The four reasons people don't vaccinate, and how to combat them

Despite the popular cultural assumption that vaccine hesitancy is strictly borne out of mistrust, stoked by recent anti-vaccination movements, there are actually four different kinds of people who decide to opt out, according to a study recently published in Policy Insights from the Behavioral and Brain Sciences.

Describing a “Four C model,” the study reports that people choose to forego vaccinations chiefly due to one of four reasons — complacency, convenience, a lack of confidence or utilitarian calculation. That is one more “C” than the previous model, developed by the WHO-SAGE vaccine hesitancy working group, which determined that complacency, a lack of confidence and convenience kept people away. However, the authors of the new study argue that those who heavily research vaccinations, and ultimately make a decision based subjective risk calculations, make up a unique, fourth category.

“The literature and our own experimental work show that weighing the pros and cons can lead to two types of non-vaccination,” said co-author Cornelia Betsch, PD, research fellow and scientific manager of the Center for Empirical Research in Economics and Behavioral Science at the University of Erfurt in Germany, in an interview with Healio. “One is free-riding, because the social benefit of vaccination is well understood and people use this opportunity to be protected without contributing to the public good. The other is being a fence-sitter which means that there is the perception that equal amounts of information suggest and oppose vaccination.

“Psychologically, it is a different motivation based on utility calculation that leads to the decision. This is in contrast to complacency, where people don’t care; to convenience, where they actually are pro vaccination but just don’t implement their positive intention; or compared to confidence, where they are very convinced that vaccination is a bad idea.”

The study, completed through a review of literature analyzing decision making factors in regard to vaccinations, also concluded that targeting the complacent, the inconvenienced and the calculating would be “more promising, economic and effective” than attempting to convince those who actively mistrust vaccinations.

According to the study, ways to reach people in those three categories include:

Raising the perceived risk of infection;
Stressing the social benefit of vaccinations;
Stressing that vaccinations are the norm;
Strengthening positive attitudes toward vaccination;
Changing the structure to better facilitate availability;
Strengthening self-control and implementation among patients;
Debunking myths; and
Adding incentives.

According to researchers this can be achieved through information campaigns that appeal to social motives and responsibilities, as well as through changing the structure of how vaccinations are administered, such as making them mandatory, or switching to an “opt-out” system rather than one in which patients must seek out their immunizations. Physicians can also make “strong recommendations” to their patients, as well as make regular use of reminders and pre-commitments, which have been shown to be effective, according to the study.

As for those who lack confidence in vaccines, the only course of action is to debunk myths, according to researchers. However, Betsch said any such outreach can easily backfire and must be carefully worded and presented.

“People with a lack in confidence are often very well misinformed,” Betsch said. “It is important that doctors know the most prominent myths and are able to explain why these are false. Health authorities should provide doctors with easy to use materials, because ‘debunking’ must be done well. The debunking handbook is a very nice example of which rules should be applied to correct misinformation.”

Nancy Ruder, DrPH, APRN, an adjunct professor at the George Washington University School of Nursing, told Healio.com that it is important that physicians not drive their patients away when they question the effectiveness of vaccines.

“Some providers dismiss patients from their practice if they do not want to be immunized, but that just reinforces the patients’ concerns and sends the patient away from good information,” Ruder said. “It helps for the provider to listen carefully to the concerns, and rather than counter the concerns or dismiss the patients’ concerns, it can be more effective to frame the value of immunizations in what matters to the patient.

“This is another area of care for utilizing motivational interviewing techniques,” Ruder noted. “Also, it might be more effective to have a patient’s peer discuss the value of immunizations and address the patient’s concerns.”

Ruder added that it “takes a team,” including the front office staff, to help promote vaccinations among patients.

“I have been in offices of physicians who are strong advocates of vaccines and heard the receptionist tell a patient that she thinks vaccines are not good,” Ruder said. “You have to get the whole team involved, onboard, and part of the cause. It helps to track immunization rates and celebrate improvements with the whole team.”

According to Betsch, the next step in the research is to test whether the “Four Cs” can be found empirically.

“It will be necessary to test if the strategies proposed for each type indeed work best for that particular type,” said Betsch. “The suggestions are literature-based only, as stated in the article, and after this first step is done, we will need the discussed subsequent steps to make the idea of behavioral insights work.” — by Jason Laday

For more information:

Betsch C. et all Policy Insights Behav Brain Sci. 2015. doi: 10.1177/2372732215600716.