Patient Engagement

Increasing Vaccination Without Changing Beliefs

Article · October 5, 2016

What makes the difference between whether you eat a piece of fruit or a candy bar for a snack? Bike to work or drive? Get a flu shot or forgo the vaccination? Would reading a persuasive message filled with facts about the nutritional benefits of fruit, the health consequences of exercise, or the safety and efficacy of the flu shot change your behavior? Research has shown that behavior is less influenced by attempts to change beliefs and more influenced by changes in the environment that facilitate the choice of the healthy option: for example, putting an attractive bowl of fruit on the kitchen table and keeping the candy in the back of the cabinet, providing bike lanes and easy access to bike shares, and offering conveniently available flu shots.

During the past decade, vaccinations have become increasingly convenient. For example, adults can now receive influenza, shingles, pneumococcal, and other vaccinations without an appointment at local retail pharmacies, many of which are open extended hours and on weekends. Expanding convenient access to vaccinations does not target patients’ beliefs or provide education. Instead, it directly influences vaccination behavior. Interventions that increase vaccination are important because vaccine coverage remains too low for many diseases, and a single behavioral act of vaccination can provide long-term protection against an infectious disease.

Education Is Not the Best Solution

Education often is not the best way to boost vaccination rates. Although it may seem logical that changing beliefs and attitudes about the safety and efficacy of vaccines will convince individuals to get vaccinated, educational efforts have a mixed track record — sometimes achieving desired effects, sometimes backfiring, and more often doing nothing at all.

Education is particularly ineffective for changing the resolute beliefs of individuals in the anti-vaccination movement. Effective responses to anti-vaccinators are certainly an important component to a public health strategy for infectious disease control; however, anti-vaccinators make up a small fraction of the population and are far outnumbered by those who miss vaccinations for less-principled reasons. Interventions directed at other segments of the population, such as fence-sitters, may be more cost effective in terms of the number of additional vaccinations administered per unit cost.

Structuring the Environment to Facilitate Vaccination

Rather than attempting to change beliefs or educate patients, an alternative approach is to facilitate action directly by making vaccination more convenient or by using other techniques to cue the desired behavior. Structuring the environment to make vaccination the easily executed behavior is consistent with behavioral insight–driven policy work, which received recent attention with the 2015 announcement of White House Executive Order 13707, authorizing the first-ever Social and Behavioral Sciences Team in the United States.

Behavioral insight interventions are most likely to work for patients who are already familiar with the vaccine and have a neutral or somewhat favorable attitude toward it but have not made getting vaccinated their top priority. Although these interventions have some boundary conditions, their untapped potential for increasing vaccination rates is substantial and often carries little or no cost.

Recent evidence supports the efficacy of the behavioral insight strategy. A meta-analysis of 29 clinical trials investigating interventions designed to encourage vaccination demonstrated that those that focused on organizational change (e.g., offering vaccinations to patients at convenient times) were most effective, whereas more traditional interventions (e.g., reminders and patient incentives) were moderately effective and patient education was least effective. Thus, although the studies in this meta-analysis predate the behavioral insights movement by a decade or more, they support the conclusion that organizational change to facilitate more effective vaccination delivery yields better results than patient education.

Harnessing the Default Effect

A powerful method for changing behavior is to make the desired behavior the default — that is, harnessing the tendency of individuals to stick with the option that will be selected by default if they do not specify otherwise. In a study demonstrating that the default effect increases vaccination rates, university employees received an email telling them that they could make an appointment for a flu shot (default = no appointment) or that they had been automatically scheduled for an appointment that they could cancel (default = appointment). All patients with a scheduled appointment (including the opt-in patients in the first group who made an appointment and the opt-out patients in the second group who did not cancel their appointment) received an automatic reminder email a few days prior to the appointment date. Vaccination rates were higher in the second group (i.e., those who had an appointment by default).

Although automatically scheduling patients for an appointment does not provide them with any additional information about the safety or efficacy of the vaccine, it does make getting vaccinated slightly easier because the appointment is already scheduled. In addition, choosing not to get vaccinated is now more difficult because it entails either cancelling the appointment or not showing up for a scheduled appointment (which some people are reluctant to do).

Planning Prompts

Influenza vaccination rates are also higher when employees are prompted to form implementation intentions (i.e., “if-then” plans that can lead to behavioral modification). In a recent study, corporate employees received postcards informing them about the availability of free on-site flu shots that either did or did not include a suggestion to write down the day and time when they planned to get vaccinated. Those who received the planning prompt were more likely to get vaccinated. As in the previous examples, this type of intervention does not target a change in beliefs or attitudes about the vaccine. Instead, once formed, implementation intentions work by letting the environment control the behavior. For example, if someone plans to stop by the occupational health department for a flu shot on Thursday afternoon right after yoga class, then the act of leaving yoga class serves as the cue to walk over to the occupational health department.

Simple Steps Can Encourage Healthy Behavior

If you want to convince your spouse, sister, or friend to get a flu shot, you could tell them how safe, effective, and pain free it is. But you will likely be more successful if you schedule an appointment for them or if, when you are out doing errands together, you simply stop by a pharmacy that offers flu shots. Environmental designs that increase the convenience of healthy behaviors such as vaccination are often more effective than educational efforts that target beliefs.

New Call for Submissions ­to NEJM Catalyst


A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

More From Patient Engagement
Different Means of Initiating and Sustaining Behavior Change

Patient Engagement Survey: What Creates Behavior Change May Not Sustain It

An NEJM Catalyst Insights Council survey finds that human interaction and social support are vital for patient behavior change and employee wellness programs.

How the EpxSubstanceUse Substance Use Disorder Mobile Health Texting Program Works - Preferred Family Healthcare Epharmix Technology Assisted Care Coordination Project Opioid Abuse

Messaging System Helps Caregivers Keep Tabs on Growing Number of Patients with Substance Use Disorder

One behavioral health provider pilots cost-effective outreach to patients with SUD that checks up on their recovery, triages needs, and facilitates communication.

Gary Kaplan Head Shot

Improving Patient Involvement in Care

The CEO of Virginia Mason on facilitating and enhancing patient participation in care.

Chou01_pullquote_Time to Start Using Evidence-Based Approaches to Patient-Provider Communication

Time to Start Using Evidence-Based Approaches to Patient Engagement

Clinicians must acknowledge that there is a dramatic difference between learning a concept about patient-provider communication and learning the actual skills for effective execution.

Nash01_pullquote - A Requiem for Value-Based Care Population Health.

A Requiem for Population Health?

Despite some fits and starts for value-based care, there is abundant evidence that the concept will continue to survive and thrive.

Steps for Deploying Nudge Unit in Health Care

Nudge Units to Improve the Delivery of Health Care

Key information and important choices are constantly being presented in health care. Yet often the frames or default options used are selected without attention to strategic goals.

What Is Telehealth?

Telehealth: The delivery of health care, health education, and health information services via remote technologies. Read about telehealth technologies, services, and reimbursement issues.

Example Cost of Custom-Built PRO Collection Platform

The Cost of Patient-Reported Outcomes in Medicine

Implementation of routine PRO collection is paramount to measuring and maximizing value in health care.

Mentoring, Education, and Engagement: An Employee Training Technique to Improve Patient Experience and Employee Satisfaction

How open communication and one-to-one mentoring generated team spirit and a learning environment.

Face-to-Face Group Sessions Are the Most Useful Mode of Communication in Health Social Networks

Survey Snapshot: Patient Networks Are Important for Outcomes

NEJM Catalyst Insights Council members overwhelmingly agree that social networks can impact chronic diseases and healthy behaviors, but time commitment and funding prevent their prevalence.


A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »


Patient Engagement Survey: What Creates Behavior…

An NEJM Catalyst Insights Council survey finds that human interaction and social support are vital…

Patients As Customers

103 Articles

Cultivating “Systemness” to Create Personalized, High-Reliability…

Becoming a high-reliability health system that is personalized, efficient, and effective means making some tough…

Patient Incentives

59 Articles

Patient Engagement Survey: What Creates Behavior…

An NEJM Catalyst Insights Council survey finds that human interaction and social support are vital…

Insights Council

Have a voice. Join other health care leaders effecting change, shaping tomorrow.

Apply Now