State health officials have recently praised the nation’s vaccine rollout, which just this week surpassed three important milestones. More than 30% of the U.S. population has been fully vaccinated, while 90% of the U.S. population now lives within five miles of a designated vaccination site, largely due to the expanded federal retail pharmacy program. And all states and territories have expanded their vaccine eligibility to anyone aged 16 or older.

But a new problem looms. In the early days of the vaccine rollout, people eager to be vaccinated raced to set up appointments and doses were hard to come by. Now, some states are seeing vaccine supply exceed demand. That’s partially due to vaccine hesitancy, access and other issues.

At a press conference held by the Association of State and Territorial Health Officials (ASTHO) this week, health officials discussed how to reach the final 50% – the remaining Americans who are either on the fence about getting vaccinated or simply altogether uninterested.

“Our hope, of course, is that we can move them,” said Dr. Nirav Shah, director of the Maine Center for Disease Control and Prevention, at the press conference. “But we have to do work there to make sure we’re understanding their motivation.”

Shah divides Americans into four groups. The first is comprised of individuals who were eager to receive the vaccine and actively sought out appointments in the first months of the rollout. The other three groups – people who aren’t able to get vaccinated immediately because of their work schedules, transportation issues or homebound status; the wait-and-see contingent holding out for more detailed information on safety and efficacy; and individuals who say they don’t want to be vaccinated at all – are the ones that concern him, for obvious reasons.

Shah said that state public health departments are putting plans in place to meet people where they are and address their needs and concerns. That might include making vaccines available on a walk-in basis, providing door-to-door transportation or bringing vaccines directly to peoples’ homes.

“Whether it’s the not-able, not-now or not-ever, we have to [reach those groups] with an attitude and a tone of respect,” Shah stressed.

By way of example, about 50% of Alaska’s population has received at least one vaccine dose – and that’s in a state that is largely remote and rural, and has historically had low levels of vaccine confidence. There are also a variety of cultural needs, with 229 sovereign tribes calling Alaska home.

As a result, public health officials have had to experiment with new ways of reaching those communities, according to Dr. Anne Zink, the state’s chief medical officer.

“How we got there was by building on equity,” Zink explained. “We had to build in equity at the beginning by giving communities the tools and resources they need to be able to control the pandemic. That may mean dogsleds or snow machines, partnering with our faith communities or working with disability communities.”

Recent polling found that 36% of Alaskans were still not confident in the vaccine. But the state is focused on providing transparent, data-driven answers to people’s questions, distributing trusted information on social media and partnering with businesses, Zink noted. She emphasized the importance of communicating the idea that vaccination has economic benefits: hesitant individuals won’t need to quarantine and they can keep their businesses open.

Then there’s the ongoing need for trusted messengers willing to share positive vaccine stories. “We continue to find that friends and families are one of the most trusted messengers to the community,” Zink said.

Stimulating demand may also come down to making it easier to secure same-day appointments, or providing walk-in hours. Such an approach could be more successful among the not-yet crowd, who may be frustrated by scheduling issues that prevent them from getting vaccinated sooner.

When asked whether the pause in the Johnson & Johnson vaccine rollout lowered vaccine confidence in their states, the panelists said it had a very minimal effect, if any at all. Instead, they argued that the J&J pause should be interpreted as a sign that the nation’s public health safety and surveillance system was working as intended.

“It should be very reassuring,” said Dr. Steven Stack, commissioner of the Kentucky Department for Public Health. “Six individuals out of 7 million people vaccinated should reassure Americans that the surveillance systems are in place, data is being submitted to them and people are actually watching the data and using it to take action.”

In light of incidents like this, it’s important to inform people of the overall safety and efficacy of the vaccines, Stack added. “We need to address individuals’ concerns, reassure people about the science and help them reach their physician of comfort so they can exercise their freedom to choose,” he explained.

A final important step as the vaccination push approaches the six-month mark is adjusting delivery of the vaccine doses. Stack recommended sending smaller vials to more modestly sized settings (like primary care offices) so that expired doses don’t go to waste. He believes such settings facilitate reaching people in their persuadable moments.

“[There needs to be a] focus on smaller events more tailored to address the needs and concerns of focused communities that have different sensitivities and different needs,” Stack said. “Part of the optimization of this vaccine rollout will involve having to get to smaller quantities so primary care physician offices and clinics have the ability to go to the fridge and pull out a single dose of the vaccine, like we do with tetanus and MMWR shots.”

Part of what makes the federal retail pharmacy program so effective is that a primary care doctor isn’t needed for administration. But people who might not independently pursue vaccination might be more effectively reached through trusted family members – or trusted physicians.

The smaller-quantities, smaller-settings approach may become more commonplace as the vaccination rollout continues. “It’s very important to activate the primary care force,” Stack said. “People have trust in their primary care physicians and their staff. These are the settings [in which] we’re most likely to reach the remaining 50%. This is the way we put the pandemic in the rearview mirror.”