The global rollout of COVID-19 vaccines has been instrumental in reducing the spread of the virus. However, beyond issues with availability of the vaccine and equitable access, challenges around trust in vaccination have affected the uptake of the COVID-19 vaccine. Addressing vaccine hesitancy and promoting behaviour change are critical components of achieving successful vaccination campaigns. This resource is designed for Water, Sanitation, and Hygiene (WASH) actors, and other COVID-19 response actors, who have been working on prevention programs and are now adapting their strategies to support vaccine delivery and uptake.

Section 1: How can COVID-19 response actors challenge vaccine hesitancy, and support vaccine confidence and uptake?

WASH actors and others involved in COVID-19 response programmes have been frontline workers throughout the pandemic to date, and many have developed trusted modes of communication with communities. Response actors are therefore in a unique position to listen and learn about community concerns and build community confidence in vaccines. This section highlights some specific actions that can be taken to mitigate misconceptions and misinformation about vaccines and encourage populations to come forward for vaccination.

Section 2: Why is it critical to continue to promote existing COVID-19 prevention methods?

The second section recognises that vaccines will not be a quick solution and discusses reasons why we need to work with communities to continue to promote covering coughs and sneezes, mask-wearing, physical distancing, and hand hygiene.

Section 3: How can initiatives promoting COVID-19 prevention behaviours be integrated into vaccine roll-out?

The third section summarises prior examples of where hygiene and other preventative behaviours have been incorporated into vaccination programmes and identifies potential opportunities for this synergy during the COVID-19 pandemic.

Vaccine hesitancy is a state of indecision and uncertainty about vaccination before a decision is made to take it or not to take it. Vaccine hesitant people can be unsure of taking a vaccine and in the end decide to take it, or they may have accepted a vaccine but still have concerns about it. It is complex, context-specific, and varies across time, location, disease burden and vaccines available. Attitudes towards vaccines fall on a continuum - as shown in the diagram below. It is therefore critical to acknowledge and respond with communities to challenge misperceptions and misinformation and promote vaccine confidence and uptake.

Figure 1. Source: Johns Hopkins University of Medicine - Coronavirus Resource Center

It is important to highlight that vaccine hesitancy is one of the barriers to vaccine uptake, but there may be other reasons for people not getting a vaccine when its available, such as access.

The Vaccine Confidence Project has developed a Vaccine Confidence Index (VCI), which defines four domains influencing vaccine confidence including importance, safety, effectiveness, and compatibility with beliefs. This tool has been used to conduct global studies to map vaccine confidence for routine, new and underutilised vaccines since 2015. This has allowed the team to monitor vaccine confidence over time. It is worth noting that vaccine hesitancy is not a new issue, it was first defined in 2011, but has existed since the first vaccine was developed by Edward Jenner in the late 18th century.

In October 2018, WHO established the Behavioural and Social Divers of Vaccination Global group.

The Vaccine Hesitancy working group within the WHO Strategic Advisory Group of Experts (SAGE) outline reasons for vaccine hesitancy across three domains.

Misinformation, rumours and misunderstanding about COVID-19 vaccines contribute to vaccine hesitancy within each of these three domains. Additionally, the changing information environment, including changing in guidance and requirements, new information and epidemic context affected risk perceptions and the felt need for vaccination. The working group also highlights that it is critical to use local insight, knowledge, and data in every context. This is because the willingness to accept vaccines is not static - it is highly dependent on real-time information, the status of the pandemic, the perceived risk of contracting the infection and subsequent disease, and previous experience with vaccination campaigns and roll-out, vaccines and rumours about vaccines. This necessitates a dynamic, compelling, and productive two-way conversation to challenge vaccine misinformation and misunderstandings and enable vaccine uptake.

Below are some general principles to consider in order to build vaccine confidence:

Below we list a range of response interventions and tools, which could be replicated and or adapted across a range of settings:

1. Conduct formative research (and or make use of existing findings) about the factors that influence vaccine perceptions in your context. This should aim to explore patterns of social influence and sharing patterns, historical, cultural, and religious beliefs related to vaccines, common vaccines concerns, local disease coping strategies and community level innovations or mechanisms that could support the vaccine roll-out and continuation of preventive behaviours. Think carefully about how you ask about vaccines. Rather than just asking “Would you accept the vaccine?”, frame and convey the right questions so that they are more action-oriented questions, i.e., “What information would you like, what do you need, from who and how?”.

2. Map and understand where conversations about vaccines are happening within the community as different countries and social groups will use different platforms.

3. Make use of existing ways that vaccine perceptions are being tracked and try to align your work to these. Some examples include, but are not limited to COVID-19 Misinfo.org, Oxfam’s Community Perception Tracker, Rumour has it by CDAC Network, UNICEF’s Talkwalker National Country Dashboards, Rooted in Trust - Global Rumour Bulletin, Internews Rumour Tracking Methodology, First Draft and WHO’s infodemic management toolkit. Utilisation of these resources may help you pre-empt the emergence of similar perceptions in your local community and can allow you to connect with people in other regions of the world to understand what is working to encourage vaccine acceptance.

4. The World Health Organization has created a helpful tool to better understand why some people might choose to get vaccinated while other do not. This tool is called “Behavioural and Social Drivers of Vaccination” (BeSD).

BeSD is composed by four main domains that measure different aspects of people’s beliefs and experiences related to vaccines: thinking and feeling, social processes, motivation, and practical issues (Figure 2)

As we had mentioned, it is important to note that while vaccine hesitancy is one factor that can impact someone’s decision to get vaccinated, there are many other factors that can also influence their decision. Vaccine hesitancy falls under the “Thinking and feeling” domain in this framework.

This framework includes a series of guidelines and tools that can help you improve your vaccine programme planning and evaluation. It intends to guide you in the planning, investigation and acting. The tools are also useful for collecting information in a systematic way and being comparable across different contexts.

You can have a look at all the resources in Vaccination Demand Hub.

5. Develop a strategy to engage and communicate with a range of audiences via a range of delivery channels. The following resources incorporate useful guidance and tips to inform this process. The Vaccine Misinformation Management Field Guide provides a phased approach (preparation, listen, understand and engage), with tips to make your content resonate more than misinformation, examples of inoculating messages, and interventions to build immunity to misinformation. Other tools related to effective Risk Communication and Community Engagement (RCCE) include 10 steps, RCCE tools, behavioural indicators, the Global COVID-19 RCCE strategy and the Interpersonal Communication For Immunization Package.

You may also be interested in checking out the Social Science and Humanitarian Action Platform. They provide comprehensive briefings that draw on a variety of sources, including academic and grey literature, to present considerations for special populations such as migrants. Some of the briefings place particular emphasis on community engagement and communication.

6. Develop a list of frequently asked questions that are emerging from communities and recommend ways that staff can address these if they arise in the course of their work. Keep this list updated and ensure information is in line with current evidence and national vaccine roll out plans. Having this document to refer to will boost the confidence of staff when discussing vaccines, given that this topic is unfamiliar to many frontline workers.

7. Share personal experiences of getting vaccinated as this can be a powerful motivator for others. Ethan Lindenberger, who initiated a wave of pro-vaccine advocacy in 2018 conveyed that “people resonate with people, not data” and emphasised, “it’s important to start with empathy as a way of opening up the conversation”. Sharing experiences can be as simple as encouraging people to take vaccine selfies and share their vaccine status on social media or it could involve developing short videos of well-known individuals getting their vaccine and talking about the factors that influenced their decision making.

8. Engage religious leaders, social groups, health workers, teachers and other influential individuals and encourage them to discuss vaccine uptake with people in their community.

9. Use presumptive communication by framing vaccination as the default or normative behaviour.

10. Help communities to understand vaccine concepts like herd immunity and focus on the fact that vaccination is something that you can do to protect everyone in society, not just yourself. See our resource: What information should COVID-19 response actors know about the COVID-19 vaccines?

11. Build public resilience to misinformation, including by building digital and media literacy. This helps individuals understand what to look out for in fake news or false information and when they should or shouldn’t share content with their network of friends and family. For example, GoViral is a 5-minute game that helps protect you against COVID-19 misinformation. Studies have also shown that encouraging critical reflection can make people less likely to share misinformation. The use of different audio-visual communication formats can help people to stop and think before they share information or content on social media without fact-checking it first.

12. Focus on making vaccine-related communication clear, simple, and actionable. This could include developing clear ‘calls to action’ to drive behaviours and ensuring information is contextualised and tailored to specific sub-groups of the communities and certain types of beliefs. Using terms like ‘you’ and ’we’ is more likely to drive motivation and action and prioritising and grouping key messages can prevent people being overwhelmed with information. For example, the ‘rule of three’ can be a helpful approach to enable people to remember key behaviours (e.g., hand hygiene, mask use, physical distancing).

13. Mass media such as television and radio are a trusted source of information for many. Response actors can work with the media as a partner to create opportunities for two-way communications which address factors contributing to vaccine hesitancy. Some examples include:

While vaccines for COVID-19 have been developed rapidly and efficiently, there are still substantial challenges for global vaccination programmes in terms of vaccine access and delivery at an unprecedented scale. Given this, we need to create reasonable expectations about how the pandemic will evolve, what it will take for COVID-19 to no longer be a public health threat, and to encourage people to continue to practice COVID-19 preventative behaviours. Vaccines are only one tool in controlling the pandemic and we must avoid presenting them as the sole solution, but rather as part of a comprehensive approach. It important to note that while the COVID-19 vaccine can prevent severe illness and hospitalization it may not prevent infection. Additionally, the emergence or a new variant may affect the vaccine’s effectiveness.

When it comes to wearing a mask in the community, guidelines depend on the vaccination rates and level of community transmission of the virus. Medical masks are recommended for individuals at risk for severe COVID-19 (e.g., elderly or with high risk underlying conditions) when in public settings where distancing is not possible and for household contacts of those suspected or confirmed COVID -19 when in the same room.

The main objective of wearing masks in the community is to prevent transmissions from infected individuals by containing their respiratory secretions.

Studies show that mask mandates and high levels of self-reported mask-wearing are associated with a decreased community incidence rate, and lifting mask mandates can lead to an increase in case rates. In multiple observational studies, consistently wearing a mask has been associated with a lower risk of infection.

Moreover, other respiratory viruses such as flu, respiratory syncytial virus (RSV) and new coronavirus variants can be partially prevented by non-pharmacological interventions, such as wearing masks, washing hands and respiratory hygiene (e.g., covering the cough or sneeze). These interventions are particularly important for people with vulnerable immune systems, such as elderly, infants, and those with health conditions. The CDC reported a decrease of flu cases during the 2020 and 2021 flu season, likely due to the adoption of community mitigation measures.

We must adopt a comprehensive approach that promotes vaccines and prevention measures together to protect individuals, families, and communities. For more information on the effectiveness of other COVID-19 prevention behaviours search the Hygiene Hub resources.

There are no specific criteria to declare a pandemic is over. This BBC article provides a visual explanation of how other pandemics have evolved and makes the point that many of the diseases which rampaged through societies in the past, are still around but are no longer major public health threats.

In March 2020, the World Health Organization (WHO) declared the COVID-19 outbreak a public health emergency of international concern (PEHIC), a designation with legal implications that can trigger actions and resource redirection at a Global scale.

Three years after declaring the SARS-CoV-2 outbreak a PHEIC, the WHO Director General released a new statement at a media briefing on the 5 May 2023 stating that, “the Emergency Committee met for the 15th time and recommended to me that I declare an end to the public health emergency of international concern. I have accepted that advise. It is therefore with great hope that I declare COVID-19 as a global health threat". In other words, this is now a time for countries to transition from emergency mode to managing COVID-19 alongside other infectious diseases.

This means that the virus will continue to circulate, but the sense of emergency will shift as the high levels of immunity begin to limit the virus’s impact and reach. Nevertheless, the WHO is encouraging countries to maintain and strengthen surveillance and vaccination programs as infectious diseases can be unpredictable. It is crucial to remain vigilant and take appropriate measures.

Response actors can be resourceful, relevant, and supportive during the vaccine roll-out by integrating activities across vaccine roll-out initiatives, health care services and prevention programmes .

There is unfortunately limited information on the effectiveness of integrating hygiene programming into vaccine programmes. A few examples include:

Despite limited data, there are compelling arguments that support efforts to integrate hygiene promotion into vaccination programmes. Immunisation programmes reach many people and serve as a critical entry point to integrate WASH, with a particular emphasis on hygiene behaviour change interventions. Strategically, such collaborations provide an opportunity for efficient utilisation of resources and to communicate that there are multiple routes contributing to disease and therefore multiple prevention strategies needed at an individual or household level.

Originally written by: Jenny Lamb (LSHTM – Hygiene Hub)

Revised and reviewed by Ana Bolio (LSHTM – Vaccine Confidence Project) and Jenny Lamb (LSHTM – Hygiene Hub)

Last update: 10.08.2023