Abstract
Although public and private institutions have spent billions of dollars on COVID-19 vaccination campaigns, many of which claim to be “equity-focused,” few articles to date have objectively described the landscape of these campaigns or identified existing gaps with a focus on those populations disproportionately impacted by the virus. To these ends, a high-level landscape analysis of COVID-related communication campaigns was conducted. Analysis of 15 COVID-related communication campaigns based on six criteria (i.e., understandability, accessibility, actionability, credibility/trustworthiness, relevance/relatability, and timeliness) identified successful efforts, including campaigns aligned with the World Health Organization’s Strategic Communications Framework and rooted in community co-design and communication science. The analysis also revealed five common shortcomings: campaigns were not end-user focused, only “checked the box” when communicating with historically under-resourced communities, were largely broadcast-focused and rarely involved two-way engagement strategies or tactics, demonstrated poor use of online communication approaches and failed to moderate campaign comment boards/social media sites, and commonly targeted “intermediary” audiences with materials that were not “end user ready.” Based on these findings, the authors offer recommendations to guide funding and development of future health communication campaigns focused on reaching diverse audiences.
Funding for public health has been steadily declining for decades. During the period 2010–2020, state and local public health department spending dropped by 16% and 18%, respectively (Weber et al., Citation2020). Most states currently spend less than $100 per resident on public health each year and state and local public health workforces shrank by almost 40,000 between 2008 and 2020 (Weber et al., Citation2020).
Chronic public health spending shortages have led to far costlier responses when crises have arisen (Committee on Public Health Strategies to Improve Health, & Institute of Medicine, Citation2012), and in the current COVID-19 pandemic we have seen the challenges faced by the Centers for Disease Control and Prevention (CDC), as well as state and local health departments, to respond to the needs of the public in the face of systemic underfunding. In the vacuum produced by this chronic underfunding of public health, several entities have stepped in to help fill the gap. First, philanthropies have filled the void for a variety of areas traditionally managed by public health, including health messaging, funding a wide array of community-focused health and vaccine awareness, access, and equity initiatives. Second, both governmental agencies (e.g., Department of Health and Human Services, CDC, Health Resources and Services Administration [HRSA]) and philanthropies directly funded public health institutes and other intermediaries to provide the infrastructure and process for local grant making, often embedding parameters for resourcing local public health campaigns in their request for proposals and grants (Georgia Health Policy Center, & Milken Institute School of Public Health, The George Washington University, Citation2022).
Although effective communication can positively affect public health outcomes, including by increasing vaccine uptake (Wakefield, Loken, & Hornik, Citation2010), successful health communication campaigns are deceivingly complex and often lack the cultural nuance, theory-base, formal evaluation, and sustained resourcing for establishing trusted messengers that are critical to reaching diverse audiences. The multiple parties responsible for the deluge of legitimate pandemic-related public health information are well intentioned, but not all COVID-19 communication efforts have been created equal—or equitable. These campaigns have often been diffuse, scattered, uncoordinated, and under-evaluated, in no small part due to the current state of the public health system, maligned and too underfunded to shoulder urgent burdens.
In the United States alone, governmental, philanthropic, and other organizations have spent billions of dollars on hundreds of COVID-19 vaccination outreach, promotion, and distribution campaigns, which have been scoped from the local to national level. Yet, apart from limited efforts at self-evaluation of individual efforts and a recent review of the use of health behavior theory in these interventions (Orr & Gordon, Citation2022), few articles have objectively described the landscape of COVID-19 vaccine and prevention campaigns, formally measured campaign effectiveness, or identified existing gaps with a focus on those populations disproportionately impacted by the virus. As federal and local officials consider allocation of funding and resources for future COVID-19 prevention efforts, develop new communication campaigns to promote COVID-19 vaccination (The White House, Citation2022), and prepare for inevitable future pandemics, objective evaluation of the campaigns over the past few years is of particular importance.
As social service protections established during 2020 and the following years expire, and as confidence wanes in national and state level public health authority broadly, the question of philanthropic funding for public health becomes more critical. Recent research on trust in federal, state, and local public health agencies has demonstrated that reasons for trust and support in health agencies varies depending on size and scale of the agency though robust health communication to stakeholders at every level is critical (SteelFisher et al., Citation2023). Without significant federal investment in public health systems, it is likely that capacity and trust will continue to wane, and private philanthropies will take on a larger role.
To these ends, and with a focus on racial health equity (Boyd, Lindo, Weeks, & McLemore, Citation2020), the Vaccine Equity Cooperative (VEC) spearheaded a high-level landscape analysis of COVID-related communication campaigns. The VEC is a collaboration between national and community organizations, philanthropy, and government committed to health equity with the goal of making it easier for people working in communities to access the most useful, relevant, community-tailored, and up-to-date tools for learning and communicating about the COVID-19 vaccine. Our review of this effort sheds light on the successes, limitations, quality, and related impacts of the communication campaigns so that ongoing and future efforts may better address the challenges related to promoting vaccine uptake and the consequences for public health, the economy, and future health communication strategies.
Methods
The VEC partners analyzed hundreds of well-resourced campaigns and thousands of COVID-19 prevention-related articles and blog posts, compiled a list of 400 national and state-based campaigns along with their target audiences, and from this list chose 15 campaigns on which to focus the analysis. This analysis is not meant to be a comprehensive landscape analysis yet one is needed. The study sample was purposive in nature, with the intent of representing a range of communication efforts across many domains of interest, including:
Scope. Both national and state/local-level campaigns.
Audience persuadability. The different types of campaigns based on the target audiences’ likelihood to get a vaccine, broadly categorized as:
a. Vaccine-hesitant, uncertain, and/or distrustful of institutions, but could be persuaded to get vaccinated with more factual information and resources.
b. Accepting of vaccines, but facing barriers to accessing them.
c. Skeptical of vaccines and/or susceptible to misinformation.
Equity lens. Campaigns targeted at historically underrepresented or under-resourced communities or vulnerable populations.
Political leaning. Campaigns from states that lean conservative or liberal.
Region. Campaigns from across the U.S., including the West, South, Midwest, and Northeast.
Based on the World Health Organization’s Strategic Communications Framework (World Health Organization, Citationn.d.) and research conducted by FrameWorks Institute related to successful vaccination efforts (FrameWorks Institute, Citation2021a, Citation2021b; O’Shea et al., Citation2021), the 15 campaigns were assessed using the following strategic health communication criteria:
Understandable. How easy the information is to navigate, understand, and engage with in order to comprehend the health risks and take the action required to get vaccinated.
Accessible. Whether information is shared through communication channels that intended audiences can easily access and are familiar with.
Actionable. How well barriers to getting vaccinated are addressed and whether “enabling” factors for getting vaccinated (e.g., providing resources to overcome known barriers) are highlighted.
Credible and trusted. How well known and trusted the organization behind the campaign is, whether the campaign addresses specific concerns about the vaccine, and the degree to which the campaign combats mis/disinformation about COVID-19 and vaccines.
Relevant and relatable. How well do audiences relate to the information presented in the campaign and how messaging reflects intended audience demographics.
Timely. Whether information is delivered through quickly updateable channels, and how regularly messages and resources are updated as information and guidelines evolve.
The evaluation of the 15 campaigns involved desk research and a digital audit of publicly available campaign information, including website content and downloadable material, social media channels, and earned media discoverable via a web search. The digital audit was conducted using a social listening tool (Sprout Social) to analyze and track trends on social media, informing the reviewers on how vaccine public health campaigns communicated their messages. A variety of keywords pertaining to vaccine campaigns in general (e.g., “vaccine,” “vaccine equity,” “vaccine hesitancy”) were searched under campaign-specific Facebook pages and then terms specific to the 15 chosen campaigns (e.g., campaign names, hashtags) were searched on Twitter, Facebook, and YouTube. The main insights sought included the volume of conversation about the key terms, engagements (i.e., comments, shares, likes), and potential impressions of content containing the keywords.
Results and Discussion
The 15 campaigns included in the analysis () varied in their target audience, perception of the target audience’s willingness to accept COVID-19 vaccines, messages, messengers, and other factors. While some solid elements of strategic communication were evidenced, most of the campaigns were lacking by the six criteria against which they were assessed ().
Table 1. 15 Vaccination Information Campaigns Included in VEC Assessment
Table 2. Summary of Findings of VEC Assessment
What Worked
The analysis revealed several elements of success that were best exemplified by two campaigns: the NAACP’s “COVID No More” and the National Resource Center for Refugees, Immigrants, and Migrants’ (NRC-RIM’s) “Vaccination Is” campaign. These were strong campaigns that were aligned with the World Health Organization’s Strategic Communications Framework and were rooted in community co-design and communication that mobilized local chapters and community members to lead the conversations.
The NAACP’s “COVID No More” campaign targeted Black communities across the nation. The campaign’s website was easy to navigate, used relatable and understandable language, and included a glossary with brief and simple definitions of important terms such as “herd immunity.” It provided factual, non-judgmental information as a way to build trust; contextualized the pandemic outside of a health issue, tying the impact of the pandemic (and thus the importance of vaccines) to other social issues (e.g., income inequality and health inequities, how COVID-19 is widening the learning gap for Black students); and encouraged its audience to trust the majority of the Black community, which was getting vaccinated and boosted, and getting their children vaccinated. The campaign addressed barriers to receiving the vaccine, including by partnering with Lyft to offer free rides to vaccination sites. In addition, the campaign worked closely with local NAACP chapters to understand local questions and concerns and identify trusted messengers and vehicles of communication (e.g., Milwaukee Community Journal; see https://content.communityjournal.net/content/uploads/20210930071746/All-MCJ092921-Pages.pdf).
NRC-RIM’s “Vaccination Is” campaign was a nationwide campaign working to provide guidance to community organizations doing COVID-19 vaccination outreach to local refugee, migrant, and immigrant communities. It was co-developed with members of these communities with experience in community health, in partnership with a nonprofit design firm (IDEO.org) with expertise in working with and for diverse communities. The campaign tailored content to audience member vaccine-related concerns (e.g., by highlighting the fact that vaccines are free, halal [i.e., permitted under the religious laws of Islam], and do not require proof of immigration status). Campaign materials and website copy were written in simple and inclusive language and resources were available in multiple languages (English, Arabic, Creole, Daria, Kinyarwanda, Nepali, Russian, Somali, Spanish, Swahili, and Ukrainian). The campaign offered live webinar Q&As, outreach guides, and in-person training sessions to its initial target audience of community health workers, and used these community health workers to interact with target audience members on the ground in order to encourage one-on-one conversations that build audience member trust. To address physical access issues like transportation, the campaign’s local partners hosted vaccine events and mobile vaccine clinics that brought vaccines directly to community members.
What Didn’t Work and Should Be Avoided for Future Campaigns
The initial environmental scan of COVID-19 communication efforts found that efforts were largely unstrategic. “Information dumping” was the primary approach used to educate the public about both COVID-19 and vaccination, with a large volume of content making it difficult for the most accurate and credible information to rise to the top. Most efforts were mass media broadcast-focused and few involved two-way engagement strategies or tactics. Significantly, most of the campaigns were not targeted for an audience with historical reasons to mistrust medical institutions (Warren, Forrow, Hodge, & Truog, Citation2020). In addition, little information was available about what impact the campaigns had or even how or if they were evaluated.
Analysis of the 15 vaccination campaigns revealed five common shortcomings:
Campaigns were not end-user focused. The campaigns analyzed did not seem to consider where and when people are most likely to access content or how people might respond after consuming content. Messages lacked a clear, segmented approach for reaching specific audiences of interest and campaigns commonly failed to make the information easy to consume. For instance, several of the campaigns—including “Stronger Together,” a statewide campaign run by the Missouri Department of Health and Senior Services that targeted the general population and “This is Our Shot,” a statewide initiative implemented by the Salt Lake County Health Department that targeted the general population, faith communities, and people skeptical of vaccines—assumed a high level of health literacy and background knowledge about science and medicine. Campaign resources were text-heavy; included complex, medical terminology jargon; and failed to effectively use graphics to enhance understandability.
Campaigns only “checked the box” when communicating with historically under-resourced communities. Although campaign funders often stressed the intent to research historically under-resourced communities, the approach taken by most of the campaigns in the analysis reflected little more than shallow representation of vulnerable communities in campaign creative and direct language translation. There was little evidence of cultural literacy or the sustained community investment that we know are critical for building trust. For example, although the “Our Voices Campaign,” a statewide effort run by the Tennessee Department of Health, purported to target Black and Latinx communities, the campaign produced only one video in Spanish, had no written testimonials in Spanish, and did not have messaging tailored to its Black and Latinx target audiences.
Campaigns were largely broadcast-focused and rarely involved two-way engagement strategies or tactics. Effective communication distribution strategy was lacking and campaigns rarely made full use of social media to proactively reach, educate, and engage target audiences around vaccination efforts. Few offered virtual or in-person events, provided information on how the campaign could be contacted with questions, or monitored social media posts to respond to questions. For example, “Roll Up Your Sleeves NY,” a statewide campaign implemented by the Task Force for Vaccine Equity and Education and targeted toward Black New Yorkers, did not use social media at all. “This Is Our Shot” and the “Our Voices Campaign” lacked campaign hashtags or devoted campaign social media channels. Although “This Is Our Shot” regularly posted across social media channels and audience members could comment and ask questions on posts, the campaign did not appear to respond to questions or comments.
Poor use of online communication approaches and unmoderated campaign comment boards/social media sites that fed mis/disinformation. Content was often added into poorly organized repositories on campaign websites and there was little to no social media comment moderation, enabling anti-vaccination efforts to target and thrive in the comment sections of many campaign posts and other online venues. Campaigns were combating mis/disinformation with large volumes of data and medically driven content, rather than with target-relevant messaging approaches. For instance, “This Is Our Shot” and the “Our Voices Campaign,” both of which were targeting a population that is susceptible to misinformation, did not moderate the comments of any of its social channels, allowing the channels themselves to become avenues for misinformation, anti-vaccine propaganda, and conspiracy theories.
About half of all campaigns targeted “intermediary” audiences with materials that are not “end user ready.” These campaigns targeted their communication approaches toward community-based organizations, health care officials and providers, educators, and other intermediary audiences with the expectation that they would pass the information on to populations of interest. However, these entities likely have neither the time nor training to adapt materials for the general public (or special populations). When these materials are shared “as is” they are unrelatable, and thus unlikely to lead to attitude or behavior change. For example, most of the information produced by the “Public Health Communications Collaborative,” a national campaign launched by the CDC Foundation, de Beaumont Foundation, and Trust for America’s Health, was aimed only at public health officials. While the campaign did provide fact sheets, social graphics, and other materials, presumably for those in the lay community, it was not always clear for whom these materials were intended. Furthermore, the materials included clinical and academic language, failed to speak to people’s concerns, and lacked a warm, personal, inviting style.
Learning from COVID-19 to Prepare for Current and Future Public Health Crises
Given the chronic underfunding of public health, increasing mistrust in public institutions, and growing channels for mis/disinformation, utilizing lessons from COVID-19 will enable better public health communications in future times of crisis. While more comprehensive analysis of COVID-19 vaccination campaigns is needed, findings from the analysis discussed above, combined with the knowledge, applied research, and expertise of our team of authors, provide insights from COVID-19 prevention efforts to guide future ones. The following four recommendations highlight areas to both avoid and replicate.
1. Move from “audience testing” to community co-design to build trust
In the current climate of mis/disinformation and mistrust, integration of formative research strategies is critical to have the target audience as part of design, implementation, and evaluation. In addition to the examples provided earlier, there are frameworks and published case studies to guide co-design with the community. Examples of frameworks include the New York City Department of Health and Mental Hygiene (NYC DOHMH) Community Engagement Framework, which centers on racial justice and provides step-by-step guidance on how to co-design with communities (New York City Department of Health and Mental Hygiene, Citation2017). In addition, there are many published examples of successful community codesign in the United States and globally that can be used as a model for design (e.g., McKelvie-Sebileau et al., Citation2022).
Co-design is complicated and time intensive. The relationships that enable this co-design should be a sustained effort—not just part of a public health emergency—with government and academic organizations building authentic and mutually beneficial partnerships with community-based organizations by focusing on trust building, power sharing, capacity development, co-learning, and co-creating (Asan, Yu, Crotty, & Serrano, Citation2021; AuYoung et al., Citation2022; Bollyky et al., Citation2023; Dada et al., Citation2022; Lazarus et al., Citation2022; Simonetti & Anderson, Citation2023).
Strategies for promoting community ownership and sustainability of these programs include supporting long-term program staffing, reducing barriers to securing funds, increasing staffing flexibility such that staff member skills match community needs, investing in capacity development (e.g., through creating community toolkits, videos, and websites that can be used to disseminate health information and serve as training resources), creating infrastructure to support interagency information sharing, and increasing the potential pool of multi-cultural/lingual trusted messengers of various ages by training scientists, clinicians, and public officials (AuYoung et al., Citation2022).
Some of the campaigns included in the analysis had success in this area. For example, as mentioned above, NRC-RIM’s “Vaccination Is” campaign was co-developed with refugee, immigrant, and migrant community members with experience in community health, therefore credibly and authentically by and for the communities that campaign served. Unidos US’s “Esperanza Hope For All” campaign tailored their resources to address the concerns of the target audience (i.e., the Latinx community), including language barriers, immigration status, and health insurance. However, the larger campaigns developed materials primarily for the general public, with resources only “tacked on” for specific, often historically under-resourced communities. One campaign that partnered with clinicians and community health workers to provide direct video messages in accessible language about the vaccine science and dispel common misconceptions and worries was Greater Than COVID’s “The Conversation: Between Us, About Us.” It included videos, a digital tool kit, and was made in partnership with clinicians, community, philanthropy, and government. In addition, the campaigns highlighted as “Beacons of Light” (see Box) serve as examples of successful initiatives that were co-designed and enacted with audience and community members.
2. Use existing science, evidence, and best practices
Communication efforts need to be evidence-, science-, and theory-based to produce measurable impact. Campaigns should approach the development, dissemination, and evaluation of the COVID-19 communication initiatives strategically, which requires formative, process, and outcomes research as well as the use of appropriate psychosocial and communications theory, public health communications and campaign planning models, and overarching program theory.
The standard health communication science on best practice health communication planning, implementation, and evaluation detailed by well-entrenched guidelines and models, such as the National Cancer Institute’s (NCI’s) four-step health communication approach (National Cancer Institute, Citationn.d.) and the Social Marketing Wheel (Evans, Citation2006) for strategic campaign development, have provided campaign planners with comprehensive procedures. In the current age of social media and mis/disinformation, with instantaneous opportunities for engagement, these models may need updating and refinement. Logic models should be used to aid in program conceptualization, illustrating how program inputs and outputs will lead to short-, intermediate-, and long-term outcomes. Logic models from effective campaigns can then be leveraged as a shared “roadmap” to unite current and future COVID-19 communications across agencies/organizations.
The opportunity to fully integrate theory-based approaches was also missed in many of the campaigns. Although theory-based communication interventions have been found to be more effective than non-theory-based interventions, a recent scoping review of COVID-19 vaccine communication and messaging interventions found that few involved use of health behavior theory in the intervention design (Orr & Gordon, Citation2022).
Using the latest social marketing and behavioral science strategies can better deliver on campaign goals by virtue of making strategic decisions most likely to impact the hearts and minds of intended audiences. The campaigns that were reviewed showed little integration with behavioral economic approaches (e.g., nudges) as well as social marketing strategies to prompt timely action for prudent health decision-making at all levels and in developing public policy. Behavioral science research shows the power of environmental incentive structures to make the healthier and safer choice easier and the riskier choice harder. Nudges also operate by creating an environment whereby those that are distrustful of the vaccine are more likely to get vaccinated, thus creating an observable trend (and eventual social norm) that influences like-minded peers to do the same (Gostin & Ratzan, Citation2021; Reñosa et al., Citation2021).
3. Design campaigns with an intent to evaluate process and impact at individual and community levels
A surprising finding of the campaign analysis was how little publicly available information exists on the effectiveness of the campaigns in terms of reach or behavior change. Whether this scarcity of data can be explained by an actual absence of impact or by campaign design that lacked mechanisms to measure effectiveness, future campaigns addressing either a public health crisis or routine prevention should be designed with an intent to evaluate program inputs, outputs, and short- and long-term outcomes. Future formative research can also reinforce co-design, ensuring that campaign messages align with the audience’s knowledge, attitudes, beliefs, awareness, concerns, and/or behaviors related to COVID-19. Further research and evaluation of co-design approaches and impact are also needed in the field (Iniesto, Charitonos, & Littlejohn, Citation2022).
Additional research on COVID-19 vaccination campaigns to understand the reach of both local and national campaigns would offer significant value. While extensive research exists on health communications campaigns, less exists to understand how effective the aforementioned frameworks or other frameworks and theories are in complex environments with a high degree of distrust (Jones, Khader, & Branch-Elliman, Citation2022). Additionally, for those campaigns who aimed to reach and enable a specific community, geography, or population (e.g., Black Americans) to get the COVID-19 vaccine, there is still an opportunity to research methods used and impact, and to distill best practices for future public health crises.
4. Ensure comprehensive funding and expertise to combat growing complexities and mistrust
With the chronic underfunding of public health and growing mistrust (Funk & Tyson, Citation2022) of those that have the technical expertise to provide core campaign messaging (e.g., the CDC and the Department of Health and Human Services), more and more private philanthropists and companies are running and funding what should be publicly funded health campaigns. This includes government agencies who often fund intermediaries to conduct community outreach. One example is the HRSA, which distributed $390 million to intermediaries who were more proximate to communities to develop and support a community-based workforce to enable better COVID-19 vaccine uptake (HRSA, Citation2022). Those who have the funds must understand their own expertise and outreach gaps, and the gaps of those they are funding, and hire or assemble a team to minimize those gaps.
In addition to the above three recommendations, those entities funding health communications campaigns must also consider how the campaigns will use digital and social media and, relatedly, address mis/dis information. Campaigns should take advantage of the popularity of social media—an estimated 82% of Americans reported using it in 2021 (Dixon, Citation2022)—and should execute social media strategies that ensure campaign material is present where and when intended audiences are active. Successful use of social media involves more than achieving a high number of followers, which does not guarantee that content will reach large numbers of people or members of the target audience. Likewise, funding should be provided to ensure availability of staff needed to monitor social media comments sections for mis/disinformation to maintain campaign effectiveness and counter the coordinated efforts by the anti-vaccination movement to create doubts about vaccines (Lazarus et al., Citation2022).
Although the impetus for a philanthropic entity or private company to “do something” in the form of running a campaign often stems from altruistic places like an equity-driven mission, doing so may not only be a waste of money, but also can cause harm. Any entity that is considering funding a health communications campaign or running one themselves without the expertise or community trust should conduct a landscape analysis to understand if there are national and/or local organizations that may be better suited for the task. One example of a philanthropy and privately funded campaign that partnered with and relied on the expertise of clinicians, community health workers, and governmental public health was Greater Than COVID’s “The Conversation: Between Us, About Us,” created for Black and Latinx communities by Black and Latinx health care workers. The campaign provided short video messages by trusted messengers to provide facts and dispel misinformation about the COVID-19 vaccines (KFF, Citation2021). This is one of several examples of highly collaborative approaches to a COVID-19 vaccine campaign and further research is needed to understand the impact of these campaigns and lessons learned.
In addition to collaborating on a national scale, often there are local community-based organizations and local health clinics that have the expertise and community trust but lack funding and additional capacity to both promote and distribute vaccines. In these cases, a partnership between funding entities and local experts leads to a better designed, measured, and effective campaign. Examples of these kinds of partnerships in COVID-19 that led to broader reach while also building trust and combatting mis/disinformation include Roots Community Centers in California (The Rockefeller Foundation, Citation2021) and Yee Ha’ólníi Doo in Navajo Nation (Relief Fund, Citation2022).
Conclusions
Billions of dollars have been invested into COVID-19 vaccine promotion, outreach, and distribution by philanthropy and government (see supplemental online information for a summary of COVID vaccine campaign investments), with many claiming to reach a diverse audience—including $475 million allocated by the White House to hasten the pace of COVID vaccinations in the last 6 weeks of 2022 (The White House, Citation2022). While proven public health communication approaches, lessons from the landscape analysis, and a focus on six domain areas (i.e., understandable, accessible, actionable, credible and trusted, relevant and relatable, timely) can help guide future public health campaigns, the return on investment remains to be determined in this environment of growing mistrust, targeted mis/disinformation, and decreasing funding for public health.
When planning for future public health crises, or managing current crises such as mental health, it is critical to ensure there are resources to co-design campaigns with those audiences that are being targeted; to utilize, monitor, and manage social media and mis/disinformation; and to include and resource local trusted messengers (e.g., community health workers, pediatricians, religious leaders) who can help design the communications and share it with their patients, peers, and communities. In addition, this kind of investment means funding public health and local community-based organizations to not only design campaigns that can be delivered directly and enhanced with appropriate paid media and integrated with earned media, but also to appropriately resource the infrastructure needed to support community outreach and co-design, address additional equity barriers (e.g., translations and access) and enable on-going support for wrap-around services (e.g., transportation). Additionally, in future efforts, theories (e.g., the Social Ecological Model) could be used to identify intervention targets beyond the individual to situate health communication efforts within a broader, community-based approach to vaccine promotion.
To overcome the current plateau in COVID vaccination and the decrease in routine childhood immunizations, we need to reevaluate our current communication efforts and the funding needed to enable vaccine uptake across communities in the United States. The ultimate communication approach incorporates not only the six critical domain areas deemed necessary in the VEC study, but a clear health communication framework and plan for evaluation and strong local relationships between public health, community, and health care. It is only with a racial health equity lens and a multi-sector design and distribution approach that optimal community health, which includes vaccinations, can be achieved.
Study Limitations
The landscape analysis detailed in this study should serve as a jumping off point rather than a definitive evaluation effort.
The review was not a comprehensive census of all COVID-related communication-related initiatives in the United States. The small sample size (n = 15) was based on a convenience sample and was not intended to be representative of all COVID-prevention campaigns launched in the United States. While the analysis was national in scope, it did not include numerous of the smaller or more community-focused campaigns which were more targeted, customized, and focused on local outreach. The review was limited to publicly available information available via desk research and the Sprout Social digital audit. Furthermore, the study was cross-sectional in nature and does not account for campaign content that has evolved since the fourth quarter of 2021. Nor has the analysis been independently validated. Analyses were based on single-reviewer qualitative assessments of six attributes deemed of most interest among a self-selected team of program specialists, communications experts and behavioral scientists. While the six attributes used to measure the campaigns constitute well-vetted measures of campaign quality in the literature, there may be other areas of agreed-upon import to successful campaign impact that were not considered in the analysis.
However, as this is the first comprehensive analysis conducted to date, it does shed light on the promise and lessons from public health education efforts in the COVID-19 space. While directional in nature, the findings from this study serve as an important initial step for future COVID communications landscape assessment work.
Acknowledgments
The communications firm RALLY led the compilation and analysis of campaigns referenced in this article. The complete report can be found in the resource section of the Vaccine Equity Cooperative website. Thanks to Rachel Koo for research on COVID-19 vaccine spending.
Disclosure Statement
No potential conflict of interest was reported by the author(s).
Additional information
Funding
References
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Appendix
Box:
Beacons of Light
Roots Community Health Center
Roots Community Health Center, headquartered in “deep East” Oakland—an area that was particularly hard hit in the early days of the pandemic (Shabazz, Citation2020)—was already a trusted community health anchor prior to the pandemic. In April 2020, Roots stood up the region’s first walk-up testing site, which served as a destination for community members to receive services as well as trusted information, and for Roots to hear directly from community members regarding their questions and concerns. Roots also became a trusted resource for other community-based organizations, churches, and small businesses to receive testing, personal protective equipment, and up-to-date, trustworthy information through various venues. For example, Roots co-developed with local barbers COVID-related educational resources and materials that are made available across multiple barbershops in Oakland.
In addition, Roots immediately embedded Health Navigators (community health workers and health coaches hired from the community) into testing site operations to direct patients, survey to both understand barriers and answer their questions, and ensure they felt safe and cared for. Roots honed in on responses from the most impacted zip codes and racial/ethnic groups to help inform improvements in COVID operations and to tailor COVID communications. In July 2020, Roots launched The People’s Health Briefing, a weekly briefing with the goal of responding to the community’s most pressing concerns and questions with up-to-date information based on national and local data, existing science and research, and Roots’ own data and insights, in an easy-to-digest format. These 15–30-minute briefings continue to be widely disseminated and viewed by community members, patients, and community and faith-based partners.
Roots used insights gained from the surveys and subsequent interviews and focus groups not only to inform Briefing topics, but to refine communication strategies and messaging more broadly. In response to data pointing to fear that the vaccine was developed too quickly, Roots produced a 2-minute video titled “6 Reasons the COVID Vaccine Was Developed So Quickly,” launched on social media using geofencing, looped at Roots’ health center sites, and condensed into materials disseminated on social media and via handouts to the community. After the release of this information in September, Roots vaccinated its highest number of African American community members outside of early Spring 2021, when the vaccines first became widely available. Of all vaccines administered by Roots in Oakland, 47% have been to African American and 33% to Latinx community members. About 9% were to the White population which made up the majority of vaccine uptake elsewhere. Over 50% of vaccine doses have been administered to residents of the highest priority zip codes, a proportion that has increased month over month following the initial rush of vaccines from individuals from outside cities and counties.
Yuma County Public Health Services District
In March 2021, the Centers for Disease Control and Prevention (CDC) identified Arizona as one of two states with higher vaccination rates in counties ranking high on the Social Vulnerability Index then in low-vulnerability counties and cited Yuma County, a rural country with a diverse and seasonally variable population located in the southwest corner of Arizona, as one of three counties that “significantly contributed to this result” (Hughes et al., Citation2021; The Kresge Foundation, Citation2022). Yuma County’s year-round agricultural production attracts large numbers of migrant farm workers, some of whom follow the crop cycle, moving between Yuma County, Arizona and California, and with others who have dual citizenship living in Mexico and working in Arizona. These factors combine to present linguistic, cultural, and logistical challenges to vaccinating a large proportion of this population.
Among the steps taken by the Yuma County Public Health Services District to promote COVID-19 vaccine uptake in their community of agricultural workers included were working with community leaders to identify community needs and assess for possible opportunities for collaboration; engaging trusted messengers in each community, such as the Community Health Worker (Promotoras) network (a group that is established in and trusted by the community of agricultural workers), who visited neighborhoods and conducted outreach, collecting questions from community members, and identifying migrant movement patterns so that they could coordinate opportunities for migrant farm workers to complete their vaccine series; and collaborating with local universities and nonprofit partners to develop culturally and linguistically appropriate material, including bilingual infographics, public service announcements (PSAs), and outreach campaigns.
Native American Tribes and Territories
In mid-September 2021, the percentage of Native Americans who were fully vaccinated (47.5%) exceeded that of Asian Americans (41.8%), White Americans (37.8%), and Black Americans (29.9%). As of late September 2022, 62.2% of Native Americans were fully vaccinated, a number that is only slightly lower than the percentage of fully vaccinated Asian Americans (62.9%) and substantially higher than the numbers for White Americans (50.0%) or Black Americans (43.4%); (CDC, Citation2023).
These results, which may surprise some for reasons that include historically rooted low trust in the federal government in Native American communities, can be attributed to three main factors: (1) the decision by the federal government to allow Native American communities to control vaccine distribution, thereby eliminating the need to wait for states to receive vaccine allotments and allowing them to define their own prioritization strategies; (2) the incorporation of cultural values into campaigns; and (3) the use of trusted community members as advocates. Results of a national survey of Native Americans conducted December 2020, which confirmed high levels of vaccine hesitancy, was used help guide choice of the right messenger (community members, not White government officials) and the right message (that vaccination is the right thing to do for the community, rather than focusing on vaccination to protect the individual) to persuade Native Americans to get vaccinated (Silberner, Citation2021).