Carrot or stick? The impact of reinforcement and government trust on persuading vaccine-hesitant parents during the pandemic
Keywords:
vaccine hesitancy; COVID-19; parental decision-making; government trust; reinforcement theory; health communication; childhood vaccination; public health messaging; pandemic responseAbstract
This study examined the effectiveness of different vaccination promotional strategies among parents of unvaccinated children aged 12–17 years during the COVID-19 pandemic. Using a 2 (reinforcement: positive vs. negative) × 2 (trust in government: high vs. low) between-subjects experimental design with 286 participants, we investigated how reinforcement strategies interact with government trust to influence parental attitudes and intentions toward child vaccination. Results revealed no significant main effect of reinforcement type on vaccination attitudes or intentions. However, trust in government emerged as a powerful predictor of both outcomes, with high-trust parents demonstrating substantially more positive attitudes and stronger intentions to vaccinate their children compared to low-trust parents. Importantly, significant interaction effects were observed—parents with low government trust responded more favorably to positive reinforcement (incentives) than negative reinforcement (restrictions), while parents with high government trust showed similar responses to both approaches. These findings highlight the critical role of trust in vaccine communication and suggest that tailored reinforcement strategies based on pre-existing trust levels may improve communication effectiveness. As declining vaccination rates for routine childhood immunizations create new public health vulnerabilities, these insights offer practical guidance for developing targeted vaccination campaigns that can effectively reach diverse populations, particularly those most resistant to standard public health messaging.
References
1. Penn M. Statistics say large pandemics are more likely than we thought. Duke Global Health Institute. Available online: https://globalhealth.duke.edu/news/statistics-say-large-pandemics-are-more-likely-we-thought (accessed on 15 May 2025).
2. Willis ED, Montgomery B, Selig JP, Andersen J. COVID-19 vaccine hesitancy and racial discrimination among US adults. Prev Med Rep. 2022; 31(18):102074. doi: 10.1016/j.pmedr.2022.102074
3. Weintraub K. As COVID turns 3, experts worry where the next pandemic will come from – and if we’ll be ready. USA Today; 2023.
4. Walrath-Holdridge M. How did the measles outbreak spread? A look at vaccine exemption rates in Texas. USA Today; 2025.
5. Monte L. Household pulse survey shows many don’t trust COVID vaccine, worry about side effects. US Census Bureau. Available online: https://www.census.gov/library/stories/2021/12/who-are-the-adults-not-vaccinated-against-covid.html (accessed on 15 May 2025).
6. Szilagyi PG, Shah MD, Delgado JR, et al. Parents’ intentions and perceptions about COVID-19 vaccination for their children: Results from a national survey. Pediatrics. 2021; 148(4). doi: 10.1542/peds.2021-052335
7. Lazarus JV, Ratzan SC, Palayew A, et al. A global survey of potential acceptance of a COVID-19 vaccine. Nat Med. 2020; 27(2): 225-228. doi: 10.1038/s41591-020-1124-9
8. Jennings W, Stoker G, Bunting H, et al. Lack of trust, conspiracy beliefs, and social media use predict COVID-19 vaccine hesitancy. Vaccines. 2021; 9(6): 593. doi: 10.3390/vaccines9060593
9. Trujillo KL, Green J, Safarpour A, et al. COVID-19 spillover effects onto general vaccine attitudes. Public Opin Q. 2024; 00(0): 1-26. doi: 10.1093/poq/nfad059
10. World Health Organization. COVID-19 pandemic fuels largest continued backslide in vaccinations in three decades. 15 July 2022. Available online: https://www.who.int/news/item/15-07-2022-covid-19-pandemic-fuels-largest-continued-backslide-in-vaccinations-in-three-decades (accessed on 15 May 2025).
11. Centers for Disease Control and Prevention. Vaccination coverage among children in kindergarten—United States, 2022–23 school year. MMWR. 2023; 72(44): 1179–1187.
12. Grills LA, Wagner AL. The impact of the COVID-19 pandemic on parental vaccine hesitancy: A cross-sectional survey. Vaccine. 2023; 41(41): 6127-6133. doi: 10.1016/j.vaccine.2023.08.044
13. Skinner BF. The behavior of organisms: An experimental analysis. New York, NY: Appleton-Century; 1938.
14. Thorndike EL. Animal intelligence: Experimental studies. New York, NY: Macmillan; 1911.
15. Ohio Department of Health. Ohio Vax-a-Million details announced. Available online: https://odh.ohio.gov/media-center/odh-news-releases/odh-news-release-05-17-21 (accessed on 15 May 2025).
16. City of New York. Mayor Adams announces $100 incentive push for COVID-19 first doses, boosters. Available online: https://www.nyc.gov/office-of-the-mayor/news/073-22/mayor-adams-100-incentive-push-covid-19-first-doses-boosters (accessed on 15 May 2025).
17. Sidman M. Coercion and its fallout. Boston, MA: Authors Cooperative; 1989.
18. Iwata BA. Negative reinforcement in applied behavior analysis: An emerging technology. J Appl Behav Anal. 1987; 20(4): 361-378. doi: 10.1901/jaba.1987.20-361
19. Baron A, Galizio M. Positive and negative reinforcement: Should the distinction be preserved? Behav Analyst. 2005; 28(2): 85-98. doi: 10.1007/bf03392107
20. Sprengholz P, Betsch C, Böhm R. Reactance revisited: Consequences of mandatory and scarce vaccination in the case of COVID-19. Appl Psychol Health Well-Being. 2021; 13(4): 986–995. doi: 10.1111/aphw.12285
21. Petry NM, Alessi SM, Olmstead TA, et al. Contingency management treatment for substance use disorders: How far has it come, and where does it need to go? Psychol Addict Behav. 2017; 31(8): 897-906. doi: 10.1037/adb0000287
22. Campos-Mercade P, Meier AN, Schneider FH, et al. Monetary incentives increase COVID-19 vaccinations. Science. 2021; 374(6569): 879-882. doi: 10.1126/science.abm0475
23. Adams J, Bateman B, Becker F, et al. Effectiveness and acceptability of parental financial incentives and quasi-mandatory schemes for increasing uptake of vaccinations in preschool children: Systematic review, qualitative study and discrete choice experiment. Health Technol Assess. 2015; 19(94): 1-176. doi: 10.3310/hta19940
24. Orenstein WA, Hinman AR. The immunization system in the United States—the role of school immunization laws. Vaccine. 1999; 17(Suppl 3): S19–S24. doi: 10.1016/S0264-410X(99)00290-X
25. Betsch C, Böhm R. Moral values do not affect prosocial vaccination. Nat Hum Behav. 2018; 2(12): 881-882. doi: 10.1038/s41562-018-0478-1
26. Sprengholz P, Betsch C. Herd immunity communication counters detrimental effects of selective vaccination mandates: Experimental evidence. EClinicalMedicine. 2021; 38: 101000. doi: 10.1016/j.eclinm.2021.101000
27. Schmelz K, Bowles S. Overcoming COVID-19 vaccination resistance when alternative policies affect the dynamics of conformism, social norms, and crowding out. Proc Natl Acad Sci U S A. 2021; 118(25). doi: 10.1073/pnas.2104912118
28. Thirumurthy H, Milkman KL, Volpp KG, et al. Association between statewide financial incentive programs and COVID-19 vaccination rates. PLoS One. 2022; 17(3): e0263425.
29. Naeim A, Guerin RJ, Baxter-King R, et al. Strategies to increase the intention to get vaccinated against COVID-19: Findings from a nationally representative survey of US adults, October 2020 to October 2021. Vaccine. 2022; 40(52): 7571-7578. doi: 10.1016/j.vaccine.2022.09.024
30. Goldstein DAN, Wiedemann J. Who do you trust? The consequences of partisanship and trust for public responsiveness to COVID-19 orders. Perspect Polit. 2021; 20(2): 412-438. doi: 10.1017/s1537592721000049
31. Blair RA, Morse BS, Tsai LL. Public health and public trust: Survey evidence from the Ebola Virus Disease epidemic in Liberia. Soc Sci Med. 2017; 172: 89-97. doi: 10.1016/j.socscimed.2016.11.016
32. Newton K. Government communications, political trust and compliant social behaviour: The politics of COVID‐19 in Britain. Political Q. 2020; 91(3): 502-513. doi: 10.1111/1467-923x.12901
33. Quinn SC, Parmer J, Freimuth VS, et al. Exploring communication, trust in government, and vaccination intention later in the 2009 H1N1 pandemic: Results of a national survey. Biosecur Bioterror. 2013; 11(2): 96-106. doi: 10.1089/bsp.2012.0048
34. Lindholt MF, Jørgensen F, Bor A, et al. Public acceptance of COVID-19 vaccines: Cross-national evidence on levels and individual-level predictors using observational data. BMJ Open. 2021; 11(6): e048172. doi: 10.1136/bmjopen-2020-048172
35. Murphy J, Vallières F, Bentall RP, et al. Psychological characteristics associated with COVID-19 vaccine hesitancy and resistance in Ireland and the United Kingdom. Nat Commun. 2021; 12(1): 1-15. doi: 10.1038/s41467-020-20226-9
36. Siegrist M, Cvetkovich G. Perception of hazards: The role of social trust and knowledge. Risk Anal. 2000; 20(5): 713–720. doi: 10.1111/0272-4332.205064
37. Larson HJ, Clarke RM, Jarrett C, et al. Measuring trust in vaccination: A systematic review. Hum Vaccin Immunother. 2018; 14(7): 1599-1609. doi: 10.1080/21645515.2018.1459252
38. Vraga E, Tully M, Bode L. Assessing the relative merits of news literacy and corrections in responding to misinformation on Twitter. New Media Soc. 2021; 24(10): 2309-2329. doi: 10.1177/1461444821998691
39. Lee C, Whetten K, Omer S, et al. Hurdles to herd immunity: Distrust of government and vaccine refusal in the US, 2002–2003. Vaccine. 2016;34(34):3972-3978. doi:10.1016/j.vaccine.2016.06.048
40. Freeman D, Waite F, Rosebrock L, et al. Coronavirus conspiracy beliefs, mistrust, and compliance with government guidelines in England. Psychol Med. 2020; 52(2): 251-263. doi: 10.1017/s0033291720001890
41. Vinck P, Pham PN, Bindu K, Nilles EJ. Institutional trust and misinformation in the response to the 2018-19 Ebola outbreak in North Kivu, DR Congo: A population-based survey. Lancet Infect Dis. 2019; 19(5): 529-536. doi: 10.1016/S1473-3099(19)30063-5
42. Woskie LR, Fallah MP. Overcoming distrust to deliver universal health coverage: Lessons from Ebola. BMJ. 2019; 366: l5482. doi: 10.1136/bmj.l5482
43. Callaghan T, Moghtaderi A, Lueck JA, et al. Correlates and disparities of intention to vaccinate against COVID-19. Soc Sci Med. 2021; 272: 113638. doi: 10.1016/j.socscimed.2020.113638
44. Khubchandani J, Sharma S, Price JH, et al. COVID-19 vaccination hesitancy in the United States: A rapid national assessment. J Community Health. 2021; 46(2): 270-277. doi: 10.1007/s10900-020-00958-x
45. Fridman A, Gershon R, Gneezy A. COVID-19 and vaccine hesitancy: A longitudinal study. PLoS One. 2021; 16(4): e0250123. doi: 10.1371/journal.pone.0250123
46. Hamel L, Lopes L, Kearney A, et al. KFF COVID-19 vaccine monitor: Parents and the pandemic. Kaiser Family Foundation. Available online: https://www.kff.org/coronavirus-covid-19/poll-finding/kff-covid-19-vaccine-monitor-parents-and-the-pandemic/ (accessed on 15 May 2025).
47. Brehm SS, Brehm JW. Psychological reactance: A theory of freedom and control. San Diego, CA: Academic Press; 1981.
48. Petty RE, Cacioppo JT. Communication and persuasion: Central and peripheral routes to attitude change. New York, NY: Springer-Verlag; 1986.
49. Opel DJ, Lo B, Peek ME. Addressing mistrust about COVID-19 vaccines among patients of color. Ann Intern Med. 2021; 174(5): 698-700. doi: 10.7326/m21-0055
50. SteelFisher GK, Blendon RJ, Caporello H. An uncertain public—encouraging acceptance of COVID-19 vaccines. N Engl J Med. 2021; 384(16): 1483-1487. doi: 10.1056/NEJMp2100351
51. Liu Y, Bruine de Bruin W, Kapteyn A, et al. Role of parents’ perceived risk and responsibility in deciding on children’s COVID-19 vaccination. Pediatrics. 2023; 151(5). doi: 10.1542/peds.2022-058971
52. Pew Research Center. About four-in-ten Americans say social media is an important way of following COVID-19 vaccine news. Available online: https://www.pewresearch.org/short-reads/2021/08/24/about-four-in-ten-americans-say-social-media-is-an-important-way-of-following-covid-19-vaccine-news/ (accessed on 15 May 2025).
53. Capasso M, Caso D, Zimet GD. The mediating roles of attitude toward COVID-19 vaccination, trust in science and trust in government in the relationship between anti-vaccine conspiracy beliefs and vaccination intention. Front Psychol. 2022; 13: 936917. doi: 10.3389/fpsyg.2022.936917
54. Walsh JC. Increasing screening uptake for a cervical smear test: Predictors of attendance and the use of action plans in prior non-attenders. Ir J Psychol. 2005; 26: 65-73.
55. Funk C, Gramlich J. 10 facts about Americans and coronavirus vaccines. Available online: https://www.pewresearch.org/fact-tank/2021/09/20/10-facts-about-americans-and-coronavirus-vaccines/ (accessed on 15 May 2025).
56. Lin C, Tu P, Beitsch LM. Confidence and receptivity for COVID-19 vaccines: A rapid systematic review. Vaccines. 2020; 9(1): 16. doi: 10.3390/vaccines9010016
57. Pennisi F, Genovese C, Gianfredi V. Lessons from the COVID-19 pandemic: Promoting vaccination and public health resilience, a narrative review. Vaccines. 2024; 12(8): 891. doi: 10.3390/vaccines12080891
58. Quinn SC, Hilyard KM, Jamison AM, et al. The influence of social norms on flu vaccination among African American and White adults. Health Educ Res. 2017; 32(6): 473-486. doi: 10.1093/her/cyx070
59. Brewer NT, Chapman GB, Rothman AJ, et al. Increasing vaccination: Putting psychological science into action. Psychol Sci Public Interest. 2017;18(3):149-207. doi: 10.1177/1529100618760521
60. Thomson A, Vallée-Tourangeau G, Suggs LS. Strategies to increase vaccine acceptance and uptake: From behavioral insights to context-specific, culturally-appropriate, evidence-based communications and interventions. Vaccine. 2018; 36(44): 6457–6458. doi: 10.1016/j.vaccine.2018.08.031
Downloads
Published
Issue
Section
License
Copyright (c) 2025 Author(s)
This work is licensed under a Creative Commons Attribution 4.0 International License.
