December 2017

It's Flu Season! What's Up with the Vaccine Controversy?


It’s 2017. New controversies abound in America, but one that has persisted over time, even after being scientifically debunked over and over again, is the vaccine controversy. Unfortunately for herd immunity and individual health and wellness, the vaccine controversy extends well past childhood vaccines and into vaccines that recommended for adults, such as influenza (flu) vaccine. This post shows how behavioral economic concepts and decision theory play a role in what’s often referred to as “vaccine-hesitancy,” but I first want to draw your attention to the health and economic costs the nation incurs when people don't get vaccinated against the flu.  

Flu Facts

Herd immunity” protects infants and people who are too sick to be vaccinated against preventable diseases. It occurs when a significant proportion of the population is immune to a contagious condition because they have been vaccinated against it. When this occurs, infants and people whose immune systems are compromised have a much smaller risk of coming into contact with the illness in question because much of the community is already protected.  Influenza vaccination is important enough to individual and public health that multiple HEDIS measures track the percentage of health plan members who are vaccinated.

Reduced flu vaccination rates, also known as reduced vaccination coverage, can even present a problem for those who have been vaccinated against the flu. Due to the challenges of predicting which strains of flu will affect the nation in a particular flu season, flu vaccines vary in their effectiveness from year-to-year. The Centers for Disease Control and Prevention (CDC) estimates the overall effectiveness of the influenza vaccine in the U.S. to vary between 10% and 60% between 2004 and last year’s flu season. That means that in any given year, even if you get vaccinated, you may still contract the flu.

During the 2015-2016 flu season, nearly 42% of U.S. adults were vaccinated. That’s a drop of 2% from the previous season, and it means that 58% of the U.S. adult population was unvaccinated. That could include your neighbors and coworkers, who could [G6] come down with the flu and pass it along to you. That's a form of sharing that no one is really interested in engaging in. “But it’s just the flu,” you say. “No big deal.” Ah, that is where you are incorrect, my dear reader. The flu kills.

The CDC estimates that up to 56,000 people have died each year in the U.S. since 2010. And you know how you keep hearing about high hospital bills that are bankrupting Americans? Well, the flu sends up to 710,000 to the hospital each year. That means some big medical bills and lost income for something that could have been prevented with a flu shot. And the cost to the national economy? Nearly $6 billion in 2015, topping the economic cost of all other vaccine-preventable illnesses examined in one study. The researchers found that most of the economic burden caused by vaccine-preventable illness is caused by people who chose not to get vaccinated (about 79% of the total burden). When people make a decision not to get vaccinated, they’re making a decision that affects us all, and in multiple ways. So if the influenza vaccine can prevent all of this physical and financial suffering, what gives?

The Vaccine Controversy

The term “vaccine-hesitancy” is relatively new. Think of it as the middle section of a continuum that ranges from people who demand vaccines to those who totally refuse all vaccines. But a simpler definition that better aligns with the public’s understanding of the term is “an active desire to defer or omit any of the vaccines routinely recommended…” In the U.S., the controversy over vaccines[G9]  dates back to the 1850s, and today is driven by a number of factors, from the sources Americans often consult for health information, to increasing societal distrust in the nation’s institutions (e.g., business, media, and governmental institutions). Let’s face it – the internet is a platform for misinformation. One study, published in 2013, found that vaccine-hesitant people are more likely to use the internet as an information source than those who either get vaccinated or report that they are undecided about flu vaccination. Another driver of vaccine-hesitancy is the historical exploitation of minority communities in medical research which generated mistrust of the healthcare system that has been handed down through generations. This mistrust leads some to question medical guidelines and avoid engaging with the system.

But the Big Fish in this story is a discredited British researcher who published a study that claimed there was a link between the childhood MMR vaccine and autism (the paper has since been retracted). The author of that 1998 study, Dr. Andrew Wakefield, subsequently had his medical license revoked and a prominent medical journal reported that Wakefield’s research was fraudulent. The study’s co-authors no longer want anything to do with the work after learning that Wakefield was being paid by a law firm that was preparing to sue vaccine companies when he published his study. Dr. Wakefield had omitted this important detail from the report. In fact, the British Medical Journal (BMJ) reported that the researcher received the equivalent of more than a half-million dollars from the firm. But before the BMJ investigation broke the case open, the damage was done. Vaccination rates fell in the U.K and the U.S. The discredited Wakefield study, which BMJ calls “an elaborate fraud,” tarnished the image of life-saving vaccines.

Another issue implicated in the vaccine controversy is the inconvenient fact that new scientific findings are released all the time, and they sometimes conflict with each other. This cannot be helped — it's the nature of science. But the public can find it confusing, and confusion can lead to inaction. In 2012, researchers reported a paradox – people who are regularly vaccinated against the flu were less protected than those who don’t. That is exactly the type of scientific finding that leads to internal conflict and anticipated regret for people who are making decisions about whether to get vaccinated. As another example, some people fear that flu vaccines actually cause flu (they do not).[2] So what’s the average American supposed to think when combined with the fact that vaccination does not translate into 100% protection?

Cognitive Biases at Play

Well, I’m not here to tell you what to think, but I can tell you about some of the cognitive biases that affect the way people make decisions about vaccinations. Cognitive biases are tricksters that can cause people to make poor decisions. They’re studied in multiple disciplines that have a common theme – the study of how people process information and behave. They’re very useful for explaining why people make irrational decisions and fail to select the options we hope they will select.

Confirmation Bias

There are many types of heuristics and cognitive biases I could tell you about here, but I’m going to focus on three that are particularly relevant to the decision not to get vaccinated against the flu. The first is confirmation bias. Confirmation bias likely impacts most of our daily lives whether we like it or not. It occurs, in part, when you notice or seek out information that confirms your own beliefs while dismissing information that contradicts your beliefs. For example, if you have strong feelings about climate change or another hot-button topic, information that confirms your beliefs is going to stand out when you see it, while you may choose to disregard stories that present alternative viewpoints, believing that they have little credence. Perhaps, if you have strong political views, you seek out information on websites that align with your political views and actively avoid websites that are on the other side of the political spectrum. Or, in the case of vaccines, if you are vaccine-hesitant, information that asserts that there is an association between vaccination and autism may stand out to you more readily than information about vaccines saving lives. We all entertain our own confirmation bias from time-to-time. It takes active monitoring of your thought processes to avoid doing it, and it's hard to keep up with that monitoring 24 hours a day! Researchers from Yale and UCLA have posited that this type of bias, along with other defensive biases, are adaptive and serve to help you maintain a sense of individual self-worth.[3]  

Bandwagon Effect

The bandwagon effect is especially relevant now that social media is so pervasive in our society. You’ve heard of things “going viral,” of course. The bandwagon effect on vaccine hesitancy occurs when society begins to adopt the views of those who are vaccine-hesitant, increasing the probability that additional people will adopt vaccine-hesitant viewpoints. The bandwagon effect provides some explanation for social trends, like the use of Twitter and Facebook. Human beings are influenced by others around them. When they hear about people refusing vaccines, some will jump to a conclusion that must mean there is something bad about vaccines. Fortunately, there are ways of addressing this form of bias. Member outreach that uses social norming techniques and works to improve member self-efficacy can counteract the bandwagon effect.

Availability Heuristic

Finally, the availability heuristic is a mental shortcut. When you weigh the pros and cons before making a decision, if you find yourself placing more emphasis on the cons because past examples are more memorable than examples of the pros, you’re using the availability heuristic. It’s easier to remember the bad than it is to remember the good! A lot of times, the good just seems like the status quo, so it doesn’t stand out in your memory. For example, you may remember a time when you went and got your flu shot, but you contracted the flu anyway and lived in misery for a week. On the other hand, the years when you received a flu shot and remained healthy all season probably go unnoticed and fade from memory.

Heuristics help people make decisions under uncertain conditions, but they can lead to errors in logic that result in poor decision-making.

We at Eliza have the expertise and experience required to successfully tackle heuristics and biases head-on! Using a principle from decision science and behavioral economics, called “loss aversion,” Eliza crafts messages that use loss aversion to health plans’ advantage. For example, we can let members know that skipping the flu shot can dramatically increase the chance of getting the flu (by 400%)![4]

Theory Ties It Together

The use of the loss aversion concept dovetails nicely with our use of the Health Belief Model (HBM), a well-regarded theory frequently used in behavior change communication. The HBM is made up of five key factors that can be used to understand and predict health behaviors. The first of these is “perceived susceptibility,” or the degree to which a member believes that he or she is likely to come down with the flu. Perceived severity, another key piece of the HBM, ties-in here, as well. Using a conversational tone and simple-to-understand language, rather than providing a litany of statistics that aren’t very meaningful or impactful for the average person, we can also remind members that the flu is very unpleasant by invoking memories of members’ previous flu experiences. The final three pieces of the model are perceived benefits, perceived barriers, and cues-to-action. Previous studies have found that the perceived benefits portion of the HBM is the most important predictor of influenza vaccination (e.g., belief that getting vaccinated protects the member’s family and that the flu shot is safe). Eliza’s messaging serves as a cue-to-action and we explain the benefits of vaccination. We can also assess member barriers so that plans can evaluate whether additional intervention is warranted.

The HBM is just one of several health communication theories Eliza employs, in combination with decision theory and behavioral economic concepts, to drive member behavior change. Our designers have advanced degrees in health communication and know how to tackle cognitive biases and identify barriers that can prevent members from closing HEDIS gaps. Our outreaches get results for a reason — they’re scientifically-based!

Did you get your flu shot yet? It’s getting late in the season, but there’s still time



Dr. Gaiser holds a Ph.D. and MA in Health Policy, both from Brandeis University, an MPH with a concentration in Health Communication from Tufts University School of Medicine, and a BA in Journalistic Communication from Purdue University. Her doctoral research examined shared medical decision-making (SDM) for antidepressant treatment. It also examined how SDM and patient-provider trust affect treatment acceptance for three chronic conditions. Melanie has additional content expertise in behavioral health and healthcare cultural competence. Her work in broadcast and print journalism spanned more than a decade in the local (Boston), national, and international arenas.

In her role as Manager of Engagement Research and Strategy at Eliza, Melanie focuses on strategic research and development with a home base in Eliza’s Data Science group. She combines her diverse experience in research methodology, sales, and communication to serve as a boundary spanner, facilitating collaborative partnerships between Eliza’s technical, science, and creative groups.

A dog-obsessed Francophile, Melanie enjoys gardening, traveling, writing, making (and eating) cheese, and hiking in search of alpine waterfalls. She geeks out by reading about food policy issues and behavioral economics.

[1] Brownlee, S., & Lenzer, J. (2009, November). Does the vaccine matter? The Atlantic. Retrieved from  

[2] Mayo, A.M., & Cobler, S. (2004). Flu vaccines and patient decision making: What we need to know. Journal of the American Association of Nurse Practitioners, 16(9), 402-410. doi: 10.1111/j.1745-7599.2004.tb00390.x

[3] Sherman, D.K., & Cohen, G.L. (2002). Accepting threatening information: Self-affirmation and the reduction of defensive biases. Current Directions in Psychological Science, 11(4), 119-123. doi: 10.1111/1467-8721.00182

[4] Chen, F., & Stevens, R. (2016). Applying lessons from behavioral economics to increase flu vaccination rates. Health Promotion International, 32(6), 1067-1073. doi: 10.1093/heapro/daw031

Image Source: "Flu Shot Advertising" by Whoisjohngalt is licensed under CC BY 2.0

It’s 2017. New controversies abound in America, but one that has persisted over time, even after being scientifically debunked over and over again, is the vaccine controversy. Unfortunately for herd immunity and individual health and wellness, the vaccine controversy extends well past childhood vaccines and into vaccines that recommended for adults, such as influenza (flu) vaccine. This post shows how behavioral economic concepts and decision theory play a role in what’s often referred to as “vaccine-hesitancy,” but I first want to draw your attention to the health and economic costs the nation incurs when people don't get vaccinated against the flu.

Identifying & Addressing Social Determinants of Health

Social determinants of health (SDOH) are “the structural determinants and conditions in which people are born, grow, live, work and age.”[2] They include factors like socioeconomic status, education, the physical environment, employment, and social support networks, as well as access to healthcare.


Socioeconomic Barriers to Care

Consider, for a moment, some statistics[3]:

  • 28% of US adults reported that they had at least two chronic conditions
  • 26% of US adults said that they had experienced emotional distress in the past year that was difficult to cope with alone.
  • US adults were more likely than adults in all other countries to report that they were “always” or “usually” worrying about having enough money to buy nutritious meals and to pay their rent or mortgage.
  • 33% of US adults reported that they had had a cost-related access problem in the past year. US adults are the most likely to report financial barriers to health care compared to other countries.

Healthcare providers tend to think that people care about the same things they do – getting and staying healthy through a range of preventive care activities including annual well visits, chronic condition management, medication adherence programs and health education. However, we need to acknowledge that the same things aren’t often on the minds of the typical healthcare consumer. For them, healthcare is one of many competing priorities, and it is often put on the back burner when compared with the long list of things that is really on their mind

It is now widely recognized that the health outcomes of populations often are determined more by social factors than by medical care. 3

We’ve passed the point where more evidence is needed to prove the relationship between socioeconomic factors and health outcomes and are now at the point where early identification, screening and effective interventions and services are needed.

Health plans and providers need to assess members' access to healthy food, safe and stable housing, and healthcare, as these things are influenced by income and racial disparities and are related to poor health outcomes. Socioeconomic factors also contribute to chronic stress, which negatively impacts physical and mental health. But too often, socioeconomic barriers fall outside the benefit structure of health plans. One could argue that effective care cannot be delivered when we ignore life factors that have such an enormous impact on the health of members. It is critical for healthcare organizations to direct efforts and resources towards addressing issues of social inequities, diagnose problems, and remove barriers that negatively impact the health status and quality of life of their members. But how to do this when this type of information doesn’t come in on a claim? 

Know Your Members

Go beyond claims data and have conversations to identify life beyond the models.

Eliza develops strategies to assess and address social determinants of health in order to promote the health and wellness of health plan members. We do this by having a direct and open dialogue with members, with the intention of better understanding individual needs and barriers to care, and connecting members to valuable plan and community resources. 

An Eliza program assessing social determinants of health for Marketplace members revealed that people who report concerns about life necessities (food, shelter, safety) are:

  • 5x more likely to report having poor health
  • 2.5x more likely to report their health negatively impacting their work
  • 8x more likely to report high emotional stress
  • 40% reported having difficulty getting to the doctor

Our Social Determinants of Health module can be added to any Eliza outreach, from a welcome call with an HRA to a flu immunization reminder. The following topics are covered:

  • Life necessities (food, shelter, safety)
  • Mental and physical health changes
  • Health impact on taking care of others and employment
  • Money/financial worries
  • Caretaker stress
  • Housing stability over time
  • Access to transportation
  • Perceived ability to overcome problems and seek help

In order to get the most out of this activity, we recommend you follow these general guidelines:

  • Use multiple opportunities to collect Social Determinants of Health responses from members throughout their tenure
  • Monitor changes in responses over time
  • Offer immediate assistance to members reporting issues for which health plans have resources to address
  • Analyze member health behaviors in light of their responses




Eliza took this approach when partnering with Gateway Health to evaluate their Medicaid and Medicare population for socioeconomic barriers to care. Once barriers were identified, members were connected with a care manager who was able to provide support and plan or community resources. Over 30% of respondents said they were ‘moderately’ or ‘severely’ concerned with life necessities. These members are 2-3 times more likely to also report fair or poor health, compared to those with little or no concern for life necessities. 

Eliza Insights

We’ve found that the dually-eligible population is most likely to report high concerns about life necessities, followed by the Medicaid population and then Marketplace members (of which, about 85% are below 400% the federal poverty level).

It makes sense that those who are low income and older and/or disabled are most likely to experience socioeconomic barriers to health.

We also found that those who report high concerns about life necessities are 2-9% less likely to close clinical gaps than those who were neutral or had no concerns about food, shelter or safety. 


Those with concerns for life necessities are more likely to report that physical and emotional health problems affect their productivity, or their ability to do a good job at work, at home, or when caring for others. Not surprisingly, dually-eligible members are slightly more affected than Medicaid members, as age and disability status play a larger role in one’s ability to be “productive,” (as we define it). 

Emotional Health Impact on Productivity and Concerns About Life Necessities


Physical Health Impact on Productivity and Concerns About Life Necessities


How are you addressing social determinants of health for your low-income populations? Are you confident in your ability to catch members who don’t have access to life’s necessities? How can you leverage technology to identify and address social determinants of health? For more information on how Eliza can support you in answering these difficult questions, email or call us at 1-844-343-1441. 


[1]   "Community Healthcare Network Closeup" by jonny goldstein is licensed under CC BY 2.0

[3] Health Affairs, November 16, 2016

4 Taylor, L., Hyatt, A., Sandel, M. (2016, November 16). Defining The Health Care System’s Role In Addressing Social Determinants And Population Health. Health Affairs Blog.


Let's Connect