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June 2, 2021

When Vaccine Apathy, Not Hesitancy, Drives Vaccine Disinterest

Author Affiliations
  • 1Consumer Innovation Collaborative, Poole College of Management, North Carolina State University, Raleigh
  • 2Clinical Excellence Research Center, Department of Medicine, Stanford University, Stanford, California
  • 3Graduate School of Business, Stanford University, Stanford, California
JAMA. 2021;325(24):2435-2436. doi:10.1001/jama.2021.7707

Even before COVID-19 vaccines were available, different interest levels in vaccination across the US were noted.1 Populations with less interest in vaccination were quickly considered vaccine hesitant, and public health campaigns have primarily, and understandably, focused on reaching persons anxious about vaccine safety, vaccine-related adverse effects, or both. But while vaccine anxiety is an important hurdle to overcome, the assumption that all segments of the population with low interest in vaccination are hesitant is a misconception.

The COVID-19 vaccine is arguably the most important new product of 2021, but until recently, vaccine promotion efforts have not addressed the full implications of marketing a single product to a large, heterogeneous population.2 From a marketing perspective, disinterest in vaccination from some segments of the population is unsurprising and reflects typical innovation-adoption patterns in which half of the market is usually slow to make a choice. This appears to be a description of the sizeable segment of the population that has not participated in public vaccination campaigns.

News reports now recognize the challenges of vaccinating an entire population, but the sophistication of the current collective vaccine-promotion strategies have evolved more slowly and focus on alleviating vaccine anxieties related to efficacy and safety.2 However, for much of the estimated 39% of the US population currently not vaccinated or reportedly not planning to receive the vaccine as soon as possible,3 vaccine apathy rather than true hesitancy may be an important major concern, and addressing apathy necessitates an entirely different communication approach than addressing hesitancy.

Vaccine hesitancy is a mindful emotional/cognitive response to assessing the risks and benefits of vaccination. For example, Black individuals or Native American individuals may make a deliberate choice to “wait and see” about vaccines based on their experiences with systemic racism in health care. Conversely, vaccine apathy is disinterest characterized by weak attitudes and little time spent considering vaccination; populations characterized by apathy have yet to make the psychological investment required to be described as hesitant.

Vaccine apathy exists across socioeconomic groups. For example, adults younger than 25 years of age may perceive vaccination as a low-priority task given perceptions of a return to normal due to loosening COVID-19 restrictions; whereas middle-aged working poor individuals may be overwhelmed by other higher-priority daily stressors such as food insecurity or family responsibilities. The Elaboration Likelihood Model (ELM) from marketing provides a formal characterization of subpopulations based on levels of decision involvement, whereby involvement refers to the decision maker’s motivation to actively engage in processing choice-relevant information.3,4 Those who are hesitant are high-involvement decision-makers; whereas those with apathy are low-involvement decision-makers. Importantly, the most effective communications strategies to influence these 2 groups differ markedly.

The size of vaccine-apathetic populations is difficult to determine for the same reasons that voting polls can be unreliable. Social desirability bias (ie, the tendency to respond to questions in normatively appropriate ways) may mean people are embarrassed to report indifference to preventive health care. Given the media spotlight on vaccine hesitancy, some people may explain disinterest in terms of the vaccine (eg, safety, method of development, efficacy) rather than in personal terms (eg, lack of concern, health disinterest/fatalism). Current attitude surveys about COVID-19 do not include responses clearly indicating apathy (eg, “This doesn’t concern me” or “Just not interested”). As a possible proxy for apathy, a Pew survey of 10 121 individuals, conducted in February 2021, reported that of the 30% (3036) of US adults who indicated they probably or definitely will not be vaccinated, 42% listed “Don’t think I need it” as a major reason for their decision.1

Persuading Those With Vaccine Apathy

The ELM is a robust dual-pathway persuasion framework touted as one of the most important marketing theories ever published.4 It argues that what persuades people differs by their involvement level in the decision. ELM demonstrates a counterintuitive phenomenon; the less involved a person is with a choice, the less persuaded they are by strong arguments based on logical or fact-filled appeals (termed a central appeal in the model).5 Central appeals are effective with high-involvement recipients, but low-involvement individuals are more persuaded by quick, catchy, affective, or big picture appeals (termed peripheral appeals in the model [eg, 1987 “This Is Your Brain on Drugs” and 1993-2014 “Got Milk?” campaigns).

With low motivation to engage in effortful processing of an argument, the peripheral route instead relies on argument cues that are quick and easy to process. This approach is an appeal to system 1 thinking described by Kahneman; information processing that is fast, instinctive, and predisposed to use inputs like emotions and heuristics.6 Low-involvement people seek a correct answer but do so using a less cognitively intense process.4 In a health care emergency, it is difficult for clinicians and communication experts to put aside material they find most convincing and craft messages that seem weak.2 But different elements can make these weak peripheral messages effective in shaping decisions for this population.

Message Source

One message element processed by all decision-makers is the question of who is the source? However, different source characteristics are more persuasive for the peripheral route; in fact, for this group, source characteristics can be more important than the evidence the source provides. Low-involvement people prefer highly likable sources that trigger positive feelings. Source expertise may be judged by quick authority cues (eg, fame, wealth, white coat) rather than careful assessment of a source’s resume. Quick cues that indicate trustworthiness are important, such as similarity to the recipient’s in group or self-perceived community where membership confers a sense of identity (often based on race, religion, politics, professions, interests, lifestyles, or smaller groups represented by an intersection of these factors) or if a source has provided good information in the past.3,7 For vaccine-apathetic persons, the right message source requires careful consideration and may not be the top expert (eg, Dr Anthony Fauci) that more involved decision-makers may favor; examples may include aspirational celebrities known for their own health and strength (eg, sports figures such as Nick Saban or Kareem Abdul-Jabbar) or caring about others’ health (eg, Oprah Winfrey or Dolly Parton).

Message Characteristics

How should peripheral messages to promote vaccination, such as public service announcements, social media campaigns, or advertisements be crafted? Both characteristics of message design (eg, type of information, layout, images) and message modality (eg, print, video, audio) are important. For design, peripheral messaging is effective when it attracts attention and requires relatively low cognitive effort to process.4 Such messages may use bright color, emotion, humor, sensory information, and memorable catchy slogans.3,5 Peripheral messages benefit from novel elements (like appearing in an atypical place or using an unusual medium) or novel arguments.8 Message channels (ie, where the message appears) should reach people in everyday places because low-involvement consumers are unlikely to go out of their way to look at or look for vaccine information.2 Peripheral messages are intentionally limited in terms of data and should not encourage message processing, but they can refer people to more detailed information elsewhere that is presented in a high-involvement manner; in this way, some decision-makers may be converted from low-involvement to high-involvement.

Apathy vs Antivaccination Concepts

Apathy is not synonymous with antivaccination concepts. People who are apathetic about vaccines may have weakly negative attitudes toward vaccines in general, but these attitudes are the not strongly held and highly defended attitudes that characterize people with antivaccine positions. Because antivaccine populations have high decision involvement on this issue (and thus are avid consumers of [mis]information supporting their decision), the peripheral messages that can persuade those who are apathetic about COVID-19 vaccines will not be effective in addressing these high-involvement negative groups. These 2 populations should not be considered concurrently when designing vaccine promotion campaigns.

In the next wave of vaccine promotion, attention to low-involvement populations (the “vaccine-apathetic”) and the development of specific vaccine-promotion messaging to help overcome vaccine apathy may be a critical element for achieving national vaccination goals.

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Article Information

Corresponding Author: Kevin Schulman, MD, Clinical Excellence Research Center, Department of Medicine, Stanford University, 366 Galvez St, John A. and Cynthia Fry Gunn Bldg, Room 326, Stanford, CA 94305 (kevin.schulman@stanford.edu).

Published Online: June 2, 2021. doi:10.1001/jama.2021.7707

Conflict of Interest Disclosures: Dr Schulman reports grants from NBA Incorporated; other with Grid Therapeutics (board member and shareholder), Faculty Connection (managing member), Prealize (board of advisors), Reserve Therapeutics (board member and shareholder), Altitude Ventures (investor), Business School Alliance for Health Management (president), Civica RX (advisory board), Catalysis (board of directors), and Excelerate Health Ventures (investor); and personal fees from Novartis, Cytokinetics, Health Quest, Business Roundtable, Motley Rice, Frazier Healthcare Partners, ISMIE, and Health Services Research, outside the submitted work. Dr Wood reports no disclosures.

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    5 Comments for this article
    Fiorenzo Albani |

    Very interesting Viewpoint but I could not find the Schumann reference in reference 4 (1)?


    Schumann DW, Kotowski MR, Young HO. The elaboration likelihood model: a 30-year review. In: Rodgers S, Thorson E, eds. Advertising Theory. Routledge; 2019:81-98.

    Reason for Apathy?
    Dena Davis, PhD. JD | Lehigh University
    I am wondering what percentage of people who say "I don't need it" have had the virus and consider themselves immune. Do the studies sort for that?
    Helena Felts |
    In the subheader 'Anxiety vs Antivaccination Concepts,' 'anxiety' seems a bit out of place. I'm wondering if the author meant to write 'Apathy vs Antivaccination Concepts."
    Author Reply (June 7)
    Stacy Wood, PhD | Consumer Innovation Collaborative, Poole College of Management, North Carolina State University, Raleigh
    Thank you for your interest and your comments!

    Regarding the Schumann et al reference, the book is no longer in print, but we hope will be available via university libraries.

    Regarding those who have had Covid-19, this is an excellent point and current studies don't capture it. Future surveys that seek to capture apathy as distinct from hesitancy should consider adding natural immunity as a question!

    Regarding the subheading, Helena Felts, you are entirely right. Thanks to your quick eye, we will be able to correct this in the print edition in JAMA.
    Thank you!

    Observations on Definitions
    Tom Kocsis, BS ME, MS Telecom | Individual
    Thank you for this Viewpoint that caught my attention. Just some observations to share if I may:

    (1) The statement "vaccine hesitancy is a mindful emotional/cognitive response to assessing the risks and benefits of vaccination" does not sound like an accurate definition. The definition of "hesitancy" is to be unsure, wavering, undecided. That is not someone who is "mindful" and has "assessed" anything. It would seem that the "vaccine hesitant" are those who are concerned enough to think somewhat and inquire to some degree into whether to get a vaccine but have not reached a point where they feel
    informed enough to make a firm decision and therefore are "hesitant."

    (2) There is a third group of individuals that need to be acknowledged, the "vaccine informed."  This is the group that has done the in-depth "mindful emotional/cognitive" investigation, reading, and assessment to become fully convinced to make an objective, informed and rational decision based on risks and benefits.

    (3) As mentioned in the viewpoint, future surveys should include clear statements to distinguish between "hesitant", "apathetic" and "informed" individuals. A recommended question for "informed" individuals would be "I did personal research and determined vaccine was not appropriate in my case".

    Respectfully, Tom K