This section summarizes the scientific evidence and jurisdictional experiences regarding strategies to
encourage vaccine acceptance and address vaccine hesitancy or uptake. Jurisdictions reviewed include
Canada, Australia, China, New Zealand, the United Kingdom (UK), and the United States (US). Most of
these sources do not address a COVID-19 vaccine specifically; COVID-19-related information is included
where available.

Scientific Evidence

• Research Findings: Overall, research suggests that vaccine acceptance is encouraged and hesitancy reduced through: 1) multi-component community-based strategies that typically include information, education, and reminder and recall interventions; and 2) availability of vaccines through familiar and accessible locations (e.g., pharmacies). Key findings related to interventions targeting different population groups include
  • General Public:
    • Community-Based Interventions: Two systematic reviews found that community-based interventions using informational or educational resources (e.g., brochures, pamphlets, posters) improves attitudes about vaccines. Other effective interventions may include home visits, technology-based health literacy, and monetary incentives. Another systematic review suggested that: 1) resource-intensive interventions (e.g., manual outreach, tracking, home visits) may be necessary strategies to increase vaccination rates amongst populations who typically have low rates of vaccination; and 2) costs could be reduced if interventions are implemented in a stepped approach, starting with less resource-intensive interventions (e.g., reminder and recall systems) and progressing to other interventions if needed.
    • Reminder and Recall Interventions: A systematic review found that reminding people (e.g., by telephone and automatic calls, sending a letter or postcard, sending a text message) to get a vaccination likely increases the number of people who receive vaccines. Reminding people over the telephone may be more effective than other types of reminders.
    • Pharmacy-Based Interventions: A systematic review found an increase in vaccine coverage when pharmacists were involved in the immunization process, regardless of the role (e.g., educator, facilitator, administrator) or vaccine administered (e.g., influenza, pneumococcal) when compared to vaccine provision by traditional providers without pharmacist involvement. Convenience and accessibility (e.g., extended hours, availability of walk-in appointments) of pharmacies are important facilitators of immunization acceptance and uptake, but political and organizational barriers may limit the feasibility and effectiveness of pharmacies for sites of vaccination.
    • Facilitators for COVID-19 Vaccine Uptake: A global survey (October 2020) of 13,426 people in 19 countries found that respondents that reported higher levels of trust in information from government sources were more likely to accept a vaccine and take their employer’s vaccine advice. One survey from the US found that: 1) messages that emphasize personal health risks and collective health consequences of not vaccinating significantly increased intentions to vaccinate; 2) the effects were similar regardless of the message source (ordinary people or medical experts) and efforts to pre-emptively de-bunk concerns about the safety of expedited clinical trials; and 3) the ‘economic cost’ related framing had no discernible effect on vaccine intentions. Another US survey found that public opinion toward COVID-19 vaccinations may be responsive to political motivation and support, with findings highlighting that positive statements by President Donald Trump and Dr. Anthony Fauci had a significant positive effect on public reactions towards a COVID-19 vaccine.
  • Parents and Children: In terms of facilitators for vaccine uptake in children, a systematic review found that parents: 1) want balanced information about harms and risks that is accessible (not just in health settings) and clearly presented in advance of a vaccination appointment; 2) view health workers as an important source of information, but poor communication and negative relationships can impact vaccination decisions; and 3) find it difficult to know which information sources to trust and/or find unbiased and balanced information.
  • Older Adults: A systematic review indicated that several interventions were found to be effective for increasing demand for vaccination among community-dwelling older adults, including reminder/recalls by letters and leaflets, pharmacist-provided education, nurse provided vaccinations, personalized phone calls, home visits, client group clinic visits, and free vaccination programs.
  • People Who are Hesitant/Opposed to Vaccination: A systematic review found that the attitude of parents who are hesitant about vaccines substantially improved after receiving educational resources and information (e.g., brochures, pamphlets, posters). Additionally, a rapid review reported that vaccine uptake may be improved by setting up vaccination clinics in familiar and accessible locations and leveraging community partners to reach individuals who are hesitant about or opposed to vaccination
• Expert Recommendations:
  • Two guidelines from the World Health Organization (WHO) provided general insights about vaccine delivery, but also described specific steps for ministries of health to encourage vaccine acceptance and address vaccine hesitancy. The Vaccine Introduction Readiness Assessment Tool includes information on establishing data systems to collect social-media misinformation and behavioural data.
  • A rapid review from the UK’s national academy of sciences, The Royal Society, published five key recommendations to address vaccine hesitancy and improve vaccine uptake: 1) public dialogue about vaccine concerns and misinformation; 2) convenient locations for vaccination that build on existing vaccination programs; 3) decentralized local vaccination programs with visually appealing, multi-language toolkits for local jurisdictions and partners; 4) ethical allocation of vaccines by prioritizing age and comorbidity-based groups; and 5) accountability from media and responsibility from citizens to report misinformation and remove harmful information.
  • The expert opinion of a 23-member Working Group of Readying Populations for COVID-19 recommended that governments should: 1) value social science, generate research on social, behavioural, and communication science, and develop active partnerships; 2) inform public expectations about COVID-19 vaccination benefits, risks, and supply (e.g., temper expectations, be transparent about vaccine-safety systems, seek input from marginalized populations); 3) communicate in meaningful ways (e.g., reject political tensions, conduct qualitative studies to understand local and community needs and attitudes, engage networks of trusted champions and spokespeople to deliver a unified message); 4) earn public trust and confidence in allocation and distribution (e.g., develop strategies that take marginalized populations into consideration, implement guidelines that are consistent across providers and locations); 5) make vaccination available in safe, familiar places (e.g., schools, pharmacies, places of worship, workplaces, health departments, senior centres, home visits), prepare educational materials, train providers and other allied professionals, develop hesitancy campaign plans, and foster intersectoral partnerships with government, health departments and media); and 6) establish an independent body to instill public ownership (e.g., establish public committees to report on measures such as public understanding, access, and acceptance).

International Scan

• General Population-Based Interventions: Australia, China, New Zealand, the UK, and the US generally reported efforts to encourage vaccine acceptance and address vaccine hesitancy through existing population-based interventions, which include:
  • Launching vaccination campaigns with an emphasis on the importance of vaccination;
  • Providing tailored information to describe evidence on the risks and benefits of vaccines through common modalities (e.g., radio/podcasts, television, email alerts and reminders, text messages, face-to-face, social media) and through less frequently mentioned modalities (e.g., financial incentives, reminder-recall notifications);
  • Engaging health care providers to provide information and address concerns from vaccinehesitant individuals during clinic visits; and
  • Combating myths and misinformation about vaccines through community engagement and transparency of the vaccine development process.
• COVID-19-Specific Interventions: The US Department of Health and Human Services National Vaccine Advisory Committee released five recommendations to build confidence on the vaccine, which outline the need to:
  • Deliver effective COVID-19 vaccines to the public through the Food and Drug Administration’s Biologics License Application process;
  • Rapidly deploy and coordinate vaccine safety monitoring through the federal-level immunization task force;
  • Create proactive and highly impactful communication for the general public on the development, safety, approval, and recommendation criteria;
  • Establish an independent group of vaccine and public health experts to conduct rapid reviews of available vaccine safety monitoring data; and
  • Conduct community-based studies and engagement to increase the likelihood of vaccine uptake in communities and marginalized populations.

Canadian Scan

• Expert Recommendations: There is existing guidance to encourage vaccine acceptance and
  help address vaccine hesitancy for the general public, such as strategies outlined by the Public
  Health Agency of Canada, Canadian Vaccination Evidence Resource and Exchange Centre
  (CANVax), and the Canadian Pediatric Society. For example:
  • A Public Health Agency of Canada report (2016) described engagement strategies. For
    vaccine acceptors, strategies include encouraging resiliency, describing common side
    effects and rare adverse events, and using verbal and numeric descriptions of disease
    risks. For those who are vaccine hesitant, key strategies include building rapport and
    accepting questions and concerns, establishing honest dialogue with information about risk
    and benefits of the disease and vaccine, using decision aids and other information tools,
    and providing the opportunity to book additional appointments with health care providers for
    further discussion. Lastly, for those who refuse vaccines, strategies include avoiding
    debates about vaccination, providing opportunities for brief open-ended discussions,
    providing information about the risks of non-vaccination, and offering access to clinical care
    during adverse events.
  • A presentation (January 24, 2020) from the Vaccine Evaluation Centre at the University of
    British Columbia provided recommendations for health care providers to improve vaccine
    hesitancy, which includes maintaining trust, reinforcing the role of community immunity,
    emphasizing pro-social reasons for vaccination, and acknowledging diversity by working
    with culturally specific health promotion groups and patient/parent communities.
• General Population-Based Interventions: All Canadian provinces and territories reported
  strategies to encourage immunization among the general population, which were often cited
  within flu-vaccination campaigns. The most-reported strategy included information or education campaigns on social media, including web-based advertising to address hesitancy, fact sheets about the risks and benefits, and information on immunization schedules and where to get their vaccine. For example, Yukon’s 2020 influenza vaccine campaign featured public education and engagement through YouTube, and explained key vaccination dates, provided information on COVID-19, and addressed vaccine hesitancy.

Ontario Scan

• The Government of Ontario’s Fall Preparedness Plan for Health, Long-Term Care and Education states that there are actions underway to engage with stakeholders to promote the flu vaccine and run a public-education and targeted flu campaign.
• Prior to the COVID-19 pandemic, the Ontario Medical Association launched the #AskOntarioDoctors social media and public information campaign to combat vaccine misinformation and hesitance.

The COVID-19 Evidence Synthesis Network is comprised of groups specializing in evidence synthesis and knowledge translation. The group has committed to provide their expertise to provide high-quality, relevant, and timely synthesized research evidence about COVID-19 to inform decision-makers as the pandemic continues. The following member of the Network provided an evidence synthesis product that was used to develop this Evidence Synthesis Briefing Note:

Gauvin FP, Lavis JN. COVID-19 rapid evidence profile #24: What is known about strategies for encouraging vaccine acceptance and addressing vaccine hesitancy (including efforts to combat misinformation that may lead to vaccine hesitancy) or uptake (when interpreted, at least in part, through the perspective of vaccine acceptance or hesitancy)? Hamilton: McMaster Health Forum, 17 November 2020.