Applying Behavioral Economics to the Thorny Issue of Vaccine Acceptance

The Theory and Practice

Can insights from behavioral economics inform creative approaches to increasing vaccination rates, and help prevent outbreaks of vaccine-preventable diseases? In a JAMA Pediatrics Viewpoint, LDI Senior Fellows Alison Buttenheim and David Asch suggest how to apply behavioral economic principles to the thorny issue of vaccine acceptance, and discuss the challenges in doing so.

Buttenheim and Asch suggest vaccine interventions that leverage default and omission biases, increase the salience of vaccine-preventable diseases, and make vaccination social and the benefits immediate. Each of these suggested approaches come with caveats about what could go wrong in putting them into practice.

• Increasing the salience of vaccine-preventable diseases through images or stories can make those with unfavorable beliefs about vaccines even less inclined to vaccinate. In a 2015 blog post on the Disneyland measles outbreak, Buttenheim noted that the same facts that might convince a moderately hesitant parent to vaccinate will only reinforce previously-held beliefs in a strongly anti-vaccine parent. So beware your audience.
• On making vaccination visible and social, Buttenheim and Asch stress that it’s important to publicize high vaccination rates rather than exemption rates (as several states currently do). As an example of the unintended consequences of socializing the wrong action, they cite an anti-drug media campaign that clearly said that drugs are bad for you, but also had the underlying message that lots of teenagers use them. It turned out that more exposure to the advertisements was associated with increased initiation of drug use.
• Finally, will these behavioral economics insights work with the complex issue of vaccine acceptance? “Even though some of these strategies have been tested in other contexts, more research is needed to evaluate their effect on vaccine acceptance, and to identify at which level they may be most effective.”

A recent Buttenheim-led study, with colleagues including LDI Senior Fellows Alex Fiks and Kristen Feemster, put some of the behavioral economics theories to the test. The feasibility trial tested the effectiveness of an intervention to increase the uptake of the Tdap vaccination (against pertussis) among unvaccinated adults caring for newborns. It randomized these adults to receive one of four interventions during well-child visits at a Philadelphia pediatric primary care clinic. Some received a voucher for a free vaccination at a retail clinic close to the pediatrician’s office, while others received a $5 off voucher. Some watched a one-minute public service announcement (PSA) promoting Tdap vaccination that featured celebrity Jennifer Lopez, while others weren’t shown the video.

The interventions had no effect on vaccination rates, with just one of 95 subjects redeeming the voucher. A follow-up survey revealed some of the barriers to vaccination, including the lack of immediate access to the vaccination when highly motivated at the pediatrician’s office. Linked to this was the perception that the pharmacy locations were inconvenient (although two were within four blocks of the clinic). But even reducing the financial and time costs of vaccination and reinforcing social norms through a PSA may not address a key barrier the authors identified: a person’s beliefs about the risk of contracting pertussis and its severity.

The authors conclude:

Infant caregivers with high reported awareness of pertussis risk but a lack of perceived personal risk are still unlikely to receive a Tdap vaccine in a retail pharmacy, even when prompted with vaccine vouchers that reduced cost and a high-salience video promoting the vaccine.  The time and effort involved remain significant barriers. Future interventions should focus on identifying the optimal time and place to both promote and deliver Tdap vaccination to infant caregivers.

Insights from behavioral economics may offer creative ways to boost vaccination rates, but the caveats are many, and careful implementation is critical. Feasibility tests like Buttenheim’s are important, and over time we’ll see whether what works in theory also works in practice.

This blog post originally appeared on LDI Health Policy$ense.