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The Morning Newsletter

Vaccine Persuasion

Many vaccine skeptics have changed their minds.

example of persuasive speech about vaccination

By David Leonhardt

When the Kaiser Family Foundation conducted a poll at the start of the year and asked American adults whether they planned to get vaccinated, 23 percent said no.

But a significant portion of that group — about one quarter of it — has since decided to receive a shot. The Kaiser pollsters recently followed up and asked these converts what led them to change their minds . The answers are important, because they offer insight into how the millions of still unvaccinated Americans might be persuaded to get shots, too.

First, a little background: A few weeks ago, it seemed plausible that Covid-19 might be in permanent retreat, at least in communities with high vaccination rates. But the Delta variant has changed the situation. The number of cases is rising in all 50 states .

Although vaccinated people remain almost guaranteed to avoid serious symptoms, Delta has put the unvaccinated at greater risk of contracting the virus — and, by extension, of hospitalization and death. The Covid death rate in recent days has been significantly higher in states with low vaccination rates than in those with higher rates:

(For more detailed state-level charts, see this piece by my colleagues Lauren Leatherby and Amy Schoenfeld Walker. The same pattern is evident at the county level, as the health policy expert Charles Gaba has been explaining on Twitter.)

Nationwide, more than 99 percent of recent deaths have occurred among unvaccinated people, and more than 97 percent of recent hospitalizations have occurred among the unvaccinated, according to the C.D.C. “Look,” President Biden said on Friday, “the only pandemic we have is among the unvaccinated.”

The three themes

What helps move people from vaccine skeptical to vaccinated? The Kaiser polls point to three main themes.

(The themes apply to both the 23 percent of people who said they would not get a shot, as well as to the 28 percent who described their attitude in January as “wait and see.” About half of the “wait and see” group has since gotten a shot.)

1. Seeing that millions of other Americans have been safely vaccinated.

Consider these quotes from Kaiser’s interviews :

“It was clearly safe. No one was dying.” — a 32-year-old white Republican man in South Carolina “I went to visit my family members in another state and everyone there had been vaccinated with no problems.” — a 63-year-old Black independent man in Texas “Almost all of my friends were vaccinated with no side effects.” — a 64-year-old Black Democratic woman in Tennessee

This suggests that emphasizing the safety of the vaccines — rather than just the danger of Covid, as many experts (and this newsletter) typically do — may help persuade more people to get a shot.

A poll of vaccine skeptics by Echelon Insights, a Republican firm, points to a similar conclusion. One of the most persuasive messages, the skeptics said, was hearing that people have been getting the vaccine for months and it is “working very well without any major issues.”

2. Hearing pro-vaccine messages from doctors, friends and relatives.

For many people who got vaccinated, messages from politicians, national experts and the mass media were persuasive. But many other Americans — especially those without a college degree — don’t trust mainstream institutions. For them, hearing directly from people they know can have a bigger impact.

“Hearing from experts,” as Mollyann Brodie, who oversees the Kaiser polls, told me, “isn’t the same as watching those around you or in your house actually go through the vaccination process.”

Here are more Kaiser interviews:

“My daughter is a doctor and she got vaccinated, which was reassuring that it was OK to get vaccinated.” — a 64-year-old Asian Democratic woman in Texas “Friends and family talked me into it, as did my place of employment.” — a 28-year-old white independent man in Virginia “My husband bugged me to get it and I gave in.” — a 42-year-old white Republican woman in Indiana “I was told by my doctor that she strongly recommend I get the vaccine because I have diabetes.” — a 47-year-old white Republican woman in Florida

These comments suggest that continued grass-roots campaigns may have a bigger effect at this stage than public-service ad campaigns. The one exception to that may be prominent figures from groups that still have higher vaccine skepticism, like Republican politicians and Black community leaders.

3. Learning that not being vaccinated will prevent people from doing some things.

There is now a roiling debate over vaccine mandates , with some hospitals, colleges, cruise-ship companies and others implementing them — and some state legislators trying to ban mandates. The Kaiser poll suggests that these requirements can influence a meaningful number of skeptics to get shots, sometimes just for logistical reasons.

“Hearing that the travel quarantine restrictions would be lifted for those people that are vaccinated was a major reason for my change of thought.” — a 43-year-old Black Democratic man in Virginia “To see events or visit some restaurants, it was easier to be vaccinated.” — a 39-year-old white independent man in New Jersey “Bahamas trip required a COVID shot.” — a 43-year-old Hispanic independent man in Pennsylvania

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Here’s the latest on the extreme heat and wildfires in the West.

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A Times classic: Try this science-based 7-minute workout .

Quiz time: The average score on our most recent news quiz is 8.1 out of 11. See if you can do better .

Lives Lived: Gloria Richardson famously brushed aside a National Guardsman’s bayonet as she led a campaign for civil rights in Cambridge, Md. She died at 99 .

ARTS AND IDEAS

What matters in a name sign.

Shortly after the 2020 presidential election, five women teamed up to assign Vice President-elect Kamala Harris a name sign — the equivalent of a person’s name in American Sign Language.

The women — Ebony Gooden, Kavita Pipalia, Smita Kothari, Candace Jones and Arlene Ngalle-Paryani — are members of the “capital D Deaf community,” a term some deaf people use to indicate they embrace deafness as a cultural identity and communicate primarily through ASL.

Through social media, people submitted suggestions and put the entries to a vote. The result: A name sign that draws inspiration, among other things, from the sign for “lotus flower” — the translation of “Kamala” in Sanskrit — and the number three, highlighting Harris’s trifecta as the first Black, Indian and female vice president.

“Name signs given to political leaders are usually created by white men, but for this one we wanted to not only represent women, but diversity — Black women, Indian women,” Kothari said. Read more about it, and see videos of the signs . — Sanam Yar, a Morning writer

PLAY, WATCH, EAT

What to cook.

Debate ham and pineapple pizza all you want. There’s no denying the goodness of caramelized pineapple with sausages .

What to Watch

Based on books by R.L. Stine, the “Fear Street” trilogy on Netflix offers gore and nostalgia.

“ Skipped History ,” a comedy web series, explores overlooked people and events that shaped America.

Now Time to Play

The pangram from Friday’s Spelling Bee was lengthened . Here is today’s puzzle — or you can play online .

Here’s today’s Mini Crossword , and a clue: Hot tub nozzles (four letters).

If you’re in the mood to play more, find all our games here .

Thanks for spending part of your morning with The Times. See you tomorrow. — David

P.S. Ashley Wu , who has worked for Apple and New York magazine, has joined The Times as a graphics editor for newsletters. You’ll see her work in The Morning soon.

Here’s today’s print front page .

“ The Daily ” is about booster shots. On the Book Review podcast , S.A. Cosby talks about his new novel.

Lalena Fisher, Claire Moses, Ian Prasad Philbrick, Tom Wright-Piersanti and Sanam Yar contributed to The Morning. You can reach the team at [email protected] .

David Leonhardt writes The Morning, The Times's main daily newsletter. Previously at The Times, he was the Washington bureau chief, the founding editor of The Upshot, an Op-Ed columnist, and the head of The 2020 Project, on the future of the Times newsroom. He won the 2011 Pulitzer Prize for commentary. More about David Leonhardt

Persuasive Essay Guide

Persuasive Essay About Covid19

How to Write a Persuasive Essay About Covid19 | Examples & Tips

11 min read

Steps to Write a Persuasive Essay About Covid-19

Here are the steps to help you write a persuasive essay on this topic, along with an example essay:

Step 1: Choose a Specific Thesis Statement

Your thesis statement should clearly state your position on a specific aspect of COVID-19. It should be debatable and clear. For example:

Step 2: Research and Gather Information

Collect reliable and up-to-date information from reputable sources to support your thesis statement. This may include statistics, expert opinions, and scientific studies. For instance:

COVID-19 vaccination effectiveness data
Information on vaccine mandates in different countries
Expert statements from health organizations like the WHO or CDC

Step 3: Outline Your Essay

Create a clear and organized outline to structure your essay. A persuasive essay typically follows this structure:

Introduction
Background Information
Body Paragraphs (with supporting evidence)
Counterarguments (addressing opposing views)

Step 4: Write the Introduction

In the introduction, grab your reader's attention and present your thesis statement. For example:

Step 5: Provide Background Information

Offer context and background information to help your readers understand the issue better. For instance:

Step 6: Develop Body Paragraphs

Each body paragraph should present a single point or piece of evidence that supports your thesis statement. Use clear topic sentences, evidence, and analysis. Here's an example:

Step 7: Address Counterarguments

Acknowledge opposing viewpoints and refute them with strong counterarguments. This demonstrates that you've considered different perspectives. For example:

Step 8: Write the Conclusion

Summarize your main points and restate your thesis statement in the conclusion. End with a strong call to action or thought-provoking statement. For instance:

Step 9: Revise and Proofread

Edit your essay for clarity, coherence, grammar, and spelling errors. Ensure that your argument flows logically.

Step 10: Cite Your Sources

Include proper citations and a bibliography page to give credit to your sources.

Remember to adjust your approach and arguments based on your target audience and the specific angle you want to take in your persuasive essay about COVID-19.

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Examples of Persuasive Essay About Covid19

When writing a persuasive essay about the Covid-19 pandemic, it’s important to consider how you want to present your argument. To help you get started, here are some example essays for you to read:

Check out some more PDF examples below:

Persuasive Essay About Covid-19 Pandemic

Sample Of Persuasive Essay About Covid-19

Persuasive Essay About Covid-19 In The Philippines - Example

If you're in search of a compelling persuasive essay on business, don't miss out on our “ persuasive essay about business ” blog!

Examples of Persuasive Essay About Covid-19 Vaccine

Covid19 vaccines are one of the ways to prevent the spread of Covid-19, but they have been a source of controversy. Different sides argue about the benefits or dangers of the new vaccines. Whatever your point of view is, writing a persuasive essay about it is a good way of organizing your thoughts and persuading others.

A persuasive essay about the Covid-19 vaccine could consider the benefits of getting vaccinated as well as the potential side effects.

Below are some examples of persuasive essays on getting vaccinated for Covid-19.

Covid19 Vaccine Persuasive Essay

Persuasive Essay on Covid Vaccines

Interested in thought-provoking discussions on abortion? Read our persuasive essay about abortion blog to eplore arguments!

Examples of Persuasive Essay About Covid-19 Integration

Covid19 has drastically changed the way people interact in schools, markets, and workplaces. In short, it has affected all aspects of life. However, people have started to learn to live with Covid19.

Writing a persuasive essay about it shouldn't be stressful. Read the sample essay below to get idea for your own essay about Covid19 integration.

Persuasive Essay About Working From Home During Covid19

Searching for the topic of Online Education? Our persuasive essay about online education is a must-read.

Examples of Argumentative Essay About Covid 19

Covid-19 has been an ever-evolving issue, with new developments and discoveries being made on a daily basis.

Writing an argumentative essay about such an issue is both interesting and challenging. It allows you to evaluate different aspects of the pandemic, as well as consider potential solutions.

Here are some examples of argumentative essays on Covid19.

Argumentative Essay About Covid19 Sample

Argumentative Essay About Covid19 With Introduction Body and Conclusion

Looking for a persuasive take on the topic of smoking? You'll find it all related arguments in out Persuasive Essay About Smoking blog!

Examples of Persuasive Speeches About Covid-19

Do you need to prepare a speech about Covid19 and need examples? We have them for you!

Persuasive speeches about Covid-19 can provide the audience with valuable insights on how to best handle the pandemic. They can be used to advocate for specific changes in policies or simply raise awareness about the virus.

Check out some examples of persuasive speeches on Covid-19:

Persuasive Speech About Covid-19 Example

Persuasive Speech About Vaccine For Covid-19

You can also read persuasive essay examples on other topics to master your persuasive techniques!

Tips to Write a Persuasive Essay About Covid-19

Writing a persuasive essay about COVID-19 requires a thoughtful approach to present your arguments effectively.

Here are some tips to help you craft a compelling persuasive essay on this topic:

Choose a Specific Angle

Start by narrowing down your focus. COVID-19 is a broad topic, so selecting a specific aspect or issue related to it will make your essay more persuasive and manageable. For example, you could focus on vaccination, public health measures, the economic impact, or misinformation.

Provide Credible Sources

Support your arguments with credible sources such as scientific studies, government reports, and reputable news outlets. Reliable sources enhance the credibility of your essay.

Use Persuasive Language

Employ persuasive techniques, such as ethos (establishing credibility), pathos (appealing to emotions), and logos (using logic and evidence). Use vivid examples and anecdotes to make your points relatable.

Organize Your Essay

Structure your essay involves creating a persuasive essay outline and establishing a logical flow from one point to the next. Each paragraph should focus on a single point, and transitions between paragraphs should be smooth and logical.

Emphasize Benefits

Highlight the benefits of your proposed actions or viewpoints. Explain how your suggestions can improve public health, safety, or well-being. Make it clear why your audience should support your position.

Use Visuals -H3

Incorporate graphs, charts, and statistics when applicable. Visual aids can reinforce your arguments and make complex data more accessible to your readers.

Call to Action

End your essay with a strong call to action. Encourage your readers to take a specific step or consider your viewpoint. Make it clear what you want them to do or think after reading your essay.

Revise and Edit

Proofread your essay for grammar, spelling, and clarity. Make sure your arguments are well-structured and that your writing flows smoothly.

Seek Feedback

Have someone else read your essay to get feedback. They may offer valuable insights and help you identify areas where your persuasive techniques can be improved.

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Common Topics for a Persuasive Essay on COVID-19

Here are some persuasive essay topics on COVID-19:

The Importance of Vaccination Mandates for COVID-19 Control
Balancing Public Health and Personal Freedom During a Pandemic
The Economic Impact of Lockdowns vs. Public Health Benefits
The Role of Misinformation in Fueling Vaccine Hesitancy
Remote Learning vs. In-Person Education: What's Best for Students?
The Ethics of Vaccine Distribution: Prioritizing Vulnerable Populations
The Mental Health Crisis Amidst the COVID-19 Pandemic
The Long-Term Effects of COVID-19 on Healthcare Systems
Global Cooperation vs. Vaccine Nationalism in Fighting the Pandemic
The Future of Telemedicine: Expanding Healthcare Access Post-COVID-19

In search of more inspiring topics for your next persuasive essay? Our persuasive essay topics blog has plenty of ideas!

To sum it up,

You have read good sample essays and got some helpful tips. You now have the tools you needed to write a persuasive essay about Covid-19. So don't let the doubts stop you, start writing!

If you need professional writing help, don't worry! We've got that for you as well.

MyPerfectWords.com is a professional essay writing service that can help you craft an excellent persuasive essay on Covid-19. Our experienced essay writer will create a well-structured, insightful paper in no time!

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Frequently Asked Questions

Are there any ethical considerations when writing a persuasive essay about covid-19.

Yes, there are ethical considerations when writing a persuasive essay about COVID-19. It's essential to ensure the information is accurate, not contribute to misinformation, and be sensitive to the pandemic's impact on individuals and communities. Additionally, respecting diverse viewpoints and emphasizing public health benefits can promote ethical communication.

What impact does COVID-19 have on society?

The impact of COVID-19 on society is far-reaching. It has led to job and economic losses, an increase in stress and mental health disorders, and changes in education systems. It has also had a negative effect on social interactions, as people have been asked to limit their contact with others.

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Keep reading

Lessons learned: What makes vaccine messages persuasive

You’re reading Lessons Learned, which distills practical takeaways from standout campaigns and peer-reviewed research in health and science communication. Want more Lessons Learned? Subscribe to our Call to Action newsletter .

Vaccine hesitancy threatened public health’s response to the COVID-19 pandemic. Scientists at the University of Maryland recently reviewed 47 randomized controlled trials to determine how COVID-19 communications persuaded—or failed to persuade—people to take the vaccine. ( Health Communication , 2023 DOI: 10.1080/10410236.2023.2218145 ).

What they learned: Simply communicating about the vaccine’s safety or efficacy persuaded people to get vaccinated. Urging people to follow the lead of others, by highlighting how many millions were already vaccinated or even trying to induce embarrassment, was also persuasive.

Why it matters: Understanding which message strategies are likely to be persuasive is crucial.

➡️ Idea worth stealing: The authors found that a message’s source didn’t significantly influence its persuasiveness. But messages were more persuasive when source and receivers shared an identity, such as political affiliation.

What to watch: How other formats, such as interactive chatbots and videos, might influence persuasiveness. And whether message tailoring could persuade specific population subgroups.

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Rhetorical Questions and Real Answers About Vaccination

Reflections on the third act of the pandemic: the jab.

Posted April 26, 2021 | Reviewed by Matt Huston

Decision making in the face of uncertainty is complex.
Using a risk-benefit framework is an effective means of making decisions in the face of uncertainty.
What we know so far about vaccination indicates that its benefits outweigh its risks.

I hope this will be my last post on the pandemic. Not because it is “over,” but because the advice I have to offer is unlikely to be updated beyond this reflection.

This weekend I got my second vaccine dose. I felt fine afterwards, and even got to work on addressing my “quarantine 15 (pounds)” with a run the next day. In a few weeks, I am looking forward to eating inside a restaurant for the first time in over a year. I will order an appetizer, wine, and dessert—and when I am done I will not have to wash the dishes. It will be decadent .

I joined about 3 million other Americans in getting a dose that day, including about 1.5 million getting their first dose. That over 40 percent of Americans have gotten at least one shot already, only four months since the first vaccine was approved, is a medical miracle. Why do I use such flowery language? Because of how confusing and frustrating the vaccine rollout has been. The media keeps reporting on “ softening demand ” for the vaccine, but let’s be real: There is a special breed of person who is willing to camp outside Best Buy starting at 3 a.m. the day after Thanksgiving to get a deal on a TV and deal with a mob, and then there is the vast majority of people who want a TV but don’t want to sleep on a sidewalk to get one.

Every state had to submit their own “plan” for how they were going to roll out the vaccine this fall, and in my estimation, those plans were graded on a “participation award” scale. At least here in Michigan , prior to the past 10 days, if you wanted to get a vaccine it meant checking multiple websites, multiple times a day, in hopes of finding an appointment. Most sites had no ability to be added to a waitlist. And when you did get an appointment, it meant driving a long distance—most people I know drove about an hour each way—to get the jab. I am not surprised that more Americans weren’t chomping at the bit to get into that circus.

Yes, there is about 20 percent of Americans who are pretty hesitant about vaccination (a group that spans the political spectrum ). If you are in that 20 percent, I encourage you to talk to people you trust—healthcare providers, pastors, family, and friends about those concerns. In the meantime, let me try to answer some of the (rhetorical) questions you may be asking yourself.

For example, if you feel that the vaccine was “rushed,” ask yourself: Under what circumstances would you feel that the vaccine pace was appropriate? That is, how long would it have taken for you to not feel it was “rushed?" One year? Two years? A decade?

If you don’t have a clear answer to that, then maybe your concern is really about the “emergency” nature of the FDA authorization. Do you have a clear idea of what “emergency” means in this situation? I certainly didn’t, but I looked it up and now I know that it means a) there is a serious health threat, b) there is a product that may be effective at addressing that threat, c) “the known and potential benefits of the product, when used to diagnose, prevent, or treat the identified disease or condition, outweigh the known and potential risks of the product,” and d) there is no alternative to address the threat. Seems reasonable, and I’m glad the FDA can grant such authorizations during crises like the one we are in now.

Still feeling unsure? Well, when the FDA approves the first vaccine fully (which will likely happen within the next month or so), will that convince you of its safety and efficacy? If not, why not? Does this mean you don’t trust the FDA as a whole? If so, why not?

I’m not an advocate of blind trust in any institution—government, private business, non-profits, etc.—but I am an advocate of realism. If there is literally no evidence that would convince you that the vaccine is safe and effective—that you are better off with it than without it—then your issue likely isn’t just with the vaccine, but with the entire practice of medicine and scientific research . That's a big pill to swallow (metaphorically, of course).

If you say you need “more data” to feel comfortable with the vaccine, ask yourself : How much data did you require the last time your doctor prescribed you antibiotics for an infection? Or advised you to start taking statins for your high cholesterol?

You can pore over the factsheets for these vaccines (akin to the advertisements for drugs you see in magazines), but if you are like me, the answer is "next to none," even though I have the quantitative chops to drill down into studies and data if I wanted to. That is, I trusted them that they had my best interest in mind when they gave me that advice or wrote me that prescription.

Do I read about the risks and benefits of any treatment I consider taking? Of course, and sometimes I even read the original studies. But do I demand evidence that does not and cannot yet exist—like, “Will the COVID vaccine protect me for more than six months? What if there are side effects from the vaccine that only emerge years later?”—when not enough time has passed for us to even begin to answer those questions? No.

Now, I understand why these questions feel compelling: they feel persuasive because the truth is “We don’t know...” But here’s the second half of that truth that I ask you to keep in mind: “...but what we know so far indicates that the benefits of vaccination far outweigh the risks.”

Every decision has risks and benefits—even the decision to not get vaccinated has the mental benefit of “ not being told what to do .” But that benefit won’t end the pandemic any sooner, it won’t reduce the risk of you inadvertently infecting your loved ones with the virus, it won’t comfort you if you are unlucky enough to get infected and require hospitalization (which will involve you being alone, with your family unable to visit you), and it won’t reduce your risk of dying from this virus to nearly zero. All of those are benefits that you can expect from vaccination .

If you don’t have a healthcare professional in your life that you trust, I suggest you fire the ones you have and find someone who works better for you—not just for the vaccine, but for all your healthcare needs. And by healthcare professional, I don’t mean a “wellness” coach or someone trying to sell you oils, crystals, or something else. I mean a person that you trust with your health, the most important asset you have.

People who have been through a health crisis—whether cancer, a stroke, a heart attack, or a serious accident—know the true value of that asset, how quickly it can shift from minor troubles to a life-threatening emergency, and how no one gets through that kind of crisis alone. And the same is true for this collective crisis.

Briana Mezuk, Ph.D. , is a Professor of Epidemiology and Director of the Center for Social Epidemiology and Population Health at the University of Michigan's School of Public Health.

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Here’s What Will Actually Convince People to Get Vaccinated

O ne of evolution’s cleverest tricks was giving us a sense of shame. It’s a miserable feeling—low, humbling, publicly discomfiting—but it’s supposed to be: if you do something lousy you ought to feel something lousy, so you don’t do it again.

In theory, when so many of the strategies for beating the COVID-19 pandemic depend on abiding by social distancing and other rules, shaming people who don’t ought to be a powerful way to bring us back in line. But increasingly, experts believe, the opposite is true. “The thinking has been that the more you shame people the more they will obey,” says Giovanni Travaglino, an assistant professor of social psychology at Kent University. “But this turns out to be absolutely wrong.”

Last month, Travaglino and Chanki Moon, an assistant professor of psychology at Leeds Beckett University, published a paper in Frontiers in Psychology that threw the ineffectiveness of shaming into relief. They assembled nearly 1,900 people from the U.S., Italy and South Korea—choosing those countries on the basis of their differing sense of the collective culture, with the U.S. judged the most individualistic, South Korea the most group-oriented and Italy in between. The subjects were asked to rate how ashamed or guilty they’d feel if they contracted COVID-19. They were also asked to rate how often they obey guidelines like social distancing and how likely they’d be to tell friends, acquaintances and health authorities if they tested positive. In all three countries, the higher the level of shame and guilt people felt over falling ill, the less likely they were to play it safe and to report their COVID-19 status.

In the U.S. and elsewhere, the antivaccine movement has long been a threat to public health, and many pro-vaccine messages have been designed to shame adherents. A December story in the U.K.’s Metro featured the headline “People think anti-vaxxers are ‘stupid and selfish.'” Attention-grabbing, maybe, but counterproductive. “It’s hard to get people to act in a cooperative manner when you approach them that way,” says Travaglino. “It’s associated with subordination to authority, and people don’t like that.”

A new TIME/Harris Poll survey similarly suggests individual authority figures aren’t very effective at convincing vaccine skeptics.

Of U.S. adults who had recently been vaccinated, only 32% said they were influenced by a local official reaching out directly via email, phone or mail. Much more effective, it seems, are appeals to people’s individual needs and desires. Some 52% of those polled said they got the vaccine because they wanted to travel, for example. The people around us also play a major role, with 56% of respondents saying they got vaccinated after a friend or family member did, and 59% saying they were influenced merely by having a conversation with such a closely connected person. And despite our ostensible mistrust in the media, 63% said they were influenced by news reports about people who had already been vaccinated.

Indeed, past research shows value in appealing to us through personal stories. In a 2015 study published in the PNAS , volunteers took a survey on their attitudes about vaccines and were then divided into three groups, each given one of three things to read: material showing that autism and vaccines are not related; a paragraph of a mother describing her child’s bout with measles; and material on an unrelated science topic. When the subjects took the vaccine survey again, all were more pro-vaccine than before, but the ones who read the mother’s account were dramatically more so, with an increase five times as great as that of the group that had read the material on autism and six times that of the control group.

Personal accounts can have a negative impact too. A new study published in PLOS ONE, by researchers from the University of Illinois and the Annenberg Public Policy Center, found that subjects who saw a video clip of Dr. Anthony Fauci talking about the safety and effectiveness of the measles vaccine came away from it more favorably disposed to vaccination overall. But the positive effect was diminished when they saw another video clip first, of a mother describing the severe rash one of her children developed after receiving the vaccine. The solution, the paper concluded, is not for the media to censor such accounts but to precede them with real-world data on the minimal risks and the considerable benefits of vaccines.

What doesn’t work, clearly, is pointing fingers and casting blame and shame. It’s the virus that’s the enemy, after all, not the people it infects.

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Write to Jeffrey Kluger at [email protected]

How to persuade people to take the COVID-19 vaccine

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It will inject a microchip so Bill Gates can track your every move; it will turn you into a monkey; it will alter your DNA; it will allow Russia to spy on you.

These are just a few of the crazy conspiracy theories circulating on social media about the COVID-19 vaccine. Governments are not only waged in a war against the virus but a battle with misinformation as they look to roll out vaccines.

While in the UK the Government is battling against ‘vaccine hesitancy’ over more legitimate concerns around safety and critics arguing regulators have approved the Pfizer BioNTech vaccine too quickly.

Indeed, in a recent study by the Vaccine Confidence Project at the London School of Hygiene and Tropical Medicine, only 54 per cent of UK respondents said they would definitely take the COVID-19 vaccine and this dropped to 47.6 per cent after viewing misinformation on social media. And people from lower income, black and ethnic minority backgrounds were least likely to go and get vaccinated.

So how do Governments overcome these barriers and persuade the public that the vaccine is safe and they need to be vaccinated?

This is where insights from behavioural science can help Governments’ messaging and present a more powerful and persuasive case for vaccination. This will take more than logistics and simple messaging, only with a behavioural approach as part of the programme will the system deliver the 80 per cent coverage needed to gain herd immunity.

As part of the UK’s National Health Service’s (NHS) COVID Behaviour Change Unit I have been detailing the behavioural science insights that policymakers will need. We have developed evidenced-based behavioural policies for each of the priority groups: care home residents and the over-80s, health and care workers, the over-65s and young people.

Our research has found that across all the population cohorts there are significant potential barriers to taking the vaccine, ranging from anxiety to determined resistance, mild scepticism to overt mistrust, and disinterest to conscious non-compliance. For instance, young people are highly sceptical and more likely to believe false information, such as that seen on social media that the vaccine includes a microchip to track your every move or that it contains lung tissue from an aborted foetus.

By using the MINDSPACE framework – a simple tool to diagnose problems and create interventions – we detailed a litany of nudges that should be used to persuade the doubters and hesitant to take the vaccine for eahc group.

Care home residents and over-80s

The barriers to take-up in care homes is the anxiety about being one of the first to take the vaccine, a feeling that they are the country’s guinea pigs.

There is also a question of trust, many of those in the 11,000 care homes across the UK have mental health issues or complex medical needs, with 40 per cent of residents suffering from dementia, and so they rely on the familiar faces of staff.

This is where the messenger effect can help. A well-researched phonemenon is how we trust the message being delivered more when the person conveying it is like us or an authority figure. Thus, it would be best if care home staff were trained to administer the vaccine or known GPs, but if this can’t be done then trusted members of staff should accompany the immuniser. Align known staff with ‘strangers’ to reassure residents. Also use known local GP surgery staff and other known community staff.

Salience – where our behaviour is influenced by what seems relevant to us and to our personal experiences – is also a powerful nudge. Thus, accessible and evidence-based messaging about the positives that over-80s and care home residents are among the first to be vaccinated can be more persuasive with celebrities they trust. This has already been done with Great British Bake Off judge Prue Leith and there should be more.

It is vital that having the vaccination is a good experience because of our propensity to accept any default setting and the influence of ‘affect’, where our emotional associations can powerfully shape our actions. This is especially important as everybody will require a second dose. So, being clear on any potential side-effects and providing leaflets and good communication on how to deal with them is crucial.

We respond well to incentives, so rewarding those vaccinated with a badge will appeal to our powerful ego, which can also be nudged by providing care homes with a certificate from an official body recognising when all residents have been immunised.

Social norms are also powerful drivers of behaviour, thus, producing a chart that the public can easily follow showing how many people have been vaccinated each day will active this and show we are all in this together.

Health and care workers

As you would expect, our research has found that health and care staff have a strong desire to return to their pre-pandemic roles and this can be used as an incentive.

A clear plan with time frames should be distributed across digital media showing when health services will start to return ‘to normal’.Health and care workers have been through a lot of stress coping with the pandemic and many have voluntarily gone beyond Government guidelines in isolating themselves from family and friends. To reward such sacrifices and incentivise takeup of the vaccine ‘staff and family parties’ should be organised.

This is a knowledgeable group and research on other vaccines has shown nurses and doctors are more willing the more information they read on it. Thus, evidence on the effectiveness of the vaccination should be provided across hospital and workplace communications and a dedicated webpage, with contributions from relevant experts and organisations such as the National Institute for Health and Care Excellence (NICE). The messenger effect can also help with this by using hospital CEOs, medical and nursing directors to champion the vaccine and take it first.

Hospital leaders can also be used to activate another powerful force – commitment, where we seek to be consistent with our public promises, and reciprocate acts. They can send a clear message that the vaccination programme is about staff health, and not workforce numbers, to show they care and are committed to their wellbeing.

Is the fear of the vaccine greater than the fear of the virus? This is a consideration for the over-65s and particularly relevant for black and ethnic minorities (BAME) who were perceived as higher risk but have not caught the virus.

Indeed, research shows vaccine hesitancy is higher among BAME groups and lower income households and with diminished levels of education.

Using trusted channels such as faith groups, charities and community groups is important as well as using messaging that taps into the affect bias to evoke an emotional response, such as “over-65s are over three times more likely to die if you get COVID than someone younger than you”. And use traditional media such as newspapers, billboards and broadcast alongside digital channels.

Use salience by emphasising that the vaccine will allow the ove-65s to return to their normal activities, social life and see their children and grandchildren. They also need reassuring that there will be enough vaccine for their family and friends so they are not taking the dose away from someone who needs it more. This will appease their ego.

While a single webpage on the NHS explaining what to expect when having the vaccine, possible side effects, and how to manage them can help alleviate their fears.

Young People

This group ranges from teenagers to 29 and they are least likely to become severely ill, which may lead to a complacent attitude to receiving the vaccine. However, if herd immunity is to be achieve it is vital they participate.

Social media is a key communication channel for them so employing the messenger effect with influencers to champion the vaccination is vitally important. Research has shown how much of an impact social media influencers’ opinions have and it will help dispel the plethora of misinformation and conspiracy theories.

Trust of politicians and leaders is low among young people and so they are more susceptible to misinformation. Any false stories gaining traction on social media need to be identified and countered head on through clear evidenced-based messages from influencers.

Young people have been denied a lot of freedom, with their social life being severely impacted. Returning to this can be used as an incentive with the introduction of vaccination passports for universities, work, attending sports events and going to clubs and concerts.

Alongside these incentives messaging needs to acknowledge the impact the virus has had on this group. Explain why they are lower down the vaccine roll-out and back-up the statements with science, actual research numbers and a link to 'geting your life back'.

Use of affect – where our emotional associations can powerfully shape our actions – can also be used with this cohort by emphasising the regret they would feel if they were not vaccinated and subsequnetly infected loved ones.

By using behavioural science insights each potential barriers can be identified, understood and mitigated with tailored strategies for the different population groups. This will give the UK a much better chance of reaching herd immunity and bringing an end to the pandemic.

Ivo Vlaev is Professor of Behavioural Science and part of the UK National Health Service’s (NHS) COVID Behaviour Change Unit. He teaches Mobilising Resources and Incentives for Healthcare Innovation on the E xecutive MBA Healthcare Specialism . He also lectures on Judgement and Decision Making on the MSc Finance .

For more articles on Behavioural Science sign up to Core Insights here .

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Persuasive messaging to increase COVID-19 vaccine uptake intentions

Affiliations.

1 Yale Institute for Global Health, New Haven, CT, USA; Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, USA.
2 Institution for Social and Policy Studies, Yale University, New Haven, CT, USA; Center for the Study of American Politics, Yale University, New Haven, CT, USA.
3 Institution for Social and Policy Studies, Yale University, New Haven, CT, USA; Center for the Study of American Politics, Yale University, New Haven, CT, USA; Department of Political Science, Yale University, New Haven, CT, USA.
4 Yale Institute for Global Health, New Haven, CT, USA; Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, USA; Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA; Yale School of Nursing, West Haven, CT, USA.
5 Institution for Social and Policy Studies, Yale University, New Haven, CT, USA; Center for the Study of American Politics, Yale University, New Haven, CT, USA; Department of Political Science, Yale University, New Haven, CT, USA. Electronic address: [email protected].
PMID: 34774363
PMCID: PMC8531257
DOI: 10.1016/j.vaccine.2021.10.039

Widespread vaccination remains the best option for controlling the spread of COVID-19 and ending the pandemic. Despite the considerable disruption the virus has caused to people's lives, many people are still hesitant to receive a vaccine. Without high rates of uptake, however, the pandemic is likely to be prolonged. Here we use two survey experiments to study how persuasive messaging affects COVID-19 vaccine uptake intentions. In the first experiment, we test a large number of treatment messages. One subgroup of messages draws on the idea that mass vaccination is a collective action problem and highlighting the prosocial benefit of vaccination or the reputational costs that one might incur if one chooses not to vaccinate. Another subgroup of messages built on contemporary concerns about the pandemic, like issues of restricting personal freedom or economic security. We find that persuasive messaging that invokes prosocial vaccination and social image concerns is effective at increasing intended uptake and also the willingness to persuade others and judgments of non-vaccinators. We replicate this result on a nationally representative sample of Americans and observe that prosocial messaging is robust across subgroups, including those who are most hesitant about vaccines generally. The experiments demonstrate how persuasive messaging can induce individuals to be more likely to vaccinate and also create spillover effects to persuade others to do so as well. The first experiment in this study was registered at clinicaltrials.gov and can be found under the ID number NCT04460703 . This study was registered at Open Science Framework (OSF) at: https://osf.io/qu8nb/?view_only=82f06ecad77f4e54b02e8581a65047d7.

Publication types

Research Support, Non-U.S. Gov't
COVID-19 Vaccines*
United States
Vaccination
COVID-19 Vaccines

Associated data

ClinicalTrials.gov/NCT04460703

Grants and funding

UL1 TR001863/TR/NCATS NIH HHS/United States

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http://orcid.org/0000-0003-4530-8466 Nicholas Yee Liang Hing 1 ,
http://orcid.org/0000-0003-4834-9175 Yuan Liang Woon 1 ,
http://orcid.org/0000-0002-3034-8601 Yew Kong Lee 2 ,
http://orcid.org/0000-0001-6224-835X Hyung Joon Kim 3 ,
http://orcid.org/0000-0002-2307-4075 Nurhyikmah M Lothfi 2 ,
Elizabeth Wong 3 ,
http://orcid.org/0000-0003-3539-8605 Komathi Perialathan 4 ,
Nor Haryati Ahmad Sanusi 4 ,
Affendi Isa 5 ,
http://orcid.org/0000-0002-3688-5467 Chin Tho Leong 1 ,
http://orcid.org/0000-0001-7174-7919 Joan Costa-Font 6
1 Centre for Clinical Epidemiology , Institute for Clinical Research, National Institutes of Health , Shah Alam , Selangor , Malaysia
2 Department of Primary Care Medicine , Faculty of Medicine, University of Malaya , Kuala Lumpur , Malaysia
3 United Nations Children's Fund Malaysia , Putrajaya , Malaysia
4 Centre for Health Communication and Informatics Research , Institute for Health Behavioural Research, National Institutes of Health , Shah Alam , Selangor , Malaysia
5 Health Education Division , Ministry of Health Malaysia , Putrajaya , Malaysia
6 Department of Health Policy , The London School of Economics and Political Science , London , UK
Correspondence to Nicholas Yee Liang Hing; nicholas.hingyl{at}gmail.com

Introduction Vaccine safety is a primary concern among vaccine-hesitant individuals. We examined how seven persuasive messages with different frames, all focusing on vaccine safety, influenced Malaysians to accept the COVID-19 vaccine, and recommend it to individuals with different health and age profiles; that is, healthy adults, the elderly, and people with pre-existing health conditions.

Methods A randomised controlled experiment was conducted from 29 April to 7 June 2021, which coincided with the early phases of the national vaccination programme when vaccine uptake data were largely unavailable. 5784 Malaysians were randomly allocated into 14 experimental arms and exposed to one or two messages that promoted COVID-19 vaccination. Interventional messages were applied alone or in combination and compared against a control message. Outcome measures were assessed as intent to both take the vaccine and recommend it to healthy adults, the elderly, and people with pre-existing health conditions, before and after message exposure. Changes in intent were modelled and we estimated the average marginal effects based on changes in the predicted probability of responding with a positive intent for each of the four outcomes.

Results We found that persuasive communication via several of the experimented messages improved recommendation intentions to people with pre-existing health conditions, with improvements ranging from 4 to 8 percentage points. In contrast, none of the messages neither significantly improved vaccination intentions, nor recommendations to healthy adults and the elderly. Instead, we found evidence suggestive of backfiring among certain outcomes with messages using negative attribute frames, risky choice frames, and priming descriptive norms.

Conclusion Message frames that briefly communicate verbatim facts and stimulate rational thinking regarding vaccine safety may be ineffective at positively influencing vaccine-hesitant individuals. Messages intended to promote recommendations of novel health interventions to people with pre-existing health conditions should incorporate safety dimensions.

Trial registration number NCT05244356 .

Randomised control trial
Public Health
Health education and promotion

Data availability statement

Data are available upon reasonable request. The data set used for this study belongs to the Ministry of Health, Malaysia. Hence, the data set may be available from the corresponding author via a formal request through relevant authorities at the Ministry of Health, Malaysia.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjgh-2022-009250

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WHAT IS ALREADY KNOWN ON THIS TOPIC

Persuasive messages have been shown to influence COVID-19 vaccination intentions, but evidence from low and middle-income countries is limited.

Little is known regarding the effect of persuasive messages in influencing decisions to recommend the COVID-19 vaccine, especially while considering the health and age profile of the individual receiving the vaccination recommendation.

WHAT THIS STUDY ADDS

Persuasive messages that addressed vaccine safety concerns using facts and statistics to stimulate rational thinking did not positively influence Malaysian adults to take the COVID-19 vaccine or recommend it to healthy adults and the elderly.

Addressing vaccine safety concerns via persuasive messages is appealing towards individuals who are being nudged to recommend the COVID-19 vaccine to people with pre-existing health conditions.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

In addition to providing verbatim facts and stimulating rational thinking, messages addressing vaccine safety concerns to improve vaccination intent should stimulate emotional reasoning and communicate the gist of the message convincingly.

The decision to take up or recommend a health intervention is based on perceived need that is derived from an internalised and externalised risk-benefit assessment for oneself and others, respectively, while accounting for individual health profiles.

Persuasive messages that are intended to promote uptake of a novel health intervention should incorporate safety dimensions as a form of assurance for others to recommend it to people with pre-existing health conditions, given that they may be perceived as more susceptible to harms from adverse effects due to the intervention.

Introduction

The COVID-19 pandemic has sparked global efforts to develop countermeasures against SARS-CoV-2. One such measure lies with the rapid research and development of effective COVID-19 vaccines 1 which are critical to achieve impactful COVID-19 vaccination campaigns. 2 Although credible vaccine information from official sources is abundantly available, 3–6 vaccine-hesitant individuals risk compromising widespread vaccination 7 as they delay or refuse to take a vaccine once it is made available. 8

Vaccine safety remains one of the top concerns cited by vaccine-hesitant individuals in Malaysia and abroad. 9–12 This is aggravated by misinformation regarding COVID-19 vaccine safety. 13 Hence, a question that emerges is how best to effectively communicate vaccine safety information. A potential method stems from applying nudges, which alters the choice architecture or information context to encourage a particular behaviour. 14 One such form involves using various frames of persuasive messages to encourage behaviour change. 15 16

Multiple studies have experimented with persuasive messages to influence COVID-19 vaccination intentions. The use of goal-framed messages that seek to influence behaviour by highlighting benefits achieved or lost depending on vaccination acceptance has been widely explored. 17–24 Dai et al used messages to reduce barriers to schedule a vaccination appointment, provide salient information about vaccine effectiveness, and issue reminders that leveraged on psychological ownership. 25 Messages that detail information promoting personal or collective benefits through vaccination have also been explored. 26 Some studies have used social norms to motivate individuals to take the COVID-19 vaccine with mixed successes. 20 27–29

Amidst this broad coverage of studies, few have found messages that specifically address COVID-19 vaccine safety to be effective among unvaccinated individuals. Positive effects were observed when a risky choice framed message was tested among employees of a healthcare organisation through a personalised email message. 29 However, results may not be generalisable to the public as healthcare organisation employees may have higher levels of health awareness. Barnes and Colagiuri also observed positive effects with messages applying attribute framing where vaccine side effect rates were framed positively or negatively. 30 However, they investigated booster shot intentions among fully vaccinated individuals.

Based on current available evidence pertaining to vaccine safety, there are several knowledge gaps. The effects of attribute framing have yet to be explored among individuals unvaccinated against COVID-19. Attribute framing manipulates the descriptive valence of an object or event and has been shown to affect the cognitive and evaluation process of decision-making, 31–33 which potentially influences health-related behaviour. 32 34 35 Risky choice frames are another nudge technique that describes the outcome of potential choices involving differing levels of risk and can be applied to favourably highlight a frame being evidently advantageous when comparing competing frames. 36 Although already proven effective at influencing vaccination intentions, 29 framing generic health messages that juxtapose vaccine-related death rates or side effects against the COVID-19 disease has not been studied among the general public. Descriptive norm messages have been widely studied in the context of COVID-19 vaccination by communicating that the majority are getting vaccinated, so that individuals become psychologically convinced that vaccinating is a societal norm deemed as effective and hence adopt it. 37 However, these messages have not been framed to imply vaccine safety as a motivation for vaccination among the majority. Additionally, using vaccinated health authorities to imply vaccine safety and recommend the vaccine has the potential of leveraging on authority bias. 38 For instance, the use of descriptive norms to highlight medical consensus among medical professionals regarding vaccine safety helped reduce risk perceptions and improved attitudes towards the measles, mumps, and rubella (MMR) vaccine. 39 However, this effect has not been thoroughly studied in an Asian context. Finally, given that individual decision and behaviour are intrinsically linked to context and culture, 40–42 there are reasons to believe that vaccination nudges ought to be adapted to low and middle-income countries (LMIC) such as Malaysia. However, there exists a paucity of information for using such nudges in LMICs, with most published evidence originating from developed countries. 16

Furthermore, previous studies have widely investigated nudges to influence personal interests to vaccinate one’s self or own child 16 43 44 rather than a person’s decision to recommend vaccination. Although James et al did investigate the effects of persuasive messages in recommending a COVID-19 vaccine to a friend, they did not consider the health or age profile of the person being recommended. 21 Having a finer gauge on which group of people have higher likelihoods to be recommended is important especially in Asian communities who pay special attention to advice sought from family and friends with significance when making a health-related decision. 45

Therefore, we conducted an experiment in Malaysia using various message frames intended to narrow the current knowledge gaps. Our primary objectives were to investigate whether persuasive messages focusing on vaccine safety influenced the intention to take up the COVID-19 vaccine, and recommend it to healthy adults, the elderly (individuals who are aged 60 and above), and people with pre-existing health conditions. We hypothesise that, compared with a control message, exposure to a single message emphasising vaccine safety can significantly improve intentions among individuals who are initially hesitant to accept or recommend the vaccine. Apart from examining single messages, we investigate the effects of combining messages together to mimic a real-world environment where people are exposed to multiple messages. We hypothesise that, in contrast to the control group, exposure to two persuasive messages will create higher positive shifts in intent among hesitant individuals compared with a single message exposure. Testing this hypothesis allows us to determine if combining messages will improve effectiveness from a higher message dose effect, 46 or reduce effectiveness due to message interactions causing a boomerang effect.

Study design

We conducted a prospective 14-arm randomised controlled experiment with a parallel design. The experiment was conducted using a web-based survey that was launched on a platform belonging to Dynata, an international market research company based in America. The company has an online survey panel composed of Malaysians who have signed up on the survey platform. Participants who complete a survey will receive reward points as per Dynata’s policy.

Study participants and setting

The experimental survey was conducted from 29 April to 7 June 2021 (more details about the COVID-19 situation in Malaysia during participant recruitment can be found in the online supplemental material ). The survey was launched during the initial phases of the national COVID-19 vaccination programme which targeted the general adult population. Thus, data involving actual vaccination uptake were largely unavailable as the majority of the population were unvaccinated. 47 Participants were recruited from Dynata’s online survey panel. Eligible participants were adult Malaysians aged 18 years and above who could understand either the English or Malay language and had not received any dose of the COVID-19 vaccine. The latter criterion allowed us to investigate the effectiveness of messages in an unvaccinated population, which is an important aspect prior to any novel vaccination roll-out.

Supplemental material

Sample size requirement was calculated based on a logistic model to detect a small effect size of 0.1, with the baseline proportion of people who definitely will take the COVID-19 vaccine set at 0.67. This baseline value was chosen based on the reported proportion of Malaysians willing to accept the COVID-19 vaccine in a national survey that was conducted before this study was being planned. 12 Sample size was calculated to be 318 respondents per arm, after setting power at 80% and significance level at 0.05. Taking into account a 20% dropout rate in the event of invalid responses, the estimated sample size was 400 participants per arm. Participants were recruited via stratified sampling based on age, sex, ethnicity, and household income to obtain an approximately population-representative sample (more details about the stratified sampling can be found in the online supplemental material ).

All participants selected the language of their choice and were then shown a page that described background information about the study. They provided informed consent by clicking on a button indicating agreement to join the experiment.

Randomisation and masking

Enrolled participants were randomly allocated into a particular experimental arm by Dynata through an automated computer randomisation system. This experiment was double blinded whereby participants were unaware of what interventional message was given to them and investigators had no control over treatment assignment as this aspect was completely handled by the market research company.

Data collection and intervention

Sociodemographic variables that screened for inclusion criteria and enabled stratified sampling during experimental arm allocation were first collected from approached participants. General attitude towards vaccines was elicited from recruited participants as this factor has been shown to significantly influence vaccine uptake intent. 44 48 Attitude was elicited by measuring the level of agreement (via a five-point Likert scale) with two statements regarding the efficacy of vaccines in protecting against serious diseases, and personal religious or cultural backing for vaccination. Participants were also asked in the remaining sociodemographic section whether they had refused to vaccinate their child in the past. These questions were adapted from locally conducted studies. 48 49 Participants were categorised as having a potential negative attitude if they provided responses indicating disagreement, uncertainty, or refusal to any of those questions.

Participants were then asked a series of questions related to their baseline intentions to accept and recommend the COVID-19 vaccine before being randomly assigned to an experimental arm. Participants were exposed to either one or two messages from a selection of eight different types of messages and were instructed to read the message completely before clicking a button to proceed to the next message or section. Each message was calibrated to be on screen for at least 8 seconds before the button becomes active to ensure participants read the message without skipping. Table 1 describes the content of each message and the corresponding nudge technique that the content was incorporated with. The source of the information displayed is stated below the message’s content to provide information credibility.

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Content of each experimental treatment message used along with the corresponding nudge technique employed

The control message was devoid of any nudge or persuasive element and only displays a slogan that rallies the reader to get the COVID-19 vaccine because it is safe and effective. The other experimental messages began with an opening tagline highlighting the main concern that Malaysians have about the COVID-19 vaccine and serves as a precursor for the following message content which attempts to alleviate that concern. Each message concludes with a rally slogan that is identical with the control message. All messages were validated with at least five people and went through a series of iterations to ensure that the content was interpreted correctly (details about the message design and examples of actual messages can be found in the online supplemental material and figure S1 , respectively). Messages were also translated to Malay and similarly validated.

Our experiment presents a total of 14 arms. Participants were exposed to one message in the first eight arms, and two messages in the remaining arms. The control arm was made a common comparator against all other experimental arms. DN(70%) exposure was held constant in arms that applied two experimental messages; that is, arms 9–14. This message was made a constant because it focuses on the Malaysian general public as the reference group, making it the most personally relevant message to our survey’s target participants who are from the Malaysian public. Participants who received two messages were exposed to one message at a time, with the sequence of appearance being random.

After message exposure, participants were asked again regarding their intentions to receive and recommend the COVID-19 vaccine. Participants who were hesitant about taking or recommending the vaccine after exposure were asked about the possible reasons for such responses. Lastly, the remaining sociodemographic variables such as education level and history of contracting COVID-19 were collected.

Intent to accept the COVID-19 vaccine was elicited by asking participants using a four-Likert scale with responses ranging from ‘Definitely no’, ‘Not sure, but probably no’, ‘Not sure, but probably yes’, and ‘Definitely yes’. This scale was used to eliminate subjective ambiguity and allows participants to express their intent in detail which is capably determined as it involves an internalised decision. 50

Intent to recommend the COVID-19 vaccine was elicited by asking participants to rate their level of agreement with recommending the vaccine to three groups of family members, namely healthy adults, elderly, and members with any pre-existing health conditions. Family members were chosen as a target character because they are related to respondents, thus they can be interpreted as unbiased responses regarding intent to recommend the vaccine to each of the three studied groups. Participants rated their agreement via a five-Likert scale which provided options of ‘Strongly disagree’, ‘Disagree’, ‘Not sure’, ‘Agree’, and ‘Strongly agree’. This scale was chosen to provide a neutral answer in the form of a ‘Not sure’ option, because the decision to recommend may influence the outcome of another individual, which may be a difficult decision and thus warrant a neutral stance.

Our four study objectives were based on outcomes measured at baseline and post-intervention. Positive intent was defined as responding ‘Definitely yes’ and ‘Agree’ or ‘Strongly agree’ for accepting and recommending the vaccine, respectively. These responses indicated no hesitancy towards the action in question whereas the remaining options reflected uncertainty or refusal.

Statistical analyses

Summary statistics (frequency and percentages, mean and standard deviation) of recruited participants’ demographics, attitude towards vaccines, and intent to accept and recommend the COVID-19 vaccine in each experimental arm were reported. Balance tests were conducted to check if baseline characteristics were significantly different between each experimental arm.

Since the responses for all four outcome measures were ordinal in nature, we applied four separate generalised ordered logistic regressions to estimate how each experimental arm affected the propensity of selecting a particular level of intent. Each regression model was adjusted for general attitude towards vaccines and baseline intent that corresponds to the outcome measure analysed. Generated regression models were subsequently used to compute the average marginal effects of each interventional arm relative to the control arm based on changes in the predicted probability of responding with a positive intent for each of the four outcome measures. This provided an estimate behind the effectiveness and probability change magnitudes exerted by experimented messages. As post hoc analyses, we tested heterogeneous treatment effects of age, sex, and education level to investigate whether our intervention messages impacted certain groups of individuals differently.

All results were reported and presented graphically at the 5% significance level. However, to account for multiple hypothesis testing, we adjusted our p values by applying the sharpened false discovery rate method and reported these together with the marginal effects summary for all outcomes tested. 51 All analyses were conducted using Stata V.16. This study was registered on ClinicalTrials.gov (ID number: NCT05244356 ). An author reflexivity statement was included to address the international partnership that stemmed from this study (the reflexivity statement can be found in the online supplemental file 2 ).

Patient and public involvement

Patients or the public were not involved in the design, or conduct, or reporting, or dissemination plans of our research.

A total of 5784 participants were recruited into the experiment. Each arm was assigned between 410 and 416 participants. Table 2 provides a summary of the sociodemographic characteristics of recruited participants while figure 1 presents the experimental design flow chart. Sampled participants were approximately representative of the Malaysian national population with regard to sex, ethnicity, and household income. 52 53 However, given that the experiment was conducted as an online survey, the proportion of participants from the youngest age group (ages 18–39) was 70% higher compared with the national proportion. 52 Similarly, our sampled data set was skewed towards more educated participants, with the proportion of samples having education above secondary level surpassing the national proportion by more than threefold. However, all experimental arms were balanced and showed no significant differences with respect to key baseline characteristics. The average baseline proportion of participants with positive intent in each arm to take and recommend the COVID-19 vaccine to healthy adults, the elderly, and people with health conditions was 61.6%, 84.9%, 72.7%, and 51.4%, respectively. Almost all participants did not contract COVID-19 before. Summary statistics of survey participants stratified according to experimental arms can be found in the online supplemental table S1 .

Sociodemographic characteristics of all recruited participants (n=5784)

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Experimental design flow chart presenting sample size, arm allocations, and item wordings for outcomes.

Figure 2 depicts forest plots that describe the average marginal effects of providing positive responses for each interventional arm relative to the control arm in all outcomes measured. A summary of marginal effects for all levels of responses can be found in the online supplemental tables S2 and S3 . In terms of participant’s intent to accept the COVID-19 vaccine or recommending it to healthy adults and the elderly, none of the interventional arms were significantly effective at improving intent compared with the control message. Instead, intent to vaccinate significantly dropped among participants assigned to both the NF message, and its combined exposure with DN(70%). Recommendation intentions towards healthy adults significantly dropped in the DN(70%) and RC(S) arm. Intent to recommend the vaccine to healthy adults in the combination message arm containing DN and RC(S) was also lowered. However, all these findings were not robust after p value adjustments.

Average marginal effects for each interventional arm relative to the control arm based on changes in the predicted probability of responding with a positive intent for each primary outcome measure: (1) intention to vaccinate, (2) recommend to healthy adults (Healthy adults), (3) recommend to the elderly (Elderly), (4) recommend to people with pre-existing health conditions (Health condition). Forest plots present point estimates, 95% CIs, and the line of indifference.

Conversely, five interventional arms were significantly effective at improving recommendation intentions to people with pre-existing health conditions. Both the DN arm and PF arm showed highest significant improvements, with effect sizes measuring about 8 percentage points (95% CI 4.1 to 12.0) and 5.6 percentage points (95% CI 1.7 to 9.5), respectively. These findings were robust after p value adjustments. The remaining arms showing significant improvements were the combination messages containing DN (4.2 percentage points, 95% CI 0.2 to 8.1), HCW (4.7 percentage points, 95% CI 0.8 to 8.6), and RC(S) (4.6 percentage points, 95% CI 0.7 to 8.5) message. However, the significance level of these findings dropped to 10% after p value adjustments.

Being worried about the safety or side effects of the vaccine was the main reason for hesitancy, with 70%–80% participants who were hesitant in each outcome answering as such. A tabulation that reports the proportion of respondents citing reasons for hesitancy for each outcome can be found in the online supplemental figures S2–S5 . We found no significant differences between all arms with respect to proportion of respondents citing this top reason ( online supplemental table S4 ).

Figure 3 displays the forest plots with 95% CIs for heterogeneous treatment effects that indicate definite intentions of accepting the COVID-19 vaccine and agreeing to recommend it. A summary of treatment effect values can be found in the online supplemental tables S5–S7 . There is evidence showing certain sociodemographic groups are more impacted by our experimented messages.

Sociodemographic determinants of average marginal effects with respect to age, sex, and education level, for each interventional arm relative to the control arm based on changes in the predicted probability of responding with a positive intent for each primary outcome measure: (1) intention to vaccinate, (2) recommend to healthy adults (Healthy adults), (3) recommend to the elderly (Elderly), (4) recommend to people with pre-existing health conditions (Health condition). Forest plots present point estimates, 95% CIs, and the line of indifference.

Subgroup analysis for participants aged below and above 30 years old was conducted. This grouping was selected to investigate if youths, who have much lesser risk for suffering severe consequences from contracting COVID-19 but have their future well-being affected by the pandemic, 54 responded differently compared with the older age groups who have a higher risk for serious complications from a COVID-19 infection. 55 Although we found that intent to vaccinate among older participants was significantly affected by the NF message both on its own and in combination with DN(70%) , this finding was not robust after p value adjustments. Similarly, experimental arms which registered significant drops in recommendation intentions to healthy adults and the elderly became non-significant after p value adjustments. Both age groups responded positively to the DN message for recommendation intentions to people with health conditions, in which youths and older people saw an increase in intent by 6.6 percentage points (95% CI 0.1 to 13.0) and 8.7 percentage points (95% CI 3.7 to 13.8), respectively. Older people also showed an increase in intent to recommend by 5.3 percentage points (95% CI 0.3 to 10.3) when exposed to PF . Intent increased to 7.4 percentage points (95% CI 2.5 to 12.3) when DN(70%) was added. Additionally, older people were more likely to make a recommendation when DN(70%) was combined with HCW (6.5 percentage points, 95% CI 1.5 to 11.5). All messages that significantly influenced older people were robust after p value adjustments.

We find some gender heterogeneity, male respondents were more negatively impacted by the NF message. Vaccination intent further declined when DN(70%) was added. In contrast, females were more negatively influenced by the RC(S) message, causing a reduction in recommendation intentions to healthy adults. However, all these findings were not robust after p value adjustments. We documented a significant increase in recommendation intentions to people with health conditions when they were exposed to the DN message, irrespective of gender. Intent improved by 6.8 percentage points (95% CI 1.2 to 12.3) and 9.4 percentage points (95% CI 3.8 to 15.1) for males and females, respectively. Males were also more positively influenced by both PF and RC(SE) messages. Moreover, males tended to positively respond when DN(70%) was combined with RC(S) while females exhibited a similar response when DN(70%) was combined with HCW . After p value adjustments, only the positive influence of DN message among females remained significant at the 5% level while all other findings except for the influence of RC(SE) on males were significant at the 10% level.

Subgroup analysis was conducted between participants with and without tertiary education to observe any differences in behavioural response to the messages, given that Malaysians with a bachelor’s degree or higher were more likely to accept the COVID-19 vaccine. 56 None of the messages significantly impacted vaccination intent among the two groups. However, several messages significantly reduced intent to recommend the vaccine to healthy adults among participants with tertiary education. The DN(70%) arm showed the highest drop in intent (−7.9 percentage points, 95% CI −12.6 to −3.2), followed by the NF arm (−5.7 percentage points, 95% CI −10.1 to −1.2), DN arm (−4.6 percentage points, 95% CI −8.8 to −0.3), and RC(S) arm (−4.5 percentage points, 95% CI −8.8 to −0.1). There were also significant reductions in intent between 5.5 and 6.6 percentage points among tertiary educated participants who were exposed to combination messages containing PF and RC(S) . Most of these findings remained significant either at the 5% or 10% significance level after p value adjustments. However, participants without tertiary education revealed significantly lower recommendation intentions to the elderly when exposed to combination messages containing NF (−7.2 percentage points, 95% CI −12.4 to −2.1) and RC(SE) (−5.5 percentage points, 95% CI −10.6 to −0.5), but with only the former result remaining significant at the 10% significance level after p value adjustments. Apart from DN(70%) , HCW, and combination messages containing PF and RC(SE) , all arms showed significant improvements in intent among those with tertiary education to recommend the vaccine to people with health conditions, ranging from 6.0 to 11.6 percentage points. These findings remained robust after p value adjustments. Participants with lesser than tertiary-level education were also positively influenced by the DN arm, but this finding lost significance after p value adjustments.

This study reports the results of one of the first experiments in the Southeast Asian region, and Malaysia specifically, that apply persuasive health messages to influence vaccine uptake and recommendation intentions. Hence, our results may serve as a reference benchmark for expected outcomes when using various types of message frames in a middle-income country. Two single experimental messages, that is, DN and PF , and two message combinations, that is, DN(70%)+HCW and DN(70%)+RC(S) , supported the first and second hypotheses, respectively, for only one outcome, which is intent to recommend the COVID-19 vaccine to people with pre-existing health conditions.

None of our experimented messages improved vaccination intentions, with some showing signs of backfiring. Our results concur with other studies that similarly employ messages explaining about COVID-19 vaccine safety. Persuasive messages emphasising vaccine safety either through explaining the rigorous process of drug development and the rarity of side effects, leveraging the authority of a clinician to explain vaccine safety, or highlighting vaccine approval from a regulatory agency, failed to significantly improve vaccination intent. 22 28 57 58 Although Diament et al found positive findings with a message explaining the vaccine’s approval process by a regulatory authority to infer vaccine safety, their results were weakly significant. 59 There are several possible explanations to our findings. Our experimented messages provided brief verbatim representations that promoted vaccine safety. However, this stimulus did not translate to gist representations that was sufficiently convincing to influence hesitant individuals from a vaccine safety perspective, in accordance with the fuzzy-trace theory. 60 Vaccine-hesitant individuals also display a higher reliance on experiential thinking systems, 61 62 which poses a formidable challenge when attempting to alter decisions using rational arguments and statistics. Another explanation refers to the limited effect of brief textual messages at capturing attention and sounding convincing. Perhaps delivering messages through an engaging media might have yielded better results. 63 For instance, a study reports a positive behavioural change when using a video clip to deliver vaccine safety information. 64

Our persuasive messages did not improve recommendation intentions to healthy and older individuals. In contrast, we find significant and sizeable effects of persuasive messages in improving recommendation intentions to people with pre-existing health conditions across several experimental arms. Attribute appeal is a possible reason driving the differences in recommendation intentions between our studied outcomes. More than 80% of our participants agreed to recommend the vaccine to healthy adults at baseline. This observation suggests a general perception that healthy adults are fit enough to take the vaccine without any cause for safety concerns. Hence, addressing vaccine safety may not be a suitable dimension to persuade the hesitant minority who may have deeper qualms about other issues. Conversely, about half of our participants were hesitant at baseline to recommend the vaccine to people with health issues. Such low baseline proportions may be driven by perceptions that vaccines are potentially harmful to individuals with pre-existing health conditions who may have higher susceptibility of being harmed by vaccine adverse effects, given their poorer health state. This presumption is evidenced by the significant improvement in recommendation intentions after exposure to several of our messages promoting vaccine safety, a key attribute that appealed to influenced participants. Similarly, vaccine safety may be a concern among participants who were hesitant to recommend the vaccine to the elderly, given that they are frailer and more fragile to be recommended an intervention perceived as risky. This effect is not driven by ageism, as older people are regarded highly in Asian societies such as Malaysia. 65 However, given that our current sample is skewed towards younger individuals, recommending a perceived risky intervention to an elder may seem disrespectful. Therefore, persuasive vaccine safety messages proved insufficient to nudge those hesitant to recommend amidst an additional cultural barrier.

Interestingly, our results suggest that vaccine recommendation intentions to people do not necessarily reflect on one’s own intention to vaccinate. Whilst the decision to vaccinate is based on a personal risk-benefit assessment from getting vaccinated, the decision to recommend the take up of a vaccine refers to an externalised risk-benefit assessment based on another person’s needs. This assessment might be reflective of some overconfidence, or perceived relative risk of disease severity from contracting COVID-19 together with perceived risk tolerance for vaccination, all of which is dependent on an individual’s health profile. For instance, individuals with pre-existing health conditions are presumably at higher risk of being severely ill from COVID-19, while also perceived to bear higher risks of suffering harm from vaccine adverse effects. However, once the latter concern is dispelled, the decision to recommend becomes clearer based on perceived benefits for these individuals.

Our descriptive norm messages are grounded on the perceived sense of safety generated from knowledge that a vast majority are taking or have taken the COVID-19 vaccine, making it a social norm deemed as the right choice. However, such social nudges proved ineffective in significantly raising self-vaccination intent compared with the control message, consistent with other COVID-19 vaccine studies involving norms. 20 27 Despite being significant, the norms message performed the poorest in a study by Jensen et al . 64 Helfinstein et al also found that descriptive norms had little effect on risk recommendation to others, which reflects our negative observations with respect to vaccine recommendation. 66 In contrast, we observe the DN message increase recommendation intentions to people with pre-existing health conditions. Message targeting may have made the DN message relatable to the recommended target group, since it highlights that many people with health conditions have tested and taken the COVID-19 vaccine. 67 However, the addition of DN(70%) weakened this effect. Additionally, although insignificant after p value adjustments, there are indications that DN(70%) on its own reduced recommendation intentions to healthy adults. These effects could be specifically due to the reference to "70% of Malaysians", as stated in the DN(70%) message. Such a proportion might be insufficient to be perceived as a convincing norm since mass media widely reports target inoculation rates of 80% by the government through the national immunisation programme. 68

Both NF and PF messages induced opposite effects in two separate outcome measures. The PF message improved intentions to recommend the vaccine to people with health conditions. Although insignificant, there were signs that the NF message reduced intent to accept the COVID-19 vaccine and this was similarly observed when the DN(70%) message was added. Generally, studies have shown attribute frames to be more effective when framed positively rather than negatively. 31 32 35 69 However, Barnes and Colagiuri found that both positive and negative attribute framed messages increased intentions to accept a booster dose among COVID-19 vaccinated participants if the offered vaccine was unfamiliar and familiar, respectively. 30 Their findings differed from our results possibly because our participants have not been vaccinated but were already familiar with the type of COVID-19 vaccine offered that was being widely promoted on mass media, given that our survey coincided with the national immunisation programme. 70 71 Inexperience with the vaccine may have heightened negative safety perceptions arising from negative attribute framing while negating positive effects observed with positive attribute framing with respect to vaccination intent. Familiarity with the vaccine’s safety profile may have also attenuated positive attribute framing effects. 72 A study involving influenza vaccine similarly found that participants who were exposed to negative framed messages had higher expectations or perceived severity of side effects. 73 Interestingly, inexperience did not cloud positive perceptions arising from the PF message to drive improved intentions to recommend the vaccine to people with health conditions. Instead, it appears that preconceived views that such a target population is more susceptible to harms from vaccine adverse effects given their poorer state of health may have been alleviated by this extra boost in safety perception.

Participants exposed to the HCW message did not show any significant changes in intent for all outcome measures examined. There are several possible reasons. The social norm cue used with reference to the majority of healthcare workers already vaccinated was probably ineffective due to participants being unable to identify with the reference population used. 27 Furthermore, the message may not have provided the personal touch and physical interaction from a healthcare provider necessary to invoke changes in intent, a condition which is observed among studies reporting raised vaccination intents. 43 74–76 This explanation is further supported by findings from Motta et al suggesting that vaccination intent did not differ from the control group when the message encouraging vaccine uptake came from a medical expert. 17 Additionally, leveraging the Director General of Health’s influence, who is a government official, may portray him as accomplishing a bureaucratic task driven by political motives. 77 The use of a celebrity who is viewed as politically neutral yet popular could prove more efficacious, as shown in a study which found celebrities inducing higher vaccine scepticism reductions compared with government officials or medical experts. 77 Interestingly, when both HCW and DN(70%) were combined, recommendation intentions to people with health conditions were significantly raised. This observation is probably borne from positive interactions between a low descriptive norm and a high injunctive norm. Recommendations coming from a convincing proportion of healthcare workers confers the perception that getting vaccinated is a socially desirable action that is expected, which results in a high injunctive norm. 37 Habib et al found that willingness to register as an organ donor increased when a low descriptive norm was combined with a high injunctive norm, as opposed to applying the norms individually. 78 This interaction arises by stoking a sense of responsibility to act after the incongruent norms highlight salient inconsistencies existing within the group. Although unmeasured, we believe this sense of responsibility to recommend was invoked from this similar interaction. Our finding thus expands knowledge on normative influence by proving such interactions also exist for behaviour recommendation.

Although insignificant, there were signs that recommendation intentions to healthy adults were significantly negatively affected by RC(S) . The use of death rates from COVID-19 could be perceived as an irrelevant risk to healthy adults, since most deaths are associated with elderly and people with pre-existing health conditions. 79 A mismatch with the target group could have led to drops in intent. Moreover, the number of deaths featured on the message may not be convincing enough to require a need for healthy people to take the vaccine. However, this effect was slightly reduced when DN(70%) was added together, presumably because the higher dosage of pro-vaccination messages counteracted the negative effects of each message when applied individually. 46 A similar dose–response interaction may be occurring when DN(70%) was combined with RC(S ) to yield a significant increase in intent to recommend the vaccine to people with health conditions. Although RC(S) and RC(SE) addressed safety attributes which are relevant to elderly and people with health conditions, their effects did not differ from the control message when applied alone. A possible reason lies with the message bringing attention to possible health risks associated with the vaccine such as deaths or blood clots. Despite the probability favouring vaccine uptake, the mention of these health risks may have caused hesitant individuals to remain hesitant for fear of recommending something harmful.

Our analysis on heterogeneity treatment effects revealed varied impacts of different messages for each sociodemographic variable. There were indications that intent to vaccinate for both older participants and males was negatively influenced by a negative attribute frame. Studies show older people have higher risk perceptions towards health-related risks. 80 This characteristic makes them more susceptible to negatively framed attribute messages as negative frames heighten risk perception. Studies have also shown that men tend to be more optimistic about perceived susceptibility and severity from COVID-19, 81 82 rendering males as more likely to take a risk of contracting the virus as compared with taking a vaccine that is perceived unsafe due to the negative attribute framing effect. Our findings highlight the damaging effect such frames can cause among males who generally have higher vaccination intentions compared with females. 83

Most of the messages which induced positive recommendation intentions to people with health conditions impacted the older age group, males, and those with a tertiary education. There are several postulations to this pattern of results. Studies show that self-esteem increases with age. 84 85 This may confer older people with more confidence to recommend the vaccine if there is information that supports this action. Moreover, our youths may be more hesitant to make recommendations even when nudged as Malaysia practices a collectivist culture. 65 People with pre-existing health conditions tend to be older, which makes it more challenging for youths to make recommendations due to social hierarchy barriers. Males having higher intentions to make recommendations are arguably driven by risk acceptance. Recommending a health intervention involves some risk taking since it advocates something that may expose another individual to a certain level of risk. Studies have shown that men exhibit a higher risk-taking behaviour compared to women. 86 However, females were also found to similarly respond to the DN message, which underscores the potential of this social norm message in influencing people regardless of gender. On the other hand, behavioural differences to make recommendations based on education level are probably related to cognitive capabilities to synthesise information and perceived vaccine safety. People with tertiary education could have understood and synthesised the health messages better to infer that the vaccine was safe to be used by people with health issues. Being highly educated also increases confidence and imparts a higher sense of social responsibility to recommend.

Individuals with tertiary education were also more impacted by messages which reduced intent to recommend the vaccine to healthy adults. A deeper synthesis of messages by those who have higher education does not necessarily produce positive results and could backfire instead. These people may tend to have more complex interpretations amidst wider information obtained from various sources, resulting in certain messages inducing negative responses. Studies have shown that there is a strong association between education level and extent of COVID-19-related knowledge, both factual and perceived. 87 88 Coupled with a lesser perceived severity of the virus by more educated individuals, these messages may have been interpreted with a risk-benefit analysis to suggest healthy individuals not requiring the vaccine. 88

Limitations

Our experiment exhibits the following limitations. Study outcomes measured how messages affect intent and do not really indicate whether participants would actually receive or recommend the vaccine in reality. Although actual vaccination behaviour should be the prime outcome of interest, intent has been shown to be a strong predictor for behavioural actions over various contexts, even for actual vaccination uptake. 89 However, significant intention–behaviour gaps for vaccination have been shown to exist, 90 with a study even concluding that nudges are ineffective at significantly raising actual COVID-19 vaccination rates. 22 Previous research has also shown differing results when applying behavioural nudges to promote COVID-19 vaccination under experimental conditions versus in the field. 25 These findings underscore the need to field test behavioural interventions that are proven successful in survey experiments to confirm their true effectiveness under real-world conditions.

The extent of misinformation that participants were exposed to prior to our experiment was not measured. Misinformation has been proven to significantly affect vaccination intent. 50 Actual vaccination rates declined depending on the theme and quantity of misinformation exposure. 13 Therefore, misinformation exposure may be a strong predictor for resisting nudges from health messages. Future studies should find ways of incorporating this measure to further elucidate true effectiveness of messages under various levels of misinformation exposure.

The dynamic nature of the COVID-19 pandemic may have altered attitudes towards the COVID-19 vaccines since our experiment was initiated. This is especially so after the vaccines have been safely rolled out and shown to be effective as time progresses. Hence, the efficacy of these messages may have changed over the course of the pandemic.

Lastly, we did not specify any particular COVID-19 vaccine when asking participants to take up or recommend. During the experimental survey roll-out, vaccines from three different companies were widely mentioned in Malaysia, namely Pfizer-BioNTech, Oxford/AstraZeneca, and Sinovac. 71 91 Each of these vaccines was developed using different technologies to yield differing effectiveness and safety profiles. The public may hold differing views about the vaccines based on the familiarity of the technology used to develop them. Hence, we were unsure whether responses obtained were based on a particular vaccine in mind or aggregated in nature.

Further work

Explanations regarding behavioural responses observed were inferred based on past research. More in-depth qualitative research based on theoretical frameworks should be conducted to gain a firmer understanding on how these messages affect individual perceptions that result in provided responses. Additionally, more research should be conducted to understand the science behind individuals recommending healthcare interventions to others, as this aspect of knowledge in the health behavioural field is scarce.

Despite safety being the main concern for COVID-19 vaccine hesitancy, crafting messages that focus solely on this attribute does not significantly improve vaccination intent or vaccine recommendation, except to people with pre-existing health conditions. Our findings highlight the challenges of addressing vaccine safety concerns via frames that present verbatim facts and stimulate rational thinking. Future messages addressing similar concerns should consider adding content that stimulates emotional reasoning and communicates the gist of the message convincingly.

We have documented several examples where combining messages weakened or strengthened intent, thus providing further proof about message interactions between different frames. A deeper understanding of such interactions is needed, especially when conducting health promotion campaigns that use a series of messages together to influence individual decision-making.

On a bigger picture, our study suggests two important findings. First, the decision to take up or recommend a health intervention, such as vaccination, is based on perceived need that is derived from both an internalised and externalised risk-benefit analysis, respectively, which may not necessarily be parallel with one another. Lastly, messages incorporating safety dimensions can update the belief of individuals to advocate an intervention that was previously deemed risky to a vulnerable population. This evidence suggests that persuasive messages should emphasise on safety when promoting recommendations of novel health interventions to individuals with pre-existing health conditions, especially if the intervention is perceived as potentially harmful to them.

Ethics statements

Patient consent for publication.

Not required.

Ethics approval

This study involves human participants and ethical approval was granted by the Medical Research Ethics Committee of the Ministry of Health, Malaysia (ID: KKM/NIHSEC/P21-130(4)). Participants gave informed consent to participate in the study before taking part.

Acknowledgments

We would like to thank the Director General of Health Malaysia for his permission to publish this article. We would also like to thank the team at Dynata for their efficient service in making the data collection process for this study a success. Lastly, we would also like to thank Dr. June Fei Wen Lau and Ms. Yan Yee Yip for designing the layout of the messages used.

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Supplementary materials

Supplementary data.

This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

Data supplement 1
Data supplement 2

Handling editor Seye Abimbola

Contributors NYLH, YLW, YKL, NML and JC-F contributed to the conception and design of the study. NYLH, YLW, YKL, NML, HJK, EW, KP, NHAS and AI contributed to content and design of experimented messages and questionnaire development. Questionnaire and message validation was conducted by NYLH, YLW, YKL, NML, KP and NHAS. Project management was handled by NYLH. NYLH and CTL conducted statistical analysis. JC-F was consulted for data analysis. Visualisations of results were prepared by NYLH. NYLH wrote the original draft of the manuscript and is responsible for the overall content as guarantor. JC-F supervised the drafting of the manuscript. All authors interpreted the results and critically reviewed the drafts of this manuscript. All authors read and approved the final manuscript.

Funding This study was supported by an Australian aid initiative from the Department of Foreign Affairs and Trade of the Australian Government for COVID-19 Vaccines Strategic Communications (award number: SM210337). Funding was mainly used to engage the services of Dynata to execute the online survey.

Disclaimer The funder had no involvement in the study design, data collection, analysis or interpretation of the study. The views expressed are those of the author(s) and not necessarily those of the Malaysian Ministry of Health, United Nations Children’s Fund (UNICEF) Malaysia, University of Malaya or The London School of Economics and Political Science.

Competing interests HJK and EW are employees of UNICEF Malaysia and assisted with administrating the funds that supported the work reported in this paper. Funding was channelled from the funder to UNICEF Malaysia under a cooperation agreement.

Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Provenance and peer review Not commissioned; externally peer reviewed.

Author note The reflexivity statement for this paper is linked as an online supplemental file 2.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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These are the pro-vaccine messages people want to hear

Successful strategies showcase celebrities such as dolly parton and tyler perry, but also local doctors, pastors and neighbors.

With all Americans 16 and over now eligible to receive a coronavirus vaccine, health-care workers and public health officials are turning their attention to the approximately one-third of Americans who say that they are on the fence or that they do not want to get vaccinated.

No single message will persuade everyone, but experts say a combination of strategies is already convincing reluctant people that getting vaccinated is for them.

Here are some of those strategies, from the broadest to the most personal.

Make vaccination visible

For any strategy to work, people first have to perceive vaccination as a normal part of life.

That is why public health officials, nonprofit groups and major brands are collaborating on nationwide public service campaigns and partnering with celebrities to make vaccination more visible.

The model for the celebrity shot dates to 1956, when few teenagers were getting the year-old polio vaccine. Two critical things happened that fall to reverse the trend.

First, 21-year-old Elvis Presley got the shot in front of cameras before “The Ed Sullivan Show.” Second, the March of Dimes launched a wildly successful peer-to-peer campaign among teen social groups. In short, it leveraged the cool kids, but it may not have gotten the cool kids without the King.

The wide range of celebs touting coronavirus vaccines includes musicians and actors (such as Elton John , Britney Spears and Lin-Manuel Miranda ), sports personalities ( Patrick Mahomes, Richard Petty , Kareem Abdul-Jabbar ), WWE stars and Fox News personalities. “Don’t be such a chicken-squat,” chided country music icon Dolly Parton in a video as she got an injection of the Moderna vaccine, which she helped finance. “Afterwards, I felt like superwoman,” Oprah Winfrey wrote.

[ Could Beyoncé do for coronavirus vaccine what Elvis did for polio? ]

Tyler Perry was vaccinated live on a BET special. TV shows as varied as “South Park” and “This Is Us” have incorporated vaccinations into their story lines.

Broad public service announcements, however, inevitably turn some people off. One person may find Google’s “ Get back to what you love ” message poignant, while another finds it manipulative.

“No national ad campaign is ever going to be as effective … as people who look like you and come from your community saying: ‘This is important. It’s the right thing for us,’” said Kelly Moore of the vaccine education group Immunization Action Coalition.

It’s why the polio campaign needed both Elvis and the teens next door.

Have nationally trusted messengers recommend it

The opinions of our leaders matter, whether that is the president or a prominent public health official such as Anthony S. Fauci , the nation’s top infectious-disease expert.

“When the people in the front of the room — political leaders and so on, people in charge of vaccination — speak up in favor of vaccination, confidence rises and stays high,” said University of North Carolina researcher Noel Brewer, who studies the intersection of public health and human behavior. “When the government and the folks in charge of vaccination do not speak in favor of it, confidence falls.”

Both of those scenarios have played out since the first vaccine became available in December .

Although President Donald Trump led the initiative that sped vaccines to the market, he was vaccinated privately in January before leaving office and did not disclose it or encourage his supporters to get a shot until March . (Vice President Mike Pence and his wife were vaccinated on television in December.)

It was a puzzling missed opportunity to celebrate a big achievement, Brewer said, “and we see the remnants of that in today’s society.” According to an Economist-YouGov poll released this week, 30 percent of Republicans said they would not get vaccinated, compared with 22 percent of adults overall.

President Biden , Vice President Harris and all other living former presidents have rolled up their sleeves in public.

While politicians’ cheerleading can be useful for some, it won’t convince everyone. A focus group of vaccine-hesitant Trump voters last month said pitches from politicians — Trump included — were not persuasive.

It is the medical professionals who can best convey the possible risks of both the vaccines and the disease to a jittery public, Moore said.

This is why many are still listening to Fauci.

“He established trust by saying things people didn’t want to hear when they needed to be said, then also saying encouraging things,” Moore said. “There is nothing more easily lost in this process and nothing more precious in the process than that real trust.”

But not everyone likes what he has to say, either. This week in a different focus group, vaccine-hesitant Trump voters said they do not want to hear from Fauci.

[ ‘We want to be educated, not indoctrinated,’ say Trump voters wary of coronavirus vaccination ]

Make vaccination come with privileges

Of the many strategies Brewer and his colleagues explored in a 2017 study on the psychology of vaccine uptake, one of the most effective was simply requiring it.

For some people, being allowed to travel to see the grandkids, to take a cruise or to return to the office or school is enough of an incentive to persuade them to get vaccinated. According to a Kaiser Family Foundation poll conducted in late March, 7 percent of respondents said that they would get a vaccine “only if required.”

However, that step cannot occur before people believe vaccinations are safe.

“If there’s not some community-wide level of confidence in the vaccine,” Brewer said, “policymakers cannot implement all of these super-effective approaches without receiving a great deal of blowback from the general public.”

In the Economist-YouGov poll, 61 percent of respondents thought the Moderna vaccine was very safe or somewhat safe, compared with 59 percent for the Pfizer-BioNTech vaccine and 42 percent for the Johnson & Johnson vaccine.

Pushback against “vaccine passports” has already begun in the United States, even though the Biden administration has said it does not plan to create them . But private businesses such as cruise lines, sports teams and others are already beginning to require proof of vaccinations.

[ 'Vaccine passports' are on the way, but developing them won't be easy ]

“Being confident in the vaccine and deciding to get vaccinated — those need to be voluntary, personal decisions,” said Elisabeth Wilhelm, a vaccine confidence strategist with the Centers for Disease Control and Prevention. “We ask people to think very, very carefully when they talk about incentives, whether it’s a bag of rice for your kid getting vaccinated in Nigeria or getting a coronavirus vaccine in your workplace in the United States. It is a lever that can be used — it just should not be the first that you pull on.”

[ Everything travelers need to know about vaccine passports ]

Tailor the message to the audience

Traditionally, public health messages — from smoking cessation to seat-belt campaigns — have been broadcast widely, on billboards, in public service announcements and on popular TV shows. That one-size-fits-all approach doesn’t work well for vaccines, experts say, because pregnant women, for example, probably have concerns very different from those of Republican men or Latino immigrants.

“When it comes to vaccine hesitancy, it is more like personalized medicine,” said Christopher Graves, founder of the Ogilvy Center for Behavioral Science at Ogilvy Consulting, “more customized to specific worldviews and cultural filters.”

And unlike conventional vaccine messaging, which aims to persuade parents to get children vaccinated, the coronavirus messages are aimed at persuading adults to get their shots.

“Respecting their autonomy is important,” Moore said.

As is adapting the message to the recipient.

People who say they prize individual choice are more likely to be convinced by messages emphasizing that getting vaccinated increases your freedom to get together with friends and colleagues, experts say.

Gabriel Salguero, founder of the National Latino Evangelical Coalition , said he is using biblical references in his sermons to quell the fears of some Christians who falsely believe the vaccines contain microchips or fetal tissue or are an ominous sign of the End Times.

Successful messaging isn’t only about finding the right words. Olajide Williams, a Columbia University neurologist, uses music and art in the Hip Hop Public Health program to reach communities of color.

And for those who are skeptical of the science, data can make a real difference: 95 percent of doctors who have been offered a vaccine have taken it — a figure that helped turn around 19 vaccine-hesitant Trump voters who took part in a two-hour virtual focus group .

“The one group everyone trusts is doctors,” said Claire Hannan, executive director of the Association of Immunization Managers , a nonprofit that coordinates with states to control vaccine-preventable diseases.

Have friendly faces in familiar places

While many people are eager to sign up for mass vaccination sites, others are unable or unwilling to take a place in line, for reasons such as a lack of transportation or worries about showing up at sites where staffers are often dressed in uniform.

[ Lack of health services and transportation impede access to vaccine in communities of color ]

When it comes to relieving those worries, nothing beats a friendly face in a familiar place, say experts who have documented the value of enlisting primary-care physicians, community leaders and pastors. It’s better still if the shot can be given right there, in their office or sanctuary.

“It’s one thing for a pastor to say it, another to have a pop-up vaccination site in the church,” Wilhelm said.

In Maryland, the Health Advocates In-Reach and Research Initiative (HAIR) is using barbershops and beauty salons to debunk misinformation within the Black community.

Ideally — and particularly if an easily stored, single-shot vaccine were widely available — doctors could offer shots during regular appointments, just as they do the flu shot.

“It is done as a matter of routine, rather than a big issue,” said former CDC director Tom Frieden, who has advocated for primary-care physicians to play a bigger role.

Messengers need to be honest about risks, communicating how they compare with the benefits, said Moore, who advocates for transparency with issues such as the rare but worrisome clotting associated with the AstraZeneca and Johnson & Johnson vaccines. Federal officials paused the use of the Johnson & Johnson vaccine last week.

“If you hedge, you can undermine the entire vaccination campaign in a moment if you appear to be covering up,” Moore said.

And trusted spaces exist on social media, where small groups can engage in Q&A sessions or Facebook live streams.

Meeting people where they are could even involve going door-to-door, as in a political campaign or with the census.

The key to getting more people vaccinated, said UNC’s Brewer, is “to make it easier.”

Make vaccination routine in peer groups and social networks

Seeing Elvis or Fauci getting vaccinated is helpful. But most people who are considering getting the shot want the answer to a straightforward question.

“Are people like me taking this vaccine, and how are they doing?” said Bruce Gellin, president of global immunization at the Sabin Vaccine Institute .

You are more likely to roll up your sleeve, Gellin and other experts say, if you’ve talked to your neighbor, co-worker, cousin or golf buddy about having done so.

That’s why the Philadelphia Department of Health began building connections with vaccine role models people may spot in their neighborhoods rather than on TV or at the ballpark, looking to block captains, pastors and barbers to lead the way.

“They are people where someone will say: ‘I know this guy. I’ve seen them on the block,’” said James Garrow, the department’s communications director.

Vaccine experts leverage the peer pressure with other tools, giving out “I’m vaccinated” stickers and buttons, offering selfie opportunities at mass vaccination sites and encouraging people to post their just-vaxxed pictures online to create a sense of solidarity. “Vaxxies” have become one of the defining social media images of 2021.

It’s all about creating links with people where they are — online or in person.

“Don’t mute your crazy uncle,” said the CDC’s Wilhelm. Instead, she said, share your experience with family and friends and talk to them about the advantages of getting a shot — such as new opportunities to get together safely.

The bottom line, Wilhelm said, is that vaccination is contagious.

Scott Clement contributed to this report.

About this story

Design, development and animation by Chloe Meister. Graphics by Tim Meko. Illustrations by The Washington Post using images from iStock, AP (Presley, Parton), Jabin Botsford/The Washington Post (Fauci) and IAC (vaccine button).

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Does free speech protect COVID-19 vaccine misinformation?

We all know, or have heard about, someone who's refused to get a COVID-19 vaccine. While some individuals have medical or religious reasons for avoiding vaccination, for some, other factors influence their decision. Despite the importance of vaccines for public health -- and the serious risk associated with being unvaccinated -- getting the shot may feel like a betrayal of certain political beliefs.

But where does this feeling come from? Throughout the pandemic, some politicians and other influencers have promoted advice that's not based on scientific data -- sometimes it's with good intentions, other times it's intentionally misleading. But the outcome is the same: misinformation.

This led Michelle Mello , JD, PhD, a Stanford Medicine professor of health policy and Stanford Law professor, to dig into questions that surround this issue.

While some might say making or spreading known false statements related to the vaccine should be criminalized, the First Amendment, which guarantees free speech, continues to provide protection for people who promulgate such faulty information. So, how can the spread of misinformation be stopped without quashing free speech?

I spoke with Mello and asked her to address the Supreme Court's view on vaccine misinformation -- an issue she addressed in a recent Viewpoint piece in JAMA Health Forum . The following Q&A has been edited and condensed.

Several countries have criminalized vaccine misinformation, but the United States has not. Has the Supreme Court's interpretation of the First Amendment allowed the continued spread of false claims?

The Supreme Court has held that many kinds of false statements are protected speech under the First Amendment. In a 2012 case called United States v. Alvarez , the Supreme Court struck down a law that made it a criminal offense to lie about having received military medals. It refused to hold that a statement's falsity put it outside the realm of First Amendment protection.

But there are some kinds of false speech that can be penalized by the government, including lying in court, making false statements to the government, impersonating a government official, defaming someone and committing commercial fraud. But it's a pretty limited list. The Supreme Court's general finding is that false statements can often be valuable in terms of allowing people to challenge widely held beliefs without fear of repercussions, and that things could go pretty wrong if the government had a wider berth to regulate them.

What risks would be involved in allowing the government to police false claims?

One problem is that we may not all agree on how demonstrably false something has to be in order for it to be restricted. For vaccine risks, for example, some claims about health harms have been persuasively disproven, while others have simply not been studied. So, if I claim that a vaccine was the reason my hair fell out, is that false or just not demonstrably true? Should the difference matter?

A related problem is that for some claims, especially scientific ones, the knowledge base that makes a statement true or false evolves over time. To complicate things further, some people who disseminate false statements know they are lies, while others believe they're true. Finally, many people just don't trust the government to not abuse the power to declare something false speech.

All of these challenges make the Supreme Court wary of restricting speech that might ultimately prove to be truthful, or at least contribute to public debate that aids in discovering the truth. The Supreme Court would prefer to let the decision about what's true be hashed out by "the marketplace of ideas."

But the interesting thing is, these problems also apply to areas where courts do allow regulation of false statements. Lawmakers have found ways of addressing them, such as requiring the government to prove certain things about the statement or the speaker's state of mind. It's not clear, therefore, why the Supreme Court draws the lines it does.

How does our reverence for freedom of speech in the United States intensify our vulnerability to public health threats?

It limits our policy toolkit. Rather than curbing misinformation about health issues, the government is relegated to trying to fight it with counter-speech. Although the idea that clashing ideas will surface the best ideas is appealing to judges, it doesn't always work out in practice. People's false beliefs arising from vaccine misinformation, in particular, are extremely difficult to change.

First Amendment protections also make it hard for the government to do things like require warnings about health risks. For example, the Food and Drug Administration fought legal battles for years over its initiative to require cigarette makers to put pictorial warning labels on cigarette packs, with the industry arguing that the requirement constituted compelled speech in violation of free speech rights. The City of San Francisco had similar problems when it tried to require beverage companies to put warnings on their billboard advertisements about the link between consumption of sugary drinks and obesity.

What is the broader impact of taking medical advice from non-medical professionals who may have an agenda not grounded in science or medicine?

Many people -- including some medical practitioners -- have made it harder for Americans to understand how to protect themselves during the pandemic by crowding the information space with claims that aren't evidence-based.

It can be hard for people to distinguish between reliable and unreliable sources of information, especially about a new health threat and especially when unreliable information is disseminated by individuals who seem trustworthy by dint of their professional role.

In the case of COVID-19 vaccines, misinformation has led as many as 12 million Americans to forgo vaccination, resulting in an estimated 1,200 excess hospitalizations and 300 deaths per day, according to Johns Hopkins' Center for Health Security.

What are the ramifications of the continued politicization of the COVID-19 pandemic on our ability to make public health decisions?

Often, when an issue becomes politicized, people view messages from the group they don't identify with as suspicious, and messages from the group they do identify with as trustworthy -- regardless of how well the messages align with the evidence. If we can't make sound decisions about how we interact with information, we can't make sound decisions about health.

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J Med Internet Res
v.17(5); 2015 May

Vaccination Persuasion Online: A Qualitative Study of Two Provaccine and Two Vaccine-Skeptical Websites

Lenny grant.

1 Vaccination Research Group, Department of English, Virginia Tech, Blacksburg, VA, United States

Bernice L Hausman

Margaret cashion, nicholas lucchesi, kelsey patel, jonathan roberts.

Current concerns about vaccination resistance often cite the Internet as a source of vaccine controversy. Most academic studies of vaccine resistance online use quantitative methods to describe misinformation on vaccine-skeptical websites. Findings from these studies are useful for categorizing the generic features of these websites, but they do not provide insights into why these websites successfully persuade their viewers. To date, there have been few attempts to understand, qualitatively, the persuasive features of provaccine or vaccine-skeptical websites.

The purpose of this research was to examine the persuasive features of provaccine and vaccine-skeptical websites. The qualitative analysis was conducted to generate hypotheses concerning what features of these websites are persuasive to people seeking information about vaccination and vaccine-related practices.

This study employed a fully qualitative case study methodology that used the anthropological method of thick description to detail and carefully review the rhetorical features of 1 provaccine government website, 1 provaccine hospital website, 1 vaccine-skeptical information website focused on general vaccine safety, and 1 vaccine-skeptical website focused on a specific vaccine. The data gathered were organized into 5 domains: website ownership, visual and textual content, user experience, hyperlinking, and social interactivity.

The study found that the 2 provaccine websites analyzed functioned as encyclopedias of vaccine information. Both of the websites had relatively small digital ecologies because they only linked to government websites or websites that endorsed vaccination and evidence-based medicine. Neither of these websites offered visitors interactive features or made extensive use of the affordances of Web 2.0. The study also found that the 2 vaccine-skeptical websites had larger digital ecologies because they linked to a variety of vaccine-related websites, including government websites. They leveraged the affordances of Web 2.0 with their interactive features and digital media.

Conclusions

By employing a rhetorical framework, this study found that the provaccine websites analyzed concentrate on the accurate transmission of evidence-based scientific research about vaccines and government-endorsed vaccination-related practices, whereas the vaccine-skeptical websites focus on creating communities of people affected by vaccines and vaccine-related practices. From this personal framework, these websites then challenge the information presented in scientific literature and government documents. At the same time, the vaccine-skeptical websites in this study are repositories of vaccine information and vaccination-related resources. Future studies on vaccination and the Internet should take into consideration the rhetorical features of provaccine and vaccine-skeptical websites and further investigate the influence of Web 2.0 community-building features on people seeking information about vaccine-related practices.

Introduction

Current concerns about vaccination resistance often cite the Internet as a source of vaccine controversy. Despite the United States’ high vaccination rates among children and adults, physicians and researchers have perpetuated the belief that vaccine-skeptical websites contribute to lower levels of vaccination among children by effectively persuading parents against immunizing their children. Websites promoting vaccine-skeptical discourses are scrutinized routinely in the academic literature; however, the preponderance of this research aims at demonstrating that the information they circulate is inaccurate and deceptive to visitors seeking information on vaccines and vaccination-related practices. It is true that as a result of these studies, the medical community has gained a greater understanding of the types of information presented on vaccine-skeptical websites and deeper insights into how these websites deploy this information to make persuasive arguments against vaccines and vaccination. The majority of academic studies of vaccine-skeptical websites use quantitative methods to taxonomize arguments against vaccination on these websites. Although this information is useful for categorizing their generic features, it has not provided insights into why these websites successfully persuade their viewers.

To date, there has been no attempt to understand the qualitative features of vaccine-skeptical websites. The research presented in this paper attempts to fill this gap by employing a case study approach to a smaller number of websites than is typical of quantitative studies of vaccine skepticism on the Internet. In addition, this study examines both vaccine-skeptical and vaccine-promoting websites to compare the rhetorical features through which they attempt to reach their audiences. By deploying a qualitative methodology, researchers can better understand the rhetorical features of both types of websites. As a result of this study, we can better understand the specific mechanisms by which vaccine-skeptical organizations have been able to use the Internet to successfully spread their messages.

Literature Review

Since the United Kingdom passed the Vaccination Act of 1853, vaccine-skeptical groups have leveraged the available means of persuasion to voice their opposition to compulsory vaccination. Some groups resorted to public demonstrations, legal actions, and the occasional riot after the passage of the 1853 law, but others, such as the Anti-Compulsory Vaccination League, which formed in response to the 1867 Vaccination Act, found publishing their ideas in newsletters and journals to be a more effective means of responding to government vaccine mandates for children [ 1 ]. Other groups followed suit. The Anti-Vaccinator journal was founded in 1869 followed by the National Anti-Compulsory Vaccination Reporter in 1874 and the Vaccination Inquirer in 1879 [ 2 ]. After a smallpox epidemic in the 1870s, US vaccine-skeptical movements circulated pamphlets and journals in response to state attempts to pass new vaccine legislation or enforce extant laws. During the Progressive Era, regional antivaccination movements, such as the one in Portland, Oregon, assumed the political mantle of the populist democracy movement [ 3 ]. At that time, resistance to vaccination in the United States took 2 dominant forms: ordinary Americans who resisted compulsory vaccination and self-identified antivaccination activists who joined societies, wrote newsletters, and were largely middle class [ 4 ]. Political opposition to vaccine mandates and the circulation of populist information continued throughout the 20th century, although it changed as a result of the rapid development of many vaccines in the second half of the century.

In the late 20th century, the Internet transformed mass communication, affording its users new means of sharing information, forging interpersonal connections, and establishing association [ 5 - 8 ]. The relatively short history of the Internet can be divided into 2 epochs: Web 1.0, which emerged in the 1980s, and Web 2.0, which emerged in the mid-2000s. Web 1.0 is characterized by static webpages that display information [ 9 , 10 ] and text-based online virtual communities where users interact with one another on topics of mutual interest [ 6 , 8 , 11 ]. Web 1.0 also introduced hyperlinking, the now-familiar clicking process that redirects a Web user to another website. One static website could be hyperlinked to another for a myriad of rhetorical purposes, including demonstrating affinity, offering additional information, or leveraging another website’s credibility [ 7 ]. Web 2.0 is best characterized as a platform for Internet applications that afford users the ability to “harness collective intelligence” [ 9 ]. Web 2.0 permits users to generate and post their own content and comment on what others have shared [ 9 , 10 ]. One of its most defining characteristics is that it affords 2-way communication via social media, such as blogs, Facebook, Twitter, YouTube, and other websites. Where the static Web pages of Web 1.0 allowed unidirectional communication (a user reading text on a screen), Web 2.0 promotes interactivity between users who can easily respond to one another via text and images.

The Internet and Web 2.0 have changed the way that people access health information. Ordinary people have greater access to medical information [ 12 ] and online patient communities have organized on websites [ 13 ] and social media [ 14 ] to provide information and support for many diagnoses. Easy access to information has led to both self-diagnosis and self-doctoring [ 15 ]. According to Pew Research’s Health Online 2013 poll, 72% of Internet users surveyed looked for health information online and 35% opted to self-diagnose with Web-based information rather than visit a clinician [ 16 ]. It is estimated that 16% of those seeking online medical information searched for vaccination information, with 70% of this group stating that their findings influenced their vaccine decisions [ 17 ]. In addition to peer-reviewed medical information, Internet users also have access to health information generated by nonmedical practitioners, which has raised concerns about the quality of online medical information available on the Internet [ 18 ].

Online Vaccination Skepticism and Web 1.0

Current accounts of vaccine skepticism tend to identify its origins in the present period with the circulation of information on the Internet (eg, Kodish [ 19 ]). Although early proponents of the Internet saw its potential as a means of promoting democracy through the circulation of information [ 8 , 20 ], others viewed the Internet as a “Pandora’s box” of misinformation [ 21 ]. As Internet use proliferated at the end of the 20th and beginning of the 21st centuries, researchers began to pay attention to the World Wide Web as a site of information dissemination for vaccine skeptics. Many of these studies employed a Web 1.0 understanding of online communication even after Web 2.0′s social media paradigm was well in place (ie, they conceived the Internet as a repository of information and not a dynamic space were users interact with one another). The main objectives of these studies were to ascertain the philosophies of so-called antivaccination websites and point out the misleading or inaccurate information they circulated in cyberspace. A number of these studies created taxonomies or tried to identify specific features of the misunderstandings that these sites were thought to perpetuate. The article that best exemplifies this tendency is Jacobson et al [ 22 ], the title of which is indicative of the approach: “A Taxonomy of Reasoning Flaws in the Anti-Vaccine Movement.”

During this period, 2 studies about vaccination influenced by the Pandora’s box metaphor appeared in the pages of medical journals [ 23 , 24 ]. Taking as his exigence the concern that vaccine-skeptical groups were using the Internet to gain political momentum in the United States and Western Europe, Nasir [ 23 ] analyzed 51 websites that opposed routine childhood vaccination, addressing content, common themes, philosophy, links to other websites, and strategies to avoid routine immunization. Although the websites promoted a variety of philosophies, they exhibited some commonalities: they listed adverse effects of vaccines and presented themselves as unbiased toward vaccination [ 23 ]. Nasir found that clicking deeper into the websites revealed a strong bias against vaccines and vaccination and concluded that the availability of vaccine-skeptical information on the Internet is troublesome. Nasir expressed concern that Web surfers are ill equipped to assess its reliability, an argument that is nearly ubiquitous in subsequent studies of vaccine skepticism on the Internet [ 23 ].

Two years later, Davies et al [ 25 ] examined the content of 100 similar websites from a rhetorical perspective to better understand the social discourses in which vaccine-skeptical claims are embedded. Their rhetorical analysis revealed that vaccine-skeptical websites portrayed themselves as authorities on vaccination, appealed to viewers’ emotions through personal testimonies of vaccine injury and calls for parental responsibility, and maintained a discourse of truth seeking often advancing evidence of medical conspiracies bolstered by their own privileged information. Davies and colleagues caution medical practitioners from refuting vaccine-skeptical discourses based solely on “the facts,” suggesting instead that provaccination websites employ emotional counterappeals featuring “images and stories of children harmed by vaccine-preventable illnesses” [ 25 ].

Another study by Wolfe et al [ 26 ] made similar observations in its analyses of the content and design attributes of 22 vaccine-skeptical websites. From their content analyses, they found that all websites in their sample expressed “a variety of claims that are largely unsupported by peer-reviewed scientific literature,” including themes of concern about vaccine safety and efficacy, “governmental abuses” of civil liberties, and preferences for alternative (nonbiomedical) health practices. Their analyses of the websites’ design attributes resulted in a list of 10 common themes that, from a rhetorical perspective, conflate content (narratives of parents of vaccine-injured children), digital ecology (the content to which the website links), visual rhetoric (images of “scary needles” and “harmed children”), and commerce (solicitations of donations and merchandise for sale) [ 26 ]. The authors do note that defining what counts as content on a website is “a problem” [ 26 ]. Such a problem is likely to occur when websites are treated like pages in a book rather than interactive spaces where users connect to share experiences, expertise, and interpretations of information.

Online Vaccine Skepticism and Web 2.0

The ascendency of social media in the mid-2000s adds another layer of complexity to online vaccine discourses. The multimedia nature of Web 2.0 websites allows vaccine-skeptical groups a means of constructing more sophisticated arguments than a single medium could afford. One study notes that antivaccine movements are well versed in multimedia communication because the groups often are led by spokespersons who use a variety of media (eg, books, television appearances) to build their ethos (credibility) as whistleblowers [ 27 ]. Although researchers have created sophisticated taxonomies of static websites [ 22 , 28 , 29 ], the strategies they offer to counter vaccine-skeptical discourses either have not been adopted by provaccine websites or have not been effective in general. For instance, one strategy offered is mass education campaigns that share images and personal narratives of people affected by vaccine-preventable diseases, such as pertussis [ 28 ]. They also suggest communicating statistics that demonstrate how vaccine-preventable diseases increase as vaccination rates decline. Using scare tactics and arguing about facts has not proven to be an effective strategy for making vaccine-skeptical parents amenable to childhood vaccination [ 24 , 30 ]. One main reason is the social networking features of Web 2.0 [ 31 ] that transform static Web pages into information hubs where viewers can share personal experiences in the form of images and narrative to create or participate in a community with individuals who share their vaccination beliefs.

Web 2.0′s social networking capabilities have aided health communicators in targeting messages to specific audiences [ 32 ] and helped patients and medical practitioners to gather information about diseases and diagnoses [ 27 ]. Although social networking technologies make it easy for users to crowdsource information, there is widespread concern about the quality of the information that is circulated among users and the extent to which that information influences people’s decisions to vaccinate themselves [ 33 ] and their children [ 34 ]. As users grow more accustomed to Web 2.0 technologies, it becomes more difficult to impose the authority of establishment medicine on online discourse. Witteman and Zikmund-Fisher [ 35 ] suggest “in this Web environment, effective communication about vaccinations is not about controlling what is available but rather, it is about responding and participating in an interactive, user-responsive environment.” To this end, a growing number of studies attempt to understand the flow of information on specific Web 2.0 sites.

Research on vaccination and Web 2.0 suggests that websites featuring user-generated content are more likely to support vaccination viewpoints that counter or question medical science [ 36 ]. Venkatraman et al [ 36 ] found that websites that support greater freedom of speech (ie, the website’s content is not moderated, edited, or peer-reviewed), such as YouTube and Google, are more likely to contain antivaccination content than moderated websites such as Wikipedia and PubMed. Another study analyzed nearly 40,000 opinionated Twitter users’ posts about the H1N1 vaccine and found that more information was circulated among users who shared the same positive or negative sentiments about the vaccine [ 37 ], suggesting that social media is more of an echo chamber for circulating opinions among like minds than a means of randomly influencing less opinionated users. A study of 172 YouTube videos about the human papillomavirus (HPV) vaccines found that slightly more than half of the videos expressed explicitly negative sentiments about the vaccine and that negative videos garnered a higher number of average likes than videos endorsing the HPV vaccine [ 38 ]. Compared to previous studies of HPV vaccines on YouTube, which found that approximately one-quarter [ 39 ] to approximately one-third [ 40 ] of videos opposed the HPV vaccine, Briones et al’s [ 38 ] findings suggest that vaccine critics are more effective than vaccine promoters at using social media to communicate their messages. It is also worth noting that the shift from majority positive HPV vaccine sentiments to majority negative occurred in fewer than 5 years. The relatively short time span in which attitudes change also appears to be a feature of Web 2.0, where private and public discourses about vaccines can spread virally around the Internet [ 31 ].

In an effort to counter the rhetorical efficacy of online vaccine skepticism [ 25 ], provaccine researchers have developed a 2-pronged approach that is grounded in earlier Internet studies. It begins by first attributing contemporary vaccine skepticism to Wakefield et al’s [ 41 ] now discredited claim that the measles, mumps, and rubella (MMR) vaccine contributed to the development of autism in children and then calls for the medical community to do a better job of communicating accurate medical information about childhood vaccination [ 42 - 44 ]. This 2-step maneuver attempts to deny the premise of vaccine skepticism through a reductio ad absurdum argument and creates a space for new, more accurate facts to fill the social vacuum. This tactic seems logical to vaccine proponents, but it appears to be ineffective. Although some research suggests that psychological investments may be the cause of entrenchment in antivaccine positions [ 45 ], another reason may be that vaccine-skeptical discourses predate the Wakefield debacle [ 46 ]. After all, many 21st-century arguments against vaccines are rhetorically similar to discourses in the 19th and early 20th centuries [ 26 , 28 , 47 ].

Online Vaccination Skepticism and Postmodern Medicine

The strategy of correcting vaccine-skeptical beliefs appears to be based on a misreading of both the context of and reasons for those views. Public health attempts to correct so-called flawed reasoning are inadequate in the full context of vaccine skepticism in culture [ 48 , 49 ]. Hobson-West’s [ 30 ] study found that “vaccine-critical groups” tend to be differently oriented to issues of vaccination, with “radical” groups outright rejecting vaccine and “reformist” groups seeking changes to vaccination policy [ 30 ]. Both groups distrust provaccine discourses and policies and, as a result, they have reframed the notion of risk to be incommensurable with medicine’s traditional understanding [ 30 ]. Similarly, recent research suggests that corralling all discourse that does not promote vaccination under the big tent of the “antivaccination movement” collapses the variety of critical stances on vaccination [ 48 , 50 - 52 ]. Terms such as “vaccine selective” [ 50 ], “vaccine resistance” [ 51 ], and “vaccine hesitancy” [ 52 ] are used to reflect a spectrum of orientations rather than the catch-all “antivaccination.” We prefer the term “vaccine skeptical” because it denotes a variable attitude toward vaccines and vaccination versus a term, such as vaccine resistance, which forefronts an action taken against vaccines.

Beyond rejecting or reframing provaccine discourses, vaccine-skeptical websites do not subscribe to one notion of the truth; therefore, these websites’ adherents do not seem to be persuaded by claims that their beliefs are misinformed [ 45 ]. Under the current postmodern medical paradigm [ 53 ], doctors are no longer the sole arbiters of authoritative information about health and healing. The expectations that patients should inform themselves to take charge of their health decisions has resulted in “new priorities for health care” [ 54 ], such as medicine based on both social values and empirical evidence, an increased emphasis on the risks of treatment, and informed patients taking charge of their own health care decisions [ 53 ]. Kata [ 54 ] has articulated the relationship between postmodern medicine and Web 2.0 as one of flattened hierarchies where “infinite personal truths presented online are each portrayed as legitimate, thus supplanting the primacy of medical facts with a multiplicity of personal meanings and ways of knowing.” Thus, vaccine-skeptical groups appear to use the Internet to leverage postmodern notions of truth that are based on their own experiences with vaccines and their own understandings of medical science. Within the postmodern paradigm, the knowledge they generate and circulate online is not easily dismissible by attempts to better educate the public about vaccination.

Previous studies of vaccination information websites have taken objective approaches to locating websites via search engines. These methods included gathering and examining websites based on keyword searches. We opted for a fully qualitative case study methodology, choosing to carefully review the rhetorical features of 1 provaccine government website, 1 provaccine hospital website, 1 vaccine-skeptical information website, and 1 vaccine-skeptical website focused on a specific vaccine. The websites selected for analysis were the US Department of Health and Human Services (HHS) vaccine website Vaccines.gov [ 55 ], the Children’s Hospital of Philadelphia (CHOP) Vaccine Education Center (VEC) [ 56 ], National Vaccine Information Center (NVIC) [ 57 ], and SANE Vax, Inc [ 58 ], respectively.

Website Selection

The websites were chosen specifically for their representativeness of specific positions in the current vaccination controversy—their choice was deliberate, not random, to demonstrate proof of concept in this pilot study. Both the Vaccines.gov and VEC websites are targeted to the general public and meant to educate. They were chosen as the representative provaccine websites because they are the US federal government’s website for the education of its citizens and a hospital-based educational site developed overseen by one of the most prominent medical proponents of vaccination, Dr Paul A Offit [ 59 - 61 ]. The vaccine-skeptical websites included the most established vaccine-skeptical organization (NVIC) which began in the early 1980s as Dissatisfied Parents Together [ 57 ] and a newer organization targeting concerns about the HPV vaccine, SANE Vax. Opposition to the HPV vaccines Gardasil and Cervarix has coalesced around specific injury narratives [ 62 ], and SANE Vax is one of the prominent Web venues proffering a space for these discourses. Choosing these specific websites allowed us to focus on the specific rhetorical features of each website to determine if the provaccine and vaccine-skeptical sites differed in this regard.

Data Acquisition

To gather information from the websites, we adapted the qualitative research method of thick description to the online environment. Thick description requires the researcher to pay close attention to the contextual aspects of a research setting including minute details of the setting, the social events taking place therein, and the behaviors of the participants [ 63 ]. As a means of controlling data acquisition for consistency across the 4 websites, 5 categories of analysis were developed: information about the websites’ owners, the visual and textual content of websites, user experience, hyperlinking, and social interactivity within the website. Each of these categories corresponds to a different rhetorical element of effective communication with respect to the interactive nature of Web 2.0.

Digital Ecologies

Aristotelian rhetoric holds that 3 modes are necessary for persuasion to take place [ 64 ]. These features are ethos, pathos, and logos. Ethos refers to the character of the speaker who attempts to persuade an audience. Pathos is the manner in which the speaker appeals to the audience’s emotions. Logos refers to the types of information a speaker uses to make an argument. These modes linked to the 5 categories of analysis in the following way. The website’s ownership and hyperlinks to other websites determined its ethos. The visual and textual content was the website’s logos. Social interactivity and user experience lent to the website’s pathos. Taken together, these features contributed to the website’s rhetorical efficacy.

The theoretical framework that guided this study took these Aristotelian rhetorical elements as an analytical starting place. In the second half of the 20th century, rhetoricians came to understand that persuasion is situational [ 65 - 68 ]. Theorists first formulated the rhetorical situation as a response to a problem, or exigence, in the world that commanded a person to communicate to change it [ 65 ]. Yet despite the robust, multifactorial nature of theories of the rhetorical situation, such a framework cannot account for the fluidity of rhetoric in networked environments. To address this shortcoming and to create a notion of rhetoric that accounted for the interconnectedness of human communication and the viral circulation of information, Edbauer [ 69 ] developed the concept of rhetorical ecologies. In a rhetorical ecology, rhetoric is not limited to a taxonomy of tropes; instead, rhetorical ecologies enable the flow information from one part of an ecosystem, such as the Internet, to another.

Because the viral circulation of information is not bounded by specific media in Edbauer’s model, we followed the lead of scholars of digital rhetoric who examined ecologies in online spaces, such as websites and gaming platforms [ 70 , 71 ]. Throughout this paper, we employ the term “digital ecology” to mean the discursive connections created and propagated by a website. There are 2 benefits to using the term digital ecologies to refer to rhetorical ecologies within digital spaces. The first is that the term suggests the active engagement of readers of online discourse as well as underscoring the rhetorical nature of hyperlinking [ 72 ]. The second benefit of using a term such as ecology to describe online activity is that it recalls ecosystems in nature. A website, through its links to other websites and its interactive features, can be analyzed by its size (the number it links it contains) and its diversity (whether it is open to discourses from vantage points other than its own or closed to differing opinions). For Web 2.0, an ecological model addresses the fact that the quality of information alone is insufficient to persuade someone. Rather, persuasion is effected by the information, where it is found online, how the user interacts with that information, how that information interacts with other information, and the community surrounding it.

In considering these factors, this study also took the usability of vaccine websites into account. Usability studies are traditionally focused on making a product or application more functional for the end user [ 73 ]. When applied to online health information, a usability perspective can highlight the ways that Web design and content presentation can deny users access to information because a website is visually overwhelming, difficult to navigate, or written in such a way that it misses its target audience [ 74 , 75 ]. Although the prime objective of usability studies is ease of use [ 76 ], the straightforward transmission of information online has the potential to make Internet users “passive consumers of digital content” [ 77 ]. More recent studies of the usability of websites evaluated the usefulness [ 78 , 79 ] of websites based on the website’s ability to facilitate inquiry about the topic at hand, promote collaboration between the website’s users, and offer a multidimensional perspective that extends beyond the mere transmission of information. For the purpose of our study, we used the website usability guidelines available at Usability.gov [ 80 ] because it incorporated aspects of both ease of use and usefulness; in addition, it provided the guidelines that the federal government uses itself to evaluate website information and user experience.

Data Analysis

Data analysis was conducted by a team of 4 advanced undergraduate researchers, who participated in Virginia Tech’s Vaccination Research Group. Each researcher was assigned a website and asked to conduct 5 rounds of observation using the thick description criteria. After each round, the group convened to discuss the findings and develop an initial analysis. Through this iterative process, each researcher synthesized his or her findings into a preliminary report with brief conclusions. These reports were a starting point for the final analysis of each case as the primary author went back to each website to confirm the findings, deepen the interpretation, develop conclusions, and write the article.

The results are brief descriptions of the websites examined in our study. Websites are content-rich, interactive genres that do not easily lend themselves to concise textual description. Rather than offering in-depth descriptions of all aspects of each website, we present 4 case studies of the salient features of Vaccines.gov [ 55 ], VEC [ 56 ], NVIC [ 57 ], and SANE Vax [ 58 ].

Case Study 1: Vaccines.gov

The US federal government’s omnibus website, Vaccines.gov [ 55 ], bills itself as a “gateway” to information on vaccines and immunization for infants, children, teenagers, adults, and seniors” ( Figure 1 ) The HHS National Vaccine Program Office (NVPO) coordinates the website and its content, which is created by US federal agencies including the Food and Drug Administration (FDA), Health Resources and Services Administration, National Institutes of Health, HHS, and NVPO. The intended audience of Vaccines.gov is the US general public and, as per federal mandate, the website is designed to be accessible to individuals of varying levels of literacy and ability [ 81 ]. Although all information on the website is sanctioned by the US federal government, the website carries several disclaimers, stating that the “site is not intended to be a substitute for professional medical advice, diagnosis, or treatment” and advising viewers to seek the advice of physicians and qualified health care providers regarding any questions or health concerns they may have.

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Screenshot of the Vaccine.gov home page.

Vaccines.gov contains general information about vaccines and vaccination-related practices, as well as vaccine-specific information for 22 diseases. General information is listed under 2 separate tabs on the website’s toolbar. The “Basics” tab contains information on the safety of vaccines, the efficacy of vaccines, prevention of diseases, and community (or herd) immunity. The “Getting Vaccinated” tab contains information about what children and adults can expect during vaccination, an interactive section in which visitors can enter their zip codes to find providers of adult vaccines near them, an interactive map of the United States that links to each state’s department of health, and information on how to pay for vaccinations with the Affordable Care Act and the Centers for Disease Control’s (CDC) Vaccine for Children Program. There is also a separate “Travel” tab on the navigation bar with information that links to the CDC Travel Health site.

Vaccine-specific information is categorized under 2 tabs: “Diseases” and “Who and When.” Under the “Diseases” tab, 22 vaccine-preventable diseases are listed. Each disease has its own page, most with subsections with information about the disease, information on its respective vaccine, and a tab labeled “Take Action” that includes additional government information about the disease and resources for finding where to get vaccinated. The “Who and When” tab contains vaccination schedules for 7 specific populations: infants, children, and teens aged 0 to 18 years; the Catch-up Schedule for Children aged 4 months to 18 years; college and young adults aged 19 to 24 years; adults aged 19 and older; seniors aged 65 years and older; pregnant women; and persons with health conditions.

Vaccines.gov is predominantly text based and all information references either government or scientific literature. The website also includes a limited number of images, videos, spreadsheets, and an infographic. Images feature most prominently on the website’s landing page, where they serve to illustrate the seasonal content Vaccines.gov promotes. The videos embedded on its “Features: News & Video” page offer flu vaccine information targeted at a variety of audiences, such as cartoons about the flu shot for children and scientific simulations of how the disease spreads for adults. All 19 videos are produced by government agencies.

As a repository of US federal government vaccine information, Vaccines.gov links exclusively to federal and state government websites. Although hyperlinks are numerous, the website functions as a hub for vaccine information within a relatively small network of websites.

Vaccines.gov’s limited social interactivity mirrors the website’s small digital ecology. The website’s sole interactive feature is a checkbox at the bottom of each page that asks the user “Was this page helpful?” The results of these page-by-page surveys are not available on the website, so there is no means for a user to see the feedback left by others. Additionally, the website does not include any functions that would permit users to communicate directly or indirectly with one another.

Using the guidelines published on the US federal government’s encyclopedic usability website, Usability.gov [ 80 ], as a heuristic, Vaccines.gov is best characterized as a website that employs a subject organizational scheme that organizes its content according to a variety of topics while also supporting task-oriented navigation. Visually, the website is uncluttered and easily legible due to its predominantly black text on a white background.

Case Study 2: Children’s Hospital of Philadelphia Vaccine Education Center

The VEC website was launched by CHOP in 2000 to “provide accurate, comprehensive, and up-to-date information about vaccines and the diseases they prevent to parents and health care professionals” [ 32 ] ( Figure 2 ). The website’s main goal is to correct “misinformation” and “misconceptions” about vaccines and vaccination practices. The VEC is a member of the World Health Organization’s Vaccine Safety Net “because its website meets the criteria for credibility and content as defined by the Global Advisory Committee on Vaccine Safety” [ 56 ].

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Screenshot of the Vaccine Education Center home page.

On the “About” page, VEC discloses that funding for the website comes entirely from CHOP and not from “vaccine manufacturers.” Visitors have the option to donate to the CHOP Foundation via a button on the main CHOP website; however, there is no donation link displayed on the VEC website itself. Additionally, the “About” page provides short biographies of the “team of scientists, physicians, mothers, and fathers” who administer, advise, and staff the VEC. The website also carries the disclaimer that none of its information is intended to be patient-specific or replace the viewer’s relationship with a qualified health care professional.

The VEC website contains information on 21 individual vaccines and 9 combination vaccines. Information on each vaccine is accessible either through the website’s sidebar or through a cluster of buttons within body of the landing page. Clicking on the “A Look at Each Vaccine” button in either location directs the viewer to a page with specific information about the vaccine and its corresponding disease. The pages are structured in a question-and-answer format, with questions moving from generic inquiries about what the disease is and how it is contracted to more population-specific questions. For instance, clicking on “Anthrax Vaccine” displays the question “Why should military personnel be vaccinated?” Similarly, “Meningococcus Vaccine” contains information targeted at college students.

The VEC uses a variety of textual and visual genres to provide information to visitors. Its landing page features links to 2 videos about infant and childhood vaccination, as well as downloadable materials for parents and health care providers. In addition to information on each vaccine, the website’s sidebar offers many other resources including vaccine schedules and vaccine safety information. There are also other scientific resources under tabs labeled “Vaccines: Practical Considerations,” “Vaccine Science,” and “Rash Information.” Information on all these pages is accompanied by references to scientific publications. The “Vaccine-Related News” tab directs users to information and resources from the CDC. Other than images of the CHOP app, links to downloadable documents, and links to videos, only one static image is used throughout the website. The VEC banner features a tightly cropped headshot of a smiling girl accented by a pink background with stars.

All content on the VEC website is created by the organization, including links to scholarly and popular press publications by the VEC’s staff, and all pages within the website are reviewed and dated by the VEC director, Dr Paul A Offit. Although the vast majority of hyperlinks direct the viewer to content within the VEC website, there are external links to “Professional and Parent Groups,” “Resources for Kids and Teens,” and “Further Reading” on the “Additional Resources” page. There are also downloadable PDF versions of CHOP’s booklets, pamphlets, and other brief communications in both English and Spanish.

The VEC website does not offer users any means of interacting with one another within its pages. Each page on the VEC website contains links to CHOP’s Twitter, Facebook, and YouTube sites; however, the content of these pages informs visitors about CHOP in general and is not specific to the VEC.

Although there is no social networking capability on the VEC website, it does offer some Web 2.0 features, such as an email newsletter, games, and a mobile app. The mobile app, called “Vaccines on the Go: What You Need to Know,” is available on both iOS and Android platforms. In addition to content from the VEC website, it includes “[a] place to save questions for the next doctor’s visit” and gives users “[t]he opportunity to easily email the VEC for answers to vaccine-related questions.”

Much like Vaccines.gov [ 55 ], the VEC website employs a combination topic and task schema. The website is easily legible with its use of black text on a white background; soft accent colors indicate items that can be clicked for more information. Its streamlined design omits a navigation bar; therefore, more content appears on screen. Despite the lack of this typical feature, its sidebar-content-sidebar layout makes the site easily navigable. The website extends its utility through its numerous downloads, which can be read offline.

Case Study 3: National Vaccine Information Center

A nonprofit organization, NVIC describes itself as “the oldest and largest consumer-led organization advocating for the institution of vaccine safety and informed consent protections in the public health system” [ 57 ] ( Figure 3 ). NVIC states that its mission is to prevent vaccine-related injuries and deaths through public education and to promote informed consent in medicine. Additionally, NVIC funds research on vaccines and vaccination and “provides assistance to those who have suffered vaccine reactions.”

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Screenshot of the National Vaccine Information Center home page.

Barbara Loe Fisher, NVIC’s founder, has a significant presence on the website because the current organization grew out of her advocacy against childhood vaccines in the 1980s. Fisher’s commentary runs throughout the website and much of the site is dedicated to documenting her past and present advocacy efforts. Although her presence is ubiquitous on the website, NVIC includes graphical links to its 2 partner organizations: Mercola.com, a self-described natural health information website, and the United Way of the National Capital Area.

The landing page of the NVIC website is separated into 2 columns under a navigation bar. Atop the broad left column headed is a set of links imbedded in a rotating picture box displaying links to the website’s subsections and a right side bar with Breaking News. Current News fills up the lower left-hand side. Along the bottom of the banner at the top of the page, a series of navigation tabs lead the user into the site: “Home,” “About Us,” “Vaccines,” “Law and Policy,” “News and Events,” “Resources,” “Vaccine Reactions,” and “FAQs.” “Subscribe Now!,” “Donate Now!,” “PayPal Donation,” and “Volunteer Now!” buttons appear above and below the picture on the left side of the screen, next to links for Facebook, Twitter, and YouTube. The links embedded in the rotating picture box include “Ask 8 Questions,” “Diseases and Vaccines,” “State Vaccine Law,” “NVIC Advocacy Portal,” “Vaccine Ingredients,” “Injury Compensation,” “Informed Consent,” “Vaccine Victim Memorial,” and “Vaccine Freedom Wall.”

Although the group states on its “About Us” webpage that it “does not advocate for or against the use of vaccines,” the preponderance of the content on its website questions the safety and efficacy of vaccines and vaccination practices, such as the CDC childhood vaccination schedule. Visitors can also download informational pamphlets designed by the organization. The downloadable literature is targeted at parents and is designed to raise questions about current vaccination practices, with emphatic titles such as “49 DOSES OF 14 VACCINES BEFORE AGE 6? 69 DOSES OF 16 VACCINES BY AGE 18? Before you take the risk, find out what it is. ”

As an “information clearinghouse,” the NVIC website connects visitors to a diverse array of resources about vaccine safety, ranging from government agencies, such as the CDC and the Institute of Medicine, to news outlets that broadcast interviews with the group’s founder, Barbara Loe Fisher. It also provides links to vaccine advocacy events, such as Vaccine Awareness Week and antivaccination conferences.

The NVIC relies heavily on its social media outreach program, and much of its work is done through this outlet. Indeed, many of the sources on the traditional Web pages appear to be somewhat out of date, whereas its Facebook page is updated daily. In its 2011 Annual Report, NVIC states that “350,000 unique visitors accessed information on NVIC.org during FY2011,” [ 57 ], that the “Vaccine Ingredient Calculator (VIC) alone attracted more than 46,000 visits from users in 133 nations,” that its “online vaccine freedom wall saw an increase in reports of harassment by parents and health care professionals,” and that the NVIC’s “Facebook and social media outreach experience sustained growth in FY2011” [ 57 ]. Although NVIC’s traditional Web pages have as their purpose the dissemination of information about infectious disease and vaccination, the NVIC Facebook page contains posts about vaccination and other controversies in health, such as gluten allergy.

Although visitors to the NVIC website will find a great deal of governmental and scientific information on vaccines and vaccination, they are also faced with a vast number of resources that cast vaccines as dangerous. The landing page, as described previously, presents visitors with several types of information, which can make for less than straightforward navigation for the visitor seeking to learn more about a specific vaccine. The website is a repository for information on vaccine injury with links to state and federal legislation, such as the National Childhood Vaccine Injury Act of 1986, as well as links to agencies and groups that report and compensate vaccination injuries. To bolster its legitimacy, the website reflects the design choices typically employed on governmental and medical websites, replete with patriotic red, white, and blue accents on an easily legible white background, a layout resembling Vaccines.gov [ 55 ].

Case Study 4: SANE Vax, Inc

SANE Vax states that its mission is “to promote only safe, affordable, necessary, and effective vaccines and vaccination practices through education and information” [ 58 ] ( Figure 4 ). The nonprofit organization espouses a belief in science-based medicine and states that it offers information necessary for its visitors to make informed health decisions. Of its 5 board members, 2 state in their biographies that they are the parents of vaccine-injured children. SANE Vax presents itself as a grassroots organization in need of financial support to keep up with “popular demand” and solicits donations via a PayPal link on each page.

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Screenshot of the SANE Vax, Inc home page.

The majority of content on the SANE Vax website focuses on the dangers of the HPV vaccines Cervarix and Gardasil (sold in some countries as Silgard). The website’s landing page is divided into several sections corresponding to the group’s mission. Against a purple background, the upper half of the page features 2 columns: “Victims,” which is a series of short, clickable posts featuring images of vaccine-injured young women and their stories, and “SANE Vax Press Releases,” a list of position papers on vaccine policy last updated in 2011. Atop the press release column, a rotating picture box displays images of young women with narrative descriptions of their lives before and after they were vaccinated against HPV. Visitors can explore the webpage via 2 navigation bars that categorize its almost overwhelming amount of content into a series of blogs, resource pages, press release pages, and video pages. Additionally, a sidebar on the right side of the page solicits donations, displays “This Week’s Victim,” additional links to HPV-related groups, and a table listing data about HPV claims from the most recent report of the Vaccine Adverse Event Reporting System, a surveillance program sponsored by the CDC and FDA which permits anyone to submit an incident report about vaccine-related adverse effects.

There are several ways for visitors to access victims’ stories. For example, clicking on the “Victims” tab at the top of the page drops down a list of pages including a “Victims Memorial” dedicated to family remembrances of young women who died after receiving an HPV vaccine and a blog page where users submit stories about their family members who died after receiving an HPV vaccine. Most of the information on the website is text based; however, SANE Vax contains a great deal of images and videos that illustrate the stories of vaccine-injured young women. These stories tend to be narrated by family members who chronicle the young women’s healthy lives before they received the vaccination and their subsequent declines postvaccination. The text and video narratives almost always conclude by urging viewers to “investigate before you vaccinate.” The narratives are structured to juxtapose emotional appeals of vaccine injury with logical appeals to scientific research. By placing these 2 forms of persuasion side-by-side, SANE Vax achieves 2 rhetorical effects. First, it makes the argument that the scientific record is inaccurate because it omits information about vaccine injury and, second, it hopes that the viewer will place personal narratives on equal footing with scientific studies. SANE Vax’s postmodern understanding of scientific truth enables it to construct a broad digital ecology where personal truths, clinical truths, and scientific truths coexist. Although the website privileges vaccine-skeptical information, it provides a space where information can be produced and consumed in a fluid, nonhierarchical manner that, in turn, creates a more capacious understanding of vaccine and vaccine-related practices.

Like NVIC [ 57 ], SANE Vax supports a considerable digital ecology. The website links to a variety of advocacy groups, news websites, and government agencies. Keeping in-line with the website’s content, all the external information presented focuses on the dangers of vaccine and vaccination. This information comes from news reports and personal accounts from several continents giving SANE Vax a global reach, despite its status as a US nonprofit organization.

SANE Vax houses several blogs to which users can contribute after they register for a free membership to the website. The membership also permits users to upload their own text and video HPV vaccine injury narratives as well as comment others’ content. In this regard, SANE Vax creates an online community of users from around the world who share personal stories and opine about current vaccine policies.

Unlike the Vaccines.gov [ 55 ] and VEC [ 56 ] websites, SANE Vax attempts to use an exact organization scheme. According to Usability.gov, “exact organization schemes objectively divide information into mutually exclusive sections” [ 80 ]. One of the challenges this type of website organization poses to visitors of SANE Vax is that they are presented with numerous discrete categories of information on the website’s many dropdown menus. Visitors to the Vaccines.gov [ 55 ] and VEC [ 56 ] websites can access all the information about a specific disease and its vaccine with a single click, whereas visitors to the SANE Vax website are presented with information about HPV vaccines in numerous tabs and dropdown menus. The implications of this organization scheme are discussed subsequently in “User Experience.”

Each of the websites presented in this study offered information about its sponsoring organization. Only VEC [ 56 ] and SANE Vax [ 58 ] offered biographical information about the personnel affiliated with the website and the organization it represents. Vaccines.org [ 55 ] presented disclosures of the institutions that created the content displayed on the website. As a governmental entity, it is more interested in presenting the positions of government agencies than the backgrounds of individuals holding positions within those agencies. On the other hand, the NVIC [ 57 ] “About Us” page offered no biographical data about the organization’s founder, Barbara Loe Fisher. The only mention of Fisher in this section of the website was found in a list of Frequently Asked Questions: “How do I contact NVIC, Barbara Loe Fisher, or update my contact information with NVIC?” However, Fisher’s writings and videos are showcased throughout the website.

VEC and SANE Vax disclosed their affiliated personnel’s professional achievements and personal attachments, a feature that permits users to learn more about the people presenting them with information on vaccine and vaccination-related practices. This feature also allows the website’s visitors to assess the ethos of the organizations in light of the people who founded and work for it. Although such an omission of data on Vaccines.gov is understandable because it is a convention of government agency websites, it raises questions with regard to the NVIC website. The majority of the content on NVIC was dedicated to Fisher’s advocacy work. Omitting information about her role in the organization may appear to give NVIC an official, authoritative ethos, such as that of Vaccines.gov; however, it distances the organization from the actions and positions of its founder, a rhetorical maneuver that attempts to maintain the appearance of a balanced position on vaccines and vaccination that some viewers might question.

The Vaccines.gov and VEC websites were the only 2 that included disclaimers about the medical information they presented in their “About Us” sections (and in other parts of the websites). The disclaimers functioned in 3 rhetorical ways. First, the disclaimers underscored that the information presented was not a substitute for medical treatment and opinion. These websites endorsed vaccine and vaccination. Appealing to the authority of medical practitioners demonstrated that the content presented was aligned with best medical practices. It also assumed that medical practitioners endorse vaccine and vaccination. Second, the disclaimers offered visitors a means of finding further information in the form of a medical consultation specific to their health needs. Lastly, they signified that the information presented on the website was not monolithic despite the ethos of the organizations that presented it.

Textual and Visual Content

All the websites in this study presented findings from the scientific literature about vaccines and vaccination. The VEC [ 56 ] and Vaccines.gov [ 55 ] websites presented the scientific information either directly or in a synthesized form and offered no further commentary on it. Thus, the logos of VEC and Vaccines.gov relied on the straightforward distribution of scientific information and governmental policies. On the other hand, NVIC [ 57 ] and SANE Vax [ 58 ] tended to present scientific information indirectly and with commentary about its quality and the conflicts of interest of its authors. It was common to find allegations on these sites that research is sponsored by the pharmaceutical industry accompanying scientific data on vaccines and vaccination.

Both NVIC and SANE Vax constructed arguments in conjunction with the presentation of scientific information and government policy. These organizations created their logos through questioning, clarifying, and challenging scientific findings. Additionally, NVIC and SANE Vax promoted alternative scientific research that accorded with their vaccine-skeptical positions. These 2 organizations constructed their “watchdog” ethos through challenging scientific and governmental knowledge and, therefore, presented counterarguments in the form of differing scientific findings and opinions on vaccine and vaccination.

Visual content played a minor role on the VEC, Vaccines.gov, and NVIC websites. Because scientific information is disseminated in text form, these websites assumed the logos, or logical argument structure, of scientific medicine even when the mission was to challenge its findings. Text-based websites are easily skimmable and searchable, aiding visitors in finding the information they seek. The encyclopedic feel of these websites added to their ethos of reputable information providers.

SANE Vax was the only website in this study that presented large amounts of visual data to its viewers. Images are the currency of Web 2.0 because they can present a large amount of information in an efficient package. SANE Vax fused its logos with the pathos of emotionally charged images that display the dangers of HPV vaccine, effectively placing scientific logic on equal ground with the personal experiences of the lay visitors and thus building a community of lay experts sympathetic to vaccine injury. Its predominately text-based counterparts in this study tended to make assertions about vaccines and vaccination based on logic and scientific reasoning. SANE Vax subverted this way of understanding vaccines by linking the faces of human suffering to vaccine. This method of argumentation requires the viewer to construct meaning in a way that differs from reading text. Reading a video image calls on the viewer’s personal knowledge, in this case about the human body and illness, thus creating a relationship between the viewer and the image. Compared to text-based reading, reading images is a more intersubjective and affective experience that makes the viewer empathize with the suffering and loss illustrated in the images. Thus, SANE Vax used pathos to build its arguments against vaccination.

As a comparison, Vaccines.gov included a few videos, but those watched by the research group seemed overly scripted and unnatural, limiting their rhetorical efficacy. This rather amateur use of video seemed half-hearted in its attempt to respond to authentic viewer concerns, presenting instead its own version of those concerns in a way that rang false. Because the videos seemed like attempts to engage viewers but were experienced as inauthentic, they not only failed to convince viewers but also diminished the ethos of the website overall.

Hyperlinking

The hyperlinking feature of websites (eg, its digital ecology) describes its interconnectivity with other sites. Of the 4 case studies presented, Vaccines.gov [ 55 ] contained the fewest hyperlinks to other websites. The few websites to which it linked were government agencies. The other websites in this study had considerably larger digital ecologies because they linked to numerous other websites. VEC linked to other vaccine-promoting websites, where viewers could find additional resources on special topics, such as vaccines for tween girls, and products such as provaccination children’s books. Although VEC’s [ 56 ] digital ecology may be larger than Vaccine.gov’s, its overall ecology was somewhat closed because it omitted positions on vaccines that differed from its own.

Both NVIC [ 57 ] and SANE Vax [ 58 ] linked to websites that questioned vaccine and vaccination practices as well as vaccine-related medical journal articles and government websites. Viewers navigating these websites were exposed to a variety of resources and perspectives on vaccine. NVIC and SANE Vax adopted this logical strategy to familiarize viewers with the provaccine discourses they challenged. In turn, viewers learned argumentative strategies and counterpoints to challenge the messages of websites such as VEC and Vaccines.gov. Their rhetorical strategy for hyperlinking is to demonstrate that there are many available positions on vaccines and vaccination for viewers to take. Additionally, the hyperlinking strategy demonstrated that scientific and government information is open to interpretation. In this way, NVIC and SANE Vax acknowledged the breadth and diversity of thought on vaccines and vaccination on the Internet by representing and linking to a greater diversity of positions on the subject. That is, their rhetorical ecologies were open and diverse, encouraging a variety of viewpoints even as they focused more insistently on skeptical perspectives.

Social Interactivity

Each of the websites offered some kind of interactive feature for viewers. Vaccines.gov [ 55 ] offered viewers surveys at the bottom of each of its pages; however, it solicited feedback to make future design and content changes to its websites. This practice is typical of US government websites. VEC [ 56 ] offered a mobile app so that viewers could reference information from its website in a smartphone-friendly format, but it did not include any social networking functions. NVIC [ 57 ] and VEC [ 58 ] displayed links to their social media accounts, where users could interact with one another. SANE Vax was the only website that permitted users to contribute their own content to its website. The website also enabled users to comment on others’ content. Contributing and commenting are 2 key community-building functions of Web 2.0 websites. The lack of interactivity of the provaccine websites seems to fit with their hierarchical understanding of scientific authority about vaccines and vaccination. The vaccine-skeptical websites allowed for more interaction and, thus, engaged the viewer in the coconstruction of knowledge about vaccination, especially with the links to social media. The most vaccine-skeptical of the websites, SANE Vax, allowed the most user engagement with content creation on the website.

As a result, SANE Vax built and supported a community of lay experts who circulated alternative knowledge about vaccines. Instead of presenting peer-reviewed scientific literature, the website created a community of peers who could view and comment on one another’s narratives. Rather than reading information on vaccines, the community members shared their experiences with vaccines, adding another level of vaccine data that Vaccines.gov and VEC could not support with their Web architecture. On the other hand, Vaccines.gov and VEC directed users to seek personal support and information from medical practitioners. These differences in interactivity clearly affect user experience and help the vaccine-skeptical websites build loyal and engaged communities, whereas the provaccine websites merely exist as online information repositories. The NVIC website occupied a somewhat middle position in this regard.

User Experience

All 4 of the websites in this study presented themselves to their visitors as information resources. The organizational structure of Vaccines.org [ 55 ] and VEC [ 56 ] lent itself to targeted searches about specific vaccines and vaccination-related topics. Neither of these websites offered additional commentary about vaccines and vaccination outside the realms of science and government, nor did they offer news on current events pertaining to vaccines or vaccination.

NVIC [ 57 ] and SANE Vax [ 58 ] offered many types of information about vaccines and vaccination. As a result, the websites were more difficult to navigate and their overall purposes were more difficult to discern. The NVIC website was particularly interesting with regard to purpose because it presented a more neutral position concerning vaccination on its landing page than in the rest of the website. Navigating into the site revealed deeply antivaccination sentiments that were often presented through tautological citations and links to publications by Fisher and other prominent vaccine-skeptical figures (eg, Dr Mercola of Mercola.com).

As noted previously, SANE Vax used an exact organization scheme to organize its links and information. The exact organization scheme benefits visitors looking for specific information about political action groups, manufacturers of vaccines, and victims of Gardasil in different countries. Users seeking more general information were potentially overwhelmed with scientific and lay data on vaccines, vaccine news from governments around the world, and transmissions from the website’s staff. However, SANE Vax’s design reinforced the relationship between scientific and governmental literature and personal testimony that could be used for 2 purposes. A visitor interested in personal accounts of HPV vaccine injury would find that SANE Vax’s research blogs and analyses of scientific literature reinforced the video accounts, whereas a visitor researching vaccines would find that the testimonials provided additional information to bolster SANE Vax’s claims. Thus, despite the potential confusion, SANE Vax’s architecture reflected its 2 purposes, which were to show that there are vast bodies of knowledge (in the form of personal accounts of vaccine injury) that are suppressed in the scientific and governmental literature and to demonstrate that HPV vaccines are controversial and injurious around the world. By placing personal accounts on equal footing with scientific information, the website invited visitors to share their own personal experiences in a manner that the other websites did not.

The provaccine websites examined in this study do not leverage the affordances of Web 2.0. The primary purpose of Vaccines.gov [ 55 ] and VEC [ 56 ] is to transmit medical and government information to viewers who are seeking specific vaccine information. Although they incorporate different types of media, those media reinforce the information-driven purposes of the websites. The unidirectional transmission of information denies viewers the opportunity to share their experiences with vaccines or to challenge the information that is presented to them. Their rhetorical ecologies are closed rather than open. The content on Vaccines.gov and VEC is vetted by physicians and government workers, but neither website acknowledges the effect that the information and policies have on the lived experiences of those who visit the websites. This unidirectional flow of information is reinforced by both websites’ hyperlinking practices. Vaccines.gov only links to other government agencies; VEC only links to provaccine websites. This practice reinforces the websites’ positions on public health while denying that there are members of the public who do not subscribe to their provaccine stances. Of course, it is not in the interest of either website to acknowledge positions that challenge their own, which may explain why neither website permits visitors to comment publicly on the information they present.

By not including interactive or community-building features on their websites, both Vaccines.gov and VEC attempt to solidify their positions as authorities on vaccines and vaccination-related practices. The obverse side of this decision is that the websites foster an image of unsympathetic authoritarians who only care about well-being at the level of the public instead of at the level of the individual. In effect, individuals whose experiences differ from the health outcomes presented on these websites have no means of interacting with those who tout vaccines and mandate vaccination practices. It is clear that many of these individuals seek an online forum where their experiences can be publicly presented and validated by a receptive community. As stated previously, according to a Pew Research’s Health Online 2013 poll, 72% of Internet users surveyed looked for health information online and 35% opted to self-diagnose with Web-based information rather than visit a clinician [ 16 ]. Considering these statistics, the lack of interactivity on the Vaccines.gov and VEC websites may turn people who have had adverse experiences with vaccines into vaccine skeptics because the only online places where their alternative experiences will be acknowledged may be vaccine-skeptical websites.

Although the quality of online vaccination information is a constant concern for researchers and practitioners, both NVIC and SANE Vax demonstrate that studies conducted in the early 2000s are inaccurate in their claims that vaccine-skeptical websites misunderstand scientific information. Rather than circulating deliberate misunderstandings of medical research, both websites strip evidence-based scientific information of its authority by questioning its primacy and call for alternative scientific studies that are sympathetic to its claims. The websites substantiate their calls for alternative research by fostering a community of individuals whose experiences with vaccines counter the information transmitted by medical and governmental websites. Through the community-building functions of Web 2.0, they curate interactive accounts of vaccine injury and skepticism, thus providing a corpus of medical texts that adhere to a different standard for scientific information; that is, the personal experience of vaccination, a purview that is absent in the information offered by Vaccines.gov and VEC.

The research presented in this study is necessarily limited because it makes case studies of only 4 of the many vaccine-related websites on the World Wide Web. However, it presents an opportunity for future research on Internet vaccine information. By employing a rhetorical framework, this study found that both provaccine websites studied concentrate on the accurate transmission of evidence-based scientific research about vaccines and government-endorsed vaccination-related practices. On the other hand, the vaccine-skeptical websites investigated focus on creating communities of people affected by vaccines and vaccine-related practices. From this more personal framework (see also Lawrence et al [ 49 ]), the websites then challenge the information presented in scientific literature and government documents. At the same time, the vaccine-skeptical websites in this study are repositories of vaccine information and vaccination-related resources.

Future studies on vaccination and the Internet should take into consideration the rhetorical features of provaccine and vaccine-skeptical websites and further investigate the role of Web 2.0 community-building features on vaccine-related practices. More work needs to be done to determine if the findings of this small pilot study can be replicated across more provaccine and vaccine-skeptical websites; that is, whether the features identified here are generalizable.

Abbreviations

Authors' Contributions: Lenny Grant is the primary author. Bernice Hausman is the second author. Margaret Cashion, Nicholas Lucchesi, Kelsey Patel, and Jonathan Roberts provided preliminary research for the study.

Conflicts of Interest: None declared.

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Persuasive Speech Outline, with Examples

March 17, 2021 - Gini Beqiri

A persuasive speech is a speech that is given with the intention of convincing the audience to believe or do something. This could be virtually anything – voting, organ donation, recycling, and so on.

A successful persuasive speech effectively convinces the audience to your point of view, providing you come across as trustworthy and knowledgeable about the topic you’re discussing.

So, how do you start convincing a group of strangers to share your opinion? And how do you connect with them enough to earn their trust?

Topics for your persuasive speech

We’ve made a list of persuasive speech topics you could use next time you’re asked to give one. The topics are thought-provoking and things which many people have an opinion on.

When using any of our persuasive speech ideas, make sure you have a solid knowledge about the topic you’re speaking about – and make sure you discuss counter arguments too.

Here are a few ideas to get you started:

All school children should wear a uniform
Facebook is making people more socially anxious
It should be illegal to drive over the age of 80
Lying isn’t always wrong
The case for organ donation

Read our full list of 75 persuasive speech topics and ideas .

Preparation: Consider your audience

As with any speech, preparation is crucial. Before you put pen to paper, think about what you want to achieve with your speech. This will help organise your thoughts as you realistically can only cover 2-4 main points before your audience get bored .

It’s also useful to think about who your audience are at this point. If they are unlikely to know much about your topic then you’ll need to factor in context of your topic when planning the structure and length of your speech. You should also consider their:

Cultural or religious backgrounds
Shared concerns, attitudes and problems
Shared interests, beliefs and hopes
Baseline attitude – are they hostile, neutral, or open to change?

The factors above will all determine the approach you take to writing your speech. For example, if your topic is about childhood obesity, you could begin with a story about your own children or a shared concern every parent has. This would suit an audience who are more likely to be parents than young professionals who have only just left college.

Remember the 3 main approaches to persuade others

There are three main approaches used to persuade others:

The ethos approach appeals to the audience’s ethics and morals, such as what is the ‘right thing’ to do for humanity, saving the environment, etc.

Pathos persuasion is when you appeal to the audience’s emotions, such as when you tell a story that makes them the main character in a difficult situation.

The logos approach to giving a persuasive speech is when you appeal to the audience’s logic – ie. your speech is essentially more driven by facts and logic. The benefit of this technique is that your point of view becomes virtually indisputable because you make the audience feel that only your view is the logical one.

Ethos, Pathos, Logos: 3 Pillars of Public Speaking and Persuasion

Ideas for your persuasive speech outline

1. structure of your persuasive speech.

The opening and closing of speech are the most important. Consider these carefully when thinking about your persuasive speech outline. A strong opening ensures you have the audience’s attention from the start and gives them a positive first impression of you.

You’ll want to start with a strong opening such as an attention grabbing statement, statistic of fact. These are usually dramatic or shocking, such as:

Sadly, in the next 18 minutes when I do our chat, four Americans that are alive will be dead from the food that they eat – Jamie Oliver

Another good way of starting a persuasive speech is to include your audience in the picture you’re trying to paint. By making them part of the story, you’re embedding an emotional connection between them and your speech.

You could do this in a more toned-down way by talking about something you know that your audience has in common with you. It’s also helpful at this point to include your credentials in a persuasive speech to gain your audience’s trust.

Speech structure and speech argument for a persuasive speech outline.

Obama would spend hours with his team working on the opening and closing statements of his speech.

2. Stating your argument

You should pick between 2 and 4 themes to discuss during your speech so that you have enough time to explain your viewpoint and convince your audience to the same way of thinking.

It’s important that each of your points transitions seamlessly into the next one so that your speech has a logical flow. Work on your connecting sentences between each of your themes so that your speech is easy to listen to.

Your argument should be backed up by objective research and not purely your subjective opinion. Use examples, analogies, and stories so that the audience can relate more easily to your topic, and therefore are more likely to be persuaded to your point of view.

3. Addressing counter-arguments

Any balanced theory or thought addresses and disputes counter-arguments made against it. By addressing these, you’ll strengthen your persuasive speech by refuting your audience’s objections and you’ll show that you are knowledgeable to other thoughts on the topic.

When describing an opposing point of view, don’t explain it in a bias way – explain it in the same way someone who holds that view would describe it. That way, you won’t irritate members of your audience who disagree with you and you’ll show that you’ve reached your point of view through reasoned judgement. Simply identify any counter-argument and pose explanations against them.

Complete Guide to Debating

4. Closing your speech

Your closing line of your speech is your last chance to convince your audience about what you’re saying. It’s also most likely to be the sentence they remember most about your entire speech so make sure it’s a good one!

The most effective persuasive speeches end with a call to action . For example, if you’ve been speaking about organ donation, your call to action might be asking the audience to register as donors.

Practice answering AI questions on your speech and get feedback on your performance .

If audience members ask you questions, make sure you listen carefully and respectfully to the full question. Don’t interject in the middle of a question or become defensive.

You should show that you have carefully considered their viewpoint and refute it in an objective way (if you have opposing opinions). Ensure you remain patient, friendly and polite at all times.

Example 1: Persuasive speech outline

This example is from the Kentucky Community and Technical College.

Specific purpose

To persuade my audience to start walking in order to improve their health.

Central idea

Regular walking can improve both your mental and physical health.

Introduction

Let’s be honest, we lead an easy life: automatic dishwashers, riding lawnmowers, T.V. remote controls, automatic garage door openers, power screwdrivers, bread machines, electric pencil sharpeners, etc., etc. etc. We live in a time-saving, energy-saving, convenient society. It’s a wonderful life. Or is it?

Example 2: Persuasive speech

Tips for delivering your persuasive speech

Practice, practice, and practice some more . Record yourself speaking and listen for any nervous habits you have such as a nervous laugh, excessive use of filler words, or speaking too quickly.
Show confident body language . Stand with your legs hip width apart with your shoulders centrally aligned. Ground your feet to the floor and place your hands beside your body so that hand gestures come freely. Your audience won’t be convinced about your argument if you don’t sound confident in it. Find out more about confident body language here .
Don’t memorise your speech word-for-word or read off a script. If you memorise your persuasive speech, you’ll sound less authentic and panic if you lose your place. Similarly, if you read off a script you won’t sound genuine and you won’t be able to connect with the audience by making eye contact . In turn, you’ll come across as less trustworthy and knowledgeable. You could simply remember your key points instead, or learn your opening and closing sentences.
Remember to use facial expressions when storytelling – they make you more relatable. By sharing a personal story you’ll more likely be speaking your truth which will help you build a connection with the audience too. Facial expressions help bring your story to life and transport the audience into your situation.
Keep your speech as concise as possible . When practicing the delivery, see if you can edit it to have the same meaning but in a more succinct way. This will keep the audience engaged.

The best persuasive speech ideas are those that spark a level of controversy. However, a public speech is not the time to express an opinion that is considered outside the norm. If in doubt, play it safe and stick to topics that divide opinions about 50-50.

Bear in mind who your audience are and plan your persuasive speech outline accordingly, with researched evidence to support your argument. It’s important to consider counter-arguments to show that you are knowledgeable about the topic as a whole and not bias towards your own line of thought.

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COMMENTS

Vaccine Persuasion
2. Hearing pro-vaccine messages from doctors, friends and relatives. For many people who got vaccinated, messages from politicians, national experts and the mass media were persuasive.
Persuasive Speech On Vaccination
Vaccinate Persuasive Letters. 265 Words | 2 Pages. Each year in the U.S., 50,000 adults die from a disease that could have easily been prevented if they simply got vaccinated. Also, most vaccines are for deadly diseases; if someone neglects getting vaccinated, that makes them very vulnerable.
Why You Should Get Vaccinated Persuasive Essay
The success of vaccines in preventing widespread disease outbreaks and managing public health threats demonstrates their profound impact as a medical innovation. 400 Words Essay on Vaccination. Vaccination is one of the most effective public health measures, crucial in preventing infectious diseases and saving countless lives.
Persuasive Essay About Covid19
Step 1: Choose a Specific Thesis Statement. Your thesis statement should clearly state your position on a specific aspect of COVID-19. It should be debatable and clear. For example: Thesis Statement: "COVID-19 vaccination mandates are necessary for public health and safety."
Lessons learned: What makes vaccine messages persuasive
Vaccine hesitancy threatened public health's response to the COVID-19 pandemic. Scientists at the University of Maryland recently reviewed 47 randomized controlled trials to determine how COVID-19 communications persuaded—or failed to persuade—people to take the vaccine. (Health Communication, 2023 DOI: 10.1080/10410236.2023.2218145).
Persuasive messaging to increase COVID-19 vaccine uptake intentions
Here we use two survey experiments to study how persuasive messaging affects COVID-19 vaccine uptake intentions. In the first experiment, we test a large number of treatment messages. One subgroup of messages draws on the idea that mass vaccination is a collective action problem and highlighting the prosocial benefit of vaccination or the ...
The 7 Best Tactics to Persuade the Vaccine-Hesitant
1. Use Analogies to Explain the Vaccine. The vaccine can seem confusing or dangerous to people. So, comparing key aspects of the vaccine to examples they can understand (i.e., analogies) can be ...
Rhetorical Questions and Real Answers About Vaccination
Key points. Decision making in the face of uncertainty is complex. Using a risk-benefit framework is an effective means of making decisions in the face of uncertainty. What we know so far about ...
Here's What Will Actually Convince People to Get Vaccinated
The people around us also play a major role, with 56% of respondents saying they got vaccinated after a friend or family member did, and 59% saying they were influenced merely by having a ...
How to persuade people to take the COVID-19 vaccine
Indeed, in a recent study by the Vaccine Confidence Project at the London School of Hygiene and Tropical Medicine, only 54 per cent of UK respondents said they would definitely take the COVID-19 vaccine and this dropped to 47.6 per cent after viewing misinformation on social media. And people from lower income, black and ethnic minority ...
Persuasive messaging to increase COVID-19 vaccine uptake ...
We find that persuasive messaging that invokes prosocial vaccination and social image concerns is effective at increasing intended uptake and also the willingness to persuade others and judgments of non-vaccinators. We replicate this result on a nationally representative sample of Americans and observe that prosocial messaging is robust across ...
Examining persuasive message type to encourage staying at home during
Behavioral change is the only prevention against the COVID-19 pandemic until vaccines become available. This is the first study to examine the most persuasive message type in terms of narrator difference in encouraging people to stay at home during the COVID-19 pandemic and social lockdown.
When do persuasive messages on vaccine safety steer COVID-19 vaccine
Introduction Vaccine safety is a primary concern among vaccine-hesitant individuals. We examined how seven persuasive messages with different frames, all focusing on vaccine safety, influenced Malaysians to accept the COVID-19 vaccine, and recommend it to individuals with different health and age profiles; that is, healthy adults, the elderly, and people with pre-existing health conditions.
How to talk to friends and family about getting a covid vaccine
Federal officials paused the use of the Johnson & Johnson vaccine last week. "If you hedge, you can undermine the entire vaccination campaign in a moment if you appear to be covering up ...
Persuasive Speech On Vaccinations
Persuasive Speech On Vaccinations. Decent Essays. 905 Words. 4 Pages. Open Document. Throughout history, the introduction of vaccinations in societies around the world have significantly reduced the threat of deadly viruses. Despite the many benefits of immunizations, some parents refuse to vaccinate their children due to the health risks ...
Does free speech protect COVID-19 vaccine misinformation?
Stanford researcher discusses whether free speech rights fuel COVID-19 vaccine misinformation and how that misinformation can be stopped. ... For example, the Food and Drug Administration fought legal battles for years over its initiative to require cigarette makers to put pictorial warning labels on cigarette packs, with the industry arguing ...
How to talk about vaccines
How to have conversations about vaccination. 1. Listen with empathy. Start by listening with empathy to those who have questions around vaccination. Don't dismiss them, and acknowledge how they're feeling (without necessarily agreeing, for example "it's okay to have questions, or want more information before getting a vaccine"). 2.
WHO Director-General's opening remarks at the Vaccines and Global
As you know, the first major speech I gave after my election as Director-General in 2017 was at the World Leaders Forum at Columbia, on the subject of health security. ... The West African Ebola outbreak gave rise to vaccines, but it also gave rise to WHO's Research and Development Blueprint for epidemics, a strategy to facilitate the rapid ...
Coronavirus Vaccine- Persuasive Speech by Anna Alonso on Prezi
By- Anna Alonso. Paragraph 1. The Coronavirus Vaccination. A solution to something we have been dealing with for a year and three months. In this large period of time, there were many different, but necessary, changes to millions of lives. With these changes, there have been people who either wish for normality again, or people who want to stop ...
Vaccination persuasion: Personal stories most likely to influence
Civis plans to periodically repeat the coronavirus message testing because as Son noted, it's likely that both the baseline and persuasive message sway will change over time. COVID-19 flu ...
Vaccination Persuasion Online: A Qualitative Study of Two Provaccine
It is true that as a result of these studies, the medical community has gained a greater understanding of the types of information presented on vaccine-skeptical websites and deeper insights into how these websites deploy this information to make persuasive arguments against vaccines and vaccination.
This simple text message can encourage people to get vaccinated ...
CNN —. A simple text message may be able to provide the nudge some people need to get vaccinated, researchers say. Researchers with the University of Pennsylvania found that people who received ...
Persuasive Speech Outline, with Examples
Ideas for your persuasive speech outline 1. Structure of your persuasive speech. The opening and closing of speech are the most important. Consider these carefully when thinking about your persuasive speech outline. A strong opening ensures you have the audience's attention from the start and gives them a positive first impression of you.

Vaccine Persuasion

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How to Write a Persuasive Essay About Covid19 | Examples & Tips

Steps to Write a Persuasive Essay About Covid-19

Step 1: Choose a Specific Thesis Statement

Step 2: Research and Gather Information

Step 3: Outline Your Essay

Step 4: Write the Introduction

Step 5: Provide Background Information

Step 6: Develop Body Paragraphs

Step 7: Address Counterarguments

Step 8: Write the Conclusion

Step 9: Revise and Proofread

Step 10: Cite Your Sources

Examples of Persuasive Essay About Covid19

Examples of Persuasive Essay About Covid-19 Vaccine

Examples of Persuasive Essay About Covid-19 Integration

Examples of Argumentative Essay About Covid 19

Examples of Persuasive Speeches About Covid-19

Tips to Write a Persuasive Essay About Covid-19

Choose a Specific Angle

Provide Credible Sources

Use Persuasive Language

Organize Your Essay

Emphasize Benefits

Use Visuals -H3

Call to Action

Revise and Edit

Seek Feedback

Common Topics for a Persuasive Essay on COVID-19

Frequently Asked Questions

What impact does COVID-19 have on society?

Keep reading

Lessons learned: What makes vaccine messages persuasive

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