Can we nudge our way to higher vaccination rates?

Published on
February 20, 2015

When it comes to the media’s coverage of the measles outbreak, Dr. Douglas J. Opel of the University of Washington is suddenly very much in the spotlight.

That’s largely because Opel, a pediatrician based at Seattle Children’s Hospital and the University of Washington School of Medicine, conducts research that looks at how doctors talk to parents about vaccines. And as the media cycle looks for fresh angles on what’s becoming an increasingly saturated beat, the topic of how doctors talk about vaccines has come to seem like the leading edge of the conversation over how to boost immunization rates (legislative efforts aside).

In a recent Wall Street Journal story, Opel explained why he zeroes in on parents who might be uneasy about vaccines, but not unequivocally opposed:

From a research standpoint, we’re probably most interested in the vaccine-hesitant parents, because they are a growing group, and there’s evidence to suggest that although they’re on the fence about vaccines, they’re still willing and able to change their mind,” said Dr. Opel, who also conducts research on vaccine hesitancy.

Science writer Seth Mnookin may have sparked the surge of interest in Opel’s work with a Feb. 4 online post for The New Yorker, “Talking To Vaccine Resisters.” The post cast him as part of a small vanguard of researchers seeking better data and evidence on how to dispel unfounded fears and speak effectively to parents who may be worried about the safety of proposed vaccines.

That kind of scientific evidence is critical, according to Mnookin, because in the past, “the dearth of reliable data often resulted in a bunch of people relying on their intuition to determine the best way to convince parents that they shouldn’t rely on their intuition.” And that hasn’t always worked out so well, if current rates of vaccine exemptions are any indication.

Last week, Opel published a “viewpoint” piece in the journal JAMA Pediatrics, co-authored by Saad B. Omer of Emory University, that summarizes the essential public health dilemma the measles outbreak has brought to the fore:

[M]ore parents are exercising their choice to refuse or delay vaccination for their child, yet continued widespread acceptance of vaccination is critical to maintain herd immunity and protect the community from diseases that still circulate.

So what are some forward-thinking policy options, aside from raising the bar parents must clear to obtain personal belief exemptions? The available data lead Opel to suggest that doctors should present vaccines as the “default” option, with parents having to opt-out from the requirement rather than opt-in.

While more research is needed, beginning the vaccination discussion… with a statement regarding which vaccines the child will be getting or are due for — rather than a question soliciting parental vaccine preferences — is substantiated by evidence in the fields of behavioral economics and social psychology that suggests that choice architecture can be a powerful means to achieving a desired goal.

Opel is referring here to “nudge theory,” a set of ideas most notably championed by behavioral economist Richard H. Thaler and legal scholar Cass R. Sunstein. Their 2009 book, “Nudge,” is devoted to showing that the way in which decisions are framed can greatly influence the choices people make. (Their work has also captured the attention of the Obama administration, which hired Sunstein as its “regulatory czar.”) To mention one well-known example, some European countries have adopted a rule that presumes citizens are willing to donate their organs unless they explicitly opt out. It turns out that even though the basic options are the same, far more people end up participating in the program when that’s the default choice.

In a 2009 article for The New York Times, Thaler summarized the dramatic differences in organ-donation consent rates between two countries using two different approaches to the problem:

Consider the difference in consent rates between two similar countries, Austria and Germany. In Germany, which uses an opt-in system, only 12 percent give their consent; in Austria, which uses opt-out, nearly everyone (99 percent) does.

Would such a nudge-based approach be similarly effective in persuading hesitant parents to fully vaccinate their children? Opel appears to believe so. He writes that the “nudge” or opt-out approach “leverages the propensity humans have to stick with a decision that is already made, especially among decisions perceived to be complex.”

Vaccination constitutes such a decision for many parents; not only is it complicated by an overwhelming amount of information, it is also fraught with emotion. It is often easier in these situations to simply accept what is recommended, especially when that recommendation is made by someone as influential and trusted as their child’s pediatrician or family practitioner.

Critics may deride such approaches as overly paternalistic or the latest affront by the nanny state, but such a policy ultimately leaves parents with the same choices as before – just through a different frame. For those concerned about balancing a parent’s individual liberties with the larger claims of public health, that’s a far more delicate approach than, say, uniform legislation by states that makes it harder for parents to exempt their child.

Photo by Steven Depolo via Flickr.