The trajectory of the pandemic has changed — and will continue to change — until COVID-19 no longer presents a significant health risk.

Risk communication strategies have changed.

The changing nature of an evolving pandemic has resulted infrequent updates to guidelines and recommendations which are based on the real-time emerging medical and scientific consensus. Initial risk communications were centered around the novel SARS-CoV-2 virus and defining the COVID-19 disease.  As we learned more, communications moved on to virus transmission and non-pharmacological interventions like masks and social distancing, then as the science developed, onto innovative breakthroughs for diagnostic and clinical testing, efforts to support and sustain contact tracing mitigation efforts, awareness, and access to therapeutic treatment methods and medications, and finally, vaccine trials, and real-world safety and efficacy data.

It has been a significant struggle for all administrations to communicate reliable evidence about the risks associated with COVID-19 along with the applicable guidelines, policies, recommendations, and legal requirements as they apply to the public's health. Unfortunately, ineffective risk communication approaches have created public confusion when state or national leaders disagree with or establish regional policies that conflict with evidence-based guidelines. In addition, poor risk communication paired with frequent revisions to public health recommendations and guidelines since the public health emergency was declared in January 2020 may have undermined the perceived credibility of medical and scientific experts from a public eager for stability and consensus.

The challenge of public health, scientific, and risk communication has been monumental. This has made communicating vaccine recommendations even more difficult than before the pandemic when less than half of all adults were vaccinated as recommended to protect against shingles, pneumonia, and influenza, and up to 10% of parents regularly opted out of school immunization mandates due to personal belief exemptions.

Next steps and key takeaways:

Public outreach and engagement programs must continue to inform but must expand to refocus on motivating people willing to get vaccinated.

The term "vaccine-hesitant" describes personal indecision about accepting vaccines. In contrast, a "vaccine refusal" is typically associated with clearly identified, firmly held belief(s) against getting vaccinated. Identifying and working on modifying individual and community-level factors that influence vaccine decision-making and providing accurate information from credible sources are strategies that public health outreach programs used to build vaccine confidence and raise vaccination rates. The first 70% of vaccinations were accomplished primarily by reducing barriers to access, expanding vaccination clinics, and addressing the practical issues that impact vaccinations.

In the early stages of COVID-19 vaccine distribution, it was sufficient to provide information about timing, side effects, efficacy, and other essential facts. However, the limitations of available vaccines made communicating about the urgency and importance of getting vaccinated unnecessary -- and made such campaigns possibly counterproductive. That time has passed. As voluntary-vaccination rates have plateaued, the critical strategy must shift toward the persuasion and motivation of vaccine-hesitant people who are willing to reconsider their decision.

Changing what people think and feel about COVID-19 disease and the vaccine, their personal, subjective outlook and beliefs, requires tailored data-informed outreach strategies. It is crucial to understand communities and to identify, test, and engage the right message with the right messenger. Vaccine decisions can be deeply personal and are heavily influenced by our immediate micro-culture within the larger context of pandemic response and communications.

For effective vaccine outreach, it isn't sufficient to continue to use traditional media, social media engagement, or public information strategies because those methods have already reached most of their audiences. Instead, success in changing behaviors and overcoming hesitancy requires influencing perceived vulnerabilities and perceived benefits which agencies can do through enlisting social processes, community coalitions, and interpersonal connections.

Looking to the future

There are real opportunities to collaborate with providers and existing programs to encourage vaccine acceptance among our most vulnerable citizens. Leveraging existing data to maximize opportunities and engage directly with target populations can boost vaccine confidence and acceptability among people receiving health services.

We have seen many states considering expanding existing programs to address vaccine hesitancy, combining evidence-based vaccine confidence interventions with existing outreach infrastructure. For example, extending operations so that contact tracing interactions are followed up with information about vaccine recommendations for those with prior COVID-19 exposures, integrating vaccine outreach with Medicaid and other benefits eligibility and enrollment calls, and providing assistance with vaccine appointments in workforce training programs. Connecting directly with vaccine-eligible citizens to give individualized information and offer vaccine appointments will have the biggest impact on people who have previously identified as "wait and see" and may now be ready to make a decision following the full FDA approval. Individual outreach using a personalized approach can provide the motivation and information needed to update decisions about the COVID-19 vaccines.

Promising practices: Using data-driven engagement strategies to access the hardest-to-reach communities.

• Treating hesitancy with respect and patience, decision-making takes time and may require several touchpoints.
• Personal outreach to support decision making with information, encouragement, and appointments
• Sharing personalized stories of taking the virus seriously, including from those who have changed their initial decision not to vaccinate
• Motivating decision-making around the benefits of immunization, such as connecting with family or friends and a return to much-loved activities without concern of exposure.

The Maximus Center for Health Innovation is helping federal, state, and local governments to serve the public and end the pandemic.