Professional Documents
Culture Documents
COVIDReport Final
COVIDReport Final
Communication:
Applying Behavioral and Social Science
to Address Vaccine Hesitancy and
Foster Vaccine Confidence**
Wen-Ying Sylvia Chou, Ph.D., M.P.H.,1 Caitlin E. Burgdorf, Ph.D.,2
Anna Gaysynsky, M.P.H.,1 Christine M. Hunter, Ph.D.2
1
National Cancer Institute, National Institutes of Health (NIH)
2
Office of Behavioral and Social Science Research, Division of Program Coordination, Planning, and Strategic Initiatives, NIH
* Although technically these are SARS-CoV-2 vaccines, we refer to them as COVID-19 vaccines to be consistent with how most
lay people describe them.
** The content of this paper is based on what was known as of December 2020 regarding COVID-19 vaccines. Recommendations
from this report may need to be adapted as new information becomes available.
Acknowledgements
Members of the NIH Behavior and Social Sciences Research-Coordinating Committee Rapid
Working Group on COVID-19 Vaccine Communication
Rebecca Campo, Ph.D., National Heart, Lung, and Blood Institute, NIH
Stephanie George, Ph.D., National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH
Chris Gunter, Ph.D., National Human Genome Research Institute, NIH
Monica Webb Hooper, Ph.D., National Institute on Minority Health and Health Disparities, NIH
Rosalind King, Ph.D., Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH
Barbara Mulach, Ph.D., National Institute of Allergy and Infectious Diseases, NIH
Janine Simmons, M.D., Ph.D., National Institute on Aging, NIH
Rona Siskind, M.H.S., National Institute of Allergy and Infectious Diseases, NIH
Robin Vanderpool, Dr.P.H., National Cancer Institute, NIH
Expert Panelists
Michele Andrasik, Ph.D., University of Washington
Emily Brunson, Ph.D., Texas State University
Alison Buttenheim, Ph.D., M.B.A., University of Pennsylvania
Joseph Cappella, Ph.D., University of Pennsylvania
Tara Haelle, M.A., Tara Haelle Media
Alex Kemper, M.D., M.P.H., M.S., Nationwide Children’s Hospital
Heidi Larson, Ph.D., London School of Hygiene & Tropical Medicine
Saad B. Omer, Ph.D., M.P.H., M.B.B.S., Yale University
Sherry Pagoto, Ph.D., University of Connecticut
Megha Ramaswamy, Ph.D., M.P.H., University of Kansas
Amelie Ramirez, Dr.P.H., M.P.H., The University of Texas Health Science Center at San Antonio
Ken Resnicow, Ph.D., University of Michigan
Brian Southwell, Ph.D., RTI International
Victor Sutton, Ph.D., M.P.P.A., Mississippi State Department of Health
Vish Viswanath, Ph.D., Harvard University
Table of
Contents
Contents
Executive Summary 1
Introduction 3
Foundational Communication Considerations 5
Specific Objectives 6
1. Define the goals of vaccination communication 6
1.1 Establish top-line messages regarding COVID-19 vaccination 7
1.2 Address vaccine hesitancy before and during rollout to reinforce COVID-19 vaccine confidence 7
1.3 Mitigate the impact of COVID-19-related misinformation 8
2. Identify the needs and perspectives of the intended audience 10
2.1 Health care professionals 11
2.2 Older adults and individuals with underlying medical conditions 11
2.3 Non-health-care essential workers 12
2.4 Racial and ethnic minority populations 12
2.5 Vulnerable communities with limited access to routine vaccination services 12
2.6 Individuals living in congregate settings 13
2.7 Children and pregnant women 13
3. Create and disseminate targeted and tailored messages for the intended audience 14
3.1 Identify and partner with trusted COVID-19 vaccine messengers 14
3.2 Create accurate, transparent, and truthful vaccine messages 16
3.3 Frame vaccine acceptance as a social norm 16
3.4 Use behavioral nudges 17
3.5 Enact value-concordant messaging that is sensitive to the emotional state of the audience 17
3.6 Creative strategies: Going beyond didactic vaccine messages 18
Conclusion 19
References 19
WHAT
Define the goals of vaccination communication
Identification of specific communication goals is necessary to inform the development of message content
and format. In addition to provision of top-line information regarding the vaccines, it is important to consider
and address underlying reasons for vaccine hesitancy to instill trust. Doing so in an empathic way is crucial
to avoid alienating those who have concerns about the development and deployment of these vaccines.
Monitoring the spread of both general and COVID-19-specific vaccine misinformation, and taking steps to
mitigate its impact, will be critical for successfully addressing vaccine hesitancy. It is important that the goals
of communication efforts—whether they focus on the delivery of top-line messages or on addressing vaccine
hesitancy and misinformation—continue to evolve in response to emerging pandemic- and vaccine-related
information and shifts in public sentiment to sustainably reinforce vaccine confidence.
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COVID-19 Vaccination Communication
WHO
Identify the needs and perspectives of the intended audience
The COVID-19 pandemic is having a disproportionate impact on communities already experiencing health and
social disadvantages by virtue of their race, ethnicity, health status, age, access to health care, occupation,
and socioeconomic conditions. To develop the most effective, trustworthy, and equitable communication
strategies, the perspectives of the intended audience—including concerns, motivations, values, and
information needs—must be considered. These factors should dictate vaccination communication priorities,
including understanding and responding to different reasons for vaccine hesitancy in diverse communities.
This document highlights some of the unique challenges and factors associated with vaccine hesitancy in
specific communities and describes methods that may help increase vaccine confidence in these populations.
HOW
Create and disseminate messages tailored to the intended
audience
Given the diversity of factors that drive vaccine hesitancy in different groups, communication efforts cannot
take a “one size fits all” approach. Effective communication goes beyond the provision of accurate content; it
must also be tailored to the community’s values and priorities and come from trusted messengers. The only
way to truly “listen” to the community is to co‑develop and co-disseminate COVID-19 vaccination messages
through meaningful partnerships with trusted information sources. In addition to partnering with trusted
entities and leaders during message development, certain communication tactics may prove effective across
a variety of communication campaigns. For example, it may be helpful to frame COVID-19 vaccination as
a social norm that is collectively beneficial and acceptable and to reinforce the idea that vaccination is an
apolitical, nonpartisan health care decision. Promotional materials, such as “I got the shot” stickers, may
help establish vaccination as a socially supported behavior and enhance vaccine confidence by making
vaccination behavior more visible.
Furthermore, modifying the choice architecture in ways that make vaccination the easy and convenient action
(for example, by asking people to opt out of rather than opt into vaccination at health care appointments) could
increase the likelihood of vaccination uptake, while still preserving autonomy in decision making. However,
efforts to promote the vaccines must also take care to ensure that all messages are accurate, transparent,
and truthful and neither exaggerate nor minimize the vaccine benefits or risks. Similarly, overactivation of
fear and overly directive message framing should be avoided, because these approaches are likely to be
counterproductive and heighten vaccine hesitancy. Ensuring value-concordant messaging and eliciting
positive emotions, whenever possible, will enhance trustworthiness and increase the impact of the message.
Finally, several creative communication strategies, such as the use of personal narratives (e.g., from celebrity
spokespeople) and short videos (e.g., “edutainment”), may help effectively convey key messages in an
accessible way.
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COVID-19 Vaccination Communication
Introduction
The historic public health crisis resulting from the SARS-CoV-2 (hereafter COVID-19) pandemic has resulted
in tremendous mortality and morbidity, as well as unprecedented economic loss and disruption to daily
life in the United States and across the world. Long-term control of the COVID-19 pandemic hinges on
the development, distribution, and uptake of vaccines. Although highly effective COVID-19 vaccines have
been developed rapidly and a phased plan for national vaccine distribution has been established, ensuring
the success of national vaccination efforts will require a communication plan to address vaccine hesitancy
and foster vaccine confidence. To enhance acceptance and trust in COVID-19 vaccines among the diverse
populations in the United States, communication activities should be informed by insights from behavioral and
social sciences and continuously adapt to a complex and dynamic vaccination landscape across all phases
of vaccine distribution and administration.
Despite the considerable suffering and disruption caused by the COVID-19 pandemic, polls suggest that a
sizable proportion of the U.S. population either does not plan to receive a COVID-19 vaccine or is unsure
about receiving a vaccine.1,2 Furthermore, a recent report found that despite the disproportionate impact the
pandemic is having on minority communities in the United States, only 48 percent of Black Americans and
66 percent of Latinx individuals surveyed would receive the vaccine even if it was available for free.3 The
hesitancy observed regarding COVID-19 vaccines is, in many ways, understandable given the novelty of the
virus, mixed messages about the severity of the disease, concerns about the rapid vaccine development
timeline, and perceived politicization of the process.4 These COVID-19-specific concerns may be exacerbated
by factors that reduce vaccine confidence in general, including distrust in traditional sources of health information
(e.g., government agencies, scientists, the medical system), the rapid and extensive spread of misinformation
online, and disinformation campaigns that take advantage of the divisive public discourse around vaccines.3,5,6
In addition to vaccine hesitancy, the fact that most candidate vaccines require a two-dose regimen administered
several weeks apart7 creates additional challenges for full vaccine uptake. Communication efforts will need
to make it clear that individuals will not only need to initiate the vaccine, but also to return to receive another
shot at the right time to be fully vaccinated. In addition to logistical complexities, the two-dose regimen could
add to communication challenges if individuals experience unpleasant side effects in response to the first
dose, making them reluctant to complete the series.8,9 Experience with other multiple-dose vaccines, like the
shingles vaccine, suggests that educational efforts that highlight the efficacy of the vaccine and set appropriate
expectations about any initial side effects will be crucial to overcoming this barrier.8,9
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COVID-19 Vaccination Communication
It is clear that public health entities charged with communicating about COVID-19 vaccines face notable
challenges, including a compressed timeline for developing communication strategies to educate the public
about the vaccine and address vaccine hesitancy ahead of rollout. Moreover, vaccination communication
must be connected to the broader context of COVID-19 pandemic control, including critical preventive
behaviors, such as mask wearing, hand washing, and social distancing. Consequently, the rapid, coordinated
dissemination of effective messages will be an essential element in addressing one of the most significant
public health challenges in decades. Although ensuring successful vaccine uptake across the nation will require
addressing demanding logistical and structural challenges, strategic and evidence-informed communication
regarding vaccine safety, efficacy, distribution, and access will also play a key role in the complex national
COVID-19 vaccination process. Drawing on behavioral and social science research, in addition to establishing
collaborative partnerships with trusted community organizations, can increase the likelihood that COVID-19
vaccine communication endeavors will be successful.
To identify evidence-informed strategies for communicating about COVID-19 vaccines, the NIH Behavioral
and Social Sciences Research Coordinating Committee formed a COVID-19 vaccine communication working
group in September 2020 and convened an expert panel on November 5, 2020. The panel, which comprised
15 leading experts in public health and social sciences (e.g., communication, psychology, behavioral
economics, health disparities, anthropology), focused on identifying evidence-informed communication
approaches that could guide government entities in communicating COVID-19 vaccine-related information
to a variety of constituents. The panel also made recommendations about how these communication
strategies could be optimized, tailored, targeted, and delivered to address the unique needs and perspectives
of diverse populations. The panel discussion formed the basis of this report, which is designed to summarize
evidence from behavioral and social science to inform COVID-19 vaccine communication efforts across
U.S. federal agencies and partners at the state and local levels. This report begins by outlining foundational
considerations for any public health communication effort and then delves into more specific evidence-informed
communication strategies for reducing hesitancy and enhancing confidence in COVID-19 vaccination.
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COVID-19 Vaccination Communication
Foundational
Communication
Considerations
Effective health communication relies on foundational best practices. Although these are not the primary focus
of this report, some of the COVID-19 vaccine communication recommendations highlighted in subsequent
sections will build on these general best practices:
• Foster transparency and build trust through partnerships: Presenting clear and accurate
information that does not exaggrate or minimize the benefits or potential risks is vital. In addition,
leveraging trusted sources to disseminate the messages is as essential as the content itself, and it
can be accomplished through sustainable partnerships between federal agencies and trusted entities
or individuals who reflect the diversity and views of the intended audience.
• Consider the range of health literacy: Plain language and visual representations should be used
where possible. Additionally, communication strategies should be developed to accommodate
different levels of health literacy (e.g., the capacity to understand health information), digital literacy
(e.g., the capacity to discern the credibility of online sources), and science literacy (e.g., understanding
of the evolving nature of science). Furthermore, language preferences for those with limited English
proficiency must also be taken into account. It is important that translations into other languages be
done in a culturally sensitive way so that the information is conveyed in an accurate, nuanced, and
accessible manner.
• Prioritize equity: Suboptimal communication has the potential to exacerbate health disparities and
undermine the goals of fostering equity and trust. Communicators should make additional efforts
to engage with and address the needs of vulnerable, underserved, and traditionally marginalized
populations during communication development and dissemination to avoid exacerbating disparities.
Communication efforts should be sensitive to the fact that people may have to balance competing
priorities.
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COVID-19 Vaccination Communication
Specific
Objectives
This report highlights recommended practices drawn from behavioral and social science research that can be
used to inform COVID-19 vaccine communication efforts. The intended users of this report are those charged
with COVID-19 vaccine communication across federal health agencies and their partners at the state and
local levels. The recommendations put forth in this report are evidence-informed, actionable, and responsive
to the unique circumstances and challenges facing the United States with regard to the COVID-19 pandemic.
The recommended strategies are organized around three critical and interrelated strategic considerations
that should guide the planning and implementation of COVID-19 vaccine communication:
The following sections provide details and examples for each of the strategic considerations. For any
communication planning and implementation effort, all three considerations are important and may intersect
in unique ways depending on the goals, target audience, resources, and time available for message tailoring
and dissemination, among other practical factors.
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COVID-19 Vaccination Communication
1.1 Establish top-line
messages regarding Key goals of COVID-19 vaccination
communication
COVID-19 vaccination
Developing a core set of messages, along with • Provide assurance of vaccine safety and
harmonized themes, images, and branding can efficacy.
help ensure consistency of vaccine information
• Highlight the collective and individual
across different entities and sources. Top-line benefits of vaccination.
messages should provide accurate vaccine
• Explain the vaccine development, FDA
information, acknowledge people’s concerns
approval, monitoring, and distribution
where appropriate, and increase vaccine process.
confidence and acceptance. Currently (as of
• Address vaccine hesitancy and respond to
December 2020), critical content for COVID-19
dominant concerns without judgment or
vaccination messages should include overly directive language.
assurance of vaccine safety and efficacy,
• Monitor misinformation and develop counter
evidence that the benefits of vaccination
messages.
(i.e., protection from the virus) outweigh the
risks, and a focus on the collective benefits
of high vaccination coverage. Emphasizing
the importance of completing the two-dose vaccine series will also be critical to ensure adherence. In addition,
messages should establish social norms for vaccination—for example, by increasing the perception that
members of one’s social group plan to or have already been vaccinated10—and emphasize how herd immunity
resulting from high vaccine uptake can protect the health and well-being of others.11,12 Finally, vaccination
messages cannot be divorced from overall pandemic control efforts and the need for continued preventative
behaviors, including social distancing and mask wearing, until COVID-19 community transmission is halted.
Messages should therefore clearly explain why vaccination alone, although beneficial, will not offer a quick
end to the pandemic, at least in the early stages of rollout.
This core content then can be adapted to fit a given community’s context, concerns, and preferred
communication channels and developed into a tailored message (detailed in Section 3 below). Moreover, in
crafting top-line messages, it will be critical to acknowledge and respond to the evolving scientific knowledge
about various COVID-19 vaccines, which is an expected part of the vaccination administration process. Top-
line message content may need to be adjusted to account for any documented differences in the various
vaccines, who will receive them, and when they will receive them, so that this information can be quickly and
consistently communicated to the public.
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COVID-19 Vaccination Communication
essential to reducing vaccine hesitancy. For others, hesitancy may be driven by concerns over the accelerated
development timeline for COVID-19 vaccines. These individuals may be eager to gain knowledge from
trusted experts about the steps taken to develop and evaluate the vaccine to support them in making an
informed decision about vaccination. Hesitancy arising from the false, but understandable, perception that the
development and approval of COVID-19 vaccines has not been as stringent as the process for other vaccines
could be addressed by transparently explaining the vaccine development processes from clinical trials
to reviews by U.S. Food and Drug Administration (FDA) panels to authorize use to subsequent monitoring
for safety and effectiveness. It is important to note, however, that as knowledge about vaccines and rollout
evolves, new concerns and questions about particular vaccines may emerge, requiring government agencies
and their partners to adjust and respond quickly.
In addition to unique concerns driving vaccine hesitancy, individuals’ personal values and beliefs, such as
those related to self-determination vs. fatalism or individualism vs. collectivism, are likely to influence uptake of
preventative health measures, including vaccination.15–18 Understanding a community’s dominant values and
beliefs can help inform the development of effective messages to build vaccine confidence in the community.
Furthermore, a distinction exists between those who may be hesitant about COVID-19 vaccines and those
who have complete mistrust in vaccines. A poll conducted in November 2020 found that 42 percent of
Americans are hesitant about receiving a vaccine, with 12 percent reporting not trusting vaccines in general.2
Communicators should avoid grouping those who are only hesitant to vaccinate, but not entirely opposed,
with people who are actively opposed to all vaccination. Research on childhood vaccines suggests that there
is a window of opportunity for influencing people who are initially vaccine hesitant before their views
become ingrained.19 Therefore, hesitancy should be addressed early in the vaccine rollout process, because
the longer people stay uncertain and their concerns go unaddressed, the less likely they are to get vaccinated.
For those who have expressed a deeper general mistrust in vaccines, communication should still be balanced,
empathetic, and compassionate. Even if this approach does not immediately lead to vaccine acceptance,
it could help build relationships and trust, which may lead to greater willingness to consider vaccination in the
future.20 Furthermore, attempting to directly contradict their anti-vaccine stance could lead to defensiveness
and psychological reactance and further reduce their willingness to vaccinate.21 Messages targeting this
group might include acknowledgement of some of the dominant concerns about vaccines but emphasize
the evidence for the vaccine’s safety and efficacy.
More generally, communication efforts targeting any group should avoid judgment, shaming, or excessive
directiveness, because messages with these characteristics have been found to be counterproductive
in previous public health campaigns.22,23 Avoidance of judgment allows people to feel that their concerns
and values are respected and indeed “heard” by public health officials. Dismissing or leaving these vaccine
concerns unaddressed creates an opportunity for anti-vaccine groups to further sow doubt in vaccines and
gain credibility for their own misinformation by effectively aligning their anti-vaccine messages with their target
groups’ core concerns and values.24
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COVID-19 Vaccination Communication
by misinformation.25,26 Anti-vaccine groups have leveraged political and social divisions to diminish trust in
vaccines, pushed false narratives questioning the safety and effectiveness of vaccines, spread false claims
about adverse outcomes, and downplayed the risks of the diseases vaccines protect against.24,27–30 In the case
of the current pandemic response, a recent joint statement from global public health organizations asserted
the extent to which misinformation and disinformation have undermined public health response.31 Social media
has facilitated the rapid and widespread sharing of inaccurate information and outright falsehoods about many
aspects of the COVID-19 pandemic,32 from denying or downplaying the severity of the virus to casting doubt
on public health guidance to spreading vaccine conspiracy theories. COVID-19 vaccine communication efforts
cannot ignore misinformation and must take actions, informed by behavioral and communication research,
to identify emerging rumors and respond in a way that is informed by behavioral science.
It is important to recognize that not every piece of misinformation requires an immediate counter-response.
Public health organizations do not typically have the resources or capacity to address every piece of
misinformation. When a rumor seems to be gaining widespread traction and has the potential to either cause
harm or undermine critical health promotion efforts, however, intervention will be required. Correcting the false
claim contained in the message, exposing the tactics used by disinformation agents, and inducing skepticism
by highlighting the ulterior motives of these actors are all potentially effective strategies for mitigating the impact
of misinformation.37–39 Communication research also points to a few general actions to avoid when responding
to misinformation: (1) Do not repeat the falsehood, because such repetition can have a priming effect.
(2) Do not assume that those who are generally well informed about health information are immune to being
influenced by falsehoods. (3) Do not assume a one-time effort will be sufficient, because communication
effects are often incremental and require persistence and consistency.39
Finally, although research suggests that certain tactics can effectively mitigate the impact of misinformation
and that debunking can work in certain situations, preemptive measures that either prevent people from
being exposed to misinformation in the first place or allow them to identify and dismiss misinformation when
they encounter it could be the more effective approach. For example, communication science indicates
that inoculating people against misinformation by warning them about potential misinformation exposure
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COVID-19 Vaccination Communication
and preemptively refuting a “weak” version of the misinformation could make people more psychologically
resistant to misinformation.40
Importantly, the COVID-19 pandemic is having a disproportionate impact on people who already experience
disadvantage by virtue of their race, ethnicity, and socioeconomic conditions. Research shows that racial and
ethnic minorities, in addition to having less access to health care, are more likely to be infected and have poor
outcomes after infection with COVID‑19, such as being four to five times more likely to be hospitalized.44,45
Some communities of color also have historically justified distrust of the medical system, which requires careful
attention and understanding. Transparent and effective communication must acknowledge and address this
interplay between population-specific needs and motivations, vaccine allocation and distribution, and the
current and historical context driving hesitancy in various high-risk populations.
Another key consideration in audience segmentation, given that the initial availability of vaccines is likely to be
limited, is alignment with the vaccine rollout process developed by the federal, state and local governments.46,47
Certain factors—such as risk for acquiring infection, risk for severe morbidity and mortality if infected, and
potential to transmit infection to others—will determine an individual’s vaccine access over time. When
limited doses of the vaccine are available, individuals working in health care settings will be the first to
be eligible for vaccination, followed by those at highest risk for poor outcomes, such as those with high-
risk comorbidities and individuals 65 years of age or older. Other populations of focus include those who
perform the essential functions of society other than health care (e.g., public safety, food supply chain, school
and daycare personnel); those at increased risk of acquiring COVID-19, such as those living or working in
congregate settings; and those with limited access to health care, such as rural communities and individuals
experiencing homelessness. The initial response to vaccine rollout (e.g., rate of uptake, expressed hesitancies
and concerns, any purported serious adverse events) will have a substantial impact on subsequent vaccination
in later groups. Therefore, it is imperative that vaccination communication efforts that can rapidly address
emerging concerns are in place for the first groups who are allocated to receive the vaccines.
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COVID-19 Vaccination Communication
Important population-specific considerations and concerns could contribute to lower vaccine confidence,
and communication strategies must be mindful of these issues to be effective. The sections below highlight
a sample of specific populations to consider. Note that this is not a comprehensive list but is intended to
illustrate a range of communication considerations based on unique population attributes and contexts.
Additionally, communication efforts must account for intersectionality across age, health status, race, and
other sociodemographic factors.
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COVID-19 Vaccination Communication
2.3 Non-health-care essential workers
Those playing a critical role in keeping society’s essential functions running and who cannot effectively socially
distance in the workplace are likely to be among the groups that receive priority vaccine allocation. These
essential workers include emergency and public safety personnel, food packaging and distribution workers,
teachers and school staff, and childcare providers. It is important to note that many essential workers are
also from groups that have been historically marginalized in society. Many service-industry jobs, for example,
are low wage and filled by people of color or new immigrants. Compassionately addressing their concerns
and priorities in communication about the vaccines will require an assessment of unique and critical factors
contributing to essential workers’ vaccine hesitancy, such as fear about being used as vaccine “guinea
pigs” resulting from distrust in the government or pharmaceutical companies. Although the reasons for early
vaccine allocation to this group are scientifically sound and well justified from a public health perspective,
there is the potential for widening disparities and suboptimal uptake if the perception is that low-paid and
often historically undervalued workers are being asked to take the risks of early vaccination. Therefore,
communication strategies should address this groups’ information needs to foster vaccine confidence while
preserving their decisionmaking autonomy.
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COVID-19 Vaccination Communication
insurance, long distances from vaccine administration sites, lack of childcare to allow them to take the time to
get vaccinated) while also lacking access to accurate information regarding COVID-19 vaccines (e.g., due to
limited Wi-Fi access or literacy challenges). Messages targeting these populations need to directly address
actual and perceived barriers, facilitate information access, and foster self-efficacy to take the
actions needed to get vaccinated.
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COVID-19 Vaccination Communication
3. Create and disseminate targeted and tailored
messages for the intended audience
For any identified goal and target audience, effective message development should align with the community’s
values and preferences and come from trusted sources, which might not include government agencies.
Because communication needs to persist over
time, vaccination communication strategies
Targeted and tailored
must also adapt to evolving information about
vaccination messages
the vaccines (e.g., newly published trial results)
and guard against information fatigue. The
following evidence-informed strategies have • Partner with a wide range of trusted
information sources: Co-design and co-
demonstrated success in other health behavior
disseminate messages with community
domains and can inform the development and partners.
dissemination of COVID-19 vaccine messages.
• Establish COVID-19 vaccination as an
accepted social norm (e.g., through “I
got the shot” stickers or sharing vaccine
3.1 Identify and partner intention through social media).
with trusted COVID-19 • Consider behavioral nudges for vaccination
vaccine messengers (e.g., favoring opt-out vs. opt-in, making
receiving vaccination convenient) while
Successful partnerships between governmental
respecting decision autonomy.
agencies and trusted community entities
and leaders as “messengers” can facilitate • Avoid language of requirement and
mandate.
tailored communication and enhance message
acceptance in different communities. The • Convey a message of unity and
partnerships should be sustained throughout bipartisanship in vaccination, and avoid
language that sows divisions or conveys
the communication planning process, rather
judgment.
than simply asking messengers to “lend their
microphones.” In fact, co-creation and co- • Ensure that all messages are accurate,
transparent, and truthful; avoid exaggerating
dissemination of key messages and delivery the benefits or minimizing the risks of
formats between public health agencies and vaccination; be clear that the vaccine is not
these trusted messengers is more likely to an instant fix or a “silver bullet.”
ensure that the communication strategies align • Incorporate the values and beliefs of the
with the values and priorities of the communities target audience, such as protecting one’s
of focus. Moreover, while rapidly activating community or caring for those at higher risk.
existing and new partnerships are required by • Induce positive emotions and avoid
the urgency of the pandemic crisis, public health communication (including nonverbal) that
communication needs will continue into the heightens negative emotions, such as fear
future, well past the current pandemic. It would or shame.
be a significant lost opportunity if current COVID- • Use simple graphics, images, personal
19-related efforts do not expand the base of experience narratives, “edutainment”, or
public health messengers and build stronger short videos to creatively distill vaccine
and more sustainable partnerships—that
information.
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COVID-19 Vaccination Communication
endure beyond the current health crisis—between governmental agencies and communities hit hardest by
the pandemic. The following strategies can inform effective partnerships with trusted messengers.
First, it is critical to identify the most trusted sources of information for the population of focus,
including individuals, organizations, and media outlets/platforms (e.g., online influencers, journalists, religious
leaders, community organizations, and celebrities and other public figures). Building partnerships with
entities that have established trusted relationships with communities can help rapidly activate and mobilize
a community and dispel concerns or distrust. Examples of potential messengers include tribal leaders,
historically Black colleges and university (HBCU) leaders, sororities and fraternities, the U.S. Department of
Agriculture’s Cooperative Extension Service, and multidenominational religious leaders and organizations.
Relationships with these entities need to be bi-directional, and public health agencies must proactively listen
to community concerns.
Even when partnering with trusted brokers of information, careful consideration of how activities might be
perceived by the target community is important. As an example, some HBCU leaders recently volunteered in
COVID-19 vaccine clinical trials to counteract the distrust that they worried was putting communities of color
in greater risks for COVID-19. They received opposition from their communities for their involvement in the
trials, however, because of the ingrained hesitancy to trust medical systems based on the history of unethical
medical experimentation on African Americans.60 This situation demonstrates that building partnerships with
trusted sources, such as HBCU leaders, may not be sufficient as a standalone strategy to overcome distrust.
Moreover, one group’s trusted source may, in fact, be considered very untrustworthy by another group
(e.g., scientists, political leaders), therefore partnership efforts should be carefully considered to ensure that
attempts to increase trust in one community do not undermine trust in another.
Vaccine communication partnerships should include diverse sectors and stakeholders. Collaborations with
health care organizations and pharmacies are critical, and these partnerships must go beyond front-line
caregivers, such as doctors and nurses, and include organizations like Federally Qualified Health Centers
and state and local public health departments and jurisdictions, as well as health care extenders, such
as pharmacists and community health workers. Moreover, partnerships across different government
communicators, scientists, and journalists will inform how the science of vaccines is conveyed.
Broadening the links between journalists and the scientific, pharmaceutical, and public health communities
will ensure that as the situation evolves, new information is communicated in a truthful manner that avoids
inflaming divisions or furthering mistrust and distrust in the health sciences. In addition to organizations, public
figures and online influencers will also be important partners in communicating to audiences who are less
likely to attend to information disseminated by government, traditional media, or scientists. Examples include
celebrities, such as actors, musicians, athletes, and social media influencers. These types of communicators
can improve vaccine attitudes and acceptance by conveying messages that resonate with the target audience
in both style and substance.61
As part of the partnership-building process, it is important to acknowledge that although COVID-19 efforts
in the United States have been hampered by politicization, vaccine confidence could be enhanced through
unified, bipartisan communication of consistent messages across diverse communities and information
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COVID-19 Vaccination Communication
silos. Indeed, COVID-19 vaccine messages should aim to promote unity and apolitical decisionmaking
regarding vaccination. Prior politicization may need to be acknowledged and addressed in some cases,
but moving forward, ideological divisions should be de-emphasized in all communication efforts to create a
message focused on unity and collective benefit. An example of promoting unity around vaccination
might include having politicians from across the political spectrum jointly signal their vaccine confidence in a
public health campaign.
As part of societal reinforcement for getting vaccinated, communication must acknowledge that herd immunity
will not be reached until a sizeable majority of the population is vaccinated, with estimates that anywhere
between 75 and 90 percent coverage likely will be needed, depending on vaccine efficacy.62,63 Communication
may stress that the sooner most people complete their vaccinations, the sooner we will be able to return to
normal social and economic activities. Messages, however, should also emphasize that, at least during initial
phases of the rollout, a COVID-19 vaccine is not a “magic bullet” that will immediately allow a full return to
social functioning. Instead, it is important that messaging emphasize that until society is widely vaccinated, the
need continues for both preventive behaviors—such as mask wearing, hand washing, and social distancing—
and public health measures, such as contact tracing and widely accessible testing.
Another example of a communication strategy to influence social norms would be a campaign that encourages
individuals who chose to get vaccinated to share their vaccination experience with others in their social network
(e.g., verbally, through text messages, on social media) and encourage their networks to get vaccinated if
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they have not done so already. Visual aids—such as thermometers, heatmaps, or dashboards—can also be
used to reinforce social norms by tracking increasing vaccination uptake at the state or local levels. Finally,
publicizing the vaccination of celebrities and public figures, including bipartisan political leaders, could have
a powerful impact on normalizing vaccination across diverse segments of society.
Similarly, providers, health care systems, and pharmacies may also leverage electronic patient portals
(e.g., by sending messages to patients prior to a medical appointment or prior to a prescription refill) to
encourage individuals to vaccinate. These messages could provide information on the vaccine’s availability,
logistics of where and how to receive the vaccine, and electronic reminders about receiving the second
shot. Social media platforms could also be used to nudge people toward vaccination against COVID-19;
in addition to providing information on where and how to receive a vaccine, these sites could be used to
offer opportunities for individuals to publicly commit to vaccinate. Such public commitment increases the
chances that a person will follow through with the desired behavior68 and could encourage others in their
social networks to do the same.
Additional strategies to encourage vaccine uptake could include competition, gamification, and incentives
related to vaccination behaviors. Incentives, particularly, are increasingly seen as an important tool for health
behavior change, and research suggests that appropriately designed incentives can be effective for some
behaviors.69 It is important to consider carefully how to message incentives, however, so that they promote
autonomy and motivation for getting vaccinated.70 Otherwise, incentives might encourage some to get
vaccinated, while for others, an incentive may inadvertently signal a risk (e.g., “if they are paying me to receive
a vaccine, there must be something wrong with it”), which could undermine their motivation to be vaccinated.
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target audience group and then embedding such values into vaccination messages. For example, some
messages might invoke a personal leadership role as a protector of the community (be a hero/shero),
whereas other messages might build on desires to resume certain activities (get back to work/school) or
frame vaccination as a way to enact social justice, equity, or altruism (protect vulnerable people or those
at higher risk). Messaging such as “Protect your family, if not yourself” can help reframe the motivation for
getting vaccinated from decreasing personal risk to helping others (e.g., older parents, teachers, those who
are immunocompromised), thus preventing message reactance (resulting from the perception that choices
are being taken away).
Vaccination communication should also avoid language such as “requirement” or “mandate” as this
type of directive and authoritative language can generate further resistance and be perceived as restricting
individual choice. Relatedly, vaccination messaging should consider emotional valence. Messages and
images that heighten negative emotions, such as fear or shame, may induce avoidance behavior,
and such emotional over-amplification should generally be avoided.73 Conversely, messages that evoke
positive emotions—such as happiness, hope, and a sense of self-worth for engaging in the vaccination
behavior—may effectively promote vaccine confidence. Considering emotions, neither the message text nor
the accompanying imagery should elicit fear or dread, but they should instead convey hope and well-being
associated with getting vaccinated, including taking action to protect one’s loved ones.
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Conclusion
This report outlines foundational considerations for health communication activities and expands on those
considerations with evidence-informed strategic communication recommendations specific to fostering
COVID-19 vaccine confidence across diverse audience segments. To achieve herd immunity, a high rate of
COVID-19 vaccine uptake in the population is crucial, and this will require timely and effective communication
to address the public’s concerns. Evidence-informed communication is a critical component of the complex
puzzle that will help end the COVID-19 pandemic. In this way, communication about COVID-19 vaccines
can benefit from drawing on the extant social and behavioral science literature about successful strategies
to influence health decisions and behaviors. Communication strategies, however, would also benefit from
ongoing evaluation so that they can efficiently adapt to real-time changes in COVID-19 vaccine research, as
well as the evolving public health communication context. No single communication approach or message
can address all COVID-19 information needs, perspectives, and concerns over time, but careful consideration
and continuous reevaluation of communication efforts will help reduce vaccine hesitancy, enhance vaccine
confidence, and bolster uptake.
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