Vaccine Demand is an all of society challenge and needs support and solutions at all levels of society.
Building and maintaining Vaccine Demand requires significant investment in people and programs, adjustments in policies and regulations, and a commitment to building structures of trust, increasing health equity, and meeting the information needs of diverse communities.
These policy recommendations provide an overview of key reforms needed to improve vaccine demand generation. The list at the end of this section is by no means exhaustive, and we look forward to working with others on building out this framework to better understand and address vaccine demand.
“The goal isn’t to assume that I have the information, or the advisory board, or folks that I’m associated with have the information. The goal is to connect our communities with folks within our communities that do have the information and the insight to kind of bridge that gap so that folks get the information that they need from a trustworthy source.”
Vaccine demand assessments and strategic planning must be part of pandemic preparedness and resilience efforts at all levels of government, industry, and the nonprofit sector – from the start. The current practice of focusing government efforts and funding further downstream, on top-down communications and behavior change efforts that happen once vaccines are ready for distribution, has led to many missed opportunities. How vaccines are being distributed, where and by whom, and through which mechanisms, for example, all have significant impact on vaccine demand. Supply and demand teams need to work closely together from day one. There are also communications deserts – migrants and marginalized people who remain unreached by current efforts.
Many aspects of the overall response impact vaccine demand. Federal funding for testing in schools for example was restricted to testing teams. By the time vaccines for teenagers and children over 5 years old became available, states relying on this funding were unable to repurpose the testing teams – who had already built trust and relationships – for in-school vaccination drives, and instead needed to put time into a new round of funding applications, planning and hiring.
To bridge the gulf between where quality information is available and where people most in need of quality information seek it, vaccine demand assessments and planning also need to include significant funding for and updates to public health communications departments at the community, local, state, and federal levels.
This funding has not been forthcoming. Asked in early 2021 what was needed to design and run an effective engagement campaign for Covid-19 vaccination, a team in one U.S. state calculated it would cost around $7 million. The team was awarded $900,000, and the state continues to lag in vaccinations. (This information was shared confidentially with our team.)
[In migrant populations] there is a lack of trust in the current government with all these anti-immigrant feelings. There is fear about whether these things that they are being injected into their body will be something to get rid of them. It doesn’t help that there is a lot of misinformation.
Strategic communications that deeply engage with the public need to be adequately staffed and part of the preparedness and response leadership structure. While building readiness to provide clear guidance and key health literacy through these efforts, authorities also need to become comfortable with letting go of control of message uniformity and letting communities lead with their customized messaging, framing, and needs.
Too often, vaccination interventions are set up in a static way, with no ability to adapt to changes. Just as in other supply and demand work, approaches need to be iterative and able to learn and pivot quickly. Assessments of progress and barriers need to be part of the management structure, and stakeholders need to be included early in the process so that managers and stakeholders make decisions in real-time.
Like all other aspects of preparedness, a communications infrastructure needs to be in place at all times so that trusted communications in a crisis is a continuation of trusted communications in regular times. For example, if a city or state hasn’t built sizable social media audiences and isn’t directly and consistently in conversation with the public on the platforms people frequent, in creative and engaging ways, crisis efforts start with a familiarity and trust deficit.
Leaving it to others to interpret press conferences for modern communications platforms similarly has shown to have devastating consequences in this pandemic. The traditional model of journalists interpreting information shared by authorities – and applying a set of principles such as verification, and ethical standards such as putting information in context – is being disrupted: Misinformation actors who have a direct line to the public after having built large online audiences have been able to dominate vaccine narratives, turning official information and announcements into misinformation and clickbait for their gain. Government agencies and leaders need to invest in building their own audiences, and in working with organizations who are trusted by communities.
“We need to look beyond the Covid-19 vaccination campaign as a one-off public health intervention and think about how to build a legacy in terms of local public health governance.
How to build to have a lasting transformation in the relationship that communities of color have with authorities and institutions whose mission is to protect public health and safety and engender collective wellness.
So it’s both the immediate needs of vaccine uptake, but also sort of a longer term institutional legacy of strengthening and continuing a two way trusting relationships between communities and governmental public health and medical institutions.”
If mechanisms to fund and equip community organizations to run crucial on-the-ground efforts are spotty and unclear, demand generation will lag as CBOs lack adequate and timely support to build capacity and engage community members. A key lesson learned from the pandemic is the need to build stronger ties between community organizations and local and state officials as part of pandemic resilience and vaccine demand efforts.
In Illinois, for example, the Chicago Community Trust utilized some of its unrestricted Rockefeller Foundation funding in 2021 to better understand what it takes to support and build up small organizations serving diverse communities. CCT works with the state to clarify funding requirements, certifications and other barriers.
Elements of vaccination efforts that aim to align with the priorities, needs, and values of the community can make it easier for individuals to see how the vaccine fits into their life and frame vaccination as a decision that makes sense. When folks can see that the “systems” that shape their health and their lives care about them beyond a shot of vaccine, they may be more trustworthy.
The many inputs that construct vaccination attitudes and perceptions are formed by all sorts of signals and cues given to individuals by the systems, structures, and processes present in day to day life. For example, a dismissive or stressed physician signals (unintentionally) to their patient that they don’t really care about their situation. Pharmacists are not trained to respond to a customer who starts sharing misinformation about vaccines with people waiting in line to get vaccinated. Federal and state agencies as well as the healthcare and other industries need to invest in the development of updated training programs and support systems.
Resolving the vaccine demand crisis will also require a shift away from the current overfocus on “vaccine hesitancy” as well as an overfocus on the role of political leanings in people’s vaccination decisions.
“Vaccine hesitancy” is a term used by scientists in a specific context. In the broader public conversation, it has become a catch all that mostly alienates diverse Americans who are unvaccinated or undervaccinated . By placing the attention solely on the individual, regardless of structural and information barriers to vaccination, the “vaccine hesitant” label can also lead to mistargeted interventions.
Similarly, interpreting vaccination decisions predominantly through the lens of political leanings and suggesting that individuals are not accessing vaccines because of their political leanings, as opposed to in correlation with these political leanings, contributes to the creation of divisions and politically-charged vaccine identities. It also overlooks the nuances and complexities explained in this report. For example, Black Democratic voters who don’t fit the expected partisan pattern struggle to be heard and seen as they explain their important reasons to be wary of vaccine clinics and public health interventions.
Baltimore Health Corps (BHC) was created to address the parallel economic and public health crises brought on by Covid-19. BHC aimed to generate sustainable, long-term career trajectories for individuals who lost work during this pandemic while simultaneously addressing the city’s emergency response. By September of 2021, BHC had hired more than 300 local Baltimore residents, initially concentrating on contract tracing and then, with the arrival of vaccines, support vaccination in the city, with the focus on the city’s hardest to reach populations. Moreover, for the applicants who weren’t initially hired into BHC, were provided job placement assistance to roles supporting vaccination by the Mayor’s Office of Employment Development. This model demonstrates solidarity – supporting the urgent health needs of residents, leveraging the power of local knowledge and networks, while also improving supporting the other determinants of health like income and economic mobility.
Vaccination has been politicized in ways that are harmful for all Americans. Billions of people around the world have been safely vaccinated, and vaccines remain highly effective in preventing hospitalizations and deaths. Significant undervaccination in the U.S. is contributing substantially to prolonging the pandemic.
Narratives about a political divide in vaccinations have intensified in the nation since spring 2021 – more so than almost anywhere else in the world – supported by polls emphasizing that more Republicans than Democrats remain unvaccinated. As explained in chapter 3, this framing reduces the complex factors at play to an artificial binary, and prevents a more granular and actionable understanding of people’s root attitudes, lived experiences, and information and structural barriers. Being against vaccines and identifying as Republican for example may stem from the same underlying attitudes – or not. Being against vaccines and a Black Democrat stems from an entirely different set of attitudes, experiences and circumstances, and people who don’t fit the partisan divide pattern often struggle to be heard and seen.
Leaders of the Lancet Commission on Vaccine Refusal, Acceptance, and Demand in the USA call the politicization of vaccines “a problem of unprecedented scope”, and ask for systematic monitoring of the phenomenon to develop solutions. The group recommends policy makers and professional organizations examine available legal, regulatory, and private sector options to reduce the impact of well-financed organizations spreading misinformation.
Politicians and public figures have the responsibility to lead by example and share accurate information that promotes health. Evidence shows that people often follow cues from their party’s elites and ignore, or do the opposite of, cues from the other party’s elites. A recent study replicated this finding, showing that unvaccinated people who identify as Republican, after being exposed to an endorsement from a Republican elite, reported 7% higher vaccination intentions than those who viewed a Democratic elite endorsement. Similarly, a conservative county in Ohio saw high vaccine uptake in 2021 by “making it unpolitical from beginning.”
Evaluations of disparities typically use the vaccination rates of white Americans as the comparative standard. However the experiences that influence vaccination of white Americans are different from the experiences and knowledge shared among unvaccinated people, such as historically oppressed groups. For example, Black Americans are approximately 1.5 times more likely to be uninsured than white people.
Using vaccination rates of white Americans as the norm reveals that equity is not at the core of vaccination efforts. Equity means distributing resources based on needs of the recipients. Considering the significantly higher rates of Covid-19 infection, hospitalization, and death in marginalized groups, this means these groups require correspondingly higher investment in vaccination efforts.
“We need an investment in resources in black communities and other communities of color, because what we’re seeing in terms of racialized health and equities is a result of decades of disinvestment.”
As laid out in this report, vaccine demand challenges are deeply tied to intersecting systemic inequalities. Americans who are not yet vaccinated are more likely to be poor, more likely to have lower education levels, more likely to get most of their information from social media, more likely to have had negative encounters with the healthcare system and more likely to have no or substandard health insurance. They are also more likely to be Black or brown relative to their share of the population. While these inequities won’t be fixed overnight, it is important to recognize the true cost of these practices and systems for both affected individuals and the nation as a whole.
For some Americans, protecting themselves or their family during the pandemic means forgoing vaccination to ensure a paycheck rather than risk taking time off because of side effects. A strong sense of belonging to a group that constantly speaks out against vaccines can supersede concerns about one’s health. The most well-executed communications campaign alone cannot overcome historic mistrust deeply rooted in decades of experience – or the impact of years of consuming toxic information on an individual’s identity, worldview, and related behaviors.
While not all systemic challenges can be solved at once, not understanding and beginning to address the intersections of these challenges results in failed efforts.
To strengthen vaccine demand, agencies and institutions should work to be in dialogue with people about how they want to protect themselves, and open the framework to all protective measures – vaccines, tests, and therapeutics. The three drivers – informational, behavioral science, and structural interventions – should go hand in hand in the design of cohesive and comprehensive strategies to build vaccine demand.
An excellent example of a more holistic approach that puts communities at the center of the vaccination rollout is CommuniVax, a national alliance of social scientists, public health experts, and community advocates who work together on strengthening local and national vaccination efforts by putting communities of color at the center of their efforts. Communivax focuses on strategies like hiring Community Health Workers to work together with community-based and faith-based organizations to build the human capital necessary to align vaccination implementers and community members’ worlds, increasing greater access to and acceptability of Covid-19 vaccines.
In Prince George’s County, Maryland, for example, the local CommuniVax team administered out of the University of Maryland’s Center for Health Equity utilized their preexisting Health Advocates In-Reach and Research (HAIR) program as a key platform for their community engagement and ethnographic research in connection with the coalition. The HAIR program leverages area barbershops and hair salons as “culturally relevant portals for health education and delivery of public health and medical services in the community,”10 and relies upon collaboration between the university, local business, and local health systems.
As the pandemic progressed, the team developed additional partnerships to facilitate this work with organizations including the Black Coalition Against COVID and companies like SheaMoisture. They have also worked directly with the Biden administration as part of the White House-supported “Shots in the Shop’’ initiative.11 Their efforts with HAIR are now no longer local—the program is expanding to barbershops, hair salons, and health systems nationwide to improve COVID-19 vaccine coverage in African American/Black communities.