Complications of the Personal Choice to Get Vaccinated Against COVID-19

The Corona pandemic confronts people these days with yet another challenge: deciding whether to get vaccinated as protection from the potentially serious disease of COVID-19. The answer seems obvious: people would want to be vaccinated to avoid the risks involved with the disease, and to see the pandemic with all its repercussions behind them. However, the events surrounding the development of vaccines against a strain of coronavirus unfamiliar until late 2019, SARS-CoV-2, and the flow of information patients-consumers are exposed to, are raising concerns and hesitation in their minds. The personal decision has become more tenuous, less straightforward than perhaps it ought to be.

  • Aspects and issues concerning the coronavirus and methods of vaccination against it are touched in this post at surface, only with respect to information consumers may learn about vaccination options and how it may affect their decision process and outcome.

The decision problem engaged may be divided into two crucial choices: (1) Whether to get vaccinated against COVID-19; and (2) How to get vaccinated, that is, what type of vaccine to receive. From the latter derives also a choice when to be vaccinated. For most people (55%-75% according to various surveys), the first choice is clear, to get vaccinated for the sake of one’s health, the health of relatives and friends, and the chance it gives to end the pandemic crisis sooner. Patients with background illnesses or vulnerabilities may be in a more difficult position regarding their response to a vaccine, but even then it is hoped that a form of vaccine safe for many of them to uptake will be available.

  • Part of the objection to vaccines developed against SARS-CoV-2 is mainly ideological and comprehensive, targeted at nearly any vaccination; this type of objection is not addressed here. Any causes of concern, deliberation, or reservations that may be raised by patients-consumers and discussed in the post will focus on the specific circumstances surrounding the COVID-19 vaccination programme and the public campaign to persuade people to get vaccinated.

Yet, there appears to be greater room for manoeuvre on the second choice. The situation related to the drive to develop a vaccine for a new strain of virus as soon as possible creates uncertainty for patients. The revealed information, that innovative approaches and methods are being applied, adds to the puzzlement of patients-consumers, lowering further their confidence, at least in the short term. Many of them would need more time to absorb the situation, possibly to learn more about the possibilities as they emerge or talk to people already vaccinated, in order to build their confidence before reaching a choice decision (i.e., to be vaccinated with a particular type of vaccine). The timespan for making a personal decision as such should be a matter of months, not years. Having gone so far in bearing this pandemic, a few more months can reasonably be allowed to let more people decide to ‘join in’ at their own will, so as to reach a higher vaccination uptake rate of the population in any country (towards the so-called ‘herd immunity’).

There are several approaches and methods for developing a vaccine for a virus like SARS-CoV-2 which consumers are seemingly only partially familiar with. Consumers would know even less of the differences between alternative versions of vaccines that are developed by research institutes and companies. An interested patient-consumer may learn of three categories of methodological approaches (see for example the American CDC: Different COVID-19 Vaccines).

  1. The ‘classic’ approach makes use of inactivated or weakened forms of the target virus, or inactivated subunits of the virus, to upstart the human immunity system (e.g., a vaccine developed in China).
  2. The ‘novel’ approach employs a substance of the genetic code of the target virus: the messenger RNA (mRNA) includes instructions for the production of a specific protein of the virus, spike protein on the surface of SARS-CoV-2; when injected to a patient’s body (muscle) it launches the production of the spike protein upon human cells, and that would trigger the creation of antibodies (and associated memory cells) against the virus (the protein alone is incapacitated yet it ‘signals’ the malicious virus to attack). This approach is most identified publicly with the vaccines of Pfizer-BioNTech and Moderna.
  3. However, there is a third approach that uses a virus vector as a carrier. The ‘vector’ is a virus which does not harm humans (e.g., it causes a cold in chimpanzees); this weakened virus is neutralized and ‘uploaded’ with a component of the target virus (SARS-CoV-2). We might call this type of approach ‘intermediary’; it can be utilised in versatile ways wherein the virus vector can carry either the mRNA for SARS-CoV-2, and operate as in the ‘novel’ approach (e.g., AstraZeneca with Oxford University), or directly ‘import’ the spike protein into the human body (e.g., Janssen [a subsidiary of Johnson & Johnson], Russian Sputnik V, Israel’s Institute for Biological Research). This approach is evidently much less talked about.

The novel mRNA-based approach is innovative and has not reached until now the stage of practical implementation for vaccinating populations. It has been researched though for several years already. That brings about various questions on the workings of the vaccine. For instance, will the mRNA be dissolved as expected after it fulfills its duty? and, might the genetic code have any effects on human DNA beyond its designated function? Additionally, will the spike protein of the coronavirus execute its mission of triggering the creation of antibodies (efficacy), and nothing but this mission (i.e., will not have any delayed impact on other body systems)? Of course there also are the usual questions about short-term side effects. Scientists and medical practitioners provide answers to at least some of these questions (e.g., the mRNA includes very specific instructions, it cannot penetrate the nucleus of human cells and hence will not intervene with DNA, the spike protein is isolated and should have a very specific function). The concerns of patients-consumers are nevertheless legitimate and deserve to be addressed by the professionals in charge.

Patients-consumers may refer to different sources online (e.g., websites of health ministries, healthcare organisations /HMOs, pharma & biotech companies, academic, and news media) to learn about the coronavirus and vaccines. In some sources the information is in the form of Q&A and includes assurances and brief explanations, while other sources provide more elaborate background and explanations. People can also read about statistical results of the Phase 3 large-scale trials (a topic for separate discussion beyond the scope of this post). Yet, one may need to accumulate a certain basis of knowledge, sufficient to obtain some understanding of the vaccination methods and options. It may be just enough to give patients general orientation, not feeling completely lost, and build their confidence a little. Eventually, however, patients need to rely on the judgement and recommendations of those with professional authority in the field. Vaccination is a good example of a credence product. That is why having confidence and trust in the scientists and medical practitioners is so important. But being able to trust policymakers, politicians and senior administrative officials (some officials are medical professionals), is also vital.

Two salient factors are present in this decision problem. First, when the consequences of choices made are more significant, such as with an impact on one’s health, consumers are likely to engage in more careful consideration of the options, evaluating trade-offs between decision criteria, and deliberate longer. However, a more consequential choice decision may become more emotional. The possible negative outcome of contracting the disease can be expected to receive greater weight, albeit people tend to underestimate the probability of a negative event occurring to them. Second, while the patients-consumers are attempting to evaluate their options, difficult trade-offs might deter them from proceeding and make them seek easier strategies and rely on gut feelings. Trade-offs between outcomes of choice alternatives become more difficult when they involve stronger conflicts between values or goals. They are furthermore difficult when knowledge is more limited (e.g., about different vaccines) and uncertainty is greater.

Consumers-patients may weigh-in the disease against plausible side effects (short-term and long-term); perceived risks; the mRNA approach versus other methods; time waited until vaccination versus risk. The decision to get vaccinated could be more stressful especially if only a single vaccine is available; it may lead patients to focus more on the timing to be vaccinated (e.g., postpone the vaccination until more options are introduced).

The human factors, behavioural and social, entailed in an effort to protect people through vaccination from the coronavirus (SARS-CoV-2) should receive greater attention through research and be taken into account during planning by policymakers. A research working group led by Monica Shoch-Spana from Johns Hopkins Center for Health Security and Emily Brunson from the Anthropology Department at Texas University recommended (July 2020) that next to the time and resources dedicated to medical and bioscience research, time and resources should also be dedicated to social and behavioural research for understanding the human factors in response to the COVID-19 vaccination (e.g., understanding of the disease, perceived risk, acceptance or hesitancy, and social factors)[The Public’s Role in COVID-19 Vaccination]. The researchers argued that this effort should start with putting order in the profusion of information provided about the pandemic itself, and neutralising misinformation, to increase the public’s understanding about the pandemic and confidence in being able to overcome it; they added that the “efforts must be apolitical and should involve direct, longitudinal engagement with communities”. It was added that the human dimensions should find expression in the vaccination campaign so as to “help assure that a clinically successful vaccine is also socially acceptable” (p. 4).

  • Notably, the research group recommended the application of human-centered principles of design thinking to the planning and implementation of a vaccination campaign, thus giving the human perspective (user or patient) the consideration it deserves.

People received with a degree of disbelief the news about the development and introduction of vaccines against the just-recently-recognised coronavirus within one year, after being told that a vaccine takes five to ten years to develop and test until it is approved (note: the FDA is issuing at this time exceptional authorization for emergency use, not final approval). That spurred wondering mixed with worries among patients-consumers whether the R&D and trials have been sped up too much while “cutting corners”. Professional and governmental authorities in different countries offer their guarantees that research and development processes of authorised vaccines were properly and fully scrutinised. But there is another explanation to the achievements of research teams in introducing their vaccines much earlier than usual, particularly those based on employing mRNA. As indicated above, research efforts have been on-going gradually and on a “low burner” for about a decade (e.g. Moderna was established in 2010, BioNTech in 2008). The Corona pandemic has given an impetus (and released larger funds) for making progress built on existent knowledge more intensively, developing a vaccine against SARS-CoV-2 virus, conducting the trials, and implementing the vaccine.

A few points may be offered in favour of the use of novel methodologies in vaccination: (1) Important advances are being made in recent years in research on the use of genetic or biological characteristics of a threat, and turning that information against the threat; an important area for application of this kind of strategy is the fight against cancer by developing idiosyncratic treatments. (2) Research and development of vaccines with mRNA as well as virus vectors already occurs against other types and strains of viruses (e.g., HIV, Ebola, Zika, and Influenza); a vaccine based on virus vector approach (non-mRNA) has actually been implemented successfully already in the fight against Ebola in Africa. (3) The mRNA approach is set ready for making updates to a vaccine much quicker than with other methods in response to changes in properties of the target virus — this may prove particularly essential and beneficial amid the concerning news lately of an apparent new version of SARS-CoV-2 that spreads faster discovered in Britain.

  • The name given by the Trump Administration in the US to the country’s programme for development of vaccines, Operation Warp Speed, has been criticised for just exacerbating the worries and suspicions of Americans. The report of Johns Hopkins Center for Health Security described this name as ‘high-tech, space-age name’ (apparently referring the the sci-fi TV series Star Trek from the 1960s). In an article in The New York Times (18 July 2020), Jan Hoffman argues in this regard: “Overall, the worry that is consistently invoked by those hesitant about this vaccine is haste. When health authorities repeatedly tout the rapidity of development — an idea underscored by the name Operation Warp Speed — they inadvertently aggravate the public safety concerns.”

People are naturally and understandably also concerned about side effects of sickness following a vaccination shot, a familiar phenomenon. Unpleasant side effects to expect after a shot of mRNA vaccines (Pfizer-BioNTech, Moderna) include strong headache, muscle ache, and fever. These effects may occur after the first dose shot, but the effects experienced after the shot of second dose may be even harsher. Some participants in the vaccine trials testified that they were not able to function due to sickness for a day, yet they fully recovered the next day and resumed life as usual. Those effects are not supposed to stop people from receiving the vaccine but patients should be aware and prepared for them, and reckon that they may have to take a day off from work or other activities. Dr. Sandra Fryhofer (American Medical Association) is concerned that patients unprepared and alarmed by suffering from strong effects after the first shot will not return for the second dose, which would make their vaccination treatment void (CNBC.com, Berkeley Lovelace, 23 November 2020).

In the event of diffusion and assimilation of new and innovative products and technologies, marketers identify different consumer groups and adoption stages; they are often described as innovators & early adopters, followers (early & late majority), and laggards. Such a model of diffusion is frequently applicable to products and services that help consumers better perform functions and tasks in their lives, give pleasure and joy, and improve the quality of life, without necessarily having an impact of consequence (e.g., health, finances). The tendency to adopt an innovative product depends on personality traits (e.g., open-mindedness, trying new things) and attitudes (e.g., readiness to take risks) that are more stable and influence behaviour in various situations. Moreover, policymakers should have little reason to believe that the attitude and behaviour of consumers-patients will diverge considerably when concerning vaccination that directly impacts their health.

There are, however, some special circumstances in the case of a vaccination campaign against COVID-19. Mainly two types of patients-consumers could come first to get vaccinated: (a) those who perceive greater urgency in getting protected from the disease, because they might be at greater risk from COVID-19, which exceeds their concerns about the vaccine applied; (b) those who are more open and inclined to accept new approaches and innovative methods and are less sensitive to risks that may be involved in receiving a vaccine. The larger segment of followers, who observe the progress of vaccination, would join-in as their confidence grows that it is safe enough to get vaccinated and are convinced of its benefits. Yet, a prioritizing policy set for administering vaccines to the public is likely to change somewhat the order of ‘adoption’. For instance, it might require some of the adopters of type (b) to wait for most of a higher priority group (e.g., older patients, at higher risk from COVID-19) to be vaccinated, and it may give longer time for some of the followers to track the progress of vaccination, and perhaps await more vaccines to enter, before making their decision to get vaccinated. Essentially, however, after a critical number of people (perhaps 20%-30% of the population in a country) get vaccinated within a short, initial period of the vaccination campaign, the larger mass of the remaining followers can be expected to draw in. All that is contingent clearly on the efficient organisation and operation of a vaccination campaign by healthcare authorities. [Also see an article on innovation adoption and COVID-19 published in HBS Working Knowledge on 29 January 2021.]

Most patients-consumers seem to accept that getting vaccinated is the reasonable and responsible decision for them to take. Still, they would likely appreciate flexibility permitted to them in choosing a type of vaccine and when to get vaccinated (expectedly before the summer of 2021). People should be informed and counselled to encourage them to get vaccinated, not pressured or coerced The goal should be to build and strengthen their confidence to make the recommended decision to receive vaccination.

Ron Ventura, Ph.D. (Marketing)

One thought on “Complications of the Personal Choice to Get Vaccinated Against COVID-19

  1. Danny Rainer

    Excellent article, Dr. Ventura! I would like to advance two comments. In regard to the “how to get vaccinated” question, it seems that in Israel this decision will be made by the authorities, based on the vaccines available. I don’t know how it will work in other countries, but I don’t think in Israel the people will have a say on that. Concerning the issue of “herd immunity”, it seems to me that this is not straightforward because the available vaccines are functional (address the symptoms) and not sterilizing (they don’t seem to be able to curb transmission). Of course, this is not a binary situation, but it seems that with “functional” vaccines, attaining herd immunity will be extremely challenging.

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