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.
Section 1: How can COVID-19 response actors challenge vaccine hesitancy, and support vaccine confidence and uptake?
What is vaccine hesitancy and what factors influence it?
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.
Individual and group influences – This includes people who are against vaccines in general, feel that vaccines are at odds with alternative or traditional medicines, perceive the risk of getting COVID-19 to be low, deem personal vaccination unnecessary if everyone else in their vicinity is vaccinated, and that certain social groups have different levels of immunity.
Contextual influences – This includes people who are vaccine hesitant due to issues of health equity, distrust in national institutions, fears of ethnic persecution, experiences with past vaccinations (HPV, MMR), and those who feel vaccines are incompatible with their religious, political, cultural, social, economic and or philosophical views. Past negative experiences related to vaccines or other aspects of health service delivery may colour people’s decision making about COVID-19 vaccines, even if those experiences related to events many decades before.
Vaccine and vaccination – This includes people who may resist vaccines due to concerns about safety, the side effects, the pace of the vaccine development, perceived lack of efficacy, vaccine roll-out schedules and accessibility, and the emerging mutations and variants.
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.
What can response actors do to promote vaccine confidence and uptake?
Below are some general principles to consider in order to build vaccine confidence:
Meaningful community engagement is key - Response actors should seek to strengthen community engagement components of their programmes and develop their skills in active listening, tolerance and empathy in order to build vaccine confidence. This may involve setting up structured and informal mechanisms to gather and document questions, concerns, and opinions on vaccines. Where possible, data should be collected on a rolling basis to capture changes in perceptions. Response organizations should also facilitate regular opportunities for staff to come together to discuss community perceptions and decide on potential courses of action to address these within programming.
Identify diverse ways of promoting vaccine confidence - For each individual there will be a different combination of factors that will influence their attitudes towards vaccines. For example, it is important to recognise that your programmes are not the only source of vaccine information that people are exposed to. Each individual will have their own combination of people within their social circles that influence their behaviour and beliefs, and they will be exposed to a range of information (including mis-information) and stories about vaccines. Therefore, there also needs to be a range of programmatic responses to promote vaccine uptake.
Facts alone may not shift opinions - The sharing of correct information about vaccines is critical in promoting vaccine confidence but may not always be sufficient to overcome vaccine hesitancy. This is because vaccine hesitancy is often related to deeper underlying values that an individual may hold. Facts and figures will only be accepted after people feel they have been listened to and that their concerns and values have been acknowledged. For others, they may be more persuaded by seeing and hearing the vaccination experiences of people who are similar to them or by hearing ‘thought leaders’ within their communities endorse the use of vaccines.
Utilise behaviour change thinking - Behavioural science plays a leading role in understanding and addressing a range of opportunities and constraints to vaccine uptake. The Little Jab Book presents common barriers, such as structural (cost, access, infrastructure), behavioural (inertia, prevailing social norms, misperception, social motives etc), and informational barriers (misinformation, lack of and complexity of information). Additionally, the following existing Hygiene Hub briefs might be useful when trying to understand and define effective behaviour change interventions:
Build trust - Mistrust is often the most common reason for vaccine hesitancy. Trust can be broken down into three levels - trust in the vaccine (the product), trust in the vaccinator (the provider), and trust in those who make the decisions about vaccine provision (the policymaker/institution responsible for development and delivery). It is important to realise that mistrust normally exists for a reason, such as inadequate health care services or decision making that lacks transparency or is not always in the best interests of populations. Building trust may require response actors to look at strengthening broader aspects of health care systems and re-evaluating the conduct of health care staff and policy makers.
Be honest about what is not known - Response actions must be transparent and honest about both their own expertise and the state of evidence around COVID-19 vaccines. It’s perfectly ok to respond to community questions by saying “I don’t know but I will find out”, and then follow up with this individual when you have more information. The amount of new evidence about COVID-19 is so overwhelming that no one has all the answers, and pretending that you have all the answers is setting organisations up for failure. Build realistic expectations from the community and enable community-led solutions.
Below we list a range of response interventions and tools, which could be replicated and or adapted across a range of settings:
Practical approaches for understanding and learning from communities:
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.
Useful resources to guide the development of your strategy for promoting vaccine confidence
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.
Possible activities and approaches for promoting vaccine uptake
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:
COVID and Me which are short film-based dramas which share conversations about vaccine research and the importance of being vaccinated. Each story is based on real patient experiences and conversations are conveyed in multiple languages.
BBC Media Action’s updated handbook on communication about COVID-19 includes ideas and tips for effective communication to support prevention behaviours, vaccine confidence, and counter misinformation. It is designed for media but is useful for anyone communicating about the pandemic and response.
Team Halo, an active global network which uses a network of scientists and health professionals who communicate Q&A videos of COVID-19 vaccine research and immunisation programmes to demystify their work and address the issues around vaccine fears. Their bite-sized videos are posted to TikTok, Twitter, and Instagram.
Willingness to accept a vaccine is not static, therefore it is critical to understand historical, contextual, and social factors that may affect attitudes towards vaccines.
Learn about COVID-19 vaccine concerns and create opportunities for ongoing dialogue.
Identify community skills, strengths, advocates, and trusted individuals that could facilitate uptake.
Section 2: Why is it critical to continue to promote existing COVID-19 non-pharmacological prevention methods along with vaccination?
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.
For the foreseeable future, COVID-19 response actors should promote in equal measure – vaccination, hand hygiene, covering coughs and sneezes, mask-wearing, physical distancing, and tackle misinformation on a rolling basis.
Is the pandemic over?
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.
Section 3: How can initiatives promoting COVID-19 prevention behaviours be integrated into vaccine roll-out?
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 .
Invest in health systems strengthening and the protection of healthcare workers
Support healthcare workers and health facilities with access to and use of WASH infrastructure, hygiene consumables and Personal Protective Equipment (PPE).
Provide training on vaccine communications and building vaccine confidence, Infection Protection & Control (IPC) training and PPE for all healthcare workers – cleaners, guards, traditional healers, and other stakeholders where relevant.
Provide hygiene consumables both at the workplace and at home to protect staff, patients, and family members.
Health care workers and vaccine programme staff should support community outreach to solicit trust, confidence, and uptake in the vaccine roll-out.
Continue with disease surveillance
Although we know much more about the virus three years later, it is still fundamental that surveillance efforts remain, to continue understanding the evolution of the virus, identify new variants of interest, and risk factors for severe disease as well as the impact of vaccination. Coordinate and integrate disease surveillance efforts for COVID-19 and other diseases between health and WASH stakeholders. Keep sight of other health issues and impacts, alongside the COVID-19 vaccine roll-out and routine immunisation.
Aligning communication approaches and programming.
Build communication networks across different types of response actors and leverage those that have already been established. For example, Risk Communication and Community Engagement networks often combine government and non-governmental actors from a variety of sectors and expertise. These groups meet regularly and can be a good starting point for finding out who is doing what in a country or region. Encouraging partners to share information about community perceptions, communication and programmes that are being delivered or that are being planned can avoid duplication or confusion in communication. Ongoing sharing on what is working well, as well as common challenges, can help improve programme quality. Where possible work together to develop a strategy for risk communication and community engagement that covers prevention behaviours and vaccine promotion.
Trusted and established communication systems which have already been utilised to share information about COVID-19 prevention behaviours are well-placed to support the vaccine roll-out as well.
Many countries’ populations are facing other crises, such as conflict, drought, other disease burdens, food insecurity and livelihood constraints. These broader concerns are likely to affect vaccine-related perceptions. By collaborating with other sectors, you may be able to develop programming that is more holistic, which acknowledges these competing concerns and which is ultimately more relevant to communities.
Use vaccine delivery sites as opportunities to continue promoting prevention behaviours
Conduct capacity strengthening activities to support the work of health workers and frontline response so that they have sufficient information about vaccines and prevention behaviours and so that they are able to effectively listen to populations. This may include skills to understand the secondary impacts of the pandemic or other health and livelihood concerns and to communicate about vaccine side effects.
Consider using vaccine centres as locations for the promotion of COVID-19 prevention behaviours and the promotion of other health behaviours and services. This could include distributing COVID-19 prevention or hygiene kits, informing people about other health services (e.g. routine vaccinations) or promoting the uptake of other health behaviours (e.g. use of mosquito nets)
As part of the WHO Immunization Agenda 2030, integration of vaccination with other health services is part of one of the seven strategic priorities. Examples of integration include providing Vitamin A during routine immunizations to children, deworming campaigns and treatment for malaria control. Equally, other health events and spaces can be used to deliver immunizations such as health fairs and social gatherings.
Using vaccine delivery sites as opportunities to promote prevention behaviours can be an effective strategy. Community health fairs, for example, can provide integral health care, promote preventive behaviours and deliver vaccines all in one setting. The Baylor Community Engagement Alliance team in Texas, USA successfully organized a health fair, where they offered COVID-19 vaccines and information alongside other health services. Another approach is to attend special events, not necessarily health-related and offer information treatment and immunizations for different diseases. During the Monkeypox outbreak health agencies like the CDC organized campaigns to attend Pride events and Music Festivals to offer information about the disease and vaccination. These approaches demonstrate the potential to leverage vaccine delivery sites to promote broader health initiatives and behaviours. The selection of approach will depend on the community and setting you are working in.
Create an enabling environment with products, information, services, and infrastructure.
The pandemic necessitates response actors to be empathetic, have robust listening and analytical skills.
Utilise vaccination centres as opportunities to promote preventative behaviours.
One size does not fit all – we need adaptive programming for each and every context.
Is there experience in integrating preventative hygiene programmes into vaccine roll-out?
There is unfortunately limited information on the effectiveness of integrating hygiene programming into vaccine programmes. A few examples include:
A cluster randomised control trial in Bangladesh demonstrates the impact of adding handwashing and water disinfection promotion in conjunction with oral cholera vaccination on diarrhoea-associated hospitalisation in Dhaka, Bangladesh. They trialled targeted interventions to provide handwashing hardware and hygiene promotion at both the household and compound level in conjunction with cholera vaccination programmes. Two years after the interventions, 45% of households receiving hygiene promotion sessions had a functioning handwashing station compared to 22% of households receiving the vaccination alone.
In Kenya, hygiene kits (including supplies for household water treatment and soap for handwashing) were combined with hygiene promotion and distributed to carers during infant vaccine campaigns. While data on water treatment were mixed, reported practices and demonstration of correct handwashing technique increased almost two-fold compared to households not receiving the intervention.
In Nepal, WaterAid and the Government of Nepal’s Ministry of Health decided to maximise having a ‘captive audience’ of thousands of caregivers who visited immunisation clinics at least five times in the first nine months of their child’s life. Outcomes from formative research created a hygiene intervention package (with the theme of ‘Clean family, Happy family’) which was later delivered through hygiene awareness sessions at vaccination centres. Rotavirus immunisation brought hygiene and public health sectors together and helped avoid miscommunication about the rotavirus vaccine being a ‘diarrhoea vaccine’ and highlighted the need for a comprehensive strategy rather than an individual approach to control diarrhoeal diseases. The programme continues to be delivered at scale.
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