Strategies to Improve Adult Vaccination Rates in the United States

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The US Department of Health and Human Services launched the Healthy People 2020 initiative to increase rates of influenza vaccination in adults from 40% to 70%.
The US Department of Health and Human Services launched the Healthy People 2020 initiative to increase rates of influenza vaccination in adults from 40% to 70%.

While the public health value of vaccines is generally well-known in terms of disease prevention in infants and children, its role in improving adult health may be less obvious. Each year as many as 4000 and 49,000 deaths result from pneumococcal disease and seasonal influenza, respectively, in US adults for example, and there are approximately 1 million reported cases of herpes zoster.1-3 In addition, the cost associated with health care and lost productivity due to these illnesses is well into the billions.

One of the goals of the Healthy People 2020 initiative launched by the US Department of Health and Human Services (HHS) in 2010 is to increase rates of influenza vaccination in adults to 70% from the baseline rate of roughly 40%.4 Despite the risks, recent data show that the rate has barely changed since the plan was released, even with the availability of no-cost routine vaccinations for many insured Americans under the Affordable Care Act.

In fact, the rate of adult vaccinations against influenza decreased by 1.9% between 2014 to 2015 and 2015 to 2016.5 “The low uptake of adult vaccines has led public health and medical experts to conclude that [the] use and acceptance of adult vaccines in the US are lacking because they are ‘severely undervalued' by the public and healthcare providers” wrote the investigators in a recent review published in Vaccine.6

In a 2012 report from the National Vaccine Advisory Committee of the HHS, lack of public knowledge was cited as one of 9 barriers to adult vaccination, and an outreach campaign aimed at the public and health providers was recommended.7 Many other public health organizations and experts have made similar calls for increased education of individuals and clinicians via increased communication and campaign efforts.

However, it is “rarely the case that simply providing more information or refuting misinformation will improve perceptions or increase vaccination uptake,” according to the current paper. Therefore, facts and statistics about vaccine safety and efficacy or information about the economic value of vaccines such as quality-adjusted life years (QALY) or disability-adjusted life years (DALY) saved are not likely to have a significant impact on individual beliefs or behaviors regarding vaccines.8-10

“Rather, fostering vaccine acceptance and active demand requires investments in strategic direction, having a strong understanding of the psychological and social dimensions of vaccine acceptance, doing research that enables strong understanding, and evaluation to identify and monitor outcomes,” the investigators stated. Campaigns should recognize the importance of subjective appraisals, personal values, and desired outcomes in patient and provider decision making about vaccines.

To that end, they highlighted 5 core concepts and strategies that can increase integration of social psychological components with health communication principles to improve the perceived benefits of adult vaccination.

  • Target audience focus. Messaging should be tailored to each target audience by emphasizing the priorities and goals that are most relevant to the group using language and imagery that resonate with their perceptions of vaccine value, and spokespeople and other sources that are trusted by the target group should be used.
  • Exchange of value. Efforts to increase perceptions of the value of vaccination must clearly demonstrate how it will meet the valued needs of the target audience.
  • Clear understanding and specification of campaign success. Specific indicators “should be used to gauge the current valuation of adult vaccination, guide efforts to change value perceptions, and assess the effects or effectiveness of efforts to increase a targeted group's assessment of adult vaccination."
  • Promotion, product, price, and place influence value perceptions, as they do in social marketing.
  • Communication research is needed to inform and evaluate communication efforts.

“Implementing sophisticated campaign approaches will be demanding, but the alternative — failing to act aggressively to improve the current state of adult immunization — is a far less attractive option,” the review concluded.

To learn more about the implications for healthcare providers, Infectious Disease Advisor spoke with lead investigator Glen Nowak, PhD, professor of advertising and public relations and director of the Grady College's Center for Health and Risk Communication at the University of Georgia in Athens.

Infectious Disease Advisor: What are your thoughts about why adult vaccines may be undervalued by healthcare providers?

Glen Nowak, PhD: Healthcare providers face many demands when it comes to patient care, and many adult patient visits are focused on diagnosing and treating illness or other pressing medical needs. Unless a patient comes back for an annual physical or wellness check, there may not be an opportunity to offer adult vaccinations. Vaccines are also something that need to be initiated by the healthcare provider since most adults have little or no awareness of which immunizations they should be receiving and when.

Conversations about recommended vaccines can take time and require a good understanding of the basis for the recommendation. Some adult healthcare providers lack confidence in their ability to confidently and effectively provide a strong recommendation, or may lack the resources to do so. 

Infectious Disease Advisor: In general, and for our clinical audience particularly, what are some of the top takeaways from your review?

Dr Nowak: It will likely take more than facts and information about which vaccines adults should receive and when if we're going to foster a greater appreciation of adult vaccines, and in turn increase adult vaccination rates. Providing basic information about vaccine safety and effectiveness is needed and helpful, but you shouldn't assume it's going to be influential or persuasive in and of itself. In many cases, effectively communicating the value of adult vaccines involves addressing the emotional and non-rational factors that affect people's decisions.

In addition, as the review indicates, healthcare providers will likely need to tailor their adult immunization messages. You need to take these steps to help patients see adult vaccines as relevant, beneficial, and worthwhile. The review also reaffirms the importance of healthcare providers using personal experience and examples to highlight the value of adult vaccinations. This is especially important given that with the exception of influenza, most adults are likely to be unfamiliar with the disease that adult vaccines provide protection against. 

Infectious Disease Advisor: What should be the focus of future research in this area?

Dr Nowak: It's important to continue to do research to identify the social psychological factors and communication approaches that matter most when it comes to adult vaccinations, and that needs to be done with adults in general, healthcare providers, and policymakers. For each group, we need a better understanding of what it takes to move them from having little or no appreciation or urgency for adult vaccines and immunization to highly valuing them. We don't need a majority of adults to know there is an adult immunization schedule, but we do need a majority of adults to perceive vaccinations as desirable and beneficial. In a similar fashion, we need policymakers to have similar perceptions so that they will be supportive of programs and efforts that could increase or facilitate adult immunization.

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  1. Centers for Disease Control and Prevention (CDC). Active bacterial core surveillance report, emerging infections program network, Streptococcus pneumoniae, 2010. Accessed November 17, 2017.
  2. Centers for Disease Control and Prevention (CDC). Estimated influenza illnesses, medical visits, hospitalizations, and deaths averted by vaccination in the United States. Updated April 19, 2017. Accessed November 17, 2017.
  3. Harpaz R, Ortega-Sanchez IR, Seward JF; Advisory Committee on Immunization Practices (ACIP) Centers for Disease Control and Prevention (CDC). Prevention of herpes zoster: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2008;57:1-30; quiz CE2-CE4.
  4. Healthy People 2020. Immunization and infectious diseases: national snapshots. Accessed 11/17/17.
  5. Centers for Disease Control and Prevention (CDC). Flu vaccination coverage, United States, 2015-16 influenza season. Updated November 1, 2017. Accessed November 17, 2017.
  6. Nowak GJ, Shen AK, Schwartz JL. Using campaigns to improve perceptions of the value of adult vaccination in the United States: health communication considerations and insights. Vaccine. 2017;35:5543-5550.
  7. Committee National Vaccine Advisory. A pathway to leadership for adult immunization: recommendations from the National Vaccine Advisory Committee. Public Health Rep. 2012;127(Suppl 1):1-42.
  8. Kitta A, Goldberg DS. The significance of folklore for vaccine policy: discarding the deficit model. Crit Publ Health. 2017;27:506-514.
  9. Nyhan B, Reifler J, Richey S, Freed GL. Effective messages in vaccine promotion: a randomized trial. Pediatrics. 2014;133:e835-e842.
  10. Larson HJ. Vaccine trust and the limits of information. Science. 2016;353(6305):1207-1208.
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