As this report describes, the “‘The unvaccinated’ are not a monolith of defectors” but extremely diverse, and a one-size-fits-all solution will continue to leave people behind. Effective vaccine demand strategies require hyperlocal efforts, operating at the neighborhood or zip code level and across affinity groups.
Groups and advocates working in specific neighborhoods or zip codes are the most knowledgeable about how to support their communities because wherever people face challenges, they are always already working to deal with those challenges. Local organizations who are in relationship with residents and neighbors have a deep knowledge of common concerns, questions, challenges and communication preferences; they know the history of their community and how people have interacted with local systems and institutions, from the local police to local policy makers. They know peoples’ aspirations, how they care for each other, and what it looks like to be in solidarity with them, which makes local organizations experts in building and sustaining the trust central to vaccination.
This goes beyond the typical model of working with communities, which usually includes consultation of community organizations, advocates, and members to obtain knowledge and experience while interventions are ultimately led by external groups or funders. Instead, vaccine demand strategies need to empower local organizations to ensure community members can act as leaders and designers in initiatives.
Vaccine demand efforts need to allow communities to lead. Rather than asking how to ensure community participation in top-down vaccination efforts, they should focus on amplifying, supporting, and leveraging existing community based strategies.
This means funding or supporting community-defined projects or preexisting community initiatives, and asking what is the most useful way to strengthen the work. It also means adequately compensating organizations for their leadership and participation. CBOs are often under-resourced and under-staffed and require additional funding to build capacity to take on vaccination efforts, including hiring mental health support for staff and technical assistance to teams.
To center trust and trustworthiness in vaccination demand efforts, building relationships must also be at the center. When relationships cultivate a shared sense of mutuality, care, and trust, people rely on those connections to meet their needs and find support amid challenges. They give each other rides, feed each other’s children, watch out for each other on the street, check in on each other when someone is sick and follow each other’s guidance on vaccines.
“The burden is on leaders to walk among the people and to build relationships.”
Many Americans don’t have these kinds of meaningful relationships with the structures, systems, and organizations that are leading vaccination efforts. In turn, it’s a struggle to reach, engage, and communicate with them.
Relationship building shouldn’t be seen as a task to be operationalized and completed, or an objective on a timeline. Building authentic relationships, particularly with disinvested communities, is an ongoing activity.
Top-down communications often assume that a deficit of factual information is behind ambivalence towards vaccination, and that people only need to be told the facts to change their behavior. Experts and authorities then get frustrated that people don’t “accept” the facts.
As explained in Chapters 2 and 3 of this report, people’s lives and decision-making processes are complex, and knowledge is only one of many factors that influence behavior. Listening and staying connected with individuals and their communities is an effective way to ensure that vaccine demand approaches are aware of and responsive to people’s realities, rather than driven by the needs and goals of authorities. Listening makes people who have been disenfranchised and undervalued feel heard, and builds trust. It also provides insights on what misinformation narratives resonate with people.
To be effective, listening activities need to be a core, recurring activity rather than ad-hoc pursuits.
In practice, listening includes activities such as:
Effective listening sessions create empathetic and collaborative interactions that are centered on the community or individual. They draw on strategies of deep listening and motivational interviewing to unearth the experiences, values, principles, beliefs, core identities, and social norms that guide the decision to get vaccinated.
Facilitators ask open ended questions such as:
“I realize that communication is cyclical. For each new authorization of vaccines for a different age group, we need to start with listening again.”
Facilitators of listening sessions try to gather stories about what has motivated a person’s past health decisions, what their concerns are, and future aspirations.
Misinformation narratives often show up in listening sessions, and provide important insight into which falsehoods need immediate attention. National misinformation narratives may or may not be what drives concern or confusion in specific groups – granular, hyperlocal assessments are essential.
Social media listening allows further insights into what communities are talking about, where their concerns are, and which misinformation narratives they are exposed to and might be inadvertently perpetuating.
Listening is a continuous process as the information needs, social and behavioral drivers, and the structural barriers of a community shift and update along with the shifting and evolving pandemic situation.
From late April to July of 2021, Houston in Action facilitated seven listening sessions with community members, focusing on those living in predominantly Black and Latinx neighborhoods where vaccination rates are low, refugee & immigrant communities, as well as people from these communities in low-income households, young adults, and people whose primary language is Spanish. In their Safer Together report, HIA shares the unique insights revealed by the listening sessions including:
“[It’s important to] create an ecosystem where researchers are informing public health communicators on what they know works or what they’ve actually done research on. And then the public health communicators work with community organizers to get the information shared.
This is a model that has been implemented politically with ‘get out the vote’ campaigns, and can be used effectively with public health campaigns”
Staying on top of evolving evidence and being able to clarify what is known and not known at different points in the pandemic is another key part of an effective vaccine demand strategy. Like listening, this step informs all other aspects of the strategy, from messaging and campaign choices to decisions about where to host vaccination clinics.
Too often in this pandemic, experts with little or no communications experience have struggled to communicate effectively, while communications specialists have struggled to understand and accurately represent the evidence. It is important to build a network of experts (including someone who knows behavioral science), communicators, community leaders and Covid-19 response teams – at the federal, state or community level – that can quickly contextualize emerging evidence, answer specific questions about individual studies, complicated data, and uncertainties, and incorporate this clarity about the evidence into vaccine demand strategies, including messages, campaigns, and events.
Effective vaccine demand communication matches the understanding gained from listening sessions and evidence clarification with insights from behavioral and information sciences, as well as overall knowledge of the community, to develop specific messaging and outreach strategies for each audience.
Practitioners should identify the main goal for their messaging and their vaccine demand strategy more broadly, and adapt approaches accordingly. For example, a campaign could mainly be focused on sharing facts and building people’s knowledge, or it could target other parts of the behavior change continuum, such as trying to change beliefs about whether it is socially acceptable to get a vaccine, or being clear about how and where to access it.
As outlined earlier in this report, insights from behavioral sciences – such as how peoples’ biases, values and root attitudes affect knowledge and behavior – can be applied to craft tailored messaging. Practitioners should draw from one or more models of behavior change.
Messages and interactions should harmonize with insights about morals, values, beliefs and principles gathered from the community. Messaging can be tailored in a way that activates and engages these factors and could reveal opportunities for collaboration that is built upon common goals.
“Our idea was to think about the vaccine decision as a journey. It is really helpful because you start to think that the journey is different for different people – where are the touch points, where are the pain points, how do you think about targeting and tailoring different interventions for different people at different points in time?”
People tend to share the same opinions and beliefs of members of their own social group and/or people they identify with.
In January 2022, Phalanx Family Services in Chicago, whose mission is to “assist economically disadvantaged youth and families in the pursuit of self-sufficiency through employment centered programs, mentoring, advocacy, and workforce development solutions”, launched the “Real Men Get Vaccinated” campaign.
The campaign aimed to spread awareness of the low vaccination rate of Black men in the city of Chicago. The campaign harnessed a number of the strategies recommended in this report:
Covid-19 is still a new virus and scientists are learning new details about its behavior every day. This means that CBOs frequently have to communicate the latest changes in information in ways that maintain trust and make sense to people.
What community members need and want is honesty about what is uncertain and what is unclear. People respond to transparency about uncertainty with trust — because they know it’s true — while they respond to certainty that later turns out to be partially wrong with increased mistrust. As one partner from Oakland shared, “When we’re honest about what we don’t know, our community sees us as more authentic and more trustworthy.”
Communicators can combine both what they know – “these are the facts” – with how they feel – “I’m confused too” – because it reinforces their position as trusted, credible messengers who are authentic and dedicated to meeting people where they are at.
This visual campaign aids community partners by using matching design to pair problems with recommended solutions.
One highly effective way to connect with people is storytelling. Those who design disinformation campaigns know this, which is why storytelling is one of the most common tactics in mis- and disinformation efforts. Stories are the backbone of all human learning, starting with the stories parents tell their children and the stories in faith communities used to teach morals, values, and beliefs. Stories tap into our identities and engage us emotionally, cognitively and socially.
Stories strengthen relationships by giving people a window into how others see and experience the world and make complex, abstract problems relevant to our own lives. They provide context on the “why”, anchoring facts and data to personal experiences and helping us make sense of abstract figures and statistics.
Baltimore’s #BMoreVaxxed campaign centered the stories from Baltimore residents, sharing their answers to “How I knew I wanted to get the vaccine”. For example, James shared how after a family member was in critical condition after contracting Covid, that’s when he knew he wanted to get vaccinated.
Personal stories can be the most effective because they:
Research has shown how the use of personal stories can motivate people to action.
Note that stories are most meaningful when the story’s main character is from the same group as the listener or audience – to tap into the social norms that are at play when people consider their health decisions. This is why vaccine ambassador programs in Chicago, Baltimore and elsewhere—which recruit community members to knock on doors or otherwise engage with peers—are successful.
One way in which misinformation often supersedes accurate information is by being produced in images, GIFs (especially memes) and videos. Images travel fast as screenshots shared on closed messaging apps. YouTube is the most used media platform in the world, as News consumption habits have changed dramatically, with people of all backgrounds consuming more and more information visually as opposed to written formats.
In vaccine demand work, we need to understand and execute on the power of visuals and invest in video and graphic design to translate complicated guidance at each point in time, and to tell stories with images. This still includes billboards, which visually speak to people while they are out and about. On the next page are a few examples.
The Power of Visuals
We have discussed the many barriers that make the decision to get vaccinated difficult, including the additional pain brought on by the pandemic – mourning those who were lost, unemployment, a rise in violence, increased childcare responsibilities, and disproportionate risk caused by racism.
To overcome these and other barriers and connect with people, vaccine efforts should provide opportunities to engage and learn no matter where people are, both physically and in their journey to getting vaccinated.
Successful approaches design their communication and engagement less like a checklist of unconnected, one-off activities (a one-time vaccine event, a single webinar) and more like an integrated constellation of interactions, in the spaces already built into day-to-day life, that compound to build relationships, trust, access and incentives.
Change doesn’t happen overnight or in some linear progression. It’s essential that opportunities to learn and engage – what’s called ‘touchpoints’ in marketing and user design – are ubiquitous and part of the community fabric. This is true for all communities, regardless of income, political leanings, education levels or racial makeup.
EVI partners in Chicago, Baltimore and other cities have shared the importance of understanding and working with where the vaccine fits into the day-to-day priorities unique to each individual. For some, the virus may not be the biggest threat to their health amid concerns such as gun violence, homelessness or food insecurity. For others, the vaccine might be one more thing on a long list of competing concerns and responsibilities. EVI partners have found it is critical to ask community members “where does the vaccine fit into your life?” And then supporting people wherever they are, helping them address their needs – securing rental assistance, providing school supplies to students, addressing other health concerns, or getting vaccinated- in whatever order makes sense to them.
The best engagement happens when people have a reason to be present, and want to engage. This is why vaccine conversations at town fairs, churches, dances and other community events for example can be effective ways to increase vaccine confidence and uptake.
Since November 2020 Allen Temple Baptist Church has been live streaming Sunday services, weekly bible study and other virtual events on Facebook live. Facebook is the platform their congregation uses compared to others – with more than 4,400 followers on Facebook to just over 900 on Instagram.
The church leveraged this following and their community’s familiarity with Facebook live to host a number of webinars on Covid for their community, covering vaccine science, the disproportionate impact on communities of color and boosters. The videos range from 300-500 views each with hundreds of comments from congregation members with questions for speakers and discussion about Covid in their community.
Moreover, webinars about other challenges facing the community were hosted, creating an accessible, culturally congruent, body of knowledge for Allen Temple’s audience about multiple topics they cared about.
This also includes strategies such as meeting Fox News audiences where they are – for example on Fox News’ and similar channels. In October 2021, researchers created an advertisement that included different clips of Donald Trump and Melania Trump in interviews with Fox News hosts, each encouraging supporters to get vaccinated. The researchers then placed the ad on more than 100,000 YouTube channels, including Fox News’ YouTube channel, where it was paired with segments hosted by lead anchors such as Laura Ingraham, Tucker Carlson and Sean Hannity. The ad was able to increase vaccinations in target counties, as opposed to the control group – and the more ads a county received and the more the viewers engaged, the larger the increase in vaccinations.
A lot of vaccine confidence and trust building work happens in one-on-one conversations, and here, too, meeting people where they are with their concerns, understanding and attitudes about vaccines is key. Motivational interviewing is a way to engage people is a way to engage people where they are at. It means listening to and affirming people, for example by saying “You are right, the vaccine was developed in record time” or “You have thought about this a lot” or “You value your freedom” or “You are right, the U.S. government has mistreated Black people and there’s still so much to fix.” Facts and arguments only harden people’s positions, and few people change their mind about a health decision in just one sitting.
Trusted Messenger research from the Ad Council shows that in order to shift perceptions and influence behavior, it takes both experts and amplifiers (those more traditionally identified as messengers like public health officials and celebrities) and the individuals people are personally connected to, “…those whom they deem most trustworthy—honest, credible, unbiased—and typically familiar, such as family, friends, accredited experts, and local business and community leaders”.
To be successful, vaccine demand strategies should employ but also look past the messengers who are easily identifiable and whose message can be easily controlled, such as a state medical director or healthcare leader. “Trusted messengers” can be found everywhere: The individuals or organizations that people trust for information about their health may not be “official” or an “expert”. Public health organizations should let go of requiring expertise and widen the circle of who they trust as a trusted messenger, while providing the tools and resources for messengers to be knowledgeable communicators to their neighbors, in their own way, empowering folks to “speak from the heart and with authority”.
Anchor community organizations in the EVI applied this insight intuitively. As they took the lead in identifying community partners, for example, they each independently settled on working with a wide net of organizations.
As a result, only about 14% of the nearly 90 organizations involved in the EVI are part of the traditional healthcare or public health sectors.
Similarly, only 26% of EVI partners’ mission statements mentioned “health” or “well-being”
Vaccinations, just like health and wellness overall, are an all-of-society job.
To be successful, public health authorities also need to be ready to let go of control of message uniformity and need to let communities lead with their customized messaging, framing, and needs.
In May 2021, the Chicago Department of Public Health partnered with the City Colleges of Chicago to launch the Malcolm X College vaccine ambassador course to empower community members to become trusted vaccine educators who are able to provide high quality information to their neighbors.
The course, which is open to anyone and everyone, is a free, two-hour online training available in both English and Spanish. It uses a variety of videos, surveys, quizzes and interviews with healthcare providers to teach participants about the background on Covid-19 and U.S. healthcare system, the answers to common Covid-19 questions and concerns, the history of medical mistrust and causes of vaccine hesitancy and how to approach difficult conversations.
Chicagoans who complete the course receive a certificate of completion and are recognized as trusted messengers of Covid-19 vaccine education. Upon completion, Partners In Health provides trusted messengers access to an online learning community where they can connect with other Vaccine Ambassadors and receive support through additional training, and stay involved in community health activities.
Within just two weeks of the course launching close to 1,300 people had signed up to become ambassadors.
There’s no silver bullet to combatting mis- or disinformation directly in vaccine demand work but there are several interventions that can help prevent it or curb its potential damage.
Even general warnings (“the media sometimes does not check facts before publishing information that turns out to be inaccurate”) can make people more receptive to later corrections. Specific warnings that content may be false have been shown to reduce the likelihood that people will share the information online.
No one likes to be manipulated, and letting people know about the tactics and tools disinformation efforts use to try to influence them has shown to be effective in building resilience against such tactics. There are many ways to inoculate people against bad information, including games such as Go Viral!” or this First Draft’s text message course that texts people one lesson per day.
Research finds that direct corrections are effective in reducing — although frequently not eliminating — reliance on misinformation in someone’s reasoning. For debunking to be influential, it is essential to give a detailed counterargument that clearly explains (1) why it is now clear that the information is false and (2) what is true instead.
Building Information Resilience in Oakland
In fall 2021, staff at the Roots Community Health Center in Oakland noticed a disinformation campaign circulating in closed social media groups that included ambiguous statements about not “ignoring our deadly history” and how people shouldn’t “let them vaccinate you, with their history of treachery through medication…”
The false messages intended to drive Black Americans away from vaccinations, by appealing to their identity as a community who have been mistreated and neglected by the medical system for centuries. Community members were affected by the manipulative content. The Roots team wondered: How can a Health Center respond, and prevent further erosion of trust caused by such harmful misinformation?
Like many other community-oriented centers across the country, Roots didn’t have a communications team before the pandemic. Recognizing that Covid-19 information challenges were increasingly interfering with the Center’s ability to provide access to health and health care, Roots had started to build communications capacity in 2020.
With the support of the EVI communications partners, the Roots team decided to develop an education campaign that informs community members about some of the tactics of misinformation – including identifying manipulative messages and how to spot a fake doctor on social media.
People need the time and space to initiate their vaccination on their own terms. Often people need many interactions to get answers to their questions and feel assured before getting their shot. EVI partners emphasize the importance of leaning on strategies rooted in harm reduction to keep unvaccinated people safe — by taking care of community members while they decide.
Harm reduction—most familiar as a philosophy and set of practical strategies aimed at reducing negative consequences associated with drug use—offers several helpful principles for (re)building the trust central to increasing vaccination.
Harm reduction is grounded in justice and empathy and the principle of advising individuals how to mitigate risk, while acknowledging the real world conditions that may lead individuals to take some risks, and that people should be met “where they are” with dignity and respect ((National Harm Reduction Coalition, 2022). Below are established harm reduction principles translated for vaccine communications:
For example, CASA of Baltimore, whose mission is to provide court appointed special advocates to support abused and neglected children involved in Baltimore’s juvenile court system, distributed Personal Protective Equipment, such as masks, to over 4,900 residents.
Allen Temple Baptist Church in Oakland has been hosting backpack distribution events and Community Learning Forums – a health series co created by the church and Samuel Merritt University – for years. Strategically, they have hosted their vaccination events on the same days so that residents can get vaccinated alongside getting school supplies and getting concerns and questions about their health answered.
For instance, when someone shares a belief in a vaccine conspiracy theory rather than saying, “That doesn’t make any sense” shift to “Can you help me understand this better?”
For example, a Q & A about vaccines should answer questions that have been collected from community members.
Strategies that integrate these harm reduction principles indicate to communities that the systems and organizations established to serve them are genuinely dedicated to improving their health and well-being – and are a key pathway to building long-term trust.
One of the central goals of the Newark Equitable Vaccine Initiative is to ensure that Newark residents have access to accurate information about the vaccines. To achieve this, inoculation efforts were included as a central component of the communication and outreach strategies that were developed in partnership with participating CBOs.
Specifically, the resources provided to CBO’s explained how communities of color are targeted directly by mis- and disinformation, co-opting the Black community’s vaccination concerns and histories of medical exploitation to further anti-vaccination efforts. The resources also shared guidance on how to go about addressing misinformation.
Residents could also get clarity on misleading information on NEVI’s website which provided well-crafted refutations to common Covid myths.