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Resources and Strategies to Build Vaccine Confidence among Adults

Kathryn A. Stofer, Alissa V. Katsaras, Skye Dougan, Miranda Jones, andLaToya J. O'Neal

Introduction

This publication serves Extension personnel and other health educators and communicators as they work to build health equity and overall healthy communities. Many health disparities such as those in vaccine uptake existed long before the COVID-19 pandemic, so there is both overlap with COVID-19 vaccine confidence and separate issues for other recommended adult vaccines. As Extension continues to expand its purview in adult immunization education, it should provide strategies for communicating one-on-one and in smaller and larger groups, as well as links to resources to build confidence and promote access for adults who have lower confidence in or who may face barriers to vaccination in Florida. This publication is a companion to two others (Katsaras et al., 2024; Stofer et al., 2024) which examine the general trends in and reasons behind adult perceptions of vaccination.

Overall Approach

As outlined in Stofer et al. (2024) and Katsaras et al. (2024), standalone immunization education may not be as effective as integrating information within a whole person health approach (National Institutes of Health, 2021; United States Department of Veterans Affairs, 2022). Each community is unique and will have different concerns and preferences for immunization education and engagement around the topic. Quality collaboration, co-design, continual listening to the communities, as well as an ability to adapt to changing guidance, (mis)information, and risk are crucial to ensure success.

This publication discusses strategies for both communication of information (i.e., what to share) and engagement (i.e., how to share with priority communities). We outline ideas such as listening first, building trust, identifying specific potential talking points, and determining whether and how to debunk myths. Understanding and working with your communities can guide you to appropriate and impactful strategies. We conclude with a brief overview of evaluation strategies.

Communication Strategies

Determining what to share with communities is vital to balance transparency and remaining areas of scientific uncertainty while motivating action. In general, access to information and awareness of a need are overemphasized when compared to other important considerations (Christiano & Neimand, 2017; Goldstein et al., 2015), so simply providing information is often not an effective way to build confidence and move people toward behavior change. Other publications from Extension personnel and Ask IFAS discuss background and theory related to how people move through stages as they prepare to change behaviors (Harder, 2013; Warner et al., 2015; Warner et al., 2022), and how to encourage behavior change through tools such as social marketing (Kumar Chaudhary et al., 2017; Kumar Chaudhary & Warner, 2015). Understanding specific areas of concern, barriers to access, and histories with messengers can shape the content most likely to resonate with each priority group.

Several specific strategies for communicating about vaccines are listed below.

  • Get an accurate understanding of any individual’s or community’s perceived threat of illness (Quinn et al., 2019), as the perceived risk of illness may be outweighed by the perceived risks posed by vaccination, especially in the case of a new illness or vaccine.
  • Address emotions and validate fears rather than dismissing concerns. Specifically for understanding barriers faced and supports needed for vaccination, use motivational interviewing (Washington State University EXCITE [Extension Collaborative on Immunization Teaching and Engagement] Project Team, 2023).
  • Demonstrate empathy in communication. The first step in empathizing is listening (Bauchat et al., 2016; Maurici et al., 2019). Many communities have long felt left out of conversations about them.
  • Share facts directly if debunking myths or misinformation. Consider carefully whether you need to address myths or misinformation; see more information below about motivational interviewing to discover reasons for lower confidence in vaccines. Try not to repeat the myths because doing so might solidify the myth or still reduce intent to vaccinate even if knowledge increases (Clayton et al., 2021; Nyhan, 2020).
  • Think about whom people trust and use them as sources for messages if possible (Public Health Communications Collaborative, 2022). Extension may or may not enjoy trust among certain groups, and the same is true for the CDC. Examples of trusted messengers include local physicians, physicians who share similar backgrounds and identities as members of the community, influential family and friends, faith leaders, or other local government or public health leaders. It is imperative that you know and listen to your community in this regard.
  • Work with communities who have trusted leaders to help amplify the messages. Consider hiring local ambassadors to strategically share vaccine education. This can help work to rebuild trust in institutions that have historically done wrong or otherwise broken trust.

Additionally, typical communication practices apply to vaccine-related messaging, as outlined by the Public Health Communications Collaborative (2022):

  • Remove jargon. Be clear and match your language and register (Staples, 2016) to those of your community.
  • Use language that reflects the communities with whom you work (American Medical Association, 2023; CDC, 2023).
  • Prioritize recognizing and working to repair disparities. Acknowledge historical and systemic contexts.
  • Meet communities where they are. If your priority communities are on a particular media platform, make sure your messages are on that platform, not just where you might find it convenient to post.
  • Think about the long term. Vaccine communication is one of hopefully many points of contact in your relationship with the community. Bridge to vaccine communication from previous campaigns and build the partnerships to continue to other topics in the future.

Engagement Strategies

One of the most important strategies for building confidence and motivating action in any context, whether it be health, political misinformation, or climate change, for example, is to listen to and validate the person’s views and fears. This does not mean you have to agree they are correct, but you should recognize that their feelings are legitimate and often grounded in at least some truth.

Finally, there are some cases where people do start with a lack of information. Engagement professionals and communicators should not presume people know vaccination is good for them (Baumgaertner et al., 2020); again, dialogue and listening are key to making meaningful exchanges. While the CDC has for many years recommended vaccination for adults, the U.S. has not had a sustained, widespread public adult vaccination education program until the last ten years (Roper et al., 2021; U.S. Department of Health and Human Services, 2016).

Specific strategies for engaging communities about vaccines include the following:

  • Consider co-creation of messages. These could be through community partnerships (ASTHO, 2019). Another option is to use advisory boards or community consultants to make sure language is appropriate and meaningful for the audience (Clinical and Translational Science Awards Consortium Community Engagement Key Function Committee Task Force on the Principles of Community Engagement, 2011).
  • In terms of meeting communities where they are, think about providing programming where the communities already are. Instead of asking them to come to you at an Extension office or a university campus, host events in their community centers, churches, and libraries. Engaging with communities in a place that resonates with their social and cultural context will create meaningful interactions with individuals (Clinical and Translational Science Awards Consortium Community Engagement Key Function Committee Task Force on the Principles of Community Engagement, 2011).
  • Integrate your programming into existing events such as county fairs, health fairs, employment recruitment fairs, and art and music festivals. Such integration will also reinforce messages over time.
  • Develop engagement strategies that integrate vaccines into a whole health approach. Whole person health considers multiple factors that promote health on the individual, family, community, and population levels (National Institutes of Health, 2021). Integrating health and disease into one programming area can effectively demonstrate their interconnectedness and overall impact on a person’s well-being (National Institutes of Health, 2021).

Building a strong and trusting relationship with audiences strengthens the effectiveness of communications and leads to healthier community outcomes. Consider these five steps when refining your communications process, outreach, and content (Public Health Communications Collaborative, 2022).

  1. Draft a comprehensive plan: Create a detailed plan that includes key messaging, priority audiences, outreach channels, anticipated complications, and timeline. Use plain language to establish clear and consistent messaging for all audiences.
  2. Ask for input: Seek feedback to ensure that your audience’s perspectives are captured in the published material.
  3. Read it back: Incorporate the received feedback into the plan.
  4. Prepare for launch: Verify that your communication channels are appropriate for your focus audience. Engage community outreach partners to provide credibility to the messaging.
  5. Improve for next time: After publishing, track and analyze engagement and reach while welcoming additional feedback.

Example Extension Programs

In 2021, the Extension Foundation launched a nationwide funding program for adult COVID-19 vaccine education funded by the CDC and USDA-NIFA, called the Extension Collaborative for Immunization Teaching and Engagement (EXCITE). As of 2024, teams from over 70% of land-grant institutions have been creating, adapting, and updating a whole range of media examples, one-on-one, and population-specific programs as well as feedback on their effectiveness for all recommended adult vaccines, including those for flu, pneumonia, RSV, and tetanus. In particular, the EXCITE Vaccine Messenger Toolkit offers resources to help Extension and other health educators improve their own confidence in promoting vaccination in their communities, focusing on three strategies: motivational interviewing, science media literacy, and neuromarketing.

In Florida, we work with a number of rural communities and hold listening sessions to help develop programs tailored for their needs around vaccine education. This results in our version of a whole health approach to education, which includes but is not limited to vaccine information and recommendations, cancer prevention, and diabetes prevention and care. The Protect Your Health program, offered by UF/IFAS Extension, adopts a comprehensive approach to health. Protect Your Health is a community resource for those interested in learning more about physical activity, nutrition, sleep, stress management, and adult vaccines. This program provides science-based information to help Floridians make informed decisions regarding how to best protect themselves, their families, and their communities from chronic and vaccine-preventable diseases.

Evaluation and Reporting

While this document cannot cover the entire scope of resources on evaluation, evaluating your programming iteratively to improve is vital, as is reporting those results to internal and external groups. As many of these strategies for engagement may be new, they may be supported best by evaluation strategies beyond a pre-/post- knowledge and attitude assessment. Partnering with evaluation specialists to measure reach creatively in terms of number of attendees and impact through evaluation can maximize your understanding of a program’s effectiveness. For Extension, matching program intended outcomes to an Initiative team will help align to existing Plans of Work and Reports of Accomplishments. For example, Initiative 5’s Healthy Living focus is likely an obvious fit, while others may be possible in consultation with your supervisor.

Many Extension professionals record one-on-one conversations as consultations. An easy way to evaluate these consultations more deeply could be to expand your record of how you conducted the consultation (e.g., recording time spent, date, location in office or in the “field”), to include a short reflection of your effectiveness at employing strategies such as those outlined here, and to note any reactions of the client about what seemed to resonate with them or alternatively, what did not work. You could even take the time to write down how you might respond differently in future consultations.

For evaluating other types of programs designed to build confidence, general strategies found in other Extension and education programs can be helpful. Some suggested resources to consider are listed below.

  • An Ask IFAS publication by Warner et al. (2015) features an example evaluation question that could be used on a survey to determine a person’s intention to change behavior and over what time frame they intend to change. This information can identify their stage of change.
  • If you are trying to get deep, rich data or are working with smaller numbers of participants, consider qualitative interviewing (Stofer, 2019a; Stofer, 2019b) or focus groups (Israel & Galindo-Gonzalez, 1992).
  • For quantitative data from a larger population, consider the Savvy Survey series on Ask IFAS.
  • When you are directly partnering with healthcare providers who may be able to provide vaccinations, especially when rolling out a sustained program or other intervention, they may recommend evaluation tools from medical research, including Translational Science and Dissemination and Implementation Science. Two options are the RE-AIM and PRISM frameworks.

Resources

The three appendices at the end of this publication share more specific resources. These include resources to share with clientele, resources for rural and marginalized audiences for vaccine confidence, and resources to help educators stay up to date.

Conclusion

As vaccination receives increased attention following the onset of the COVID-19 pandemic, Extension and other educators are playing a larger role in helping communities understand the benefits of such preventive healthcare and helping them access resources to obtain vaccinations and other care. Understanding strategies that center on listening to concerns and validating fears while offering the latest research information can help build confidence and ultimately health equity among adults.

References

American Medical Association. (2023, December 7). Advancing Health Equity: A Guide to Language, Narrative and Concepts. American Medical Association. https://www.ama-assn.org/about/ama-center-health-equity/advancing-health-equity-guide-language-narrative-and-concepts-0

ASTHO. (2019). Improving Influenza Immunization Uptake through Community Partnerships. https://www.astho.org/globalassets/report/improving-influenza-immunization-uptake-through-community-partnerships.pdf

Bauchat, J. R., Seropian, M., & Jeffries, P. R. (2016). Communication and empathy in the patient-centered care model — Why simulation-based training is not optional. Clinical Simulation in Nursing, 12(8), 356–359. https://doi.org/10.1016/j.ecns.2016.04.003

Baumgaertner, B., Ridenhour, B. J., Justwan, F., Carlisle, J. E., & Miller, C. R. (2020). Risk of disease and willingness to vaccinate in the United States: A population-based survey. PLOS Medicine, 17(10), e1003354. https://doi.org/10.1371/journal.pmed.1003354

CDC. (2023, August 11). CDC’s Health Equity Guiding Principles for Inclusive Communication. Centers for Disease Control and Prevention. https://www.cdc.gov/healthcommunication/Health_Equity.html

Christiano, A., & Neimand, A. (2017, January). Stop raising awareness already. Stanford Social Innovation Review. https://ssir.org/articles/entry/stop_raising_awareness_already

Clayton, K., Finley, C., Flynn, D. J., Graves, M., & Nyhan, B. (2021). Evaluating the effects of vaccine messaging on immunization intentions and behavior: Evidence from two randomized controlled trials in Vermont. Vaccine, 39(40), 5909–5917. https://doi.org/10.1016/j.vaccine.2021.08.047

Clinical and Translational Science Awards Consortium Community Engagement Key Function Committee Task Force on the Principles of Community Engagement. (2011). Principles of Community Engagement (PCE), Second Edition. (NIH Publication 11–7782). U.S. Department of Health and Human Services.

Goldstein, S., MacDonald, N. E., & Guirguis, S. (2015). Health communication and vaccine hesitancy. Vaccine, 33(34), 4212–4214. https://doi.org/10.1016/j.vaccine.2015.04.042

Harder, A. (2013). Using the TOP Model to measure program performance: A pocket reference. WC092. EDIS. http://edis.ifas.ufl.edu/wc092

Israel, G. D., & Galindo-Gonzalez, S. (1992). Using focus group interviews for planning or evaluating Extension programs. AEC 387. EDIS. http://edis.ifas.ufl.edu/pd036

Katsaras, A. V., Stofer, K. A., Yates, H., & O’Neal, L. J. (2024). Factors preventing widespread vaccine uptake among adults: AEC812/WC474, 10/2024. EDIS, 2024(6). https://doi.org/10.32473/edis-wc474-2024

Kumar Chaudhary, A., & Warner, L. A. (2015). Promoting behavior change using social norms: Applying a community-based social marketing tool to Extension programming. Journal of Extension, 53(3).

Kumar Chaudhary, A., Warner, L. A., & Stofer, K. A. (2017). Online certificate program moves participants to advanced stages of concern for social marketing. Journal of Agricultural Education, 58(4), 210–224. https://doi.org/10.5032/jae.2017.04210

Maurici, M., Arigliani, M., Dugo, V., Leo, C., Pettinicchio, V., Arigliani, R., & Franco, E. (2019). Empathy in vaccination counselling: A survey on the impact of a three-day residential course. Human Vaccines & Immunotherapeutics, 15(3), 631–636. https://doi.org/10.1080/21645515.2018.1536587

National Institutes of Health. (2021, May). Whole person health: What you need to know. NCCIH. https://www.nccih.nih.gov/health/whole-person-health-what-you-need-to-know

Nyhan, B. (2020). Facts and myths about misperceptions. Journal of Economic Perspectives, 34(3), 220–236. https://doi.org/10.1257/jep.34.3.220

Public Health Communications Collaborative. (2022). Communicating through COVID-19 and beyond: Insights from the field of public health. https://publichealthcollaborative.org/file/?id=9443

Quinn, S. C., Jamison, A. M., An, J., Hancock, G. R., & Freimuth, V. S. (2019). Measuring vaccine hesitancy, confidence, trust and flu vaccine uptake: Results of a national survey of White and African American adults. Vaccine, 37(9), 1168–1173. https://doi.org/10.1016/j.vaccine.2019.01.033

Roper, L., Hall, M. A. K., & Cohn, A. (2021). Overview of the United States’ Immunization Program. The Journal of Infectious Diseases, 224(Supplement_4), S443–S451. https://doi.org/10.1093/infdis/jiab310

Staples, S. (2016). Identifying linguistic features of medical interactions: A register analysis. In L. Pickering, E. Friginal, & S. Staples (Eds.), Talking at Work: Corpus-based Explorations of Workplace Discourse (pp. 179–208). Palgrave Macmillan. https://doi.org/10.1057/978-1-137-49616-4_8

Stofer, K. A. (2019a). Preparing for one-on-one qualitative interviews: Designing and conducting the interview: AEC675/WC338, 8/2019. EDIS, 2019(4). https://doi.org/10.32473/edis-wc338-2019

Stofer, K. A. (2019b). Preparing for one-on-one qualitative interviews: Logistics: AEC676/WC339, 8/2019. EDIS, 2019(4). https://doi.org/10.32473/edis-wc339-2019

Stofer, K. A., Katsaras, A. V., Dougan, S., & O’Neal, L. (2024). Adult vaccine confidence and disparities in Florida: AEC803/WC464, 6/2024. EDIS, 2024(4). https://doi.org/10.32473/edis-wc464-2024

United States Department of Veterans Affairs. (2022, December 9). Circle of Health overview. https://www.va.gov/WHOLEHEALTH/circle-of-health/index.asp

U.S. Department of Health and Human Services. (2016). National Adult Immunization Plan. https://www.hhs.gov/sites/default/files/nvpo/national-adult-immunization-plan/naip.pdf

Warner, L. A., Cantrell, M., & Diaz, J. M. (2022). Social norms for behavior change: A synopsis: WC406/AEC745, 1/2022. EDIS, 2022(1). https://doi.org/10.32473/edis-wc406-2022

Warner, L. A., Galindo-Gonzalez, S., & Gutter, M. (2015). Building impactful Extension programs by understanding how people change: AEC527/WC189, rev. 9/2021. EDIS, 2021(5). https://doi.org/10.32473/edis-wc189-2014

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Acknowledgments

The authors wish to thank Dr. Michael Gutter for the idea for this series.

Appendix 1: Resources to Share with Clientele

This appendix lists resources that could be shared directly with community members in Extension and other educational programs.

Final vaccine schedule recommendations from the CDC for children (ages birth to 18 years) and adults (ages 19 years or older). Immunization schedules are updated annually; check regularly for updates.

A concise and straightforward Ask IFAS publication introducing basic vaccine-related terminology and background information can offer readers a preliminary understanding of vaccines, emphasizing their importance.

Appendix 2: Resources for Rural and Marginalized Audiences and Vaccine Confidence

This appendix presents resources specifically to support rural and marginalized communities.

Given the lack of an adult-focused education program for vaccination prior to 2020, many of these resources focus on COVID-19. The CDC has added COVID-19 to the regular adult vaccination schedule, so these resources provide a starting point to uncover and understand particular concerns and messaging strategies for various communities.

The National Rural Health Association conducted a comprehensive study exploring beliefs regarding vaccinations, COVID-19 vaccination status, motivators and barriers surrounding COVID-19 vaccination, and post-vaccination behaviors. This presentation presents numerous graphs illustrating their key findings.

The National Rural Health Association developed a collection of various tools and resources to assist rural community leaders in tackling specific questions and concerns community members may have regarding the COVID-19 vaccine.

This guide facilitates empathetic conversations regarding COVID-19 vaccination within a congregation. The toolkit helps faith leaders to create an open space to start a discussion and answer questions about the effectiveness and importance of the vaccine.

Webinar presenting the insights from a successful COVID-19 vaccine messaging outreach campaign in rural communities.

The webinar focuses on a case study that illustrates successful strategies for disseminating COVID-19 messaging within rural communities. It emphasizes the significance of addressing considerations for marginalized populations and concludes with specific examples.

The National Rural Health Resource Center COVID-19 Vaccine Confidence Campaign aids rural community-based groups, faith-based organizations, businesses, public health agencies, schools, and healthcare organizations by assisting them in creating materials that encourage COVID-19 vaccination.

NRHA offers a set of strategic measures aimed at assisting and meeting the requirements of health providers and organizations in rural areas.

This report presents the initial significant discoveries derived from a 2020 survey centered on comprehending the factors that influenced individuals’ decisions regarding their interest in vaccination. It also examines the role that local, state, territorial, and tribal health departments can play in fostering well-informed decision-making processes.

Appendix 3: Resources to Help Educators Stay Up to Date

This appendix offers resources for program facilitators to keep themselves up to date on scientific information as well as engagement strategies.

Exercise caution when using this with clients, as offering information about myths, even for the purpose of debunking, can potentially reinforce the myth and result in unintended consequences.

Various communication resources provided by the CDC that focus on COVID-19 and other commonly administered vaccines. Resources include a digital media toolkit that can be used to communicate the importance of the flu vaccine.

This page covers the updated standards for adult immunization practices for all healthcare professionals. Practice standards include the assessment of a vaccine need, recommendations of certain vaccines, administration or referral to a vaccine provider, and documentation of vaccines received by the patient.

Several fact sheets that may be appropriate for adult audiences on both vaccine-preventable diseases and the vaccines for those diseases. Best used in conjunction with programs where discussions can be prioritized rather than as standalone resources.

This paper describes the involvement with a Theater for Vaccine Hesitancy training initiative that aims to equip healthcare workers with skills to engage in collaborative discussions with unvaccinated individuals.