WHEN Hollywood studio executives rejected a screenplay by the writer Nora Ephron (Silkwood, When Harry Met Sally, Sleepless in Seattle) telling her not to take it personally, she allegedly responded, “How am I supposed to take it — as a group?”

A key issue for Australia’s COVID-19 vaccination campaign is the resistance of people who think in personal terms about vaccination, rather than taking it as a group.

I think there are two crucial pockets of society to consider: the anti-COVID-19 vaccination movement, which is framed by the politics of personal rights, and the COVID-19 vaccination fence sitters, who could go either way depending on fluctuating influences.

The reasons people choose not to be vaccinated are complex and there are sub-groups with different perspectives. Broadly, both groups perceive vaccination as a matter for individual decision making. The anti-COVID-19 vaccination movement promotes personal choice an inalienable right, while arguing that the vaccine is more dangerous than the disease. This may influence fence sitters who are enacting the right to choose without being tied to any particular philosophy regarding the rights of individuals versus the needs of the community.

Individual decision making in these two key groups is informed by the legacy of Australia’s messy start to the COVID-19 vaccination. For many months, the government’s messaging around vaccination was variable and lacked any sense of urgency. Meanwhile, the only readily available vaccine had a well-publicised side-effect rap sheet.

Unconvinced about the need for vaccination, dubious about vaccine safety, and each left to their own decision-making logic, those against vaccination and the fence sitters are locked into positions of abject rejection or disinclination, respectively.

Although Australian vaccination rates are rising – as of Sunday 19 September 46.2% of the population had been fully vaccinated (according to the Australian Government) – we need to address the ongoing unwillingness of these two groups, which together make up the 24% of adult Australians unsure about having a COVID-19 vaccine. Individual decision making is shaped by personal logic. Wisdom and rationality are not dispassionate qualities, as much as we like to pride ourselves on being objective. Our decision making is culturally and socially adaptive and, therefore, inconsistent and unpredictable.

We need to make vaccination more collectively consistent and predictable, in order to influence the fence-sitters.

Australia’s current vaccination campaign asks people to be individually proactive in making vaccination appointments and following up in a timely way. There is nothing intrinsic in this campaign that drives a collective response. It is a static “get vaccinated” message, erratically laced with variable political idealising but with no built-in features that pivot people toward vaccination.

In contrast, some countries embed group momentum in their vaccination campaigns. The message to get vaccinated comes by way of automatically generated vaccination invitations and appointments. If you don’t show up for the appointment, you receive subsequent appointments and/or reminders to vaccinate. If you do not want reminders and have no intention of being vaccinated, you can actively opt out.

In Spain, where I am living, if you are registered with the public health scheme you will be sent an invitation to book or issued an appointment time and place. Contact is made via a text message and/or phone call or letter. You are told what brand of vaccine you will receive and you are sent reminders in the lead-up to the appointments.

Spain is decentralised so different territories have their own campaigns. I live in Valencia where they run “Operation Catch-Up” generating automatic appointment dates and times.

These kinds of campaigns are pragmatic in making vaccination easy and they endorse vaccination as the norm. Everyone you know has been vaccinated or contact about an appointment. Some Spanish territories also offer no-appointment vaccination days or deploy mobile vaccination units, bringing vaccination to prioritised local populations. This strategy may also support vulnerable populations who find it hard to navigate a vaccination booking system.

Making vaccination a group activity in this way is not a far stretch from Australia’s public health campaigns for non-COVID-19-related disease prevention and early detection. We are sent reminders to vaccinate our children at various stages of their lives, and we receive reminders for breast, prostate and bowel screening. Automatically generating an invitation to book an appointment that we can confirm or reschedule is just one step further.

Spain can be an administratively challenged country but the vaccination roll-out has been efficient and effective (here and here). Large sites have been turned into vaccination hubs that process thousands of people per day. Using the auto-appointment strategy, without transgressing personal freedoms or offering clunky incentives, Spain has fully vaccinated 80.14% of its population of 46.7 million people, as of 19 September 2021.

Of course, Spain, like most European countries, has also had the advantage of multiple available vaccines: AstraZeneca for 60–69-year-olds, Pfizer, Moderna and Janssen (Johnson & Johnson’s one-shot vaccine), for everyone else.

Australia is finally on its way to an adequate supply of demographically relevant vaccines, but it will take more than that to bump up our vaccination rates. We need strategies that push vaccination in hard-to-reach groups, adding momentum to the campaign and making vaccination the norm. Vaccination options that are trouble-free and that lighten the burden of personal decision-making may be enough to tip the hesitant and the averse into taking vaccination as a group.

Dr Klay Lamprell is a health care systems researcher with the Australian Institute of Health Innovation, Macquarie University, and a postdoctoral researcher with the National Health and Medical Research Council Centre of Research Excellence in Implementation Science in Oncology. Her views are her own.



The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.


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One thought on “Automatic COVID vaccine appointments may shift reluctance

  1. Anonymous says:

    Thank you for your article.
    I would like to offer a differing angle on this issue, one that may certainly be seen as unpopular and “anti-establishment” but one that certainly needs to be voiced.
    For years we have been taught that as medical professionals we must always keep in mind that the old paternal style of doctoring is long gone. Patient autonomy is championed, for everything from refusing lifesaving treatment to refusing medication and even healthcare and lifestyle advice. Patients and families are actively encouraged to speak out and complain about trivialities against healthcare professionals, mainly doctors, and those very doctors must then go through endless hoops of anxiety and loss of reputation and income to prove their innocence to their own regulators, who are very often very distanced from their work environment and practices and adopt a punitive “you must keep the customer happy at all costs” approach.
    Add to that years of doctors being demonised in the Australian media.
    We then now question why people have the audacity to question health advice rightly or wrongly and actually make their own choices regarding vaccinations?
    We don’t do it with food, we don’t do it with cigarettes, we don’t even do it with (illicit) drugs – and yet the morbidity and mortality from the abuse of these 3 groups alone probably accounts for the majority of our healthcare expenditure.
    Is this really an acceptable selective disregard of patient autonomy?

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