What Works to Increase Vaccination Uptake

Behavioral science offers several ideas about what it takes to get people to vaccinate. Colleagues and I previously reviewed the evidence for these propositions and put forward what has become known as the Increasing Vaccination Model. To make the model more accessible to practitioners, the current paper summarizes the main insights from the earlier work. First, observational studies show clearly that thoughts and feelings are correlated with vaccine uptake. Such constructs include perceived risk of harm from infectious disease and confidence in vaccine safety and efficacy. However, interventions have not generally shown that changing thoughts and feelings increases vaccine uptake. Second, social processes are promising in observational studies. Such constructs include social norms, altruism, and sharing through social media. More research is needed in this promising area before it will be possible to conclude whether social processes are effective intervention targets. Third, interventions that directly change behavior—without trying to change what people think or feel or their social experience—are reliably effective ways to increase vaccine uptake. Such interventions include reminders, defaults, and vaccine requirements. Finally, the most potent intervention for increasing vaccine uptake is a health care provider recommendation, but it is still unclear whether such recommendations are effective because they increase confidence, set a social norm, or reflect a direct behavior change technique. The paper ends by describing use of the model by a World Health Organization working group as it considers opportunities to address low vaccination uptake globally

Ways That Mental Health Professionals Can Encourage COVID-19 Vaccination

The potential of mental health professionals and agencies to address barriers to COVID-19 vaccination has received inadequate attention. Mental health professionals and teams are trained to use empathy, reflective listening, and cooperative goal setting to help patients address challenges. These professionals actively support patients’ well-being, including their adoption of health behaviors such as receiving COVID-19 vaccination. Around 18% of US adults see a mental health professional in a 12-month period, providing an important opportunity. Such care may be particularly important in the context of greater mental health problems during the pandemic. We briefly review what little is known about mental health and vaccination behavior and then address 3 areas for intervention by mental health professionals, based on the Increasing Vaccination Model (IVM). The model identifies 3 main influences on vaccination behavior: what people think and feel, their social experiences, and opportunities for direct behavior change. This descriptive model of health behavior is in use in an adapted form by the World Health Organization and the US Centers for Disease Control and Prevention

Resilience of HPV vaccine uptake in Denmark: Decline and recovery

Background: Immunization programs’ resilience to shocks is central to their success, but little empirical evidence documents resilience in action. We sought to characterize the decline of HPV vaccination in Denmark after negative media coverage and recovery during a national information campaign. Methods: We conducted a population-based retrospective cohort study of all girls born in Denmark from 1997 to 2006 (N = 328,779), aged 12–15. The outcome measure was HPV vaccine uptake (first dose), as reported to the Danish national health registry from 2009 to 2019, when HPV vaccine was freely available to girls in primary care clinics in Denmark. Events that created 4 natural time periods for study were HPV vaccine reaching the uptake of other vaccines in the national program (2009), some negative media coverage of HPV vaccination (2013), extensive negative media coverage (2015), and a national information campaign about the vaccine's safety and effectiveness (2017–2019). Results: In the period with some negative media coverage, HPV vaccine uptake fell to 83.6% (95% CI:78.0%–89.7%) of baseline uptake. In the period with extensive negative media coverage, uptake fell even further to 49.6% (95% CI:44.5%–55.2%) of baseline uptake. After the information campaign, HPV vaccine uptake recovered to its baseline level (109.2%, 95% CI:90.1%–132.4%) due in part to catch-up doses. Despite the recovery, an estimated 26,000 fewer girls initiated the vaccine than if uptake had not declined. Conclusions: The experience in Denmark offers one of the first opportunities to document how a nation grappled with negative media coverage of HPV vaccination and the steadying impact of action by national authorities

RE: Progress in HPV vaccine hesitancy

In the article by Sonawane et al, the important question of parental hesitancy regarding adolescent human papillomavirus (HPV) vaccination is examined. The authors reported an increase in hesitancy over a 6-year period (from 50% to 64%) among US parents asked about it. This apparent increase is due to progressively restricting the denominator in later years. Most importantly, the analytic choice masks a more general truth: HPV vaccine hesitancy actually fell among parents overall

Disparities and reverse disparities in HPV vaccination: A systematic review and meta-analysis

Studies disagree about whether racial and ethnic groups have lower or higher human papillomavirus (HPV) vaccination uptake, an important issue given large disparities in some HPV cancers. We sought to characterize and explain racial and ethnic differences in HPV vaccination. We systematically searched PubMed, CINAHL, Embase, and Web of Science to identify US studies through mid-2017 reporting associations of race and ethnicity with HPV vaccination. We identified 118 studies (n = 3,095,486) published in English that reported HPV vaccine initiation or follow-through in the US from which we could calculate effect sizes. We used random effects meta-analysis to synthesize effect sizes for comparisons of Whites or non-Hispanics to Blacks, Hispanics, Asians, or all minority groups combined. Studies showed no racial or ethnic differences in HPV vaccine initiation overall. However, when restricting to studies using provider-verified vaccination data, minorities were 6.1% [3.3%–8.8%] more likely than Whites to initiate HPV vaccination. Advantages were larger for Hispanics, males, and younger samples (age < 18). In contrast, minorities were 8.6% [5.6%, 11.7%], less likely than Whites to follow-through with the full HPV vaccine series, a disparity present across all participant and study characteristics. More recent studies found larger advantages for racial and ethnic minorities in HPV vaccine initiation and smaller disparities in follow-through. In summary, high-quality studies found racial and ethnic minorities are more likely to initiate but less likely to follow-through with HPV vaccination, a clear finding that self-report studies obscure. Higher HPV vaccine initiation among minorities suggests potential reductions in HPV cancer disparities

Is a cigarette brand with fewer chemicals safer? Public perceptions in two national US experiments

By law, the US government must publicly display the quantities of harmful chemicals in cigarettes by brand, but doing so could mislead people to incorrectly think that some cigarettes are safer than others. We evaluated formats for presenting chemical quantities side-by-side to see if any were misleading. We recruited US convenience (n = 604) and probability (n = 1440) samples. We randomized participants to 1 of 5 formats: checklist, point estimates, ranges, a visual risk indicator, or no-quantity control. Participants were far more likely to incorrectly endorse one cigarette brand as riskier than the other in the checklist (65% made error), point estimate (67–70%), range (64–67%), or risk indicator (68–75%) conditions as compared to the no-quantity control (1%, all p <.001). Among smokers, erroneous risk perceptions mediated the impact of quantity format on interest in switching brands. People viewing chemical quantities for cigarette brands side-by-side misperceived differences in risk, suggesting limited public health value of this information

Association between genomic recurrence risk and well-being among breast cancer patients

Background Gene expression profiling (GEP) is increasingly used in the rapidly evolving field of personalized medicine. We sought to evaluate the association between GEP-assessed of breast cancer recurrence risk and patients’ well-being. Methods Participants were Dutch women from 10 hospitals being treated for early stage breast cancer who were enrolled in the MINDACT trial (Microarray In Node-negative and 1 to 3 positive lymph node Disease may Avoid ChemoTherapy). As part of the trial, they received a disease recurrence risk estimate based on a 70-gene signature and on standard clinical criteria as scored via a modified version of Adjuvant! Online. \Women completed a questionnaire 6–8 weeks after surgery and after their decision regarding adjuvant chemotherapy. The questionnaire assessed perceived understanding, knowledge, risk perception, satisfaction, distress, cancer worry and health-related quality of life (HRQoL), 6–8 weeks after surgery and decision regarding adjuvant chemotherapy. Results Women (n = 347, response rate 62%) reported high satisfaction with and a good understanding of the GEP information they received. Women with low risk estimates from both the standard and genomic tests reported the lowest distress levels. Distress was higher predominately among patients who had received high genomic risk estimates, who did not receive genomic risk estimates, or who received conflicting estimates based on genomic and clinical criteria. Cancer worry was highest for patients with higher risk perceptions and lower satisfaction. Patients with concordant high-risk profiles and those for whom such profiles were not available reported lower quality of life. Conclusion Patients were generally satisfied with the information they received about recurrence risk based on genomic testing. Some types of genomic test results were associated with greater distress levels, but not with cancer worry or HRQoL

Provider communication and HPV vaccine uptake: A meta-analysis and systematic review

Provider communication can be critically important to families as they consider HPV vaccination. We sought to characterize the association of provider communication and HPV vaccine uptake, and when communication better motivates vaccination. We searched four databases for studies published between 2006 and 2019. Eligible studies examined health care provider communication (defined as recommendation or discussion) and HPV vaccine uptake (defined as initiation, completion, or follow-through) in the US. Two coders independently identified eligible studies and coded effect sizes and study characteristics. We pooled effect sizes using random-effects meta-analysis. We identified 59 eligible studies of 265,083 patients. Receiving a provider recommendation was associated with higher HPV vaccine initiation (pooled OR = 10.1, 95% CI: 7.6–13.4). HPV vaccine initiation was 24% for patients without and 60% for patients with a provider recommendation. The pooled effect size for provider recommendation and initiation was smaller for probability samples, clinical records, and NIS-Teen (all p < 0.002). Recommendations were equally effective for males and females, for different patient ages, and over time. Provider recommendation was also associated with higher HPV vaccine series completion and follow-through. Provider discussion was similarly associated with higher HPV vaccine initiation (OR = 12.4, 95% CI: 6.3–24.3). In summary, provider communication was robustly associated with HPV vaccination initiation, completion, and follow-through. These findings suggest that US public health efforts to increase HPV vaccine coverage should continue to emphasize provider communication

Communicating about chemicals in cigarette smoke: Impact on knowledge and misunderstanding

Background The USA must publicly share information about harmful and potentially harmful constituents (chemicals) in tobacco products. We sought to understand whether webpages with chemical information are "understandable and not misleading to a lay person."Methods Participants were a national probability sample of US adults and adolescents (n=1441, 18% smokers). In an online experiment, we randomly assigned participants to view one of the developed webpages (chemical names only, names with quantity ranges, names with visual risk indicators) or no webpage in phase one (between subjects). Participants completed a survey assessing knowledge, misunderstanding, perceived likelihood, perceived severity of health effects from smoking and quit intentions (smokers only). In phase two (within subjects), participants viewed all three webpage formats and reported webpage perceptions (clarity, usability, usefulness) and perceived impact (affect, elaboration, perceived effectiveness). Results In phase one, viewing any webpage led to more knowledge of chemicals (48%-54% vs 28% no webpage, ps<0.001) and health harms (77% vs 67% no webpage, ps<0.001). When exposed to any webpage, 5%-23% endorsed misunderstandings that some cigarettes are safer than others. Webpage format did not affect knowledge or reduce misunderstandings. Viewing any webpage led to higher perceived likelihood of experiencing health effects from smoking (p<0.001) and, among smokers, greater intentions to quit smoking (p=0.04). In phase two, where participants viewed all formats, a visual risk indicator led to the highest perceived impact. Conclusions Knowledge of chemicals and health effects can increase after viewing a website. Yet, websites may not correct the misunderstanding that some cigarettes are safer

How should sugar-sweetened beverage health warnings be designed? A randomized experiment

Health warnings are a promising strategy for reducing consumption of sugar-sweetened beverages (SSBs), but uncertainty remains about how to design warnings to maximize their impact. Warnings already implemented in Latin America use nutrient disclosures, while proposed U.S. warnings would describe the health effects of consuming SSBs. We sought to determine whether warning characteristics influence consumers' reactions to SSB health warnings. A national convenience sample of U.S. adults (n = 1360) completed an online survey in 2018. In a factorial design, we randomly assigned participants to view SSB health warnings that differed in: 1) inclusion of health effects (“Drinking beverages with added sugar contributes to obesity, diabetes, and tooth decay”); 2) inclusion of a nutrient disclosure (“High in added sugar”); 3) inclusion of the marker word “WARNING;” and 4) shape (octagon vs. rectangle). The primary outcome was perceived message effectiveness (PME, range 1–5). PME was higher for warnings that included health effects (average differential effect [ADE] = 0.63, p < 0.001) or nutrient disclosures (ADE = 0.32, p < 0.001) compared to warnings without this information. However, adding a nutrient disclosure to a warning that already included health effects did not lead to higher PME compared to warnings with health effects alone. The marker “WARNING” (ADE = 0.21) and the octagon shape (ADE = 0.08) also led to higher PME compared to warnings without these characteristics (ps < 0.001). The same pattern of results held for the secondary outcomes, fear and thinking about harms. SSB health warnings may have more impact if they describe health effects, use the marker “WARNING,” and are octagon-shaped