The Public's Role in COVID-19 Vaccination: Planning Recommendations Informed by Design Thinking and the Social, Behavioral, and Communication Sciences

"Human factors - including understandings of disease, perceptions of risk, and social factors affecting access - are central to vaccine uptake."

To help advance the United States (US) public's understanding of, access to, and acceptance of vaccines that protect against COVID-19, a working group convened by the Johns Hopkins Center for Health Security created this resource with recommendations for a people-centric approach to the planning and implementation of the COVID-19 vaccination programme. The report's intended users include those involved in SARS-CoV-2 vaccine development, allocation, deployment, and communication. For instance, it may be of use to social/behavioural researchers studying vaccination-related human factors and to entities new to public health's vaccination mission, such as grassroots organisations that are able to provide hyper-localised understanding of vaccine access and acceptance issues in their communities and to serve as trusted vaccination champions.

When it comes to public acceptance of a COVID-19 vaccine, the goal is to ensure that all who are eligible can get the vaccine, including high-risk populations, frontline and essential workers, and the young and healthy who can transmit the disease to others. However, despite vaccination's promise of release from multiple stressors associated with the pandemic (e.g., lockdowns), "some Americans - including those most at risk of COVID-19 impacts - may miss out on, or opt out of, this life-preserving public health measure. Some may worry about whether SARS-CoV-2 vaccines are safe or if they work at all. Some may be mistrustful of vaccine manufacturers, the agencies that regulate the industry, and/or the public health authorities recommending the products. For others, the issue may be access: Will a COVID-19 vaccine be affordable, easy to get to without losing wages or taking public transportation and risking infection, and/or provided in a place that feels safe?"

Under these circumstances, the question the report addresses is: What can be done to ensure that US populations, particularly those at high risk for serious illness, benefit from SARS-CoV-2 vaccines? As Operation Warp Speed (OWS), a public-private partnership, works toward the (arguably overly ambitious) goal of delivering 300 million doses of a safe, effective vaccine by January 2021, US vaccination planners and implementers can exercise foresight and take proactive steps to overcome potential hurdles to vaccine uptake.

The report recommends 6 steps to facilitate broad public uptake of SARS-CoV-2 vaccines:

1. Put people at the centre of the SARS-CoV-2 vaccine enterprise - In 2010, for instance, many Americans rejected the H1N1 influenza vaccine because of perceived safety concerns. In addition, the H1N1 vaccine amplified health disparities and feelings of racial bias. In Los Angeles, California, US, distrust in the government resulting from prior experimentation on Black men and women led Black faith-based leaders, radio personalities, and other community leaders to advise local Black community members to avoid vaccination. Even though the Los Angeles County Health Department actively sought to address these concerns, the local suspicions, coupled with a lack of convenient access to vaccines, ultimately resulted in many people remaining unvaccinated. Some best practices to avoid such a scenario with COVID-19 include:
   • Reconfigure research investments to value the contributions of both bioscience and social and behavioural science to the development of SARS-CoV-2 vaccines.
   • Embed rapid social, behavioural, and communication science within the COVID-19 response, helping to deliver timely data and empirically based advice.
   • Transform the vaccine research enterprise by having communities participate as active partners, not as passive study subjects.
   • Apply human-centred design principles to the planning and implementation of the COVID-19 vaccination programme. (Design thinking involves asking: What does the person on the receiving end think, expect, experience, and sense about the valued good intended for him or her? In design thinking, users also become collaborators in developing the system, activity, or product that directly affects them.)
2. Understand and inform public expectations about vaccine benefits, risks, and supply - For example, emphasis on the unprecedented speed with which vaccines are being developed (i.e., OWS) has inadvertently prompted safety concerns. Moving forward, vaccine refusal and vaccine hesitancy - both on the rise globally and in the US before the pandemic - are likely to exacerbate safety concerns further. Some best practices amid this increasingly complex communication landscape:
   • Temper expectations of a vaccine as a "quick fix".
   • Forecast a range of vaccine possibilities, from best-case to worst-case scenarios, regarding vaccine supply and effectiveness.
   • Be transparent about vaccine safety systems, and actively work to protect their integrity.
   • Early on, seek the counsel and input of communities who have historic reluctance toward novel vaccines and understandable fears of being "experimented on". (This could involve forming partnerships with grassroots-level organisations, practitioners, and other stakeholders to engage early and often with communities around COVID-19 vaccination.)
3. Earn the public's confidence that vaccine allocation and availability are evenhanded - The current climate of racial, political, and economic division in the US has created a charged environment that necessitates a fair vaccination campaign and widespread public recognition of its fairness. Best practices for boosting public confidence that allocation decision making is neither capricious nor unjustly weighted in favour of other people:
   • Employ public engagement efforts to better understand group values and beliefs regarding the allocation and distribution of potential COVID-19 vaccines.
   • Implement vaccination allocation guidelines consistently across different geographic locations and healthcare providers.
   • Develop allocation strategies that take into account racial, ethnic, and social factors and vaccine attitudes.
   • Provide concrete proof that the allocation process is objective and apolitical.
4. Make vaccination available in safe, familiar, and convenient places - Public health authorities will need to disseminate up-to-date, comprehensible, and trustworthy information about vaccination opportunities - keeping in mind that what vaccine recipients consider to be a "safe" place to be vaccinated may differ across various social groups. Best practices for proactive, thoughtful coordination and communication that allows for widespread availability and acceptance of vaccines include:
   • Use nontraditional vaccination sites such as schools, pharmacies, workplaces, grocery stores, health departments, mass vaccination clinics, faith centres, barber shops, senior centres, dental offices, and home visits.
   • Ensure that federal authorities, state and local public health officials, and other entities design communication strategies that "under-promise and over-deliver" on vaccination.
   • Strengthen partnerships between local and state health departments and media news sources to communicate effectively to local communities about vaccine availability and access.
   • Prepare in advance any necessary educational materials and training that may be needed for clinicians tasked with vaccination at nontraditional sites.
   • Anticipate hesitancy among marginalised populations who may be fearful or wary of seeking vaccination at sites that have historically caused mistrust, and plan to either expand sites to better serve these populations or engage these populations earlier to earn and build trust.
5. Communicate in meaningful, relevant, and personal terms - crowding out misinformation - Information about SARS-CoV-2 vaccination, both true and false, is widespread on both traditional and social media, making it hard to sort through health information and confirm its veracity. At the same time, scientific facts do not motivate a majority of people to act. Past research suggests specific steps that can be taken to ensure meaningful and relevant communication and to mitigate the effects of misinformation:
   • Put communities' well-being at the centre of SARS-CoV-2 vaccine communication to lessen the risk of COVID-19 vaccines being seen in a political context.
   • Start engaging communities early to discern the matters of most importance to them in relation to SARS-CoV-2 vaccine - and keep listening.
   • Use surveys to identify the prevalence of attitudes and beliefs across the US population, among specific subpopulations, and, over time, to detect any changes.
   • Invest in qualitative research to identify specific community concerns, hopes, and trusted spokespersons in connection with COVID-19 vaccination.
   • Engage a broad network of trusted spokespersons who can deliver and reinforce a unified message about COVID-19 vaccination.
   • Amplify vaccine-affirming, personally relevant messages to neutralise misinformation about SARS-CoV-2 vaccine and vaccination operations.
6. Establish independent representative bodies to instill public ownership of the vaccination programme - Governance structures for the US COVID-19 vaccination programme that incorporate public oversight and community involvement have the potential to inspire greater public confidence in, and a sense of ownership over, the public health intervention. Best practice involves shifting the public health response to COVID-19 - including vaccination - from the position of working on behalf of affected communities to working with affected communities.

The Working Group concludes: "As experts in a wide variety of vaccination-related topics, we fear that unless these critical steps are taken, any future COVID-19 vaccination campaign will be less than hoped for. A worst-case scenario would involve an inability to stop the ravages of the disease and its cascading social and economic effects; further erosion of public trust in government, public health, and vaccine science; and potential threat to other life-preserving and live-enhancing vaccination efforts. That said, a successful COVID-19 vaccination endeavor promises an alternative future: a return to a sense of normalcy, major innovations in vaccine research and operations, and the investment of US society as a whole in making vaccines a public good in which all can share and derive value."