Background and Objectives
On March 11, 2020, the World Health Organization (WHO) declared coronavirus disease 2019 (COVID-19) a pandemic (World Health Organization, 2021). The first approved vaccine against COVID-19—the Pfizer-BioNTech vaccine—received emergency use authorization by the U.S. Food and Drug Administration (FDA) on December 11, 2020 (U.S. Food and Drug Administration, 2020). But even before the United States started administering COVID-19 vaccines, anti-vaccine sentiments were apparent across the country.
Prior research has been conducted on hesitancy related to other vaccines in the United States and worldwide, and numerous reports have documented the ongoing challenge of COVID-19 vaccine hesitancy in the United States and its repercussions (Fridman, Gershon, and Gneezy, 2021; Khubchandani et al., 2021; Loomba et al., 2021). However, despite the number and extent of the multilevel and multimodal solutions proposed to boost vaccine acceptance, there is little understanding of the feasibility and the effectiveness of these solutions in the context of COVID-19 vaccine hesitancy.
COVID-19 vaccination has uniquely challenged our current understanding of vaccine hesitancy, both because of the use of novel vaccination technology and the unprecedented timeline of vaccine development in the setting of an evolving pandemic. Further, ongoing politicization of the public health response to the COVID-19 pandemic and widespread misinformation on social media have influenced how willing individuals have been to obtain the vaccine. How to boost vaccine acceptance among those who are hesitant based on political ideology, religious objections, conspiracy theories, or misinformation is not well understood.
In this study, we present the results of a quick-turn evaluation of the root causes of COVID-19 vaccine hesitancy to inform strategies to boost vaccine acceptance among vaccine-hesitant populations in the United States. The goals of this project were to
- examine the root causes of COVID-19 vaccine hesitancy
- seek patient, hospital-based health care provider, pre-hospital first responder, and expert perspectives to identify potential strategies to boost COVID-19 vaccine acceptance
- provide recommendations to help inform appropriate practice, policy, and research priorities and the development of tools to boost COVID-19 vaccine acceptance.
We performed an environmental scan of peer-reviewed and gray literature to understand what is known about the root causes of vaccine hesitancy (in general and with respect to COVID-19 vaccines) and strategies to boost vaccine acceptance. To further our understanding of reasons for vaccine hesitancy and vaccine acceptance among different U.S. populations, we conducted focus groups with patients, pre-hospital first responders (e.g., emergency medical responders and police officers), and hospital-based health care providers. To augment the knowledge that we gained about COVID-19 vaccine attitudes from our focus group analysis, we conducted a social media platform sentiment analysis to review attitudes regarding the COVID-19 vaccine across a broader population. To complete the social media sentiment analysis, we relied on Meltwater, which is a comprehensive media monitoring, analysis, and social listening platform (Meltwater, undated). The sentiment analysis identified how users on Twitter, Reddit, Facebook, and Instagram feel (positive, neutral, and negative) about the COVID-19 vaccine (from April 2020 through April 2021 for Twitter, Reddit, Facebook and from April 26, 2021, through May 2, 2021, for Instagram). A total of 11.8 million comments or mentions across the four platforms met inclusion criteria for the analysis.
Finally, to understand what solutions are most actionable and grounded in existing evidence, we conducted an expert roundtable that included a pediatric emergency physician, two social scientists, a political scientist, and a behavioral scientist. During this roundtable, we reviewed the results of the above analyses and identified key recommendations for policy solutions to address vaccine hesitancy moving forward.
Our mixed-methods analysis revealed common themes associated with COVID-19 vaccine hesitancy in the United States. The four methodologies employed by this study identified similar themes with respect to the root causes of COVID-19 vaccine hesitancy and regarding strategies to boost vaccine acceptance. Strategies to boost COVID-19 vaccine acceptance need to be tailored to root causes of hesitancy in different populations, including racial and ethnic minority groups, young adults, individuals hesitant because of political and/or religious beliefs, those with fixed beliefs against the use of vaccines more generally (e.g., those who may identify with the anti-vaxxer movement), and those who subscribe to prevailing conspiracy theories related to the development and nature of COVID-19 vaccines. These currently hesitant populations might be willing to obtain the vaccine if the right influencer helps to convey a recommendation to do so, including a personal physician or other trusted health care provider, a religious and/or political leader, celebrities (e.g., musicians, athletes, actors), COVID-19 patients and/or individuals who lost loved ones to COVID-19, and a personal network of family, friends, and colleagues.
We offer three tiers of recommendations for public health and health care officials, health care providers, policymakers, and researchers who strive to boost COVID-19 vaccination rates in the United States in order to achieve herd immunity and overcome the pandemic. The three tiers of recommendations are based on how frequently the recommendation was supported in each part of our mixed-methods analysis: the environmental scan, focus groups, social media platform sentiment analysis, and expert roundtable:
- Tier 1 recommendations are strongly supported by the analyses. These recommendations are supported by the environmental scan and social media sentiment analysis and are based on themes that were identified multiple times across the focus groups and expert roundtable.
- Tier 2 recommendations are moderately supported by the analyses. These recommendations are supported by the environmental scan and social media sentiment analysis and/or are based on themes that were identified multiple times in at least one focus group or the expert roundtable.
- Tier 3 recommendations may or may not be supported by the environmental scan and social media sentiment analysis but were discussed in at least one focus group or the expert roundtable and are deemed notable and/or innovative.
The full list of recommendations is provided in Table 1.
Each of these recommendations can inform the development of a toolkit of strategies to boost vaccine acceptance that features the most effective messages, messengers, and messaging platforms among various hesitant populations in the United States. These recommendations are presented according to the WHO “three Cs” model of confidence, complacency, and convenience, which addresses trust in vaccines and the systems administering them, perceptions of being low-risk for diseases in question, and characteristics of immunization delivery services, respectively (World Health Organization, SAGE Working Group on Vaccine Hesitancy, 2014). One limitation of the three Cs model that should be noted is that it does not incorporate hesitancy that is due to misinformation.
Ultimately, each of these recommendations should help policymakers and public health officials develop and deploy an effective COVID-19-vaccine-acceptance-boosting toolkit aimed at addressing the root causes of vaccine hesitancy among different populations that remain hesitant and enable efforts to boost vaccine acceptance to be tailored in terms of messages, messengers, and messaging platforms.
Table 1. Recommendations for Boosting COVID-19 Vaccine Acceptance
|Boost confidence in COVID-19 vaccines and combat complacency|
1. Increase awareness, knowledge, and dissemination of vaccination information
Improve penetration of accurate vaccine information among hesitant populations
Develop culturally sensitive educational materials in various languages and literacy levels
Explain both the purpose and value of vaccination while alleviating concerns about effectiveness and safety
2. Communicate effectively through the use of personal narratives and stories about the “why” for vaccination
Communicate the need for vaccination through short, personal narratives to appeal to people's emotions
Communicate the “why” of people who got vaccinated in messaging to boost vaccine acceptance
|Boost vaccine confidence in COVID-19 vaccines, combat complacency, and promote convenience||
1. Employ multiple vaccination strategies directed at more than one level of engagement
Improve convenient access to vaccination for those ready to get a vaccine
Directly target unvaccinated or under-vaccinated populations
Engage influential leaders to promote vaccination
Personalize messaging to hesitant populations based on value-assessment and use of trusted voices within the community
2. Target populations and segment initiatives for vaccination
Identify and implement strategies for addressing vaccination needs of marginalized and vulnerable populations (e.g., BIPOC [Black, Indigenous, and people of color], children, older adults, immigrants, refugees, and LGBTQ+ [lesbian, gay, bisexual, transgender, and queer, or questioning] individuals)
Target populations who share similar beliefs, attributes, and health-seeking behaviors in order to shape interventions that can be most effective in each segment
Focus on the vaccine-hesitant, as opposed to those with “extreme” anti-vaccine views, as the latter may not be persuadable
3. Identify components of the ultimate toolkit to boost COVID-19 vaccine acceptance
Develop vaccine-promoting templates with tailored messages, messengers, and messaging platforms deemed most effective for given populations
Use nuanced messages based on an understanding of the root causes of a community's vaccine hesitancy and continue monitoring perceptions (e.g., through social media) to modify messaging
Include inspirational-based messaging (“why I got the vaccine”) as opposed to fear- or shame-based messaging
4. Tailor messages, messengers, and messaging platforms
Use familiar or trusted health care settings to promote vaccination (as opposed to settings with which the community has a history of distrust)
Promote health care provider education, use of clinical decision support, or collaboration with public-private stakeholders to successfully address provider/practice-related barriers
1. Expand vaccination access through various settings and services
Arrange vaccination services through community groups, including home services, employers, neighborhood community centers, elder care centers, and religious groups
Expand access to vaccination sites by employing community settings with extended operating hours and flexible scheduling (e.g., pharmacies, workplace clinics, churches)
|Boost confidence in COVID-19 vaccines and combat complacency||
1. Combat conspiracy theories, misinformation, and disinformation through different media
Improve the overall social media presence of health agencies and governments and foster partnerships with social media platforms to accelerate promotion of evidence-based public health strategies
Monitor online media messaging and conversations to identify and evaluate early signals of crisis and inform on the real needs of those who are truly hesitant
Use social media to track trends and map out unique concerns of different groups or populations and “micro-target” emerging issues around vaccinations
|Boost vaccine confidence in COVID-19 vaccines, combat complacency, and promote convenience||
1. Develop and implement vaccination programs through partnerships
Health systems and community-based organizations should partner with existing federal, state, and local vaccination programs
Acknowledge through government platforms that the federal response and messaging has been haphazard and the dependence on states has produced mixed results
Partner with industry/business leaders to develop and deploy COVID-19-vaccine-acceptance-boosting tools
Partner with faith leaders, use public service announcements, and create state-level partnerships while acknowledging that in some states the implementation may not be great
Partner with industry/business leaders (banks, grocery stores, gas stations, airlines) so that messages can become woven into everyday life with “captive” audiences
2. Develop and implement national public health campaigns and initiatives with a unified evidence-based message to counter inconsistent messaging
Include provider and patient education
Use practice-based immunization “champions” to improve adult vaccine uptake
Highlight personal risks of the disease as well as community benefit when communicating to populations that are less susceptible to COVID-19
Convene experts representing different sets of stakeholders with a view to brainstorming and discussing creatively how to better support national communication campaign efforts, how to respond and build resilience in crises situations, and how to better engage with grassroots and civil society organizations that can support advocacy for vaccination
3. Identify strategies to combat hesitancy among the politically vaccine-hesitant
Use health care providers as messengers for this group
Unify health care and public health messaging to prevent confusion and frustration
4. Identify strategies to combat hesitancy among members of the anti-vaxxer movement
Understand the idea of “remove and replace”—i.e., replacing a hesitant patient's reliance on a movement that gives them a sense of community with a different focus—recognizing that, within the anti-vaxxer movement, being anti-vaccine is not typically a stand-alone point of view but is part of a broader worldview and misunderstanding of science
Give members of the anti-vaxxer movement something to “replace” their current worldview
5. Identify strategies to combat hesitancy among other conspiracy theorists
Recognize that conspiracy theorists and purveyors of mis- and disinformation are often conflated with the politically and/or religiously vaccine-hesitant and the anti-vaxxer movement in sharing a general distrust of experts and/or the establishment and/or science
6. Normalize vaccination
Normalize the vaccine through messages, messengers, and platforms emphasizing that getting the vaccine is not a political or religious statement
|Boost confidence in COVID-19 vaccines and combat complacency||
1. Implement vaccination policies to increase vaccination rates and decrease disease incidence
Consider legislation mandating vaccination in various settings (e.g., places of employment)
Make access to valued settings (e.g., health care facilities, large workplaces, K–12 schools, and collegiate institutions) conditional on vaccination status as a motivator for getting vaccinated
|Boost confidence in COVID-19 vaccines, combat complacency, and promote convenience|
1. Leverage transportation, technology, and other less utilized tools to promote vaccination
Leverage transportation networks and subsidize ride-share platforms to help people access vaccines without financial burden or increased time away from work or other responsibilities
Use technology via mobile devices for appointment scheduling and reminders
Implement standing orders for nursing visits, point-of-care prompts, and reminder/recall systems to leverage opportunities to offer the vaccine to patients at any health encounter
Ensure sick time for those who experience symptoms after vaccination
2. Prioritize research, evaluation, and other targeted vaccination interventions
Research context-specific factors to inform tailored approaches to immunization
Implement processes to evaluate the drivers of hesitancy and measure the effectiveness of interventions over time
3. Foster a sense of belonging, togetherness, and/or community associated with vaccination
Create a sense of belonging and community through vaccination events (rather than just through messaging)
Consider financial incentives like the lottery, prizes, rewards, and other gifts, certificates, and coupons for some communities