600716

research-article2015
BBSXXX10.1177/2372732215600716Policy Insights from the Behavioral and Brain SciencesBetsch et al.

Health

Policy Insights from the

Using Behavioral Insights to Increase

Behavioral and Brain Sciences
2015, Vol. 2(1) 61­–73
© The Author(s) 2015
Vaccination Policy Effectiveness DOI: 10.1177/2372732215600716
bbs.sagepub.com

Cornelia Betsch1, Robert Böhm2, and Gretchen B. Chapman3

Abstract
Even though there are policies in place, and safe and effective vaccines available, almost every country struggles with vaccine
hesitancy, that is, a delay in acceptance or refusal of vaccination. Consequently, it is important to understand the determinants
of individual vaccination decisions to establish effective strategies to support the success of country-specific public health
policies. Vaccine refusal can result from complacency, inconvenience, a lack of confidence, and a rational calculation of pros
and cons. Interventions should, therefore, be carefully targeted to focus on the reason for non-vaccination. We suggest
that there are several interventions that may be effective for complacent, convenient, and calculating individuals whereas
interventions that might be effective for those who lack confidence are scarce. Thus, efforts should be concentrated on
motivating the complacent, removing barriers for those for whom vaccination is inconvenient, and adding incentives and
additional utility for the calculating. These strategies might be more promising, economic, and effective than convincing those
who lack confidence in vaccination.

Keywords
anti-vaccination, behavioral insights, tailoring, targeting, vaccination, vaccine hesitancy

Tweets •• When people do not vaccinate because they lack con-

•• Why people don’t #vaccinate: complacency, conve-
nience, confidence, calculation #vaccineswork #vac-
cine #protecttheherd
•• When people don’t #vaccinate because of compla-
cency, communicate the risk of disease
•• When people don’t #vaccinate because it’s inconve-
nient, remove barriers and add incentives
•• When people don’t #vaccinate because they lack con-
fidence in vaccines, it’s important to correct myths:
#vaccineswork
•• When people don’t #vaccinate because the calculated
risks outweigh benefits, emphasize the social good:
#protecttheherd
fidence in vaccines, it is important to correct myths.
•• When people do not vaccinate because they calculate
that risks outweigh benefits, emphasize the social
benefit of vaccination and add incentives.
Vaccination’s Success and Vaccine
Hesitancy
Vaccination has greatly reduced the burden of infectious
diseases. Only clean water, also considered to be a basic human
right, performs better. . . . The benefits of vaccination extend
beyond prevention of specific diseases in individuals. They
enable a rich, multifaceted harvest for societies and nations. . . .
A comprehensive vaccination programme is a cornerstone of
good public health and will reduce inequities and poverty.

Key Points —Andre et al. (2008, p. 140; 143; 144)

•• Non-vaccination can result from complacency, conve-
nience, a lack of confidence, and utility calculation
(the Four C Model).
•• Depending on the reason for non-vaccination, inter-
ventions should be targeted to the active determinants
that impede vaccination.
•• When people do not vaccinate because of compla-
cency, use informational interventions to explain dis-
ease risks and to stress social benefits of vaccination.
•• When people do not vaccinate because it is inconvenient,
remove barriers, support self-control, and add incentives.
Vaccinations save an estimated number of 2 to 3 million lives
per year (World Health Organization [WHO], 2012). For
1
University of Erfurt, Germany
2
RWTH Aachen University, Germany
3
Rutgers University, Piscataway, NJ, USA
Corresponding Author:
Cornelia Betsch, Department of Psychology and Center for Empirical
Research in Economics and Behavioral Sciences (CEREB), University of
Erfurt, Nordhäuser Str. 63, 99089 Erfurt, Germany.
Email: cornelia.betsch@uni-erfurt.de
62 Policy Insights from the Behavioral and Brain Sciences 2(1)
instance, smallpox has been eliminated from the landscape
of diseases due to concentrated efforts—and partially with
policies that mandated vaccination. Diseases such as polio,
measles, and rubella are the next on the list for planned elim-
ination. This dramatic success of vaccinations is recognized
globally and mirrored in country-specific vaccination poli-
cies. In most countries, vaccination is voluntary and based on
expert recommendations from a National Immunization
Technical Advisory Group (Duclos, 2010; WHO, 2015).
Almost every country struggles with vaccine hesitancy,
that is, “the delay in acceptance or refusal of vaccination
despite availability of vaccination services. Vaccine hesi-
tancy is complex and context specific, varying across time,
place and vaccines” (MacDonald & the Strategic Advisory
Group of Experts [SAGE] working group, 2015, p. 1). As a
consequence, there are repeated outbreaks of vaccine-
preventable diseases that consume resources and cost lives.
In addition, the resulting sub-optimal vaccine uptake often
fails to reach thresholds of uptake that are necessary to reach
elimination of certain diseases (e.g., 95% uptake is required
to reach herd immunity to eliminate measles; Fine, Eams, &
Heymann, 2011).
It is, therefore, important to understand the determinants
of individual vaccination decisions to establish effective
interventions that support or complement the success of
country-specific public health policies. Ideally, interven-
tions are directed at the factors that impede vaccination
(Butler & MacDonald, 2015). Among the reasons that are
usually mentioned first in discussions about vaccine refusal
are the anti-vaccination movements and negative attitudes
toward vaccination. However, as we will show, there are
other reasons with a much broader scope and a potentially
more effective set of interventions to increase vaccine
uptake. For example, it can sometimes be more successful
to assist people in the implementation of their decision for
vaccination rather than to run an educational campaign to
change risk perceptions. In general, the current article does
not aim at suggesting policies based on insights from epide-
miology or public health, such as the vaccination of certain
age groups or conducting immunization activities in
schools. Other sources provide valuable insights on this
(such as Briss et al., 2000; Sadaf, Richards, Glanz, Salmon,
& Omer, 2013; Shefer et al., 1999). Rather, this contribu-
tion summarizes strategies that can be used to overcome
vaccine hesitancy and increase vaccine uptake building on
evidence from social and behavioral sciences, particularly
from psychology.
Overview
In this article, we will first outline major psychological deter-
minants of individual-level decision making about vaccina-
tion. In relation to these determinants, we will suggest
psychological profiles of four types of decision makers who
have different reasons to decline vaccination, namely,
(a) those who are complacent and do not care about immuni-
zation, (b) those who do not vaccinate because it is inconve-
nient, (c) those who have a lack of confidence in the vaccine
and the health system, and (d) those who engage in some
reasoning process by weighting pros and cons (utility calcu-
lation). Calculation can lead to non-vaccination either due to
free-riding, that is, the perception that vaccination is unnec-
essary as long as enough other people vaccinate, or due to
fence-sitting, that is, the refusal or inability to make a deci-
sion when pros and cons are weighted equally. We will
finally discuss evidence for the effectiveness of several strat-
egies and outline which determinants of the vaccination
decision each strategy targets. Based on this, we will propose
which strategies might be successful to address compla-
cency, convenience, lack of confidence, and free-riding or
conflict issues, respectively. Table 1 gives an overview of
this analysis.
Factors Influencing Vaccination Behavior
To change vaccination behavior, it is important to understand
which factors determine the decision to vaccinate or to omit
vaccination. Figure 1 visualizes selected determinants of
vaccine decision making. These determinants proved partic-
ularly relevant in predicting the vaccination decision. The
central idea is that individuals take up protective behaviors
(vaccination) when they feel threatened or at risk (Norman,
Boer, & Seydel, 2005), that is, if they perceive high levels of
risk of disease, they will be more likely to vaccinate; if they
perceive high levels of risk of vaccination, they will become
less likely to vaccinate. Perceived risk is often channeled via
anticipated emotions, such as anticipated regret and worry
(e.g., Betsch & Schmid, 2013; Chapman & Coups, 2006;
Loewenstein, Weber, Hsee, & Welch, 2001). Feeling at risk
is usually more strongly related to behavior than knowing
about risks (Loewenstein et al., 2001). Any information, for
example, from campaigns, conversations, information from
anti-vaccination websites, and so on, will be translated to a
subjective representation of risk. As humans are not perfect
information processors, this will not result in a 1:1 represen-
tation of the encoded information. Individual differences,
such as numeracy (ability to process and use numbers; Peters
et al., 2006) or health literacy (Berkman, Sheridan, Donahue,
Halpern, & Cotty, 2011), can influence the translation from
objective to subjective representations. Moreover, the format
in which information is displayed can influence the percep-
tion of risk (Hawley et al., 2008; Slovic, Finucane, Peters, &
MacGregor, 2012) as can a range of cognitive biases (nega-
tivity bias, Siegrist & Cvetkovich, 2001; narrative bias,
Betsch, Renkewitz, Betsch, & Ulshöfer, 2010; Betsch,
Renkewitz, & Haase, 2013; availability bias, Tversky &
Kahnemann, 1973). It is also important to note that the
encoded information is not always correct, as several myths
Betsch et al. 63

Figure 1.  Determinants of vaccine decision making.

Note. The summary of determinants follows theoretical and empirical work by Janz and Becker (1984); Rosenstock (1974); Betsch and Wicker (2012);
Ajzen (1991); Betsch, Böhm, and Korn (2013); Roberto, Krieger, Katz, Goei, and Jain (2011); Gerend and Shepherd (2012); Milne, Sheeran, and Orbell
(2000); Payaprom, Bennett, Alabaster, and Tantipong (2011). Interventions should address these determinants to increase vaccine uptake. Table 1 shows
which interventions are suitable for changing the major active determinants that impede vaccination clustered by type of non-vaccinator.

about vaccination circulate (e.g., about vaccine safety; Kata,
2012).
In addition, there are several factors that directly affect
the vaccination decision or that modify the effect of subjec-
tive risk perception on vaccination intention and behavior.
Importantly, attitudes toward vaccination are a strong predic-
tor of vaccination and also moderate the effect of risk percep-
tions on vaccine uptake (Godin, Vézina-Im, & Naccache,
2010; Herzog et al., 2013; Hollmeyer, Hayden, Poland, &
Buchholz, 2009; LaVail & Kennedy, 2012). Strong attitudes
against vaccination often come out of a particular identity
(e.g., anthroposophy; Sobo, 2015) and can override rational
thought and decision processes (Fazio & Olson, 2014).
Furthermore, social norms affect a decision maker’s vaccina-
tion intention and behavior in various ways (Allen et al.,
2009). Social norms are shared rules within a group that
determine behavior (Cialdini et al., 2006). The so-called
“injunctive” norm expresses the way in which people should
behave. Non-adherence can be sanctioned, which makes
injunctive norms effective (Oraby, Thampi, & Bauch, 2014).
The descriptive norm reflects what people usually do, such
as the current level of vaccine uptake. When the majority is
vaccinated, individuals are likely to conform to the majoity’s
behavior and will get vaccinated, too (bandwagoning;
Hershey, Asch, Thumasathit, Meszaros, & Waters, 1994).
However, there is recent evidence that high population
uptake also induces free-riding behavior (Böhm, Betsch, &
Korn, under review; Ibuka, Li, Vietri, Chapman, & Galvani,
2014; Vietri, Li, Galvani, & Chapman, 2012). That is, some
individuals do not vaccinate if they are aware that there is
sufficient uptake in the population to keep infection risks low
(due to herd immunity; Fine et al., 2011). Norms can also be
counter-productive if the social norm is to refuse vaccination
(e.g., Sobo, 2015). Moreover, a new decision may not be
prompted each time a vaccination is due. In line with the
psychological saying, “Past behavior is the best predictor of
future behavior” (Mischel, 1968, p. 139), past vaccinations
(e.g., against influenza) predict future vaccination behavior
very well (e.g., Lin et al., 2010; Nowalk et al., 2010). Last,
even if an individual is generally willing to vaccinate, struc-
tural barriers can hinder eventual implementation of the vac-
cination (Gerend, Shepherd, & Shepherd, 2013; Rosenstock,
1974). Greater barriers are therefore associated with less
behavioral change (Abraham & Sheeran, 2005; Harrison,
Mullen, & Green, 1992) and less vaccination (Kimmel,
Burns, Wolfe, & Zimmerman, 2007). Such barriers include
the ease of accessibility and the resulting effort, and inconve-
nience or potential financial costs.
In sum, information about objective risks leads to a sub-
jective representation of risks related to vaccination and non-
vaccination. Other variables such as vaccination attitude, the
salience of social norms, vaccine uptake in the population,
64 Policy Insights from the Behavioral and Brain Sciences 2(1)
and barriers influence vaccination decision making. In the
next section, we will refer to these determinants when we
describe four prototypical types of non-vaccinators.
Why People Do Not Vaccinate:
The Four C Model
Global efforts to understand vaccine hesitancy were concen-
trated in the WHO–SAGE vaccine hesitancy working group.
The main outcome is the “Three C model,” claiming that
complacency, a lack in confidence, and convenience issues
impede vaccination (e.g., Dubé, Gagnon, Nickels, Jeram, &
Schuster, 2014; MacDonald & the SAGE Working Group,
2015). Based on the determinants reported above, we will try
to sketch a more psychological profile of these types and
suggest constellations of determinants that match and com-
plement the description of the SAGE working group. In
addition, we would like to propose a fourth “C,” namely, the
degree of rational calculation that individuals engage in
before deciding, as there is converging evidence that strate-
gic behavior also plays a role in vaccination decision making
(e.g., Bauch & Bhattacharyya, 2012; Bauch & Earn, 2004;
Betsch, Böhm, & Korn, 2013; Chapman et al., 2012; Cohen,
Brezis, Block, Diederich, & Chinitz, 2013; Galvani, Reluga,
& Chapman, 2007; Ibuka et al., 2014).
Complacency “exists where perceived risks of vaccine-
preventable diseases are low and vaccination is not deemed a
necessary preventive action” (MacDonald & the SAGE
Working Group, 2015, p. 2). Thus, general involvement in
the decision is low because complacent individuals do not
feel threatened by infectious diseases. And if individuls do
not feel at least a minimum level of threat, they will not
engage in protective behavior (Schwarzer & Fuchs, 1996). It
can be assumed that knowledge, awareness, and the level of
active information search are also low (Fischer et al., 2011).
The attitude toward vaccination is weak, which means that it
does not predict behavior very well (Glasman & Albarracín,
2006). The preventive behavior is not seen as the descriptive
or injunctive norm in the society. It is likely that there is no
habit to vaccinate. Thus, complacent people passively omit
vaccination rather than actively decide against it.
Convenience is an issue when “physical availability,
affordability and willingness-to-pay, geographical accessi-
bility, ability to understand (language and health literacy) and
appeal of immunization service affect uptake” (MacDonald
& the SAGE Working Group, 2015, p. 3). In other words,
even if there is a positive intention to vaccinate, structural
barriers such as difficult access or a lack of self-control (will
power) block the implementation of the vaccination decision.
Barriers can be seen as “gate-keepers” as, for instance,
although most people agree that vaccination is important,
other personal issues seem more important or urgent—and
then making the vaccination appointment gets subordinated
under other obligations. This type relates to what is known as
the intention-behavior gap in the psychological literature
(Sheeran, 2002). Attitudes are not strongly against or in favor
of vaccination in this case, which means that vaccination is
not important enough to actively overcome barriers.
Consequently, when decision makers face barriers such as
lack of access, cost, or travel time, they decline vaccination
to avoid these barriers.
The term confidence “is defined as trust in (i) the effec-
tiveness and safety of vaccines, (ii) the system that delivers
them, including the reliability and competence of the health
services and health professionals, and (iii) the motivations of
policy-makers who decide on the need of vaccines”
(MacDonald & the SAGE Working Group, 2015, p. 2).
Lack of confidence can lead to a failure to vaccinate
(LaVail & Kennedy, 2012). This type of non-vaccinators
usually holds strong negative attitudes toward vaccination
(in contrast to the complacency and convenience types).
Vaccination knowledge is likely to be distorted by misinfor-
mation about risks posed by vaccination (Zingg & Siegrist,
2012) or by affiliation to certain social groups close to the
anti-vaccination movement (Sobo, 2015). If there is a per-
ception of vaccination as a norm or coercion, reactance will
lead to consciously counteracting this norm (Betsch &
Böhm, in press; Brehm, 1966). Thus, this type of vaccine
hesitancy results from a plethora of circumstances that can
cause a strong negative vaccination attitude that stops any
deliberate decision process and leads directly to behavior
determined by the negative attitude (Fazio & Olsen, 2014;
Glasman & Albarracín, 2006).
The involvement in the vaccination decision is high for
parents who engage in subjective expected utility calcula-
tion. They engage in an extensive information search for pros
and cons of vaccination. These individuals do not have a
strong pre-existing attitude toward vaccination but base their
decisions on utility maximization, which leads to vaccination
or non-vaccination, depending on the subjective evaluations
of risks. If the risk of infection is perceived to be lower than
the risk of vaccination, the decision will be against vaccina-
tion. One reason for this perception is that usually many others
in the population are vaccinated, which leads to a low overall
risk of infection (Fine et al., 2011). This can result in free-rid-
ing, that is, the idea that it is selfish-rational to omit vaccina-
tion as long as enough other individuals are vaccinated to keep
the infection risk low. In addition, high involvement and cal-
culating can also lead to an abundance of contradictory infor-
mation. Facing conflicting information, for example, when
doctors present different information than friends or vaccine-
critical websites, will lead to indifference, that is, the same
expected utility from vaccination and non-vaccination, which
leads to fence-sitting. Fence-sitting refers to a state of indeci-
sion or refusal of decision making, which means that there is
no clear preference for or against vaccination (Leask, 2011)—
similar to someone sitting on a fence who cannot decide on
which side he or she should jump down. Any additional
Betsch et al. 65
information about costs or (social) benefits will influence the
decision because it is included in and updates the utility
calculation.
The next section presents strategies demonstrated in the
literature to increase vaccination behavior that have been
proven effective in the domain of vaccinations or other areas
of health decision making. In the final “Policy Implications”
section, we will link the Four C Model to specific interven-
tions (cf. also Table 1).
Strategies to Increase Vaccination
Strategies to increase vaccination uptake can be directed at
different aspects of the decision process and at different
determinants of the decision. The decision process starts
with information that the decision maker translates into sub-
jective representations. Thus, informational interventions
can be used to influence risk perceptions, correct myths,
raise awareness, and strengthen the positive attitude toward
vaccination. Structural interventions can increase the proba-
bility of vaccination by changing parts of the vaccination
policy that are related to known biases and behavioral habits
(e.g., changing from opt-in systems to opt-out systems).
Finally, interventions can aim at minimizing the intention-
behavior gap by fostering the implementation of existing
positive intentions to vaccinate, for example, via increasing
individuals’ self-control or creating external reminders that
facilitate vaccination.
Informational Interventions: Providing Necessary
Information
Informational interventions aim at improving the data base,
i.e., the available and accessibe information that an individual
decision maker uses to make a decision. These interventions
can improve knowledge about risks of diseases, explain the
social value of vaccinations, or correct misperceptions (e.g.,
about risks of vaccination) and myths about vaccination.
Campaigns to change risk perceptions. Fear appeals can be
used to increase the perceived risk of infectious diseases. A
meta-analysis from the year 2000 demonstrated that health
messages creating strong fear in the receiver and, at the same
time, providing advice that increases self-efficacy were most
successful in changing behavior (Witte & Allen, 2000).
Another overview concludes that self-efficacy information is
more important than the actual arousal of fear (Ruiter, Kes-
sels, Peters, & Kok, 2014). In addition, a recent study showed
that presenting pictures of sick children or dramatic narra-
tives about a child in danger from vaccine-preventable dis-
ease did not lead to the intended change in vaccination
intention (Nyhan, Reifler, Richey, & Freed, 2014). Thus,
although it is important that public health agencies explain
the risks that are related to vaccine-preventable diseases as
well as to increase self-efficacy to overcome this threat by
vaccination, creating fear for persuasive reasons is not
advisable.
Campaigns with appeal to social motives.  Vaccinations provide
direct protection to the vaccinating individual. Additionally,
they also have an indirect effect on other non-vaccinated
individuals by increasing herd immunity (Fine et al., 2011).
This is important because some individuals are too young or
ill to vaccinate themselves. It has been shown that the com-
munication of such social (rather than individual) benefits
from vaccinations increases the vaccination intention, par-
ticularly when the risk associated with vaccination is low and
vaccination comes with low effort (Betsch, Böhm, & Korn,
2013; Shim, Chapman, Townsend, & Galvani, 2012). Hence,
such appeals to social motives should increase vaccination
intentions among individuals with social preferences regard-
ing the welfare of others. This type of intervention is effec-
tive when it is directed at pregnant women, as a recent study
shows (Wiley, Cooper, Wood, & Leask, 2015), where moth-
ers expressed a higher intention to get vaccinated against
pertussis when the vaccine was described as a protection for
their baby rather than for themselves.
Campaigns debunking vaccination myths.  Parents who decide
against vaccination often hold misperceptions about vaccina-
tion (Zingg & Siegrist, 2012). Therefore, it is necessary to find
interventions that effectively correct the misinformation and
myths. Interventions that provide an alternative account of the
myth have been proven successful in eliminating misinforma-
tion (H. M. Johnson & Seifert, 1994; Tenney, Cleary, & Spell-
man, 2009). However, debunking attempts can also backfire or
have only partial positive effects. For instance, Nyhan et al.
(2014) presented parents with one of four messages about the
measles, mumps, and rubella (MMR) vaccine or a control mes-
sage. The messages corrected misinformation about the link
between vaccination and autism, conveyed information on the
risk of the diseases prevented by the MMR vaccine, presented
a narrative about the dangers of measles, or presented pictures
of children with measles, mumps, and rubella. None of the
messages increased the intention to vaccinate. Some of these
messages even had counter-predicted effects. Whereas the
message correcting misinformation about the link with autism
did decrease parents’ stated belief that vaccines cause autism, it
also decreased intention to vaccinate one’s next child. Further-
more, the pictures of sick children actually increased parents’
belief in the link between vaccination and autism. The narrative
about the dangers of measles increased parents’ concern about
MMR side effects. In another study, debunking was combined
with an intervention that increased the individual’s self-worth
(Nyhan & Reifler, under review). This led to more effective
debunking, showing that holding on to misinformation can also
be related to keeping up a certain identity (Sobo, 2015). Thus,
as messages debunking vaccination myths do not always
66 Policy Insights from the Behavioral and Brain Sciences 2(1)
have the desired effect, they should be created carefully, pre-
tested for their effectiveness, and potentially combined with
other interventions.
A recent publication by the European Centre for Disease
Prevention and Control (ECDC) provides several examples
of how to debunk myths about the measles, mumps, and
rubella vaccine (ECDC, 2014), based on extensive psycho-
logical research on how to create effective debunking materi-
als (Lewandowsky, Ecker, Seifert, Schwarz, & Cook, 2012).
The basic building blocks are to emphasize the facts, not the
myth. The introduction should start with the facts to make
them easy to memorize and use a limited number of key facts
to keep it simple. Explicit warnings should precede any men-
tion of a myth. Any gaps in the mental model left by the
debunking need to be filled, for example, by providing an
alternative explanation. Core facts should be displayed
graphically if possible. Language should be careful as strong
risk negations can backfire (ECDC, 2014).
Campaigns to foster vaccine acceptance.  It is not only impor-
tant which information is given, but also how to provide it.
For many health behaviors, framing information in terms of
gains versus losses has differential effects on behaviors (Gal-
lagher & Updegraff, 2012; Updegraff & Rothman, 2013).
Ferguson and Gallagher (2007) found that for participants at
high perceived risk of the flu, a gain-framed message (flu
shot is effective in 80% of cases) was more effective than a
loss-framed message (flu shot is ineffective in 20% of cases).
In addition, a negatively framed goal message (if you don’t
get a flu shot, you fail to take advantage of an 80% chance of
preventing flu) was more effective than a positively framed
goal message (if you get a flu shot, you reduce your risk of
the flu by 80%). Participants at low perceived risk showed no
framing effects.
Structural Interventions: Changing the Structure
of the Decision
Making changes in the structure of the vaccination decision
can affect the likelihood of deciding in favor of vaccination. If
incentives are introduced (by giving rewards or reducing costs),
the utility of vaccination increases, which makes vaccination
more likely. Moreover, it is crucial what the default option is,
that is, the option that is implemented if one does nothing.
Finally, a drastic change in the decision structure is to make
vaccination mandatory, as this eliminates nearly all choice. The
following discusses these structural interventions.
Changing incentives.  Incentives are rewards and/or fines asso-
ciated with vaccination decisions that have been shown to
significantly increase vaccine uptake (for a meta-analysis
see, for example, Stone et al., 2002). For instance, college
students were more likely to get a flu shot when offered a
US$20 reward (19% vs. 9%; Bronchetti, Huffman, &
Magenheim, 2015). Furthermore, a study by Moran, Nelson,
Wofford, Velez, and Case (1996) showed that a US$50 gift
certificate for groceries offered for vaccination increased
vaccine uptake from 20% in the baseline to 29%. Interest-
ingly, in combination with mailed client reminders, the
incentive increased uptake only by 6%. This is a good exam-
ple of how incentives can increase vaccine uptake; however,
it also points to potential motivational crowding-out effects,
that is, the phenomenon that voluntary behavior may decrease
when it is rewarded (see also, for example, Gneezy & Rus-
tichini, 2000). Another possibility to change incentives is to
reduce costs: A review concludes that there is convincing
evidence that reducing out-of-pocket costs increases vaccine
uptake (Briss et al., 2000).
Changing defaults. People pre-scheduled for a flu shot
appointment (which they can cancel if they do not want it)
are more likely to get vaccinated than those who are not pre-
scheduled but who can make an appointment if they want
one (Chapman, Li, Colby, & Yoon, 2010). This intervention
capitalizes on the default effect or the tendency for people to
stick with the option they will get automatically if they do
not take explicit action. For the pre-scheduled group, the
default is having a flu shot appointment, whereas for the
comparison group, the default is not having an appointment.
Whereas both groups have a choice to have a flu shot appoint-
ment or not, most people tend to stick with their default sta-
tus. Furthermore, having a flu shot appointment is a strong
predictor of actually getting a flu shot (in part, because those
with an appointment received a reminder email prior to the
appointment date, in line with standard clinic practices).
Mandatory/compulsory vaccination.  Vaccination mandates for
health care workers are met with high compliance rates
(Pitts, Maruthur, Millar, Perl, & Segal, 2014; Rakita, Hagar,
Crome, & Lammert, 2010). In the United States, public
school districts and private schools routinely mandate that
children be current on vaccinations as a precondition for
school registration. However, families are permitted to opt-
out of the mandatory vaccinations for medical, religious, or
personal reasons, and so the mandate acts as a type of opt-out
default. The ease of opting out varies by State, and the States
where opting out of the mandate is easier have lower vacci-
nation rates and higher rates of pertussis disease (Omer et al.,
2006). The January 2015 measles outbreak at the Disneyland
theme park was made possible because of the number of
unvaccinated children visiting the park (Centers for Disease
Control and Prevention [CDC], 2015). In response to this
incident, California passed a law in June 2015 removing all
non-medical exemptions to vaccine requirements for school
entry, making California the strictest State in the United
States in terms of vaccination policy other than Mississippi
and West Virginia (Haelle, 2015). Indeed, making the opt-out
more difficult proved effective in increasing vaccine uptake
Betsch et al. 67
in previous studies (Omer et al., 2006; Omer, Richards,
Ward, & Bednarczyk, 2012).
The (negative) consequences in case of an individual’s
non-vaccination, that is, punishment, are either rather direct
(e.g., enforced vaccination by administrative bodies) or indi-
rect by excluding the individual from certain activities (e.g.,
unvaccinated children are excluded from child care facili-
ties). Mandatory/compulsory vaccination applies either to
the whole vaccine program of a country (e.g., Czech
Republic) or as a method to partly force people to some par-
ticularly important vaccinations (e.g., Belgian mandate for
polio vaccination). Whether to make vaccinations mandatory
is certainly a matter of ethics and ideology. Beyond ethical
concerns, recent evidence suggests that partial compulsory
vaccination may also backfire as it leads to reactance among
those with a negative vaccination attitude, decreasing, in
turn, their vaccine uptake in other voluntary vaccinations
(Betsch & Böhm, in press).
Interventions Supporting Self-Control and
Implementation
Although the intention to vaccinate should, theoretically,
lead to vaccination (Ajzen, 2012), there is ample evidence
that the relation between intention and behavior is imperfect
(Sheeran, 2002). Several interventions have been proposed
to translate the intention into behavior by means of fostering
self-control or by reducing external barriers that impede vac-
cination. The following provides an overview of the relevant
interventions.
Implementation intentions.  Implementation intentions (Goll-
witzer & Sheeran, 2006) are specific plans about when and
how one will carry out an action. In one study, employees
who received a postcard about available workplace flu shots
were more likely to vaccinate if they were prompted to write
down when they planned to come for the vaccination (Milk-
man, Beshears, Choi, Laibson, & Madrian, 2011). The effect
was most pronounced if the flu shots were only available
on-site for 1 day.
Pre-commitment. Several strategies targeting self-control
have never been evaluated with vaccination but have proved
effective with other health behaviors. Pre-commitment
entails binding oneself to a course of action such that one
cannot later reverse course without incurring a cost (Rogers,
Milkman, & Volpp, 2014). For example, Schwartz et al.
(2014) invited grocery store shoppers to pre-commit to buy-
ing more healthy foods such as fresh produce. The shoppers
received a discount for the healthy foods they purchased.
Those who pre-committed agreed to relinquish that discount
unless they met their goal of increasing their purchase of
health foods by a specified percentage. The shoppers who
were invited to make an actual binding pre-commitment
increased their healthy food purchase relative to a group who
merely indicated hypothetically whether they would pre-
commit. This idea could be applied to vaccination if patients
were asked to pre-commit to the recommended vaccination
plan far in advance. For example, when scheduling one’s
child’s wellness exam for next year, the parent could be
asked to pre-commit to approving the scheduled vaccines for
the child and to put down a deposit that would only be
returned (with perhaps a bonus) once the vaccine had been
administered.
Reminders and recall systems.  There is large support for the
effectiveness of reminders/recall on vaccine uptake (for
meta-analysis/review, see Briss et al., 2000; Groom et al.,
2014; Stone et al., 2002; Szilagyi et al., 2000). To just name
a few examples, influenza immunization in children
increased when parents received a reminder in a U.S. field
experiment (42% compared with 25% in the control group;
Daley et al., 2004). Recalls have been shown to be a particu-
larly cost-effective tool to increase vaccine coverage among
adults and children (Kempe et al., 2013; Suh et al., 2012).
Text-message reminders via telephones or smartphone,
which are suitable to also reach a low-income, urban popula-
tion (Stockwell et al., 2012), complement classic approaches
that build on emails or phone calls.
Recommendations. A lack of physician recommendations is
among the most common reasons for non-vaccination (D. R.
Johnson, Nichol, & Lipczynski, 2008). Studies show that
recommendations increase uptake (Bovier, Chamot, Gallac-
chi, & Loutan, 2001; Gargano et al., 2013), especially if they
are strong: Women who received a strong recommendation
were 4 times more likely to get vaccinated against human
papillomavirus (HPV) than women who received one that
was not strong (Rosenthal et al., 2011).
Conclusions and Policy Implications:
How to Enhance a Vaccine Policy’s
Success by Targeting Reasons for
Vaccine Hesitancy
We suggest that different types of non-vaccinators have dif-
ferent sets of “active determinants” that influence their deci-
sions. Furthermore, we propose that interventions should be
targeted to these differences (see also Butler & MacDonald,
2015). This section discusses which interventions can be
promising for which type of non-vaccination based on the
evidence currently available. Table 1 summarizes the discus-
sion. Further research is needed to test whether these inter-
ventions and combinations of interventions are especially
suitable for the suggested types of non-vaccinators.
Strategies directed at complacent individuals should raise
the perceived risk of disease, stress the social benefit, and
highlight that vaccination is the norm. Furthermore, a posi-
tive attitude toward vaccination should be strengthened.
68 Policy Insights from the Behavioral and Brain Sciences 2(1)

Table 1.  Suggestions for Interventions According to the Reason for Non-Vaccination.

Complacency Convenience Confidence Calculation

Goals: Goals: Goal: Goals:
•• Raise perceived risk of •• Strengthen positive •• Debunk myths •• Raise perceived risk
infection attitude toward of infection
•• Stress social benefit vaccination •• Debunk myths
•• Stress that vaccination is •• Change structure to •• Stress social benefit
the norm facilitate vaccination •• Add incentives
•• Strengthen positive •• Strengthen self-control
attitude toward and the implementation
vaccination
Informational interventions
  Campaigns to raise risk X X X
perceptions
  Campaigns with appeal to social X X X
motives
  Debunking vaccination myths X X X X
  Campaigns to foster vaccine X X  
acceptance: framing
Structural interventions
 Incentives X X X
  Default = Opt-out X X  
 Mandatory/compulsory X X X
vaccination
Interventions to support self-control and implementation
  Implementation intentions X  
 Pre-commitment X  
 Reminders X  
  Making strong X X  
recommendations

Note. The table gives suggestions regarding which strategy can address potential determinants of vaccine refusal that we see as predominant in certain
types of non-vaccinators. There are not enough studies to make evidence-based recommendations. Moreover, it has not been tested whether these
interventions are especially suitable for the suggested types of non-vaccinators. Future research should address this question.

Informational interventions to correct misinformation, raise
awareness, and increase the visibility of the topic should lead
to a stronger positive attitude (Fazio, 2007). Furthermore,
structural interventions help to provide (external) reasons or
motivation to vaccinate. Interventions that are directed at the
implementation of the decision require an already formed
intention, which does not exist in complacent individuals.
Only strong recommendations should increase uptake:
Physicians can anchor strong recommendations in explicat-
ing the risk of diseases and make clear that vaccination is
important to prevent them.
For individuals heavily influenced by convenience issues,
interventions should aim at eliminating structural barriers to
vaccination if they are known (Kimmel et al., 2007). In addi-
tion, it is important to strengthen a positive attitude toward
vaccination. The latter can be achieved by informational inter-
ventions. Structural interventions such as changing the default
option should also be effective, because here the implementa-
tion of the decision is the major problem. For the same reason,
all interventions that strengthen self-control or the implemen-
tation should have a positive impact in this group.
Individuals with a lack of confidence usually possess a
considerable amount of incorrect knowledge that distorts
risk perceptions and undermines the general trust in vaccina-
tion. It is important that interventions aim at debunking these
myths and that trustworthy sources, such as doctors, do so.
We assume that all other strategies will have no positive
effect and could even have negative effects. Other informa-
tional interventions seem too weak to change strong anti-
vaccination attitudes. Their persuasive appeal (such as fear
appeals or gain-framed messages) is likely to be devaluated
and leads to reactance. Structural interventions such as
changing defaults should not work in this group, as there is
usually high involvement in the decision process (cf. large
opt-out rates in States where opting out is easily attainable;
Omer et al., 2012). Similarly, incentives would likely need to
be very high to convert those principally opposed to vaccina-
tion. In a similar vein, all interventions directed at self-con-
trol or the implementation of the decision are not suitable for
this type of non-vaccinators. This analysis reveals that those
who lack confidence and have a negative attitude are the
hardest to convert.
Betsch et al. 69
For individuals that rationally calculate by weighting
potential gains and losses of vaccination, it is important to
provide a basis of correct knowledge and to increase the cor-
rect translation of the objective information into subjective
representations. Informational interventions help to correct
misinformation or add information in favor of vaccination,
which is particularly important when calculation results in
fence-sitting, that is, inaction due to contradictory informa-
tion. Moreover, structural interventions that increase the
utility of vaccination are well targeted at calculating indi-
viduals. If we assume that calculating individuals are per-
fectly rational decision makers, framing and changes of the
default should be fairly ineffective. In a similar vein, all
interventions that aim to improve the implementation of the
decision should not be necessary, as a rational decision
maker should implement the option with the highest expected
utility.
To make such a targeted approach successful, it is crucial
to regularly monitor a societies’ attitudes toward vaccination
and to assess the distribution of confidence, complacency,
convenience, and calculation within a society before inter-
ventions are planned and rolled out. Social media such as
Twitter can serve as a valuable tool to learn more about a
societies’ thinking about vaccination (e.g., Infoveillance,
Eysenbach, 2009; Vaccine Confidence Project, Larson et al.,
2013). Other approaches, such as the “Tailoring Immunization
Programs” tool by the WHO/Euro (Butler & MacDonald,
2015), work toward targeted solutions by applying a social-
science research approach to the population in question (e.g.,
health care workers, asylum seekers, etc.).
The usual first guess is not correct, which assumes that
vaccine hesitancy occurs because anti-vaccination move-
ments infect the public with a lack of confidence and mis-
trust (see also Dubé et al., 2014). Instead, complacency,
convenience, and calculation can also play a role. As the
above analysis has shown, there are a lot more interventions
that promise to be effective for complacent, convenient, and
calculating individuals whereas there is only one method that
might be effective for those who lack confidence. Thus,
efforts should be concentrated on motivating the complacent,
removing barriers for those for whom vaccination is incon-
venient, and adding incentives and additional utility for the
calculating. These strategies might be more promising, eco-
nomic, and effective than convincing those who lack confi-
dence in vaccination.
Acknowledgments
The authors gratefully acknowledge the valuable support by Cindy
Holtmann and Lars Korn. The authors also thank Mandeep K.
Dhami for her helpful feedback on an earlier version of this article.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
References
Abraham, C., & Sheeran, P. (2005). The health belief model. In
M. Conner & P. Norman (Eds.), Predicting health behaviour:
Research and practice with social cognition models (pp. 28-
80). New York, NY: Open University Press.
Ajzen, I. (1991). The theory of planned behavior. Organizational
Behavior and Human Decision Processes, 50, 179-211.
doi:10.1016/0749-5978(91)90020-T
Ajzen, I. (2012). The theory of planned behavior. In P. A. M.
Lange, A. W. Kruglanski, & E. T. Higgins (Eds.), Handbook of
theories of social psychology (pp. 438-459). London, England:
SAGE.
Allen, J. D., Mohllajee, A. P., Shelton, R. C., Othus, M. K.
D., Fontenot, H. B., & Hanna, R. (2009). Stage of adop-
tion of the human papillomavirus vaccine among college
women. Preventive Medicine, 48, 420-425. doi:10.1016/j.
ypmed.2008.12.005
Andre, F. E., Booy, R., Bock, H. L., Clemens, J., Datta, S. K., John,
T. J., . . . Schmitt, H. J. (2008). Vaccination greatly reduces
disease, disability, death and inequity worldwide. Bulletin of
the World Health Organization, 86, 140-146. doi:10.2471/
BLT.07.040089
Bauch, C. T., & Bhattacharyya, S. (2012). Evolutionary game theory
and social learning can determine how vaccine scares unfold.
PLoS Computational Biology, 8(4), e1002452. doi:10.1371/
journal.pcbi.1002452
Bauch, C. T., & Earn, D. J. D. (2004). Vaccination and the theory
of games. Proceedings of the National Academy of Sciences of
the United States of America, 101, 13391-13394. doi:10.1073/
pnas.0403823101
Berkman, N. D., Sheridan, S. L., Donahue, K. E., Halpern, D. J.,
& Crotty, K. (2011). Low health literacy and health outcomes:
An updated systematic review. Annals of Internal Medicine,
155, 97-107. doi:10.7326/0003-4819-155-2-201107190-00005
Betsch, C., & Böhm, R. (in press). Detrimental effects of introduc-
ing partial compulsory vaccination: Experimental evidence.
European Journal of Public Health. doi:10.1093/eurpub/
ckv154
Betsch, C., Böhm, R., & Korn, L. (2013). Inviting free-riders or
appealing to prosocial behavior? Game-theoretical reflections
on communicating herd immunity in vaccine advocacy. Health
Psychology, 32, 978-985. doi:10.1037/a0031590
Betsch, C., Renkewitz, F., Betsch, T., & Ulshöfer, C. (2010).
The influence of vaccine-critical websites on perceiving vac-
cination risks. Journal of Health Psychology, 15, 446-455.
doi:10.1177/1359105309353647
Betsch, C., Renkewitz, F., & Haase, N. (2013). Effect of narra-
tive reports about vaccine adverse events and bias-awareness
disclaimers on vaccine decisions: A simulation of an online
patient social network. Medical Decision Making, 33, 14-25.
doi:10.1177/0272989X12452342
Betsch, C., & Schmid, P. (2013). [Does fear affect the willingness to
be vaccinated? The influence of cognitive and affective aspects
of risk perception during outbreaks]. Bundesgesundheitsblatt,
70 Policy Insights from the Behavioral and Brain Sciences 2(1)
Gesundheitsforschung, Gesundheitsschutz, 56, 124-130.
doi:10.1007/s00103-012-1595-z
Betsch, C., & Wicker, S. (2012). E-health use, vaccination knowl-
edge and perception of own risk: Drivers of vaccination uptake
in medical students. Vaccine, 30, 1143-1148. doi:10.1016/j.
vaccine.2011.12.021
Böhm, R., Betsch, C., & Korn, L. (under review). Strategic vacci-
nation: Experimental evidence from an interactive vaccination
game. Manuscript submitted for publication.
Bovier, P.A., Chamot, E., Gallacchi, M-B., & Loutan, L. (2001).
Importance of patients’ perceptions and general practitioners’
recommendations in understanding missed opportunities for
immunisations in Swiss adults. Vaccine, 19(32), 4760-4767.
Brehm, J. W. (1966). A theory of psychological reactance. New
York, NY: Academic Press.
Briss, P. A., Rodewald, L. E., Hinman, A. R., Shefer, A. M.,
Strikas, R. A., & Bernier, R. R., . . . Task Force on Community
Preventive Services. (2000). Reviews of evidence regarding
interventions to improve vaccination coverage in children, ado-
lescents, and adults. American Journal of Preventive Medicine,
18, 97-140. doi:10.1016/S0749-3797(99)00118-X
Bronchetti, E. T., Huffman, D. B., & Magenheim, E. (2015).
Attention, intentions, and follow-through in preventive health
behavior: Field experimental evidence on flu vaccination.
Journal of Economic Behavior & Organization, 116, 270-291.
doi:10.1016/j.jebo.2015.04.003
Butler, R., & MacDonald, N. E. (2015). Diagnosing the determi-
nants of vaccine hesitancy in specific subgroups: The guide to
Tailoring Immunization Programmes (TIP). Vaccine. Advance
online publication. doi:10.1016/j.vaccine.2015.04.038
Centers for Disease Control and Prevention. (2015). Measles cases
and outbreaks. Retrieved from http://www.cdc.gov/measles/
cases-outbreaks.html
Chapman, G. B., & Coups, E. J. (2006). Emotions and preventive
health behavior: Worry, regret, and influenza vaccination.
Health Psychology, 25, 82-90. doi:10.1037/0278-6133.25.1.82
Chapman, G. B., Li, M., Colby, H., & Yoon, H. (2010). Opting
in vs opting out of influenza vaccination. The Journal of the
American Medical Association, 304, 43-44. doi:10.1001/
jama.2010.892
Chapman, G. B., Li, M., Vietri, J., Ibuka, Y., Thomas, D., Yoon, H.,
& Galvani, A. P. (2012). Using game theory to examine incen-
tives in influenza vaccination behavior. Psychological Science,
23, 1008-1015. doi:10.1177/0956797612437606
Cialdini, R. B., Demaine, L. J., Sagarin, B. J., Barrett, D. W.,
Rhoads, K., & Winter, P. L. (2006). Managing social
norms for persuasive impact. Social Influence, 1, 3-15.
doi:10.1080/15534510500181459
Cohen, M. J., Brezis, M., Block, C., Diederich, A., & Chinitz,
D. (2013). Vaccination, herd behavior, and herd immunity.
Medical Decision Making, 33, 1026-1038. doi:10.1177/02729
89X13487946
Daley, M. F., Barrow, J., Pearson, K., Crane, L. A., Gao, D.,
Stevenson, J. M., . . . Kempe, A. (2004). Identification and
recall of children with chronic medical conditions for influ-
enza vaccination. Pediatrics, 113(1 Pt 1), e26-33. doi:10.1542/
peds.113.1.e26
Dubé, E., Gagnon, D., Nickels, E., Jeram, S., & Schuster, M. (2014).
Mapping vaccine hesitancy—Country-specific characteristics of
a global phenomenon. Vaccine, 32, 6649-6654. doi:10.1016/j.
vaccine.2014.09.039
Duclos, P. (2010). National Immunization Technical Advisory
Groups (NITAGs): Guidance for their establishment and
strengthening. Vaccine, 28(Suppl. 1), A18-A25. doi:10.1016/j.
vaccine.2010.02.027
European Centre for Disease Prevention and Control. (2014).
Measles and rubella elimination: Communicating the impor-
tance of vaccination. Stockholm, Sweden: Author. Retrieved
from http://ecdc.europa.eu/en/publications/Publications/
Measles-rubella-elimination-communicating-importance-
vaccination.pdf
Eysenbach, G. (2009). Infodemiology and infoveillance: frame-
work for an emerging set of public health informatics methods
to analyze search, communication and publication behavior on
the internet. Journal of Medical Internet Research, 11(1):e11.
doi: 10.2196/jmir.1157.
Fazio, R. H. (2007). Attitudes as object–evaluation associations of
varying strength. Social Cognition, 25, 603-637. doi:10.1521/
soco.2007.25.5.603
Fazio, R. H., & Olson, M. A. (2014). The MODE model: Attitude-
behavior processes as a function of motivation and opportu-
nity. In J. W. Sherman, B. Gawronsk, & Y. Trope (Eds.), Dual
process theories of the social mind (pp. 155-171). New York,
NY: Guilford Press.
Ferguson, E., & Gallagher, L. (2007). Message framing with
respect to decisions about vaccination: The roles of frame
valence, frame method and perceived risk. British Journal of
Psychology, 98, 667-680. doi:10.1348/000712607X190692
Fine, P., Eames, K., & Heymann, D. L. (2011). “Herd immunity”:
A rough guide. Clinical Infectious Diseases, 52, 911-916.
doi:10.1093/cid/cir007
Fischer, P., Kastenmüller, A., Greitemeyer, T., Fischer, J., Frey,
D., & Crelley, D. (2011). Threat and selective exposure: The
moderating role of threat and decision context on confirmatory
information search after decisions. Journal of Experimental
Psychology: General, 140, 51-62. doi:10.1037/a0021595.
Gallagher, K. M., & Updegraff, J. A. (2012). Health message
framing effects on attitudes, intentions, and behavior: A meta-
analytic review. Annals of Behavioral Medicine, 43, 101-116.
doi:10.1007/s12160-011-9308-7
Galvani, A. P. J., Reluga, T. C., & Chapman, G. B. (2007).
Long-standing influenza vaccination policy is in accord
with individual self-interest but not with the utilitarian opti-
mum. Proceedings of the National Academy of Sciences of
the United States of America, 104, 5692-5697. doi:10.1073/
pnas.0606774104
Gargano, L. M., Herbert, N. L., Painter, J. E., Sales, J. M., Morfaw,
C., Rask, K., . . . Hughes, J. M. (2013). Impact of a physi-
cian recommendation and parental immunization attitudes on
receipt or intention to receive adolescent vaccines. Human
Vaccines & Immunotherapeutics, 9, 2627-2633. doi:10.4161/
hv.25823
Gerend, M. A., & Shepherd, J. E. (2012). Predicting human papil-
lomavirus vaccine uptake in young adult women: Comparing
the health belief model and theory of planned behavior. Annals
of Behavioral Medicine: A Publication of the Society of
Behavioral Medicine, 44, 171-180. doi:10.1007/s12160-012-
9366-5
Betsch et al. 71
Gerend, M. A., Shepherd, M. A., & Shepherd, J. E. (2013). The
multidimensional nature of perceived barriers: Global versus
practical barriers to HPV vaccination. Health Psychology, 32,
361-369. doi:10.1037/a0026248
Glasman, L. R., & Albarracín, D. (2006). Forming attitudes that
predict future behavior: A meta-analysis of the attitude-
behavior relation. Psychological Bulletin, 132, 778-822.
doi:10.1037/0033-2909.132.5.778
Gneezy, U., & Rustichini, A. (2000). Pay enough or don’t pay
at all. The Quarterly Journal of Economics, 115, 791-810.
doi:10.1162/003355300554917
Godin, G., Vézina-Im, L.-A., & Naccache, H. (2010). Determinants
of influenza vaccination among healthcare workers.
Infection Control and Hospital Epidemiology, 31, 689-693.
doi:10.1086/653614
Gollwitzer, P. M., & Sheeran, P. (2006). Implementation inten-
tions and goal achievement: A meta-analysis of effects and
processes. Advances in Experimental Social Psychology, 38,
69-119. doi:10.1016/S0065-2601(06)38002-1
Groom, H., Hopkins, D. P., Pabst, L. J., Morgan, J. M., Patel, M.,
Calonge, N., . . . Zucker, J. (2014). Immunization informa-
tion systems to increase vaccination rates: A community guide
systematic review. Journal of Public Health Management &
Practice, 21, 227-248. doi:10.1097/PHH.0000000000000069
Haelle, T. (2015, June 30). California Vaccination Bill SB 277
signed by governor, becomes law. Forbes. Retrieved from
http://www.forbes.com/sites/tarahaelle/2015/06/30/california-
vaccination-bill-sb-277-signed-by-governor-becomes-law/
Harrison, J. A., Mullen, P. D., & Green, L. W. (1992). A meta-anal-
ysis of studies of the health belief model with adults. Health
Education Research, 7, 107-116. doi:10.1093/her/7.1.107
Hawley, S. T., Zikmund-Fisher, B., Ubel, P., Jancovic, A., Lucas,
T., & Fagerlin, A. (2008). The impact of the format of graphi-
cal presentation on health-related knowledge and treatment
choices. Patient Education & Counseling, 73, 448-455.
doi:10.1016/j.pec.2008.07.023
Hershey, J., Asch, D., Thumasathit, T., Meszaros, J., & Waters, V.
(1994). The roles of altruism, free riding, and bandwagoning
in vaccination decisions. Organizational Behavior and Human
Decision Processes, 59, 177-187. doi:10.1006/obhd.1994.1055
Herzog, R., Álvarez-Pasquin, M. J., Díaz, C., Del Barrio, J. L.,
Estrada, J. M., & Gil, Á. (2013). Are healthcare workers’ inten-
tions to vaccinate related to their knowledge, beliefs and atti-
tudes? A systematic review. BMC Public Health, 13, Article
154. doi:10.1186/1471-2458-13-154
Hollmeyer, H. G., Hayden, F., Poland, G., & Buchholz, U. (2009).
Influenza vaccination of health care workers in hospitals—
A review of studies on attitudes and predictors. Vaccine, 27,
3935-3944. doi:10.1016/j.vaccine.2009.03.056
Ibuka, Y., Li, M., Vietri, J., Chapman, G. B., & Galvani, A. P.
(2014). Free-riding behavior in vaccination decisions: An
experimental study. PLoS ONE, 9, e87164. doi:10.1371/jour-
nal.pone.0087164
Janz, N. K., & Becker, M. H. (1984). The health belief model:
A decade later. Health Education Quarterly, 11, 1-47.
doi:10.1177/109019818401100101
Johnson, D. R., Nichol, K. L., & Lipczynski, K. (2008). Barriers to
adult immunization. American Journal of Medicine, 121, 28-
35. doi:10.1016/j.amjmed.2008.05.005.
Johnson, H. M., & Seifert, C. M. (1994). Sources of the continued
influence effect: When misinformation in memory affects later
inferences. Journal of Experimental Psychology: Learning,
Memory, and Cognition, 20, 1420-1436. doi:10.1037/0278-
7393.20.6.1420
Kata, A. (2012). Anti-vaccine activists, Web 2.0, and the postmod-
ern paradigm—An overview of tactics and tropes used online
by the anti-vaccination movement. Vaccine, 30, 3778-3789.
doi:10.1016/j.vaccine.2011.11.112
Kempe, A., Saville, A., Dickinson, L. M., Eisert, S., Reynolds, J.,
Herrero, D., . . . Calonge, N. (2013). Population-based versus
practice-based recall for childhood immunizations: A ran-
domized controlled comparative effectiveness trial. American
Journal of Public Health, 103, 1116-1123. doi:10.2105/
AJPH.2012.301035
Kimmel, S. R., Burns, I. T., Wolfe, R. M., & Zimmerman, R. K.
(2007). Addressing immunization barriers, benefits, and risks.
The Journal of Family Practice, 56, S61-S69.
Larson, H. J., Smith, D. M. D., Paterson, P., Cumming, M.,
Eckersberger, E., Freifeld, C. C., . . . Madoff, L. C. (2013).
Measuring vaccine confidence: Analysis of data obtained by
a media surveillance system used to analyse public concerns
about vaccines. The Lancet Infectious Diseases, 13, 606-613.
doi:10.1016/S1473-3099(13)70108-7
LaVail, K. H., & Kennedy, A. M. (2012). The role of attitudes
about vaccine safety, efficacy, and value in explaining parents’
reported vaccination behavior. Health Education & Behavior,
40, 544-551. doi:10.1177/1090198112463022
Leask, J. (2011). Target the fence-sitters. Nature, 473, 443-445.
doi:10.1038/473443a
Lewandowsky, S., Ecker, U. K. H., Seifert, C. M., Schwarz,
N., & Cook, J. (2012). Misinformation and its correc-
tion: Continued influence and successful debiasing.
Psychological Science in the Public Interest, 13(3), 106-131.
doi:10.1177/1529100612451018
Lin, C. J., Nowalk, M. P., Toback, S. L., Rousculp, M. D., Raymund,
M., Ambrose, C. S., & Zimmerman, R. K. (2010). Importance
of vaccination habit and vaccine choice on influenza vaccina-
tion among healthy working adults. Vaccine, 28, 7706-7712.
doi:10.1016/j.vaccine.2010.07.009
Loewenstein, G. F., Weber, E. U., Hsee, C. K., & Welch, N.
(2001). Risk as feelings. Psychological Bulletin, 127, 267-286.
doi:10.1037/0033-2909.127.2.267
MacDonald, N. E. & SAGE Working Group on Vaccine Hesitancy.
(2015). Vaccine hesitancy: Definition, scope and determi-
nants. Vaccine. Advance online publication. doi:10.1016/j.vac-
cine.2015.04.036
Milkman, K. L., Beshears, J., Choi, J. J., Laibson, D., & Madrian,
B. C. (2011). Using implementation intentions prompts to
enhance influenza vaccination rates. Proceedings of the
National Academy of Sciences of the United States of America,
108, 10415-10420. doi:10.1073/pnas.1103170108
Milne, S., Sheeran, P., & Orbell, S. (2000). Prediction and inter-
vention in health-related behavior: A meta-analytic review
of protection motivation theory. Journal of Applied Social
Psychology, 30, 106-143. doi:10.1111/j.1559-1816.2000.
tb02308.x
Mischel, W. (1968). Personality and assessment. New York, NY:
Wiley.
72 Policy Insights from the Behavioral and Brain Sciences 2(1)
Moran, W. P., Nelson, K., Wofford, J. L., Velez, R., & Case, L.
D. (1996). Increasing influenza immunization among high-risk
patients: Education or financial incentive? American Journal of
Medicine, 101, 612-620. doi:10.1016/S0002-9343(96)00327-0
Norman, P., Boer, H., & Seydel, E. R. (2005). Protection motivation
theory. In M. Conner & P. Norman (Eds.), Predicting health
behaviour: Research and practice with social cognition models
(pp. 170-222). Maidenhead, UK: Open University Press.
Nowalk, M. P., Lin, C. J., Zimmerman, R. K., Fox, D. E., Raymund,
M., Tanis, M. D., & Harper, J. D. (2010). Establish the habit:
Influenza vaccination for health care personnel. Journal for
Healthcare Quality, 32(2), 35-42.
Nyhan, B., Reifler, J., Richey, S., & Freed, G. L. (2014). Effective
messages in vaccine promotion: A randomized trial. Pediatrics,
133, e835-e842. doi:10.1542/peds.2013-2365
Nyhan, B., & Reifler, J. (under review). The role of information
deficits and identity threat in the prevalence of misperceptions.
Manuscript submitted for publication.
Omer, S. B., Pan, W. K. Y., Halsey, N. A., Stokley, S., Moulton,
L. H., Navar, A. M., . . . Salmon, D. A. (2006). Nonmedical
exemptions to school immunization requirements: Secular
trends and association of state policies with pertussis inci-
dence. The Journal of the American Medical Association, 296,
1757-1763. doi:10.1016/S0084-3954(08)70403-2
Omer, S. B., Richards, J. L., Ward, M., & Bednarczyk, R. A.
(2012). Vaccination policies and rates of exemption from
immunization, 2005–2011. New England Journal of Medicine,
367, 1170-1171. doi:10.1056/NEJMc1209037
Oraby, T., Thampi, V., & Bauch, C. T. (2014). The influence of
social norms on the dynamics of vaccinating behaviour for pae-
diatric infectious diseases. Proceedings of the Royal Society,
Series B: Biological Sciences, 281, 20133172. doi:10.1098/
rspb.2013.3172
Payaprom, Y., Bennett, P., Alabaster, E., & Tantipong, H. (2011).
Using the health action process approach and implementation
intentions to increase flu vaccine uptake in high risk Thai indi-
viduals: A controlled before-after trial. Health Psychology, 30,
492-500. doi:10.1037/a0023580
Peters, E., Västfjäll, D., Slovic, P., Mertz, C. K., Mazzocco,
K., & Dickert, S. (2006). Numeracy and decision making.
Psychological Science, 17, 407-413. doi:10.1111/j.1467-
9280.2006.01720.x
Pitts, S. I., Maruthur, N. M., Millar, K. R., Perl, T. M., & Segal, J.
(2014). A systematic review of mandatory influenza vaccina-
tion in healthcare personnel. American Journal of Preventive
Medicine, 47, 330-340. Retrieved from http://www.ncbi.nlm.
nih.gov/pubmed/25145618
Rakita, R. M., Hagar, B. A., Crome, P., & Lammert, J. K. (2010).
Mandatory influenza vaccination of healthcare workers: A
5-year study. Infection Control and Hospital Epidemiology,
31, 881-888. doi:10.1086/656210
Roberto, A. J., Krieger, J. L., Katz, M. L., Goei, R., & Jain, P.
(2011). Predicting pediatricians’ communication with parents
about the human papillomavirus (HPV) vaccine: An applica-
tion of the theory of reasoned action. Health Communication,
26, 303-312. doi:10.1080/10410236.2010.550021
Rogers, T., Milkman, K. L., & Volpp, K. G. (2014). Commitment
devices: Using initiatives to change behavior. The Journal of the
American Medical Association, 311, 2065-2066. doi:10.1001/
jama.2014.3485
Rosenstock, I. M. (1974). The health belief model and preventive
health behavior. Health Education Monographs, 2, 354-386.
doi:10.1177/109019818801500203
Rosenthal, S. L., Weiss, T. W., Zimet, G. D., Ma, L., Good, M. B.,
& Vichnin, M. D. (2011). Predictors of HPV vaccine uptake
among women aged 19–26: Importance of a physician’s
recommendation. Vaccine, 29, 890-895. doi:10.1016/j.vac-
cine.2009.12.063
Ruiter, R. A. C., Kessels, L. T. E., Peters, G. J. Y., & Kok, G.
(2014). Sixty years of fear appeal research: Current state of
the evidence. International Journal of Psychology, 49, 63-70.
doi:10.1002/ijop.12042
Sadaf, A., Richards, J. L., Glanz, J., Salmon, D. A., & Omer, S.
B. (2013). A systematic review of interventions for reducing
parental vaccine refusal and vaccine hesitancy. Vaccine, 31,
4293-4304. doi:10.1016/j.vaccine.2013.07.013
Schwartz, J., Mochon, D., Wyper, L., Maroba, J., Patel, D., &
Ariely, D. (2014). Healthier by precommitment. Psychological
Science, 25, 538-546. doi:10.1177/0956797613510950
Schwarzer, R., & Fuchs, R. (1996). Self-efficacy and health behav-
iours. In M. Conner & P. Norman (Eds.), Predicting health
behaviour: Research and practice with social cognition models
(pp. 163-196). Buckingham, UK: Open University Press.
Sheeran, P. (2002). Intention–Behavior relations: A conceptual
and empirical review. European Review of Social Psychology,
12(1), 1-36. doi:10.1080/14792772143000003
Shefer, A., Briss, P., Rodewald, L., Bernier, R., Strikas, R., Yusuf,
H., . . . Hinman, A. R. (1999). Improving immunization
coverage rates: An evidence-based review of the literature.
Epidemiological Review, 20, 96-142.
Shim, E., Chapman, G. B., Townsend, J. P., & Galvani, A. P.
(2012). The influence of altruism on influenza vaccination
decisions. Journal of the Royal Society Interface, 9, 2234-
2243. doi:10.1098/rsif.2012.0115
Siegrist, M., & Cvetkovich, G. (2001). Better negative than posi-
tive? Evidence of a bias for negative information about possible
health dangers. Risk Analysis, 21, 199-206. doi:10.1111/0272-
4332.211102
Slovic, P., Finucane, M., Peters, E., & MacGregor, D. G. (2012).
Risk as feeling: Some thoughts about affect, reason, risk and
rationality. In L. Asveld & S. Roeser (Eds.), The ethics of tech-
nological risk (pp. 165-181). London, England: Routledge.
Sobo, E. J. (2015). Social cultivation of vaccine refusal and delay
among Waldorf (Steiner) school parents. Medical Anthropology
Quarterly. Advance online publication. doi:10.1111/maq.12214
Stockwell, M. S., Kharbanda, E. O., Martinez, R. A., Lara,
M., Vawdrey, D., Natarajan, K., & Rickert, V. I. (2012).
Text4Health: Impact of text message reminder-recalls for pedi-
atric and adolescent immunizations. American Journal of Public
Health, 102(2), e15-e21. doi:10.2105/AJPH.2011.300331
Stone, E. G., Morton, S. C., Hulscher, M. E., Maglione, M. A.,
Roth, E. A., Grimshaw, J. M., . . . Shekelle, P. G. (2002).
Interventions that increase use of adult immunization and can-
cer screening services: A meta-analysis. Annals of Internal
Medicine, 136, 641-651. doi:10.7326/0003-4819-136-9-
200205070-00006
Suh, C. A., Saville, A., Daley, M. F., Glazner, J. E., Barrow, J.,
Stokley, S., . . . Kempe, A. (2012). Effectiveness and net cost of
reminder/recall for adolescent immunizations. Pediatrics, 129,
e1437-e1445. doi:10.1542/peds.2011-1714
Betsch et al. 73
Szilagyi, P. G., Bordley, C., Vann, J. C., Chelminski, A., Kraus,
R. M., Margolis, P. A., & Rodewald, L. E. (2000). Effect of
patient reminder/recall interventions on immunization rates: A
review. The Journal of the American Medical Association, 284,
1820-1827. doi:10.1001/jama.284.14.1820
Tenney, E. R., Cleary, H. M. D., & Spellman, B. A. (2009).
Unpacking the doubt in “beyond a reasonable doubt”: Plausible
alternative stories increase not guilty verdicts. Basic and Applied
Social Psychology, 31, 1-8. doi:10.1080/01973530802659687
Tversky, A., & Kahneman, D. (1973). Availability: A heuristic for
judging frequency and probability. Cognitive Psychology, 5,
207-232. doi:10.1016/0010-0285(73)90033-9
Updegraff, J. A., & Rothman, A. J. (2013). Health message framing:
Moderators, mediators, and mysteries. Social & Personality
Psychology Compass, 7, 668-679. doi:10.1111/spc3.12056
Vietri, J. T., Li, M., Galvani, A. P., & Chapman, G. B. (2012).
Vaccinating to help ourselves and others. Medical Decision
Making, 32, 447-458. doi:10.1177/0272989X11427762
Wiley, K. E., Cooper, S. C., Wood, N., & Leask, J. (2015).
Understanding pregnant women’s attitudes and behavior toward
influenza and pertussis vaccination. Qualitative Health Research,
25, 360-370. doi:10.1177/1049732314551061
Witte, K., & Allen, M. (2000). A meta-analysis of fear appeals:
Implications for effective public health campaigns.
Health Education & Behavior, 27, 591-615. doi:10.1177/
109019810002700506
World Health Organization. (2012). World immunization week
2012. Retrieved from http://www.who.int/immunization/news-
room/events/immunization_week/2012/further_information/
en/
World Health Organization. (2015). National advisory committees
on immunization. Retrieved from http://www.who.int/immuni-
zation/sage/national_advisory_committees/en/
Zingg, A., & Siegrist, M. (2012). Measuring people’s knowl-
edge about vaccination: Developing a one-dimensional scale.
Vaccine, 30, 3771-3777. doi:10.1016/j.vaccine.2012.03.014