Vaccine Confidence Fund Insights Report

"In low resource settings, bridging online engagement with participatory on-ground activities amplifies community voices and experiences resulting in increased public interest in health topics and an uptake in vaccines."

Just under half of the world population use social networks. While social media can be a place where vaccination misinformation spreads, these online platforms also present opportunities to address issues associated with vaccine confidence and uptake. With these considerations in mind, the Alliance for Advancing Health Care Online (AAHO) launched the Vaccine Confidence Fund (VCF) as its inaugural initiative in June 2021. VCF's goal is to support targeted research that increases access and equity regarding vaccination confidence and uptake, particularly among historically marginalised or excluded communities globally. This report provides an overview of VCF grantees' projects, key findings, and more detailed results.

Guided by the principles of equity, interdisciplinary collaboration, actionable focus, community engagement, external validity, and transparency and information sharing, VCF sought to explore the primary research question: "How can social media be best utilized to understand and increase vaccination confidence and uptake?" Meta and Merck & Co., Inc. (known as MSD outside the United States and Canada) are financially sponsoring the Fund, which is independently managed by Global Impact. Among nearly 300 applications from 48 countries across 6 continents, VCF selected 33 teams to grants averaging around US$220,000, for a total of over US$7 million disbursed.

Total numbers of people reached (viewed or interacted with social media), engaged (participated in survey activity, etc.) and vaccinated as reported by grantees: 34,273,993 reached, 7,171,618 engaged, and 106,030 vaccinated.

Common key findings include:

• Customising messaging: Larger mass information campaigns that focus on general information may be less effective than engagement activities and messages tailored for specific geographies and communities (e.g., language and cultural context).
• Successfully reaching populations: Social media presents a key opportunity to share tailored information, provide a neutral platform to discuss and engage around vaccines and vaccinations, and tap into the social power of influencers and trusted members of the community. As noted, these factors are key to impacting perceptions and behaviors around vaccines. At the same time, recruiting study participants and reaching specific populations can be tricky.
• Providing safe spaces: Many of the demographics studied, especially those who are vaccine hesitant or in a position of responsibility (e.g,, parents and healthcare workers) are more likely to engage in online conversations in small, trusted groups. Many of the studies in this report noted that either providing a "safe" online space to discuss concerns among the vaccine hesitant, gaining access to trusted physicians or medical professional who could answers specific questions, or being able to engage on platforms with other individuals from similar demographic backgrounds (e.g., mothers) often had significant impact in increasing vaccine confidence.
• Engaging trusted voices: Hearing representations of themselves in communications was key for many communities. For many of the communities participating in the studies, there was mistrust of the government and health organisations. While there was not necessarily consistency in who those trusted sources were, identifying them and having them play a role in sharing information and engaging the community was likely to have a positive impact on vaccine confidence. In addition, the influence of families, as well as concern for their health and wellbeing, could drive both for and against vaccination.

The bulk of the report provides a more detailed look into some of the insights coming out of the 33 research projects conducted under the VCF. It explores findings by types of vaccinations, key population groups, and by methodology type. Further information on the studies mentioned can be found in the Appendix and links in the footnotes. Here are a few highlights:

• Insights on what drives vaccine uptake: In one study, conducted by the International Longevity Centre, click-through rates for vaccine appointments were used as a proxy to measure uptake following engagement with their social media campaign. The study found that "(s)ocial media campaigns targeting older adults in deprived areas directly have significant potential to increase vaccine uptake - especially for less well-known vaccines."
• Findings on members of historically excluded and marginalised communities: For example, looking at minority populations in 4 countries, the Minority Rights Group found that ignoring significant and deep-rooted differences between minority and majority populations can mean efforts do not reach whom they intend - or can even backfire. 19 Working closely with trusted local minority organisations, researchers found that when data are "disaggregated by ethnicity, language and religion, findings help explain issues such as residual pockets of non-vaccination in Sri Lanka, or the fivefold difference in vaccination rates between different areas of Kenya." The research emphasizes the ethnic, religious, and linguistic barriers to vaccine access and uptake. This likely means more locally relevant information, in local languages and through trusted community figures, will have a greater impact than general, centrally broadcasted information. The study also showed that while social media findings can be very useful for areas with high levels of usage, for those in more remote areas, social media may not have the reach needed to impact the community, both in terms of actual signal and in terms of a presence of trusted community figures engaging online.
• With regard to methodology: One study, looking at the impact of crowdsourcing, found that it was challenging, but possible, to generate local science-based media content to address vaccine hesitancy and misinformation. The study found that, while social-media-based video content improves when instructional infographics are provided, "people who submit videos come up with creative and intuitive strategies to persuade people that are consistent with behavioral theory, for example, highlighting social norms, downplaying risks, emphasizing social benefits and economic effects, peace of mind and stress reduction. Storytelling (e.g., people who were affected by Covid) was also used as a common motivator". The study did find that the success of the campaigns and sourcing "local content is possible but challenging and varies significantly by context....A comparable small-scale campaign run across countries was more successful in Kenya and the Philippines, and less so in Nepal."

Going forward, overall suggestions to increase vaccine confidence through social media include:

• Community engagement
  • Involve communities, or local organisations, particularly those in hard-to-reach or marginalised communities, at every step, including in the study or technology design as well as implementation. To be most effective, these approaches should be adapted to the realities of each community or population it is trying to serve, including in the language and images used, the social-cultural and gender norms, the kinds of misinformation circulating, and the specific concerns of the community.
  • Pair with researchers with policymakers from the beginning of their projects to ensure their findings get translated into policy and become actionable at the local, state, and, if appropriate, national level.
  • Partner with local organisations to help plan, understand, and implement programming.
  • Consider amplifying existing expressions of vaccine confidence from within the community, as hearing from individuals trusted in the community can have a more significant impact.
• Listening to needs
  • Provide information to help individuals make their own decisions rather than seeking to instruct - e.g., by sharing positive and negatives in an unbiased fashion that is still supportive of vaccines.
  • Where possible, create a platform for small-group dialogues and peer support for targeted communities, with relevant moderation.
  • Where distrust exists between local populations and health authorities or government, make extra efforts to involve trusted figures to convey key information and rebuild trust.
  • Seek to understand social and accessibility barriers to vaccination.

The report looks at what governments, health authorities, researchers, and other stakeholders can do. For example, recommendations for community-based organisations (CBOs) include:

• In light of preexisting priorities and projects that may compete for time and human resources, any project under development must be designed to ensure the research, and potential implementation project developed from that research, serves the organisation’s purpose and mission from the beginning.
• Research can help guide CBOs towards more efficient and effective targeting of interventions.
• Understanding local dynamics around who is trusted and why can allow for better targeting of resources. Trusted CBOs and leaders can have an outsized impact on lives when trust in central government is low.
• Technology and social media can be leveraged to change behaviours. As social media use increases in historically marginalised communities, it can be used as a platform for CBOs and leaders to communicate and influence health decision making.
• Community voices must be front and central in dissemination activities. Ensuring community partners are leading the way on podcasts and interviews with press, and are active members and authors on journal article writing teams, is critical for appropriate recognition, capacity-building, and continuity.

AAHO disseminated a survey to grantees and valued partners to collect external input on areas of needed research, which include: influencing social norms, and driving community and healthcare provider engagement. Two additional underpinning priorities were articulated and should be considered across all research: equity (better target and measure impact related to reaching and impacting underserved groups and ethnic minorities) and closed-loop feedback (vaccine message exposure should be causally linked with actual vaccine uptake). To ensure closed-loop feedback can be collected and measured, participants recommend: rigid requirement for causal identification strategies; real-time involvement and engagement of key stakeholders and experts; agreements with local or central governments or entities to integrate or share data to help validate uptake and/or vaccinations from research; and more time to run focus groups before and after campaigns, such as representative samples, quick surveys to ask about action, and better links to book vaccinations.

Looking forward, AAHO announced a new call to action with another round of funding to support research on vaccine confidence, with a strong emphasis on routine immunisations. The call for proposals focuses on two intended populations, healthcare workers and local communities, and seek to improve understanding on how they can be supported to drive positive health actions via social media engagement and build vaccine confidence around COVID-19 vaccines and routine immunisations.

Editor's note: On behalf of the Sabin Vaccine Institute, the Bay Area Global Health Alliance and the AAHO hosted a webinar on August 9 2022 to explore how social media can be best used to understand and increase vaccine confidence and uptake. Speakers discussed key findings from the VCF report and shared best practices from projects implemented in Guatemala, Algeria, Kenya, the United States, and the United Kingdom that designed engagement activities and customised, targeted messaging to increase vaccine confidence in marginalised and underserved communities.