Behavior Models as a Public Health Strategy to Address Vaccine Hesitancy

Updated: Feb 13

Author: Rose D.


My new role as Pandemic Health Care Resource Coordinator has provided a front-row seat to the many social-ecological factors and complexities around the pandemic. Naturally, my immediate and initial thoughts of implementing theoretical models to address the multiple facets around vaccine hesitancy have crossed my mind several times. Behavior models may provide a meaningful public health policy strategy. While the topic of vaccine hesitancy appears recent, literature reflects that the topic has been long-standing, a systematic review of peer-reviewed studies increased in the early to mid-2000s, due to the re-emergence of communicable measles among children [3, 4]. Most notably the Disney measles outbreak of 2015. Public health experts, epidemiologists, and medical personnel trace back the most recent measles outbreaks from 2016 to 2020 to the rise of the anti-vaccination movement; brought on by multiple factors, including a distrust of "big" pharma and government institutions; misinformation among parent groups, especially the erroneous research on the debunked link between vaccines and Autism [4] and other diseases/disorders; and a greater emphasis on “natural” health movements [1]. While individually each concern/subject is worthy of inquiry, the collective piecemeal and false equivalency of misinformation, has been detrimental to public health. This has been magnified during this recent pandemic.

Though hesitancy appears like a recent topic, historically, vaccine hesitancy started much earlier; during the 1800s, in Victorian England. This period coincides with the smallpox outbreak and the work of Edward Jenner [1].

As a health services coordinator, my previous background at a charter school, serving children from Kindergarten to 12th grade, made me familiar with vaccine hesitancy. But I was unprepared for the many associated nuances during an active outbreak and worldwide pandemic.

Namely, the emotional investment and toll due to the immediacy of individual decisions on the collective whole. In that role, I had the authority of mandatory compliance and state mandates, with procedures and protocols developed through many years of guidance, research, and collaboration at the local, state, and federal levels.

The relative novelty of COVID-19 and the subsequent vaccines that have followed are unprecedented in scope and swiftness, though not at the behest of long-standing rigorous vaccination research and study. By virtue, it is only through this body of knowledge that made these vaccines' possible. It seems contradictory to chastise the swiftness, safety, and efficacy of the vaccines’ development; while also engaging in behaviors that directly contradict personal & health safety. For instance, the consumption of vitamins and supplements, which have few efficacy studies and research, and largely go unregulated.

Two behavioral models could serve to address vaccine hesitancy. The most prominent and well studied is the Transtheoretical Model (TTM)/Stage of Change, which is a socio-ecological model that accounts for an individual’s affiliations to other people their family/culture, organizations and institutions, and their larger community including their physical and social environments; while also assessing for their readiness for change concerning those factors. The Transtheoretical Model (TTM)/Stage of Change contains four constructs which include: Stage of Change, Processes of Change, Decisional Balance, and Situational Efficacy, and these constructs account for Individual, Interpersonal, Organizational/Community, and Public Policy factors. The construct of the Stage of Change contains the five stages: pre-contemplation, contemplation, preparation, action, maintenance.

The second behavioral model is the Health Belief Model (HBM).

The Health Belief Model (HBM) contains constructs that focus on health-related motivations. Essentially, the model addresses how do individuals respond to personal threats about a physical health condition; and assess if the benefits of taking action, through individual behaviors, will outweigh the barriers both actual and psychological.

The Health Belief Model (HBM) uses four constructs to assume the health behaviors and people's readiness to act. The four constructs are perceived susceptibility; perceived severity, perceived benefits; and perceived barriers. In short, these constructs will dictate behavioral change. First, we must address and narrow what vaccine hesitancy means. Vaccine hesitancy exists on a continuum, and essentially means different things and degrees to different people. To diminish the negative connotation associated with vaccine hesitancy, working groups like the SAGE Working Group on Vaccine Hesitancy have strived to define it as vaccine refusal rather than hesitancy.

The group concluded that vaccine hesitancy is influenced by contextual, individual, group, and vaccine/vaccination-specific factors. The last factor highlights that the behavioral decision to accept, delay or reject a vaccine can be further divided between some or all vaccines [3].

The "Three C's" Model of Vaccine Hesitancy reflects constructs from both the Health Belief Model and the Transtheoretical Model (TTM)/Stage of Change. Complacency addresses the Health Belief Model constructs of perceived susceptibility, severity, and benefits. These constructs weigh a person's opinion of risk to illness; level of perceived threat which can be influenced by such factors as knowledge, education, age, socioeconomic status, and cultural group [2]. These factors will be used to determine if the behavior change or preventative action will address the risk or threat of disease. While the constructs of Confidence and Convenience overlap HBM, these two constructs of the "Three C's" model are best reflected in the TTM/SOC. TTM/SOC can be used to assess at what stage of action, an individual, is at in their vaccine hesitancy/refusal. As educators, counselors, advocates, and health professionals, we can provide resources, guidance, and give opportunities that enhance Confidence & Convenience by addressing barriers.

Vaccine hesitancy is on a continuum and if we realize that individuals are assessing their needs constantly; in the way, they interact with their environment and others, and their perceptions and needs are continually being reassessed. These are areas of advocacy that can target the areas that can increase Confidence, Convenience, and diminish Complacency.

Behavioral Health Models have been widely studied and their constructs have been the basis of public health strategies that can truly facilitate behavioral change for individuals that lead to better outcomes, including vaccination.


[1] David Callender, David. (2016). Vaccine hesitancy: More than a movement. Human Vaccines & Immunotherapeutics, 12 (9): 2464–2468

[2] Holli, Betsy B. and Beto, Judith A. (2018). Nutrition Counseling and Education Skills: Guide for Professionals. Wolters Kluwer, 7, 3-460.

[3] MacDonald, Noni E. et al. (2015). Vaccine hesitancy: Definition, scope and determinants. Vaccine, 33 (34): 4161–4164.

[4] Rao, T. S., & Andrade, C. (2011). The MMR vaccine and autism: Sensation, refutation, retraction, and fraud. Indian journal of psychiatry, 53(2), 95–96.

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