Addressing Intuitive Barriers to Childhood Vaccinations

With Christina Baker

Despite concerns about a new Omicron variant, the current state of COVID-19 prevention in the U.S. is moderately optimistic: 

• About 78% of all people living in the United States had received one dose of vaccine by 4/18/22, 66% were fully vaccinated, and 33% had received at least one booster dose. Even one dose provides some level of protection against severe illness, and as more people are fully vaccinated and boosted the average person’s chance of encountering someone who could infect them with SARS-CoV-2 is correspondingly reduced. 
• Whether this is enough to prevent a resurgence of hospitalizations or deaths remains to be seen, but it’s certainly better than where we were even last summer -- only 67% of adults had even one dose by July 4^th 2021.

Unfortunately, children (who make up 22% of the total population) are much less likely than adults to have been vaccinated:

• As of 4/13/22, the CDC reported that only 34% of children ages 5-11 (who at that point were eligible for about 6 months) had received at least one dose of vaccine, and 28% were fully vaccinated. 
• Among children ages 12-17 (eligible since May 2021) the rates are closer to those of adults, with 68% having received at least one dose and 58% fully vaccinated. But low vaccination rates can put children at risk personally – early reports that “children don’t get sick with COVID-19” were simply not true, with hospitalization rates around 1% and death rates about a quarter of that. (The initial reports were likely due to school closures that resulted in very few children being exposed). 1% is a lower hospitalization rate than that of older adults, but it’s a cause of cost and worry for families whose child is hospitalized. Long-term effects of COVID-19 in children are still largely unknown, but can be significant in adults. And at the societal level, even 1 in 1000 children dying still feels like an unacceptable rate.

In light of these facts, why don’t more parents seek COVID-19 vaccination for their children? Cost and access are the usual suspects in health care, but both of those barriers have been minimized by an intensive Federal and state efforts. COVID-19 vaccines have been available for months at no cost, with limited paperwork, and in mobile vans, pop-up clinics, or community pharmacies close to where families live. (Paul will confess here that he was able to get his 11.5-year-old daughter vaccinated in September, before the age-5-to-11 vaccine was FDA-approved, simply by visiting a public health van in his neighborhood). Families even received incentives like gift cards to encourage vaccination; in Christina’s experience as a vaccination volunteer, free zoo admission was one excellent incentive because the opportunity to go there also reduced resistance from the child. The remaining barriers to vaccination, which apply to nearly two-thirds of parents in the U.S., largely have to do with values, beliefs, and emotions. The rest of this blog post will examine those factors and how to address them.

Patients generally have autonomy in their own medical decision-making, but decision-making is more complicated in health care for minors. In some cases, parents might disagree about the best course of action, might be involved in a role dispute with other caregivers, or might disagree with an adolescent who has not yet reached the legal age of consent. Besides legal complexities, this type of complex interpersonal decision-making can create moral distress for health professionals faced with competing ethical demands. In some cases, conflicts between parents or between parents and their children might even spill over as intuitive reactions to authority figures such as health professionals. In Christina's current research with school nurses, parents are sometimes less interested in the risks or benefits of the vaccine itself than in the question of whether school policies would require them to get a vaccine for their children. (Some school nurses themselves expressed concerns about this issue). Case management, mediation, or family systems counseling might be needed to address these barriers to immunization.

Omission bias has been identified as another important reason that parents choose not to vaccinate children for other diseases. The term means that parents often feel more responsible for the effects of vaccination than for the effects of disease. In that context, COVID-19 vaccination refusal starts to make more sense: Even if a parent knows that the risk of a serious adverse reaction to the vaccine is very low (about 100 serious events reported to CDC out of 4.8 million 5-to-11-year-old children vaccinated, or 1 in 50,000), the parent’s fear of harming his or her own child may nevertheless be persuasive. At the same time, parents might discount the much higher risk of serious illness due to COVID-19 (about 1 in 100, or a 500-times-greater risk than vaccination). Parents’ differential sense of responsibility is due to an intuitive-level perceptual quirk, in which people tend to view illness as an act of God or fate rather than as someone’s own responsibility. Part of the parent’s mental calculus might also involve the complex emotion called “anticipated regret,” in which people imagine themselves feeling worse in the future if they had acted in a way that caused negative consequences than if they had failed to act with similar results. These intuitive-level factors have little to do with the actual odds of harm. Comparing absolute risks of harm from vaccination versus COVID-19 requires a narrative mode of thought that many parents might be less able to access because of their very strong feelings for their children. Even if the relative probabilities are pointed out, parents might discard the statistics as “cold” or “calculating” because they feel that their intuitive-level emotional response is a better way to make parenting decisions. This is consistent with Leventhal’s dual-process theory of health behavior, in which emotions are more convincing than rational cognitions. Mindfulness strategies have proven effective in efforts to promote acceptance of other vaccines, and might help to decrease anxiety which could in turn create mental space for a narrative-level mental comparison of risks to occur.

Another consideration in vaccine decisions is the level of uncertainty involved. Even when a vaccine has been well-studied in clinical trials, parents might reasonably wonder about how it will perform in the general population (Indeed, the only way to know this for any drug is to release it and monitor the results, e.g. via the FDA’s MedWatch program). For newer vaccines, parents might want to delay their decision until more children have received the drug – a reasonable decision last October, although it’s one that looks less reasonable with each passing day. One of the most common concerns expressed by parents is cardiomyopathy, because heart conditions are frightening, but CDC reports that this problem is actually more common as a consequence of COVID-19 itself than as a side effect of vaccination, so getting a COVID-19 vaccine actually reduces this risk. A harder concern to address is the possibility that childhood vaccines might have important long-term harms, which is a common theme of COVID-19 vaccine misinformation, and also a common barrier identified in Christina’s vaccine hesitancy study with school nurses. For example, some people worry that these vaccines might affect girls’ later fertility (parents’ number one concern in Christina’s ongoing research). Any conclusive evidence either for or against this type of problem is a decade or more away, so parents need to base their decisions on other factors like intuitive reactions (“this just feels risky,” “it’s all happening too fast”) or narrative considerations (“there’s no plausible mechanism of action by which the vaccine would affect the reproductive system”). Again, when it comes to the health of one’s children, the intuitive-level mode of thought may prove more compelling. Rather than providing facts, it might be helpful to provide parents with tips on how to think about complex scientific questions like the long-term risks and benefits of COVID-19 or the long-term effects of vaccines. Alternately, for “watchful waiters,” highlighting the level of disease risk that they are currently incurring might help to promote vaccine acceptance.

Under conditions of uncertainty, people’s subjective perception of risk is often at odds with the objective benefits of health behavior. In such situations, the ways in which information is presented can affect vaccine choices. For instance, the statements “1 child out of 100 is hospitalized with COVID-19” and “99% of pediatric COVID-19 cases are mild to moderate” both convey the same information, but the first one might be perceived as frightening while the second is seen as reassuring. Some research has found that gain-framed messages (those that emphasize the benefits of engaging in a health behavior) are more convincing than loss-framed messages (those that emphasize the potential risks of skipping a health behavior). This might lead to a recommendation that public health workers emphasize “keeping kids healthy” as a benefit of COVID-19 vaccines instead of trying to convince parents of the risks of COVID-19 itself. But in a 2021 study, Borah and colleagues found that a loss frame (highlighting the costs of not getting the vaccine) was more useful in prompting parents to seek vaccination for their children as long as they already perceived COVID-19 vaccination to be beneficial. (This might be consistent with the general finding that fear is most helpful in changing health behavior when “preaching to the choir”).

Parents with more medical knowledge are generally more accepting of vaccines, but improving parental knowledge is not as simple as just providing information. Parents’ attitudes can be affected not only by valid scientific information, but also by misinformation or disinformation. Unfortunately, up to 80% of Americans say that social media is an important source of knowledge about vaccines, and social media platforms may be uniquely capable of disseminating false stories. Some misinformation comes from vendors seeking to profit from unvalidated treatments, while active disinformation might come from speakers seeking political action. The World Health Organization is fighting this 'infodemic' with projects such as the Information Network for Epidemics (EPI-WIN), which responds to questions posted on social media platforms with science-based answers. Unfortunately, parents who already have a negative feeling about vaccines are more likely to utilize motivated reasoning and information search strategies that support the conclusion they already have in mind. For instance, they tend to ignore base rates (like a 1/100 versus 1/50,000 chance of adverse events), they over-weight present versus future risks, and they avoid information that contradicts their expectations. They thus might be “inoculated” against true medical information, and more vulnerable to misinformation, based on their preconceptions. Another study used an enhanced-refutation intervention that not only debunked misinformation but also labeled it as deceptive and misleading; these steps resulted in reduced sharing of misinformation on social media. This intervention’s relative success might lie in its ability to tap into intuitive-level moral judgments by highlighting deception or exploitation (e.g., “the people who shared this information are trying to take advantage of you”) in addition to providing more accurate facts.

Finally, the way in which health professionals interact with parents about their vaccine concerns can make a difference. Communicating respect for parents' concerns and questions, as in motivational interviewing (MI), can be effective with vaccine-hesitant parents. MI focuses on developing collaborative patient-centered relationships that help to guide parents towards intentions to change. MI is associated with significantly increased vaccination intention among mothers of newborns, and with improved parental attitudes towards children’s human papillomavirus (HPV) vaccination. MI strategies include empathic communication, supporting personal agency, and guiding parents to articulate their own arguments for the benefits of vaccination. MI-based conversations may be particularly important for "system distrusters" or "COVID skeptics," who cite political reasons for refusing vaccines. MI is a conversational style that avoids reactance by not arguing, and gives people room in the conversation to articulate both the pros and cons of vaccination for themselves.

Because of the wide range of factors that might affect parents’ decision-making about COVID-19 vaccines, an individualized approach is probably required. The different reasons people give for COVID vaccine skepticism are one place to start in designing a tailored messaging strategy. Demographic factors also probably make a difference, including income, age, educational attainment, rurality, health literacy, and parental status. A parent’s baseline knowledge and attitudes toward COVID-19 vaccines (e.g., perceived benefits) also could be used to select gain- versus loss-framed message frames. A group from the NIH Office of Behavioral and Social Science Research produced a helpful guide with principles for COVID-19 vaccine message tailoring via social media (strategies that unfortunately have not been well utilized in the Federal response). By now many people’s attitudes toward COVID-19 vaccination are well entrenched, but there is still potential to improve America’s health by increasing vaccination rates specifically among children. This can be done by shifting the dialogue from narrative-level arguments to more emotion-based ones, by listening to people’s concerns rather than trying to educate or argue, and by matching messages to parents’ individual needs and concerns.