12 COVID-19 Vaccination Strategies for Your Community

Vaccine ambassadors train community members to disseminate important health information in their communities. Derived from the lay health advisor model, ambassadors are most effective when they are trusted community members and share similar beliefs and characteristics with their peers.

• Barriers Addressed: Equity, Access, Prevailing Social Norms, Mistrust, Mis- and Disinformation, Cultural Relevance
• Research Base: Framing vaccine uptake as a prevailing social norm has a positive impact. A survey study showed that when people think that most people around them want to be vaccinated, they are more likely to be vaccinated as well. Discussing with peers the risk of contracting disease and the decision to vaccinate impacts one’s decision. Endorsements from peers in one’s own social network can also help spread credible information about the vaccines

The “Motivate, Vaccinate, and Activate” campaign encouraged residents of the under-resourced, predominantly Latinx Mission District of San Francisco, California, to be vaccinated against COVID-19.

The culturally-tailored initiative was organized through a community-academic-city public health partnership among Unidos en Salud (United in Health), the University of San Francisco, and the City of San Francisco. They engaged trusted messengers and social networks and used a convenient vaccination site. These efforts helped increase vaccinations and overcome hesitancy due to misinformation, distrust of institutions, and access to the vaccines. Community health workers educated the community about the vaccines, texted people to let them know of their eligibility, and used public media to spread the word about vaccination locations.

Vaccinated community members became ambassadors to recruit friends and family members to get vaccinated.

Important steps in this strategy included:

• Two dedicated staff shared their personal experiences modeling how this could be done.
• Staff then encouraged others to share their own vaccination experiences with their unvaccinated friends and family to encourage them to become vaccinated.
• Staff provided tips on how to handle difficult conversations, provided myth-busting information, and role played.

A partnership between two health systems and community leaders in Philadelphia established COVID-19 vaccination clinics to overcome equity barriers among communities of color. Faith and other community leaders were engaged as vaccine ambassadors who helped design the intervention, activated their networks, and acted as trusted messengers to increase vaccinations.

The strategy used other components in addition to the vaccine ambassadors, including a no- to low-tech approach to scheduling vaccination appointments, text or phone reminders of future vaccination appointments, and personal outreach. 

Key components of this effort included:

• Health system leaders met virtually with area pastors to ensure they felt comfortable recommending the COVID-19 vaccines.
• Pastors led by example and received their first doses at the clinic.
• During a virtual event held by two faith leaders for their congregations, Black physicians shared their vaccination stories, provided scientific information about the vaccines, and answered people’s questions and concerns. The event was recorded for future use by new partners.  WURD, a Black-owned and operated talk radio station, aired segments about the COVID-19 vaccines and the community clinic initiative.

Medical provider vaccine standardization refers to offering vaccination as a default option during patient visits and integrating vaccination into medical practice procedures.

• Barriers Addressed: Policy, Mistrust, Health Literacy
• Research Base: Medical practices and hospitals can take steps to increase vaccine uptake through standard practice measures, including default scheduling and presumptive announcements.
  In one study, scheduling patients by default increased flu vaccination by 10%. Another study showed patients with “standing orders” received flu and pneumococcal vaccines significantly more often than those with reminders. For patients with standing orders, the hospital’s computerized system identified eligible patients and automatically produced vaccine orders directed to nurses at the time of discharge.
  Even standardizing what the doctor says when entering the room can impact vaccine uptake. For example, one study found doctors trained to announce human papilloma virus (HPV) vaccines during visits with a brief statement that assumed parents were ready to vaccinate (the presumptive approach) increased uptake by 5.4% over the approach of engaging parents in open-ended conversations about vaccinating their child.

Standardization measures could become routine practice. As the vaccines become more available in medical practices and hospitals, standardizing COVID-19 vaccination into routine practice will help reduce missed opportunities for vaccination, which are encounters where a person eligible for a vaccine receives health services that do not result in them getting vaccinated.

In Arizona, a local 10-physician practice received detailed guidance from their county health department that helped them obtain COVID-19 vaccine supply and establish a protocol for administration. The county health department provided both supplies and weekly instructional webinars to guide practices through the vaccine administration process.

The Arizona physician office trained their staff to provide accurate information to patients who call with questions and developed a new scheduling system to standardize outreach and scheduling for vaccine-eligible patients.

Because their office space was too small to monitor patients for post-vaccine allergic reactions during normal business hours, they organized special weekend COVID-19 vaccination clinic hours. Yet, the groundwork has been laid for integrating vaccination into routine practice.

Medical reminders are messages sent to patients to remind them of recommended or upcoming treatment. Messages can be sent by autodialed phone calls, text messages, or post-cards, for example.

• Barriers Addressed: Equity, Access, Forgetfulness, Friction, Health Literacy, Lack of Adequate Information
• Research Base: Reminders of upcoming vaccination appointments can increase vaccination rates. This intervention is often part of a multi-pronged approach combined with removing access barriers to optimize uptake.
  • Duval County Health Department in Florida successfully increased childhood vaccination rates by using data from the Florida Shots Registry to identify families with upcoming or overdue child vaccinations and sending them reminders with educational materials through phone calls, letters, and home visits.
  • A study in Rochester, New York, showed that when interventions included patient reminders, provider reminders, and telephone outreach combined, older adults were up to six times as likely to be vaccinated against flu.
  • A University of Pennsylvania study found that simple reminder text messages sent to 47,306 patients in two health systems increased flu vaccinations by around 5%. Of the 19 different messages tested, those most effective were presented in a professional format and tone—surprisingly not casual  or interactive. The most successful messages reminded patients twice to get their reserved shot at their upcoming doctor’s appointment.

Several state and local health departments, including in Michigan, Oklahoma, and Baltimore, Maryland, are using text messages to:

• Help people schedule COVID-19 vaccination appointments
• Provide education and vaccination site information
• Gauge views on vaccination

Certain populations can be reached with messaging, either based on race, ethnicity, or age, or used in geographic locations with low vaccination uptake. In most cases, texts are provided in English and Spanish, but health departments or other entities sending texts can translate and customize to any language spoken in their community of focus. This can also be used to remind people of their second vaccination appointment, if applicable.

Well-crafted emails containing behavioral nudges can also be used as reminders to get vaccinated.

A large Pennsylvania health system found that after a five-week effort to have employees vaccinated against COVID-19, 41% still had not scheduled their vaccination. They found through a study that individually addressed emails containing behaviorally informed messages increased vaccination registration.

The emails had three important components:

• Told the healthcare worker that vaccines would soon be available more broadly, thus, reducing employees’ access and emphasizing scarcity.
• Contained a message either about social norms, saying that many fellow employees had already chosen to get vaccinated; or about risks, comparing the risk of vaccination with the risk of COVID-19.
• Asked employees to make an active choice by clicking through to schedule their vaccination appointment.

Motivational interviewing refers to patient-centered conversations designed to increase patient motivation and likelihood of health behavior uptake.

• Barriers Addressed: Misperception, Health Literacy, Uncertainty
• Research Base: Motivational interviewing aims to support decision making by strengthening a person’s intention to vaccinate based on their own arguments. The healthcare professional informs about vaccination in alignment with the individual’s specific informational needs and with respect for their beliefs. Motivational interviewing has been shown to decrease parental vaccine hesitancy.

  A pilot study using motivational interviewing in maternity wards during postpartum stays found the strategy led to:

  • 15% increase in mothers’ intention to get their child vaccinated
  • 7% increase in infants’ vaccination coverage at seven months
  • 9% greater chance of complete vaccination at two years

  Motivational interviewing significantly improved HPV vaccination completion among adolescent patients in a study that used a presumptive vaccine recommendation with motivational interviewing follow up for parents who remained resistant. Some healthcare providers have concerns that this approach takes too long and that such a conversation is not billable.

Motivational interviewing can be a strategy to promote COVID-19 vaccine uptake.

For example, a demonstration project in the Pittsburgh area showed that innovative notification and motivational interviewing strategies at a regional chain supermarket pharmacy increased the number of herpes zoster, flu, pertussis, and pneumococcal vaccines given to adults.

Pharmacy staff identified the patient, who then received an automated notification about their vaccination status. The staff used motivational interviewing techniques face-to-face or by telephone to engage patients in conversation about getting vaccinated.

Community pharmacies are accessible and able to provide COVID-19 vaccinations to many customers, along with their other patient-centered products and services and may be able to model programs like this.

Financial incentives aim to motivate people to participate in a health behavior by providing a tangible reward, or a chance at a tangible reward, for completion of the behavior.

• Barrier Addressed: Inertia
• Research Base: While evidence supporting the use of incentives to increase vaccine uptake is overall limited, the type that appears effective is of a guaranteed gift incentive. For example, offering a $30 incentive increased vaccination rates at college campus clinics according to one study.
  Two recent studies of the Ohio COVID-19 vaccine lottery have been less positive, showing the likelihood that the approach has not increased vaccine uptake. It is important to note that these are two different approaches—one is a guaranteed gift and the other a chance at winning. Also, the audiences differ with the first comprised of young adult college students and the latter a general population. Thus, the approach and audience may affect vaccine uptake differently.

• West Virginia state government is offering residents ages 16 to 35 who have been vaccinated a choice of receiving either a $100 savings bond or a $100 gift card. The governor estimates this might cost the state up to $20 million.
• California offered $50 in the form of a virtual Mastercard or grocery gift card to residents who started their vaccination series between May 27 and July 18. The money is limited to the first 2 million requests, which limits the total cost to the state.
• Employers are also offering cash incentives to their staff. Maryland state employees will receive $100 and the Colorado Department of Corrections will provide $500 to staff who elect to get vaccinated.
• Many large private corporations are also providing cash incentives to employees, often ranging from $75 to $500 including Amazon, Kroger, PetCo, AutoZone, and Bolthouse Farms.
• Many businesses are offering free products to those who have been vaccinated, including the well-publicized free Krispy Kreme donut. Several states are offering free admission to state parks or similar incentives for vaccinated visitors. Offers like these non-monetary guaranteed incentives have not been well-studied for effectiveness.

School-located vaccination programs are events held at a school campus to remove logistical barriers and increase vaccine uptake. These can be open to students only or offered to faculty, families, and the greater community as well.

• Barriers Addressed: Access, Friction, Prevailing Social Norms, Uncertainty, Lack of Adequate Information
• Research Base: Voluntary school-located vaccination programs have demonstrated high coverage, though they are not without challenges. One of the major challenges is obtaining informed parental consent when needed. School-located programs can be effective even with “controversial” vaccinations such as for HPV. The setting also has been shown to yield higher completion rates of multi-dose vaccine series as compared to community health center settings.

Parkway School District in St. Louis County, Missouri held its first school-located COVID-19 vaccination event on April 26, 2021. The event was held in partnership with a local pharmacy. In a survey, 350 parents said they were interested, and the 204 students who were vaccinated at the event represented about 5% of eligible students in the district.

Timing of the event may have affected turnout because some expressed concern about the second dose occurring during the week of final exams for some students. School nurses are trusted sources of health information and play an important role in educating students and families about the COVID-19 vaccines.

While this strategy focused on vaccinating students through school-located vaccination programs, school settings may also be ideal locations for community vaccination events. Much for the same reason schools are often used as voting locations, they generally are:

• Easily accessible
• Have ample parking
• Have both indoor and outdoor spaces available
• Are familiar places

Home-delivered vaccination efforts reach populations where they are; traditionally used when barriers to transportation and access exist.

• Barriers Addressed: Equity, Access, Inertia, Friction
• Research Base: Bringing vaccines to where people are, including in their homes, is an effective means to reach several hard-to-reach populations. This strategy can be applied to homebound people and to neighborhoods with low vaccination rates.

In an effective effort in New York City, individuals canvassed specific communities to educate people about the flu vaccine and offered it to people on the spot. They focused on:

• People with substance use disorders
• Immigrant populations
• Older adults
• Sex workers
• People experiencing homelessness

Both appointment-based home delivery and canvassing methods may be effective ways to deliver COVID-19 vaccines.

As the COVID-19 vaccination effort progresses, there have been shifts from mass vaccination sites to smaller neighborhood and community clinics, and now to home-based efforts to give all individuals the opportunity to get vaccinated.

The Emergency Operations Center in Multnomah County, Oregon, partnered with the Multnomah County Public Health Division and County Human Services to provide COVID-19 vaccinations through a mobile program to reach people where they live. Initially vaccinating those in adult care homes, they have expanded the project’s scope to include other homebound adults.

The county’s mobile door-to-door COVID-19 response team pairs Medical Reserve Corps volunteers, who are licensed medical practitioners, and other volunteers to assist in providing COVID-19 vaccinations to people in their homes. The goal of the response, launched in February 2021, is to vaccinate up to 5,000 people.

A vaccination event held on-site at a workplace to remove logistical barriers and create norms. This can be open to employees only or extended to family members or the greater community.

• Barriers Addressed: Access, Cost, Prevailing Social Norms, Friction
• Research Base: Numerous studies have shown that vaccination programs at the worksite can increase vaccination rates among workers and their families. In one study where flu vaccination rates increased significantly after the intervention, 90% of vaccinated employees received a vaccine at employer-sponsored events. The most important reasons employees reported for being vaccinated at work were not related to health, but that the vaccine was free and convenient, and would help them avoid being absent from work. There is evidence on-the-job COVID-19 vaccination may have similar uptake success:
  • A recent Kaiser Family Foundation study found that 23% of Americans would be more likely to get vaccinated if was available at their workplace.
  • Another recent survey of employees by McKinsey & Company found an even greater potential return with 83% of those surveyed saying offering on-site vaccinations would significantly (49%) or moderately (34%) increase the likelihood that they would get a COVID-19 vaccine.
  • According to a 2020 Gallup poll, small businesses are one of the most trusted institutions in the United States.

Tyson Foods is offering on-site COVID-19 vaccination at many of their facilities.

In Iowa and Illinois, the company partnered with the Midwest grocery chain Hy-Vee and state and local public health departments to vaccinate food processing workers at four locations in the two states.

Workers in that industry have been hit hard by COVID-19 and were extremely excited for the opportunity. The workers are diverse, with one facility requiring vaccine education information translation in 18 languages. Tyson Foods also offered workers up to four hours of regular pay if they needed to get their vaccine(s) outside of a normal shift or away from the jobsite.

Small businesses can also support on-site vaccination efforts. In Jackson, Mississippi, the Broad Street Baking Company partnered with the Mississippi State Department of Health and the G.A. Carmichael Family Health Center to hold mobile vaccination events in a parking lot near the restaurant in April and June 2021.

Vaccination requirements are policies that require employees, students, or patrons to be vaccinated and provide proof of vaccination to comply.

• Barriers Addressed: Policy, Inertia, Prevailing Social Norms, Politicization
• Research Base: Vaccine requirements at the organizational level may be an effective way to increase vaccination rates and decrease disease incidence. Requirements by employers or schools ask that employees or students provide proper documentation of vaccination to comply with the organizations vaccination policies. Exemptions can be offered for specific circumstances, such as medical and religious reasons.
  Vaccination requirements have not often been used for adult populations, except for military requirements and for healthcare workers to receive flu shots.
  There is evidence showing school mandates positively impact uptake for routine childhood vaccines and some studies suggest that vaccination for children and workers, including mandatory vaccination, decreases absenteeism.

Many employers and institutes of higher education such as universities are requiring staff and students to be vaccinated against COVID-19. Several large companies have most recently required staff to be vaccinated to return to the office. Many federal, state, and local governments are also requiring vaccination for employees; some with an alternative option to get tested for COVID-19 weekly. Examples of early adopters of vaccination requirements are provided below.

Houston Methodist Health System:

Houston Methodist was the first health system in the country to mandate COVID-19 vaccination for all employees to protect their patients and workforce. The health system is made up of an academic medical center and six community hospitals employing over 26,000 people.

The first phase of the policy included managers and new hires and was gradually rolled out to all staff. Those not in compliance received a two-week suspension during which they had another opportunity to get vaccinated.

Several employees pushed back on the requirement and took the hospital system to federal court. The Texas court dismissed the lawsuit and upheld the vaccine requirement stating that the requirement does not break any laws and is in line with public policy.

Morgan Stanley Office Vaccine Policy:

Morgan Stanley created a policy requiring all employees returning to their offices to be vaccinated. It also extends to clients and visitors to their two New York offices.

The company views this policy as a way to create a safe and normal office environment. Employees who remain unvaccinated have the option of working from home, but the company is strongly encouraging employees to come back into the office.

Effective messages are messages that have undergone testing with the intended population and were shown to produce the desired outcome.

Trusted messengers are people seen as credible sources of information by specific populations. Trusted messengers can be trained to be vaccine ambassadors (see Strategy 1) and may include experts.

• Barriers Addressed: Mistrust, Health Literacy, Misinformation, Lack of Adequate Information
• Research Base: The messengers and messages used to convey information about vaccines are important to improving vaccine confidence.

The COVID-19 States Project Report evaluates results from two experiments designed to test effective communication strategies for increasing COVID-19 vaccine confidence and intent. The first experiment tested five messages and a control message for the effects they had on participants’ willingness to receive a COVID-19 vaccine. The messages involved themes of:

• Patriotism
• Harm reduction
• Social norms
• Scientist recommendation
• Physician recommendation

The study found that messages involving a personal physician or a scientist recommending vaccination were the most compelling. The second experiment looked at messenger effectiveness and found that messages delivered by politicians increased resistance to vaccination, while those delivered by physicians or scientists showed increased vaccine confidence and intent.

Messages and messengers should be continually evaluated for effectiveness and tested across populations with different demographics. Continued evaluation of messages enables communication campaigns to tailor messages to specific concerns and demographic populations, which is shown to be more effective than generalized messaging.

The Black Coalition Against COVID-19, The Kaiser Family Foundation, and Esperanza Hope for All created a COVID-19 vaccine communications campaign called “The Conversation,” which uses the hashtag #BetweenUsAboutUs.

The campaign features 50 videos of Black and Latino doctors, nurses, and scientists talking about vaccine facts and dispelling misinformation.

In addition to the videos, the campaign offers graphics, print media, social media content, and TV and radio public service announcements. The content is free for educational use and communities and organizations are invited to download and use the materials in English and Spanish.

Some content features doctors sharing why they got vaccinated. One graphic shows a Black female doctor with the quote: “When we get enough people vaccinated, we’re going to see the death rates go down. Then we’re going to see the hospitalization rates go down.”

Provider recommendation refers to healthcare professionals recommending that a patient receives a COVID-19 vaccination.  

• Barriers Addressed: Inertia, Friction, Mistrust, Uncertainty, Mis- and Disinformation, Lack of Adequate Information

• Research Base: Provider recommendations have strong support for increasing vaccination. The Advisory Committee on Immunization Practices includes this strategy in their recommendations for improving vaccination rates. Some people may have more trust in their own doctor than in the medical community in general.
  • Research on vaccinations in pregnant people found that a provider recommendation increases vaccination rates, and when coupled with offering the vaccination during doctor’s office visits, doubles the likelihood of uptake.
  • In a study of flu vaccination in adults, patients whose providers recommended and offered the flu vaccine during their office visit were 1.76 times more likely than those who did not receive a recommendation to be vaccinated.
  • The HPV vaccine, which relies on healthcare professionals for distribution, depends on provider recommendations for adequate coverage. A study on low HPV vaccination rates in North Carolina found that lack of provider recommendations contributed to under-vaccination in the population.

The New York City Department of Health and Mental Hygiene created a resource called Vaccine Talks that emphasizes the importance of healthcare professional recommendations in increasing COVID-19 vaccination rates.

Vaccine Talks offers resources for healthcare providers and their staff to recommend and offer COVID-19 vaccination at multiple patient interaction points.

The health commissioner released a statement promoting Vaccine Talks  emphasizes patients’ trust in their healthcare providers and says that their strong recommendations for COVID-19 vaccines will help drive vaccination rates in the city.

Vaccine Talks includes a resource called the “Use Every Opportunity” tool, instructing healthcare offices on how to integrate COVID-19 vaccine education and offers into all healthcare settings. Vaccine Talks also provides a form providers can complete to request that the public health system contact the patient to schedule their vaccination at a clinic or in their home, if needed.

Emergency departments and urgent care facilities are important locations for COVID-19 vaccine provider recommendations due to the high number of patients seeking routine care in these settings.

The Philadelphia Department of Public Health called on emergency facilities to begin recommending and administering COVID-19 vaccines to patients upon discharge. The notice focused on postpartum discharges and patients being discharged to long-term care facilities as key demographics for provider recommendations and offers. They also provided best practices for vaccination during patient discharge.

This strategy consists of tactics used to address and dismantle misinformation and disinformation. Misinformation refers to false information shared by people who do not intend to mislead others,  and disinformation refers to false information that is deliberately created and disseminated with malicious intent to manipulate a narrative.

• Barriers Addressed: Misperception, Mis- and Disinformation, Lack of Adequate Information
• Research Base: Believing incorrect information can act as a barrier to vaccine uptake. Vaccine myths are particularly difficult to combat, in part because people tend to believe information that is in line with their existing attitudes and world view.
  Fact-checking and debunking appear to be effective tools to counteract the effects of misinformation, particularly when the correct information sources are universities and health institutions. Debunking incorrect information with messages that reflect the worldview and affirm the values of the intended audience may be the most successful approach.

  Debunking misinformation is challenging. Misinformation is often simple and more cognitively attractive than fact, and refuting a falsehood often requires repeating it, which reinforces the falsehood in the believer. Techniques that help dispel falsehoods include:

  • Warning the audience upfront that misleading information is coming
  • Using fewer arguments to refute the myth
  • Keeping the factual statements simple

Everyday social media users can play an important part in correcting misinformation. While the person originally expressing the misinformation may not be moved because the correction does not align with their world view, others see the correct information and are impacted by it. Tips for effective corrections include responding with empathy and providing facts, rather than simply saying something is wrong.

Public Good Projects (PGP) is a public health non-profit organization with a mission to stop the spread of vaccine misinformation through evidence-based media monitoring, behavioral interventions, and cross-sector initiatives. In the beginning of the COVID-19 pandemic, PGP created a misinformation tracking system to monitor misinformation being shared about COVID-19 and later about the vaccines.

Using this tracking system, PGP pinpointed ideas that could pose a threat to public health measures and worked with scientists to create evidence-based responses.

To combat the misinformation, PGP identifies social media micro-influencers with audiences who have high rates of vaccine hesitancy and equips them with science-backed messages to share with their social networks. Their vaccine-hesitant followers are more likely to accept this information when it comes from someone they trust rather than from a health expert.

Disseminating factual and easy to understand information combats mis- and disinformation. This can be done in a variety of ways, including:

• Identifying and training social media micro-influencers in your community as PGP is doing nationally
• Using your own social media account to promote accurate information