A Social and Behavioral Research Agenda to Facilitate COVID-19 Vaccine Uptake in the United States

Abstract

Since its first appearance in the United States in February 2020, novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has infected over 3.77 million and killed over 140,000 people in the United States (as of July 20, 2020).¹ Responses to the virus, including closing venues where person-to-person spread was likely (eg, schools, churches, businesses) and requiring the use of masks and physical distancing measures when person-to-person contact could not be avoided, reduced the spread of SARS-CoV-2. At the same time, these protective actions have also radically transformed social life and upended national and household economies.^2,3 As the health crisis continues and pandemic fatigue starts to take hold, political leaders, health officials, and the general public are anxiously searching for solutions.

One of the most promising solutions is vaccines—if they can be successfully developed and deployed—that could provide individual- and population-level immunity and, thus, the conditions for routine social and economic activities to resume. To facilitate the development and dissemination of such medical countermeasures, the US government has committed over $10 billion for Operation Warp Speed—a public–private partnership involving several government agencies, including the Centers for Disease Control and Prevention, the Food and Drug Administration, and the Department of Defense.⁴ Operation Warp Speed aims to deliver 300 million doses of a safe, effective vaccine by January 2021.⁴ This timeline is likely overly optimistic. Vaccine development, especially against a pathogen for which no vaccine currently exists, as is the case with coronaviruses, typically takes 10 to 15 years.⁵ Progress is being made, however. As of May 15, 2020, 14 promising vaccine candidates were in development.⁴

Despite this promising technological output, Operation Warp Speed nonetheless manifests a key social gap. The program rests upon the compelling yet unfounded assumption that “if we build it, they will come.” Past vaccination experience in routine and crisis contexts demonstrates that not all segments of the public may accept a vaccine due to concerns about safety. Uneven access to vaccines could also amplify social and economic disparities as well as feelings of racial bias. And anti-vaccination (anti-vax) sentiment could be exacerbated if mask and physical distancing opposition converges with the existing anti-vax movement, further eroding trust in public health and government.

Under these conditions, what can be done to close the gap between the technical supply and the social demand for SARS-CoV-2 (coronavirus disease 2019 [COVID-19]) vaccines? With the lag time in vaccine availability, US vaccination planners and implementers can exercise foresight and take proactive steps now to overcome potential hurdles to population uptake. Such steps would allow for evidence-informed policies and practices that would enhance public understandings of, access to, and acceptance of COVID-19 vaccines.

A Research-Setting Agenda

In April 2020, principal investigators from the Johns Hopkins Center for Health Security and the Texas State University Department of Anthropology convened the 22-person Working Group on Readying Populations for COVID-19 Vaccine, with support from the National Science Foundation-funded CONVERGE Initiative (Table 1). Members of the working group included national experts in public health and social science research in areas such as anthropology, bioethics, bioinformatics, communication, disaster medicine, epidemiology, history, political science, public health, sociology, and vaccinology. One of the key products of this group was a research-setting agenda that is meant to identify key ethical, empirical, and methodological gaps, related to COVID-19 vaccine uptake, that require urgent attention by both researchers and funders.

Table 1.

Working Group on Readying Populations for COVID-19 Vaccine

Co-Chairs
• Emily K. Brunson, MPH, PhD, Associate Professor of Anthropology, Texas State University
• Monica Schoch-Spana, PhD, Senior Scholar, Johns Hopkins Center for Health Security
Members
• Luciana Borio, MD, Vice-President, In-Q-Tel
• Janesse Brewer, MPA, Associate in Global Disease Epidemiology and Control, Johns Hopkins Bloomberg School of Public Health
• Joseph Buccina, MS, MA, Director of Intelligence Community Support, In-Q-Tel
• Nancy Connell, PhD, Senior Scholar, Johns Hopkins Center for Health Security
• Laura Lee Hall, PhD, President, Center for Sustainable Health Care Quality and Equity
• Nancy Kass, ScD, Phoebe R. Berman Professor of Bioethics and Public Health, Johns Hopkins Bloomberg School of Public Health
• Anna Kirkland, JD, PhD, Arthur F. Thurnau Professor of Women's and Gender Studies, University of Michigan
• Lisa Koonin, DrPH, MN, MPH, Founder, Health Preparedness Partners, LLC
• Heidi Larson, PhD, Professor of Anthropology, Risk and Decision Science, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine
• Brooke Fisher Liu, PhD, Professor of Communication, University of Maryland
• Rex Long, MA, Doctoral Student, Department of Anthropology, Texas State University
• Saad Omer, MBBS, MPH, PhD, FIDSA, Director, Yale Institute for Global Health; Professor of Medicine (Infectious Diseases), Yale School of Medicine; Susan Dwight Bliss Professor of Epidemiology of Microbial Diseases, Yale School of Public Health
• Walter A. Orenstein, MD, Professor of Medicine, Epidemiology, Global Health, and Pediatrics, Emory University
• Gregory A. Poland, MD, Professor, Department of Pediatric and Adolescent Medicine (Pediatric Infectious Diseases) and Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic
• Lois Privor-Dumm, IMBA, Senior Advisor, Policy, Advocacy, and Communications, and Director, Adult Vaccines, Johns Hopkins International Vaccine Access Center
• Sandra Crouse Quinn, PhD, Professor and Chair of the Department of Family Science and Senior Associate Director of the Maryland Center for Health Equity, University of Maryland School of Public Health
• Sanjana Ravi, MPH, Senior Analyst, Johns Hopkins Center for Health Security
• Ali Ruth, AB, Doctoral Student in Bioethics and Health Policy, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health
• Daniel Salmon, PhD, Director of the Institute for Vaccine Safety and Professor of International Health, Johns Hopkins Bloomberg School of Public Health
• Marc Trotochaud, MSPH, Analyst, Johns Hopkins Center for Health Security
• Alexandre White, PhD, Assistant Professor, School of Medicine, and Associate Director for the Center for Medical Humanities and Social Medicine, Johns Hopkins University

This agenda was developed through a combination of literature reviews on vaccination, pandemic planning, and health crisis communication; an assessment of current news and social media trends about COVID-19 vaccines; and interviews with each working group member focused on their respective expertise. Topics covered in these interviews included interviewees' opinions about major obstacles that could affect COVID-19 vaccine uptake, best practices to address these obstacles, and how current social conditions might alter known dynamics of vaccine uptake. After analyzing the gathered evidence, a core team of 9 working group members drafted the research agenda and then distributed it to the entire expert working group. Written and verbal feedback were obtained through email and an online meeting with the entire working group on May 14, 2020. This feedback was then incorporated into a revised version of the agenda, which was circulated to the entire working group for further comment, revision, and signoff. The research-setting agenda that follows is the result of this process.

Existing Challenges

Readying the US population for COVID-19 vaccination is a complicated task due to a convergence of known trends and critical uncertainties. First, while the context of a protracted, lethal, and disruptive pandemic has heightened the perceived value of COVID-19 vaccines, many technological uncertainties exist that complicate planning efforts. Understandings of COVID-19 virology and immunology (eg, mutations, levels of immunity necessary to prevent community spread) are still evolving.^6-8 Likewise, key vaccine attributes, such as platforms, immunogenicity, and duration of immunity are not yet known.^9,10 The potential for multiple manufacturers, the use of adjuvant, and the need for multiple doses complicates logistical planning and its explanation to the public.¹¹

Second, communication challenges related to vaccine production and safety are made even more difficult by the pandemic situation. Pressures to make COVID-19 vaccines widely available on an accelerated basis may raise concerns about how fast is too fast for adequate safety and effectiveness testing.¹² The situation is further complicated by the fact that the urgent deployment of COVID-19 vaccines—determined to be safe and effective, yet still classified as “investigational”—will require Emergency Use Authorization by the US Food and Drug Administration.¹³ The complexity of these issues creates a particularly challenging communication environment.

Lastly, because the pandemic is occurring in a social moment where partisan, racial, and other divisions run deep, additional social and behavioral challenges to future COVID-19 vaccination campaigns exist. Deeply partisan actions, like the Republican president refusing to wear a mask in public, paired with a general lack of authoritative, apolitical guidance from institutions like the Centers for Disease Control and Prevention, threatens science-based public health.^14-16 Uneven geographical effects, with communities of color disproportionally affected, create distribution and allocation dilemmas.¹⁷ Inconsistent messaging about COVID-19 risk and its mitigation foster highly divergent threat perceptions that are further exacerbated by disinformation and misinformation—eg, Plandemic, 5G cellphone towers spread the virus, and drinking bleach can cure COVID-19—spread broadly through social and even traditional media.^18-22 Finally, pandemic fatigue or other causes for reductions in perceived risk for COVID-19 could cause public demand for vaccines to drop before they are even available.²³

Urgent Lines of Inquiry

In consideration of current circumstances and existing challenges, this research-setting agenda proposes new, urgent lines of inquiry to improve 3 core components of COVID-19 vaccination planning while adding a cross-cutting objective: advancing equity and solidarity. Current models suggest that vaccine decision-making determinants are complex, context-driven, and differently weighted; they include vaccine issues (eg, cost, safety/risks), individual/social group influences (eg, personal experience, cognitive biases, social norms, racism and discrimination), and environmental factors (eg, governance systems, media environment).^3,6,7 Improving vaccination rates consequently entails reconfiguring medical and public health systems as well as altering individual beliefs.⁸ While it may not be possible to address all these issues, we argue that it is possible—and essential—to make progress, particularly with regard to the following lines of inquiry where timely research and dissemination of findings are essential to the success of a future COVID-19 vaccination campaign.

ALLOCATE: Facilitate Community Engagement in Prioritization

Strong feelings of vulnerability may prompt persons to protest their lack of access to medical countermeasures, like vaccines, that have limited availability.^9,10 This is a common occurrence in emergency situations. Lack of vaccine access was a concern during the 2014-2016 Ebola outbreak in West Africa; and following the Fukushima nuclear accident in 2011, there was concern over a lack of access to potassium iodide, despite the fact its use was not often warranted.²⁴ Preexisting socioeconomic inequalities, especially inequalities in healthcare access, can further exacerbate such concerns.^12,13,25 Given that access to COVID-19 vaccines will likely be limited at first, and consequently prioritized for certain groups such as essential workers, we suggest that at this point it is critical to seek out and listen to input from the public, as they fundamentally will bear the weight of vaccine allocation decisions.

Community input on allocation decisions can generate innovative solutions, greater trust in authorities, feelings of ownership and understanding for decisions, and result in an informed populace able to exercise responsibility for collective wellbeing.^{11,14,15,17-19} Such methods have been used in the past to address issues such as prioritization for health coverage, socioeconomic interventions, and pandemic planning.²⁶ With regard to the integrity of a COVID-19 vaccination campaign, people will judge the results of the campaign on both the biomedical merits of the vaccine and on matters of fairness and equity—that is, have people received their just portion of health services, and is disease prevention, ultimately, fairly distributed? We contend that more transparency and community engagement can increase the chance that people will understand and embrace an allocation plan, even one in which they may not be among the first groups to be vaccinated. Moreover, community ownership of allocation decisions can strengthen the intent to vaccinate, thus helping to assure the fitting use of a public good.

Given the potential promise of community input on allocation decisions, we suggest that the following questions require urgent answers:

What are communities' beliefs and values regarding COVID-19 vaccine allocation? And how might health authorities weigh this input in connection with developing, implementing, and communicating vaccine allocation decisions?

How can traditionally face-to-face public engagement methods (eg, people-centered design, deliberative democracy, principled pluralism) be modified to work in an environment of physical distancing and uneven access to communication technologies so that they remain inclusive and retain known positive effects?

DEPLOY: Meet People “Where They Are”

Another critical aspect of a COVID-19 vaccination campaign that requires urgent attention is capacity development. Having the capacity to vaccinate large populations will involve coordination between vaccine suppliers, government agencies, and state and local health systems including clinicians, pharmacists, and, very likely, community health workers and other nontraditional vaccinators as well.^27-28 At local levels it will also entail assessing what resources are available and what resources are needed to ensure COVID-19 vaccines—once they are released to the general public—are widely available, accessible, and affordable, including any needed second or third doses.^29-30

Other critical aspects of deployment plans involve understanding, usually at local levels, what areas and times of day will ensure convenient access to vaccines, and what barriers, like locations that could induce fear for members of particular groups such as immigrants, exist so they can be addressed/avoided.^31-33 Americans, especially those with already precarious lives, may define their wellbeing and experience day-to-day pressures differently than public health policymakers do. Successful COVID-19 vaccination will likely hinge on concrete actions to meet diverse people where they are—literally in terms of place and figuratively in terms of mindset—while also attending to practical delivery requirements.

Research has shown that vaccine acceptance increases when governmental health and human service delivery, as a whole, respond to community priorities and ongoing needs.^34-36 This will be the case for COVID-19 vaccines as well. At this point in the pandemic, we suggest that the answers to following questions are essential to developing such a comprehensive, inclusive delivery plan:

How have local health agencies previously overcome vaccine hesitation in crisis contexts, especially among medically and socially vulnerable persons?

Can embedding COVID-19 vaccine access within a broader system of services (eg, food security, rent assistance), trusted institutions, or familiar places that people frequent strengthen acceptance and/or reduce barriers for subsequent doses?

Can less trained, yet trusted personnel deliver vaccines successfully to groups wary of authority figures?

What innovative partnerships with mid-level entities (eg, United Food and Commercial Workers Union, Transport Workers Union, United Farm Workers) can reach non-healthcare essential workers, many of whom are from disproportionately affected communities?

What would individuals and groups seeking out COVID-19 vaccination perceive as “safe” places (eg, protections from COVID-19 exposure, absence of immigration officials, presence of a familiar health provider, lack of military involvement)?

What partnerships with national organizations representing racial/ethnic minorities can provide valuable input and collaboration?

COMMUNICATE: Inform Communities and Build Trust

Setting Expectations

The final area that needs to be addressed before a COVID-19 vaccination campaign begins is communication, specifically setting appropriate expectations and speaking meaningfully. Novel vaccine technology—particularly that which uses fast-tracked research and development, an adjuvant, and/or an accelerated regulatory approval process—has the potential to heighten perceptions of COVID-19 vaccines as “risky,” “rushed,” and “experimental,” and, thus, fuel public concern^37,38; this happened during the 2009 H1N1 pandemic. After the H1N1 vaccine was released in October 2009, uptake was lower than expected, in part because of the widespread perception that the H1N1 vaccine was unsafe.²⁴ This concern persisted despite the facts that the H1N1 vaccine was developed using standard, regulated influenza vaccine technology (ie, it was a strain change for a flu vaccine not a novel vaccine³⁹) and was fully tested before release.

Likewise, erroneous associations between adverse events and vaccination and longstanding mistrust between communities and medical/public health authorities could complicate the public's perceptions of COVID-19 vaccines' safety. As exemplified by the false link between vaccination and autism, erroneous associations between vaccination and subsequent deleterious outcomes can heighten perceptions of risk and lead to lower vaccination rates.^40,41 Past unethical practices (eg, unconsented testing on Black people's bodies) and continuing racial biases in healthcare have likewise led many persons of color to be wary of health authorities and vaccinations during prior emergencies (eg, 2009 H1N1, 2001 anthrax).^42-46

Under these circumstances—where safety and effectiveness of COVID-19 vaccines are likely to be questioned—we argue more evidence-based, salient, and tempered communication that also conveys trustworthiness is required. The answers to the following questions could set the stage for such communication efforts:

What is the best approach to set public and provider expectations? Could it be, for example, striking the right balance between fostering hope for a COVID-19 vaccine and patience in obtaining it (due to safety precautions and allocation) or readying people for reports of potential adverse effects (with broad vaccination) while educating them that not all observed effects are attributable to the vaccine?

How can vaccination be encouraged in communities of color with high rates of chronic conditions, or other marginalized communities, while properly addressing wariness toward a novel vaccine?

Speaking Meaningfully

When considering the literature on vaccination decision making, it is clear that values, worldviews, and identities (eg, independence, collectivism)—enduring influencers in vaccine decision making^47-50—tend to vary in important ways between regions, states, communities, social networks, and individuals.⁵¹ This complicated, context-dependent bricolage of vaccination decision-making factors precludes a 1-size-fits-all approach. Additionally, vaccine misinformation abounds in social media where users encounter disproportionate negative reports and images, can be moved more by personal stories of adverse effects than scientific facts, and tend to judge disparate ideas about vaccines as equally valid, regardless of the source's expertise.^52-55 In this complicated setting, health communicators face the enduring problem of how best to engage, educate, and empower audiences with diverse beliefs and life circumstances.

The situation for COVID-19 vaccination will be little different in these regards. Listening to and learning about specific COVID-19 vaccine-related hopes and worries—and tracking these sentiments over time and within particular communities—could enhance rollout success. Understanding the concerns of the US population as a whole, as well as local communities and marginalized groups, can enable tailored messaging that addresses specific aspirations and fears of members of the public. Authorities could also invest in innovative countermeasures, including identifying and working with trusted national, state, and community spokespersons, to counteract the inadvertent or deliberate misinformation common in social media.²⁴ To accomplish this, however, necessitates answering critical questions in the near term, including:

What hesitations do specific populations (eg, essential workers, parents, groups with high co-morbidity rates, racial and ethnic minorities) hold? How might concerns be effectively addressed?

Apart from scientific facts (eg, immunity), what alternate reasoning could prompt vaccination? Being free to return to work or worship more quickly? Adhering to social and cultural norms (eg, altruism, collective obligation)? Lowering risk for vulnerable loved ones?

Who (eg, religious leaders, popular personalities) can serve as trusted spokespersons for these narratives? And, how can these strategies be adapted to fit local communities?

What else can proactively and effectively counter COVID-19 vaccine misinformation, given diverse agents (eg, individuals, organizations, malicious actors, some political leaders) and media (eg, traditional, social, homemade [street flyers])?

Concluding Thoughts

The research topics and questions presented in this commentary are examples of a greater scope of work that will need to be done to facilitate wide-scale uptake of COVID-19 vaccines—initially, and over time if the need for COVID-19 vaccines becomes routine. In our collective opinion, these are the first steps that need to be taken now, while there is still time to develop evidence-informed policies and practices that will enhance public access to and acceptance of COVID-19 vaccines. We call on researchers to begin working on these and related topics, and we entreat public and private funders to support these endeavors. Unless this critical social and behavioral research is completed before COVID-19 vaccines are produced, we fear that the subsequent vaccination campaign will be less than hoped for and perhaps insufficient to stop the disease and allow a return to routine social and economic activities.

Acknowledgments

This COVID-19 Working Group effort was supported by the National Science Foundation-funded Social Science Extreme Events Research (SSEER) Network and the CONVERGE facility at the Natural Hazards Center at the University of Colorado Boulder (NSF Award #1841338). Any opinions, findings, and conclusions or recommendations expressed in this material are those of the authors and do not necessarily reflect the views of the NSF, SSEER, or CONVERGE.

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