ArticlePDF Available

Virtual reality reduces COVID-19 vaccine hesitancy in the wild: A randomized trial

Authors:

Abstract and Figures

Vaccine hesitancy poses one of the largest threats to global health. Informing people about the collective benefit of vaccination has great potential in increasing vaccination intentions. This research investigates the potential for engaging experiences in immersive virtual reality (VR) to strengthen participants’ understanding of community immunity, and therefore, their intention to get vaccinated. In a pre-registered lab-in-the-field intervention study, participants were recruited in a public park (tested: n = 232, analyzed: n = 222). They were randomly assigned to experience the collective benefit of community immunity in a gamified immersive virtual reality environment (2/3 of sample), or to receive the same information via text and images (1/3 of sample). Before and after the intervention, participants indicated their intention to take up a hypothetical vaccine for a new COVID-19 strain (0–100 scale) and belief in vaccination as a collective responsibility (1–7 scale). The study employs a crossover design (participants later received a second treatment), but the primary outcome is the effect of the first treatment on vaccination intention. After the VR treatment, for participants with less-than-maximal vaccination intention, intention increases by 9.3 points (95% CI: 7.0 to 11.5, p < 0.001). The text-and- image treatment raises vaccination intention by 3.3 points (difference in effects: 5.8, 95% CI: 2.0 to 9.5, p = 0.003). The VR treatment also increases collective responsibility by 0.82 points (95% CI: 0.37 to 1.27, p < 0.001). The results suggest that VR interventions are an effective tool for boosting vaccination intention, and that they can be applied “in the wild”—providing a complementary method for vaccine advocacy.
This content is subject to copyright. Terms and conditions apply.
1
Vol.:(0123456789)
Scientic Reports | (2022) 12:4593 | https://doi.org/10.1038/s41598-022-08120-4
www.nature.com/scientificreports
Virtual reality reduces COVID‑19
vaccine hesitancy in the wild:
a randomized trial
Clara Vandeweerdt1,2*, Tiany Luong3, Michael Atchapero1, Aske Mottelson4,
Christian Holz3, Guido Makransky1 & Robert Böhm1,5,6
Vaccine hesitancy poses one of the largest threats to global health. Informing people about the
collective benet of vaccination has great potential in increasing vaccination intentions. This research
investigates the potential for engaging experiences in immersive virtual reality (VR) to strengthen
participants’ understanding of community immunity, and therefore, their intention to get vaccinated.
In a pre‑registered lab‑in‑the‑eld intervention study, participants were recruited in a public park
(tested:
n=232
, analyzed:
n=222
). They were randomly assigned to experience the collective
benet of community immunity in a gamied immersive virtual reality environment (
2
3
of sample), or
to receive the same information via text and images (
1
3
of sample). Before and after the intervention,
participants indicated their intention to take up a hypothetical vaccine for a new COVID‑19 strain
(0–100 scale) and belief in vaccination as a collective responsibility (1–7 scale). The study employs
a crossover design (participants later received a second treatment), but the primary outcome is
the eect of the rst treatment on vaccination intention. After the VR treatment, for participants
with less‑than‑maximal vaccination intention, intention increases by 9.3 points (95% CI: 7.0 to
11.5,
p<
0.001
). The text‑and‑image treatment raises vaccination intention by 3.3 points (dierence
in eects: 5.8, 95% CI: 2.0 to
9.5,
p=
0.003
). The VR treatment also increases collective responsibility
by 0.82 points (95% CI: 0.37 to
1.27,
p<
0.001
). The results suggest that VR interventions are an
eective tool for boosting vaccination intention, and that they can be applied “in the wild”—providing
a complementary method for vaccine advocacy.
Vaccination against most infectious diseases is an individual decision with positive externalities. at is, when
individuals get vaccinated, they not only protect themselves, but typically also limit the probability that they will
transmit the disease to others1. As such, even unvaccinated citizens can be indirectly protected from infection,
known as community immunity or herd immunity1. With regard to the COVID-19 pandemic, it has been esti-
mated that 60–90% of the population needs to be vaccinated (depending, for instance, on the vaccine’s ecacy)
to stop the spread of SARS-CoV-22,3. erefore, vaccine hesitancy—dened as “the delay in acceptance or refusal
of vaccination despite availability of vaccination services”4—is a key obstacle to ending the COVID-19 pandemic.
Vaccine hesitancy is complex and may be aected by several factors5,6: lack of condence (i.e., the tendency
to trust in the safety and eectiveness of vaccines and to trust health authorities and experts who develop,
license, and recommend vaccines), complacency (i.e., low perceived risk of infectious diseases), constraints
(i.e., structural or psychological barriers in daily life that make vaccination dicult or costly), calculation (i.e.,
the degree to which personal costs and benets of vaccination are weighted), lack of collective responsibility
(i.e., the willingness to protect others and eliminate infectious diseases), lack of compliance (i.e., the support for
societal monitoring and sanctioning of people who are not vaccinated), and conspiracy (i.e., conspiracy thinking
and belief in fake news related to vaccination). Accordingly, fully informed vaccination decisions require that
people know and understand the individual costs and benets of a vaccination, as well as its collective benet.
In line with the assumption that people care not only about their own but also about others’ welfare, inform-
ing them about community immunity has sometimes (e.g.,7) but not always (e.g.,8) been shown to increase
vaccination intentions (for a review, see9). Interactive simulations have been particularly eective in increasing
OPEN
1Department of Psychology, University of Copenhagen, Copenhagen, Denmark. 2Department of Political Science,
University of Copenhagen, Copenhagen, Denmark. 3Department of Computer Science, ETH Zürich, Zurich,
Switzerland. 4IT University of Copenhagen, Copenhagen, Denmark. 5Faculty of Psychology, University of Vienna,
Vienna, Austria. 6Copenhagen Center for Social Data Science (SODAS), University of Copenhagen, Copenhagen,
Denmark. *email: clara.vandeweerdt@ifs.ku.dk
Content courtesy of Springer Nature, terms of use apply. Rights reserved
2
Vol:.(1234567890)
Scientic Reports | (2022) 12:4593 | https://doi.org/10.1038/s41598-022-08120-4
www.nature.com/scientificreports/
vaccine intentions1012, potentially because they are more engaging13 and, therefore, increase people’s learning
motivation10,14. In other words, using novel technologies that help people to better understand the collective
benet of vaccination-and the impact that their own vaccination may have on (vulnerable) others—may be a
promising strategy to increase collective responsibility and, in turn, decrease vaccine hesitancy15.
Building on these ndings, in this study we investigate whether vaccination intention is increased by a gami-
ed immersive VR experience showing how community immunity works. Immersive VR is a promising medium
for health communication (cf.16), because compared to other media it facilitates a high level of presence (the
feeling of being in the virtual environment)17 and agency (the psychological experience of controlling one’s own
actions)18, which results in higher levels of enjoyment and engagement19,20. Still, it has only just started to be
tested as a tool for vaccine advocacy, with one study showing no signicant impact on vaccination intentions21,
and a second study nding a noticeable eect22.
In our VR simulation, participants must either try not to infect other non-player characters in a virtual scene,
or try not to get infected by them. All participants play two scenarios—starting with an environment in which
few characters are vaccinated, followed by an environment where many characters are vaccinated. e simulation
thus allows participants to experience community immunity from a rst-person perspective, learning how much
more slowly infection spreads when vaccination rates are high versus low. Moreover, by using gamication in
an immersive VR simulation, participants are likely to be motivated and engaged with the learning content18,23.
We compare the eectiveness of this simulation against a typical information treatment using text and images.
We hypothesized that:
H1. Vaccination intention increases aer the VR treatment.
H2. Vaccination intention increases more aer the VR treatment than aer the text-and-image treatment.
H3. Collective responsibility increases aer the VR treatment.
H4. Collective responsibility increases more aer the VR than than aer the text-and-image treatment.
Method
e design and analysis plan of this randomized control trial was preregistered on 03/06/2021, prior to access-
ing any data. See https:// osf. io/ cjgfe/? view_ only= ac57e a9f e54ed 8bcd9 d3bee 16cc8 a4 for the anonmyized plan.
Registration DOI is https:// doi. o r g/ 10. 17605/ OS F. IO/ WUFXK. Unless otherwise noted, all steps below follow the
pre-registration plan. e full study procedure was approved by the Institutional Review Board at the Psychol-
ogy Department, University of Copenhagen. e study was performed in accordance with the ethical standards
of the Declaration of Helsinki (1964) and its subsequent amendments. Informed consent was obtained from all
participants.
Recruitment. Participants (tested:
, analyzed:
) were 207 passersby recruited in a public
park in Copenhagen during the rst weekend in June 2021, plus 15 passersby recruited one week earlier on
campus at the University of Copenhagen. All adults with basic understanding of English were eligible. e
sample size was determined by the number of passersby who agreed to participate during the pre-registered
study period. Respondents (aged 18 to 63) participated in exchange for drinks and snacks. Table1 contains key
descriptive statistics.
Design. Aer lling out a pre-treatment questionnaire,
2
3
of the participants were randomly assigned to the
VR treatment. e other
1
3
were randomly assigned to read a text and see images explaining community immu-
nity. All participants then lled out a post-treatment questionnaire. Finally, all participants also received the
treatment they had not been assigned to initially (VR or text-and-image), and lled out a second post-treatment
questionnaire (crossover design). Figure1 shows the trial prole.
Below, we detail the content of both treatments: the VR simulation and the text-and-image treatment.
Table 1. Characteristics of the analyzed study sample (
). Continuous variables are summarized as
mean (standard deviation). Last two rows are % of respondents who had maximum values on the outcome
measures before receiving any treatment.
Sample characteristic Result
Age 29.0 (9.1)
% Female 39%
% Vaccinated 16%
Previous VR experience (median) 1–3 times
Pre-treatment vaccination intention 65.8 (25.6)
Pre-treatment collective responsibility 6.0 (1.5)
% Max pre-treatment vaccination intention 12%
% Max pre-treatment collective responsibility 53%
Content courtesy of Springer Nature, terms of use apply. Rights reserved
3
Vol.:(0123456789)
Scientic Reports | (2022) 12:4593 | https://doi.org/10.1038/s41598-022-08120-4
www.nature.com/scientificreports/
VR. In the VR treatment, participants wore an Oculus Quest headset for a 5–10 min simulation developed at
SIPLAB (ETH Zurich). ey were embodied as an older character matching their gender. ey were told that
their character is vulnerable to COVID-19.
Participants were randomly assigned to one of two versions of the VR simulation. In the avoid spreading
version, the player character (“avatar”) is already infected and the player must try not to infect others. In the
avoid infecting version, the player character is uninfected and the player must try not to be exposed to infected
characters.
In a rst step, a tutorial showed the mechanics of the game. ere were healthy-and-unvaccinated, infected
(red clothing) and healthy-and-vaccinated (blue clothing) characters in the environment. Infected characters
could spread the disease when coming too close to a healthy-and-unvaccinated character. Close contact was
dened as a 2m radius around the character.
In a second step, participants were tasked with crossing a busy square to reach a marked destination, while
avoiding contact with the other 130 characters in the square. In the rst scenario, they did so in an environment
where 20% of the virtual characters were vaccinated. In the second scenario, they crossed the busy square again,
but with 70% of the characters being vaccinated. Instructions claried that the dierence between the two sce-
narios was the avatars’ vaccination rate.
When participants came into close contact with a character (infecting them or being exposed to their infec-
tion), they were made aware through graphics and haptic feedback (vibrating controllers). A small graph also
helped them see how the disease spread between characters in the square, increasing the count of infected char-
acters as they moved through the scenario. Figure2 shows the square scene and spreading graph.
Text‑and‑image. e alternative treatment, using text and images, displayed the denition of community
immunity by the US Centers for Disease Control and Prevention24, followed by two pictures (adapted from10)
238 participants started
questionnaire
232 randomised
78 assigned
to text-and-image
first
154 assigned to
VR first
145 included in
main analyses
4 dropped out
1 VR sickness
3 unknown
150 completed
post-treatment
questions
3 under 18 years old
3 dropped out
1 did not speak English
1 no informed consent
1unknown
5 not analyzed
3answered w/o completing VR
1 did not speak English
1 under influence of alcohol
78 completed
post-treatment
questions
77 included in
main analyses
1 not analyzed, under
influence of alcohol
2 dropped out, unknown
143 completed
second post-
treatment
questions
4dropped out, unknown
143 included in
exploratory
analyses
73 completed
second post-
treatment
questions
70 included in
exploratory
analyses
3 answered w/o
completing VR
Figure1. Trial prole showing ow of participants into treatment arms and analyses. Because participants
largely self-administered the questionnaires and treatments, needing assistance only to start up the VR
simulation, dropout reasons are sometimes unknown.
Content courtesy of Springer Nature, terms of use apply. Rights reserved
4
Vol:.(1234567890)
Scientic Reports | (2022) 12:4593 | https://doi.org/10.1038/s41598-022-08120-4
www.nature.com/scientificreports/
with captions. e pictures represented communities where few or many people are vaccinated. Captions
explained that in a low-vaccination community, many healthy but unvaccinated people are at risk of infection.
In a high-vaccination community, few are at risk.
Both the VR and text-and-image treatment ended with a brief summary, highlighting the takeaway message
(“As you can see, when many people are vaccinated the virus does not spread as fast and it creates a world that is
safer for everyone. You can see the dierence in [...] the low and high vaccination scenarios”). A more detailed
description of both treatments, including video, can be found in the study repository (https:// osf. io/ wufxk/?
view_ only= 56e83 d061c 6d469 637 8d29c 2940a 4a).
Randomization and masking. Simple randomization between treatment orderings (VR rst or text rst)
happened within the Qualtrics survey soware. Random assignment to a version of the VR simulation (avoid
spreading or avoid infection) was tied to participants’ ID numbers (even or uneven), which were allocated con-
secutively to both VR-rst and text-rst participants. Experimenters only assisted participants in starting up
the VR simulation. ey were blind to both the treatment ordering and the VR simulation version that each
participant was assigned to.
Outcome measures. Two key measurements were taken before and aer participants’ rst treatment, as
well as aer their second treatment: First, vaccination intention for a hypothetical new COVID-19 strain was
assessed (0–100 scale; adapted from10). is primary outcome measure was pretested in a pilot study available
in the supplemental material. Second, seeing COVID-19 vaccination as a collective responsibility was assessed
(1–7 scale)5. e supplemental material details the wording of these two items, and all other measures collected
in the study.
All preregistered hypotheses are about the eect of the participants’ rst treatment on the two outcome meas-
ures, either the VR treatment or the text-and-image treatment. e supplemental material section describes the
models used to test these hypotheses; they are simple regressions of rst dierences in the outcome measures
on medium of rst treatment (VR or text).
Results
Figure3 (le panel) illustrates the eect of each treatment on vaccination intention as the dierence between
measurements before and aer the rst treatment. e supplemental material presents the full distribution of
individual treatment eects, as well as analyses that do not exclude maximum-score participants.
Comparing vaccination intention between the pre-treatment and rst post-treatment measure, for partici-
pants who did not already have maximally positive vaccination intention (n = 195), we nd that the VR treat-
ment increased vaccination intention by 9.3 points (95% CI: 7.0 to
11.5, p
<
0.001
). e VR treatment is more
eective than the text-and-image treatment, which only increases vaccination intention by 3.3 points (dierence
in eects: 5.8, 95% CI: 2.0 to
9.5, p
=
0.003
).
Comparing collective responsibility pre- and post-treatment, for participants who did not already score the
maximum on collective responsibility (n = 104), we nd that the VR treatment increases collective responsi-
bility by 0.82 points (95% CI: 0.37 to
1.27, p
<
0.001
). e VR treatment is once again more eective than a
text-and-image treatment, which increases collective responsibility by just 0.43 points, though the dierence is
not signicant (dierence in eects: 0.39, 95% CI: 0.36 to
1.14, p
=
0.275
). e power to detect signicant treat-
ment dierences is lower here, due to the smaller number of “moveable” participants with less-than-maximum
perceptions of collective responsibility.
Figure2. e busy square scene in VR, with feedback graph showing the number of infected, healthy and
vaccinated characters.
Content courtesy of Springer Nature, terms of use apply. Rights reserved
5
Vol.:(0123456789)
Scientic Reports | (2022) 12:4593 | https://doi.org/10.1038/s41598-022-08120-4
www.nature.com/scientificreports/
Further, we conducted an exploratory analysis on whether the VR treatment further increases vaccination
intentions aer a text-and-image treatment. Indeed, as shown in the right panel of Fig.3, we nd that for par-
ticipants who experienced the text-and-image treatment rst and did not have maximum pre-treatment vac-
cination intention, the subsequent VR treatment further increased vaccination intention by 6.3 points (95% CI:
4.2 to
8.3, p
<
0.001
). In contrast, for those who received the text-and-image treatment aer the VR treatment,
there was no signicant further increase in vaccination intention (eect: 0.8, 95% CI:
0.6
to
2.3, p
=
0.309
).
We also explored any potential dierence between the eectiveness of the two versions of the VR treat-
ment: the one where participants avoided spreading COVID-19 and the one where they avoided infection with
COVID-19. ere is no dierence in the eect of these two versions on either vaccination intention (dierence
in eects: 0.2, 95% CI:
4.2
to
47, p
=
0.912
) or collective responsibility (dierence in eects:
0.003
, 95% CI:
0.46
to
0.45, p
=
0.989
).
Finally, we asked all participants who completed the full study (n = 208) whether learning about community
immunity via VR and text/pictures was fun, and whether they would like to receive more health communica-
tions via VR and text/pictures (1–5 scale). Compared to their ratings of text, participants rated VR as more fun
(dierence in means: 0.23, 95% CI: 0.11 to
0.35, p
<
0.001
). ere was no dierence on how much participants
wanted to receive future health communications via the two media (dierence in means:
0.06
, 95% CI:
0.18
to
0.05, p
=
0.301
).
Discussion
We provide seminal evidence that a rst-person experience of vaccinations’ collective benets in immersive VR
can increase vaccination intentions. Further, the VR treatment is nearly three times more eective than com-
municating the same content via text and images. As the intended eect of both treatments is quite clear, the
VR treatment’s greater eectiveness shows that its impact cannot be reduced to demand characteristics. is
is further supported by the nding that adding the VR treatment aer the text-and-image treatment further
increased vaccination intention, whereas adding the text-and-image treatment aer the VR treatment did not
provide any further benet.
Our results suggest that, due to the unique type of content it allows for, a VR intervention communicating
about the collective benet of vaccination can go beyond merely providing information. e results t into a
growing literature on the eectiveness of communicating about community immunity on vaccination intentions
(see9 for a review) and builds on the nding that such interventions appear more eective when they are more
engaging, such as via interactive simulations1012, and when they elicit emotions, such as empathy7. As we dem-
onstrate here, immersive VR is an eective alternative communication medium that can convey the collective
benet of vaccination in a highly engaging and emotional way.
ere are several potential mechanisms for why the VR treatment leads to changes in behavioral intentions
that deserve further investigation in future research. Our participants reported greater fun with the VR treatment
than with the text-and-image treatment. Previous research has shown that immersive VR increases participants’
interest in the content domain25 and enjoyment26, which can increase attention and eort18 to understand a
Figure3. Average eect on vaccination intention of rst treatment (n = 195, le panel) and second treatment
(n = 189, right panel), leaving out participants with maximum pre-treatment vaccination intention. Error bars
are 95% CIs.
Content courtesy of Springer Nature, terms of use apply. Rights reserved
6
Vol:.(1234567890)
Scientic Reports | (2022) 12:4593 | https://doi.org/10.1038/s41598-022-08120-4
www.nature.com/scientificreports/
topic. Immersive simulations also induce a sense of presence17 and agency, which are essential for experiencing
embodiment (the feeling of being in and controlling a virtual body)27. is can cause participants to associate
negative and positive emotions with low and high vaccination rates, respectively. All of these features make it
possible to create intense experiences of scenarios from another person’s perspective—increasing empathy with
vulnerable others by allowing users to share their emotional processes28. Such eects are likely to further increase
when elements of gamication are used23, as in the present study. Taken together, there are both cognitive and
emotional features of the VR treatment that are likely inuence behavioral intentions.
e current research has some limitations. Firstly, because is dicult to dierentiate between mechanisms,
it is currently unclear which aspects of the intervention may be modied by practitioners, and which ones must
be kept. In future work, we will further investigate the mechanisms behind the eect of this intervention type,
by developing more versions of the simulation, and measuring more intermediate variables (e.g., empathy).
Secondly, our outcome measures were vaccination intention and collective responsibility. We used established
measures for these constructs and both have been linked to self-reported vaccine uptake6,29. Nevertheless, future
research should investigate the eects on actual vaccination behaviour.
irdly, in contexts with limited funds and technological know-how, VR interventions are less feasible. Still,
headsets have fallen dramatically in price, and they have become easier and more versatile in use—a trend that
is expected to continue, making VR a more accessible option in the future.
Finally, since our sample was composed of passersby in a public park, people who had greater interest in VR
may have been more likely to participate. Further, despite the fact that the study was advertised as a “VR experi-
ment on COVID-19”, with no mention of vaccines or advocacy, it is possible that participants anticipated our
objectives. is means that individuals with strong (anti-)vaccine beliefs may have declined to take part. Indeed,
the strength of our invention lies in motivating the vaccine-hesitant to engage with vaccine-related content, rather
than in persuading strong vaccine deniers.
Despite these limitations of the sample, showing the eectiveness of VR in increasing vaccination intentions
“in the wild” indicates the generalizability of our ndings to non-research settings. Moreover, the fact that VR
attracts a specic audience may be benecial. In fact, most volunteers in our study were younger adults—an age
group that currently has lower COVID-19 vaccine uptake, including in countries where the vaccine is widely
available30,31.
Although we found a substantial change in vaccination intentions, future research could develop an even
more eective VR treatment. For example, subsequent versions may improve the experience’s narrative, or create
more empathy with a main character who is especially vulnerable to the target disease. And while the present
study focused on COVID-19 vaccination intentions, the VR treatment can also easily be adapted to, and tested
for, dierent infectious diseases.
Our research contributes to a potential paradigm shi in health communication generally, and vaccine advo-
cacy in particular. Finding novel methods to reduce vaccine hesitancy is critical4,32,33. Immersive, gamied VR
provides a exible tool to create more engaging and interactive learning experiences—alongside other media
and technology, such as gamied apps and augmented reality. For vaccine and community immunity informa-
tion in particular, it is crucial to reach and engage healthy members of the population (including young adults).
Immersive VR has strong potential to complement more traditional communication channels and, therefore,
contribute to decreasing the threat from infectious diseases.
Data availability
Anonymous individual participant data, plus analysis les a data dictionary with variable descriptions, are avail-
able to anyone from the study repository (https:// osf. io/ wufxk/? view_ only= 56e83 d061c 6d469 637 8d29c 2940a
4a). e repository also includes the study protocol, pre-analysis plan and informed consent form.
Received: 18 August 2021; Accepted: 23 February 2022
References
1. Fine, P., Eames, K. & Heymann, D. L. Herd immunity: A rough guide. Clin. Infect. Dis. 52, 911–916 (2011).
2. Haas, E. J. et al. Impact and eectiveness of mRNA BNT162b2 vaccine against SARSCoV-2 infections and COVID-19 cases, hospi-
talisations, and deaths following a nationwide vaccination campaign in Israel: An observational study using national surveillance
data. Lancet 397, 1819–1829 (2021).
3. Anderson, R. M., Vegvari, C., Truscott, J. & Collyer, B. S. Challenges in creating herd immunity to SARS-CoV-2 infection by mass
vaccination. Lancet 396, 1614–1616 (2020).
4. MacDonald, N. E. et al. Vaccine hesitancy: Denition, scope and determinants. Vaccine 33, 4161–4164 (2015).
5. Geiger, M. et al. Measuring the 7Cs of vaccination readiness. Eur. J. Psychol. Assess. (2021).
6. Betsch, C. et al. Beyond condence: Development of a measure assessing the 5C psychological antecedents of vaccination. PLoS
ONE 13, e0208601 (2018).
7. Pfattheicher, S., Petersen, M. B. & Böhm, R. Information about herd immunity through vaccination and empathy promote COVID-
19 vaccination intentions. Health Psychol. (2021). (Forthcoming).
8. Hendrix, K. S. et al. Vaccine message framing and parents’ intent to immunize their infants for MMR. Pediatrics 134, e675–e683
(2014).
9. Hakim, H. et al. Interventions to help people understand community immunity: A systematic review. Vaccine 37, 235–247 (2019).
10. Betsch, C., B öhm, R., Korn, L. & Holtmann, C. On the benets of explaining herd immunity in vaccine advocacy. Nat. Hum. Behav.
1, 1–6 (2017).
11. Betsch, C. & Böhm, R. Moral values do not aect prosocial vaccination. Nat. Hum. Behav. 2, 881–882 (2018).
12. Sprengholz, P. & Betsch, C. Herd immunity communication counters detrimental eects of selective vaccination mandates: Experi-
mental evidence. EClinicalMedicine 22, 100352 (2020).
13. Allcoat, D. & von Mühlenen, A. Learning in virtual reality: Eects on performance, emotion and engagement. Res. Learn. Technol.
26 (2018).
Content courtesy of Springer Nature, terms of use apply. Rights reserved
7
Vol.:(0123456789)
Scientic Reports | (2022) 12:4593 | https://doi.org/10.1038/s41598-022-08120-4
www.nature.com/scientificreports/
14. Annetta, L., Mangrum, J., Holmes, S., Collazo, K. & Cheng, M.-T. Bridging realty to virtual reality: Investigating gender eect
and student engagement on learning through video game play in an elementary school classroom. Int. J. Sci. Educ. 31, 1091–1113
(2009).
15. Böhm, R. & Betsch, C. Prosocial vaccination. Curr. Opin. Psychol. 43, 307–311 (2022).
16. Freeman, D. et al. Automated psychological therapy using immersive virtual reality for treatment of fear of heights: A single-blind,
parallel-group, randomised controlled trial. Lancet Psychiatry 5, 625–632 (2018).
17. Sanchez-Vives, M. V. & Slater, M. From presence to consciousness through virtual reality. Nat. Rev. Neurosci. 6, 332–339 (2005).
18. Makransky, G. & Petersen, G. B. e cognitive aective model of immersive learning (CAMIL): A theoretical research-based model
of learning in immersive virtual reality. Educ. Psychol. Rev. 33, 1–22 (2021).
19. Makransky, G., Andreasen, N. K., Baceviciute, S. & Mayer, R. E. Immersive virtual reality increases liking but not learning with a
science simulation and generative learning strategies promote learning in immersive virtual reality. J. Educ. Psychol. (2020).
20. Wu, B., Yu, X. & Gu, X. Eectiveness of immersive virtual reality using head-mounted displays on learning performance: A meta-
analysis. Brit. J. Educ. Technol. 51, 1991–2005 (2020).
21. Nowak, G. J. et al. Using immersive virtual reality to improve the beliefs and intentions of inuenza vaccine avoidant 18-to-49-year-
olds: Considerations, eects, and lessons learned. Vaccine 38, 1225–1233 (2020).
22. Mottelson, A. et al. A self-administered virtual reality intervention increases COVID-19 vaccination intention. Vaccine 39, 6746–
6753 (2021).
23. Bai, S., Hew, K. F. & Huang, B. Does gamication improve student learning outcome? Evidence from a meta-analysis and synthesis
of qualitative data in educational contexts. Educ. Res. Rev. 30, 100322 (2020).
24. US Centers for Disease Control and Prevention. Vaccines & Immunizations-Glossary. Accessed 30 May 2020; https:// www. cdc.
gov/ vacci nes/ terms/ gloss ary. html.
25. Petersen, G. B., Klingenberg, S., Mayer, R. E. & Makransky, G. e virtual eld trip: Investigating how to optimize immersive
virtual learning in climate change education. Brit. J. Educ. Technol. 51, 2099–2115 (2020).
26. Parong, J. & Mayer, R. E. Learning science in immersive virtual reality. J. Educ. Psychol. 110, 785 (2018).
27. Petersen, G. B., Petkakis, G. & Makransky, G. A study of how immersion and interactivity drive VR learning. Comput. Educ. 179,
104429 (2022).
28. Martingano, A. J., Hererra, F. & Konrath, S. Virtual reality improves emotional but not cognitive empathy: A meta-analysis. Tec hno l.
Mind Behav. 2, 15 (2021).
29. Nicholls, L. A. B. et al. Older adults’ vaccine hesitancy: Psychosocial factors associated with inuenza, pneumococcal, and shingles
vaccine uptake. Vaccine 39, 3520–3527 (2021).
30. European Centre for Disease Prevention and Control. COVID-19 Vaccine Tracker. Accessed 13 January 2022; https:// vacci netra
cker. ecdc. europa. eu/ public/ exten sions/ COVID- 19/ vacci ne- track er. html% 5C# age- group- tab.
31. Kaiser Family Foundation. Does e Public Want To Get A COVID-19 Vaccine? When? Accessed 13 January 2022; https:// www.
k. org/ coron avirus- covid- 19/ dashb oard/ k- covid- 19- vacci ne- monit or- dashb oard/.
32. Betsch, C., B öhm, R. & Chapman, G. B. Using behavioral insights to increase vaccination policy eectiveness. Policy Insights Behav.
Brain Sci. 2, 61–73 (2015).
33. Dubé, E. et al. Vaccine hesitancy: An overview. Hum. Vaccines Immunother. 9, 1763–1773 (2013).
Acknowledgements
is research was funded by the European Institute of Innovation and Technology (EIT Health, Grant No.
210836). Registered at Open Science Foundation, https:// doi. org/ 10. 17605/ OSF. IO/ WUFXK.
Author contributions
All authors were involved in conceiving the study idea and design. C.V. led the study design and implementation,
processed and analyzed data, and draed the paper. T.L. created the Virtual Reality application and processed
data. M.A., A.M., G.M. and R.B. were involved in study implementation. C.V., T.L., M.A., A.M., C.H., G.M. and
R.B. revised the paper.
Funding
e funder of the study (EIT Health) had no role in study design, data collection, data analysis, data interpreta-
tion, or writing of the report.
Competing interests
e authors declare no competing interests.
Additional information
Correspondence and requests for materials should be addressed to C.V.
Reprints and permissions information is available at www.nature.com/reprints.
Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and
institutional aliations.
Open Access is article is licensed under a Creative Commons Attribution 4.0 International
License, which permits use, sharing, adaptation, distribution and reproduction in any medium or
format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the
Creative Commons licence, and indicate if changes were made. e images or other third party material in this
article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the
material. If material is not included in the article’s Creative Commons licence and your intended use is not
permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from
the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/.
© e Author(s) 2022
Content courtesy of Springer Nature, terms of use apply. Rights reserved
1.
2.
3.
4.
5.
6.
Terms and Conditions
Springer Nature journal content, brought to you courtesy of Springer Nature Customer Service Center GmbH (“Springer Nature”).
Springer Nature supports a reasonable amount of sharing of research papers by authors, subscribers and authorised users (“Users”), for small-
scale personal, non-commercial use provided that all copyright, trade and service marks and other proprietary notices are maintained. By
accessing, sharing, receiving or otherwise using the Springer Nature journal content you agree to these terms of use (“Terms”). For these
purposes, Springer Nature considers academic use (by researchers and students) to be non-commercial.
These Terms are supplementary and will apply in addition to any applicable website terms and conditions, a relevant site licence or a personal
subscription. These Terms will prevail over any conflict or ambiguity with regards to the relevant terms, a site licence or a personal subscription
(to the extent of the conflict or ambiguity only). For Creative Commons-licensed articles, the terms of the Creative Commons license used will
apply.
We collect and use personal data to provide access to the Springer Nature journal content. We may also use these personal data internally within
ResearchGate and Springer Nature and as agreed share it, in an anonymised way, for purposes of tracking, analysis and reporting. We will not
otherwise disclose your personal data outside the ResearchGate or the Springer Nature group of companies unless we have your permission as
detailed in the Privacy Policy.
While Users may use the Springer Nature journal content for small scale, personal non-commercial use, it is important to note that Users may
not:
use such content for the purpose of providing other users with access on a regular or large scale basis or as a means to circumvent access
control;
use such content where to do so would be considered a criminal or statutory offence in any jurisdiction, or gives rise to civil liability, or is
otherwise unlawful;
falsely or misleadingly imply or suggest endorsement, approval , sponsorship, or association unless explicitly agreed to by Springer Nature in
writing;
use bots or other automated methods to access the content or redirect messages
override any security feature or exclusionary protocol; or
share the content in order to create substitute for Springer Nature products or services or a systematic database of Springer Nature journal
content.
In line with the restriction against commercial use, Springer Nature does not permit the creation of a product or service that creates revenue,
royalties, rent or income from our content or its inclusion as part of a paid for service or for other commercial gain. Springer Nature journal
content cannot be used for inter-library loans and librarians may not upload Springer Nature journal content on a large scale into their, or any
other, institutional repository.
These terms of use are reviewed regularly and may be amended at any time. Springer Nature is not obligated to publish any information or
content on this website and may remove it or features or functionality at our sole discretion, at any time with or without notice. Springer Nature
may revoke this licence to you at any time and remove access to any copies of the Springer Nature journal content which have been saved.
To the fullest extent permitted by law, Springer Nature makes no warranties, representations or guarantees to Users, either express or implied
with respect to the Springer nature journal content and all parties disclaim and waive any implied warranties or warranties imposed by law,
including merchantability or fitness for any particular purpose.
Please note that these rights do not automatically extend to content, data or other material published by Springer Nature that may be licensed
from third parties.
If you would like to use or distribute our Springer Nature journal content to a wider audience or on a regular basis or in any other manner not
expressly permitted by these Terms, please contact Springer Nature at
onlineservice@springernature.com
... There is emerging evidence that immersive Virtual Reality (VR) may be a promising tool in vaccination communication as it enables an interactive and embodied experience of the vaccination's collective benefit and, therefore, increases users' vaccination intention (Mottelson et al., 2021;Nowak et al., 2020;Vandeweerdt et al., 2022). However, previous research is silent about the psychological mechanisms underlying increased vaccination intentions after interactive VR experience. ...
... Vaccination intention. Consistent with previous research (Vandeweerdt et al., 2022), the main outcome variable in the study was vaccination intention, measured as participants' intention to take up a hypothetical new COVID-19 vaccine. We chose a hypothetical new vaccine because we expected that many participants would have been already vaccinated at the time of the study; the measure thus mirrors the uptake intention of (future) COVID-19 booster vaccines. ...
... First, both gamified VR interventions increased users' vaccination intentions. This finding supports previous findings on the positive effects of communicating the social benefit of vaccination in general (Betsch et al., 2013; for review, see Hakim et al., 2019) and using VR in particular (Mottelson et al., 2021;Vandeweerdt et al., 2022). The results thus strengthen the idea that using engaging communication methods such as VR is particularly appropriate to communicate even complex epidemiological phenomena (Böhm & Betsch, 2022). ...
Preprint
Full-text available
This study investigates the impact of an immersive virtual reality (VR) simulation of herd immunity on vaccination intentions and its potential underlying mechanisms. In this preregistered field study, N = 654 participants were randomly assigned to one of the three VR conditions: (1) Gamified Herd Immunity; (2) Gamified Herd Immunity + Empathy (with additional narrative elements); (3) Control (gamified with no vaccination-related content). In the Gamified Herd Immunity simulation, participants embodied a vulnerable person and navigated the wedding venue trying to avoid getting infected. A total of n = 455 participants with below maximum intentions to take a novel vaccine and without severe cybersickness symptoms were included in the analyses. The Gamified Herd Immunity + Empathy and the Gamified Herd Immunity conditions increased vaccination intentions by 6.68 and 7.06 points on a 0-100 scale, respectively, compared to 1.91 for the Control condition. The Gamified Herd Immunity + Empathy condition enhanced empathy significantly more than the Gamified Herd Immunity condition but did not result in higher vaccination intentions. The results suggest that immersive VR vaccination communication can effectively increase COVID-19 vaccine intentions; the effect is not solely a consequence of the technological experience itself and does not depend on empathy.
Article
Full-text available
Lay Description What is already known about this topic Recent meta‐analyses have found a small effect size benefit to using immersive virtual reality (IVR) learning interventions compared to than less‐immersive learning approaches. Recent reviews call for more IVR‐based research that is integrated within actual learning and training interventions. Furthermore, as with most other fields, it is common to use Western, Educated, Industrialized, Rich, and Democratic (WEIRD) samples for IVR educational and training research purposes. What this paper adds Evidence that an IVR training intervention can be successfully used in an international maritime training programme with employees from an understudied non‐Western population on UN's list of the 50 least developed countries. The finding that IVR‐based safety training on the topic of dynamic risk assessment during a mooring operation resulted in significantly higher levels of enjoyment, motivation, perceived learning and behavioural change intentions and significantly lower extraneous cognitive load compared to personal trainer instruction. The finding that IVR safety simulation with embedded reflection performed just as well as when an extra post‐simulation exercise was added to the training intervention. Implications for practice and/or policy Organizations can benefit from using IVR‐based safety training methods to increase engagement in dynamic risk assessment. IVR technology can be used broadly with employees from developing countries who have a low level of technology literacy. IVR simulations are effective when they are designed based on state of the art instructional design research and are integrated appropriately into a more general training framework.
Article
Full-text available
Effective interventions for increasing people’s intention to get vaccinated are crucial for global health, especially considering COVID-19. We devised a novel intervention using virtual reality (VR) consisting of a consultation with a general practitioner for communicating the benefits of COVID-19 vaccination and, in turn, increasing the intention to get vaccinated against COVID-19. We conducted a preregistered online experiment with a 2×2 between-participant design. People with eligible VR headsets were invited to install our experimental application and complete the ten minute virtual consultation study at their own discretion. Participants were randomly assigned across two age conditions (young or old self-body) and two communication conditions (with provision of personal benefit of vaccination only, or collective and personal benefit). The primary outcome was vaccination intention (score range 1–100) measured three times: immediately before and after the study, as well as one week later. Five-hundred-and-seven adults not vaccinated against COVID-19 were recruited. Among the 282 participants with imperfect vaccination intentions (<100), the VR intervention increased pre-to-post vaccination intentions across intervention conditions (mean difference 8.6, 95% CI 6.1 to 11.1,p<0.0001). The pre-to-post difference significantly correlated with the vaccination intention one week later, ρ=0.20,p<0.0001. The VR intervention was effective in increasing COVID-19 vaccination intentions both when only personal benefits and personal and collective benefits of vaccination were communicated, with significant retention one week after the intervention. Utilizing recent evidence from health psychology and embodiment research to develop immersive environments with customized and salient communication efforts could therefore be an effective tool to complement public health campaigns.
Article
Full-text available
Objective: An effective vaccine against COVID-19 is a desired solution to curb the spread of the disease. However, vaccine hesitancy might hinder high uptake rates and thus undermine efforts to eliminate COVID-19 once an effective vaccine became available. The present contribution addresses this issue by examining two ways of increasing the intention to get vaccinated against COVID-19. Method: Two preregistered online studies were conducted (N = 2,315 participants from the United Kingdom) in which knowledge about and beliefs in herd immunity through vaccination, as well as empathy for those most vulnerable to the virus, were either measured (Study 1) or manipulated (Study 2). As a dependent variable, individuals' self-reported vaccination intention once a vaccine against COVID-19 became available was assessed. Results: In Study 1 (N = 310), the intention to get vaccinated against COVID-19 was correlated with knowledge about and belief in herd immunity through vaccination (r = .58, p < .001), as well as with empathy for those most vulnerable to the virus (r = .26, p < .001). In Study 2 (N = 2,005), information about herd immunity through vaccination (Cohen's d = .13, p = .003) and empathy (Cohen's d = .22, p < .001) independently promoted vaccination intention. Conclusions: The motivation to get vaccinated against COVID-19 was related to and could be causally promoted by both mere information about herd immunity through vaccination and by empathy. As such, the present research provides a better understanding of the intention to get vaccinated against COVID-19. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
Article
Full-text available
Most vaccines not only directly protect vaccinated individuals but also provide a social benefit through community protection. Therefore, vaccination can be considered a prosocial act to protect others. We review the recent empirical evidence on (i) how prosocial concerns relate to vaccination intentions and (ii) promoting prosocial vaccination through explaining community protection or inducing concern for vulnerable others. The available evidence suggests that promoting the prosocial aspect of vaccinations could be a vaccination communication strategy to improve vaccine uptake. We point to several areas in which future research can test the boundary conditions of this approach and increase its effectiveness.
Article
Full-text available
Virtual Reality (VR) has been touted as an effective empathy intervention, with its most ardent supporters claiming it is "the ultimate empathy machine." We aimed to determine whether VR deserves this reputation, using a random-effects meta-analysis of all known studies that examined the effect of virtual reality experiences on users' empathy (k = 43 studies, with 5,644 participants). The results indicated that many different kinds of VR experiences can increase empathy, however, there are important boundary conditions to this effect. Subgroup analyses revealed that VR improved emotional empathy, but not cognitive empathy. In other words, VR can arouse compassionate feelings but does not appear to encourage users to imagine other peoples' perspectives. Further subgroup analyses revealed that VR was no more effective at increasing empathy than less technologically advanced empathy interventions such as reading about others and imagining their experiences. Finally, more immersive and interactive VR experiences were no more effective at arousing empathy than less expensive VR experiences such as cardboard headsets. Our results converge with existing research suggesting that different mechanisms underlie cognitive versus emotional empathy. It appears that emotional empathy can be aroused automatically when witnessing evocative stimuli in VR, but cognitive empathy may require more effortful engagement, such as using one's own imagination to construct others' experiences. Our results have important practical implications for nonprofits, policymakers, and practitioners who are considering using VR for prosocial purposes. In addition, we recommend that VR designers develop experiences that challenge people to engage in empathic effort.
Article
Full-text available
Influenza, pneumococcal disease, and shingles (herpes zoster) are more prevalent in older people. These illnesses are preventable via vaccination, but uptake is low and decreasing. Little research has focused on understanding the psychosocial reasons behind older adults’ hesitancy towards different vaccines. A cross-sectional survey with 372 UK-based adults aged 65-92 years (M = 70.5) assessed awareness and uptake of the influenza, pneumococcal, and shingles vaccines. Participants provided health and socio-demographic data and completed two scales measuring the psychosocial factors associated with vaccination behaviour. Self-reported daily functioning, cognitive difficulties, and social support were also assessed. Participants were additionally given the opportunity to provide free text responses outlining up to three main reasons for their vaccination decisions. We found that considerably more participants had received the influenza vaccine in the last 12 months (83.6%), relative to having ever received the pneumococcal (60.2%) and shingles vaccines (58.9%). Participants were more aware of their eligibility for the influenza vaccine, and were more likely to have been offered it. Multivariate logistic regression analyses showed that a lower sense of collective responsibility independently predicted lack of uptake of all three vaccines. Greater calculation of disease and vaccination risk, and preference for natural immunity, also predicted not getting the influenza vaccine. For both the pneumococcal and shingles vaccines, concerns about profiteering further predicted lack of uptake. Analysis of the qualitative responses highlighted that participants vaccinated to protect their own health and that of others. Our findings suggest that interventions targeted towards older adults would benefit from being vaccine-specific and that they should emphasise disease risks and vaccine benefits for the individual, as well as the benefits of vaccination for the wider community. These findings can help inform intervention development aimed at increasing vaccination uptake in future.
Article
Full-text available
Although vaccines are among the most effective interventions used in fighting diseases, vaccination readiness varies substantially among individuals. Vaccination readiness is defined as a set of components that increase or decrease the individual’s likelihood of getting vaccinated. Building on earlier work that distinguished five components of vaccination readiness (i.e., confidence, complacency, constraints, calculation, and collective responsibility), we revised the questionnaire used to measure these components to improve its psychometric properties, specifically criterion validity. In doing so, we also developed two new components of vaccination readiness: compliance and conspiracy. Compliance is the tendency to support monitoring to control adherence to regulations; conspiracy is the tendency to endorse conspiratorial beliefs about vaccination. The 7C scale was initially piloted in a cascade of serial cross-sectional studies and then validated with N = 681 participants from the COVID-19 Snapshot Monitoring in Denmark. We report a bifactor measurement model, convergent validity with other questionnaires, and explanation of 85% variance in the willingness to vaccinate against COVID-19. We also presented a 7-item short version of the scale. The instrument is publicly available in several languages (www.vaccination-readiness.com), and we seek collaboration to provide translations of our instrument into other languages.
Article
Full-text available
There has been a surge in interest and implementation of Immersive Virtual Reality (IVR) based lessons in education and training recently, which has resulted in many studies on the topic. There are recent reviews which summarize this research, but little work has been done that synthesizes the existing findings into a theoretical framework. The Cognitive Affective Model of Immersive Learning (CAMIL) synthesizes existing immersive educational research to describe the process of learning in IVR. The general theoretical framework of the model suggests that instructional methods which are based on evidence from research with less immersive media generalize to learning in IVR. However, the CAMIL builds on evidence that media interacts with method. That is, certain methods which facilitate the affordances of IVR are specifically relevant in this medium. The CAMIL identifies presence and agency as the general psychological affordances of learning in IVR, and describes how immersion, control factors, and representational fidelity facilitate these affordances. The model describes six affective and cognitive factors that can lead to IVR based learning outcomes including interest, motivation, self-efficacy, embodiment, cognitive load, and self-regulation. The model also describes how these factors lead to factual, conceptual, and procedural knowledge acquisition and knowledge transfer. Implications for future research and instructional design are proposed.
Article
Full-text available
Mass vaccination to create herd immunity to Covid-19 (SARS-CoV-2)
Article
Even though learning refers to both a process and a product, the former tends to be overlooked in educational virtual reality (VR) research. This study examines the process of learning with VR technology using the Cognitive Affective Model of Immersive Learning (CAMIL) as its framework. The CAMIL theorizes that two technological features of VR, interactivity and immersion, influence a number of cognitive and affective variables that may facilitate or hinder learning. In addition, VR studies often involve media comparisons that make it difficult to disentangle the relative effects of technological features on learning. Therefore, this study also aims to provide insights concerning the unique and combined effects of interactivity and immersion on the cognitive and affective variables specified by CAMIL. We employed a 2 × 2 between-subjects design (N = 153) and manipulated the degree of interactivity and immersion during a virtual lesson on the topic of viral diseases. Analyses of variance (ANOVAs) were used to examine the effects of interactivity and immersion on our variables of interest, and structural equation modeling (SEM) was used to assess the process of learning as predicted by the CAMIL. The results indicated that the process of learning involves situational interest and embodied learning. Main effects of interactivity and/or immersion on cognitive load, situational interest, and physical presence are also reported in addition to interaction effects between immersion and interactivity on agency and embodied learning. The findings provide evidence for the CAMIL and suggest important additions to the model. These findings can be used to provide a better understanding of the process of learning in immersive VR and guide future immersive learning research.
Article
Background: Following the emergency use authorisation of the Pfizer-BioNTech mRNA COVID-19 vaccine BNT162b2 (international non-proprietary name tozinameran) in Israel, the Ministry of Health (MoH) launched a campaign to immunise the 6·5 million residents of Israel aged 16 years and older. We estimated the real-world effectiveness of two doses of BNT162b2 against a range of SARS-CoV-2 outcomes and to evaluate the nationwide public-health impact following the widespread introduction of the vaccine. Methods: We used national surveillance data from the first 4 months of the nationwide vaccination campaign to ascertain incident cases of laboratory-confirmed SARS-CoV-2 infections and outcomes, as well as vaccine uptake in residents of Israel aged 16 years and older. Vaccine effectiveness against SARS-CoV-2 outcomes (asymptomatic infection, symptomatic infection, and COVID-19-related hospitalisation, severe or critical hospitalisation, and death) was calculated on the basis of incidence rates in fully vaccinated individuals (defined as those for whom 7 days had passed since receiving the second dose of vaccine) compared with rates in unvaccinated individuals (who had not received any doses of the vaccine), with use of a negative binomial regression model adjusted for age group (16-24, 25-34, 35-44, 45-54, 55-64, 65-74, 75-84, and ≥85 years), sex, and calendar week. The proportion of spike gene target failures on PCR test among a nationwide convenience-sample of SARS-CoV-2-positive specimens was used to estimate the prevelance of the B.1.1.7 variant. Findings: During the analysis period (Jan 24 to April 3, 2021), there were 232 268 SARS-CoV-2 infections, 7694 COVID-19 hospitalisations, 4481 severe or critical COVID-19 hospitalisations, and 1113 COVID-19 deaths in people aged 16 years or older. By April 3, 2021, 4 714 932 (72·1%) of 6 538 911 people aged 16 years and older were fully vaccinated with two doses of BNT162b2. Adjusted estimates of vaccine effectiveness at 7 days or longer after the second dose were 95·3% (95% CI 94·9-95·7; incidence rate 91·5 per 100 000 person-days in unvaccinated vs 3·1 per 100 000 person-days in fully vaccinated individuals) against SARS-CoV-2 infection, 91·5% (90·7-92·2; 40·9 vs 1·8 per 100 000 person-days) against asymptomatic SARS-CoV-2 infection, 97·0% (96·7-97·2; 32·5 vs 0·8 per 100 000 person-days) against symptomatic COVID-19, 97·2% (96·8-97·5; 4·6 vs 0·3 per 100 000 person-days) against COVID-19-related hospitalisation, 97·5% (97·1-97·8; 2·7 vs 0·2 per 100 000 person-days) against severe or critical COVID-19-related hospitalisation, and 96·7% (96·0-97·3; 0·6 vs 0·1 per 100 000 person-days) against COVID-19-related death. In all age groups, as vaccine coverage increased, the incidence of SARS-CoV-2 outcomes declined. 8006 of 8472 samples tested showed a spike gene target failure, giving an estimated prevalence of the B.1.1.7 variant of 94·5% among SARS-CoV-2 infections. Interpretation: Two doses of BNT162b2 are highly effective across all age groups (≥16 years, including older adults aged ≥85 years) in preventing symptomatic and asymptomatic SARS-CoV-2 infections and COVID-19-related hospitalisations, severe disease, and death, including those caused by the B.1.1.7 SARS-CoV-2 variant. There were marked and sustained declines in SARS-CoV-2 incidence corresponding to increasing vaccine coverage. These findings suggest that COVID-19 vaccination can help to control the pandemic. Funding: None.