KEY STRATEGIES AND PROMISING PRACTICES TO INCREASE VACCINE DEMAND

2. Build relationships

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.

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.

First, build relationships by:

• Sharing power – respect the knowledge and expertise of individuals gained through lived experience, engage them as collaborators, and support their autonomy.
• Demonstrating care – listen deeply to community members, encourage and commend them for their achievements.
• Providing support – help folks navigate through what might be a hard and confusing journey to vaccination, help them build their confidence to take charge of their health, and advocate for them.
• Being reliable – relationships and trust are built over many interactions. Do what you say you will do. Show people that they can depend on you.
• Creating environments for vulnerability and authenticity – Allowing individuals to express their concerns, apprehensions and conspiracies in a non-judgmental environment shows that you can be trusted.

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.

3. Listen, and do it often.

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.

In practice, listening includes activities such as:

• Hosting community listening sessions
• Running focus groups with specific audiences
• Providing opportunities for 1:1 conversations with community members
• Social media listening
• Misinformation listening

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:

• Why do you feel that way?
• Can you share what matters most to you in this decision?
• What are you or your family’s health needs or concerns?
• What concerns or fears do you have about the vaccine?
• Where do you find information about the vaccine you can trust?
• What would it take for you to get vaccinated?
• What goals do you have for your children as they go back to school?

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.

4. Build an evidence clarification muscle.

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.

5. Tailor your messaging strategies to what you know about each audience.

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.

Help mitigate the misperceptions created by cognitive biases:

• Provide concrete examples and tangible metrics to help people comprehend (often confusing) health information or guidance, making perceptions or comparisons more realistic. “The booster shot is 90% effective. This means that 9 out 10 people who got a booster shot did not have to go to the hospital after getting infected.”
• Focus on trends and patterns. Often people rely on outlier events or statistics that are more recent or dramatic. Encourage people to base their decisions on larger trends and patterns and see rare events as just that – rare- and not necessarily instructive. “Across nearly 250,000,000 million patients studied on three continents, the risk of myocarditis associated with the vaccine is between 0.002% and 0.004%. That’s about 40 to 90 people in the entire city of Houston. Of the people that did have myocarditis, most had mild to moderate cases.”
• Find ways to frame the decision to not vaccinate as more of an action than the decision to get vaccinated. Make it the default to “opt-in” with more action or implications to “opt-out”.
• Some people might give greater weight to the risks of getting vaccinated rather than the potential gains and maybe inclined to maintain the status quo – in this case, unvaccinated. Emphasize the personal benefits of getting vaccinated and the benefits to the larger community while framing the default option or maintaining the status quo as a loss.
• Support self-efficacy. Self efficacy is a person’s belief or confidence they can succeed at something. You can encourage them to make small, realistic goals and celebrate those little successes. For instance, CBOs in Houston and Newark included the number of people that made a vaccination appointment as a metric for success.

Appeal to individuals’ morals and values

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.

• 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.
• Acknowledge and celebrate the parts of someone’s perspective that are in support of others and the community. For example, fear of long-term side effects in children expressed by parents could be re-interpreted as their desire to raise a healthy and happy child. Before sharing information on the side-effects, acknowledge this. “It’s great to hear how committed you are to your child’s health.”
• Similarly, when working with conservative Christians, including cues to religious identity such as mentioning faith can help build vaccine confidence and trust in medical experts.

Appeal to social norms and in-group bias.

People tend to share the same opinions and beliefs of members of their own social group and/or people they identify with.

• Avoid messaging that focuses on what people “should do” and socially disapproved behaviors. Social norms are most influential when they describe what most people actually do, signaling social approval. “50% of black men your age have been vaccinated”
• Target specific group identities and social norms using micro (10,000-50,000 followers) or nano-influencers (100-10,000 followers) and provide them with messaging that appeals to the group’s values and attitudes.
• Social norms are also most powerful when messages refer to people who the targeted audience identifies with. This can mean more than just one part of their identity. For example, messages targeted toward Hispanic women will be different than those targeted to Hispanic men.

6. Communicate the “I don’t knows”

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.

7. Tell stories.

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.

Personal stories can be the most effective because they:

• Signify authenticity and intimacy
• Allow the listener to learn about the narrator’s values, morals, and beliefs which signal their trustworthiness
• Appeal to emotions, particularly empathy
• Can help people overcome mistrust.

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.

8. Utilize the power of visuals.

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.

9. Engage with people wherever they are. All the time.

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.

Ask “Where does the vaccine fit into your life?”

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.

Meet people in the spaces where they feel comfortable and use the language of their community

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.

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.

Set up interpersonal conversations for success

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.

Evidence-based strategies for talking with community members, friends and family about Covid-19 vaccination

• Pick your battles, start by talking to those who are on the fence rather than committed refusers.
• Understand a person’s doubts and validate their emotions associated with those doubts.
• Don’t get bogged down in a detailed debate; keep it simple.
• Don’t focus too much on the science; if your conversation partners asks about science, consider how to message facts based on what you learned about them in your conversation (see above) If unsure, ask more questions. For example, talk about safety and emphasize how many millions of people who have safely received the vaccine (and the immense amounts of safety data we have as a result).
• Don’t blame or shame.
• Use humor as appropriate and relevant.
• Understand the source of the person’s mistrust.
• Be open to discussing religion if a person’s faith plays a role in their unease.
• Share a personal story.
• Be patient; individual vaccination journeys take time.

10. Trust trusted messengers

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.

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.

11. Build Information Resilience.

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.

Simply warning people that they might be misinformed can limit later reliance on misinformation.

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.

Inoculate people against the influence of mis- and disinformation.

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.

If you can’t prevent it, debunk it.

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.

12. Draw on strategies of harm reduction.

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:

Unvaccinated individuals still deserve support (rather than isolation or condemnation) in mitigating the risks of Covid-19 infection, hospitalization, and death.

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.

Orient vaccination efforts around strengthening quality of life and well-being – not just vaccination – as the criteria for success.

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.

Maintain a non-judgmental, non-coercive approach to interactions.

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?”

Ensure that the voices of people who are not yet vaccinated are used to design and develop the programs meant to reach them.

For example, a Q & A about vaccines should answer questions that have been collected from community members.

Recognize that the realities of poverty, racism, classism, and other structures of oppression significantly impact people’s capacity for getting vaccinated.

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.