Vaccines remain a cornerstone of modern medicine, providing safe and effective protection against a wide range of infectious diseases and significantly reducing global morbidity and mortality. In fact, it is estimated that vaccines have prevented more than 154 million deaths worldwide over the past 50 years, highlighting their profound impact on public health and their essential role in controlling the spread of life-threatening diseases (Shattock et al., 2024). In the United States, routine vaccination has led to reductions in the incidence of preventable illnesses ranging from 17% for influenza to 100% for polio, totaling approximately 24 million cases in all (Talbird et al., 2022). Despite this success, significant disparities persist in vaccine coverage within the United States, with certain populations demonstrating lower vaccination uptake and higher susceptibility to preventable diseases.

American Indian and Alaska Native populations experience lower vaccination coverage rates compared to the general United States population (Zhao et al., 2025). Native adults have been found to be 30% less likely to receive an annual influenza vaccine or to have ever received a pneumococcal vaccine compared to non-Hispanic White adults (Centers for Disease Control and Prevention [CDC], 2024; U.S. Department of Health and Human Services, Office of Minority Health [OMH], 2025). Coronavirus (COVID-19) vaccination coverage among American Indian and Alaska Native adults has consistently been lower than other groups in the United States, as only 38.7% of Native adults received at least one COVID-19 vaccine by April 2021 compared to 59% of non-Hispanic White adults (Kriss et al., 2022). The disparities in COVID-19 vaccination uptake have persisted with coverage rates reaching 61.8% for Native adults compared to 78.7% for non-Hispanic White adults. Vaccine disparities are also evident among Native children, who were found to be 20% less likely to be fully immunized at 24 months of age (OMH, 2025).

Not only do disparities exist in vaccination coverage, but American Indian and Alaska Native populations also experience disproportionately high rates of morbidity and mortality from vaccine-preventable diseases. Native adults are more likely to be hospitalized for influenza, pneumococcal disease, COVID-19, and other preventable illnesses due to lower vaccination coverage and higher prevalence of chronic health conditions. Specifically, Native adults are 3.3 times more likely to be hospitalized and 2.2 times more likely to die from COVID-19 compared to non-Hispanic Whites, even after vaccines became widely available (Musshafen et al., 2022). For influenza, Native adults are 1.3 times more likely to be hospitalized than the general U.S. population, while Native children are three times more likely to be hospitalized for the disease (Gidengil et al., 2025; O’Halloran et al., 2021). In addition to higher hospitalization rates, Native children experience elevated rates of intensive care unit admissions and in-hospital deaths from influenza, highlighting the severity of vaccine-preventable disease outcomes in tribal communities.

Vaccine disparities among American Indian and Alaska Native populations are driven by factors at individual, community, and systemic levels, including socioeconomic barriers, geographic isolation, mistrust of healthcare systems, and limited access to culturally sensitive care (Zhao et al., 2025). Socioeconomic challenges contributing to lower vaccination rates include high rates of poverty, underinsurance or lack of insurance, housing insecurity, and crowded living conditions, which can also increase exposure to infectious diseases. geographic isolation and limited transportation further impede access for Native people living on reservations or in remote communities (Truong et al., 2025). At the systemic level, the Indian Health Service is chronically underfunded, and rural clinics often experience shortages in health professionals and resources to provide comprehensive care, resulting in persistent inequities in healthcare access across many Native communities.

Vaccine hesitancy may further contribute to lower vaccination coverage among Native populations. Research indicates that Native communities exhibit higher levels of vaccine hesitancy and lower vaccine confidence compared to other demographic groups in the United States, influenced by factors such as medical mistrust, systemic racism, ongoing discrimination, and limited access to culturally sensitive care (Gerretsen et al., 2021). There is an extensive history of mistrust in the government and medical systems among Native communities due to forced removal from lands, broken treaty obligations, and unethical research practices, which continues to shape perceptions of healthcare within Native communities (Zhao et al., 2025). These challenges are compounded by the persistent underrepresentation of Native populations in research and the lack of population-specific data. Many Native individuals report feeling marginalized in healthcare settings due to the limited availability of culturally responsive providers. Furthermore, the absence of culturally tailored education and messaging has been identified as a key contributor to vaccine hesitancy among Native populations (Sears et al., 2022).

Misinformation surrounding vaccines can impact how individuals receive health information and may contribute to vaccine hesitancy, particularly among the Native people who have higher levels of mistrust due to historical injustices and trauma (Gonzalez & Stewart, 2024). In fact, Truong et al. (2025) identified that many vaccine-related misconceptions among American Indians and Alaska Natives stem from the rapid spread of misinformation on social media. Such misinformation amplifies concerns about vaccine ingredients, adverse effects, safety, and efficacy, thereby increasing reluctance to receive vaccinations (Zhao et al., 2025). Consequently, misinformation remains a significant determinant of vaccine hesitancy in Native communities.

PURPOSE AND METHODS

Higher rates of vaccine hesitancy among American Indian and Alaska Native populations, coupled with persistent health disparities and comparatively lower vaccination rates, underscore the need for targeted programs designed to improve vaccine education within these communities. Addressing vaccine hesitancy is critical for increasing vaccination uptake. Effective vaccination campaigns have been identified as those that emphasize the importance of vaccination to protect culture, family, elders, and the community (African American Research Collaborative [AARC], 2021). Health professionals have also been identified as trusted and effective messengers for vaccine information among Native people.

The purpose of this project was to develop a culturally sensitive vaccination campaign aimed at strengthening vaccine confidence among Native communities. Applied neuromarketing content testing was utilized to identify effective communication strategies, which can guide future vaccine education and empower public and tribal health professionals to utilize evidence-based messages to enhance vaccine uptake. Applied neuromarketing content testing is a scientific approach to recording cognitive and emotional responses to content to gain insight into how to design education to be as effective as possible (Austin et al., 2024).

This project was derived from a larger grant-funded initiative that provided resources for the development of culturally informed vaccine messages. A nurse and nurse practitioner with long-standing relationships at a Midwestern tribal college collaborated with an advertising agency to create videos, flyers, and billboards promoting vaccination. The primary goal of these materials was to enhance vaccine confidence and increase vaccine uptake within the tribal college community and the surrounding Native populations. The development of these messages was informed by evidence underscoring the importance of representing multiple Native cultures, utilizing trusted healthcare professionals and community members as messengers, and incorporating messages that focus on protecting culture, family, and elders (AARC, 2021; Zhao et al., 2025).

Trusted messengers of vaccine information were recruited to provide video testimonials describing their reasons for receiving vaccinations. These messengers included community elders, students, faculty members, university coaches, and the university president. Testimonials were recorded by an advertising agency at various locations on campus and within the surrounding community, including the tribal college and a local powwow. Photographs of trusted messengers were also taken for use in flyers and billboards promoting vaccination. The advertising agency edited the testimo­nials into short videos ranging from 30 seconds to one minute, which were intended for dissemination via social media following neuromarketing content testing. In addition, a gameshow-style video was produced featuring questions and answers about the importance of vaccination, with the aim of engaging a young adult audience. Trusted messengers received a $100 honorarium for their time and willingness to share their vaccination experiences. The vaccine campaign adopted the slogan “Keep Our Circle Safe, Get Vaccinated,” reflecting the central cultural significance of the circle in Native communities and the interconnectedness and protection of the community. This slogan was incorporated into posters, flyers, and billboards. All videos utilized visual elements related to this slogan, and trusted messengers concluded each testimonial by stating the slogan.

Prior to any data collection, institutional review board approval was obtained through the tribal college. Students were recruited via email to participate in applied neuromarketing content testing on vaccine campaign materials, including nine videos and four posters. Before participating in the neuromarketing content testing, students reviewed a consent page that communicated risks and benefits, as well as the fact that their participation is voluntary and they may withdraw their participation at any time without negative consequences. Testing was conducted using the Murrow Media Mind Neuromarketing Lab, and the videos and flyers were presented in random order for every participant. Each participant spent approxi­mately one hour completing the neuromarketing content testing and received a $75 electronic gift card as compensation for their time.

Neuromarketing testing uses specialized physiological measures to monitor attention and emotion during exposure to content (Austin et al., 2024). Neuromarketing measures collected during testing included heart rate, skin conductance, facial electromyography (EMG) of the corrugator muscle, and eye tracking. Heart rate serves as an indicator of attention, with deceleration over time reflecting increased attentional engagement. Skin conductance measures sympathetic nervous system arousal, with higher skin conductance levels indicating more intense emotional responses. Facial EMG of the corrugator muscle provides an index of negative emotional responses, where increased activity in this region corresponds to stronger negative reactions. Eye tracking assesses visual perceptual attention, with gaze plots illustrating the distri­bution and concentration of visual focus across presented content.

Participants also answered questions after each video to provide information on emotions, attitudes, and behaviors towards the tested content. These ratings were obtained on seven-point scales immediately after exposure to each video. Experiment participants rated how aroused or intense their emotions were and how posi­tive or negative they felt after viewing each video. Also measured were how participants felt about the videos’ appeal, clarity, trust­worthiness, and desirability. Behavioral expectation was measured through the likelihood that participants would like and/or share each video if seen on social media, as well as the likelihood that the participants would seek out more information and/or consider getting vaccinated.

RESULTS

Thirty-nine undergraduate students from a Midwestern tribal college participated in the applied neuromarketing testing. Data from three participants were excluded due to invalid measurement sessions, resulting in a final analytic sample of 36 valid participants. Participants ranged in age from 18 to 61 years, with approximately 58% falling within the 18–30-year age range. All participants (n=36) were American Indian/Alaska Native. The sample included a larger proportion of women, with 26 women (72%) and 10 men (28%) completing the testing.

There was significant change in skin conductance arousal when study participants viewed the video that incorporated multiple trusted messengers and culturally relevant scenes.

Among the nine videos tested, one which incorporated multiple trusted messengers and culturally relevant scenes was most effective at capturing and sustaining attention, eliciting strong emotional and cognitive engagement, and promoting positive behavioral intention towards vaccination. Neuromarketing measures indicated sustained cardiac deceleration (reflecting cognitive engagement) and strong sympathetic arousal (reflecting emotional engagement) throughout the video, particularly during the initial powwow scene and logo animation. The video avoided eliciting negative defensive responses.

Additional videos that were found to be effective included videos integrating culturally relevant content, including personal narratives and powwow scenes. These videos demonstrated strong performance with capturing and sustaining attention, as well as with emotional and cognitive engagement among partici­pants. The gameshow-style video was found to be effective at capturing attention; however, attention was not sustained throughout the entirety of the video, suggesting it could be short­ened for enhanced engagement.

Among those who viewed the video incorporating multiple trusted messengers, self-report data demonstrated high ratings for clarity, appeal, trustworthiness, and likelihood to seek information or consider vaccination. Social media engagement intentions (liking/sharing) were also high. The gameshow-style video was also found to be effective at eliciting favorable attitudes and behaviors. Qualitative interviews reinforced the conclusion that cultural cues and personal narratives increased message relevance and recall, with the “Keep Our Circle Safe” branding being partic­ularly memorable across all videos.

United Tribes Technical College utilized results from neuromarketing content testing to inform its vaccine awareness campaign.

The posters were found to be moderately effective at capturing attention. Visual perpetual attention was predominately focused on the spokesperson in the posters, rather than on central elements, such as the “Keep Our Circle Safe, Get Vaccinated” branding. Neuromarketing results related to visual perceptual attention suggest that the branding and vaccine information should be more visually dominant in all the posters.

Self-report data for the posters indicated that, while participants experienced positive emotions toward the materials, they reported relatively low levels of arousal. Overall, the posters were moder­ately effective at eliciting favorable attitudinal responses; however, all poster designs were less effective than the videos in promoting behavioral engagement related to vaccination, including the likeli­hood to seek more information or consider vaccination. This reduced effectiveness was likely influenced by visual design issues, including dark color schemes and insufficient emphasis on key message elements. Qualitative feedback further suggested that although the posters increased awareness, they required a redesign to enhance emotional engagement.

DISCUSSION

The findings from neuromarketing content testing underscore the critical role of message design and delivery in optimizing vaccine communication strategies. The identification of minimally effective print materials and subsequent recommendations for redesign, such as increasing the visual prominence of vaccine messages and incorporating brighter, emotionally engaging color schemes, are consistent with evidence that visually salient and emotionally resonant materials enhance message recall and engagement, particularly in communities with historical mistrust or low base­line vaccine confidence (Austin et al., 2024; Sears et al., 2022). Ultimately, neuromarketing content testing was found to be an effective strategy to optimize vaccine communication and reduce negative emotions that may hinder effective health decision-making.

The results from this study are significant because they demon­strate that culturally tailored vaccine education messages can have a significant impact within Native communities. Vaccine education that included culturally relevant content, such as scenes from pow­wows and personal narratives, was found to effectively sustain attention and increase engagement. Personal narratives and stories about vaccination were found to elicit behavioral engagement and intention to vaccinate most effectively. These results add to the growing body of research confirming that culturally congruent approaches are key facilitators of vaccine confidence and uptake within Native communities (Sears et al., 2024; Zhao et al., 2025).

Personal narratives and storytelling are particularly effective strategies in American Indian and Alaska Native vaccine education. Interventions that incorporate personal stores and testimonials from community members have been found to increase message relevance and intent to vaccinate among Native people (Ignacio et al., 2023; Yzer et al., 2018). Martell et al. (2025) also found that narrative-based approaches help to build trust, foster relationships, and improve vaccination rates among Indigenous populations. Additionally, storytelling holds cultural significance within many Native communities and has long served as an effective method for conveying health information (Maudrie et al., 2024).

The findings from Truong et al. (2025) further reinforce the importance of culturally grounded messaging in vaccine education for Native communities. Their study demonstrated that American Indian and Alaska Native participants consistently prioritized protecting families, elders, and the broader community over con­cerns about vaccine safety or mistrust of government. This priori­tization is deeply rooted in cultural values, as children are seen as the future of the tribe, entrusted with preserving tribal beliefs and traditions, while elders are revered as the keepers of wisdom and knowledge essential to tribal identity.

Additional interventions to enhance the effectiveness of future vaccine education efforts among Native communities may include deeper engagement with cultural knowledge systems and trusted community figures. Consulting traditional knowledge holders, eld­ers, and healers can help ensure that educational materials are cul­turally appropriate, respectful, and aligned with community values (Zhao et al., 2025). Incorporating tribal languages into written, spoken, or multimedia resources, as well as integrating traditional songs, stories, and personal narratives, can further strengthen cultural resonance and improve message retention. Displaying vaccine information in both clinical settings and community environments, such as cultural centers or at community events, may also broaden reach and increase opportunities for engagement (Kriss et al., 2022).

Community health workers continue to serve as highly effective bridges between public health systems and Native communities. Their ability to deliver culturally grounded, trusted vaccine infor­mation positions them as key partners in efforts to improve vacci­nation coverage and strengthen public health infrastructure more broadly (Sears et al., 2022). Messaging strategies that emphasize the protection of elders, children, and other vulnerable community members may further enhance message impact and encourage community-oriented decision-making, as these values hold particular importance across many Native nations (Truong et al., 2025).

Finally, tailored efforts that incorporate long-term community partnerships and trusted messengers can substantially improve vaccine confidence and uptake. Approaches that elevate Native leadership, empower local health organizations, and respect tribal sovereignty are especially critical for advancing health equity and addressing long-standing disparities in access to preventive services (Kriss et al., 2022). Collectively, these strategies offer a pathway toward more effective, culturally grounded vaccine initiatives within Native communities.

The limitations of this project are important to acknowledge. One notable limitation is the small sample size. Although the project included participants from multiple tribes, the generalizability of the findings may be limited by the fact that the testing was conducted at a single Midwestern tribal college. To strengthen the validity and applicability of these results, future research should involve more extensive testing with a larger sample size across a broader geographic area. Additionally, participation was voluntary and may have attracted participants who were interested in health or vaccination, and this potential self-selection bias may have influenced responses regarding engagement and attitudes. Another limitation may be the timeframe of the study. While the study assessed short-term engagement, further research is needed to determine whether the neuromarketing-optimized content contributes to increased vaccination uptake among Native com­munities. Lastly, the study was limited to testing nine videos and four posters in a controlled environment, which is different than how individuals encounter vaccine information on social media or within the community and may have impacted engagement levels.

CONCLUSION

Neuromarketing testing provided valuable insight into how to optimize vaccine messages among Native populations. The findings of this study are significant because they demonstrate increased trust and willingness to vaccinate when community members are presented with effective, culturally tailored health information. Personal narratives emerged as an especially impactful method of vaccine education. given the cultural importance of storytelling in many Native communities, health professionals should consider integrating narratives alongside medical facts during vaccine conversations. Additionally, incorporating posters and print mate­rials featuring culturally relevant images may further enhance the effectiveness of vaccine education. By implementing communication strategies that align with cultural values and preferences, health professionals can help strengthen vaccine confidence and increase vaccination uptake among Native populations.

Allison Peltier, DNP, APRN, FNP-C, is the co-director of the North Dakota State University DNP Program and president of the North Dakota Nurse Practitioner Association.

Acknowledgement: Sincere appreciation is extended to United Tribes Technical College for their support and collaboration for the opportunity to conduct neuromarketing testing on their campus and for the college’s commitment to advancing culturally informed health communication research within Native communities. Their partnership was instrumental in the success of this project. Thank you to Dr. Paul Bolls and his research team from Washington State University for conducting the neuromarketing testing and providing in-depth results and actionable insights.

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