Kimberly Myers, Ph.D., is a principal at Deloitte Consulting LLP; Jitinder Kohli is a managing director at Deloitte.
While the coronavirus pandemic casts a spotlight on vaccine hesitancy and health inequity, it also offers potential lessons in how the country might address vaccine adoption challenges in the future.
Vaccination rates vary dramatically across states, due largely to concerns around trust and perceived risk. Some fear that the vaccine could harm them, driven by the speed of vaccines to market, misinformation, or lack of vaccine literacy. Others simply disbelieve that the virus is a real threat. Some hold religious or cultural objections. Longstanding mistrust of the health system is another prevalent reason. And for many communities, it’s a matter of inequitable access – not currently in terms of vaccine availability, but rather the disproportionate obstacles people must overcome to get vaccinated (such as transportation, time off work, digital access, etc.).
The experience of the COVID-19 vaccine roll-out reveals that the health care community can’t take a “one-size-fits-all” approach to outreach and engagement. We should adopt empathetic, tailored, community-centered strategies that address the true drivers of hesitancy and inequity across populations. In this article we offer five steps derived from lessons learned during the pandemic that the health care community could use in addressing future vaccine challenges.
Establishing trust Successful outreach efforts can start with an understanding of why people don’t get immunized in the first place, while respecting their concerns, and meeting them where they are. Not everyone is in the same place mentally, philosophically, or emotionally along the vaccine-acceptance continuum. It’s critical to understand the reasons people have for being skeptical, and then address those concerns with humility and an understanding of the issues they hold closely.
Lack of trust in the healthcare system or providers is also often cited as a key driver of vaccine hesitancy. While there are many reasons, much of the mistrust stems from bad experiences with health care providers and systemic inequities and injustices in the health care system. This skepticism can directly cloud peoples’ perception of vaccine efficacy and whether they can trust the health care system to work in their best interest.
For example, in a Deloitte Center for Health Solutions survey of 525 racially and ethnically diverse people, 55 percent of participants said they were mistreated or had a bad experience which made them lose trust in their health care provider, with more than one-third saying the experience caused them to skip or avoid care.
Hiring and training diverse, empathetic health care professionals and health care system leaders can help overcome these barriers to trust. Academic research shows that racial concordance is an effective strategy for vaccine acceptance. This idea was also borne out in the same Deloitte study, which found that 70 percent of people said it is important to see a health care provider who looks like them, talks like them, is from their community, or has shared life experiences.
Establish community-level support A second key component is to engage known community leaders and institutions early and often. Nearly all communities have had bad experiences that undermined their trust in their health care experts. The pandemic has intensified mistrust in the system for some, which has contributed to vaccine reticence.
A key is to build vaccine confidence at the community level by partnering with respected, trusted leaders and organizations that can influence the conversations around vaccines. The options are many – churches and religious organizations, educational institutions, community centers, local employers, fraternities and sororities, and beauty and barber shops. These community resources know how to tailor the messaging, conversations, and interventions that can be effective in establishing confidence.
Government and health care professionals could also leverage local community organizations to help build a more robust health infrastructure for outreach and engagement. For example, Deloitte worked with a large teaching hospital to provide stand up vaccination clinics aimed at lower-income and mobility-challenged residents to improve vaccination rates. Project learnings were co-published in a playbook to help enable other organizations to leverage and build upon project insights, especially as they related to advancing health equity.
Another key barrier to vaccine uptake involves access and logistics for certain communities. In the U.S., COVID-19 vaccine inventory is now abundant and available to anyone who seeks immunization. However, the common struggles of life often get in the way. The external drivers of getting health treatment – such as lack of transportation, incompatible work hours, appointment scheduling conflicts, or having lower digital literacy – are significant challenges for many underserved communities.
As a third step, health care providers can employ a number of strategies to help close these access gaps. Extending working hours for vaccine clinics, as well as for familiar family physicians, can be an effective first step. Government and healthcare professionals should also consider using simple tech outreach strategies when appropriate to counter access obstacles.
The University of Pennsylvania recently partnered with a community hospital and local leaders to establish three vaccination sites aimed at predominantly underserved Black communities. They achieved a nearly 85-percent vaccination rate with Black community members thanks to their understanding of the structural barriers the community faced, and designing a low-tech vaccination sign-up process in response.
Use data to build tailored strategies
A fourth key step is to use data to help public health agencies build highly tailored strategies for vaccine outreach and education. With so many varied communities in the U.S., data can help tailor the optimal vaccine messaging for each community from the sources they trust, using behavioral and decision science. For even greater impact, these messages can be paired with data-driven incentives to encourage getting immunized.
Public health agencies could also utilize data in a strategy that Deloitte calls precision engagement to more precisely target outreach and messages. Precision engagement involves the use of analytics to map risk levels by region, community, and neighborhood. This type of analysis can create a tailored behavior-change strategy based on needs and resources instead of a one-size-fits-all approach.
Research shows tailored solutions are best informed by engagement with communities and local organizations. Other data that could be useful in developing tailored outreach strategies are the demographics of a county or political leaning of that county and which news channels the local population follows. Data from the CMU Delphi/Facebook COVID-19 Trends and Impact Survey (CTIS), which is updated daily, can provide additional insight into perceived vaccination barriers for certain populations. The COVID-19 Vaccine Coverage Index (CVAC) can also help leaders identify which barriers each U.S. community is likely to face in achieving high vaccine coverage by honing in on data down to the county level in order to develop targeted solutions specific to each community.
All of these tools can help inform healthcare leaders on strategies to meet people where they are and address each specific barrier to getting vaccinated. The pandemic showed us how beneficial regular updates and detailed data on community level vaccine and infection rates can have on creating an informed public. In the future, public health should look to collect regular data on vaccine coverage as it successfully did in the COVID-19 case.
It is important to understand the story the data is telling us about who isn’t getting vaccinated, where they are, and the barriers they are facing. The data can help inform leaders where they should put their energy and effort to reach the communities who need it the most and move the needle in the right direction in terms of vaccination rates. The ability to use data to help understand which populations aren’t getting vaccinated, combined with the details of where people live, can be very powerful.
Monitor and tackle misinformation aggressively
Lastly, it’s essential to understand the role of misinformation in anti-vaccine efforts, and then develop strategies to actively monitor and address misinformation at its source.
For example, data revealed that many actors including certain foreign nations are actively seeking to persuade Americans that vaccinations are dangerous. The U.S. should engage very directly in building vaccine confidence in social media and other communication channels that spread misinformation. Real opportunities are emerging for organizations to proactively enter into the dialogue happening on social media and change the conversation. For example, “honeypot” groups are emerging on social media platforms, especially Facebook. Inside these moderated groups, people who believe in vaccine and COVID-19 conspiracy theories are allowed to post false and misleading articles, and volunteers will debunk myths and challenge people in comments under posts and using private messages.
Leaders should leverage the full range of public health communications, messages, influencers, and social channels when engaging with diverse populations on vaccine education. The messages should be customized and based in trusted data.
Final thoughts What we’ve learned from the COVID-19 pandemic is that vaccine hesitancy cannot be effectively addressed with broad scale approaches to outreach, education and engagement. The healthcare community should develop approaches that address true drivers of hesitancy and inequity across specific population segments, based on listening, empathy and ultimately trust, in conjunction with extensive use of data. Understanding each group's motivations, concerns, and the potential opportunity to help them can ultimately shift these populations from hesitation to immunization.
