Vaccines are one of the most powerful and cost-effective public health interventions in the history of medicine. Each year, vaccines save millions of lives and billions of dollars in indirect costs. Yet in the U.S. alone, about 42,000 adults and 300 children die of vaccine-preventable diseases (not including COVID-19) each year. And underserved populations, such as families who are underrepresented minorities and those experiencing poverty, are more likely to have lower rates of childhood vaccination – worsening already significant health disparities.
So many illnesses and deaths could be avoided if more children were vaccinated for routine diseases in a timely manner. Yet vaccine hesitancy is a persistent problem; in 2019, the World Health Organization named it as one of the ten most important threats to health globally.
The COVID-19 pandemic only exacerbated hesitancy regarding routine childhood vaccinations. Between March and May 2020, when most places were under stay-at-home orders, administration of routine childhood vaccinations in the U.S. was significantly lower than the same time period in 2018 and 2019, by as much as 71.3% in some cases. Vaccination rates bounced back later in 2020, once stay-at-home orders had been lifted, but not enough to make up for all the missed doses. Additionally, COVID-19 has sparked new conversations, concerns, and opportunities for misinformation to spread about vaccines.
Vaccine hesitancy is ripe for behavioral intervention. Over the past several years, ideas42 has examined this problem and explored ways to increase uptake and timeliness of childhood vaccines. We’ve done deep dives into the academic literature and existing field research, as well as conducted research of our own through a combination of surveys and interviews with parents, providers, and other stakeholders. Through this work, we’ve identified cross-cutting behavioral barriers keeping people from taking up vaccines, as well as promising solutions.
For more on how we identify behavioral barriers, see this blog post.
What are some common behavioral barriers to on-time childhood vaccination in the United States?
- Parents are not actively presented with the decision to vaccinate. If a parent isn’t offered the choice to vaccinate or not vaccinate their children, they’re unlikely to consider it. Yet, in many cases, parents don’t experience this moment of choice, for a myriad of reasons. For example, parents may not regularly take their children to the pediatrician, the doctor may not bring it up, or they may not have friends who vaccinate/openly discuss vaccinating their children.
- Context and framing matter. If vaccination comes up, it’s important that the person who raises the decision is a trusted and reliable source of information, such as a pediatrician families have a good relationship with, a leader in their community, or a fellow parent who has vaccinated their children.
- Many parents – particularly in communities of color – harbor justified mistrust of doctors and the healthcare system. In these cases, parents are more likely to seek advice from unreliable sources, such as anti-vaxxers and unverified internet sources, where they are more susceptible to misinformation. This leads them to conclude vaccines are not right for their children.
- The perceived downsides of vaccination are more salient to parents than the perceived benefits. The pros of vaccinating one’s child – for example, immunity from rare diseases, many of which have been largely eradicated (due to vaccination) and protecting other children who cannot be vaccinated – are less salient and compelling than the cons. Stories about terrible side effects, even if false, can be scary and stick in parents’ minds more strongly than the theoretical benefits. Stories like these also cause parents to overestimate the likelihood that side effects will occur, since they tend to be vivid and easy to remember. And, of course, shots and needles are unpleasant, and no parent wants to see their kid cry. This immediate, uncomfortable experience is much easier to imagine, and therefore the downside is perceived as higher than the unknown risk of the child developing an unfamiliar disease sometime later.
- Parents overestimate how common vaccine hesitancy is. People, like all humans, follow social norms – that is, do what others do – but norms aren’t always clear. Vaccination is a private, “invisible” behavior, so most parents don’t know how common it is and assume vaccination rates are lower than they actually are. Since vaccine hesitancy is more commonly discussed than vaccination itself, parents may perceive not getting their children vaccinated to be more common and widespread than it is.
- Hassle factors play a significant role. Vaccination schedules can be confusing. Scheduling and getting to appointments can be time consuming and frustrating. Some vaccines require multiple trips to the pediatrician’s office. For parents who are already strapped for time and attention due to juggling multiple responsibilities, these hassles can make it hard to get their children vaccinated, even if they intend to.
So how do we get people to vaccinate their kids?
The problem of vaccine hesitancy and delayed or missed childhood vaccinations is seemingly intractable, and there’s no silver bullet for addressing it. Many adept problem-solvers have been tackling vaccination rates for years, and yet the problem persists. Applying a behavioral science lens sheds light on barriers that may be overlooked, and can contribute innovative solutions.
The behaviorally informed recommendations below can help increase vaccination rates [1]. They are not targeted to any one specific implementing body; they require action from many groups, across sectors, such as obstetricians, pediatricians, pharmaceutical companies, and community groups, to name a few. A multi-pronged approach is necessary to move the needle on such a difficult behavioral problem. We have categorized the suggestions below by target audience able to implement them, though some of them could certainly be adapted to work well for a variety of actors. Some of these appear in more than one category, but we’ve duplicated them to provide full slates of recommendations by audience.
Physicians (specifically, OBGYNs, pediatricians, and family practitioners):
- Offer vaccines early and often. If parents aren’t offered the choice, they can’t make one. Use multiple channels (i.e., prenatal and pediatrician visits, social media posts, flyers at bus stations and benefits offices) so parents are exposed to the topic and credible information in several ways.
- Make the benefits of vaccination salient and concrete. Parents are more open to discussing vaccination during high-profile outbreaks. We happen to be in the midst of a high-profile outbreak of a vaccine-preventable disease. Leverage conversations about COVID-19 and other outbreaks to illustrate to parents how powerful vaccines can be at preventing illness and protecting their children.
- Work with communities to build trust. Work with trusted community leaders to offer services that are appropriate and desired by historically underserved communities. Listen to their concerns without judgment. Research and practice cultural competence. None of these things will happen overnight, but this work is needed to improve trust and help people become more comfortable seeking the care they need (including vaccinations).
- Make it easy. Offer vaccination clinics in places where families frequently spend time, such as at schools, places of worship, or grocery stores. Simplify vaccination scheduling and administration processes, such as by offering walk-in vaccine appointments and introducing easy online scheduling. Produce easy-to-follow infographics or calendars to help parents keep track of which vaccines are recommended and when.
Vaccine manufacturers:
- Communicate norms and make vaccination “visible.” Show parents the numbers to demonstrate that they would actually be in the minority if they chose not to vaccinate their children. Parents who get their children vaccinated on time should also be exemplified as champions. Encourage them to share about their decisions via social media, collateral such as buttons and bumper stickers, yard signs, and more.
- Work with communities to build trust. Work with trusted community leaders to offer services that are appropriate and desired by historically underserved communities. Listen to their concerns without judgment. Research and practice cultural competence. None of these things will happen overnight, but this work is needed to improve trust and help people become more comfortable seeking the care they need (including vaccinations).
Community groups:
- Make it easy. Offer vaccination clinics in places where families frequently spend time, such as at schools, places of worship, or grocery stores. Simplify vaccination scheduling and administration processes, such as by offering walk-in vaccine appointments and introducing easy online scheduling. Produce easy-to-follow infographics or calendars to help parents keep track of which vaccines are recommended and when.
- Communicate norms and make vaccination “visible.” Show parents the numbers to demonstrate that they would actually be in the minority if they chose not to vaccinate their children. Parents who get their children vaccinated on time should also be exemplified as champions. Encourage them to share about their decisions via social media, collateral such as buttons and bumper stickers, yard signs, and more.
Some of these strategies may seem like no-brainers, yet many of them have not been widely implemented. This may be because they require cross-sector partnerships, shifts in the way care has traditionally been delivered, and unique, creative ways of interacting with patients and communities. However, we believe that these investments, which specifically address the behavioral barriers we’ve identified, can go a long way in addressing the longstanding problems of vaccine hesitancy, delay, and avoidance.
The COVID-19 pandemic has increased both the urgency of this problem and created a unique moment of action. Let’s take this opportunity, when vaccines are being discussed more than ever, to tackle pediatric vaccine avoidance–because our children deserve bright futures free of vaccine-preventable diseases.
