A flashing sign on Court Street in Athens, Ohio, reported the number of active covid-19 cases in the community on Dec. 4.
In Philadelphia, public health officials think block captains may be more effective than football stars in persuading people to get coronavirus vaccines.
Researchers in the Navajo Nation anticipate that directives about the shots will have to be reworded to resonate with Native people.
And in Atlanta, where a federally funded project has been working with community leaders to increase minority participation in clinical trials, physicians have a lesson to learn in how to talk to patients about vaccines.
Memo to docs? More empathy. Less authority.
These messaging strategies are aimed at winning over vaccine fence-sitters in much the way political campaigns target would-be voters. But in the life-or-death battle against the coronavirus, as much as 70 percent of the population must roll up their sleeves in the next few months to achieve herd immunity and stop the virus’s spread. And, unlike well-oiled political machines, public health officials say they are having to quickly rethink communications strategies that have long been hampered by a lack of funding. At this politically charged moment, they also face the formidable obstacles of introducing a new product to people who distrust science and are receiving competing narratives from anti-vaccination campaigns, which were seeding doubt in coronavirus shots before they were even developed.
“The old approach to public health communications was to come to a least-common denominator and repeat, repeat, repeat,” said Christopher Graves, founder of the Ogilvy Center for Behavioral Science at Ogilvy Consulting, who has been leading workshops on the behavioral science of health communications with a focus on vaccine hesitancy for the World Health Organization and UNICEF in addition to a major vaccine maker. “When it comes to vaccine hesitancy, it is more like personalized medicine,” he said, “more customized to specific worldviews and cultural filters.”
A safe, effective and widely deployed vaccine remains the best hope of conquering the virus, which continues to ravage the world. In the United States, where non-pharmaceutical interventions such as masks and social distancing have faced widespread resistance, more than 15 million people have been infected and more than 291,000 have died. The Food and Drug Administration is expected to authorize the vaccine made by pharmaceutical giant Pfizer and its German partner, BioNTech, any day, after which hospitals could receive supplies within 24 hours.
But although vaccine development has been an astounding success, far less money and attention have been focused on getting people vaccinated, particularly after the initial tranche of health-care workers.
“It’s all about putting the public back in public health,” said John Brownstein, chief innovation officer at Boston Children’s Hospital, who runs Vaccine Finder, an online service that helps people locate providers of flu shots and other immunizations. “You want to build engagement. If people feel they are forced, you start getting resistance.”
Some public service announcements have been released on YouTube as well as on radio, and federal health officials plan to roll out a more extensive campaign to win confidence. But the hurdles are considerable. Gallup found that willingness to take a vaccine decreased from 61 percent in August to 50 percent in September before rising to 58 percent in late October and early November.
Anecdotal reports suggest that people’s worries could be even more profound. Brownstein, who tracked online response to a TV appearance, said he was “blown away” by the number of people expressing concern that the vaccines have been rushed into production and may therefore be unsafe, despite the expert scrutiny they have been under.
“We need to be doing everything we can to build an Operation Warp Speed for vaccine communication,” he said. “The communication needs to match everything else.”
The signs of reluctance came early, said Sean O’Leary, a specialist in vaccine-preventable diseases at Children’s Hospital Colorado, who said his colleagues began creating focus groups after childhood vaccination rates dropped off in March, hitting minority communities hard. They did so with an eye to the arrival of a coronavirus vaccine.
“We have specifically enlisted physicians and medical leaders of color to work with those communities, to have a trusted person in a health-care role,” he said.
News that coronavirus vaccines appear close to receiving emergency authorization has prompted prominent gestures of support: Former presidents from both political parties have promised to be vaccinated on camera, much in the way that Elvis Presley bared his upper arm in 1956 to receive a polio shot.
But many local health departments say that overcoming fears and building engagement depends on understanding far more intimate neighborhood networks and providing people with role models they may spot on the street, rather than just on TV.
“They are people where someone will say, ‘I know this guy. I’ve seen them on the block,’ ” said James Garrow, communications director for the Philadelphia Department of Public Health. “They may have 20,000 followers on Instagram. And they’ll be different in West Philly versus North Philly.”
Rupali Limaye, associate director for the Institute for Vaccine Safety at the Johns Hopkins Bloomberg School of Public Health, who has worked alongside the Baltimore City Health Department as it partnered with pastors and musical artists, looks ahead to leveraging the doctors’ experience when they describe their own vaccinations, side effects and all.
“To me, that is being transparent,” Limaye said.
A particular challenge with the coronavirus vaccine is not only targeting communities with appropriate messages but recognizing that, unlike with a measles or flu shot, the messages will have to shift in coming months.
“It’s going to be changing in terms of the vaccine landscape, in terms of the actual science and vaccines and how the public is responding,” said Mallory Ellingson, whose research at the Yale School of Medicine focuses on improving vaccine communication.
All that is complicated by anti-vaccination groups that saw the potential to seed distrust before a vaccine even existed.
Although public health has traditionally relied heavily on the voice of authority — with experts such as Anthony S. Fauci, director of the National Institute of Allergy and Infectious Diseases, making their case — vaccine opponents use ordinary citizens to tell personal tales, falsely asserting that vaccines damaged family members and creating what researchers call an “asymmetry of passion.”
“They are doing a better job of putting out this content than pro-vaccine people,” said Renee DiResta, research manager at the Stanford Internet Observatory who tracks malign narratives across social networks and assists policymakers in their response.
Some have portrayed the pandemic as an engineered plot to mass vaccinate the planet, she said. Others view the outbreak as an opportunity to depict the coronavirus shots as “a rushed job that would show how risky and poorly tested vaccines are,” she said.
Public health officials are fighting back by emphasizing trustworthy messengers and transparency.
Tabia Henry Akintobi is the principal investigator in Georgia for a federally funded outreach program to ethnic and racial minority communities that have been disproportionately affected by the coronavirus pandemic.
Georgia is one of 11 states to share in a $12 million National Institutes of Health CEAL grant that Akintobi has been using to partner with community leaders, initially to encourage people to participate in clinical trials and now to focus on delivering vaccines.
A key lesson has been the need to identify and educate community messengers, but the timeline is suddenly very short.
“The time it takes to get people ready is being met with a hurry up,” Akintobi said. “It’s almost like two opposing forces.”
Robert A. Bednarczyk, a vaccine expert at Emory University’s Rollins School of Public Health, who collaborates with Akintobi, said community leaders are not the only ones in need of education about the vaccine.
“We spend a lot of time training medical students on the science behind vaccines,” he said. “We don’t spend a lot of time teaching them how to communicate effectively about this.”
The pandemic is forcing a new focus on the power of relatability that goes beyond the virus, he said, and the importance of advising people without patronizing them.
The need for cultural sensitivity can show up in tone and word choice, said Jessica Atwell, an assistant scientist in the department of international health at the Bloomberg School of Public Health.
Atwell, who is working with the Navajo Nation in Arizona, discovered during prior research on maternal health that Centers for Disease Control and Prevention directives had to be retooled to resonate with Native Americans.
Messages asking “Are YOU pregnant?” came across as criticism of an individual pregnancy, said Atwell, who found that Navajo women preferred more general messages, such as “Every mother needs to . . . ”
Such linguistic shifts can make an enormous difference, said Graves, the behavioral science expert at Ogilvy. So can using terms that reflect, rather than challenge, a person’s core beliefs and identity.
“If I were talking to somebody who is very communitarian and egalitarian, I would talk about protecting the vulnerable,” Graves said. “If I am talking to their opposites, I am talking about protecting jobs and the economy.”
Underlying these goals is a conundrum that bedevils public health. Its triumphs, including eradicating diseases such as smallpox and removing pollution from drinking water, are taken for granted.
“When something is nonexistent, it’s hard to convey the value of what made it nonexistent,” Graves said.
A customer walks past a sign indicating that a coronavirus vaccine is not yet available at a Walgreens drugstore in Long Beach, Calif., on Dec. 2.
Vaccines in particular have been their own worst enemy, eliminating the fear of diseases that made people clamor to be protected from them. It’s not clear whether fear of the coronavirus, which for many people is a mild or even asymptomatic illness, will encourage enough of them to get vaccinated to reach herd immunity.
“Everybody has an incentive to free ride,” said Erez Yoeli a research scientist at the Massachusetts Institute of Technology who specializes in motivating people to do good for others.
Hardcore vaccine opponents probably aren’t worth focusing on, said Katherine Milkman, a professor of operations, information and decisions at the University of Pennsylvania’s Wharton School, as they probably account for less than 2 percent of the population, although their reach through social media is more extensive.
Milkman, who co-directs the Behavior Change for Good Initiative, said strategies should be targeted instead at those who are persuadable — first to get them to agree to being vaccinated and then to roll up their sleeves.
She advocates “I got my vaccine” stickers to increase peer pressure. She is also expecting the results later this month of a major study with Walmart testing text messages to see which ones lead people to get flu shots, which should help in designing coronavirus messaging. Whatever emerges from that study, some key approaches should be adopted now.
“It’s critical that we reassure people about the convenience of getting the vaccine,” Milkman said. “Hassle factors like lines, paperwork and commuting time should ideally be minimized.”
The nonprofit Ad Council, which has been putting out mask-up and keep-a-distance messages for months, has turned its attention to a $50 million vaccine campaign that will use multiple platforms to try to convince Americans that shots are safe. It will focus on vaccine hesitancy and reaching communities of color that have been hard hit.
“We’re conducting extensive research to ensure that we have the right message and the right messenger for our key audiences, with a plan to have our first assets in market in early 2021,” Lisa Sherman, the Ad Council’s president, wrote in an email.
These initiatives are happening against a shifting political and social landscape that threatens to continue to erode confidence in public health measures in general and a vaccine in particular. Conservative state legislatures have sought to limit governors’ ability to impose public health restrictions, with successes in Michigan and Wisconsin. And the recent 5-4 Supreme Court ruling siding with religious groups in a dispute with New York Gov. Andrew M. Cuomo (D) about the state’s limits on the number of people who may attend services left Limaye concerned that it pits public health against clergy members — the very local leaders the Baltimore City Health Department has been seeking to engage as reliable messengers.
“How do we continue to work with religious leaders on our side?” she asked. “We need them.”
Ellingson of Yale lamented that in the race to make vaccines, messaging has taken a back seat.
“It needs to be something that happened six months ago,” she said. “We can’t change that.”
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