most often does not translate into actually behaving differently. Indeed, much of what we do at STEOPLE is designed to help individuals, teams and organisations achieve positive behaviour change.

Kegan also describes a study in which 100% of patients with life threatening heart disease voice their intention to take medication, as prescribed. However, after only a few months, more than 50% had stopped doing so, despite understanding that the drugs could save their lives. When asked why, most answered that they ‘didn’t know’.

The genius of Kegan’s work was to then to ask heart patients, ‘What is your biggest fear about taking the drug?’ to which most responded that it would mean admitting to themselves that they were ‘an old sick person’ and that carrying this identity was too heavy a burden, even if it put their lives at risk. Those diagnosed with schizophrenia can experience similar challenges when taking life changing medication means admitting to a severe mental disorder. Acknowledging these real concerns, and specifically helping patients to deal with them, is a critical part of increasing the probability that they will actually take life-saving drugs.

We already know what fears the majority of us have about not accepting a Covid-19 vaccination; sickness, potential death of ourselves and our loved ones, etc. We know far less about the fears many have about taking the vaccine. We can speculate that it has something to do with not trusting a vaccine produced at such speed, but we can’t be sure. It is important to ask the question and effectively respond if we are to help those people, with legitimate concerns, to not only form the view that taking the vaccine is a good idea, and to be sufficiently motivated to actually take it.

We are all dealing with great uncertainty in these times. Some are finding up-side in the ‘new normal’, but for many more it is generating heightened anxiety and fear, which is a most fertile ground for conspiracy theories to take root. We see this manifesting in movements like QAnon, where those attracted by the alure of greater certainty find comfort in knowing what the rest of us presumably do not, and hence being able to join the dots in ways the rest of us cannot, albeit based on the flimsiest of information and fantastical interpretation.

Sovereign citizens apparently feel so overwhelmed and aggrieved by the world, that they opt out of reality and into an imaginary global society, unbounded by collective mores and rules.

Efforts to rapidly develop a Covid-19 vaccine have also provided further confirmation to those ideologically opposed to vaccination, that big pharma cannot be trusted.

Psychologist Jonathan Haidt, in his book ‘The Righteous Mind’, illustrates that when people become so entrenched in any ideology, they channel all the intellectual capability they can muster into defending and justifying their biases. Persuading those so deeply immersed in an ideological belief to consider other possibilities grounded in reality, is exceptionally difficult. Facts and reason are manipulated and reinterpreted in ways not designed to seek truth, but to strengthen existing positions and prejudices.

Thankfully, the majority of us do not fall into this category and the number of us who do actually disappear down the conspiracy rabbit hole is small.

The truth is that most of us will be drawn to one conspiracy theory or another in our lifetime, but that does not make us a conspiracy theorist.  Apprehension about potential erosion of civil liberties does not make us sovereign citizens, and genuine concerns about taking a Covid-19 vaccine does not make us anti-vaxers.

We know that to truly influence those who have reservations about embracing a Covid-19 vaccination we must first seek to understand. If we want to positively influence them and increase the take-up rate, we need to step through their door before inviting them to step through ours.

To change individual and group behaviours in ways that stick, we must understand the underlying beliefs potentially blocking change and apply what we know from behavioural science to positively influence those beliefs.

Good medical science, working together with good behavioural science, will be needed to get us through this pandemic.