Introduction

The importance of childhood immunizations has long been established. A 2024 study in the United States estimates that “among children born between 1994 and 2023, routine vaccinations prevented approximately 508 million cases of illness, 32 million hospitalizations, and 1,129,000 deaths resulting in direct savings of $540 billion and societal savings of up to $2.7 trillion” (Zhou, 2024, p. 682). The positive impacts of childhood immunizations are also seen globally, as demonstrated by a 2024 study examining the World Health Organization’s Expanded Programme on Immunization, which states that since 1974, childhood immunizations have averted 154 million deaths and led to significant declines in global infant mortality (Shattock et al., 2024).

While demonstrable success has been achieved in realizing the benefits of childhood immunizations, ongoing attention is needed to sustain those benefits. For example, state and local immunization data show that national rates of measles, mumps, and rubella (MMR) vaccination among kindergarten students have fallen below the Healthy People 2030 target of 95% (Seither et al., 2022). In some states, vaccine coverage is much lower (e.g., 81.3% in Idaho) (Seither et al., 2023a). It is important to note that geographic and social clustering of unvaccinated children can lead to outbreaks. An outbreak of measles in New York in 2018–2019 started within a community that housed many unvaccinated children (Zucker et al., 2020) and was attributed to delays in measles vaccination (Yang, 2020).

Recognizing the importance of not only sustaining successes but also increasing vaccination rates—and especially addressing disparities that affect specific communities and populations—this rapid expert consultation focuses on targeted strategies for addressing access barriers, promoting vaccine confidence and uptake, providing accurate information, countering misinformation and disinformation, and supporting resilient immunization services. Also explored are opportunities to enhance immunization efforts across various sectors and settings that serve parents and families, including healthcare; schools; social services; and religious, cultural, and community settings.⁵

CONTEXT

This is a timely moment to focus on childhood immunizations because the COVID-19 pandemic heightened public attention to vaccines and renewed or raised some challenges and concerns related to vaccinations for children. A range of factors related to the pandemic contributed to profound disruptions in childhood vaccination schedules and access (Cunniff et al., 2023; Santoli et al., 2020). These disruptions led to delays and, in some cases, fluctuations in vaccination rates for certain diseases among different demographic groups (NASEM, 2023; Santoli et al., 2020; Walker et al., 2022). The 2023 National Academies report Addressing the Long-Term Effects of the COVID-19 Pandemic on Children and

__________________

Families attributes those delays and fluctuations to such factors as interruptions in healthcare services, parental concerns about potential exposure to COVID-19 during healthcare visits, decreased access to vaccinations, and greater distrust and hesitancy fueled by misinformation and disinformation (NASEM, 2023). Today, while childhood immunization rates have rebounded to nearly prepandemic levels, disparities in coverage by race, ethnicity, poverty status, insurance status, and urbanicity⁶ persist and in some cases have been exacerbated (Hill et al., 2023; NASEM, 2023; Seither et al., 2023b).⁷

The pandemic also highlighted and sometimes exacerbated disparities in childhood immunization rates that existed before the pandemic, with Black, Hispanic, and American Indian/Alaska Native populations; those in rural areas; people with lower incomes; and people who lack health insurance having lower immunization rates (Albers et al., 2022; Michels et al., 2022; NASEM, 2023; State Health Access Data Assistance Center [SHADAC], 2024). One study found, for example, that children born to mothers with less than a high school education and those born below the poverty line were less likely to receive the complete seven-vaccine series (Kulkarni et al., 2021).⁸ Other research showed significant gaps by race and ethnicity in the share of children receiving the recommended vaccines by age 35 months, with African American and Hispanic children having lower rates.⁹ Immunization rates demonstrate the complex interplay among race, income, and immunization, with higher income potentially mitigating some racial disparities (Lieu et al., 2015; Xiong et al., 2024).

The COVID-19 pandemic underscored the role that disparities in access can play in health-seeking behaviors, with challenges such as lack of transportation, limited availability of healthcare providers, and clinic closures exacerbating existing access issues (Andraska et al., 2021; Cochran et al., 2022; Isasi et al., 2021). Socioeconomic barriers—including the inability to take time off work, lack of insurance, and financial constraints—are especially pronounced in rural and underserved areas and play a part in delays and decreases in childhood immunization (SHADAC, 2024).

Another concern regarding childhood immunization is that spillover concerns about the COVID-19 vaccines may have amplified general concerns about vaccine safety and efficacy, increasing hesitancy in some populations (LaCour & Bell, 2024; Olusanya et al., 2021; Smith et al., 2023). While vaccines have historically enjoyed widespread bipartisan support, recent polling has shown differences in perceptions of vaccines by political affiliation. For example, a 2024 Gallup poll showed changes in perceptions among Republican and Republican-leaning Independents, including a decrease from 52% to 26% of respondents reporting that they believe it is extremely important for parents to get children vaccinated; 20% say they believe vaccines are more dangerous than the diseases they are designed to prevent (Jones, 2024).

__________________

STRATEGIES FOR INCREASING CHILDHOOD IMMUNIZATION RATES

While the Vaccines for Children (VFC) program launched by the Centers for Disease Control and Prevention (CDC) has increased immunization rates by removing financial barriers to vaccination, significant gaps and disparities persist as nationwide vaccination coverage among kindergarten students remains below prepandemic levels (Seither et al., 2023a, 2023b). Addressing these gaps and disparities necessitates multifaceted and targeted interventions, employing robust efforts at the policy, health systems, and provider levels to sustain and increase vaccination rates across diverse populations, along with individual- and community-level strategies aimed at improving vaccine attitudes (Holroyd et al., 2021; Milkman et al., 2021; Opel et al., 2011; Schoeppe et al., 2017; Walker et al., 2022). It is important to note that the evidence base for approaches in different domains, sectors, and disciplines is variable and, in some cases, limited. Some approaches that have been studied demonstrate a direct impact on vaccine uptake, while others were developed to create changes in systemic issues or individual behaviors related to known factors that affect vaccination rates and are therefore likely to have a positive effect on vaccine uptake but have not been studied rigorously.

A key component of immunization strategies is building trust with both parent and provider communities at multiple levels, including (1) trust in the vaccines; (2) trust in the providers or healthcare professionals; and (3) trust in the policy makers, including the healthcare system, public health, government, and those involved in approving and recommending vaccines (Larson et al., 2018). These levels of trust were challenged during the pandemic, especially in communities that historically have not been well served by medical institutions or have experienced racism and discrimination (Adekunle et al., 2024; Yearby et al., 2022). Medical mistrust increased vaccine hesitancy in these communities (Allen et al., 2022). Strategies for building trust need to be tailored, with particular attention to the needs of different groups.

When developing strategies, it is also important to understand how individual parents (or other primary caregivers) make decisions about childhood immunizations. Research suggests that although the majority of parents adhere to recommendations, viewing vaccination as “routine” (Brunson, 2013a; Sobo, 2016), decision making is a complex and sometimes nonlinear process that includes:

• Awareness—First-time parents become aware of the need to vaccinate their children through educational material, social networks (including family, friends, and healthcare providers), social media, and traditional media sources. While pregnancy presents the first opportunity for prospective parents to provide their offspring with protection against disease—including pertussis (whooping cough) with the Tdap (tetanus, diphtheria, and pertussis) vaccine, which is administered to pregnant mothers to allow the production of antibodies to pass to babies (CDC, 2024)¹⁰—some parents do not become “aware” of vaccination as something they need to allow their children to experience until they are born. The respiratory syncytial virus (RSV) vaccine, also given during pregnancy, protects infants from RSV-associated lower respiratory tract infection. In some cases, parents become aware of childhood vaccinations when asked/informed about hepatitis B vaccination after children are born or even later (Brunson, 2013a; Glanz et al., 2015).

__________________

• Information gathering—Parents may actively seek more information, including benefits, risks, schedules, and requirements, and discuss this information with healthcare providers, family, friends, and online communities or through social media platforms and forums. This process can range from relatively simple (or skipped, such as among those who see vaccination as routine) to highly complex (Brunson, 2013a; Glanz et al., 2015; Opel et al., 2011; Sobo, 2016).
• Risk assessment—Parents evaluate the risks and benefits of vaccinating their children, weighing the potential side effects against the protection from diseases. They also consider social, cultural, religious, and community norms regarding vaccination (Brunson, 2013a; Opel et al., 2011).
• Decision making—Parents decide whether to vaccinate their children based on the information, influences, and norms they have considered. The decision is influenced by the parents’ social networks (Brunson, 2013b), as well as their understanding of vaccine information, support and recommendations from healthcare providers, social pressure or support from family and community, and access to vaccination services and resources (Brunson, 2013a, 2013b; Paterson et al., 2016). In addition, childcare and school requirements for vaccinations can influence the decision (Greyson et al., 2019). Vaccination outcomes can be influenced further by accessibility; convenience; and logistical considerations, including time, transportation, and cost (Freed et al., 2011; National Vaccine Advisory Committee, 2015; Paterson et al., 2016).
• Implementation—Parents follow through on their decision by taking action, such as accepting vaccinations at children’s doctors’ appointments or scheduling and attending separate vaccination appointments.
• Reevaluation—Parents may reevaluate their decision based on new information, experiences, or feedback from others. This reevaluation is influenced by personal experiences with vaccination side effects or outcomes; new information from other parents, community members, or healthcare providers; or the development of new risks, such as traveling abroad or local outbreaks of disease (Brunson, 2013a, 2015; Paterson et al., 2016).

Interventions to reach and build trust with parents and families will succeed when combined with approaches at the levels of communities, systems, and policies. The remainder of this section describes strategies (Box 2) for supporting resilient immunization services, addressing access barriers, promoting vaccine confidence and uptake, and providing accurate information while countering misinformation and disinformation.

INTEGRATED COMMUNITY, POLICY, AND HEALTH SYSTEM STRATEGIES

Access and Convenience

Efforts to improve immunization rates need to consider the broader context of health equity, ensuring that all children, regardless of race or income, have equitable access to vaccinations and healthcare services (Artiga & Kates, 2020; Brumbaugh et al., 2024; Dada et al., 2022). For some communities, improving access (both to vaccinations and accurate vaccine information) and convenience can be vital; one example is deploying mobile vaccination units to rural and underserved areas (Gupta et al., 2017; Leibowitz et al., 2021). Access can also be improved by ensuring that parents have the time to vaccinate their children by providing paid time off for that purpose and establishing vaccination clinics closer to where people work. Accessible locations where vaccinations can be offered also include schools, religious settings, and recreational settings. Offering vaccinations at schools can be particularly useful, as schools can be effective communication and logistical partners; students can get vaccinated in the school clinic during school hours, reducing parents’ burdens of access, time, and effort (Arenson et al., 2019). A recommendation from the Community Preventive Services Task Force (CPSTF, 2010) cites evidence from 27 studies that found that vaccination programs located in schools and organized childcare centers effectively increase vaccination rates. Likewise, the Maternal, Infant, and Early Childhood Home Visiting

program has shown how child wellness visits can promote healthy behaviors, including childhood vaccinations, and similar programs can accomplish this goal in low-resourced areas (Condon, 2019). The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) has also been able to connect children needing immunizations with those services.¹¹

Costs associated with childhood vaccines may also contribute to lower rates of childhood vaccination uptake for some groups. For example, data show that VFC-eligible children have lower vaccination rates compared with non-VFC-eligible children, particularly for vaccines requiring multiple doses (Valier et al., 2024). As noted previously, the challenges go beyond vaccine costs and can include other barriers, such as additional fees, lack of insurance for other medical services, provider shortages, language and cultural barriers, logistical issues, and administrative and systemic barriers (Albers et al., 2022; Valier et al., 2024). Subsidies or additional funding to address some of these barriers for low-income families can improve access (SHADAC, 2024).

In addition, the costs associated with delivery of childhood vaccines by providers are substantial. Providers carry a financial burden to stock, store, and deliver vaccines. Universal vaccine purchase programs for childhood vaccines, such as the program in Maine, collaborate with insurers to reduce vaccine costs by leveraging bulk purchasing (BerryDunn, 2020). Maine’s program reduced administrative and financial costs for healthcare providers in the state with an annual savings of more than $4 million per year (BerryDunn, 2020).

Social Networks and Trusted Community and Institutional Leaders

The power of social networks¹² in parents’ decision making has long been established (Brunson, 2013b; Sobo, 2015). Social networks facilitate the exchange of information and influence and are often trusted and seen as credible. They can play a vital role in disseminating vaccine-related information and convey social norms on whether to support or not support vaccination (Brunson, 2013b; Rakocz et al., 2023). Indeed, social network analysis has shown that information about vaccines spreads within social networks, and understanding these networks can help in targeting childhood immunization campaigns (Brunson, 2013b). An example of an intervention targeting social networks is peer education programs for parents, who can share their experiences and encourage others within their social network to get their children vaccinated (Hoffman et al., in press). Another example is a pertussis vaccination campaign for adults that was targeted at grandparents (Bulik, 2015).

Social media platforms are important to social networks and can both spread and counter vaccine misinformation and disinformation. Misinformation about vaccines on social media increased 30 percent during the COVID-19 pandemic (Smith et al., 2023). Communications in online antivaccine communities “tends to occur within ‘echo chambers’ where like-minded individuals share information consistent with their views and dismiss incongruent information” (Featherstone et al., 2020, p. 2). While providing accurate vaccine information in online campaigns can help debunk common vaccine myths in some communities, not all such efforts have been shown to be effective (Dubé et al., 2015). Studies have found that correcting misinformation on social media requires citing highly credible, factual information with links to expert sources; offering a coherent alternative explanation; providing multiple corrections that reinforce the counter message; and correcting misinformation early on (Bode & Vraga, 2015; Enyinnaya et al.,

__________________

2024; Kornides et al., 2023; Lewandowsky et al., 2012; Margolin et al., 2018; Vraga & Bode, 2017, 2020; Walter & Murphy, 2018). Promoting confidence in childhood vaccinations with accurate information is an established strategy for improving vaccination rates and may also help mitigate potential spillover concerns related to the misinformation and disinformation that arose in the context of COVID-19 vaccines (Lazarus et al., 2024; Shah et al., 2022).

While not yet evaluated, examples of efforts to promote vaccine confidence in the social media space include the CDC’s Let’s Play Catch-Up on Routine Vaccines, which provides examples of social media messages that can be used to encourage vaccination.¹³ Another example is the #FluVaxJax campaign in Jacksonville, Florida, focused on increasing influenza vaccination rates among children and adults using social media. The campaign used the #FluVaxJax hashtag to create a recognizable and shareable brand on platforms such as Twitter and Instagram. The campaign also employed key community influencers to share their vaccine stories.

Another intervention that provided web-based vaccine information for pregnant persons via social media applications positively influenced parental behaviors regarding children’s vaccinations (Glanz et al., 2017). The study concluded that “interactive, informational interventions administered outside of the physician’s office can improve vaccine acceptance” (Glanz et al., 2017, p. 7). Other studies have yielded similar findings (Daley et al., 2018; O’Leary et al., 2019).

Collaborations and Partnerships

Building trust by leveraging the help of community leaders can reinforce messages, address community-specific barriers, and assist in developing culturally relevant interventions—all of which are important in encouraging immunizations (Castillo et al., 2019; NASEM, 2021b). Partnerships can encompass a wide range of stakeholders, including community members (e.g., faith communities, neighborhood leaders), decision makers, and drug companies. Studies indicate that successful partnerships are built on engaging in early and reciprocal communication to foster trust, develop a common approach to addressing issues, involve citizens in decision making, and ensure that information is conveyed in a manner that is clear and relevant to local needs (NASEM, 2020; Quinn et al., 2020). Given the importance of trust in communities with reason to have distrust, part of the work may involve listening to and naming people’s concerns, including the fact that certain populations—especially historically marginalized populations, including women; Black, Indigenous, and people of color (BIPOC) populations; LGBTQ+ people; people with disabilities; people with low incomes; and the elderly—have historically been subjected to medical mistreatment and harm (Savoia et al., 2024; Thornton & Reich, 2022). For example, the National Influenza Vaccination Disparities Partnership is a national campaign led by local influential American Indian/Alaska Native partners committed to promoting the importance of influenza vaccination among their communities (CDC, n.d.).

Collaborations with community partners need to be attuned to power dynamics, be nonexploitative, and be viewed as a long-term relationship and investment to be sustained over time. Partnering means that decision makers, pharmaceutical companies, and healthcare providers listen to and learn from community members, including shared power and leadership, and partnering across sectors to provide support and engage in a meaningful way (AuYoung et al., 2023; Lansing et al., 2023). Community outreach that is respectful and includes communities in the planning and development phase can go a

__________________

long way toward building trust, especially for communities with a historical distrust of healthcare authorities (Lansing et al., 2023). Community outreach also needs to be designed around the community’s needs, which may differ from concerns of decision makers, medical professionals, or vaccine manufacturers (Shen et al., 2023). An example of a collaboration focused on vaccine uptake is the California Immunization Coalition’s Shot by Shot Campaign,¹⁴ which includes healthcare providers, schools, and community organizations; it provides informational resources and encourages contributors to share their own stories about the impact of vaccines in preventing diseases.

Strategic Policy Initiatives and Improved Monitoring

Policy initiatives can potentially improve childhood vaccine uptake (O’Leary et al., 2019). One policy initiative showing significant impact is expanding the scope of practice for certain healthcare professionals to administer vaccines. For example, pharmacists are authorized to administer vaccines to children under age 7 in at least 33 states.¹⁵ Other states, such as Montana, have expanded this policy to include pharmacy technicians. While strong evidence supports the effectiveness of offering adult vaccines in pharmacies in increasing vaccination rates (Le et al., 2022), there is limited evidence on this strategy for child and adolescent vaccines and the potential unintended consequence of forgoing well-child visits and anticipatory guidance with their primary care clinician. Nonetheless, this strategy might be useful for rural and low-income areas with shortages of healthcare providers.¹⁶ As part of the National Vaccine Strategic Plan, the U.S. Department of Health and Human Services (2021) called for increasing the availability of vaccines in a variety of settings, including non–healthcare settings such as pharmacies, community centers, and schools. Community health workers can also be used to administer vaccines—a method employed in low- and middle-income countries (Ogutu et al., 2024). An evaluation of Arizona’s Health Start Program—a statewide maternal and child health home visiting intervention employing community health workers—found that vaccination completion rates (by age 5) were higher for Health Start children and for several subgroups of mothers, including women from rural border counties, Hispanic/Latinx women, American Indian women, women with less than a high school education, and teen mothers (Wightman et al., 2022). Team-based approaches can help ensure that all children receive immunizations and anticipatory guidance and that all parents receive the support they need; however, these approaches must involve data sharing and coordination across primary care clinicians, community health workers, school clinicians, and others.

Enhancing and maintaining robust systems for tracking vaccination rates, including information about equity in access and uptake, can provide important information to help identify and address low-coverage areas and populations (Santoli et al., 2020; Scharf et al., 2021; Scobie et al., 2020). Immunization information systems are confidential, population-based, computerized databases that record all immunization doses administered by participating providers to people living within a certain geopolitical area (Groom et al., 2015; Novick, 2014). Minnesota, for example, has a webpage offering county-level data on vaccination coverage rates across the state.¹⁷ Likewise, the Michigan Care Improvement Registry (2017)¹⁸ is an effective immunization registry that helps improve vaccination rates by tracking immunization status, forecasting the next doses, and providing easy access to vaccination records.

__________________

Strengthening vaccine safety systems to maintain trust in vaccine safety is also important (Salmon et al., 2015).

Policy initiatives that improve data sharing and interoperability among healthcare providers and local and state public health authorities can improve tracking and facilitate interventions to reach under-immunized individuals and populations. Improving the post-authorization vaccine safety system¹⁹ will aid in rapidly and objectively determining whether adverse events following immunization are coincidental or causal (involving a true adverse vaccine reaction), as well as the potential to improve confidence about vaccine safety. For adverse reactions, it is necessary to ascertain the attributable risk, identify subpopulations at increased risk, understand the biological mechanism involved, and prevent the adverse reaction whenever possible. Inadequate investments in post-authorization safety science have hampered such science (Salmon et al., 2024). Some have proposed using a portion of the Vaccine Excise Tax to fund safety science as a policy solution (Salmon et al., 2024).

INDIVIDUAL-LEVEL STRATEGIES

Core Messages About Childhood Immunizations

Childhood immunizations have a long history of success and are backed by strong evidence. Research has shown that clear, empathetic, evidence-based communication can help alleviate concerns and increase vaccination uptake (NASEM, 2021b). Accordingly, core messages that draw on this history can encourage parents to vaccinate their children (Olson et al., 2020). These messages typically focus on the safety and efficacy of vaccines, the benefits of vaccination for both individual and community health, and the importance of adhering to recommended and well-routinized vaccination schedules. A recent study tested the efficacy of a satirical book about childhood vaccinations immunizations designed to influence knowledge, attitudes, and behaviors among vaccine-hesitant parents using dark humor and found it to be more effective at improving their attitudes toward vaccination than the widely used publicly accessible booklet produced by the CDC designed to encourage childhood immunizations (McKeever et al., 2024).

These findings appear to indicate that combining narrative content with statistical evidence holds promise as an effective communication strategy for combating vaccine-related concerns among parents (Salmon et al., 2023). It is also important that both core and targeted messages be evaluated before dissemination. Examples of formative evaluations can use think-aloud interviews, where individuals from the target group can read drafts and point out any lack of clarity (NASEM, 2021a); randomized controlled trials that have different groups receiving different versions of a message or no message at all to determine which version is most effective (Clayton et al., 2021; Viskupič & Wiltse, 2024); eye-tracking studies, which measure where and how long participants focus their attention when reading or viewing content (Avery & Park, 2018; Kim et al., 2021); A/B testing, which involves presenting two or more versions of a message to different segments of an audience to see which one performs better (Gaysynsky et al., 2022); and behavioral economics experiments, which study how psychological, cognitive, emotional, cultural, and social factors affect people’s decisions (Huf et al., 2024; Viswanadham, 2023).

__________________

The following are examples of core messages that have been used:

• Vaccines are very safe and effective: This message can be supported by studies highlighting the rigorous process of vaccine testing for safety and efficacy before being approved, and continuous testing thereafter (Bolsen & Palm, 2022; Freed et al., 2011; Horne et al., 2015).
• Vaccination protects your child from serious diseases and has saved millions of lives: This message draws on the evidence showing how vaccinations have protected children from different diseases. The message has been shown to be effective in countering antivaccination attitudes (Horne et al., 2015).
• Vaccines protect the community: This message points out that vaccines’ protection extends to other vulnerable members of communities (Bonafide & Vanable, 2015). It was particularly effective and aligned with the values of certain communities, including American Indians and Alaska Natives, during the COVID-19 pandemic (Sanchez & Foxworth, 2021).
• Vaccination is a social norm or routine: Messages showing that many parents choose to vaccinate their children because it is a socially accepted norm supported by scientific evidence can be effective (Palm et al., 2021). However, relying on mere conformity with social norms without bringing along hearts and minds can produce vulnerability to misinformation (Reyna, 2021).
• Adhering to the recommended vaccine schedule is optimal: This message emphasizes that following the recommended vaccine schedule ensures that a child receives vaccines at the optimal time for maximum protection (Kaufman et al., 2018).

Research has also shown that one of the best ways to share the above information is by sharing testimonials from other parents rather than just data. A quote that is broadly used in these efforts is one attributed to Benjamin Franklin describing his own regret about not having his son, who died of smallpox at age 4, inoculated against the disease (Best, Katamba, & Neuhauser, 2007, para. 1):

I long regretted bitterly and still regret that I had not given it [smallpox] to him by inoculation. This I mention for the sake of the parents who omit that operation, on the supposition that they should never forgive themselves if a child died under it; my example showing that the regret may be the same either way, and that, therefore, the safer should be chosen.

Recent research has also suggested that focusing on values is another way to overcome skepticism that may arise from focusing solely on scientific information—an issue that has been exacerbated socially since the deployment of the COVID-19 vaccines (Cataldi et al., 2019; Olson et al., 2020). Values that may engage parents include security (e.g., protecting children from harm), self-direction (e.g., valuing making one’s own decisions), and conformity (e.g., going along with social norms) (Cataldi et al., 2019).

Parental Reminders

Well-established evidence demonstrates that reminder and recall systems can improve vaccine uptake (CPSTF, 2015). Reminders can be sent through different media, including postcards, letters, text messaging, electronic medical record messages, and phone calls. Although targeted to adult

immunization, a study of text-based nudges on influenza vaccination found that text messages can boost vaccination rates by an average of 5% (Milkman et al., 2021). The highest-performing message, which increased adoption by an estimated 11%, included two reminders to patients about getting their flu shot at an upcoming doctor’s appointment (Milkman et al., 2021). The study also found that “interventions performed better when they were 1) framed as reminders to get flu shots that were already reserved for the patient and 2) congruent with the sort of communications patients expected to receive from their healthcare provider (i.e., not surprising, casual, or interactive)” (Milkman et al., 2021, p. 1).

Frew and Lutz (2017) systematically reviewed 34 studies using reminder and recall methods, such as postcards, letters, and phone calls, to boost early childhood immunization rates. They found that most reminder systems (79%) significantly improved vaccination uptake, with increases ranging from 9% to 55%, and that personalized calendars aimed at promoting vaccinations for children up to 24 months old resulted in a 66% immunization rate in the intervention group, compared with 47% in the control group. Another study also found text message reminders about influenza vaccination among urban, low-income pediatric and adolescent populations to be effective (Stockwell et al., 2012).

A critical aspect of reminder campaigns is access to healthcare and access to accurate information. Focusing only on parents of children who visit traditional healthcare providers can potentially miss children whose parents lack the resources (money, time, transportation, or insurance) to make those visits or who take their children to alternative providers. Reminder campaigns also need to be tailored to reach communities experiencing risk, especially poorer individuals and groups. Reminders are also an opportunity to provide more information, as in the program Let’s Talk Shots.²⁰

Internet-based platforms can provide parents with easy access to vaccination schedules, personalized reminders, and educational resources. An example would be a Facebook page run by trusted sources (e.g., pediatrician or hospital system), where parents could ask questions about vaccines and receive evidence-based answers. Emphasizing the importance of social media in vaccination intentions, Daley et al. (2018) found that receiving vaccine information from a study website with vaccination and social media components increased the likelihood that parents would vaccinate their children.

Tailored Communications

Core messages alone are often insufficient; rather, some parents may respond to more targeted messages (Nyhan et al., 2014). Research has consistently shown the benefit of developing targeted education and communication campaigns to address vaccine-related concerns (Omer et al., 2022). Individually tailored messaging has been shown to increase uptake of the influenza vaccine among pregnant persons unsure about vaccination or intending not to vaccinate, and to increase vaccination among family and friends to protect the infant; it has also been found to reduce parental vaccine concerns a year after the birth of the child (Dudley et al., 2021, 2022). Tailoring information can include considering cultural, religious, and racial dynamics, particularly in communities with historical mistrust of the healthcare system (NASEM, 2021b). It may also include attention to specific attitudinal and psychological traits and specific beliefs and experiences to make the information more personally relevant (Limaye et al., 2021).

__________________

Tailored messages have been shown to significantly improve parents’ vaccine attitudes (Glanz et al., 2017). A study evaluating individually tailored versus untailored information on the MMR vaccine found that the tailored information had a significantly greater impact on vaccination intentions and attitudes (Gowda et al., 2013). Examples of these messages include tailored brochures and videos providing answers to common vaccine-related questions. Campaigns such as MomsTalksShots and Let’s Talk Shots have effectively promoted vaccine uptake by leveraging relatable stories and community engagement. The MomsTalkShots educational application has shown to be highly effective, with surveyed users finding it helpful (95%), trustworthy (94%), interesting (97%), and clear (99%) (Salmon et al., 2019). Even among vaccine-hesitant women, most found the application helpful (91%), trustworthy (85%), interesting (97%), and clear (99%) (Salmon et al., 2019). Furthermore, 72 percent of women who initially felt they lacked sufficient vaccine information reported having enough information after viewing the videos (Salmon et al., 2019). Additionally, providing vaccination information in multiple languages can overcome language barriers among non-English-speaking populations (Zimet et al., 2013).

Healthcare providers can be a critical source of tailored messages. Providers can use techniques such as motivational interviewing²¹ for hesitant parents (Brewer et al., 2021; Henrikson et al., 2015; O’Leary et al., 2023; Reno et al., 2018). A study with a significant motivational interviewing component found that it was associated with increased vaccination rates in children aged 6 years and younger and decreased documented vaccine refusals among mothers of the same population (Cole et al., 2022). Healthcare providers are also in a position to help parents reevaluate past decisions when their circumstances change, such as when their children become older, when international travel is planned, and when local outbreaks of disease occur (Brunson, 2015).

CONCLUSION

The COVID-19 pandemic highlighted disparities in childhood immunization rates. The interplay of race and ethnicity, income, and geography involved in these disparities emphasizes the need for a multifaceted approach that takes contextual factors into account. Opportunities for promoting childhood immunization exist at the integrated community, policy, and health systems level as well as at the individual level. Strategies for promoting childhood immunization include listening to the voices of families and communities regarding barriers and solutions; tailoring communications to the culture, beliefs, and religion of the intended audience; and building equitable collaborations and partnerships among decision makers, the private sector, and communities. Practical approaches, such as reminding parents, facilitating access, and increasing convenience, can make it easier for parents to vaccinate their children. Social networks can potentially improve coverage as well, as they have been shown to be relevant and influential in parents’ vaccine decision making. Finally, policy initiatives that are strategic and targeted, together with better monitoring systems, allow stakeholders to more easily share information quickly and identify any outbreaks that might arise. Promoting childhood immunization requires a multifaceted approach, with interventions at the systems and policies levels that make services available and accessible and that foster the capacity to build trust and create the conditions for success.

SEAN is interested in your feedback. Was this rapid expert consultation useful? Send comments to sean@nas.edu or (202) 334-3440.

__________________