Strategies for Building Confidence in the COVID-19 Vaccines

"Ensuring strong demand for and promoting acceptance of the COVID-19 vaccines is critical to achieving herd immunity, protecting the most vulnerable populations, and reopening social and economic life..."

Since the first COVID-19 vaccine was authorised in December 2020 in the United States (US), public confidence in COVID-19 vaccines has risen relative to reported attitudes regarding a hypothetical vaccine in early 2020. However, some people are hesitant, reluctant, distrusting, or otherwise not motivated with respect to being vaccinated. It is this group who may be most receptive to communication intervention: to resources, information, and support for making the vaccination decision that is right for them. Produced through the Societal Experts Action Network (SEAN), an activity of the National Academies of Sciences, Engineering, and Medicine, this guidance for combatting mistrust and building confidence in COVID-19 vaccines is based on research on making decisions, changing beliefs/attitudes, and reaching and engaging diverse audiences. The rapid expert consultation describes a variety of public engagement and communication strategies that can be implemented at the national, state, and local levels to change patterns of interaction with the public, address hesitancy about the vaccines, and build trust.

As the report outlines, reasons for vaccine hesitancy vary widely. While some people want to wait and see how others respond to being vaccinated, others are mistrustful of medicine or government. Some mistrust is rooted in experiences of systemic racism and discrimination. Conflicting information from multiple sources can also undermine confidence and trust in vaccine authorities. Because of these varied causes of hesitancy, strategies for increasing vaccine confidence "need to take into account that vaccine decision making is part of a nuanced ecological model in which individual beliefs and behaviors are influenced by experiences at the community, organizational, and policy levels."

Five principles of effective risk communication to consider when developing these strategies include:

1. Do not wait: Begin communicating immediately - Once formed, attitudes are difficult to change. Use cues from people's previous experiences, such as childhood vaccination, to characterise the COVID-19 vaccine as something with which they are already familiar.
2. Be credible: Be consistent and transparent - Acknowledge what is known and unknown about the vaccines. Greater transparency about the vaccine authorisation and distribution process could address concerns about the politicisation of the process.
3. Be clear: Use accessible, jargon-free messages - Use messages tailored to the health literacy and numeracy levels of the audience - e.g., explain terms that have technical meanings.
4. Express empathy and show respect: Avoid dismissing concerns - Listen to people's concerns, rephrase and restate those concerns, and present relevant new information with empathy.
5. Acknowledge uncertainty and manage expectations - For example, honestly share realistic projections of the timeline; overpromising how quickly progress will occur could undermine trust. Provide clear guidance on how to sign up for vaccine appointments to help manage expectations and reduce frustration.

"Best practices" for communication strategies designed to build confidence in the COVID-19 vaccines are outlined here as:

• Meet people where they are, and do not try to persuade everyone - Develop different messages for those who are willing to be vaccinated and need information on how to do so and those who are hesitant but open to learning more. Use phrasing such as, "I understand that you might have questions about the vaccine, and I'm here to answer them as best I can..."
• Avoid repeating false claims - Warn recipients before confronting them with the false information (e.g., "The following claim is misleading...") and emphasise the facts over the misinformation. It may also be effective to adopt a pivot approach to avoid addressing and correcting false claims and misinformation directly, instead diverting the listener to consider concerns about the risk of disease. Instead of adopting a "those people" attitude toward vaccine-hesitant individuals, adopt an approach that encourages empathy.
• Tailor messages to specific audiences - Use appropriate approaches to reach vaccine-hesitant audiences that differ by age, gender identity, marriage status, education level, refugee and immigration status, health behaviours/norms, and race and ethnicity, as well as the socially marginalised. Consider tailored messaging needs down to the individual level, including through such strategies as motivational interviewing.
• Adapt messaging as circumstances change - Undertake "constant research to monitor and understand the addressable influences on vaccine confidence over time", and set up feedback mechanisms to ensure that this information is used to shape messaging that is responsive to the dynamism of beliefs as the outbreak and media coverage of it shift.
• Respond to adverse events in a transparent, timely manner - Communicate information about side effects promptly, keeping in mind also that the rarity of adverse events is not always appreciated due to the fact that such events are often disproportionately reported in the news media and spread widely on social media.
• Identify trusted messengers to deliver messages - Consult with decision makers who can identify groups that represent trust gaps in their community and trusted sources within and outside their organisation who can convey public health messages to those groups.
• Emphasise support for vaccination instead of focusing on naysayers - In light of research showing that people look to their peers for cues about how to behave, make vaccine uptake visible (e.g., through stickers such as pictured above) can encourage COVID-19 vaccine acceptance as a social norm.
• Leverage trusted vaccine endorsers - Partner with people who have strong existing popular or community relationships with experts, adapting messages as needed. Examples of this approach include basketball star Stephen Curry's hosting of US vaccine expert Dr. Anthony Fauci on his video series and national vaccine experts participating in local town hall meetings.
• Pay attention to delivery details that also convey information - Do not neglect the user experience with enrolling and getting vaccinated; if exposed to reports of online sign-up portals crashing, dirty clinic sites, or long wait times, for example, people may infer that the vaccine itself is also faulty.

Reflecting on the above principles and practices, the researchers stress that "Everyone - employers, health care providers, faith leaders, elected leaders, and public health officials - has a role to play....As the COVID-19 vaccination campaign continues, it will be important to employ a coordinated approach that is supported at the federal and state levels and invests in local resources, expertise, and involvement. A variety of strategies at the national, state, and local levels will be required to change the pattern of interactions with the public, address vaccine hesitancy, build trust, and ultimately ensure a successful COVID-19 vaccination campaign."