The United States began the Covid-19 vaccination efforts as a global leader, having invested significantly in the development, production and distribution of vaccines, yielding access to millions of doses by early 2021. Yet as the year unfolded, a grim reality emerged: Insufficient consideration of and planning for vaccine demand resulted in more than 300,000 Americans dying from a vaccine-preventable disease. Millions more suffered illness and continued economic loss, and schools and businesses remained disrupted.

As vaccination and booster rates have remained low in 2022, the nation struggles to emerge more resilient from the grip of the Covid-19 pandemic. Breakdowns in communication and trust are frequently cited as main reasons for the failure to vaccinate more Americans, attributed variably to a culture focused on individual over collective action, misinformation, politicization, historic and current structural racism and other factors. Ineffective approaches to increase vaccinations, such as blaming people for making bad choices and applying top-down communications campaigns to ‘educate’ Americans about the value of vaccines, continue to miss underlying drivers and challenges.

More than 20 months into the largest vaccination rollout in U.S. history, it is clear that the challenges reach far beyond vaccine development, production and distribution, and urge investigation into why current models for delivering and building confidence in life-saving public health measures are failing to reach and protect all Americans equally. Already, political and public support for non-Covid vaccines is disrupted in several states, and support for other major public health protections is at risk.

In this report, we provide an analysis of the intersecting factors that have led to these outcomes, and chart a path forward. Based on our work with communities, researchers, public health authorities, and a review of available evidence, we find that unvaccinated and undervaccinated Americans are not a monolith, but instead diverse individuals with unique histories, identities and lived experiences. We find concerns about Covid-19 vaccines among people of all races and ethnicities, faith groups, education and income levels, political leanings and affinity groups — but not the same concerns. We also find significant vaccination barriers outside of people’s control, such as lack of information, the impact of misinformation, lack of access to basic health care, and the conditions created by structural racism.

By over-focusing on an inadequate “vaccine hesitancy” framework that places the onus of motivation and of accessing the vaccine on the individual, U.S. vaccination efforts have missed many opportunities to address institutional and structural failures and responsibilities alongside individual-level drivers (Chapter 1).

Moving past this framework, we describe intersecting information, behavioral/social, and structural factors as key drivers of vaccination outcomes, and suggest vaccine demand as a concept that allows connecting and addressing these intersecting drivers comprehensively in vaccination work (Chapter 2). We provide a primer on what everyone in public health, policy and community work needs to know about these drivers and how they interact (Chapter 3); and we share key strategies, promising practices and policy recommendations for increasing vaccine demand (Chapter 4).

Recognizing the intersecting information, behavioral/social and structural barriers confronted by vulnerable people and addressing them comprehensively, community organizations around the nation over the past year have delivered a blueprint for how to carry out essential vaccine demand work. Community-led activities – such as hosting listening sessions, providing free masks and free testing, connecting people with resources such as food and housing, bringing vaccination events to where people are, and sharing hyper-local messages designed to speak to specific concerns and groups – are able to meet people where they are at and build trust, including trust in vaccines, in the process.

This work has had a measurable impact: While national vaccination rates have stalled, vaccination rates for Black, Indigenous, Hispanic/Latinx, and Native Hawaiian or Pacific Islander communities have continued a slow but steady increase, and are beginning to mitigate the disproportionate burden the pandemic has had on these communities. This is a considerable win given the continued devastating impact of structural racism on health outcomes for people of color overall.

These efforts led by community organizations, carried out with support from federal, state and local authorities as well as philanthropy, illustrate that vaccine demand work can overcome some of the complex barriers to providing access and building confidence in life-saving public health measures. At a time when many are ready to all but give up on widespread vaccinations, the question for policy makers, public health practitioners, authorities and advocates is this:

What price will we pay – in lost lives, economic damages , inequities and social disruption – for not investing in the infrastructures required to generate and maintain demand for vaccines? Without adequate vaccine demand, how will the health of Americans fare in the face of waning protection from first generation Covid-19 vaccines, and protections from other critical vaccines that are losing support, including those against measles, mumps, rubella and polio?

Over the past century, vaccines have saved hundreds of millions of lives around the world. Vaccines are a great equalizer – where available, they have consistently led to improvements in life expectancy, economic stability and upward mobility.

As an all-of-society challenge, vaccine demand work requires significant investment in people and programs, adjustments in policies and regulations, and a commitment to building infrastructures of trust, increasing health equity, and meeting the information needs of diverse communities.

This report provides a fresh look at the challenges, an improved framework for response efforts as the second generation of Covid-19 vaccines becomes  available, concrete tips for vaccine demand work, promising practice examples, and an early set of recommendations for policy makers and funders.