COVID-19 Vaccine Framing and Acceptance Among Adults Who Are Vaccine Hesitant

Importance: Autonomy concerns represent one of many contributors to vaccine hesitancy, yet public health messaging often emphasizes government compliance. It is important to study whether alternative message framing is associated with stated vaccine acceptance among hesitant individuals. Objective: To evaluate whether framing vaccines as freedom enhancing is associated with higher vaccine acceptance among vaccine hesitant adults. Design, Setting, and Participants: This cross-sectional online discrete choice experiment was conducted from May 1 to 4, 2024. Each respondent completed 12 choice tasks comparing 2 vaccine options and a no-vaccine option, with vaccines described by 6 attributes, including infection prevention and severe disease protection efficacy, minor and major adverse effects, duration of protection, and additional reason to take (message framing). Exposures: Three levels for message framing, including government compliance (reference), personal freedom, and protect others. Main Outcomes and Measures: Hesitancy was measured using vaccine concerns and the Vaccine Adverse Belief Index (VABI). Main outcomes were vaccine preference shifts and estimated vaccine uptake associated with message framing variations examined using hierarchical bayesian analysis, with vaccine concerns and VABI serving as second-level factors. Results: A total of 907 adults (mean [SD] age, 69.5 [11.0] years; 454 female [50.3%]) participated in the study. Among respondents with high vaccine concern, freedom framing was associated with a preference shift of 33.8 percentage points (95% credible interval [CrI], 21.5-45.8 percentage points) and an increase in uptake of 6.3 percentage points (95% CrI, 2.9-11.5 percentage points), assuming the most favorable vaccine profile (highest efficacy, lowest adverse effects, longest duration). Among respondents with a high VABI, freedom framing was associated with a preference shift of 27.7 percentage points (95% CrI, 14.5-40.5 percentage points) and an increase in uptake of 4.6 percentage points (95% CrI, 1.8-8.8), respectively. Respondents with low vaccine concern or VABI showed no significant preference shifts associated with framing. In contrast, protect-others framing was associated with positive preference shifts and uptake, with no evidence that these associations differed by vaccine hesitancy. Conclusions and Relevance: This cross-sectional study found that compared with government recommendation framing, freedom framing was selectively associated with higher vaccine acceptance among adults who were vaccine hesitant. Protect-others framing was associated with higher vaccine acceptance regardless of hesitancy level. Absolute gains in acceptance were modest. These findings highlight how autonomy-consistent framing may influence stated vaccine preferences among hesitant adults.