From: Daniel Schwanen and Rosalie Wyonch
To: Canada’s ministers of public health
Date: January 11, 2019
Re: The Three Cs, Why We Don’t Get that Flu Shot
Despite clinical evidence showing the value of immunization against infectious diseases in the adult population, insufficient attention to lifetime immunization policies persists.
Policymakers need to understand how behavioural sciences and policy design intersect with public health to address the distressingly low rates of adult vaccination.
This brings us to the “Three Cs” of vaccine hesitancy: confidence, complacency and convenience.
Today, we explore all three.
Complacency: Consider the notion of the “default option”. In most settings in Canada, getting a vaccine as an adult – a flu shot, a tetanus and diphtheria booster, a shingles immunization – is essentially a voluntary “opt-in” process – the default option is to not get immunized. These shots are recommended and available, but an adult must actively seek out and give consent to receive these vaccines. Contrast this with childhood immunization where in many provinces parents have follow-up visits with public health nurses after birth and, at school entry, and often have to actively fill out forms to explain incomplete immunization uptake.
Complacency also touches on the behavioural concept of “bounded rationality,” where individuals may make decisions counter to their best interests. With infectious diseases, especially ones that are often treatable and non-life threatening like mumps, chicken pox and the flu, individuals may think that the likelihood of getting infected is low and even if they do get an infectious disease they will be fine. Since people underestimate the risk of serious consequences from vaccine preventable disease, they also underestimate the benefit of receiving a vaccine. This speaks to issues of both complacency and confidence, where misinformation must be overcome and issues like vaccine effectiveness and herd immunity – the need for high community-level uptake to prevent disease spread – contribute to the confusion.
Confidence: The issue of confidence in vaccine utility is a central point of study for how to best “frame” immunization benefits and risks. Pamphlets’ wording, form organization, and survey design have all been shown to affect decisions. For vaccines, much experimentation is currently taking place with the most effective method to inform patients of vaccine benefits and risks, phrasing the benefits as losses or gains – framing the potential outcomes or the positive reassurances affects uptake decisions.
Convenience: Finally, there is convenience, which most individuals will interpret as how easy or hard it is to get vaccinated. Choice architecture can be used to create environments where desirable choices are more obvious and easier to make. Examples for vaccine uptake include the time saved for individuals to be vaccinated at the workplace – something commonly available for healthcare workers – as well as the availability of vaccines to be administered in pharmacies. Both of these interventions have shown some potential to boost uptake.
Providing publicly funded flu shots in pharmacies is another example where improvements to convenience were not sufficient to move the dial on uptake in a major way but improved convenience for those getting vaccinated and reduced costs associated with physician fees and time spent in appointments. Although there are many advantages and benefits from improved convenience – saved time, improved productivity, and expanded educational efforts from pharmacies – more challenging aspects of the underlying issues, such as complacency and confidence, need to be tackled with revised policies that consider well-known aspects of behavioural economics in policy design.
Daniel Schwanen is vice president, research and Rosalie Wyonch is a policy analyst at the C.D. Howe Institute. An earlier version of this Memo appeared last year.
To send a comment or leave feedback, email us at blog@cdhowe.org.
The views expressed here are those of the authors. The C.D. Howe Institute does not take corporate positions on policy matters.
