To date, the COVID-19 vaccination effort has been largely successful for the United States; however, vaccine hesitancy is a major factor preventing the nation from reaching herd immunity. The declining vaccination rate poses complications to the Biden administration’s current goal for 70% of the U.S. population to receive their first dose by July 4th.
Since the first vaccine was administered in late December, 61.5% of all adults have gotten their first shots and 49.8% of all adults are fully vaccinated (as of May 24th). Vaccination rates reached their peak on April 13th, when the seven-day average of administered doses was 3.38 million. However, since then the daily rate has plummeted. This drop off in vaccination rates coincides with the Food and Drug Administration (FDA)’s announcement recommending a pause in the administration of the Johnson and Johnson vaccine. On May 23rd, a little over one month later, the daily vaccination rate sits at a seven-day average of 1.83 million.
This decline in vaccination rate has been attributed to a few factors, such as the decreased manufacturing and distribution of the Johnson and Johnson vaccine and the inevitable slowdown of vaccination rates as more and more people received their shots. However, one of the main reasons the vaccination rate is declining is that many individuals refuse to get vaccinated, even when they have the opportunity to do so. To combat the danger posed by vaccine hesitancy, states must draw upon best practices in developing public health messaging to incentivize vaccine hesitant populations to get inoculated.
The COVID-19 pandemic brought the issue of vaccine hesitancy—defined by the World Health Organization (WHO) as a “delay in acceptance or refusal of vaccines despite availability of vaccination services”—to the forefront of public attention. According to the WHO, reasons for vaccine hesitancy fall into three categories:
- Issues of confidence (do not trust vaccine or provider)
- Complacency (do not perceive a need for a vaccine; do not value the vaccine)
- Convenience (access)
Before 2020, vaccine hesitancy occurred within a subsection of the population, most often manifesting as parents’ refusal to allow their child to be vaccinated. Many studies have been published analyzing vaccine hesitancy among this population in attempt to develop methods of instilling and maintaining public confidence in vaccines. These strategies include developing information technology to provide tailored immunization education materials that address each parent’s unique needs; identifying immunization champions that connect with parents; and emphasizing benefits of the vaccine to mitigate parents’ concerns. However, despite the presence of existing research and recommendations, these studies highlight one common theme: there has simply not been enough research on the topic to formulate evidence-based interventions for vaccine hesitancy.
The COVID-19 pandemic has provided an opportunity for the entire population to grapple with the same vaccine acceptance questions already prevalent for years among a select subsection of the population. A UC San Diego Global Health Initiative-funded study observed a decrease in peoples’ intentions of getting a COVID-19 vaccine as the vaccines became available to the general public, despite the elevated risks that the virus poses. Behavioral studies such as this one, coupled with the declining vaccination rate, confirm that negative attitudes towards vaccination are still present even during a global pandemic. The presence of a vaccine hesitant population has complicated efforts to achieve herd immunity and mitigate the adverse effects of the pandemic, with mixed public health messaging exacerbating the problem rather than resolving it. However, the current lack of sufficient evidence-based interventions means that this problem has no easy solution.
Brief History of Public Health Messaging
Throughout its history, public health messaging has struggled with scope, goals and accomplishments. Health messaging is defined as the transmission of “persuasive messages that are designed to change any behavior within the realm of health care”. Traditionally, public health messaging has focused on individual behaviors and responsibility, and has largely been affected by the environments in which these messages are delivered.
One major disadvantage facing public health entities as they create and deliver messaging is the lack of a strong evidence base from which to create outreach campaigns, which owes to the limited amount of funding available for research and difficulty in determining casualty between messaging and results. Before the COVID-19 pandemic, public messaging focused primarily on mitigating factors, such as obesity and cigarette usage, that were linked to negative health outcomes. Such messaging emphasized personal responsibility, encouraging individuals to make lifestyle choices and changes as a way of lessening the potential impact of these health determinants. 
On the one hand, focusing messaging on individual choices and behaviors had the benefit of giving people a clear idea of how to improve their health. On the other, it had the adverse effect of spotlighting individual decisions as the only way to improve public health outcomes. According to a 2010 study on the topic, people were likely to view individual behaviors as strong determinants of public health, but less likely to view public policy in the same manner. Additionally, public health messaging with a focus on individual behavior largely excludes information explaining social determinants of health, making people less likely to credit the roles that social determinants play in improving health outcomes.
In an analysis of existing public health communication research, Sarah Gollust, an assistant professor at the University of Minnesota’s School of Public Health, synthesized three important lessons regarding public health messaging:
- Communication initiatives solely designed to increase social determinant awareness may not be sufficient to effect change.
- Communication must reflect values that resonate with people.
- It is important to recognize challenges from groups opposed to the population health messages.
Using these principles as a guide can provide insight into why the challenges surrounding the COVID-19 vaccination effort in the U.S. have shifted from grappling with vaccine supply shortages to addressing a lack of vaccine demand.
Public Health Messaging During the COVID-19 Pandemic
Throughout the pandemic, public health messaging from the Centers for Disease Control and Prevention (CDC) has consistently been more conservative than the reality of the situation has warranted, which in turn contributed to issues surrounding the continued inoculation of the American population from the virus. For example, many studies in the past year acknowledged that the threat of COVID-19 came from aerosol transmission rather than particle transmission on surfaces, but the CDC only updated its guidance to reflect that in May 2021. Additionally, the CDC was slow to issue guidance concerning which activities are safe from viral transmission. The agency stated that outdoor activities have a significantly lower risk of viral transmission compared to indoor activities—citing that “less than 10 percent of documented transmission in many studies has occurred outdoors” when the actual percentage of COVID-19 cases with outdoor transmission is below 1%. This resulted in a delay in CDC guidance on acceptable behaviors for outdoors activities versus indoors activities.
The CDC’s conservative approach extended to the vaccination process as well. Once vaccines were available to the American population, the CDC did not immediately issue updated guidance describing which activities were safe to do once vaccinated, which could have assisted in incentivizing shots for the vaccine hesitant. It was not until mid-May that the agency announced that mask wearing was no longer necessary for those who were fully vaccinated, but in many people’s minds, the perceived negative effects of the vaccines (drawn largely from misinformation spread by unreliable sources) outweighed the benefits they provided. Overall, this conservative approach from the CDC lessened the U.S. population’s trust in the agency and made them less likely to listen to its guidance surrounding the need to get vaccinated.
The CDC’s public messaging process reflects Gollust’s three lessons of public health messaging to varying degrees of success. The agency designed its communication initiatives to increase awareness of the COVID-19 pandemic’s social determinants, but could have done a better job of reflecting values that resonate with people, or the challenges from groups opposed to the public health process. Stronger support of the CDC’s messaging from the U.S. government throughout the pandemic might also have bolstered the public’s acceptance of these ideals, as demonstrated by the positive response to public health interventions in countries like Canada, Australia, and Japan, whose messaging featured a coordinated response between health agencies and the government. In America, many people have responded negatively to the CDC’s guidance or rejected it, focusing more on personal beliefs, which has helped foster a culture of vaccine hesitancy among certain populations.
Successful Strategies to Combat Vaccine Hesitancy
Given the CDC’s messaging shortfalls, states face the question of how they can improve upon this messaging to convince those who are skeptical to get the COVID-19 vaccine. To do this, states must figure out ways to incentivize vaccinations beyond simply explaining their public health benefits.
Several states have already devised creative methods of doing so:
- West Virginia, an early leader in the COVID-19 vaccination process, offers each person aged 16-35 a $100 savings bond if they get their shots.
- Ohio enrolls anyone who has been vaccinated into a lottery for a one-million-dollar cash prize, and a full ride to a four-year public university for those aged 12-17 who have been vaccinated.
- Connecticut and New York provide free drinks and food at participating restaurants for people who get the vaccine.
While these tactics may seem unrelated to larger population health goals, they provide an incentive for individuals who might not otherwise be convinced by goals and messaging related to public health benefits.
Additionally, some states and companies created ad campaigns highlighting the benefits of vaccination, utilizing trusted and familiar messengers to help people feel more comfortable with the idea of vaccination:
- Pennsylvania enlisted the support of one of its local sports teams: the Philadelphia Flyers became the first NHL team to lead a COVID-19 vaccination ad campaign, which involved filming a PSA and making a monetary donation to the Black Doctors COVID-19 Consortium.
- Florida leveraged the support of its tourism industry by partnering with Disney and Universal to promote its “I Got the Shot” campaign.
- Walgreens partnered with singer John Legend to launch an ad campaign entitled “This is Our Shot” to connect with individuals and communities, wherein Legend explains what getting vaccinated means to him.
- Magnolia Health, a subsidiary of Centene Corporation in Mississippi, collaborated with the Pro Football Hall of Fame to release a vaccination PSA from NFL legend Deuce McAllister, who played for the University of Mississippi football team.
In all these examples, states and companies used brands and celebrity voices as conduits for their public health message instead of relying on government officials alone to deliver it.
Lastly, many states made the decision to link their reopening process to state vaccination rates. States such as Michigan, Maryland, Oregon and Vermont set vaccination benchmarks for their population that, when surpassed, will allow state officials to lift capacity restrictions and mask mandates. This approach has the dual effect of incentivizing vaccination and providing consistency and transparency in the metrics used to make policy decisions, which are both important strategies in persuading people to get vaccinated and making them feel that it is worthwhile to do so.
Improving Messaging in Future Public Health Emergencies
In the wake of recent CDC guidance giving approval for fully vaccinated individuals to eliminate mask wearing and social distancing, many states have dropped their mandates for doing so. However, this guidance does not mean COVID-19 is no longer a threat; the vaccination effort and its surrounding messaging are still crucial to ensuring the country reaches herd immunity and the case count continues to decrease.
As a result of the COVID-19 pandemic, the United States and the world at large will be more prepared for future public health emergencies, with scientific advances in vaccine development technology and a better understanding of which public health measures work to mitigate the spread of any airborne virus. However, there are still improvements to be made in designing government messaging to effectively combat issues of hesitance to follow public health measures and get vaccinated. The current public health emergency showed the U.S.’s approach to this type of messaging to be an inconsistent and sometimes ineffective effort.
In the future, governments and public health officials in the U.S. should focus more on incentivizing adherence to public health measures and participation in large scale public health campaigns. States and agencies should take a step back and let trusted voices deliver their messages for them. Lastly, both state and federal agencies should focus on ensuring consistency and transparency in the messaging and governing process to improve public buy-in. As the COVID-19 pandemic has demonstrated, securing the confidence and trust of the public will be an important part of any future public health emergency response.