It’s been quite the week for hopeful vaccine developments.

Leading the news was Monday’s partial read-out of early Phase 3 results on the Pfizer/BioNTech vaccine, showing the shot was 90% effective in preventing COVID-19 in people with no history of prior SARS-CoV-2 infection. The 90% far exceeds the “good enough” boundary of 63%. 

If the Pfizer vaccine is approved, global production could reach 50 million doses this year and possibly 1.3 billion in 2021. At that point, governments would need to distribute the shots, starting with their highest-priority recipients, as determined by public health officials (the Centers for Disease Control and Prevention, in this country). 

Dr. Anthony Fauci, the nation’s top infectious-diseases official, said this week that he expects the vaccine could become available to the wider population by next April. That is, for all those who want to be vaccinated.

Even with the shot’s 90% efficacy rate, there’s likely to be a substantial amount of vaccine hesitancy. Studies have shown that 20%-30% of Americans say that they may not get a COVID-19 vaccine. That figure doubles among minority populations, which have been disproportionately hit by the disease.

It’s one thing to have a supply of vaccines on-hand, quite another to stimulate broad societal demand for it. Bridging the gap between the two is the job vaccination planners need to concern themselves with right now. We can’t just assume that if Pfizer/BioNtech – or Moderna or AstraZeneca, for that matter – build a vaccine, that patients will come. 

That’s precisely the point that Monica Schoch-Spana, PhD, senior scholar at the Johns Hopkins Center for Health Security at the Johns Hopkins Bloomberg School of Public Health, made earlier this year in a report, co-authored with Emily Brunson, about readying populations for COVID-19 vaccination and the public’s role.

As the country gears up for the tricky task of rolling out an eventual COVID-19 vaccine, community concerns over safety and affordability need to be eased, racial tensions defused and the public discourse changed, from the current biomedical mode of discussing vaccination to a more “civic conversation,” says Schoch-Spana. 

She spoke with MM+M about the kind of communications strategies and human-centered design principles needed to quell community concerns, and other recommendations for a successful introduction of the COVD-19 shot. 

The following interview has been edited for clarity and brevity. 

MM+M: In your report, you pointed out the fallacy of the “If we build it, they will come” theory of COVID-19 vaccine uptake and that, in addition to the biotech and logistics challenges, there’s a wide range of reasons why people may be unable or unwilling to get vaccinated. Which of these so-called human factors are most important? 

Schoch-Spana: There are a few that are significant. The first is that, oftentimes, issues of safety drive people’s willingness to accept vaccination. We’ve seen that with Operation Warp Speed. People have inadvertently been primed to worry that there’s corner-cutting or a rush to get something out. Some people are principally concerned about safety. For others, it’s issues of historical trauma and systemic bias within the health sector, which you see among communities of color, particularly Black Americans. Their hesitancy is based more on longstanding trust issues in terms of their relationship to public health and medicine, writ large. 

For other individuals, it could hinge on convenience and cost. Others are filing it away as yet another health benefit that they can’t access, even though it may actually, as we hear, be provided at no cost. And for others, it’s an issue of convenience: they simply cannot literally take off time and lose income in order to go get vaccinated. They’re thrust into a dilemma where they have to choose between physical health or economic well-being, both for themselves and for their families. 

Many of your earlier observations have held true. National polls from Gallup and STAT-Harris, in October and November, reveal a significant vaccine-hesitant segment, based on availability and efficacy. The first SARS-CoV-2 vaccines are likely to be novel products when initially offered to the public, with limited safety data on vaccinated individuals, and there are fears of racial bias. How do those factors inform messaging strategy?

The present framing of the value of vaccination is in terms of herd immunity and community immunity. There’s a strong use of epidemiological and clinical points of reference. We have to broaden our scope of understanding of what is the value of COVID-19 vaccination in people’s lives, to be more concrete. 

Is that change in messaging happening yet?

I thought that President-Elect Joe Biden did the country a very positive service by talking about vaccines as a potential route to get back to those activities that we all enjoy and miss terribly – hugging grandchildren, going to weddings and graduations. We have to get at the social repercussions as well. Of course, they hinge on issues of individual and community levels of immunity. Rather than having that be the central framing point for public discourse, though, if we can talk about the social economic and psychological gains that come with vaccination, including equity gains as well, we will have more people interested in potential vaccination. 

As long as we’re talking in clinical or medical/epidemiological terms, I don’t think that we are speaking the broader language of what vaccination actually means – or can mean – to people from a very practical sense. There are a lot of people out of jobs. There are people who are facing foreclosures and evictions. And so if vaccination plays a role in reducing economic hardships, then we really need to be talking about that more strongly and de-centering the epidemiological, clinical or immunological benefits of vaccination.

Elaborate on that point a bit. How can we convey the value of vaccination to as diverse a set of populations as we have in the United States?

Right now, there’s been a premium placed on other kinds of sciences, like virology and immunology, to help develop the actual medical technology that is a vaccine. What we need to do is invest in and apply the results from communication-oriented, ethnographic research. There should be a more dedicated effort to understand how people think about vaccines, what’s holding them back, what would make it easier for them to get to them. I value the data we get from national surveys, but we need to really drill down at the community level to get a more granular understanding of the social values, personal identities and worldviews that shape people’s approaches to vaccines, including those against COVID-19. 

Communication should never be an off-the-cuff type of practice. There is an entire set of evidence bases that should be mobilized as far as best practices. For instance, there should be testing right now of particular messages that would serve as antidotes to concerns about perceived rush and the production of COVID-19 vaccines. We need a communication strategy that hinges on coordination, as well as the communication sciences and including timely testing of messages that speak to people’s concerns. 

That understanding needs to be at the community level. How do we achieve that more granular level?

Communities need to feel ownership over the vaccination enterprise. That shouldn’t be top-down. There should be advisory boards, particularly at the state level and for the most populous cities, that engage leaders from community-based organizations, faith-based organizations and also local businesses, so that they are brought to the table to understand, monitor and report on what the vaccination plans are, how they’re being implemented and what the outcomes are. 

The days of “Just trust us, take the vaccine” are over. We really have to have a multitude of advocates for vaccines. That includes public health, of course, but I think we need these other sectors of society represented in advisory boards so that the whole of the community feels invested in the vaccination effort.

Cost is a prime concern – another one of your recommendations was to make vaccines available at no cost to US residents. How else does affordability factor into a comprehensive vaccine roll-out strategy?

It isn’t just the cost of the actual product; that’s the direct cost. There are the indirect costs, too. Do I have to take off work or miss out on income? Do I then need to take a bus to get to a distant vaccination site? Do I need to set up childcare so I can do that? It’s the opportunity costs as well. 

That’s why it’s going to be important that we have very comprehensive vaccine delivery strategies, including making it convenient. Workplaces, for one, are going to be very important sites for vaccination. Once vaccines become available to the wider population, being able to get vaccinated at the office will make it easier for people, so they’re not taking an economic hit. 

You issued the report in July. What kind of progress have vaccination planners made since then in taking proactive steps to overcome these hurdles?

Measures are being taken to fill the void for a coordinated communication strategy, both through government-supported activities and also foundation-supported, rapid research. The biggest challenge is that state and local public health departments, those on the front lines of vaccination, are in profound need of resources to support the vaccination effort. To engage hesitant communities, you have to have dedicated personnel who are skilled in community relationship-building and in culturally competent communications. 

That’s our biggest need right now: a workforce, and the support that state and local health departments need. Although they will, of course, be aided by other community partners in this endeavor. The National Institutes of Health, for instance, has the Community Engagement Alliance Against COVID-19 Disparities to help develop communications that resonate, particularly among hesitant communities of color. 

So it isn’t just about moving vaccines and getting a jab in someone’s arm. It’s also about the infrastructure needed to adequately attend to the human factors, and there are costs associated with having that infrastructure. Then on top of that, there’s the need to build out an effective vaccination workforce that collaborates with community partners and moves the product out, particularly to those populations who could most benefit from vaccination. 

And as you mentioned, ethnographic research can help.

Vaccine hesitancy manifests itself in many different ways. There are going to be challenges that are deeply rooted in local conditions. A national poll is helpful to inform perhaps a national-level communication effort, but face-to-face, frontline conversations between elected leaders, public health leaders and community leaders around vaccination has to be informed from the ground level up. We need more of that, to complement the types of strategies that are developed based on national polling data. 

What’s the most important thing leaders should do to close the gap between having a supply of vaccines and actually stimulating societal demand for them? 

Many states are starting to set up technical advisory groups to advise on the COVID-19 vaccination enterprises in their own jurisdictions. And on those technical advisory groups, they really do need to include experts – people who are steeped in the social, behavioral and communication sciences. I would hope that those technical advisory boards have social and behavioral scientists on them in addition to the clinicians, the epidemiologists and the community leaders. You really need people to bring that extra piece of expertise on human factors. 

Biopharmaceutical companies have experience in stimulating demand for public health services, not to mention tremendous marketing muscle. What role do you see them playing?

There are several ways in which pharmaceutical companies can play a role. First thing, as they’ve done, is to present a united voice around the fact that there won’t be any cutting of corners with regard to safety and that they are fully invested in the systems meant to assure that people are, in the end, receiving safe and effective vaccines. They should be congratulated for that united force prioritizing safety and also for making data available and creating as much transparency as there can be. On the safety issue, the expertise on communication certainly should be brought to the table. 

That said, their involvement requires a little bit of a threading of the needle. There are members of hesitant groups that perceive economic interests being served, and that that’s the principal interest of manufacturers and developers of vaccines. Pharma companies’ communication expertise should be made available to public health. 

If there are foundations attached to pharma companies that can be supportive of independent research, they can inform communications. To the extent there’s the potential danger of pharma companies being perceived as serving their own interests by marketing vaccines, we have to be careful about that. They have a lot of expertise and resources to share.