Speaking to Hearts Before Minds: Increasing Influenza Vaccine Uptake During COVID-19

In 2019, the UK health secretary Matt Hancock said that he is “open” to making vaccines compulsory, and Labour MP Paul Sweeney argued that failure to vaccinate children should be a “criminal offence”. But mandates are difficult to enforce, and punishments diminish public trust. In addition, people still opt out of mandatory policies, and effectiveness increases when people freely comply.[1] Instead of mandates, we advocate behavioural approaches that preserve individual freedom,[2] and agree with Professor Heidi Larson that additional emphasis should be placed on public perspectives when planning vaccine policies and programmes.[3]

Public health messaging about vaccines is particularly important in light of the COVID-19 pandemic. In April 2020, the United Kingdom’s ‘Vaccine Taskforce’ convened, and, in May 2020, the United States’ ‘Operation Warp Speed’ took off. This speed elicited optimism among some, but handed a megaphone to the anti-vaccination movement. Del Bigtree, founder of the Information Consent Action Network, cautioned that, “You shouldn’t rush to create a product you can inject into perfectly healthy people without doing proper safety studies”. Here, identical factual information – a vaccine is being developed quickly – elicited reasoned responses that were both optimistic and pessimistic. However, intuitions come first and strategic reasoning comes second.[4] Where public health messages do not align with people’s automatic intuitions, factual and reasoned information may fall on deaf ears.

On September 21, we conducted an online experiment to determine if public health messages aligned with people’s political intuitions influenced their intentions to take up the influenza vaccine.[5] Influenza vaccinations have long been important, but are particularly important now in the context of COVID-19 because co-infection increases mortality rates.[6] We recruited 192 participants living in England, aged 50 years+, who had not already vaccinated this season. Half of these participants identified as being affiliated with the Labour party, and half with the Conservative party. Participants viewed a message either aligned or unaligned with their automatic political intuitions (see Figures 1 and 2). Then they stated how much they agreed with a statement about their intentions to take up the influenza vaccine this season on a 7-point scale, where higher numbers indicated more positive intentions.

Fig 1. Left-Wing Message (aligned with Labour)
Fig 2. Right-Wing Message (aligned with Conservative)

Professor Jonathan Haidt describes the automatic intuitions we set out to influence as moral foundations.[4] Typically, people who identify as being more left-wing are most strongly influenced by their care and fairness intuitions (a desire to prevent harm to others and to ensure equality). In contrast, people who identify as being more right-wing are more strongly influenced by the remaining foundations: purity (a desire to avoid contaminants), authority (to preserve traditions), loyalty (to strengthen group bonds), and liberty (to preserve individual freedom).

Research conducted in the United States and Australia has already identified some of the foundations associated with parental vaccine hesitancy, and suggests that public health messages can be framed to increase parents’ intentions.[7,8] For example, a message designed to promote purity might say: Boost your child’s natural defenses against diseases! – Vaccinate! These proposals are a good start, but without evidence that they are likely to be effective, public health practitioners have little reason to prefer them to the messages developed in-house. The messages used in the present study were informed by messages used in a previous study that significantly altered people’s intentions to recycle.[9]

Our main prediction was that our left-wing message would increase labour participants’ intentions, and our right-wing message would increase conservative participants’ intentions. We did not find this. As shown in Figure 3, there was no substantial effect of the messages. One explanation is that the moral foundations used in our advertisements were not relevant in a UK context, which we plan to address in future work. We aim to conduct a general UK survey describing moral foundations in the population and use the survey results to inform a collaborative online workshop with public contributors and health specialists, which is in keeping with Professor Heidi Larson’s calls to involve public perspectives. This pilot study lays the groundwork for such future research.

Fig 3. Results of the study testing the effects of messages on vaccination intentions as measured by average agreement with the statement: “I intend to receive an influenza vaccination this season [2020/21].”

We asked people some follow up questions too. In a free-text box, participants were asked to explain their intentions to (or not to) vaccinate. Their explanations largely fell within five categories, which, in addition to their foundations, may have been influenced by the messages they read: Protect Self, Protect Others, Protect the NHS, Being Eligible/Invited, and Habits. We also asked questions about people’s intentions of taking up a COVID-19 vaccination and wearing a face mask. Similar to recent research,[10] people were more likely to express intentions to take up a future COVID-19 vaccination (72%) than the current influenza vaccination (65%). We suspect that these expressed intentions may be a bit optimistic. Indeed, most participants (89%) also expressed that they would wear a face mask in a store that did not require them to do so, which is higher than our casual observations at the grocery store around the time of the experiment (before additional penalties were introduced). Acquiescence bias may have led our participants to be agreeable in this survey, particularly as participants just saw messages promoting health-related behaviour. But this need not preclude identifying meaningful differences between randomised conditions. Our research team looks forward to better understanding the intuitive influences on vaccination behaviour.

Kelly Ann Schmidtke (Assistant Professor) and Laura Kudrna (Research Fellow)


  1. Salmon DA, et al. Compulsory vaccination and conscientious or philosophical exemptions: past, present, and future. Lancet. 2006;367(9508):436-42.
  2. Sunstein C & Thaler R. Libertarian Paternalism. Am Econ Rev. 2003; 93(2): 175-9.
  3. Larson HJ et al. Addressing the vaccine confidence gap. Lancet. 2011;378:526-35.
  4. Haidt J. The righteous mind: why good people are divided by politics and religion. New York: Pantheon Books; 2012.
  5. U.S. National Library of Medicine. ClinicalTrials.gov Influenza 2020/2021. NCT04546854. 14 September 2020.
  6. Iacobucci G. Covid-19: Risk of death more than doubled in people who also had flu, English data show. BMJ. 2020;370:m3720.
  7. Amin AB, et al. Association of moral values with vaccine hesitancy. Nat Hum Behav. 2017;1(12):873-80.
  8. Rossen I, et al. Accepters, fence sitters, or rejecters: moral profiles of vaccination attitudes. Soc Sci Med. 2019;224(1):23-7.
  9. Kidwell B, et al. Getting Liberals and Conservatives to Go Green: Political Ideology and Congruent Appeals. J Cons Res. 2013; 40(2):350–67.
  10. Boseley S. Coronavirus: fifth of people likely to refuse Covid vaccine, UK survey finds. The Guardian. 24 September 2020.

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