A COVID-19 Vaccination Strategy to Support Uptake amongst Australians: Working Paper

"Prior to and during the implementation of a COVID-19 vaccine campaign, there is an ongoing need to ensure that we have a rich understanding of the factors affecting engagement with a COVID-19 vaccine program, and particularly of the enablers/strategies that could be used to support acceptance."

Although Australia has robust immunisation programmes, suboptimal vaccine uptake amongst adults is pervasive across Australian states and territories and may compromise plans to squelch the SARS-CoV-2 pandemic by achieving herd immunity through vaccination. Many underserved and marginalised groups experience complex challenges, such as insufficient health literacy and limited interaction with health services. To support COVID-19 vaccination goals and aims outlined by the Australian Government and the Australian Technical Advisory Group on Immunisation (ATAGI), and to ensure equitable vaccination uptake across all population groups, the Collaboration on Social Science and Immunisation (COSSI) developed the 6-point strategy outlined in this report. It is designed to support policymakers, healthcare professionals, and third-party organisations in planning and delivering COVID-19 vaccine programmes that are tailored according to what is known about the structural, social, and behavioural factors that may compromise uptake.

The recommendations are structured according to 5 influences on vaccination gaps that have informed programme planning in other countries: Access, Affordability, Awareness, Acceptance, and Activation (the 5As). The strategy for COVID-19 vaccination uptake focuses on strengthening the following key foundational areas:

1. Programme strategy - Example: Ensure that the supply and distribution strategy is equitable, transparent, adaptable, and clearly communicated to relevant professionals and the public.
2. Provider support strategy - Example: Develop a robust support package including provider updates, training webinars, and skills-based workshops. As indicated here, the National Immunisation Education Framework for Health Professionals does not have sufficient flexibility to enable Aboriginal health workers from diverse communities (including those in remote settings) to meet the training requirements. Thus, for COVID-19 vaccination to reach all communities and continue the success of community-led provision of preventive health services, training requirements will need to be modified.
3. Access strategy - Example: Consult with range of communities about tailored opportunities for service provision to enhance accessibility; efforts are needed to simplify and bring services closer to where adults live, work, study, or frequent. Further, COSSI notes that people are motivated to act when they are faced with stimuli that make them imagine what might happen, and they evaluate the effect of that imagined scenario. The use of stimuli aligns with the dimension of "activation" from the 5As. Informing people of an upcoming vaccination or telling them that they have missed a vaccination might help "nudge" them. Targeted telephone calls to high-risk adults (e.g., those with low levels of engagement with primary care) explaining the rationale for vaccination and offering vaccination appointments may be effective.
4. Broad and tailored communication campaigns - Some key elements include:
   • Intrinsic to such campaigns is a communication strategy that clearly delineates the goals, intended audience, expected roles of the actors involved, and the communication tools that will be used. A national communication strategy should aim to support the general public's understanding about the COVID-19 vaccine(s), with dedicated messages focused on supporting understanding around safety/testing/licencing processes.
   • Communication materials must ensure that people consider individual vaccine behaviours but also the influence of communication for others, especially for those in the community who may not be able to receive the COVID-19 vaccine. This can be framed around helping protect family and friends. There may be a need to draw on the emotional consequences of vaccination, anticipated regret, and the salience of consequences.
   • While such universal messages may be appropriate for the general public, these messages may not prompt action in all at-risk groups; there will be a need to integrate a tailored communication strategy to reduce vaccination inequalities. Tailored communication campaigns will be needed for: Aboriginal and Torres Strait Islander communities, culturally and linguistically diverse (CALD) communities, and adults with chronic or underlying health conditions.
   • To that end, the promotion of a COVID-19 vaccine will require partnerships with a range of civil society (e.g., patient organisations, ageing associations, multicultural community groups) and health organisations (e.g., immunisation advocacy groups, non-governmental organisations (NGOs), etc.) to maximise the opportunity to reach the most at-risk populations.
   • Mass media messages will not have the same reach for all intended audiences. Thus, messages will need to be distributed via a range of channels, such as both online and offline tools including social media, websites, local/national radio (including ethnic radio broadcasters), TV, and print media (posters, outdoor ads, etc).
   • Relevant spokespersons may need to vary in age and socio-economic background to ensure maximum reach and impact and to honour the principles of equity and diversity.
5. Community and professional engagement - Example: Draw upon informed and motivated healthcare workers to serve as advocates and champions for immunisation, as well as on community leaders (including elders), community-based traditional health providers, religious leaders and groups affiliated with religious institutions, community networks/groups (e.g., mothers' groups, youth groups), and unions/associations. Such engagement could take place, for instance, through involvement of community partners in regularly scheduled programme microplanning and evaluations. These encounters could provide opportunities to learn about current community perceptions of services, to inform community leaders about the programme, and to plan activities that build community engagement while addressing relevant needs and concerns.
6. Vaccination encounter support - Example: Educate providers - including specialists, pharmacists, nurses, and midwives, who may not necessarily be in a position to deliver a COVID-19 vaccine but may be perceived as a trusted source of information - on pre-vaccination procedures, consent processes, approaches for addressing adult vaccine hesitancy, and post-vaccination procedures (e.g., adverse events following immunisation (AEFI) reporting). Well-managed vaccination encounters and interprofessional collaboration in education and practice can both boost vaccine uptake and enhance programme resilience against shocks such as vaccine safety scares.

"To support the activities outlined in this report, COSSI strongly advocates for funding and resources to be set aside to ensure that behavioural insights research informs the program. Methods such as pulse surveys, qualitative interviews and/or focus groups or community panels and trials be undertaken to capture crucial information about community perceptions and concerns regarding the implementation of a new COVID-19 vaccine and immunisation program. The use of online panels and forums to allow for 'rolling question and answer public-facing websites to address key questions and concerns in real time' may also be of assistance."

COSSI concludes that providing information and well-crafted messages alone and then assuming that the community will make the "correct" decision to be vaccinated "will not work. Vaccination behaviours are shaped by a multitude of factors such as access, cultural beliefs, community, a person's identity and their norms, education, and socioeconomic status, as well as by philosophical beliefs. The Strategy outlined in this discussion paper aims to optimise the future delivery of COVID-19 vaccine(s)."

Note from COSSI: COSSI is open to researchers, healthcare providers, policymakers, consumer advocates, and postgraduate students working or interested in social science and immunisation. COSSI also welcomes professionals in other countries who wish to learn more about social science and immunisation in Australia and to communicate their experience with us. Click here to join.