Alejandro Hortal PhD, University of North Carolina Greensboro
Vaccination Hesitancy in the Time of Covid-19
Spanish proverbs are full of wisdom. One says that we only remember Saint Barbara when it thunders, meaning that we only think of solutions when the problem is upon us, and it is too late.
In light of the recent crisis caused by the virus Covid-19 I decided to put pen to paper and share some of my previously published ideas in Behavioural Public Policy along with current research. This is with the objective of shedding light on the relationship between immunisation and behavioural public policy.
Currently, while several countries are under lockdowns and public health specialists are deploying interventions to flatten the curve of infection, people are wondering about the possibility of a Covid-19 vaccine. The role of immunization is to reduce the possibility of infection of viral diseases or to make them disappear. Humans’ risk perceptions fall once a virus is no longer an active threat due to health care interventions; we tend to forget that the vaccines are the reason for the health improvement. According to the CDC in the United States, influenza vaccination coverage among adults in 2019 was just 45%. The World Health Organization included vaccine hesitancy in a list of “Ten Threats to Global Health in 2019”.
At this moment, the majority of people understand the benefit of vaccines. In normal times (not during times of pandemic), most people fail to adhere to normal vaccination schedule; some even weigh the possible negative effects of vaccines as a risk factor to consider above the risk of the viral infection itself.
What can health care professionals and public policy experts do in order to decrease vaccine hesitancy? Our current situation can help us understand that vaccines are seen as positive interventions by most people. To this end, health care professionals and public policy experts should direct their work to explain why people fail to get an immunization and aim at changing their behaviour.
Mainstream economics can provide an understanding of why some fail to get immunization:
- Their own risk is low. The individual risk of infection may be low, so they do not see the need to spend money or time on immunization
- Reducing risk to others’ requires exceptional commitment. The idea that people should seek immunization for the benefit of others requires a major act of altruism. They are unwilling to make this sacrifice.
Accordingly, it is plausible that most young healthy econs should not get vaccinated.
Would economic incentives work? Research conducted on giving blood shows that when the act of giving is monetized there may be an increase of participants, but the perspective of the act changes. Giving blood is not the same as getting vaccines, so we must remain cautious about its possible effects. Consequently, a different frame must be used, one that moves away from economic explanations and incentives, and targets other behavioural aspects of our decisions.
Public policy interventions aimed at decreasing vaccine hesitancy must consider the reality of human (bounded) rationality. Educational information about the importance of vaccination is not enough. Nudges that will manipulate the environment to produce predicted changes in behaviour (i.e. default rules in vaccination) sometimes backfire. For example, when the Netherlands changed the default rule in organ donation from opt-in to opt-out with the objective of increasing participation, the nudge produced the opposite effect and participation hit a record low. Mandates, while effective, must work in tandem with educational interventions so citizens cognitively understand the need for such regulations. Interventions should aim at changing behaviours, but they should also target what Raymond Boudon (drawing on Weber) called their axiological rationality, that is, the reasons why they do what they do.
Vaccination avoidance should be understood as the result of many factors that are related to cognitive biases, social circumstances, economic factors, etc. It is a multi-causal event and, as such, public policy interventions should target several factors. For example, in the USA, vaccine hesitancy in African Americans can be caused by its cost or even by a type of distrust among other factors. These causes are not the same as the hesitancy in some countries in Europe or the white population in the USA. Developing public policy interventions, as we know, involves the individual and the socio-economic context. As Nancy Cartwright claims, a policy that works in one place and during a specific moment in history does not guarantee its applicability in a different time or location. Social norms (Bicchieri 2017) play a fundamental role in all this. Understanding how these norms regulate life in a community can help make interventions more effective. Targeting specific members of a community, making sure that they get their vaccines and that others are aware of their vaccinations can decrease vaccine hesitancy. Default rules at health care facilities may work, but only if people visit the facility.
Multiple factors must be considered before effective policies are deployed. In the case of vaccination hesitancy, a good policy should target:
- Cognitive aspects (making sure that people understand how vaccines work),
- Social components (government distrust, etc.),
- Economic circumstances (price, health insurance costs, etc.), and
- Social norms.
Mandates can be effective, but from an ethical and political perspective, they must work in combination with educational interventions. Nudges can also be effective, but they have the possibility of backfiring.
The era of Covid-19 is one of reflection and observation. According to Antonio Regalado explains in MIT Technology Review there are basically three ways to stop the virus for good: restriction of movement and assembly with appropriate testing; wait for it to spread and for survivors to develop herd immunity; or develop a vaccine. He says the first “may be impossible”, and the second “horrible to consider”. But a vaccine is yet to be developed. Faced with this situation countries are using different approaches and multiple methods to fight against the spread of the virus. These extraordinarily unfortunate circumstances should trigger a vast amount of research regarding different public policy interventions, their effectiveness, and their ethical consequences.
The time may be right to harness the hopeful and positive view of vaccines in the 2020 battle against Covid-19 to secure a lasting decrease in vaccine hesitancy, breathing new life into vaccination policy.