INCREASING VACCINE UPTAKE IN DIVERSE COMMUNITIES - A Working Guide for Health Care CEOs

 
INCREASING VACCINE UPTAKE IN DIVERSE COMMUNITIES - A Working Guide for Health Care CEOs
INCREASING
      VACCINE UPTAKE
      IN DIVERSE
      COMMUNITIES

      A Working Guide for
      Health Care CEOs
      MARCH 1, 2021

HEALTH EVOLUTION   |   Increasing Vaccine Uptake in Diverse Communities   1
INCREASING VACCINE UPTAKE IN DIVERSE COMMUNITIES - A Working Guide for Health Care CEOs
About this                        This working guide will be made available to the public as a PDF on a
                                  webpage with commenting functionality. New versions will be released to
Working Guide                     respond to feedback received and to the emergence of additional data and
                                  best practices.

The Roundtable                    This document was developed by Fellows on the Roundtable on Community
                                  Health and Advancing Health Equity, with support from Health Evolution staff
on Community                      and Benjamin Bolnick and with significant input from both the Work Group
Health and                        on Building Scalable Models and Community Partnerships to Address Social
                                  Determinants of Health and the Work Group on Leveraging Data to Improve
Advancing                         Health Equity. Co-Chairs for the Roundtable and Work Groups include:

Health Equity                     Mandy Cohen, MD, Secretary, North        Carrie Byington, EVP, University of
                                  Carolina Dept. of Health and Human       California Health;
                                  Services;
Please note that the views in                                              Laurie Zephyrin, MD, VP, Delivery
this document represent the       Pat Geraghty, President & CEO,           System Reform, The Commonwealth
                                  GuideWell & Florida Blue;                Fund;
collective views of the Fellows
and researchers and do not        Rod Hochman, MD, President &             Stephen Mette, CEO, University
represent the individual views    CEO, Providence;                         of Arkansas for Medical Sciences
of any specific Fellow or                                                  Medical Center;
                                  Wright Lassiter, III, President &
organization within the Forum     CEO, Henry Ford Health System;           Felicia Norwood, EVP & President,
or of Health Evolution.           Chair-Elect of AHA;                      Government Business Division,
                                                                           Anthem, Inc.
                                  Mark Smith, MD, Founding
                                  President & Former CEO, California
                                  Health Care Foundation;

                                  The Roundtable on Community Health and Advancing Health Equity supports
                                  partnerships between payer, provider and life sciences companies that can
                                  improve community health and advance health equity among racial groups
                                  and vulnerable populations. The goal of this Roundtable is to accelerate
                                  adoption of new models for improving the health of a community and
                                  promoting health equity for and among local populations.

About the                         The Health Evolution Forum is a collaboration among over 200 CEOs and
                                  other executives of payer, provider, and life science organizations and other
Health Evolution                  industry thought leaders designed to bring about near-term impact across
Forum                             the health care industry. The Forum is organized into Roundtables and Work
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Underwritten by

                                                         Insight. Innovation. Transformation.
INCREASING VACCINE UPTAKE IN DIVERSE COMMUNITIES - A Working Guide for Health Care CEOs
THE
            ISSUE                               Although data around vaccine
                                                distribution in America is sorely limited
                                                and scattered,1 one pattern is becoming
                                                increasingly clear – those who have
                                                been affected by COVID-19 the most are
                                                getting vaccinated the least.

            Based on early data from 26 states, Black and Hispanic Americans are getting
            vaccinated at approximately half and one-third the rate of white Americans
            respectively (see Figure 1 below).2,3 This is true even after controlling for
            the demographic makeup of health care workers, who were first in line to
            receive the vaccine.2 Meanwhile, Black, Indigenous, and (other) people of color
            (“BIPOC”) are contracting COVID-19 at nearly twice the rate, being hospitalized
            for COVID-19 at nearly four times the rate, and dying from COVID-19 at nearly
            three times the rate as white Americans (see Figure 2 below).4

                                                                          CONTENTS
                                                                          01 The Issue
                                                                          05 10 Steps
                                                                          06 Part I: Creating an Action Plan
                                                                          10 Part II: Increasing Confidence
                                                                          22 Part III: Increasing Accessibility
                                                                          26 Top Resources
                                                                          27 References
HEALTH EVOLUTION   |   Increasing Vaccine Uptake in Diverse Communities                                           1
INCREASING VACCINE UPTAKE IN DIVERSE COMMUNITIES - A Working Guide for Health Care CEOs
Figure 1. Vaccinations as a Share of Total Population by Race/Ethnicity3

        LOCATION               WHITE        BLACK       HISPANIC          RATIOS OF VACCINATION RATES
                                                                                 1.0x
       Total                                                                                    2.0x

       (26 states)               10%           5%           3%                                                   3.3x

                                                                                                                         4.0x
       Pennsylvania              8%            2%           2%                                                           4.0x

                                                                                                               3.2x
       North Dakota              19%           6%           7%                                          2.7x
                                                                                                           3.0x
       Arizona                   12%           4%           3%                                                           4.0x

                                                                                                           3.0x
       Wisconsin                 12%           4%           3%                                                           4.0x

                                                                                                       2.6x
       Indiana                   13%           5%           3%                                                                 4.3x

                               White-to-Black Vaccination Ratio               White-to-Hispanic Vaccination Ratio

       Based on data from KFF analysis. Vaccination data for Pennsylvania excludes Philadelphia.

        Figure 2. COVID-19 Cases, Hospitalizations, and Deaths, by Race/Ethnicity5

        Rate ratios compared to White, Non-Hispanic persons

                                                          CASES               HOSPITALIZATION                       DEATH

        American Indian or Alaska
        Native, Non-Hispanic persons
                                                            1.8x                        4.0x                            2.6x

        Asian, Non-Hispanic persons
                                                           0.6x                          1.2x                           1.1x

        Black or African American,
        Non-Hispanic persons
                                                            1.4x                        3.7x                            2.8x

        Hispanic or Latino persons
                                                            1.7x                        4.1x                            2.8x
        CDC, Nov. 2020

HEALTH EVOLUTION   |   Increasing Vaccine Uptake in Diverse Communities                                                               2
INCREASING VACCINE UPTAKE IN DIVERSE COMMUNITIES - A Working Guide for Health Care CEOs
Disparities in vaccine uptake stem from both lower confidence in and less access
                         to the COVID-19 vaccination. First, many individuals in diverse communities
                         are less confident than white Americans in the vaccine, with 43% of Black
                         adults and 37% of Hispanic adults stating they would “wait and see” how it is
                         working for others before getting it (see Figure 3 below).6, 7 Although the roots
                         of this low confidence vary by community and individual, it often stems from
                         distrust of a medical system which has historically mistreated and neglected
                         BIPOC Americans.8, 9, 10, 11, 12, 13, 14 Second, vaccine distribution is commonly done
                         in ways that are less accessible to BIPOC Americans in both obvious ways (e.g.,
                         distribution sites are placed farther from BIPOC communities), and more subtle
                         ways (e.g., accessing the vaccine requires an individual to have resources—
                         time, transportation, computer and Internet access, knowledge of how to get
                         vaccinated, etc.—that are not equitably distributed by race and ethnicity).2

    Figure 3. Young Adults, Black Adults Most Likely to Want to “Wait and See”

    Percent within each group who say, when an FDA-approved vaccine for COVID-19 is available
    to them for free, they would wait and see how it is working for other people:

                         Age 18-29                                                               43%
                       Black adults                                                              43%

                 Hispanic adults                                                       37%

                Urban residents                                                        37%

                       Republicans                                                33%

                   Independents                                                   33%

                               Total                                             31%
Essential workers (non-health)                                                   31%

            Suburban residents                                             29%

            Health care workers                                            28%

                 Rural residents                                          27%

                        Democrats                                         26%
                       White adults                                       26%
              Ages 65 and older                                     21%

    Source: KFF COVID-19 Vaccine Monitor (conducted Jan 11-18, 2021). See topline for full question wording.

HEALTH EVOLUTION   |   Increasing Vaccine Uptake in Diverse Communities                                           3
INCREASING VACCINE UPTAKE IN DIVERSE COMMUNITIES - A Working Guide for Health Care CEOs
Health care CEOs are in a unique
                          position to increase confidence in,
                          and accessibility to, the COVID-19
                          vaccine because:
                          The very mission of health care organizations is to
                          promote healthier communities;

                          Health care organizations often have more access to
                          resources, data, and expertise than government and
                          community organizations;

                          Many health care organizations also have access to the
                          vaccines and/or trained vaccinators needed to support
                          critical community vaccination efforts;

                          Health care professionals are often seen as trusted
                          voices in their communities; and

                          Finally, health care organizations are often among
                          the largest employers in their communities, providing
                          an opportunity to have an outsize impact in the
                          vaccination efforts.

HEALTH EVOLUTION   |   Increasing Vaccine Uptake in Diverse Communities            4
INCREASING VACCINE UPTAKE IN DIVERSE COMMUNITIES - A Working Guide for Health Care CEOs
10 STEPS
   HEALTH
CARE CEOS
 CAN TAKE
                                       Fixing the deep inequities embedded in the health care system is
                                       beyond the scope of this guide, but CEOs can take the following
                                       10 steps to increase vaccine confidence and accessibility in the
                                       diverse communities they serve:

                                       PART I: Creating an Action Plan
                                       Step 1: Empower a Task Force to Provide Oversight
                                       Step 2: Coordinate with Community Organizations and Local
                                       Government
                                       Step 3: Conduct a Rapid Root Cause Diagnostic

                                       PART II: Increasing Confidence
                                       Step 4: Identify and Train Trusted Messengers
                                       Step 5: Be Transparent About Vaccine, Allocation, and Distribution
                                       Step 6: Create Personal Messaging
                                       Step 7: Use Evidence-Based Messaging
                                       Step 8: Communicate Through Multiple Touchpoints Consistently

                                       PART III: Increasing Accessibility
                                       Step 9: Make Signups as Accessible as Possible
                                       Step 10: Distribute the Vaccines in Local Places

HEALTH EVOLUTION   |   Increasing Vaccine Uptake in Diverse Communities                               5
PART I:
   CREATING
  AN ACTION
      PLAN

                         Step 1:
                         Empower a Task Force to
                         Provide Oversight
                         A : For those who have not already done so, set up an oversight committee
                             or leverage an existing task force. This task force should be customized
                             to the organization’s circumstances (e.g., whether playing a direct role in
                             vaccine distribution and administration; whether a national, regional, or
                             local organization; etc.).15 Ensure that those on the oversight committee
                             are demographically diverse and representative of the community that the
                             health care organization serves,15 ideally with some community member
                             representation.16

                         B : Set goals, collect race and ethnicity data, and develop a dashboard to
                             monitor progress.17 One health system in the Southeast pledged up front
                             to allocate vaccines in line with the racial and ethnic makeup of its patient
                             population. This served as a forcing function for the organization to consider in
                             advance what steps it needed to take in order to reach diverse communities.
                             To address potential tradeoffs between efficiency and equitable vaccine
                             distribution, organizations might consider setting goals that phase in over time.
                             Regardless, data should be collected throughout the process on race, ethnicity,
                             gender, ZIP code, and occupation.17 This data can then be used to determine
                             which groups and ZIP codes need more direct interventions.

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Step 2:
                          Coordinate with Community
                          Organizations and Local Government
                          A : Coordinate with public, private, and community organizations to bring in
                              any expertise, resources, or capabilities needed to accomplish the goals
                              set by the task force.18 Resources might include an accessible location,
                              security, vaccines, tents, trailers, signage, fencing, restrooms, vendors, website
                              infrastructure, power cables, laptops, Wi-Fi, staffing, storage, documentation,
                              etc.19 For example, local health departments can put out calls for health care
                              professionals to come volunteer at vaccination stations; local sports teams
                              can provide the space and technology;19 and churches can provide accessible,
                              trusted spaces for vaccine distribution, as they are doing in Philadelphia.20
                              Partners that bring strong cultural competence with the communities being
                              served or targeted should also be identified.

                        58,000                  CASE EXAMPLE: One particularly compelling multi-
                       vaccines in
                                                organization partnership occurred between UC San Diego
                        2 weeks
                                                Health, San Diego County, and the San Diego Padres, who
                                                worked to stand up a large-scale vaccination site in five
                                                days that facilitated the vaccination of 58,000 community
                                                members in its first two weeks of operations.19

                          B : Partner with local and state government. Partner with local health
                              departments to identify ZIP codes that are hardest hit by COVID-19 and
                              that have the least access to vaccination sites. Check to see if the state
                              government has specific goals around equitable vaccine distribution.21
                              Advocate for local government to use evidence-based messaging and
                              evidence-based methods for making the vaccine more accessible, as outlined
                              in the COVID-19 Vaccine Toolkit for Mayors.16

HEALTH EVOLUTION   |   Increasing Vaccine Uptake in Diverse Communities                                            7
Step 3:
       Conduct a Rapid Root
       Cause Diagnostic
       Do not skip Step 3, as tempting as it may be to jump right into the next
       steps. As will be seen throughout this guide, this step provides a critical
       foundation for the remaining steps.

       A : Review national resources and research to provide context for vaccine
           concerns, especially of underserved populations. For example, the KFF
           COVID-19 Vaccine Monitor Dashboard has up-to-date data on numbers and
           trends regarding COVID-19 cases, vaccine confidence, and vaccine distribution
           (for more, see the Top Resources list).22 KFF’s research highlights how Black
           and Hispanic adults who indicated that they would like to “wait and see” before
           taking the vaccine are “very concerned” about the long-term effects of the
           vaccine, the potential for side effects, and overall safety and effectiveness.

       Figure 4. Concerns about Vaccines for Black Adults, Hispanic Adults,
       and White Adults (KFF)23

       Among those who want to “wait and see” how the COVID-19 vaccine is working for others,
       percent who say they are very concerned about each of the following:

                                                                                                                    65%
   The long-term effects of the COVID-19                                                                      57%
                   vaccines are unknown
                                                                                                     46%
                                                                                                            55%
        You might experience serious side
                                                                                                      47%
        effects from the COVID-19 vaccine
                                                                                         34%
                                                                                                  47%
         The COVID-19 vaccines are not as
                                                                                                44%
               safe as they are said to be
                                                                                   28%
                                                                                                     46%
         The COVID-19 vaccines are not as                                                      41%                    Black adults
           effective as they are said to be
                                                                             19%
                                                                                                                      Hispanic adults
                                                                                     31%
                                                                                                                      White adults
They might get COVID-19 from the vaccine                                             32%
                                                                      13%

       NOTE: Among those who have not been vaccinated against COVID-19
       SOURCE: KFF COVID-19 Vaccine Monitor (conducted Jan 11-18, 2021). See topline for full question wording.
                                                                                          26%

   HEALTH EVOLUTION   |   Increasing Vaccine Uptake in Diverse Communities         21%                                                  8
Conversations should be ongoing,
                                                  occurring at regular, frequent
                                                  intervals, because the community’s
                                                  concerns may change rapidly.

    B : Bring in local community representatives and organizations to learn
        what concerns specific communities have around the vaccine.6 Have open
        discussions with multiple local leaders who have an ear to the ground to learn
        about concerns of specific populations in the community. These conversations
        should be ongoing, occurring at regular, frequent intervals, because the
        community’s concerns may change rapidly. For example, in Dayton, Ohio, these
        one-hour discussions happen every week.16 Time and resources permitting,
        consider also having these conversations with local community members, in
        addition to the community leaders.15, 24, 25, 26, 27

        All these discussions should include topics such as:
        l   How has COVID-19 impacted the social and economic fabric of the community?

        l   What specific questions do community members have about the vaccine?

        l   What conceptions and misconceptions do community members have about
            the vaccine?
        l   Which populations in the community have lower confidence in the vaccine?

        l   How do these community members feel about the health care system and
            accessing health care?
        l   How do these community members best access information (e.g., newspapers,
            emails, flyers, word-of-mouth, social media, church announcements, etc.)?
        l   Who do these community members trust and listen to most regarding health
            information?
        l   What language barriers exist in the community?

        l   What are the biggest barriers for community members to access the vaccine
            (e.g., lack of information, transportation, Internet access/savviness, childcare,
            time off)?

HEALTH EVOLUTION   |   Increasing Vaccine Uptake in Diverse Communities                         9
PART II:
INCREASING
CONFIDENCE

                           Step 4:
                           Identify and Train
                           Trusted Messengers
                           A : Locate and partner with trusted messengers.28, 27, 16, 6 The information around
                               COVID-19 and COVID-19 vaccines is confusing, and a certain level of trust is
                               needed for an individual or community to believe a source of information.27
                               Although community messaging should be planned in collaboration with local
                               health departments,29 public health authorities should generally not be used
                               as the trusted messengers in working with BIPOC communities because Black,
                               Hispanic, and low-income communities tend to have lower trust in them when
                               it comes to vaccine recommendations.30

                           B : Start with own health care organization employees. It is reasonable to
                               anticipate that all employees within the organization will field questions (and
                               have questions of their own), so it is important to equip them with up-to-date
                               information on vaccine efficacy and availability. Those who are naturally in
                               direct contact with enrollees and patients should receive materials and training
                               on having non-judgmental conversations with those who have low confidence
                               in the vaccine. Finally, since the most trusted source of health information for
                               diverse communities is usually from family and friends working in the health
                               care industry, and health care professionals of the same race as the message
                               recipient are generally trusted,16 identify employees who are willing to be part
                               of a proactive campaign in their community.16 The Ad Council has produced a
                               useful COVID-19 Vaccine Education Toolkit with videos, FAQs, and social media
                               copy specifically for health care professionals.31

HEALTH EVOLUTION   |   Increasing Vaccine Uptake in Diverse Communities                                           10
C : Reach out to additional trusted messengers including family and
                             friends, local pharmacists, faith leaders, other community-based, non-
                             governmental leaders who represent the people of the community,27,
                             16, 6, 32, 33, 34
                                               micro or local “influencers,”33 popular figures,13 and national
                             “influencers.”33, 13 Generally, the more local the messenger, the more
                             trustworthy (see Figure 5 below). As one person put it, “The vice president
                             matters, but it matters more that your barber got it.”35 In practice, health
                             care organizations should use the term “trusted messenger” rather than
                             “influencer” because “influencer” has the connotation of being manipulative.
                             Government messengers are usually seen as the least trustworthy, because
                             minority groups have historically been mistreated by the government.13, 36 Adult
                             children are often the most trusted messenger for their parents – many elderly
                             parents are getting vaccinated only because their children are encouraging
                             them to do so.37 As such, consider Tik Tok, Instagram, and Facebook
                             marketing campaigns targeting millennials and Generation Z to convince their
                             parents to get the vaccine. Work with local news media, which is generally
                             seen as being the most trustworthy and in touch with the community.16

    Figure 5. Concentric Circles of Trust

                                   Being a health care professional helps at all levels

                      Family &                            Local/Micro             National Influencers
                   Friends (Best)                   Influencers (Next Best)           /Celebrities
                                                                                   (Least Effective)

    SOURCE: HEF, Feb 2021

HEALTH EVOLUTION   |   Increasing Vaccine Uptake in Diverse Communities                                          11
If people feel like their concerns are
                                               be being downplayed, unheard, or
                                               unaddressed, they are less likely to
                                               listen to messaging about getting
                                               vaccinated.

        D : Equip trusted messengers to address the concerns of their
            communities.28, 16, 38 , 27, 39, 33, 16, 29 Train and work with the trusted messengers in a
            variety of ongoing ways to continuously promote the messages of safe vaccine
            uptake. For great examples of how to equip trusted messengers, see the REAL
            TALK Case Example below, or the sample conversations on pages 9-10 of the
            COVID-19 Vaccine Communication Handbook.40 Establish forums for members
            of the community to have their questions answered in nonjudgmental ways
            by, and to have conversations with, these trusted messengers.38, 41 These
            conversations should utilize active listening16, 40 and should be supportive,
            reflective, non-judgmental, and without the intent to convince them to take the
            vaccine.41 If people feel like their concerns are be being downplayed, unheard,
            or unaddressed, they are less likely to listen to messaging about getting
            vaccinated.16, 40 Help the messengers access multiple platforms (social media,
            WhatsApp, etc.) so that their messages can “go viral” and be distributed within
            communities, families, and friend groups.27, 39, 33, 32 Personal anecdotes from
            trusted messengers are often the most persuasive.32 Share their stories.32

HEALTH EVOLUTION   |   Increasing Vaccine Uptake in Diverse Communities                                   12
SURVEY
                                                                 Myth
                                                                Buster

                                                      What to
                                                                          FAQ
                                                      Expect?

 CASE EXAMPLE: Jefferson’s REAL TALK Campaign. After conducting a survey of its
 health care professionals and measuring uptake of the COVID-19 vaccine in the first
 two days of its availability, Jefferson Health noticed that there were stark differences by
 race and ethnicity. In response, it developed a “REAL TALK” campaign—first among its
 own workforce and then in the broader community—to have candid conversations with
 individuals about their concerns.

 As part of the campaign, it developed three documents—one on what to expect after
 getting the vaccine, one with myth busters, and one with answers to frequently asked
 questions—and held 30-minute training sessions with more than 130 trusted messengers.

 The trainings focused on helping those trusted messengers know how to have
 conversations about vaccinations in an understanding, non-threatening manner, rather
 than on convincing or persuading others to get the vaccine.

 Those speaking with trusted messengers were most likely to decide to take the vaccine
 if they felt that their concerns were acknowledged and that they had a chance to ask
 questions. Vaccine uptake increased dramatically in response to the REAL TALK
 Campaign, particularly among employees.

                           E : Encourage those with low confidence in the vaccine to reach out to
                               a pharmacist or primary care physician for more information on the
                               vaccine’s development and their perspective on its effectiveness. Many
                               people have developed trusted relationships with their pharmacists and
                               primary care doctors and value their counsel. Look for opportunities to elevate
                               pharmacists’ voices in the conversation and encourage them to direct patients
                               to vaccine distribution sites. It may be useful to prepare materials for major
                               pharmacies to hand out so patients have another resource to learn more
                               about the logistics of getting a vaccine (e.g., vaccine distribution center hours,
                               what patients need to bring, how to make an appointment, etc.).

HEALTH EVOLUTION   |   Increasing Vaccine Uptake in Diverse Communities                                             13
Step 5:
                   Be Transparent About Vaccine,
                   Allocation, and Distribution
                   A : Create and distribute clear information about the vaccine. Many people
                       in the community may simply not know much about the vaccine – how it was
                       created, how it works, the cause of the side effects, the efficacy, etc.14 Where
                       possible, leverage materials already created for this purpose by respected
                       organizations, but be sure to customize based on language, literacy levels, local
                       community concerns, the best way to reach community members (e.g. mail
                       vs. email vs. social media vs. door-to-door canvassing), and local eligibility and
                       administration logistics. Regularly and transparently share easy-to-digest, data-
                       driven updates on how vaccine distribution is going.16

                   B : Be sure to note that the vaccine is free. Not everyone knows that the
                       vaccine is being distributed free of charge, regardless of insurance status, and
                       so there are many who are concerned about cost.16 In particular, undocumented
                       immigrants and communities are concerned about becoming a “public charge”
                       and vulnerable to deportation.16

                   C : Be upfront about who is getting a vaccine, in what order, and why.15, 27, 16
                       Many are concerned about the vaccine allocation and distribution, and so be
                       clear and simple in messaging about who has access to the vaccine, where, and
                       when.15 Some health systems have been careful to pair the message that the
                       individual has reserved “a spot in line” with a clarification that the exact vaccine
                       timing is uncertain and updates will be forthcoming.16

                   D : Make this information available in as many formats and places as
                       possible to reach as many community members as possible. Ensure that
                       this information – particularly the information about when and how individuals
                       can access the vaccine – is available on the platforms and media most used
                       by local community members. Create an easily accessible medium through
                       which community members can voice their concerns and have their concerns
                       addressed.27

HEALTH EVOLUTION   |   Increasing Vaccine Uptake in Diverse Communities                                       14
Step 6:
                   Create Personal
                   Messaging
                   A : Ensure that vaccine messages are personally relevant to the target
                       audience.27, 42, 43 Each community is different, with diverse experiences,
                       resources, beliefs, and values that must be considered in health
                       communications.27, 44, 32 Different narratives will resonate with different
                       communities.27, 45, 46 It is important to avoid over-generalization of groups,
                          and to be sensitive to diverse perspectives and needs within communities.
                          Communications that are not tailored to the community may be ineffective and
                          even backfire.27, 47, 6, 48, 49, 26

                   B : Promote the experiences of those who look like those in target
                       communities. Emphasize images of people who are of the same race and
                       ethnicity as those in target communities - working in the lab on the vaccine,38
                       getting the vaccine,38 and administering the vaccine.50 Work to promote the
                       expressed vaccine trial and vaccine uptake experiences of those who are of the
                       same race as those in the community; share their social media posts.38

                   C : Get feedback on the messaging. Elicit feedback, formal and informal, on
                       messaging, to see if it is resonating with community members.33, 13, 16 Find out
                       if they easily understood the message, if it influenced them to change their
                       behavior, whether they shared the message, what parts of the message were
                       most impactful, what part should have been left out, and what was missing.51, 16

                   D : Go beyond digital. Digital messaging alone will not go very far in increasing
                       confidence in the vaccine as many of the people with low confidence in
                       the vaccine are also not using digital technologies.41, 33 If people in targeted
                       communities have limited access to the Internet or do not engage heavily with
                       online or digital media, consider conference calls.33 Many people who have low
                       confidence in the vaccine need their concerns to be physically heard by a trusted
                       person in a supportive, non-judgmental context (see the Case Example above).41

HEALTH EVOLUTION   |   Increasing Vaccine Uptake in Diverse Communities                                    15
When discussing the vaccine
                                            development, focus on the large
                                            number of people already vaccinated,
                                            and on the large number of people in
                                            the clinical trials, because people are
                                            afraid of being the guinea pig.

     Step 7:
     Use Evidence-Based
     Messaging
     A : Keep message simple, clear, and actionable.40 It is best to focus on one clear
         point at a time, with as few words as possible.40 Have links and other information
         available for those who want to learn more. Be specific with action-oriented
         messaging, and pair action-oriented messages with a clear way to carry out
         that action (e.g., if encouraging people to sign up for the vaccine, also provide
         the links, phone numbers, and address where they can sign up).40, 52 Keep action
         items clear and on top.40

     B : Emphasize the specific people researching, taking, and benefitting
         from the vaccine. When discussing the vaccine development, focus on
         the large number of people already vaccinated, and on the large number of
         people in the clinical trials, because people are afraid of being the guinea pig.16
         When discussing the vaccine development, talk about the individual people
         (the individual scientists, experts, and researchers), not the organizations or
         companies, who developed the vaccine.43 Feature doctors and nurses getting
         the vaccine and encourage people to talk to their health care provider about any
         concerns.16 Highlight how getting the vaccine will keep the individual’s family and
         loved ones safe.16, 43 Emphasize that getting vaccinated will get things back to
         normal faster, allowing the individual to return to the activities they love.16, 43

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C : Avoid shaming. Do not minimize voiced concerns, shame people for having low
       confidence in the vaccine,38, 42 or tell them that getting the vaccine is the “right” thing
       to do.43 Doing so will show a lack of understanding of the roots of peoples’ lack of
       confidence in the vaccine and deepen the divide between the community and the
       medical system.43 Use empathic language and avoid judgmental language.43 Avoid
       using the term “vaccine hesitancy,” which is taken in a demeaning fashion, and
       instead use the term “low vaccine confidence.”41

   D : Be visual and emotional. Be visual and simple with vaccine efficacy data16 – even
       one powerful graph or infographic can make all the difference.38 Try and use images
       instead of text whenever possible, as people remember them more, like them more,
       and are more influenced to take action.16 And do not stick just to facts, as information
       campaigns do not always increase confidence in the vaccine for many people.41, 53
       Shared stories and images can go a long way.53, 16 When showing photos and pictures,
       make sure the people in them represent those in the community.16

   E : Know the specific audience. Which exact language and messaging to use
       depends on the political, racial, and ethnic makeup of the community – for precise
       language for different communities, see the de Beaumont Foundation’s Language
       of COVID-19 Vaccine Acceptance,43 which is broken down by race54 and by political
       party.55 Insights on precise language to use can also be found in KFF’s “Wait and
       See” Survey Analysis by race (Table 5) and by political affiliation (Table 2).23 Make the
       reference group as specific as possible when inviting people to join the larger group
       in getting the vaccine (e.g., “Join your fellow members of City Church Philadelphia in
       getting the vaccine…”).16 However, avoid using a city (e.g., “Join other Philadelphians
       in getting the vaccine…”) as a reference group, as many feel negatively towards
       their city and their city’s responses to COVID-19.16 Use local facts and figures when
       marketing the vaccine, as these are perceived as more relevant and impactful.40

      For precise language for different
      communities see the de Beaumont
      Foundation’s Language of
      Covid-19 Vaccine Acceptance.

HEALTH EVOLUTION   |   Increasing Vaccine Uptake in Diverse Communities                              17
When discussing the vaccine
                                                                      development, focus on how
                                                                      rigorous the trials were under
                                                                      the FDA’s scrutiny.

                       F : Focus on vaccine safety. When discussing the vaccine development, avoid
                           discussing the speed at which the vaccines were developed as this makes
                           people nervous,16 and instead focus on how rigorous the trials were under the
                           FDA’s scrutiny.43 If people ask about the speed, discuss how the safety measures
                           that are always in place for vaccines were still in place for the COVID-19 vaccine.
                           Explain that the vaccine was able to be developed so quickly because the
                           vaccine production steps, which are usually done in a staggered, sequential way,
                           were done simultaneously at huge expense. Repeat the word “every:” “every
                           study, every phase, and every trial was reviewed by the FDA…”43

                           Although the main focus should be on the benefits of the getting vaccinated (i.e.,
                           keeping your loved ones safe), if discussing the harms of not getting vaccinated,
                           emphasize the high rates of the lingering, long-term complications from
                           COVID-19 – brain fog, difficulty breathing, extreme fatigue, and depression.38 Do
                           not try to downplay the side effects of the vaccine, as people are scared about
                           potential long-term, currently unknown side effects.16, 43 When addressing the
                           immediate side effects, emphasize the limited nature of the immediate side
                           effects.16, 43 When addressing the potential long-term side effects, emphasize
                           how long-term side effects in vaccines across the board are generally seen
                           within the first six months,16, 43 and that researchers have already been
                           monitoring those in the vaccine trials for almost a year.

HEALTH EVOLUTION   |   Increasing Vaccine Uptake in Diverse Communities                                          18
G : Use certain words while avoiding others.43, 41, 56, 16, 40

USE                                                                       AVOID
America’s leading medical experts                                         America’s leading health experts
Research                                                                  Discover/create/invent/study

Medical researchers                                                       Drug companies

Damage from lockdowns                                                     Inability to travel easily and safely

A transparent, rigorous process                                           The money spent on the trials

Safety                                                                    Security
Pharmaceutical companies                                                  Drug companies
Your family                                                               Your community or country

A return to normal                                                        Predictability

The benefits from taking it                                               The consequences from not taking it

Globally                                                                  Internationally/around the world
Advanced/ground-breaking                                                  Historic
Vaccination                                                               Injection/inoculation/shot
Taking the vaccine will help keep you and your family safe (except        Taking the vaccine is the right thing to do (except for
for the Latinx community, where these are reversed)                       the Latinx community, where these are reversed)

America’s leading experts                                                 The world’s leading experts

Skeptical/concerned about the vaccine                                     Misled/confused about the vaccine
The benefits of taking it                                                 The consequences of not taking it
Low vaccine confidence                                                    Vaccine hesitancy

The vaccine is effective in 95% of cases                                  The vaccine is ineffective in 5% of cases

If you don’t get the vaccine, you fail to take advantage of a             If you get a vaccine, you reduce your risk of getting
95% chance of preventing COVID-19                                         COVID-19 by 95%

Taking the vaccine will protect your loved ones                           Taking the vaccine will protect you

Call the Vaccination Information Line to book an appointment (a
                                                                          Get the COVID-19 vaccine (too vague)
specific action)
                                                                          3 million people have been vaccinated in the US from
3 thousand people in your ZIP code have been vaccinated (local)
                                                                          COVID-19 (not local enough)

3 in 4 say they will get the vaccine (emphasize the prosocial             1 in 4 say they won’t get the vaccine (best not to
behavior)                                                                 mention the antisocial behavior)

A vaccine authorized by FDA based on clinical testing                     Operation Warp Speed; Emergency Use Authorization
Public Health                                                             Government

Medical experts and doctors                                               Scientists

“I can see that you need your COVID-19 vaccine today/You are due          “What do you think about getting the COVID-19
for your second COVID-19 vaccine”                                         vaccine today?”
Find more evidence-based guidance on what communications work best from the Poverty Action Lab57 and U.S. Digital Response.58

HEALTH EVOLUTION   |   Increasing Vaccine Uptake in Diverse Communities                                                        19
To impact people’s behavior,
                                                  messaging must be ongoing.
                                                  Messages repeated over time are
                                                  received as more credible.

    Step 8:
    Communicate Through Multiple
    Touchpoints Consistently
    A : Connect with community members through multiple touchpoints
        consistently over time.42, 27 To impact people’s behavior, messaging must be
        ongoing.27 Messages repeated over time are received as more credible.16 The
        messaging should come from multiple trusted messengers, across multiple
        relevant media.27 The messaging should also be updated to the current
        concerns of the community, rather than static.

    B : Promote factual information continuously to counter specific viral
        misinformation. Misinformation is one of the largest contributors to low
        vaccine confidence.59 , 60, 61 The misinformation spread both intentionally and
        unintentionally is exacerbated by both the novelty of COVID-19 and the public’s
        widespread reliance on social media for information.62, 63 Following Steps 1-7
        is one important way to counter misinformation.27, 64, 56 Make sure to tailor
        messaging to directly counter the specific pieces of misinformation circulating
        in the community.27 This requires staying in touch with the community’s
        concerns, including through close monitoring of social media to stay on top of
        misinformation circulating in the community.64, 40

HEALTH EVOLUTION   |   Increasing Vaccine Uptake in Diverse Communities                   20
Consider “prebunking” misinformation by proactively warning people that
        they may be misled, and providing the factual information that is counter
        to the misleading information they may hear.40 However, be very careful
        when discussing misinformation, as discussing misinformation, even in the
        context of actively dispelling it, may backfire and cause people to believe
        the misinformation.56 Therefore, try to focus mostly on the facts, rather than
        discussing the myths. Make these facts simple, few in number, and visual.56 If
        choosing to address myths, each myth must be proceeded by both the factual
        information and explicit warnings about the myth, and each myth must be
        followed by an explanation of why the myth is false, and a reiteration of the
        factual information.56, 40 For an easy-to-use visual guide to this process, see
        pages 14-18 the COVID-19 Vaccine Communication Handbook.40

    C : Promote trustworthy sources. Trustworthy sources include those that
        share or report on the evidence put forth by public health experts. Encourage
        these sources to be active on social media, and make sure health care leaders,
        other employees within health care organizations, and trusted community
        messengers are promoting their content (e.g., “retweeting” or “sharing”).65

   The COVID-19 Vaccine
   Communication Handbook
   offers an easy-to-use
   visual guide to address
   misinformation.

HEALTH EVOLUTION   |   Increasing Vaccine Uptake in Diverse Communities                   21
PART III:
  INCREASING
ACCESSIBILITY
                        Step 9:
                        Make Signups as
                        Accessible as Possible
                        A : Coordinate with the community to centralize vaccine appointment
                            signups.66 People are understandably very confused about where they can
                            get a vaccine, as each vaccine distributor has its own sign up. Centralizing a
                            signup takes away the frustration of going from provider to provider to try to
                            find where vaccines are available. Coordinate with government officials and
                            technology vendors to ensure interoperability between systems where possible.
                            This clarity saves both the patient from shopping around for an appointment
                            and the organization from fielding as many questions about vaccine availability.

                        B : Utilize multiple mediums for signing up. It may be the case that many
                            people in the community do not have access to, or comfort with, the Internet.
                            Make sure there are multiple ways individuals in the community can both (a)
                            learn about when and where they can access the vaccine, and (b) sign up for a
                            vaccine appointment. Create telephone hotlines, in-person information booths,
                            text messaging hotlines, door-to-door canvasing campaigns, etc.67

                        C : Be proactive in addressing barriers. Barriers to signing up that may appear
                            insignificant on the surface may in fact feel insurmountable to many in the
                            community. Target high-need communities by ZIP code and address the
                            signup barriers that are unique to that location. Proactively call, text, and visit
                            those who are eligible to sign up for a vaccine appointment in order to sign
                            them up. Send teams of people into the community with tablets to sign up
                            individuals.67 Send those with vaccine appointments email, text message,68 and/
                            or phone call reminders, depending on how people are best reached in the
                            community.56 Consider forming a working partnership with community partners
                            with boots on the ground to make this happen.

HEALTH EVOLUTION   |   Increasing Vaccine Uptake in Diverse Communities                                           22
Do not overpromise – you do not want to
 tell someone they have a vaccine available
 and then have to turn them away.

                           D : Consider notifying patients that they have an appointment to take the
                               vaccine, rather than just telling them that they can sign up, but only
                               after vaccine supply is more predictable. Telling a patient that they have
                               an appointment that they can cancel or re-schedule rather than just telling
                               them that they can sign up for an appointment can improve overall vaccination
                               rates.69, 68 However, do not overpromise to avoid having to tell someone they
                               have a vaccine available and then turn them away.

                           E : Consider carefully providing financial incentives for getting vaccinated.
                               Incentives such as gift cards or cash compensation have been shown to
                               increase uptake rates, including a study at Swarthmore College where a $30
                               incentive doubled flu vaccination rates from 9% to 19%.70, 69 However, it is
                               critical to get feedback on this method before implementing it. Many people in
                               diverse communities may feel as if they are being treated as guinea pigs16 based
                               on historical events.8, 9, 10, 11, 12, 13 Offering incentives or fast tracking a particular
                               group may only exacerbate this sentiment,14 so tread carefully. In a particular
                               community, it may be the case that financial incentives are trusted when they
                               come from employers, but not from the health care system. One method that
                               has worked is employers giving their employees paid time (e.g., two hours of
                               pay), stipends, and free transportation to go and get vaccinated.71 Consider
                               implementing these types of programs among health care employees, and work
                               with local businesses to implement such programs for their employees.69

HEALTH EVOLUTION   |   Increasing Vaccine Uptake in Diverse Communities                                                 23
Step 10:
        Distribute the Vaccines
        in Local Places
        A : Distribute the vaccines in places that are safe, familiar, and convenient
            to those in diverse communities.15, 27 Partner with community-trusted
            organizations to set up distribution sites in safe, familiar, and convenient
            locations.15 These places could include local pharmacies,72 community centers,
            places of worship, schools, parks, COVID-19 testing centers, etc.13 COVID-19
            testing centers in particular are often well-suited for this purpose because they
            already have the general infrastructure in place including check-in staff, adequate
            space and tents, etc. For those with access to their health care provider, their
            health care provider is often their most trusted distributor of the vaccine.43
            However, due to the widespread mistrust of the health care system, especially
            amongst communities of color, first verify whether this is true in each community.

        B : Those giving the vaccine should be representative of the community.73
            To the extent possible, have those giving the vaccines be representative of
            the community in terms of race, immigration status, religion, sexual identity,
            socioeconomic background, and disability.73 Past studies have shown that Black
            men were significantly more likely to agree to preventive lab work, screenings,
            and the flu shot when seen by a Black physician.50 Not only will this make those
            getting the vaccine more confident in getting the vaccine, but they will be more
            likely to share their experience about getting vaccinated from someone they can
            relate to with their friends and family.

        C : Bundle the vaccines with other services community members are already
            accessing.15, 27 If logistically feasible, try to deliver vaccines to people in their
            homes when community health nurses visit to deliver other preventative health
            services.74 But even outside the home, make vaccines available in locations
            that people are already going to in order to receive other services such as food
            assistance.15 Not only will this increase uptake, but it can reassure community
            members that health care organizations are thinking about their overall
            wellbeing, not just getting them vaccinated.15

HEALTH EVOLUTION   |   Increasing Vaccine Uptake in Diverse Communities                             24
Many people in the community
                                                          will want the vaccine, either now
                                                          or in the future, but will face
                                                          barriers in accessing it.

       D : Bridge the specific barriers to access faced by the community. Many
           people in the community will want the vaccine, either now or in the future, but
           will face barriers in accessing it. These barriers can include lack of information
           about when and where to access the vaccine, lack of transportation to and from
           the vaccine, lack of Internet access to sign up for the vaccine, lack of childcare,
           lack of time off, or something else. If transportation and childcare are significant
           barriers to members of community accessing the vaccine, consider setting up
           transportation or childcare services or partnerships with organizations who can
           provide these services. You may even want to set up mobile vaccination vans
           to bring the vaccine directly to someone’s block or workplace.75, 76 Door-to-door
           outreach for vaccination signup67 and administration is also a model that has
           been successful for populations with limited transportation and technology
           access, often with help from a local organization that has expertise and
           resources in such door-to-door outreach.

       E : Consider restricting access to certain vaccine distribution sites by ZIP
           code. Even when vaccine distribution centers are set up locally in minority
           communities, those living within the community are still often being left behind
           because those who are more tech-savvy and have more resources are shopping
           for early vaccine appointments online and driving in to get vaccinated, leaving
           the local community around the distribution site still unvaccinated.35 If this is a
           problem in a particular community, consider limiting vaccinations at particular
           sites to those who are from specific ZIP codes, and request that individuals bring
           a piece of mail with the relevant ZIP code.

HEALTH EVOLUTION   |   Increasing Vaccine Uptake in Diverse Communities                           25
TOP
          RESOURCES

          Tracking and Background Information
          1. KFF’s COVID-19 Vaccine Monitor Dashboard (ongoing tracking and analysis of
             public’s attitudes and experiences with COVID-19 vaccinations)

          2. KFF’s “What Do We Know About Those Who Want to “Wait and See” Before
             Getting a COVID-19 Vaccine?” (detailed analysis of survey of people who expressed
             low confidence in the vaccine)

          Communication Guides
          3. Ad Council’s COVID-19 Vaccine Education Toolkit (videos, FAQs, and social media
             copy for health care professionals)

          4. de Beaumont’s Language that Works to Improve Vaccine Acceptance
             (infographic on language to use and presentation on findings on hesitancy and
             messaging for different racial, ethnic, age, and political affiliations)

          5. SciBeh’s COVID-19 Vaccine Communication Handbook: A practical guide for
             improving vaccine communication and fighting misinformation (detailed
             research on public health strategies for addressing low vaccine confidence)

          6. COVID-19 Vaccine Toolkit For Mayors: Public Engagement and Communications
             (useful guide for coordinating efforts with local government and for advocating for
             evidence-based approaches by local government)

          Select Case Examples
          7. Jefferson REAL TALK Campaign (public-facing website with training session links
             and one-pagers for trusted messengers)

          8. UC San Diego Health, San Diego County, and the San Diego Padres Partnership
             (article about a successful multisector effort to launch a large vaccine site on a very
             short time frame)

HEALTH EVOLUTION   |   Increasing Vaccine Uptake in Diverse Communities                                26
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        3 Ndugga, N., Pham, O., Hill, L., & Artiga, S. “Latest Data on COVID-19 Vaccinations Race/Ethnicity.” KFF, 18 Feb. 2021.

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HEALTH EVOLUTION   |   Increasing Vaccine Uptake in Diverse Communities                                                               27
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HEALTH EVOLUTION   |   Increasing Vaccine Uptake in Diverse Communities                                                                    28
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HEALTH EVOLUTION   |   Increasing Vaccine Uptake in Diverse Communities                                                                    29
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