Vaccine hesitancy will not be overcome with threats — we need to use behavioural science to convince the sceptics

The discovery of the Omicron variant, and the recently declared fourth wave in South Africa, has highlighted the urgency to increase vaccination rates in our country. In his most recent national address, President Cyril Ramaphosa asserted that “vaccines do work. Vaccines are saving lives.” All the available data suggests that vaccine penetration rates above 80% are required to effectively reduce Covid-19 to a mild-to-moderate respiratory illness and return society to some sort of normal.

Yet, vaccine roll-out and uptake has been disappointingly slow in South Africa, with only 42% of adults vaccinated at the time of writing. The reasons for these poor rates are many and complex. At the start of the year, the roll-out was hampered by limited vaccine supply, and South Africans were made to wait for months for vaccines as wealthier nations controlled access. Mistrust of the provider of the vaccine also likely impacted uptake at a national level. It might be more challenging to shift the general sentiment around government performance but improved focused vaccine messaging might be more amenable.

A key factor driving lower-than-desired uptake rates is individual vaccine hesitancy. Recently, slow vaccine-uptake forced the South African government to request delays in delivery of Pfizer and Johnson & Johnson vaccines due to an oversupply of stock. Dr Matshidiso Moeti, the Africa Director of the World Health Organization, affirmed that there is “no doubt that vaccine hesitancy is a factor in the roll-out of vaccines” and that individuals are hesitant to get vaccinated in part due to fears of potential side effects.

Our research group has found similar results in a sample of South African women in Khayelitsha, Cape Town, enrolling in a randomised controlled trial. More than 80% reported the fear of side effects of the vaccine as being the major obstacle to vaccination. Far less frequently (in less than 10% of instances), did participants report insufficient research on vaccines, disbelief in vaccine efficacy, and mistrust in government as reasons for not getting the vaccine.

How do we, as government, healthcare workers, and citizens, overcome this hesitancy? It seems that our country is on course for mandated vaccination for persons using or entering public institutions, but even this is unlikely to achieve the penetration necessary, and certainly not in the required timeframe to curb new variants and subsequent waves of infections. Current vaccination strategies include large-scale public information campaigns encouraging individuals to vaccinate to avoid serious illness (“vaccinate” or “ventilate”).

These fear-based strategies are unlikely to work, as they immediately raise a defensive response. The normal human reaction to threat is called “fight” or “flight”, and even when presented with an apparently smaller threat (the vaccine), the automatic response is to avoid.

In order to assist people to adopt an alternative evidence-based perspective and move them into vaccine uptake behaviours, one scientific approach is nested in the practice of Motivational Interviewing (MI). It was first developed by William Miller and Stephen Rollnick in the 1980s and is described as “… a directive, client-centred counselling style for eliciting behaviour change by helping clients to explore and resolve ambivalence”.

There is a huge and growing evidence base for it. People who are vaccine-hesitant may find themselves in one of two states of mind: pre-contemplative (no intention to change) or contemplative (accepting need for change but not yet ready to change). At its core, MI adopts a collaborative, non-judgmental, and empathic approach that respects the individual’s reasons for ambivalence.

Crucially, MI offers individuals the opportunity to create healthy cognitive dissonance — the suggestion that the future holds two scenarios for the individual: one with the intervention (in this case, the vaccine), and the other without (living unvaccinated and at risk of experiencing worse Covid-19 outcomes).

A key approach to MI and using cognitive dissonance is to ensure that the messaging is positive (rather than fear-based) and responsive to prevailing concerns impacting the current position. What are the positive angles to being vaccinated?

For individuals, the current evidence indicates that the vaccinated state offers several positive outcomes: significantly reduced risk of acquiring Covid-19 in the first instance, the prospect of spending time with other vaccinated people with decreased need for masking and distancing, and the ability to move around freely in society, where vaccine mandates are likely to increase.

As tempting as it may seem to include the data on reduced risk of developing severe Covid-19 disease (including hospitalisation and death), we argue that these are negative messages that will not increase uptake. Rather, they may result in automatically negative thoughts in the individual, which will likely lead to avoidant thinking and negatively impact the state of mind in which contemplating vaccination occurs.

We need to address the issue of the fear of side-effects head on — they do occur and are common for any vaccine, including the Covid-19 vaccine. However, we need to adopt a communication strategy that reinforces what is known: that side-effects are mostly mild and manageable, and short-lived. We need to tip the scale of ambivalence in favour of enduring some side effects.

This will entail carefully re-framing the nature of side-effects into acceptable experiences for a person: “your arm may feel sore like a bee sting/a bruise…” and “you may have a slight fever like you have a slight cold/have exercised for an hour…”.

When resistance to these ideas of tolerating side effects is encountered, the interventionist must roll with it, meaning that they must not argue against the flow of the person’s thinking, but should rather accept their position while offering alternatives. This approach may assist in preparing individuals by directly addressing their concerns and subsequently unlocking the ambivalence.

How can we adopt the MI approach to address vaccine hesitancy? At the national level, one-way messaging should rely on the positive aspects of being vaccinated, over the short-term annoyance of side effects. Community-level interventions should adopt an interdisciplinary approach and involve groups from non-governmental organisations (NGOs) taking advantage of captive communities such as churches and other social organisations. The communication in these forums should ideally involve some feedback and interaction.

Finally, at an individual level, interventions using brief adapted MI, with tailored cognitive dissonance need to be manualised, taught and delivered by accessing non-specialist cadres such as community health workers, and other providers. Time is limited, so this needs to be urgently considered.

Staying positive in vaccine messaging may result in the best uptake and outcomes among South Africans. DM

Professor John Joska is Head of Clinical Services (psychiatry) at Groote Schuur Hospital and Director of the University of Cape Town HIV Mental Health Research Unit.

Dr Stephan Rabie is a Senior Research Officer in the HIV Mental Health Research Unit, Department of Psychiatry and Mental Health, at the University of Cape Town. His research interests include behavioural medicine, HIV mental health, and community participatory research.  

Associate Professor Goodman Sibeko is Head of Addiction Psychiatry at the University of Cape Town and Director of the South Africa International Technology Transfer Centre. His work has focused on interventions using non-specialist workers in the management of severe mental illness, and he has a developing research portfolio focused on task-sharing models for the treatment of harmful substance use, mental health and HIV.