ARTICLE

Social Marketing as a Strategy to Increase

Immunization Rates
Douglas J. Opel, MD; Douglas S. Diekema, MD, MPH; Nancy R. Lee, MBA; Edgar K. Marcuse, MD, MPH

T
oday in the United States, outbreaks of vaccine-preventable disease are often traced to
susceptible children whose parents have claimed an exemption from school or child
care immunization regulations. The origins of this immunization hesitancy and resis-
tance have roots in the decline of the threat of vaccine-preventable disease coupled
with an increase in concerns about the adverse effects of vaccines, the emergence of mass media
and the Internet, and the intrinsic limitations of modern medicine. Appeals to emotion have drowned
out thoughtful discussion in public forums, and overall, public trust in immunizations has de-
clined. We present an often overlooked behavior change strategy—social marketing—as a way to
improve immunization rates by addressing the important roots of immunization hesitancy and ef-
fectively engaging emotions. As an example, we provide a synopsis of a social marketing campaign
that is currently in development in Washington state and that is aimed at increasing timely im-
munizations in children from birth to age 24 months.
Arch Pediatr Adolesc Med. 2009;163(5):432-437

Although US national immunization rates an erroneous perception of low suscepti-

are high,1 outbreaks of vaccine-preven-
table diseases traced to children exempt
from school and child care immuniza-
tion requirements continue to occur in the
United States.2-6 One recent measles out-
break resulted from an index case of a child
in California who claimed an exemption
from measles-mumps-rubella vaccine for
personal beliefs.2 Of the 9 additional chil-
dren older than 12 months who devel-
oped measles from the index case in this
outbreak, 8 had claimed personal belief ex-
emptions. Nineteen states now allow a per-
sonal belief exemption from vaccina-
tions.7
In 2000, a national survey revealed that
19% of parents had concerns about vac-
cine safety, and 18% opposed immuniza-
tion requirements because these require-
ments went against freedom of choice.8
Another reason parents refuse vaccines is
Author Affiliations: Treuman Katz Center for Pediatric Bioethics, Seattle
Children’s Hospital (Drs Opel and Diekema), and Department of Pediatrics,
University of Washington (Drs Opel, Diekema, and Marcuse), Seattle, and Social
Marketing Services, Inc, Mercer Island, Washington (Ms Lee).
bility to vaccine-preventable disease.9 In
2004, 93% of pediatricians reported that
there was at least one parental refusal of
a recommended vaccine in the last year,10
and a recent analysis of data from the 2004
National Immunization Survey found that
28% of parents were unsure about, de-
layed, or refused vaccines.11 This rising tide
of immunization hesitancy is also mani-
fest by legislative initiatives to introduce
personal belief or philosophical exemp-
tions in states that have not allowed them
and increased media attention to con-
cerns about vaccine safety and immuni-
zation mandates.12 Public trust in immu-
nization and the authorities who formulate
national immunization recommenda-
tions, as a result, has declined.13
A new strategy for addressing immu-
nization concerns is badly needed. Given
the diverse reasons for parental refusal of
or delay in immunizations, a one-size-fits-
all approach to health promotion founded
on expert authority or the articulation of
the scientific evidence that supports im-

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 munization ignores the realities of how people are per-
suaded. Social marketing may hold the key. As a model
for behavior change, social marketing is a process that
applies traditional marketing principles and techniques
to influence target audience behaviors that benefit soci-
ety as well as the individual.14 In this article, we explain
how the origins of immunization hesitancy and the psy-
chology of persuasion provide the rationale for explor-
ing social marketing as an innovative solution to address-
ing vaccine hesitancy.
ORIGINS OF IMMUNIZATION HESITANCY
Despite the incredible technical achievements of mod-
ern medicine—vaccines being near the top of the list—
the boundaries of medicine, science, and technology are
evident in our limited capability to address new mor-
bidities (mental health, obesity, substance abuse) or ease
the burdens of chronic disease. These relative limita-
tions have occurred alongside a growth in consumer-
ism, product liability, and malpractice litigation as well
as an increasing number of instances where patients ques-
tion the recommendations of medical authority.15 Con-
sequently, some patients turn to alternative medical sys-
tems.16 Visits to complementary and alternative medicine
providers, in fact, have recently been found to outnum-
ber visits to primary care physicians.17
The rise of mass media and the Internet has drawn vac-
cines into this changing sociocultural landscape. From
Jenner’s era through Salk’s, medical hypotheses, such as
those concerning vaccine safety, were initially vetted in
scientific forums before being communicated to the gen-
eral public. Today, mass media allow new theories con-
cerning vaccine safety to become a topic of public de-
bate before the scientific community has had the
opportunity to deliberate on them. Unproven hypoth-
eses, even unsubstantiated or erroneous accounts of vac-
cine reactions,18 can easily be promulgated and vali-
dated simply by repetition in popular media.
Similarly, case reports, although accorded very lim-
ited weight as scientific evidence, can have great influ-
ence on public opinion. The criteria required to establish
causality in the court of public opinion are quite different
than those in science or a court of law. For example, the
parents of Hannah Poling sued the Department of Health
and Human Services under the Vaccine Injury Compen-
sation Program when she exhibited behavioral features seen
in autism after receiving immunizations at 19 months of
age. The court awarded compensation for a possible vac-
cine-related injury and, in doing so, appeared to strengthen
the claim that vaccines cause autism despite the fact that
Hannah’s autistic features were likely attributable to en-
cephalopathy due to a mitochondrial enzyme defect19 and
in the face of overwhelming scientific evidence that re-
futes any causal link between immunizations and au-
tism.20,21 Other nonvaccine examples abound: breast im-
plants are seen as the cause of chronic illness by the
public—and manufacturers of those products were found
liable—despite an absence of valid scientific evidence link-
ing breast implants to disease.22
A fundamental reason why case reports of alleged vac-
cine reactions and hypotheses about adverse events as-
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sociated with immunization are rapidly disseminated by
the Internet and electronic media is because contro-
versy sells.16 Journalists seek to achieve balance by pre-
senting both sides of a controversy but often do so irre-
spective of the qualifications and scientific credibility of
the proponents of either side. Even these attempts at bal-
ance may be in jeopardy as the threat of vaccine-
preventable disease becomes less apparent and the risks
of vaccines are perceived to be more newsworthy.
Parents are ultimately caught in the middle. As they
try to decide what is best for their child, they must navi-
gate these “controversies” in search of the truth. This is
not easy, as the media portrayal of these controversies
rarely provides an evaluation of the merits of the 2 con-
flicting viewpoints but rather propagates the notion that
“multiple rationalities and truths now prevail.”23 When
multiple “truths” carry equal weight, those who cite the
authority of evidence-based recommendations from vari-
ous professional groups and government agencies have
no more credibility than those who cite other opinions
or theories.15 What takes the place of evidence-based medi-
cine is the belief that there are “many opinions based on
very different views and theories of the world.”15
One strategy for addressing vaccine concerns is to con-
front intentional misinformers24 in public forums. These
tactics, however, are unlikely to be successful when meet-
ing with a concerned parent. Although good science is
essential in both, it is not sufficient in either. The ori-
gins of immunization hesitancy suggest that in situa-
tions where parental concern is high, medical expertise
is trumped by empathy, openness, and perceived hon-
esty. A behavior change model that embraces this is
needed.
SOCIAL MARKETING AND PUBLIC HEALTH
As a discipline, social marketing was first introduced by
Philip Kotler in the early 1970s. A useful definition of
social marketing is
the application of commercial marketing technologies to the analy-
sis, planning, execution and evaluation of programs designed to
influence the voluntary behavior of target audiences in order to
improve their personal welfare and that of society.25(p7)
Using marketing techniques proven in the commer-
cial sector to address social issues in the public sector
has had a profound positive impact.14,26
Social marketing is an approach to influencing healthy
behaviors and has roots in several behavior change theo-
ries familiar to public health. The Exchange Theory,27 the
Theory of Planned Behavior,28 and the Health Belief
Model28 all play an important part in social marketing.
Social marketing is also informed by social psychology,
marketing science, and human reaction to messages.26 Its
campaigns seek to rigorously segment the market to tar-
get specific populations and then use the “marketing mix”
(the 4 P’s of marketing: place, price, product, and pro-
motion) to develop unique strategies for each to achieve
the desired behavior change.
An illustrative example of social marketing—and why
this strategy might apply to immunization hesitancy—is
the Washington State Department of Health (WSDOH)
WWW.ARCHPEDIATRICS.COM
 tobacco cessation program. The campaign was launched
in 2000 when there were an estimated 1 million adult
tobacco users in the state, about 70% of whom had some
desire to quit. This 70% was chosen as the campaign’s
target audience because of their interest in but reluc-
tance to commit to quitting. This population has simi-
larities with parents who wish to protect their children
against vaccine-preventable diseases yet remain hesitant
to immunization. For instance, smokers who are con-
templating quitting but fail to do so may have uncer-
tainty about the beneficial health effects of quitting or
concerns about its adverse effects, such as weight gain.
They also may be influenced by peer group pressures or
a fear of failing or simply lack support in quitting. These
concerns are analogous to vaccine-hesitant parents, who
may have uncertainty about the threat of vaccine-
preventable disease, concerns about vaccine safety and
the number of injections required, or lack of trust in medi-
cal authorities.
The tobacco cessation program used the WSDOH as
the messenger of the program’s campaign elements: (1)
a product strategy—a Quit Line where callers could talk
with personal counselors; (2) a price strategy—free coun-
seling and medications for those qualifying; (3) a place
strategy—phone availability 7 days a week, 5 AM to 9 PM;
and (4) a promotion strategy—ads appearing on televi-
sion, billboards, brochures, wallet cards, bar coasters, and
posters with messages that were encouraging and sup-
portive. By the time the Quit Line received its 100 000th
call in 2007, 13% of callers had quit, there were 235 000
fewer smokers in the state, and tobacco use had de-
creased from 22% to 17%, placing Washington state fifth
in the nation. While these outcomes cannot be attrib-
uted solely to the campaign, as secular trends in smok-
ing undoubtedly contributed to the decline, they are none-
theless impressive.
SOCIAL PSYCHOLOGY OF PERSUASION
Social marketers focus intently on message delivery and
response.26 With regard to immunizations, the goal of any
social marketing strategy is to convince parents that their
child will be better off if he or she receives vaccinations.
While supporting data and a rational argument are im-
portant factors, they are not sufficient. Aristotle realized
this 2000 years ago when he argued that persuasion re-
quires not only a reasonable argument and supporting
data (logos), but also a messenger who is trustworthy and
attentive to the audience (ethos) and a message that reso-
nates with the audience’s emotions (pathos).29 There is
a rich social psychology literature that supports Aristo-
tle’s observations.30
The most effective messenger is one the audience likes
and trusts and who is working toward the same goals as
those in the audience. Messengers are most likely to be
effective if they have established trust, made clear the fact
that they share a common goal with the parent (ie, the
welfare of the parent’s child), and developed a positive
relationship by displaying a willingness to listen respect-
fully and attend to parental concerns. While pediatri-
cians are often seen as possessing these traits, they can
no longer shoulder the full burden of immunization
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communication. The relatively brief duration of the
well- or acute care visit, the myriad topics that must be
addressed (growth and development, nutrition, behav-
ior, safety), and the increasing prevalence of vaccine
safety concerns require a broader societal communica-
tion strategy.
A communication strategy that goes beyond the pe-
diatrician’s office requires that the messengers (whether
groups or individuals) be likable, trustworthy, and seen
as working toward the same goal as parents. Jenny
McCarthy has been an effective messenger for the anti-
vaccination movement precisely because she is per-
ceived this way. Having a child with autism helps estab-
lish all 3 of these factors, but just as important are the
photos that appear in popular media of her and her boy-
friend, Jim Carrey, standing elbow to elbow with other
protesters in Washington, DC.31 Those photos further con-
vey the sense that she is just like other concerned par-
ents and shares a common interest with them.
Finally, the most successful communication strate-
gies are those that recognize that in order for the mes-
sage to make an impact on the audience, it must be ca-
pable of getting their attention and engaging their minds
in a way that leads to action. An emotional element is
essential to both of these functions. A message that can
arouse the audience emotionally will be more likely to
get their attention and motivate them to change their
behavior.32
One of the most effective strategies for arousing an au-
dience emotionally is through the use of stories and nar-
ratives. Any communication strategy designed to in-
crease vaccination rates will need to use powerful stories
that resonate with the audience by engaging their emo-
tions.33 Multiple studies have found that a compelling story
about a single victim is far more likely to move an audi-
ence to action than is the use of data.34-36 For a message
to be effective, the messenger and the way the message
is presented are both important. The use of rational ar-
gument and data alone will not be sufficient.
COERCION, MANIPULATION,
AND MISREPRESENTATION
The appeals to emotion that are often made by a social
marketing campaign’s promotional strategy may leave
some feeling that social marketing is coercive. And while
coercion may not be all that bad—many argue that co-
ercion is justifiable in vaccination programs when oth-
ers are placed at substantial risk of serious harm37-39 or
generally to control behaviors that are not only harmful
but simply wrong40—we would argue that social mar-
keting is not coercive. Coercion requires that one’s choices
are unfavorably narrowed using threats, force, or other
forms of compulsion in another’s attempt to make that
person do something he or she would not otherwise do.
Social marketing does not narrow the options of its tar-
get audience; it offers new ones, and offers are not gen-
erally considered to be coercive.41
It would be more reasonable to ask, rather, whether
social marketing constitutes an inappropriate manipu-
lation by public authorities that undermines individual
freedom and autonomy. Because many social marketing
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 efforts use advertising to communicate the benefits of a
desired behavior change, and advertising “hardly aims
to make [us] more autonomous,”40(p162) social market-
ing could be considered to be a manipulative attempt to
change behavior. We would argue, however, that social
marketing falls short of inappropriate manipulation on
3 counts. First, it is not harmful. Its aim is to protect both
individual and public health. Second, since the behav-
ior change social marketing seeks is voluntary, it re-
spects autonomy at least to some degree. Finally, it pre-
sents truthful information that has been validated using
evidence-based methods.
This last aspect draws attention to the fact that a so-
cial marketing campaign must not be misrepresenta-
tive. Amidst its attempt to leverage the emotional com-
ponents of decision making, a campaign’s messages and
promotional strategy must ultimately be honest and
backed by credible science. Given the current context of
misinformation and fear surrounding vaccines, accu-
rate representation seems paramount. On achieving this,
though, social marketing, with its own appeal to emo-
tions, seems to be an appropriate and justifiable method
to address immunization hesitancy.
A SOCIAL MARKETING PLAN TO INCREASE
TIMELY IMMUNIZATION FROM BIRTH
TO AGE 24 MONTHS: THE WASHINGTON
STATE CAMPAIGN
Washington state ranks 46th among US states in immu-
nization rates for the 15-dose series42 and is not on track
to meet its goal, based on the Healthy People 2010 ob-
jective,43 for 80% of children aged 19 to 35 months to have
received all recommended vaccines. Consequently, Wash-
ington state is in the process of developing a social mar-
keting campaign to increase timely immunization in chil-
dren. To accomplish this, the market has been segmented
both demographically, to accommodate the fact that im-
munization schedules vary considerably with age, as well
as behaviorally, since the basis of knowledge, attitudes, and
behaviors relative to vaccination differ greatly among par-
ents. The intent is to focus on parents who are expecting
or currently have a child up to the age of 24 months (to
reflect that vaccination against most vaccine-preventable
disease occurs by the age of 24 months) and who might
be categorized as hesitant toward immunizations. Hesi-
tant parents are defined as being unsure whether to im-
munize their children or are intentionally delaying 1 or
more immunizations for nonmedical reasons. Hesitant par-
ents, rather than parents who refuse vaccinations, will be
targeted because they are a larger group,11 more likely to
be open to considering vaccination, and likely to proceed
to vaccination if perceived barriers are addressed.
Background characteristics of this target market in
Washington state show that hesitant parents tend to be
older than 30 years, have an income more than $70 000,
and have a college degree. The planning team will con-
duct research with this market to determine their spe-
cific and unique perceived barriers and benefits related
to timely immunizations. A positioning and marketing
mix strategy will then be carefully designed to decrease
these barriers and to highlight these benefits. Outcome
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measures of the proposed campaign include rates of timely
immunization and exemptions from the Washington state
immunization requirement to attend licensed child care
centers.
The message of the campaign will likely have to work
to dispel myths that impede adoption of a new behav-
ior. An example of such a myth is that propagated by the
“Green Our Vaccines” message that childhood vaccines
are toxic.44 To do so, the campaign will have to consider
whether to adopt a 2-sided message that both praises vac-
cination and identifies its shortcomings at the same time.
Two-sided messages have been shown to be more effec-
tive when the audience is inclined to be suspicious about
the product and when the audience is better educated,14
as is the case with the target audience in the proposed
campaign. An example of such a message might be: “Al-
though 30% of parents don’t get their kids the right shots
at the right time, most parents do.”
The campaign will need spokespersons to convey its
message who can, like McCarthy, provide a warm and
sympathetic face for vaccine advocacy and tell an emo-
tional story that resonates with parents. Two types of in-
dividuals might fit these criteria: a formerly hesitant par-
ent who has come to realize the importance of vaccinations
after their unvaccinated child became seriously ill with
a vaccine-preventable disease and/or a recognizable, re-
spected public figure who has personal life experience
with vaccine-preventable disease and is willing to advo-
cate for immunization. The parent might relay his or her
struggle with the decision of whether to vaccinate, con-
cerns about vaccination risks, and harrowing story about
the vaccine-preventable disease, sequelae, and economic
burdens he or she endured. Alternatively, a celebrity with
directly applicable personal experience can both draw at-
tention to the value of vaccination and help shape public
discourse on immunizations. While the actress Amanda
Peet’s advice for parents to “take medical advice about im-
munizations from medical experts, not celebrities”45 is a
welcome counterweight to McCarthy, a celebrity with an
emotionally compelling personal provaccination story can
capture the attention of vaccine-hesitant parents.
Along with the campaign spokesperson(s), trusted lo-
cal health care providers will serve as credible messen-
gers to the campaign by giving voice to fact-oriented mes-
sages and illustrating the value of vaccination through
the use of real stories about real people who have been
affected by vaccine-preventable disease. Local media chan-
nels, such as talk shows and television news commen-
taries, and presentations at moms’ groups and birthing
classes are a couple of possible venues for local provid-
ers to advocate for vaccination as part of the campaign.
Providers will also be integral to a place strategy that will
include counseling of hesitant parents at prenatal visits
and postdelivery.
The messenger for the campaign will also include some
of the many sponsors that have already been assembled
for the development phase of the social marketing cam-
paign. These groups include the WSDOH, Community
Pediatric Foundation of Washington, Seattle Children’s
Hospital, Group Health Foundation, and Within Reach,
a private nonprofit organization whose mission is to serve
as the foremost catalyst for improvements in maternal,
WWW.ARCHPEDIATRICS.COM
 child, and family health. Nonprofit organizations are in-
strumental to the messenger strategy, as they often are
perceived as more trustworthy than people or organiza-
tions that are paid to endorse a product. A vaccine manu-
facturer encouraging childhood immunization, for in-
stance, naturally provokes skepticism about motives. An
example of a current social marketing campaign on im-
munizations using an effective partnership is the “i choose”
campaign in California, which is sponsored by the Cali-
fornia Department of Health, the California Immuniza-
tion Coalition, University of California–Berkeley CAL Hep
B Free, and Alameda County Immunization Coalition.46
Although the development phase of the Washington
state social marketing campaign to increase timely im-
munizations in children from birth to age 24 months is
being funded by the aforementioned sponsors, the pre-
liminary budget will only become clear after fully for-
mulating a marketing mix strategy and determining how
this strategy will be monitored and evaluated. Social mar-
keting campaign costs differ depending on the size and
geographic location of the target audience, the product
and any incentives that are offered, how often the prod-
uct is offered, how the product is communicated to the
target audience, and how the impact is assessed. The
Washington state tobacco cessation program, however,
provides an example of the cost of a social marketing cam-
paign. It is estimated that $830 in promotional and op-
erating costs are needed for each person who stops smok-
ing as a result of calling the Quit Line. The state savings
per person who quits smoking is estimated at $1800 per
year, a payback of less than 6 months. In 2007-2008, the
budget for the Tobacco Quit Line and its promotion was
$2.8 million.
CONCLUSIONS
Immunization hesitancy has complex social and cul-
tural origins yet clear consequences. More parents are re-
fusing vaccines, and outbreaks of vaccine-preventable dis-
ease due to exemptors remain a problem. Social marketing
is a behavior change strategy that offers a promising, nu-
anced population-level approach toward maintaining the
societal consensus for immunizations and potentially in-
creasing vaccination rates. Its use of proven commercial
marketing techniques, behavior change theory, and so-
cial psychology is designed to capture attention and mo-
tivate change. A social marketing strategy’s appeal to emo-
tion is an appropriate way to persuade the target audience
to voluntarily achieve the desired goal and may be an ef-
fective response to the antivaccination movement. The
Washington state campaign to increase timely immuni-
zation among children from birth to age 24 months of-
fers an example of such a strategy in development.
Accepted for Publication: February 4, 2009.
Correspondence: Douglas J. Opel, MD, Metropolitan Park
W, M/S: MPW 8-2, 1100 Olive Way, Ste 800, Seattle, WA
98101 (djopel@u.washington.edu).
Author Contributions: Study concept and design: Opel,
Diekema, Lee, and Marcuse. Drafting of the manuscript:
Opel, Diekema, and Marcuse. Critical revision of the manu-
script for important intellectual content: Opel, Diekema,
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Lee, and Marcuse. Administrative, technical, and mate-
rial support: Diekema. Study supervision: Diekema.
Financial Disclosure: Ms Lee owns the consulting firm
Social Marketing Services, Inc.
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