Addressing vaccine hesitancy requires tailored, evidence-based strategies to address the causes. WHO grouped these determinants into contextual, individual, and group influences and vaccine/vaccination-specific issues.

However, most vaccine hesitancy measurement tools have limited psychometric validation. Further studies correlating measurements with vaccination behavior and validating these tools in different populations, including pediatric populations, are warranted. 

Evidence-based strategies for increasing vaccine uptake 

A recent systematic review provides an overview of evidence-based strategies for increasing vaccine uptake and indicates that multi-component interventions are more effective than single-component interventions.

Below is a summary of the findings published in that review, which includes structural and operational approaches as well as interventions for clinical encounters.

Cost and Incentives

• Reducing or eliminating costs is one of the most effective ways to improve access and increase vaccine uptake. 
• Providing incentives such as tying vaccination to insurance-related or public benefits or offering small monetary or non-monetary incentives can also improve vaccine uptake. 

Availability and Requirements

• Vaccination programs in communities, including schools, childcare centers, community gathering places, and homes, also successfully improve vaccine uptake, especially for children less likely to access healthcare. 
• Requiring vaccines for school or childcare attendance can also contribute to improving it.  

Education and Information

• Education and information about vaccines can improve vaccine uptake if there is a significant knowledge gap and if the education is culturally and linguistically appropriate. However, simply educating parents about vaccines results in little to no difference in parental attitudes toward vaccines or intentions to vaccinate.
• Likewise, training healthcare professionals on vaccine information alone has not been found to improve vaccine uptake. 

Protocols and Reminders

• Reminder and recall systems (mail, phone, text, apps, other media, and electronic health records) to identify and remind or notify individuals or parents when vaccines are due to have shown evidence of increasing vaccine uptake, and they are often combined with other strategies. 
• Standing orders allow healthcare professionals to administer vaccines according to a protocol approved by a supervising authorized practitioner and have demonstrated improved vaccine uptake. They can reduce missed opportunities for vaccination and empower non-clinician healthcare personnel to have a significant role in vaccine delivery.   
• Audit and feedback have shown improvements in vaccine uptake, mainly when used concurrently with other strategies. Immunization information systems (IISs), a confidential central source of vaccination information for a geographic area, can enhance the availability and use of multiple strategies, including provider reminders, audit and feedback, and reminder and recall strategies. 

Recommendation and Discussion

• The strength of the vaccine recommendation correlates with improved vaccine uptake. Providing a strong recommendation and pursuing adherence despite initial reluctance by reemphasizing the importance of a vaccine in follow-up communications and future visits is key.  
• Establishing an honest dialogue, actively listening, and welcoming questions are critical to the vaccination discussion.
• Motivational interviewing is an effective tool for resolving ambivalence in parents or patients who express hesitancy about vaccination.   

Communication Strategies

• Using the presumptive format for initiating vaccine communication (“Johnny’s due for three shots today”) as opposed to the participatory approach where an open-ended question is used. 
• Presenting vaccination as the default, opt-out decision to make it easier to accept than refuse the vaccine.   

This last strategy is an example of nudging. A nudge is an intervention in the decisional context that steers people’s decisions by acting on their cognitive biases. It creates behavior change by appealing to our automatic mental processes and, thus, bypassing reasoning.

There is an ongoing debate about the ethics of utilizing nudges in policy and health care that focuses on whether nudging undermines autonomy and whether it could be ethically justified even if/when it does. I discussed this debate in my previous blog post.

Given some fundamental differences between the pediatric and adult contexts regarding healthcare decisions, including those related to vaccines, the appropriateness of nudges in pediatrics warrants its own discussion, so I am adding a few considerations here.

Nudging in Pediatrics

Those in favor argue that nudging does not need to violate parental decision-making authority and can ensure parental decisions are in the child’s interests, particularly in contexts where there is high certainty that a recommended intervention is low risk and of high benefit. Also, nudging can relieve parents’ decisional burden regarding what is best for their child, particularly with decisions that have implications for public health. 

Others suggest that some autonomy-undermining nudges may be ethically justified in pediatrics. The rationale for this argument is that parental autonomy in pediatric decision-making is not as morally valuable as the autonomy of adult patients, and the interests of both the child and other community members could justify parental autonomy-infringing pediatric vaccination nudges. An important consideration in this case is the effect of pediatric vaccination nudges on parent-physician relationships.

And yet others pose the question, “On what basis should we judge whether a parent’s medical decision for their child is morally acceptable?”. They propose that formulating a method for guiding parental medical decision-making for their children should accommodate the child’s autonomy and be aligned with commonly held principles of bioethics. That is, autonomy, beneficence, non-maleficence, and justice.

Along these lines, there have been calls on the American Academy of Pediatrics to draw on scientific and bioethics research to develop guidelines for the use of nudges in pediatric practice and, in particular, for the use of pediatric vaccination nudges. There could not be a better time to follow up on this call.  

Image by Iván Díaz for Unsplash