COVID-19 | Health Equity
Alison Buttenheim’s Congressional Testimony on COVID Vaccine Hesitancy
Penn LDI Senior Fellow One of Four Top Experts Called Before House Science Committee
Testifying before a Congressional hearing about the grim challenge of COVID vaccine hesitancy, University of Pennsylvania behavioral scientist Alison Buttenheim called on the House Science Committee members to recognize and exploit the power of “fun and delight” in public service ad campaigns designed to change hesitators’ vaccine perceptions.
Quoting Cass Sunstein, Harvard Professor and author of Nudge, a landmark book on behavioral science, Buttenheim cited “a deep human need to smile and laugh,” and said “we can leverage that need through evidence-based messaging that exceeds people’s expectations about getting vaccinated.” As an example, she pointed to the recently released “Sleeves Up, NOLA” New Orleans public service TV ad campaign using local personalities, Carnival dance culture, and joyous humor to promote vaccination.
The seemingly lighthearted “fun and delight” point was part of her deadly serious emphasis on the need for sustained and effective national public messaging as part of a larger five-part strategy to break through the public’s misconceptions, fears and hesitancy about COVID inoculations.
An Associate Professor in Penn’s School of Nursing, Senior Fellow at the Leonard Davis Institute of Health Economics (LDI), and Scientific Director at the Center for Health Incentives and Behavioral Economics (CHIBE), Buttenheim, PhD, MBA, is a behavioral scientist who studies vaccine acceptance and hesitancy. Last July, she was appointed to the National Academies of Science, Engineering, and Medicine’s new Committee on Equitable Allocation of Vaccine for the Novel Coronavirus that produced the 273-page Framework document of the same name.
She is also co-author of “Strategies for Building Confidence in the COVID-19 Vaccines,” a February 2021 rapid expert consultation report produced through National Academies’ Societal Experts Action Network (SEAN), sponsored by the National Science Foundation. Much of her Congressional testimony was informed by this scientific initiative’s insights.
One of four experts
Buttenheim was one of four experts called before the February 19 House Science Committee virtual hearing entitled “The Science of COVID-19 Vaccines and Encouraging Vaccine Uptake.” The three other witnesses were Kathleen Neuzil, MD, MPH, Director of the Center for Vaccine Development at the University of Maryland School of Medicine; Philip Huang, MD, MPH, Director of the Dallas County Department of Health and Human Services; and Keith Reed, MPH, CPH, Deputy Commissioner of the Oklahoma State Department of Health.
The Committee members acknowledged that vaccine hesitancy was “not so much about virology as it is about psychology” in a country where tens of millions of people decline to be inoculated against COVID for reasons ranging from an unfounded fear of autism, bizarre conspiracy theories, an overarching mistrust of the medical system, or concerns about the fundamental safety of a vaccine developed and tested in such a brief period of time.
The urgency of the situation was underscored by Committee members’ sense of shock that such large numbers of health care workers themselves are declining to be vaccinated against the deadly disease that directly threatens them daily.
‘Last mile challenge’
In her main presentation, Buttenheim detailed the five most important science-based solutions she urged Congress to endorse, fund, and promote as the country “tackles the last-mile challenge of getting shots into arms:”
1. “Embrace the dual goal of vaccinating efficiently and equitably. This recently has been framed as sort of a false choice or an either/or with people saying that we can either be fast or be fair with vaccine rollout. We have the science to do both, but we have to be deliberate, intentional, and innovative in our approach to both tracking and achieving those complementary goals.”
2. “Fix the easy stuff. Hassle factors can be a major barrier to vaccination. Even people who are motivated and excited about the vaccine can be deterred by the smallest amount of friction in the system. Whether that’s complex logistics, inconvenience or confusing instructions, making and keeping a vaccination appointment should be easy and hassle free. And frankly, fixing those hassle factors is often easier than changing someone’s mind.”
3. “Keep doing the hard stuff even if it doesn’t scale. There are many people with very legitimate concerns about the speed of vaccine development, diversity of trial participants, or trust in the medical research establishment. What’s emerging as the most effective way to help those folks is sustained, repeated one-on-one conversations with trusted peers or vaccine validators. Now, you can’t bake that kind of engagement in a chat bot or a website FAQ or a message on the side of a bus or even a Tik Tok video. We have to stand up and support those time-intensive interventions and get them to the people who need them, even if they don’t scale.”
4. Use fun and delight. “The “Sleeves Up, NOLA” public service announcement is a truly fantastic example of the idea of leveraging fun and delight in an effective messaging campaign.”
5. “Fail fast, learn fast. Behavioral science advances in much the same way lab science does. We generate hypotheses about an effective intervention and then test those hypotheses via experiments. We need to bring the same speed and rigor to vaccine acceptance research that we brought to vaccine development research so we can get it right in real time and also learn for next time.”
Reported vaccine efficacy levels & hesitancy
Committee members expressed a rapidly growing concern about the new level of hesitancy being generated by the widely reported difference in efficacy levels between the two vaccines currently on the market and three more likely to soon win emergency use authorization. The worry is that many people will “shop” vaccine brands for what they perceive as the most effective and refuse to accept alternatives.
Congresswoman Suzanne Bonamici (D-Ore.) and Congressman Ami Bera (D-Calif.) asked Buttenheim what can be done to make people understand “there have been zero cases of hospitalization or death in clinical trials for all three of these (soon-to-be-released) additional vaccines, including Johnson and Johnson?”
“We need to think about the choice architecture that’s being used — the way we arrange environments in which people make choices,” answered Buttenheim. “The more we can take that choice away from people and not fall into the ‘I’m going to wait for Moderna or Pfizer,’ the better. Those sort of extra choices that cause a kind of cognitive load do not have a place here. The best vaccine is the one you can get tomorrow. The messaging needs to hone in on — and this is unsettled science — the adverse events you mentioned that are not happening with either Moderna or Pfizer or the additional vaccines. To achieve these things, we need to pull in our best social marketing and advertising experts to help frame the idea that any vaccine is a good vaccine decision.”
Congressman Mike Garcia (R-Calif.) disagreed. “This is different than the normal flu vaccination,” he said. “The average American is much more aware and informed about what’s going on. So when we try to ‘remove cognitive load’ from people’s decision-making process or discourage them from having choices, we have to be eyes wide open. Using language like that can cause some demographics to actually become either more paranoid about the vaccine or less trustful of the government. I agree with everything you’ve said at an academic and science level, but I think rather than discouraging people from asking questions, we should make the answers to those questions more readily available.”
Congresswoman Deborah Ross (D-N.C.) Noted that some academic researchers in her state were studying the potential use of various kinds of incentives to bring more people to vaccination. She asked Buttenheim if that is a potential option.
“The use of incentives in this context is very controversial,” said Butteheim. “Does a $20 gift card work? Does a $1,500 big investment that looks like relief money work? My personal opinion as a researcher is that this is not a great place for incentives. One thing incentives can do is signal that the behavior being incentivized is difficult or risky or unpleasant for some reason. I think that’s not the message we want to get out with the vaccine.”
The global crisis
Another strong sentiment from both Buttenheim and members of the Committee was that while the U.S. is currently tightly focused on its own pandemic crisis, the crisis is a global one that will only be completely solved when the world’s population is vaccinated — with the U.S. playing a significant role in that effort.
In response to a question from Congressman Jerry McNerny (D-Calif.) about populations beyond our borders, Buttenheim responded “We have to be mindful that none of us are protected until we’re all protected. We need to motivate people to buy into the idea that the U.S. will be a global player providing vaccines to other countries. Think about it. Americans like to travel. We like travelers from other countries to visit us. Every evening, I look at some of the amazing international COVID trackers that show the comparison rates of disease and vaccinations. It’s agonizing to see. The U.S. is moving forward with vaccines and we may have a ways to go, but much of the rest of the world hasn’t seen a single dose yet.”