Introduction

The Chinese government first detected the novel coronavirus (SARS-CoV-2) or COVID-19 in late December 2019 [1]. COVID-19 quickly spread internationally. The first confirmed case in the United States was reported by the Centers for Disease Control (CDC) on January 21, 2020. The infection spread resulting in an epidemic in February 2020, and there was rapid transmission a month later resulting in a crisis [2]. COVID-19 is the most devastating public health crisis of modern times. From January 2020 to August 2021, the United States reported more than 36 million confirmed cases and more than 618,000 deaths [3]. The death toll of COVID-19 in the United States is higher than in any other country [3].

The trajectory for the spread of the virus, treatment options, and vaccine development rapidly evolved. There are, however, many challenges including the disparate impact of the pandemic, high levels of misinformation, and a politicization of policies related to public health safeguards and vaccine options.

These factors have contributed to communication challenges that require a unified public health response. These challenges include lack of trust in science-based information, coverage gaps for routine vaccines, and the impact of COVID-19 on mental health. These challenges have an impact on how people seek up-to-date data, separate facts and science from disinformation and misinformation, and follow guidelines issued by the government.

Communication strategies, messaging and practices help to inform people about risk and access to vaccines and resources. In this chapter, we discuss the impact of COVID-19 on vulnerable populations in the United States, challenges of vaccine hesitancy, and vaccination disparities among minority populations. In addition, case studies on communications initiatives and strategies to promote vaccine uptake are presented.

Challenges of Disparate Impact

There are significant racial and ethnic disparities in the burden of morbidity and mortality associated with COVID-19. Recent data show that the age-adjusted hospitalization rates for African American, Alaska Native, and American Indian populations are five times higher than those for non-Hispanic white people [4]. Hospitalization for Latino/Hispanic persons is four times higher than that of non-Hispanic white people [5]. Disparities are, however, not limited to hospitalization. Rates of COVID-19-related deaths are significantly higher in African American/Black and Latino/Hispanic populations. According to the CDC, 18.3% of U.S. COVID-19 related deaths are among Latinos/Hispanics and 15.1% are among American Blacks [4]. As of August 4, 2021, total deaths by race/ethnicity are as follows:

  • Latinos/Hispanic: 11,15,21 deaths—18% of total deaths

  • African Americans/Blacks: 92,396 deaths—15% of total deaths

  • Non-Hispanic Whites: 37,13,03 deaths—61% of total deaths

  • Asians: 23,147 deaths—4% of total deaths

  • American Indian/Alaska Native: 6,871 deaths—1% of total deaths

  • Native Hawaiian/Pacific Islander: 1,153 deaths—0.2% of total deaths [6]

  • Total: 60,23,87 deaths

Data from CDC and other health agencies suggest that there are disparities in the disease burden among different population groups. Health professionals, policy-makers, and the media have reported that since March 2021, minority populations such as African Americans/Blacks and Latinos/Hispanics have less access to medical care, are more likely to be uninsured or underinsured, face language barriers, and are in poorer health with higher rates of medical conditions such as diabetes and high blood pressure. They also have less access to higher education and are more likely to have jobs deemed essential. These jobs, on farms, in factories, in grocery stores, and in public transportation do not allow people to work from home. Once they return home from work, they are more likely to live in crowded, multi-generational households where they are more likely to expose their loved ones to the infection [7].

Because African Americans/Blacks and Latinos/Hispanics are younger on average than non-Hispanic Whites, it could be assumed that the rate of hospitalization and death amongst these populations would be lower. But that is not what is happening. Instead adjusting for age differences, CDC estimates that Native Americans, Latinos/Hispanics, and African Americans/Blacks are two to three times more likely to have complications and die from COVID-19 than non-Hispanic Whites [4].

Scientists and healthcare professionals point to the low vaccination uptake among African American/Black and Latino/Hispanic populations compared to non-Hispanic Whites.

Vaccination Disparities

Vaccination disparities are typically associated with health equity. Health equity refers to the human right to health and equality and is designated under international law [8]. According to the CDC, there is “health equity when everyone has the opportunity to be as healthy as possible” [9]. There is vaccine equity “when everyone has fair access to vaccinations” [10].

According to data released by the Kaiser Family Foundation in 2019, African American/Blacks, Hispanic/Latino, Asian/Pacific Islander, and American Indian/Alaskan Native populations have higher morbidity and lower life expectancy than non-Hispanic Whites [11]. Specific disparities are visible in teen birth rates, infant mortality rates, and HIV/AIDS diagnosis and death rates.

Low immunization coverage is most often associated with low access to care, language barriers, low socioeconomic status, urban residence, and minority cultural status [12]. Thus, the very communities that are often most vulnerable to infectious diseases are also least likely to access vaccines to prevent them. Vaccination is the best public health tool for preventing infection and mitigating community spread. It is important to achieve high vaccination rates and herd immunity (70% of population is fully vaccinated).

Distrust in Vaccines

Vaccination is the most cost-effective preventive health intervention. Data show that there is a high return on investment. For each birth cohort vaccinated with the routine immunization schedule, 33,000 lives are saved, 14 million infections are prevented, and direct healthcare costs are reduced by USD 9.9 billion [13]. But despite scientific progress, 42,000 adults and 300 children in the United States die each year from vaccine preventable diseases. The World Health Organization (WHO) has identified anti-vaccine messages and vaccine hesitancy as the biggest threats to global health and ending the COVID-19 pandemic [14].

Vaccine hesitancy defined as individual level reluctance to take vaccines ranges from the cautious acceptor to the anti-vaxer who may also be anti-government [15]. Hesitancy is fueled by concerns about vaccine safety and efficacy due to widespread disinformation and misinformation [16]. Since January 2021, many scientific studies and polls list the most common concerns and questions that lead to hesitancy. Vaccine misinformation presents several challenges for healthcare professionals, especially those on the frontline. Falsehoods spread faster than facts and science and are difficult to counter once they made public [17]. Furthermore, vaccine hesitancy is rooted in the history of medical mistrust which is greater in racial and ethnic minority communities due to generations of systemic and institutional racism, health inequities, and misrepresentation in research [18].

Case Study: How Right Now/Que Hacer Ahora Campaign

Since early 2020, when the pandemic was first declared, AmericansFootnote 1 followed recommended mitigation measures such as staying home, social distancing, wearing a mask, getting tested, and getting vaccinated and boosted, in order to protect themselves and their loved ones against COVID-19 infection.

During this time, many people suffered substantial loss—the loss of loved ones, the loss of connections, the loss of jobs, and the loss of economic security. As a result, there was an increase in mental health challenges.

In June 2020, the CDC released a report on mental health during the COVID-19 pandemic.

Overall, more than 40% of people surveyed reported experiencing some kind of mental or behavioral health challenge. Specifically:

  • More than 30% of people reported symptoms of anxiety and depression

  • More than a quarter of people (26.3%) reported trauma- and stress-related symptoms

  • More than 13% of people reported using substances as a coping mechanism

Over the course of the pandemic, incidences of depression, suicidal ideation, and substance use continued [19, 20].

Research indicates that strategies that address emotional and behavioral issues—both at the individual and community levels—are needed.

In response to this need, on August 5, 2020, the public health campaign—How Right Now/Que Hacer Ahora (HRN/QHA)—was launched. It was supported by the CDC Foundation and the Centers for Disease Control and Prevention (CDC). The goal of HRN/QHA’s is to support increased coping and resilience. HRN/QHA focused on four groups:

  • Adults over 65 years of age and their caregivers

  • People with pre-existing mental and physical health conditions

  • People experiencing violence

  • People experiencing economic distress

HRN/QHA also aims to focus on at-risk racial/ethnic and gender-identity sub-groups. Understanding the audiences’ thoughts, feelings, and behaviors during the COVID-19 pandemic helped to develop the campaign’s communication plan. A team of public health professionals conducted rapid mixed method formative research using culturally responsive and inclusive methods. Research objectives included understanding HRN/QHA’s audiences’ mental health related challenges, information needs, available resources, perceptions of resilience, and trusted information sources.

Out of this formative research process emerged a set of evidence-based, audience-centric messages that reflect people’s lifestyles and experiences. A user-friendly website is available where people can find resources that provide support for a wide range of emotions. HRN/QHA content is culturally relevant and available in both English and Spanish in both digital and printable formats. To reach its audiences, HRN/QHA has leveraged community organizations and trusted messengers to amplify messages. Other strategies include use of English and Spanish language digital and social media advertisements and Spanish language radio advertisements.

After the campaign was launched, the team adapted it to the pandemic. Employing an evaluation design that includes a variety of data collection methods that are culturally responsive and inclusive, campaign progress was assessed in an ongoing manner and adapted, as needed, to address shifting needs over the course of the pandemic. Outcome data revealed positive effects on coping and resilience as a result of exposure to HRN/QHA messages. As well the outcome evaluation revealed that the campaign was most effective for people who reported the greatest levels of stress and discord in the family which suggests that the campaign really helped those who were most in need. As we continue to move through the various phases of the pandemic—and hopefully beyond it—HRN/QHA has the potential to continue to provide tailored support to people as their needs evolve.

Case Study: Better for It Campaign

Despite the availability of safe and Food and Drug Administration Emergency Use Authorization (FDA EUA) approved COVID-19 vaccines, many Americans remain unvaccinated. A significant proportion of unvaccinated people are adamant and will never be vaccinated. There is vaccine hesitancy among racial and ethnic minorities and other vulnerable populations, especially among African American/Black and Latino/Hispanic communities. COVID-19 has also disproportionately affected American Indian/Alaska Native, Chinese, and Korean populations.

A poster by the American Lung Association released in December 2021 during COVID-19 with a child, parents, and grandparents enjoying family time.

Source American Lung Association, December 2021

The American Lung Association and Anthem addressed the lack of culturally resonant COVID-19 resources by developing a series of toolkits for Latino/Hispanic, African Americans/Black, Korean, Chinese, and American Indian/Alaska Native populations. This series, known as Better For It, was launched to provide culturally relevant, science based factual guides for COVID-19 vaccination.

The campaign developed culturally relevant toolkits, videos and resources that engage vaccine ambassadors who are trusted messengers to amplify conversations within local communities about the benefits of vaccines and other health and safety guidelines. The toolkits encourage people to seek out the best information for making personal, familial, and community health decisions and to:

  • Become Vaccine Ambassadors

  • Supplement user’s own research on vaccines

  • Start a dialogue with families, friends, physicians, traditional healers and community members

  • Understand the contributions of scientists and public health advocates who are helping to bring this pandemic to an end.

Case Study: Protect the Ones You Love

In September 2020, the Virginia Department of Health (VDH) launched a comprehensive state-wide communications campaign to counter vaccine misinformation and increase awareness of vaccine benefits, safety, and efficacy. VDH’s priorities were to keep communities and stakeholders informed, engaged, and motivated to promote immunization. The long-term goal was to increase vaccine uptake among high-risk populations and to mitigate the impact of COVID-19 and future outbreaks.

The campaign’s three goals guided the development of strategic communication tools and tactics: (1) Counteract misinformation with facts, science, and trusted sources to discredit online misinformation; (2) Promote the safety, benefits, and guidance for childhood vaccination; (3) Promote the safety, benefits, and guidance for flu vaccination, especially in light of COVID-19.

The target audiences for the campaign included underserved communities such as Latinos/Hispanics, African Americans/Blacks, and Native Americans. A health communications team worked with VDH to design strategies by researching preferred communication platforms channels for each target audience and by facilitators to build vaccine trust and develop key messages that could motivate people to get vaccinated. Due to COVID-19 guidelines and restrictions, access to routine vaccines was limited. There is an elevated risk of a twindemic of flu and COVID-19 during the fall and winter seasons.

A health communications team implemented strategies based on the analysis and findings of the formative research. The team identified the most popular communication platforms to reach each target audience and to engage facilitators to build vaccine trust and develop messages that could motivate people to get vaccinated to protect the ones they love.

Strategies included:

A poster by the Virginia Department of Health released in October 2021 during COVID-19 with a child sleeping in between the father and the mother together making a heart shape with their hands.

Source Virginia Department of Health, October 2021

  • Identify people who are pro-vaccine and multiply the effect through trusted messengers in rural and urban areas through an aggressive partner engagement plan.

  • Draft and disseminate messages that are supported by facts and science.

  • Implement a strategic timeline to promote flu vaccines followed by an initiative that focuses on pregnant women.

  • Increase awareness through timely information on immunization as it was impacted by COVID-19 through ongoing strategic digital content dissemination.

  • Develop video testimonials from people in diverse communities that encourage others to talk to a doctor.

Campaign results in the first year, highlighted in Fig. 1, show the campaign’s success and reach through a state-wide media buy and multi-sector partnership with trusted messengers. The campaign also connected grassroots partners across Virginia with health departments, free community clinics, and pharmacy chains. Through these partnerships, community leaders organized vaccination clinics in underserved neighborhoods.

Fig. 1
An illustration lists the COVID-19 campaign results as follows. The media = 9 million impressions. Health care = 50 plus health care clinics. Active partners = 350 plus trusted messengers. Small business = 100 plus engaged business owners.

Protect the ones you love campaign results. Source HMA Associates, Inc., June 2021

Full size image

Conclusions

There is a critical need for designing communication interventions that are focused on and tailored to racial and ethnic groups. Case studies show that there is a need for developing culturally resonant communications to increase vaccine confidence and the uptake of vaccines by underserved populations. Engaging community leaders as trusted campaign messengers is key to promoting COVID-19 and routine vaccination. Tools that can be used by trusted messengers have the power to provide sources of science-based information and resonant messages and information about local access points for vaccines.

New challenges will emerge as the virus mutates into new variants that are more contagious and deadly. Government agencies like the CDC will respond by updating guidelines to enhance vaccine uptake to achieve herd immunity. Evidence-based communication strategies and grassroots efforts should be intensified and expanded to support these efforts and protect the most vulnerable and achieve vaccine equity.