Social Norms and Vaccine Uptake: College Students' COVID Vaccination Intentions, Attitudes, and Estimated Peer Norms and Comparisons with Influenza Vaccine

"As behavioral scientists seek to develop strategies that can increase societal uptake of COVID vaccines, the findings from the current study indicate that norms-based approaches may be promising."

Young adults' health behaviors and attitudes are powerfully influenced by the behaviours and attitudes of their peers (i.e., social norms). Vaccination against COVID-19 may be critical for young adults as a key step towards curbing community transmission, including spread to high-risk people (e.g., elderly relatives). Yet, as of April 2020, only 50% of young adults in the United States (US) reported intentions to get a COVID-19 vaccine, with 41% reporting being unsure. The present study examined college students' intentions and perceived importance of getting a COVID-19 vaccine (i.e., attitudes), as well as the extent to which vaccination intentions and attitudes were associated with estimated social norms.

In November of 2020 (prior to public release of COVID-19 vaccines), 647 US undergraduate students completed online surveys in which they reported intentions to get COVID-19 and influenza vaccines, perceived importance of these vaccines for young adults, and estimated social norms regarding peers' vaccination behaviours and attitudes. To explore potential barriers and reasons for COVID-19 vaccine hesitancy, the researchers calculated the proportion of the sample that endorsed each of several potential barriers/reasons.

Students reported significantly greater intentions to get a COVID-19 vaccine (91.64%) than an influenza vaccine (76.04%), and they perceived COVID-19 vaccination as significantly more important than influenza vaccination. (The latter figure is a major improvement over estimated rates from previous years, which are that only approximately 40% among college students have received the influenza vaccine. However, vaccine intentions do not necessarily predict uptake; this is the case with the COVID-19 vaccine as well.)

Pertaining to estimates of descriptive norms, participants thought that peers would be more likely to get a COVID-19 vaccine than an influenza vaccine. This pattern held for injunctive norms: Participants estimated that peers perceive COVID-19 vaccination as being more important than influenza vaccination. In addition, the sample self-reported greater likelihood of getting COVID-19 and influenza vaccinations relative to estimated descriptive norms, and also reported greater perceived importance of these vaccines relative to estimated injunctive norms. These patterns indicate that students may underestimate descriptive and injunctive norms regarding peers' intentions and attitudes toward vaccine uptake.

Multiple regression models show that estimated social norms were positively associated with participants' own intentions and perceived importance of getting a COVID-19 vaccine. For example, every 1% increase in estimated descriptive norms was associated with 1.05 times greater odds of intending to get a COVID-19 vaccine.

With regard to barriers and potential reasons for not getting a COVID-19 vaccine:

• Nearly 60% of the full sample and over 85% of those not intending to get a COVID-19 vaccine indicated they were afraid/nervous about unknown side effects.
• Nearly 50% of the full sample and almost 70% of those not intending to get a COVID-19 vaccine indicated they did not think a COVID-19 vaccine would be sufficiently tested before being made available.
• Approximately 23% of the full sample indicated being afraid a COVID-19 vaccine could give them COVID-19 or make them sick, over 16% indicated that they do not have sufficient health insurance to afford a vaccine, and 12.52% did not think a vaccine would work. These percentages were slightly higher among those not intending to get a COVID-19 vaccine.
• Just over 10% of the full sample noted a fear of needles/shots as a potential barrier, and approximately 3% of students felt that a COVID-19 vaccine was incongruent with their religious beliefs.
• Nevertheless, 24.11% indicated they had no concerns about getting a COVID-19 vaccine, while only 3.70% of participants not intending to get a COVID-19 vaccine noted they had no concerns.

Based on these data on barriers, the researchers suggest that, to increase confidence in COVID-19 vaccines, it may be helpful to convey the extent of the clinical trials conducted and the evidence indicating that the vaccines are indeed safe. Notably: "Behavioral interventions or campaigns to increase uptake should...be careful not to invalidate peoples' concerns, which may yield defensive responses and actually decrease uptake..." The study found that most participants - even those not intending to be vaccinated - believed that a COVID-19 vaccine would work, so the researchers caution that simply highlighting the efficacy statistics may not be enough to overcome vaccine hesitancy. (Levels of, and reasons for, vaccine hesitancy should continue to be monitored throughout the pandemic, they stress.)

Additional practical implications of the study are related to the finding that students may tend to underestimate their peers' intentions and attitudes towards getting a COVID-19 vaccine, which suggests that "norm-correcting strategies may be promising. Indeed, the results indicated significant associations between vaccination intentions and perceptions of social norms for typical young adults - highlighting the potential value of increasing young adults' perceptions of how many young adults actually intend to get a COVID vaccine as well as how important most young adults think getting vaccinated is for young adults."

Specifically, university stakeholders could develop personalised normative feedback interventions to correct normative misperceptions. Such interventions could include sharing individually tailored feedback contrasting personal behaviour, estimates of others' behaviours, and others' actual behaviours. On a larger scale, social norms also can be leveraged within social marketing campaigns that entail publicly highlighting the actual norms for a behaviour, which can shift perceptions and promote healthier behaviour - in this case, potentially increasing COVID-19 vaccine uptake and coverage on college campuses, which could be key in preventing the spread of COVID-19 among young people and those around them.