COVID-19 Vaccination Field Guide: 

12 Strategies for Your Community

U.S. Department of 

Health and Human Services

Centers for Disease 

Control and Prevention
Table

of Contents

4 Introduction

4 About This Guide

5 Using this Guide

6 Common Barriers

6 Structural Barriers

6 Behavioral Barriers

7 Informational Barriers

8 Understanding 

Your Community

8 The Social Vulnerability 

 Index (SVI)

9 Walk a Mile Exercise

11 Diagnostic Tool to 

 Identify Factors and

 Strategies

12 Rapid Community 

 Assessment (RCA)

13 Vaccine 

Confidence and 

 Uptake Strategies

15 Strategy 1:

 Vaccine Ambassadors

17 Strategy 2:

 Medical Provider 

 Vaccine Standardization

18 Strategy 3:

 Medical Reminders

20 Strategy 4:

 Motivational Interviews

21 Strategy 5:

 Financial Incentives

22 Strategy 6: 

 School-Located 

 Vaccination Programs

23 Strategy 7:

 Home-Delivered 

 Vaccination

24 Strategy 8:

 Workplace 

 Vaccination Programs

25 Strategy 9:

 Vaccine Requirements

27 Strategy 10:

 Effective Messages 

 Delivered by Trusted 

 Messengers

29 Strategy 11:

 Provider 

 Recommendation

30 Strategy 12:

 Combating 

 Misinformation
31 Conclusion

32 Appendices

32 Appendix A:

 References and Resources

41 Appendix B:

 Strategy Matrix Table

42 Appendix C:

 Diagnostic Tool

46 Appendix D:

 BeSD Framework

47 Acknowledgments
4

T he COVID-19 pandemic has affected millions of lives in communities across the world, 

including in the United States. COVID-19 is unique in many ways, including its global impact, 

its politicization, and the need for universal vaccination to combat the virus. When COVID-19 

vaccines became available in the United States, millions of Americans eagerly sought out 

and received them. Many see vaccination as the key to a post-pandemic life, yet millions of Americans 

have still not been vaccinated despite eligibility and plentiful supply. Desire for receiving a COVID-19 

vaccine among some minority populations, particularly Black or African American and Hispanic or 

Latino populations, is high though uptake is lagging12. This indicates barriers related to access and 

equity may be at play. For other populations, there is more hesitancy about getting vaccinated. 

Communities with vaccination rates much lower than the national average may need to further 

investigate and address barriers to COVID-19 vaccination. 

People encounter barriers that can hinder or facilitate vaccinations. Barriers and facilitators range from 

logistical and access issues, to personal beliefs and risk perception, to community beliefs and social 

norms. Insights from behavioral health research can help determine strategies to help people get 

vaccinated and promote near-universal uptake. 

Health departments, community organizations, faith-based communities, and leaders from all sectors 

of public life are making great efforts to promote COVID-19 vaccination. No single approach will work 

for every community; in fact, as the research included here demonstrates, a combination of strategies 

is generally most effective and will increase chances for success. This field guide highlights several 

strategies derived from evidence-based practices that are being applied in communities across the 

country to promote vaccine confidence and uptake. 

About this Guide 

This field guide offers intervention strategies to promote COVID-19 vaccine confidence and uptake 

based on a rapid assessment of evidence that identified research-proven methods. This guide is 

intended to support the work of health departments and community- and faith-based organizations 

across the United States. It highlights some common barriers that communities experience in vaccine 

confidence and uptake. Not all barriers are relevant in all communities; therefore, the second section 

of this guide helps you understand the various needs of different communities and offers tools to help 

you assess barriers and find potential solutions for your community of focus. 

The final section describes 12 intervention strategies drawn from historical vaccination efforts that 

have demonstrated positive outcomes through evaluation research. While most of the guide focuses 

on increasing vaccine uptake, several strategies address increasing vaccine confidence. Each strategy 

highlights the approach, population(s) served, location, barriers addressed, basis in research, and an 

example of how the strategy is currently being applied to address COVID-19 vaccination. 

Vaccine Confidence is the trust 

that people have in recommended 

vaccines and how they are 

administered and developed. 

Without some level of confidence, 

people will not move toward 

receiving a vaccine.

Vaccine Uptake refers to the 

proportion of the population 

that has received a vaccine.

1 PPRI Staff. (July 27, 2021). Religious Identities and the Race Against the Virus: (Wave 2: June 2021). Retrieved at: 

https://www.prri.org/research/religious-vaccines-covid-vaccination/.

2 Ndugga, N., Hill, L., Artiga, S., and Parker, N. (August 18, 2021). Latest Data on COVID-19 Vaccinations by Race/Ethnicity. 

Retrieved at: https://www.kff.org/coronavirus-covid-19/issue-brief/latest-data-on-covid-19-vaccinations-race-ethnicity/
5

Using this Guide

This resource consists of three primary sections: 

1. Common Barriers

This section of the guide tells about common barriers to vaccine confidence and uptake.

2. Understanding Your Community

This section offers tools you can use to identify and understand what barriers and facilitators may

be factors in your community of focus. You may need only one of these tools, or several to increase

your understanding of your community.

3. Vaccine Confidence and Uptake Strategies

Here you will find recommended strategies to increase vaccine confidence and uptake. The research

that supports the strategy is provided along with case study examples. More information about the

strategies, including guidance and implementation resources, are linked within the document

and provided in Appendix A.

Factor in cost of implementing the strategy

including dollars, time, level of effort, staffing.

 Implement the strategy to have the most success 

by having relevant community members involved in 

planning and execution; obtain leadership buy-in.

 Consider piloting the effort on a small scale 

to measure success before attempting wider 

implementation, especially if you are unsure 

about a strategy. 
6

Common Barriers

There are several common barriers to COVID-19 vaccine confidence and uptake. Leaders should 

consider which barriers the people in their community are experiencing. Understanding the barriers 

can help identify strategies most likely to increase vaccine uptake. The Behavioral and Social Drivers 

(BeSD) framework described in Appendix D offers another way to view what drives or motivates 

COVID-19 vaccine uptake. 

Structural Barriers

Equity: COVID-19 vaccines may not be equally distributed, administered, or accessed in 

communities nationwide, especially among under-resourced communities in urban and rural areas. 

Cost: While COVID-19 vaccination is currently free, it requires time and resources. This includes figuring 

out where to get vaccinated, making an appointment (if necessary), traveling to the vaccination site, 

possibly taking time off from work, and recovery times for those who experience side effects. Some 

people will need childcare or transportation, or are unable to take time off work to get vaccinated or 

recover from side effects.

Access: Proximity and travel convenience to a vaccination site plays a large part in an individual’s 

ability to get vaccinated. Vaccination clinic hours of operation may limit access for some as well. 

Some people do not have transportation access, internet access, or the technical skills required to 

search online for vaccination sites or appointments. People with disabilities, who are confined to 

their homes, or who live in a long-term care or correctional facility, cannot travel to get a vaccine. 

Policy: Existing policies, such as health insurance requirements for most medical services and 

service restrictions for non-citizens and undocumented residents, can influence understanding of 

vaccine access. People may not know they are eligible to receive a vaccine for free or be aware of 

their employer’s policies on paid and unpaid leave for vaccination purposes. Also, employers are 

encouraged, but not required, to have policies allowing employees to take paid leave to get 

vaccinated and to recover if they have temporary side effects.

Behavioral Barriers

Inertia: Getting vaccinated takes planning and effort. Many individuals have difficulty making 

decisions—especially large decisions—so instead of deciding, they do nothing. This tendency to 

do nothing leaves people unvaccinated.

Prevailing Social Norms: Community norms often drive individuals’ actions. If trusted friends 

or leaders in one’s community are against getting vaccinated, others will likely follow suit. 

Forgetfulness: People may forget non-routine activities and procedures. They may forget to book their 

vaccination appointments or to keep them.

Friction: Complex, inconvenient, or effort-provoking processes often lead people to fulfill immediate 

wants and needs. If the process of booking or attending a vaccination appointment is too complicated, 

they will not do it. 

Misperception: Individuals may have vaccine opinions and beliefs based on scientific inaccuracies, 

including that they are at low risk of getting severely sick with COVID-19, that the pandemic is being 

exaggerated, or that vaccines are not effective. These inaccuracies are often spread in communities and 

lead to fear, resistance, or mistrust.
7

Behavioral Barriers (Continued)

Mistrust: Lack of trust in institutions including government, medical institutions, and media, is 

sometimes based on individual or communal experiences, and affects decisions about vaccination. 

Uncertainty: Due to the novelty of the vaccines, many individuals feel uncertain about the short- and 

long-term side effects, causing them to take a cautious “wait-and-see” approach to getting vaccinated. 

With the course of the pandemic uncertain, people may believe it will soon be over. So, they may 

believe they do not need a vaccine or want to wait to see if a different option will be approved to 

address COVID-19 variants. Changes in official guidance can also make people feel uncertain about 

their actions or decisions.

Politicization: COVID-19 vaccines have been politicized, making political affiliation a strong 

determinant of vaccination beliefs and behaviors.

Informational Barriers

Cultural Relevance: Information about the vaccines is not always communicated in ways that reflect 

sociocultural norms, beliefs, and realities. This can make information less relevant and confusing to 

some individuals. Language may also be a barrier for non-native English speakers, especially given the 

complexity and novelty of some vaccine information. 

Health Literacy: Individuals may not fully understand the complex vaccine information being shared, 

such as the multiple types of vaccines offered or lack of a clear and simple call to action. Adding to 

confusion is changing guidance. People may lose trust or become confused when new information is 

conveyed frequently; possibly not understanding that changing data impacts guidelines. People may 

also have difficulty telling the difference between factual and false health information. 

Mis- and Disinformation: Most mis- and disinformation that has circulated about COVID-19 vaccines 

has focused on vaccine development, safety, and effectiveness, as well as minimizing the severity of the 

pandemic and COVID-19 denialism.

Lack of Adequate Information: Some individuals lack the information they need to understand the 

risks, benefits, and background of vaccine development to make an informed decision about getting 

vaccinated. Information overload can also be a form of inadequate information as it can become 

difficult for people to know what is relevant or current. 

Misinformation is false information 

shared by people who do not intend 

to mislead others.

Disinformation is false information 

deliberately created and 

disseminated with malicious intent.
8

Understanding Your Community 

To effectively address common barriers, it is important to identify and understand your community of 

focus. Existing community data and previously conducted assessments, such as a health equity impact 

assessment, may be available and useful in this process. Several tools are available to help with this, 

including the Social Vulnerability Index, the “Walk a Mile” Exercise, the diagnostic tool, and the Rapid 

Community Assessment (RCA) Guide. 

The Social Vulnerability Index

The Social Vulnerability Index (SVI) is a Centers for Disease Control and Prevention (CDC) database 

designed to help emergency response planners and public health officials identify and map 

communities that will most likely need support before, during, and after a public health emergency, 

including the COVID-19 pandemic. Data from the SVI can help local leaders identify and decide which 

populations to focus on.

About

Several factors, including poverty, lack of access to transportation, and crowded housing may weaken a 

community’s ability to prevent human suffering and financial loss in a disaster. These factors are known 

as social vulnerability. Reducing social vulnerability can decrease human suffering and economic loss. 

The SVI ranks each county and census tract based on four themes:

1. Socioeconomic status

2. Household composition and disability

3. Minority status and language

4. Housing type and transportation

The higher the ranking, the more socially vulnerable the community is compared to other communities.

How to Use

The SVI data are displayed on an interactive map and can also be downloaded for a more granular look 

into what determines a county or census tract’s SVI.

Applying the Data

Communities with higher SVI values have been disproportionately affected by COVID-19 both in terms 

of new cases and deaths. Often these communities face greater structural barriers to vaccination. Early 

in the vaccine rollout, counties with high social vulnerability had lower COVID-19 vaccination coverage 

than did counties with low social vulnerability. Efforts to increase vaccine access, confidence and 

demand can be prioritized for these communities to decrease inequities. 
Walk a Mile Exercise

The Walk a Mile (WAM) interactive exercise invites participants to “walk a mile” in the shoes of the 

population of focus in their journey to vaccination, recognizing that each population may have 

unique context and experiences. Barriers and facilitators to COVID-19 vaccination for specific 

populations are identified.

About

 The WAM exercise identifies these key steps in the vaccination process:

1. Knowledge, awareness, and beliefs

2. Intent

3. Preparation, cost, and effort

4. Point of service

5. Experience of care

6. After service

Factors at the individual, community, societal, and political level impact vaccine access, confidence 

and demand at each of these stages and should be considered throughout the exercise.

FIGURE 1: Walk a Mile Graphic

Modified from UNICEF Journey to Health, 

ESARO Network Meeting 2019

9

How to Use

The exercise is designed to be completed in small groups that are familiar with the population of 

focus. This may include health department staff, community- or faith-based organizations, community 

leaders, and others. A facilitator guides a group conversation while people play the roles of members 

of the community of focus; brainstorming their enablers and barriers at each point along 

the vaccination journey. If you would like a guide to conduct the WAM exercise, please email 

confidenceconsults@cdc.gov. 
10

FIGURE 2: Example of Completed WAM Exercise

Applying the Data

The responses from the WAM exercise give insight into how the vaccination journey is unique to 

each population. For each population, the exercise generates a list of perceived and actual barriers 

and facilitators. Understanding this can lead to identifying appropriate strategies to try to increase 

vaccine confidence and uptake.
11

Diagnostic Tool to Identify Factors and Strategies

About

The diagnostic tool (see Appendix C) can be used for guided conversations to assess factors related to 

vaccine confidence and uptake in a specific population and identify strategies to address challenges.

FIGURE 3: Example of Diagnostic Tool Questions

How to Use

The factors that build vaccine confidence, intention, and demand are located in the left column of the 

tool. Questions related to the assessment of the factors are provided for each. If the answer to 

the assessment question is yes, move to the next factor. If the answer to the question is no, proceed to 

the “Considerations” column. If sufficient information is available to talk through the considerations, 

proceed to the “Recommended Strategies” column. 

This tool is designed to be used by anyone working to increase vaccination in a specific population.

 The participants in the guided conversations could include health department staff, community- or 

faith-based organizations, community leaders, and others.

The tool can be used with large or small groups. The key is to have people involved in the discussion 

who know the most about the population of focus and the vaccination process.

Applying the Data

Once the recommended strategies have been identified, teams can think through how to design, 

implement, and evaluate these interventions.
12

Rapid Community Assessment

In attempting to apply the tools above, an organization might find that they do not have enough 

information to identify barriers and facilitators related to vaccine confidence or demand. An 

organization might also consider it necessary to conduct a more in-depth community assessment to 

determine the status of vaccine confidence or demand in their communities. In either case, the Rapid 

Community Assessment (RCA) Guide can help identify and address these challenges.

About

The RCA can be used by staff of any organization working to increase COVID-19 vaccine uptake who 

wish to better understand the needs of the population of focus. 

Use of this tool will help an organization to: 

• Identify populations of focus at risk for low COVID-19

vaccine uptake.

• Gain an understanding of what people in the community

think about COVID-19 vaccines, as well as plan for

potential solutions to increase confidence and uptake.

• Identify community leaders, trusted messengers, and other

important channels to reach populations of focus.

• Identify areas of intervention and prioritize potential

intervention strategies to increase confidence in and

uptake of COVID-19 vaccine.

How to Use

The RCA consists of five steps:

1. Identifying objectives and community(ies) of focus

2. Planning for the assessment

3. Collecting and analyzing data

4. Reporting findings and identifying solutions

5. Evaluating your efforts

Given the urgency of the COVID-19 pandemic, the suggested 

timeframe to complete the assessment is three weeks. The 

RCA guide provides a step-by-step process for the assessment 

as well as tools and scripts. The guide is available in English 

and Spanish.

Applying the Data

The data collected through the RCA will increase your 

understanding of what communities are thinking about COVID-19 vaccines, and help you plan 

potential solutions to increase vaccine confidence and uptake. The data can also reveal previously 

unrecognized leaders and trusted messengers through whom you can reach community members. 
13

Vaccine Confidence 

and Uptake Strategies

Below are selected strategies to increase 

vaccine confidence and uptake drawn from 

historical vaccination efforts and supported 

by positive outcomes from evaluation 

research. Examples from communities 

currently using the strategies to increase 

COVID-19 vaccine confidence and uptake 

are included. 

State and local health departments, 

community- and faith-based organizations, 

and local nonprofits are encouraged to try a 

combination of these strategies to increase 

vaccination rates.

Links to learn more about 

how communities have 

addressed challenges and 

implemented the strategies 

are included in Appendix A.
Vaccine 

Ambassadors

Medical 

Provider Vaccine 

Standardization

Medical

Reminders

Motivational

Interviewing

Financial 

Incentives

School-Located 

Vaccination 

Programs

Home-Delivered

Vaccination

Workplace

Vaccination

Vaccination

Requirements

Effective Messages 

Delivered by Trusted 

Messengers

Provider 

Recommendation

Combating

Misinformation

14
Strategy 1

Vaccine Ambassadors

Vaccine ambassadors are a derivative of the lay health advisor (LHA) 

model, which trains community members to disseminate important 

health information in their communities. Ambassadors are most 

effective when they are trusted community members and share 

similar beliefs and characteristics with their peers. 

Barriers Addressed: Equity, access, prevailing social norms, mistrust, 

misinformation, cultural relevance.

Research Base: Framing vaccine uptake as a prevailing social norm 

has a positive impact. A survey study showed that when people 

think that most people around them want to be vaccinated, they are 

more likely to be vaccinated as well. Discussing with peers the risk 

of contracting disease and the decision to vaccinate impacts one’s 

decision. Endorsements from peers in one’s own social network can 

also help spread credible information about the vaccines.

COVID-19 Application Examples

Location: San Francisco, CA

Population of Focus: Latino Persons

The “Motivate, Vaccinate, and Activate” campaign 

encouraged residents of the under-resourced, 

predominantly Latinx Mission District of San Francisco, 

California, to be vaccinated against COVID-19. The culturally 

tailored initiative was organized through a communityacademic-city public health partnership among Unidos en 

Salud (United in Health), the University of San Francisco, and 

the City of San Francisco. They engaged trusted messengers, 

social networks, and used a convenient vaccination site 

to increase vaccination uptake and overcome hesitancy 

due to misinformation, distrust of institutions, and access 

to the vaccines. Community health workers educated the 

community about the vaccines, texted people to let them 

know of their eligibility, and used public media to spread 

the word about vaccination locations. 

Vaccinated community members became ambassadors 

to recruit friends and family members to get vaccinated. 

Important steps in this strategy included: 

15

• Two dedicated staff shared their personal experiences

modeling how this could be done.

• Staff then encouraged others to share their own

vaccination experiences with their unvaccinated friends

and family to encourage them to become vaccinated.

• Staff provided tips on how to handle difficult

conversations, provided myth-busting information,

and role played.

Outcome: Of those who were fully vaccinated, 91% of 

survey respondents reported that they later recommended 

vaccination to one or more unvaccinated people they 

knew; 83% stated that they motivated one or more others 

to be vaccinated; and 19% reported that they motivated 

six or more others. During a 16-week period, the campaign 

administered 20,792 vaccines at the neighborhood site.

Where to Start: Learn more about how the community implemented this strategy to use social 

networks to boost vaccination coverage. 
16

Location: Philadelphia, PA

Population of Focus: African American or Black Adults

A partnership between two health systems and community leaders in Philadelphia established COVID-19 

vaccination clinics to overcome equity barriers among communities of color. Faith and other community 

leaders were engaged as vaccine ambassadors who helped design the intervention, activated their 

networks, and were trusted messengers to increase vaccinations. The strategy used other components 

in addition to the vaccine ambassadors including a no- to low-tech approach to vaccine scheduling, 

text or phone reminders of future vaccine appointments, and personal outreach. 

Outcome: The program was designed and launched with just 2 weeks of planning. Three 7-hour clinics 

vaccinated 2,821 people, 85% of whom were Black. Second dose clinics operated with an overall 0.6% 

no-show rate. 

 Key components of this effort included: 

• Health system leaders met virtually with area pastors to ensure they felt comfortable recommending

the COVID-19 vaccines.

• The pastors led by example and received their first doses at the clinic.

• During a virtual event held by two faith leaders for their congregations, Black physicians shared

their vaccination stories, provided scientific information about the vaccines, and answered

people’s questions and concerns. The event was recorded for future use by new partners, including

community organizations and health workers, senior centers, salons and barbershops with

predominantly African American or Black customers and staff, as well as WURD, a Black-owned

and operated talk radio station that aired segments about the COVID-19 vaccines and the

community clinic initiative.

Where to Start: Learn how this effort was implemented in Philadelphia including details on all the 

components and lessons learned.
17

Strategy 2

 Medical Provider 

Vaccine Standardization

Medical provider vaccine standardization refers to offering 

vaccination as a default option during patient visits and 

integrating vaccination into medical practice procedures. 

Barriers Addressed: Policy, mistrust, health literacy

Research Base: Medical practices and hospitals can take steps 

to increase vaccine uptake through standard practice measures, 

including default scheduling and presumptive announcements. In one 

study, scheduling patients by default increased flu vaccination by 10 

percentage points. Another study showed patients with standing orders 

received flu and pneumococcal vaccines significantly more often than 

those with reminders. For patients with standing orders, the hospital’s 

computerized system identified eligible patients and automatically 

produced vaccine orders directed to nurses at the time of discharge. 

Even standardizing what the doctor says when entering the room can 

impact vaccine uptake. Doctors trained to announce human papilloma 

virus (HPV) vaccines during visits with a brief statement that assumed 

parents were ready to vaccinate (the presumptive approach) increased 

uptake by 5.4% over the approach of engaging parents in open-ended 

conversations about vaccinating their child. 

COVID-19 Application Examples

Location: Arizona

Population of Focus: Adults

In Arizona, a local 10-physician practice received detailed 

guidance from their county health department that helped 

them obtain vaccine supply and establish a protocol for 

administration. The county health department provided 

both supplies and instructional webinars on a weekly 

basis to guide practices through the process of becoming 

vaccinators. The Arizona physician office trained their staff 

to provide accurate information to patients who call with 

questions and developed a new scheduling system to 

standardize outreach and scheduling for eligible patients. 

Because their office space was too small to monitor patients 

for post-vaccine allergic reactions during normal business 

hours, they organized special weekend vaccination clinic 

hours. Yet, the groundwork has been laid for integrating 

vaccination into routine practice. 

Standardization measures could become routine 

practice. Currently, many primary care and specialty 

physician offices are not offering COVID-19 vaccines. 

That is expected to change as logistical barriers are 

overcome and more physician practices become 

involved in the “last mile” effort to vaccinate everyone 

eligible, particularly in states where state and local 

health departments provide support. As the vaccines 

become more available in medical practices and 

hospitals, standardizing COVID-19 vaccination into 

routine practice will help reduce missed opportunities 

for vaccination, which are encounters during which a 

person eligible for a vaccine receives health services 

that do not result in them getting vaccinated.

Where to Start: The Arizona Department of Health 

Services Immunization Program in partnership with 

The Arizona Partnership for Immunization, a nonprofit coalition, has a free training series to improve 

vaccination practices in providers’ offices. Trainings 

cover areas including vaccine friendly office practices, 

vaccine handling and storage, shot administration.
18

Strategy 3

Medical Reminders

Medical reminders are messages sent to patients to remind them 

of recommended or upcoming treatment. Messages can be sent by 

autodialed phone calls, text messages, or post-cards, for example. 

Barriers Addressed: Equity, access, forgetfulness, friction, health literacy, 

lack of adequate information

Research Base: Reminders of upcoming vaccination appointments can 

increase vaccination rates. This intervention is often part of a multi-pronged 

approach combined with removing access barriers to optimize uptake. Duval 

County Health Department in Florida successfully increased vaccination 

rates by using data from the Florida Shots Registry to identify families with 

upcoming vaccinations due or who were behind on their child’s vaccinations 

and sending them reminders and educational materials through phone calls, 

letters, and home visits.

A study in Rochester, New York, showed that when interventions were 

combined to include patient reminders, provider reminders, and telephone 

outreach, older adults in the intervention group were up to six times as likely 

to be vaccinated against flu.

A University of Pennsylvania study found that simple reminder text messages 

sent to 47,306 patients in two health systems increased flu vaccinations by 

around 5%. Of the 19 different messages tested, those most likely to “nudge” 

patients to be vaccinated were presented in a professional format and 

tone—not casual, surprising, or interactive. The most successful messages 

reminded patients twice to get their shot at their upcoming doctor’s 

appointment and stated that a vaccine was already reserved for them.

COVID-19 Application Examples

Location: Multiple U.S. Locations

Population of Focus: Adults

Several state and local health departments, including in 

Michigan, Oklahoma, and Baltimore, Maryland, are using 

text messages to:

• Help people schedule their vaccine appointments

• Provide education and vaccination site information

• Gauge views on vaccination

Certain populations can be reached with messaging, 

either based on race, ethnicity, or age, or used in geographic 

locations with lower vaccination uptake. In most cases, texts 

are provided in English and Spanish, but health departments 

or other entities sending texts can translate and customize 

to any language spoken in their community of focus. 

This can also be used to remind people of their second 

vaccination appointment, if applicable. 

Many text-based services are available. Some, like 

CareMessage, offer a free model for nonprofits to help 

with COVID-19 vaccination. CDC recommends that 

providers without a text-message system offer their 
19

patients the COVID-19 text reminder service, VaxTextSM, which is free to providers and patients.

After enrolling in VaxTextSM, people who have received the first COVID-19 vaccine dose receive

weekly text reminders in English or Spanish about their second dose or a reminder that they are 

overdue, if applicable.

Well-crafted emails containing behavioral nudges can also be used as reminders to get vaccinated. 

A large Pennsylvania health system found that after a five-week effort to have employees 

vaccinated against COVID-19, 41% still had not scheduled their vaccination. They found through

a study that individually addressed emails containing behaviorally informed messages increased 

vaccination registration. 

The emails had three important components:

• Told the healthcare worker that vaccines would soon be available more broadly, thus, reducing

employees’ access and emphasizing scarcity.

• Contained a message either about social norms, saying that many fellow employees had already

chosen to be vaccinated; or about risks, comparing the risk of vaccination with the risk of COVID-19.

• Asked employees to make an active choice by clicking through to schedule their vaccination

appointment.

Where to Start: Learn the details on how this reminder effort was implemented. 
20

Strategy 4

Motivational

Interviewing

Motivational interviewing refers to patient-centered conversations 

designed to increase patient motivation and likelihood of health 

behavior uptake.

Barriers Addressed: Misperception, health literacy, uncertainty

Research Base: Motivational interviewing aims to support decision 

making by strengthening a person’s intention to vaccinate based 

on their own arguments. The healthcare professional informs about 

vaccination in alignment with the individual’s specific informational 

needs and with respect for their beliefs. Motivational interviewing has 

been shown to decrease parental vaccine hesitancy. A pilot study of 

using motivational interviewing in maternity wards during postpartum 

stays found the strategy led to a 15% increase in mothers’ intention to 

get their child vaccinated, a 7% increase in infants’ vaccination coverage 

at seven months, and a 9% greater chance of complete vaccination 

at 2 years. Motivational interviewing was also found to significantly 

improve HPV vaccination completion among adolescent patients in a 

study that employed an intervention of using a presumptive vaccine 

recommendation with motivational interviewing follow up for parents 

who remained resistant. Some healthcare providers have concerns that 

this approach takes too long and that such a conversation is not billable. 

COVID-19 Application Examples

Location: Western Pennsylvania

Population of Focus: Adults

Motivational interviewing can be a strategy to promote 

COVID-19 vaccine uptake. A demonstration project in the 

Pittsburgh area showed that innovative notification and 

motivational interviewing strategies at a regional chain 

supermarket pharmacy increased the number of herpes 

zoster, flu, pertussis, and pneumococcal vaccines given to 

adults. Community pharmacies are accessible and able to 

provide COVID-19 vaccinations to many customers, along 

with their other patient-centered products and services 

and may be able to model programs similar to this. 

Pharmacy staff identified the patient, who then received 

an automated notification about their vaccination status. 

The staff used motivational interviewing techniques faceto-face or by telephone to engage patients in conversation 

about getting vaccinated. 

Outcome: The 99 pharmacies in western Pennsylvania that 

took part in the project saw a 33% increase in vaccinations 

over the prior year: 45% for flu, 31% for pertussis, and 

7% for pneumococcal vaccinations, while herpes zoster 

vaccinations dropped by 5%.

Where to Start: Scripts for using motivational interviewing with those who may be COVID-19 vaccine 

hesitant are available. 
21

Strategy 5

Financial Incentives

Financial incentives aim to motivate people to participate in a health 

behavior by providing a tangible reward, or a chance at a tangible 

reward, for completion of the behavior. 

Barriers Addressed: Inertia

Research Base: While evidence supporting the use of incentives to increase 

vaccine uptake is overall limited, the type that appears effective is of a 

guaranteed gift incentive. For example, offering a $30 incentive increased 

vaccination rates at college campus clinics according to one study. Recent 

studies of the Ohio COVID-19 vaccine lottery have been less positive, 

showing the likelihood that the approach has not increased vaccine uptake. 

Clearly, these are two different approaches—one is a guaranteed gift and the 

other a chance at winning. Also, the audiences differ with the first comprised 

of young adult college students and the latter a general population.

COVID-19 Application Examples

Location: Multiple U.S. Locations

Population of Focus: Adults and Youth

• West Virginia state government is offering residents

ages 16 to 35 who have been vaccinated a choice of

receiving either a $100 savings bond or a $100 gift card.

The governor estimates this might cost the state up to

$20 million.

• California offered $50 in the form of a virtual Mastercard

or grocery gift card to residents who started their

vaccination series between May 27 and July 18. The

money is limited to the first 2 million requests, which

limits the total cost to the state.

• Employers are also offering cash incentives to their staff.

Maryland state employees will receive $100 and the

Colorado Department of Corrections will provide $500

to staff who elect to get vaccinated.

• Many large private corporations are also providing cash

incentives to employees, often ranging from $75 to

$500 including Amazon, Kroger, PetCo, AutoZone, and

Bolthouse Farms.

• Many businesses are offering free products to those who

have been vaccinated, including the well-publicized

free Krispy Kreme donut. Several states are offering

free admission to state parks or similar incentives for

vaccinated visitors. Offers like these non-monetary

guaranteed incentives have not been well-studied for

effectiveness.

Where to Start: The Equal Employment Opportunity Commission (EEOC) provides 

guidance to employers on offering incentives to employees for becoming vaccinated. 

For ideas on incentives to offer, see the list of state and local government incentives

maintained by the National Governors Association.
22

Strategy 6

School-Located 

Vaccination Programs

School-located vaccination programs are events held at a school 

campus to remove logistical barriers and increase vaccine uptake. 

These can be open to students only, or offered to faculty, families, 

and the greater community as well.

Barriers Addressed: Access, friction, prevailing social norms, 

uncertainty, lack of adequate information

Research Base: Voluntary school-located vaccination programs have 

demonstrated high coverage, though they are not without challenges. 

One of the major challenges is obtaining informed parental consent 

when needed. School-located programs can be effective even with 

“controversial” vaccinations such as for HPV. The setting also has been 

shown to yield higher completion rates of multi-dose vaccine series as 

compared to community health center settings. 

COVID-19 Application Example

Location: St. Louis County, Missouri

Population of Focus: School-age Youth

School districts of many sizes across the country are holding 

COVID-19 vaccination events. One of the first school districts 

to do so was the Parkway School District in St. Louis County, 

Missouri, which held their event on April 26, 2021. The event 

was held in partnership with a local pharmacy. In a survey, 

350 parents said they were interested, and the 204 students 

who were vaccinated at the event represented about 5% of 

eligible students in the district. 

Timing of the event may have affected turnout because 

some expressed concern about the second dose occurring 

during the week of finals for some students, according to 

the Interim Health Services Director who led the effort. The 

director also noted that school nurses are trusted sources of 

health information and play an important role in educating 

students and families about the COVID-19 vaccines. Two 

additional vaccination clinics have been held, one just days 

after the U.S. Food and Drug Administration authorized the 

Pfizer-BioNTech vaccine for those 12 years and older.

While this strategy has focused on vaccinating students 

through school-located vaccination programs, school 

settings may also be ideal locations for community 

vaccination events. Much for the same reason schools are 

often used as voting locations, they generally are easily 

accessible, have ample parking, have both indoor and 

outdoor spaces available, and are familiar places.

Outcome: So far, Parkway School District has vaccinated 

nearly 3,000 students through their three on-site clinic 

events. This was made possible, in part, due to their 

excellent relationship with a local pharmacy, which 

will pave the way for possible future student vaccination 

events should a vaccine be approved for younger 

school-age children.

Where to Start: The school district documented their 

lessons learned as guidance for other school districts 

noting the importance of details such as:

• Ensuring Ample Parking

• Working Around Educational Schedules

• Obtaining Consent

• Training Staff

• Managing Vaccine Delivery and Storage
23

Strategy 7

Home-Delivered

Vaccination

Home-delivered vaccination efforts reach populations where 

they are; traditionally used when barriers to transportation 

and access exist. 

Barriers Addressed: Equity, access, inertia, friction

Research Base: Bringing vaccines to where people are, including 

in their homes, is an effective means to reach several hard-to-reach 

populations. This strategy can be applied to people who are bound to 

their homes as well as to neighborhoods with low vaccination rates. 

In an effective effort in New York City, individuals canvassed specific 

communities to educate people about the flu vaccine and offered 

it to people on the spot. They focused on those with substance use 

disorders, immigrant populations, older adults, sex workers, and 

people experiencing homelessness. Both appointment-based home 

delivery and canvassing methods may be effective ways to deliver 

COVID-19 vaccines. 

COVID-19 Application Example

Location: Multnomah County, Oregon

Population of Focus: Adults

As the COVID-19 vaccination effort progresses, shifts are occurring from mass vaccination sites to 

smaller neighborhood and community clinics, and now to home-based efforts to do everything 

possible to give all individuals the opportunity to get vaccinated. The Emergency Operations Center in 

Multnomah County, Oregon, has partnered with the Public Health Division and County Human Services 

to provide COVID-19 vaccinations through a mobile program reaching people where they live. Initially 

vaccinating those in adult care homes, they have expanded the project’s scope to include other adults 

who are homebound. 

The county’s mobile door-to-door COVID-19 response team pairs Medical Reserve Corps volunteers, 

who are licensed medical practitioners, and other volunteers to assist in providing COVID-19 

vaccinations to people in their homes. The goal of the response, launched in February 2021, is to 

vaccinate up to 5,000 people. “Getting to meet people ‘where they are at’ and administering a lifesaving vaccine is an incredibly powerful experience. It truly brought people hope. The coordination 

it takes to make this kind of outreach happen is no small feat – but it’s precisely the kind of work we 

need to do in order to respond quickly to inequalities and gaps in vaccine distribution, especially for 

those who are most vulnerable,” said Dr. Sharon Meieran, a Medical Reserve Corps volunteer. 

Where to Start: CDC provides guidance for implementing home-bound and residential living 

COVID-19 vaccination including consideration for training requirements, planning, storage and 

handling, and administration. 
Strategy 8

Workplace

Vaccination Programs

24

A vaccination event held on-site at a workplace to remove logistical barriers and create norms. 

This can be open to employees only or extended to family members or the greater community. 

Barriers Addressed: Access, cost, prevailing social norms, friction 

Research Base: Numerous studies have shown that vaccination programs at the worksite can increase 

vaccination rates among workers and their families. In one study, where flu vaccination rates increased 

significantly after the intervention, 90% of vaccinated employees received a vaccine at employer-sponsored 

events. The most important reasons employees reported for being vaccinated at work were not related to 

health, but that the vaccine was free, convenient, and would help them avoid being absent from work.

There is evidence on-the-job COVID-19 vaccines may have similar uptake success. A recent Kaiser Family 

Foundation study found that 23% of Americans would be more likely to get a vaccine if it was available 

at their workplace. Another recent survey of employees by McKinsey & Company found an even greater 

potential return with 83% of those surveyed saying offering on-site vaccinations would significantly (49%) 

or moderately (34%) increase the likelihood that they would get a COVID-19 vaccine. According to a 2020 

Gallup poll, small businesses are one of the most trusted institutions in the U.S. 

COVID-19 Application Example

Location: Midwest; Jackson, Mississippi

Population of Focus: Adults

Tyson Foods is offering on-site vaccination at many of their 

facilities. In Iowa and Illinois, the company partnered with 

the Midwest grocery chain Hy-Vee and state and local public 

health departments to vaccinate food processing workers 

at four locations in the two states. Workers in that industry 

have been hit hard by COVID-19 and were extremely excited 

for the opportunity. The workers are diverse, with one 

facility requiring vaccine education information translation 

in 18 languages. Tyson Foods also offered workers up to four 

hours of regular pay if they needed to get their vaccine(s) 

outside of a normal shift or away from the jobsite. 

Outcome: By early March 2021, Hy-Vee staff had vaccinated 

over 2,400 employees in one of the states.

Small businesses can also support on-site vaccination 

efforts. In Jackson, Mississippi, the Broad Street Baking 

Company partnered with the Mississippi State Department 

of Health and the G.A. Carmichael Family Health Center to 

hold mobile vaccination events in a parking lot near the 

restaurant in April and June 2021.

Outcome: At both events, vaccines were given to all 

employees and other attendees who requested them.

Where to Start: CDC offers guidance to state, tribal, and local jurisdictions on reaching out to worker 

populations to increase vaccine uptake. This includes how to talk with small businesses and special 

considerations for rural communities and migratory workers. CDC also has information for employers

on how they can support vaccination of their workforce. 
Strategy 9

Vaccination

Requirements

Vaccination requirements are policies that require employees, students,

or patrons to be vaccinated and provide proof of vaccination in order to 

be in compliance. 

Barriers Addressed: Policy, inertia, prevailing social norms, politicization 

Research Base: Vaccine requirements at the organizational level may be an 

effective way to increase vaccination rates and decrease disease incidence. 

Requirements by employers or schools ask that employees or students provide 

proper documentation of vaccination to comply with the organization’s 

vaccination policy. Exemptions can be offered for specific circumstances, 

such as medical and religious reasons. Vaccination requirements have not often 

been used for adult populations, with the exception of military requirements 

and for healthcare workers to receive flu shots. There is evidence showing 

school mandates positively impact uptake for routine childhood vaccines 

and some studies suggest that vaccination for children and workers, including 

mandatory vaccination, decreases absenteeism. 

COVID-19 Application Example

Location: Multiple U.S. Locations

Population of Focus: Adults

Many employers and institutes of higher education such as universities 

are requiring staff and students to be vaccinated against COVID-19. Large 

companies have most recently required staff to be vaccinated to return 

to the office. A number of federal, state and local governments are also 

requiring vaccination for employees; some with an alternate option for 

weekly testing for COVID-19 and some without that option. Examples of 

early adopters of vaccination requirements are provided below. 

Houston Methodist Health System: Houston Methodist was the first health 

system in the country to mandate COVID-19 vaccination for all employees 

to protect their patients and workforce. The health system is made up of an 

academic medical center and six community hospitals employing over 26,000 

people. The first phase of the policy included managers and new hires and 

was gradually rolled out to all staff. Those not in compliance received a twoweek suspension during which they could get vaccinated. Several employees 

pushed back on the requirement and took the hospital system to federal court. 

The Texas court dismissed the lawsuit and upheld the vaccine requirement 

stating that the requirement does not break any laws and is in line with 

public policy. 

Outcome: Houston Methodist achieved nearly 100% compliance with 24,947 

workers being vaccinated. Medical and religious exemptions were granted to 

over 600 employees and only 153 employees out of 26,000 (.5%) resigned or 

were fired for not complying. 

25
Morgan Stanley Office Vaccine Policy: Morgan Stanley created a policy requiring all employees returning 

to their offices to be vaccinated. It also extends to clients and visitors to their two New York offices. The 

company views this policy as a way to create a safe and normal office environment that allows employees 

to forgo masks and social distancing. Employees who remain unvaccinated have the option of working 

from home, but the company is strongly encouraging employees to come back into the office.

Where to Start: The policy and procedures Houston Methodist put in place is publicly available and can 

be used as a model for other employers wanting to require COVID-19 vaccines. Other legal organizations 

also have templates available online as found in Appendix A. 

26
27

Strategy 10

Effective Messages 

Delivered by Trusted Messengers

Effective messages are messages that have undergone testing with 

the intended population and were shown to produce the desired 

outcome. Trusted messengers are people seen as credible sources 

of information by specific populations. Trusted messengers can be 

trained to be vaccine ambassadors (see Strategy 1) and may include 

experts. 

Barriers Addressed: Mistrust, health literacy, misinformation, lack 

of adequate information

Research Base: The messengers and messages used to convey 

information about vaccines are important to improving vaccine 

confidence.

The COVID-19 States Project Report evaluates results from two 

experiments designed to test effective communication strategies for 

increasing COVID-19 vaccine confidence and intent. The first experiment 

tested five messages and a control message for the effect it had on 

participants’ willingness to receive a COVID-19 vaccine. The messages 

involved themes of patriotism, harm reduction, social norms, scientist 

recommendation, and physician recommendation. The study found

 that messages involving a personal physician or a scientist 

recommending vaccination were the most compelling. The second 

experiment looked at messenger effectiveness and found that messages 

delivered by politicians increased resistance to vaccination while 

those delivered by physicians or scientists showed increased vaccine 

confidence and intent.

Messages and messengers should be continually evaluated 

for effectiveness and tested across populations with different 

demographics. Continued evaluation of messages allows 

communication campaigns to tailor messages to specific concerns 

and demographic populations, which is shown to be more effective 

than generalized messaging. 
28

COVID-19 Application Example

Location: Multiple U.S. Locations

Population of Focus: Adults

The Black Coalition Against COVID, The Kaiser Family Foundation, and Esperanza Hope for All created 

a COVID-19 vaccine communications campaign called “The Conversation,” which uses the hashtag 

#BetweenUsAboutUs. The campaign features 50 videos of Black and Latino doctors, nurses, and scientists 

talking about vaccine facts and dispelling misinformation. In addition to the videos, the campaign offers 

graphics, print media, social media content, and TV and radio PSAs. The content is free for educational 

use and communities and organizations are invited to download and utilize their materials in English and 

Spanish. Some content features doctors sharing why they got vaccinated. One graphic shows a female 

Black doctor with the quote, “When we get enough people vaccinated, we’re going to see the death rates 

go down. Then we’re going to see the hospitalization rates go down.” Currently, the campaign’s videos have 

over 21,000,000 views on YouTube. 

Where to Start: For specific messaging language tips based on COVID-19 messaging research, see the 

deBeaumont Foundation’s Tip Sheet. 
Strategy 11

Provider 

Recommendation

Provider recommendation refers to healthcare professionals 

suggesting that a patient receive a COVID-19 vaccination. 

Barriers Addressed: Inertia, friction, mistrust, uncertainty, 

mis- and disinformation, lack of adequate information

Research Base: Provider recommendations have strong support for increasing 

vaccination. The Advisory Committee on Immunization Practices includes 

this strategy in their recommendations for improving vaccination rates. 

Some people may have more trust in their own doctor than in the medical 

community in general. Research on vaccinations in pregnant people found 

that provider recommendation shows increases in vaccination rates and when 

coupled with offering the vaccination during doctor’s office visits, doubles 

the likelihood of uptake. In a study of flu vaccination in adults, patients who 

received provider recommendations with an offer of vaccination were 1.76 

times more likely than those who did not receive a recommendation to be 

vaccinated. Those receiving only a recommendation were 1.72 times more 

likely than those who did not receive a recommendation to be vaccinated. 

The HPV vaccine, which relies on healthcare professionals for distribution, 

depends on provider recommendations for adequate coverage. A study 

on low HPV vaccination rates in North Carolina, found that lack of provider 

recommendations contributed to under vaccination in the population. 

COVID-19 Application Example

Location: New York, New York; Philadelphia, Pennsylvania

Population of Focus: Adults

The New York City Department of Health and Mental 

Hygiene created a resource called Vaccine Talks that 

emphasizes the importance of healthcare professional 

recommendations in increasing COVID-19 vaccination rates. 

Vaccine Talks offers resources for healthcare providers and 

their staff to recommend and offer COVID-19 vaccination 

at multiple points of interaction with patients. The health 

commissioner released a statement promoting Vaccine 

Talks that places emphasis on the trust patients have 

in their healthcare providers and says that their strong 

recommendations for COVID-19 vaccines will help drive 

vaccination rates in the city. 

Vaccine Talks includes a resource called the “Use Every 

Opportunity” tool instructing healthcare offices on how 

to integrate COVID-19 vaccine education and offers into 

all healthcare settings. Vaccine Talks also includes a link 

to a form the provider can complete to request that the 

public health system contact the patient to schedule their 

vaccination at a clinic or in their home if needed.

29

Emergency departments and urgent care facilities are 

important locations for COVID-19 vaccine provider 

recommendations due to the high number of patients seeking 

routine care in these settings. The Philadelphia Department 

of Public Health put out a call to emergency facilities in the 

city to begin recommending and administering COVID-19 

vaccines to patients upon discharge. The notice focused on 

postpartum discharges and patients being discharged to 

long-term care facilities as key demographics for provider 

recommendations and offers. They provided best practices 

for vaccination during patient discharge. 

Where to Start: The Vaccine Talks resources include 

scripts for physicians to talk to their patients about 

COVID-19 vaccines, including talking to parents of 

eligible children, and other tools for physicians 

to support vaccine confidence building with staff 

and patients.
30

Strategy 12

Combating

Misinformation

Tactics used to address and dismantle misinformation and disinformation. Misinformation refers to the 

sharing of false information and disinformation refers to information that is deliberately misleading and 

intended to manipulate a narrative. 

Barriers Addressed: Misperception, mis- and disinformation, lack of adequate information

Research Base: Believing incorrect information can act as a barrier to vaccine uptake. Vaccine myths are 

particularly difficult to combat, in part because people tend to believe information that is in line with their 

existing attitudes and worldview. Fact-checking and debunking appear to be effective tools to counteract 

the effects of misinformation, particularly when the correct information sources are universities and health 

institutions. Debunking incorrect information with messages that reflect the worldview and affirm the values 

of the intended audience may be the most successful approach. Debunking misinformation is challenging. 

Misinformation is often simple and more cognitively attractive than fact, and refuting a falsehood often 

requires repeating it, which reinforces the falsehood in the believer. Techniques that help dispel falsehoods 

include warning the audience upfront that misleading information is coming, using fewer arguments to 

refute the myth, and keeping the factual statements simple. 

Everyday social media users can play an important part in correcting misinformation. While the person 

originally expressing the misinformation may not be moved because the correction does not align with 

their world view, others see the correct information and are impacted by it. Responding with empathy 

and providing facts, rather than simply saying something is wrong, are tips for effective corrections.

COVID-19 Application Examples

Location: Multiple U.S. Locations

Population of Focus: Adults

Public Good Projects (PGP) is a public health non-profit 

organization with a mission to stop the spread of vaccine 

misinformation through evidence-based media monitoring, 

behavioral interventions, and cross-sector initiatives. In 

the beginning of the COVID-19 pandemic, PGP created a 

misinformation tracking system to monitor misinformation 

being shared about COVID-19 and later about the vaccines. 

Using this tracking system, PGP pinpointed ideas that could 

pose a threat to public health measures and worked with 

scientists to create evidence-based responses. To combat 

the misinformation, PGP identifies micro-influencers with 

audiences who have high rates of vaccine hesitancy and 

equips them with science-backed messages to share with 

their social networks. Their vaccine-hesitant followers are 

more likely to accept this information when it comes from 

someone they trust rather than from a health expert.

Where to Start: Dissemination of factual and 

easy to understand information combats mis- and 

disinformation. This can be done in a variety of 

ways including identifying and training social media 

micro-influencers in your community as PGP is doing 

nationally or using your own social media to promote 

accurate information. To keep your finger on the pulse 

of social media misinformation nationally you can 

refer to the Virality Project’s weekly briefing. To 

monitor your local social media, you can utilize 

the RCA’s Social Listening and Monitoring Tool. 
31

Conclusion

Reaching universal COVID-19 vaccination coverage 

in the United States is a monumental challenge. 

There are barriers impeding both vaccine confidence 

and uptake. Structural barriers, such as time costs 

and transportation, lead to inequitable vaccine 

distribution, often negatively affecting populations 

that have been disproportionately affected by the 

pandemic. People’s behaviors and beliefs, often 

based on misinformation or low health literacy, 

can obstruct their willingness to get vaccinated, 

while other human nature factors make it difficult 

to motivate people to do something difficult, new, 

or unfamiliar. COVID-19 vaccination and pandemicrelated information can be perceived as complex and 

sometimes contradictory, adding yet another barrier. 

Compounding all of this is the current politicization 

of getting vaccinated. 

Understanding the specific barriers your community 

of focus faces will help you identify and initiate 

activities that will help overcome those barriers. 

Tools, including the SVI, WAM Exercise, and the 

diagnostic tool, can help to identify populations 

disproportionately affected by the pandemic and 

the barriers and facilitators to vaccination they face. 

The RCA Guide offers in-depth resources to help you 

quickly learn more about needs related to COVID-19 

vaccination in your community of focus.

While the COVID-19 vaccination effort is unique 

in many ways, applying best practices and lessons 

learned from previous vaccination efforts increases 

the likelihood of overcoming vaccine hesitancy and 

improving vaccine uptake. There is no magic formula 

to addressing vaccination barriers—communities 

need to employ multiple tailored strategies and 

tactics. The examples offered in this guide can serve 

as inspiration as well as practical guidance. Each 

community will need to customize its approaches to 

harness available resources to meet local needs.
32

Appendix A

References and Resources

To learn more about each of the strategies discussed in this guide, the research supporting them,

and information on how to implement them in your community, see the resources below.

Common Barriers

The Behavioral and Social Drivers (BeSD) of COVID-19 Vaccination Uptake

The Behavioral and Social Driver (BeSD) expert working group.

https://journals.sagepub.com/doi/full/10.1177/1529100618760521

Brewer, N. T., Chapman, G. B., Rothman, A. J., Leask, J., & Kempe, A. (2017). Increasing vaccination: 

Putting psychological science into action. Psychological Science in the Public Interest, 18(3), 149-207.

Understanding Your Community

Social Vulnerability Index

The CDC/ATSDR Social Vulnerability Index (CDC/ATSDR SVI) uses 15 U.S. census variables to help local 

officials identify communities that may need support before, during, or after disasters.

https://www.atsdr.cdc.gov/placeandhealth/svi/index.html

SVI data is displayed on an interactive map. 

https://svi.cdc.gov/map.html

RCA Guide and Tools

COVID-19 Vaccine Confidence Rapid Community Assessment Guide and tools.

https://www.cdc.gov/vaccines/covid-19/vaccinate-with-confidence/rca-guide/index.html

Vaccine Confidence and Uptake Strategies

Strategy 1: Vaccine Ambassadors

Research Base

The influence of social norms on flu vaccination among African American and White adults.

https://doi.org/10.1093/her/cyx070

Quinn, S. C., Hilyard, K. M., Jamison, A. M., An, J., Hancock, G. R., Musa, D., & Freimuth, V. S. (2017). The 

influence of social norms on flu vaccination among African American and White adults. Health education 

research, 32(6), 473-486.

Attention, intentions, and follow-through in preventive health behavior: Field experimental evidence on flu 

vaccination.

https://www.swarthmore.edu/sites/default/files/assets/documents/user_profiles/ebronch1/JEBO_2015.pdf

Bronchetti, E. T., Huffman, D. B., & Magenheim, E. (2015). Attention, intentions, and follow-through in 

preventive health behavior: Field experimental evidence on flu vaccination. Journal of Economic Behavior & 

Organization, 116, 270-291.

More Information About the COVID-19 Examples

A multi-component, community-based strategy to facilitate COVID-19 vaccine uptake among 

Latinx populations: from theory to practice

https://www.medrxiv.org/content/10.1101/2021.06.07.21258230v1.full.pdf

Marquez, C., Kerkhoff, A. D., Naso, J., Contreras, M. G., Castellanos, E., Rojas, S., ... & Havlir, D. V. (2021). 

A multi-component, community-based strategy to facilitate COVID-19 vaccine uptake among Latinx 

populations: from theory to practice. MedRxiv.
33

Operationalizing Equity: A rapid-cycle innovation approach to COVID-19 vaccination in Black neighborhoods.

https://catalyst.nejm.org/doi/full/10.1056/CAT.21.0094

Lee, K. C., Al-Ramahi, N., Hahn, LO., Donnell, T., Schonewolf, L. J., Khan, N., O’Malley, C., Ghatri, U. G., 

Pearlman, E., Balachandran, M., et al. (April 7, 2021). Operationalizing Equity: A rapid-cycle innovation 

approach to COVID-19 

vaccination in Black neighborhoods. NEJM Catalyst. 

Additional Resources for Implementing this Strategy

San Francisco Department of Public Health’s community COVID-19 vaccine communication training for 

ambassadors slide presentation. 

https://www.sfdph.org/dph/files/ig/vaccine/vaccine-ambassador-training-pdf.pdf

Strategy 2: Medical Provider Vaccine Standardization 

Research Base

Default clinic appointments promote influenza vaccination uptake without a displacement effect.

https://behavioralpolicy.org/wp-content/uploads/2017/06/chapman-web.pdf

Chapman, G. B., Li, M., Leventhal, H., & Leventhal, E. A. (2016). Default clinic appointments promote 

influenza vaccination uptake without a displacement effect. Behavioral Science & Policy, 2(2), 40-50.

Inpatient computer-based standing orders vs physician reminders to increase influenza and pneumococcal 

vaccination rates: a randomized trial.

https://jamanetwork.com/journals/jama/article-abstract/199810

Dexter, P. R., Perkins, S. M., Maharry, K. S., Jones, K., & McDonald, C. J. (2004). Inpatient computer-based 

standing orders vs physician reminders to increase influenza and pneumococcal vaccination rates: a 

randomized trial. Jama, 292(19), 2366-2371.

Announcements versus conversations to improve HPV vaccination coverage: a randomized trial.

https://pediatrics.aappublications.org/content/pediatrics/139/1/e20161764.full.pdf

Brewer, N. T., Hall, M. E., Malo, T. L., Gilkey, M. B., Quinn, B., & Lathren, C. (2017). Announcements versus 

conversations to improve HPV vaccination coverage: a randomized trial. Pediatrics, 139(1).

More Information About the COVID-19 Examples 

The Room Where It Happens: Primary Care and COVID-19 Vaccinations.

https://www.commonwealthfund.org/publications/2021/jul/room-where-it-happens 

Klein, S., Hostetter, M. (7 July 2021). The Room Where It Happens: The role of primary care in the next 

phase of the COVID-19 vaccination campaign. The Commonwealth Fund. 

The Arizona Department of Health Services Immunization Program in partnership with TAPI, a non-profit 

coalition, has a free training series to improve vaccination practices in providers’ offices. Trainings cover areas 

including setting up vaccine friendly office practices, vaccine handling and storage, shot administration.

https://whyimmunize.org/covid-19-vaccine-t-i-p-s/

Additional Resources for Implementing this Strategy

The Community Guide: Vaccination: Provider Reminders

The Community Guide: Vaccination: Standing Orders

Standing orders templates for administering vaccines

https://www.immunize.org/standing-orders/

CDC COVID-19 Vaccination Program Provider Requirements and Support

https://www.cdc.gov/vaccines/covid-19/vaccination-provider-support.html

Appendix A
34

Appendix A

The COVID-19 Vaccine Use Every Opportunity implementation tool provides strategies for ensuring COVID-19 

vaccination is offered to every eligible patient during their encounters with your organization. The Use Every 

Opportunity framework is an adaptable tool for implementing workflows to achieve the highest level of 

COVID-19 vaccine coverage possible in all health care settings.

https://www1.nyc.gov/assets/doh/downloads/pdf/covid/providers/covid-19-vaccine-use-everyopportunity-tool.pdf

Strategy 3: Medical Reminders

Research Base

The Community Guide in Action - A Good Shot: Reaching Immunization Targets for two-year-old’s in Duval 

County, Florida. 

https://www.thecommunityguide.org/sites/default/files/assets/Vaccinations-FL_0.pdf

Increasing inner-city adult influenza vaccination rates: a randomized controlled trial.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3113429/pdf/phr126s20039.pdf

Humiston, S. G., Bennett, N. M., Long, C., Eberly, S., Arvelo, L., Stankaitis, J., & Szilagyi, P. G. (2011). 

Increasing inner-city adult influenza vaccination rates: a randomized controlled trial. Public Health 

Reports, 126(2_suppl), 39-47.

A megastudy of text-based nudges encouraging patients to get vaccinated at an upcoming doctor’s 

appointment.

https://www.pnas.org/content/118/20/e2101165118

Milkman, K. L., Patel, M. S., Gandhi, L., Graci, H. N., Gromet, D. M., Ho, H., ... & Duckworth, A. L. (2021). 

A megastudy of text-based nudges encouraging patients to get vaccinated at an upcoming doctor’s 

appointment. Proceedings of the National Academy of Sciences, 118(20).

More Information about the COVID-19 Examples

Pennsylvania health system email reminders

Santos HC, Goren A, Chabris CF, Meyer MN. Effect of Targeted Behavioral Science Messages on COVID-19 

Vaccination Registration Among Employees of a Large Health System: A Randomized Trial. JAMA Netw 

Open. 2021;4(7):e2118702. doi:10.1001/jamanetworkopen.2021.18702

Additional Resources for Implementing this Strategy

VaxText is a free text messaging platform that providers can offer to their patients. Patients can opt in to 

conveniently receive text message reminders to get their second dose of COVID-19 vaccine.

https://www.cdc.gov/vaccines/covid-19/reporting/vaxtext/index.html

Strategy 4: Motivational Interviewing

Research Base

Motivational interviewing: A promising tool to address vaccine hesitancy.

https://pubmed.ncbi.nlm.nih.gov/32281992/

Gagneur, A., Gosselin, V., & Dubé, È. (2018). Motivational interviewing: A promising tool to address vaccine 

hesitancy. Vaccine, 36(44), 6553-6555.

Effects of a Health Care Professional Communication Training Intervention on Adolescent Human 

Papillomavirus Vaccination: A Cluster Randomized Clinical Trial. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5875329/

Dempsey, A. F., Pyrznawoski, J., Lockhart, S., Barnard, J., Campagna, E. J., Garrett, K., Fisher, A., Dickinson, 

L. M., & O’Leary, S. T. (2018). Effect of a Health Care Professional Communication Training Intervention

on Adolescent Human Papillomavirus Vaccination: A Cluster Randomized Clinical Trial. JAMA pediatrics,

172(5), e180016. https://doi.org/10.1001/jamapediatrics.2018.0016
35

More Information about the COVID-19 Examples

Increasing adult vaccinations at a regional supermarket chain pharmacy: A multi-site demonstration project

Increasing adult vaccinations at a regional supermarket chain pharmacy: A multi-site demonstration 

project - ScienceDirect

Coley, K.C., Gessler,C., McGivney, M., Richardson, R., DeJames, J., Berenbrok, L. A. (2020). Increasing adult 

vaccinations at a regional supermarket chain pharmacy: A multi-site demonstration project. Vaccine, 

38(24), 4044-4049. https://doi.org/10.1016/j.vaccine.2020.02.040.

Additional Resources for Implementing this Strategy

Communication Skills for Talking About COVID-19 Vaccines - These communication skills are designed for 

clinicians to use with patients and families, using an approach adapted from motivational interviewing and 

research on vaccine hesitancy.

https://www.capc.org/covid-19/communication-skills-for-talking-about-covid-19-vaccines/

Strategy 5: Financial Incentives

Research Base 

Attention, intentions, and follow-through in preventive health behavior: Field experimental evidence on flu 

vaccination.

https://www.sciencedirect.com/science/article/abs/pii/S0167268115001079?via%3Dihub#abst0005

Bronchetti, E. T., Huffman, D. B., & Magenheim, E. (2015). Attention, intentions, and follow-through in 

preventive health behavior: Field experimental evidence on flu vaccination. Journal of Economic Behavior 

& Organization, 116, 270-291.

Lottery-Based Incentive in Ohio and COVID-19 Vaccination Rates.

https://jamanetwork.com/journals/jama/fullarticle/2781792

Walkey, A. J., Law, A., & Bosch, N. A. (2021). Lottery-Based Incentive in Ohio and COVID-19 Vaccination 

Rates. JAMA.

Did Ohio’s Vaccine Lottery Increase Vaccination Rates? A Pre-Registered, Synthetic Control Study.

https://osf.io/a6de5/

More Information about the COVID-19 Examples

The Equal Employment Opportunity Commission (EEOC) provides guidance to employees regarding offering 

COVID-19 vaccine incentives. 

https://www.eeoc.gov/wysk/what-you-should-know-about-covid-19-and-ada-rehabilitation-act-andother-eeo-laws#K 

The National Governors Association maintains a list of state and local government incentives being offered for 

COVID-19 vaccination. 

https://www.nga.org/center/publications/covid-19-vaccine-incentives/

Additional Resources for Implementing this Strategy

Vaccination Programs: Client of Family Incentive Rewards

https://www.thecommunityguide.org/findings/vaccination-programs-client-or-family-incentive-rewards 

Strategy 6: School-Located Vaccination Programs

Research Base

Voluntary school-based human papillomavirus vaccination: an efficient and acceptable model for achieving 

high vaccine coverage in adolescents.

https://www.jahonline.org/article/S1054-139X1000318-6/fulltext

Skinner, S. R., & Robbins, S. C. C. (2010). Voluntary school-based human papillomavirus vaccination: an 

efficient and acceptable model for achieving high vaccine coverage in adolescents. Journal of Adolescent 

Health, 47(3), 215-218.

Appendix A
36

HPV vaccine uptake in a school-located vaccination program.

https://www.tandfonline.com/doi/full/10.1080/21645515.2016.1208326

Middleman, A. B., Won, T., Auslander, B., Misra, S., & Short, M. (2016). HPV vaccine uptake in a schoollocated vaccination program. Human vaccines & immunotherapeutics, 12(11), 2872-2874.

Addressing adolescent immunization disparities: a retrospective analysis of school-based health center 

immunization delivery.

https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2009.176628

Federico, S. G., Abrams, L., Everhart, R. M., Melinkovich, P., & Hambidge, S. J. (2010). Addressing adolescent 

immunization disparities: a retrospective analysis of school-based health center immunization delivery. 

American journal of public health, 100(9), 1630-1634.

More Information about the COVID-19 Examples

Preparing for a school-located COVID-19 vaccination clinic.

https://journals.sagepub.com/doi/full/10.1177/1942602X21991643

Park, K., Cartmill, R., Johnson-Gordon, B., Landes, M., Malik, K., Sinnott, J., ... & Wallin, R. (2021). Preparing 

for a school-located COVID-19 vaccination clinic. NASN School Nurse, 36(3), 156-163.

Additional Resources for Implementing this Strategy

Lessons learned about the need for careful and thorough planning for school-located vaccination programs 

are shared. 

Lott, J., & Johnson, J. (2012). Promising Practices for School-located Vaccination Clinics—Part I: 

Preparation. Pediatrics, 129(Supplement 2), S75-S80. 

Promising Practices for School-located Vaccination Clinics—Part I: Preparation | American Academy of 

Pediatrics (aappublications.org)

Lessons learned about clinic operations based on experience of a school-located mass vaccination program for 

influenza. 

Lott, J., & Johnson, J. (2012). Promising Practices for School-located Vaccination Clinics—Part II: Clinic 

Operations and Program Sustainability. Pediatrics, 129(Supplement 2), S81-S87.

Promising Practices for School-located Vaccination Clinics— | American Academy of Pediatrics 

(aappublications.org)

Guidance for consideration when planning school-located vaccination clinics for COVID-19.

https://www.cdc.gov/vaccines/covid-19/planning/school-located-clinics.html#additional

Resources for school-based vaccines and immunizations for kids and teens.

https://www.sbh4all.org/resources/school-based-vaccines-and-immunizations/

Strategy 7: Home-Delivered Vaccination

Research Base 

Project VIVA: a multilevel community-based intervention to increase influenza vaccination rates among hardto-reach populations in New York City.

https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2007.119586

Coady, M. H., Galea, S., Blaney, S., Ompad, D. C., Sisco, S., & Vlahov, D. (2008). Project VIVA: a multilevel 

community-based intervention to increase influenza vaccination rates among hard-to-reach populations 

in New York City. American Journal of Public Health, 98(7), 1314-1321.

More Information about the COVID-19 Examples

Door-to-door teams reach nearly all care homes within a week in Multnomah County, Oregon to distribute the 

COVID-19 vaccine.

https://www.multco.us/novel-coronavirus-covid-19/news/door-door-teams-reach-nearly-all-care-homeswithin-week

Appendix A
37

Appendix A

Additional Resources for Implementing this Strategy

Guidance for implementing home-bound and residential living vaccination. 

Centers for Disease Control: Vaccinating Homebound Persons With COVID-19 Vaccine 

https://www.cdc.gov/vaccines/covid-19/clinical-considerations/homebound-persons.html

How the Medical Reserve Corps is assisting with COVID-19 vaccination. 

https://www.phe.gov/mrc 

Strategy 8: Workplace Vaccination Programs

Research Base 

Effectiveness of worksite interventions to increase influenza vaccination rates among employees and families.

https://journals.lww.com/joem/Abstract/2013/02000/Effectiveness_of_Worksite_Interventions_to.8.aspx

Ofstead, C. L., Sherman, B. W., Wetzler, H. P., Langlay, A. M. D., Mueller, N. J., Ward, J. M., ... & Poland, G. A. 

(2013). Effectiveness of worksite interventions to increase influenza vaccination rates among employees 

and families. Journal of occupational and environmental medicine, 55(2), 156-163.

The KFF COVID-19 Vaccine Monitor is an ongoing research project tracking the public’s attitudes and 

experiences with COVID-19 vaccinations, where this topic is about vaccine attitudes among essential workers. 

https://www.kff.org/coronavirus-covid-19/poll-finding/kff-covid-19-vaccine-monitor-vaccine-attitudesamong-essential-workers/

Getting to work: Employers’ role in COVID-19 Vaccination.

https://www.mckinsey.com/industries/pharmaceuticals-and-medical-products/our-insights/getting-towork-employers-role-in-covid-19-vaccination

More Information about the COVID-19 Examples 

Hy-Vee brings mobile units directly to Midwestern food workers.

https://www.cdc.gov/vaccines/covid-19/retail-pharmacy-program/retail-stories.html

U.S. Chamber of Commerce: Small Businesses Host Vaccine Clinics to Speed Up Shots.

https://www.uschamber.com/series/above-the-fold/small-businesses-host-vaccine-clinics-speed-shots

Additional Resources for Implementing this Strategy

CDC guidance for state, tribal, and local jurisdictions on promoting workplace vaccination efforts. 

https://www.cdc.gov/vaccines/covid-19/health-departments/essential-workers/index.html 

CDC guidance for employers to promote employee COVID-19 vaccination. 

https://www.cdc.gov/coronavirus/2019-ncov/vaccines/toolkits/essential-workers.html

Guidance for planning Vaccination Clinics Held at Temporary, Satellite, or Off-Site Locations 

https://www.cdc.gov/vaccines/hcp/admin/mass-clinic-activities/index.html

Strategy 9: Vaccine Requirements

Research Base

Increasing Appropriate Vaccination: Vaccination Requirements for Child Care, School, and College Attendance 

(2009 Archived Review).

https://www.thecommunityguide.org/sites/default/files/Vaccination-Requirements-Schools-Archive.pdf

Nudges or mandates? The ethics of mandatory flu vaccination.

Nudges or mandates? The ethics of mandatory flu vaccination - ScienceDirect

Dubov, A., & Phung, C. (2015). Nudges or mandates? The ethics of mandatory flu vaccination. Vaccine, 

33(22), 2530-2535.
38

Systematic review of the effect of immunization mandates on uptake of routine childhood immunizations.

https://www.sciencedirect.com/science/article/abs/pii/S0163445316300299

Lee, C., & Robinson, J. L. (2016). Systematic review of the effect of immunization mandates on uptake of 

routine childhood immunizations. Journal of Infection, 72(6), 659-666.

More Information about the COVID-19 Examples

The complete list of higher education institutions requiring vaccination for the fall 2021-2022 semester.

https://universitybusiness.com/state-by-state-look-at-colleges-requiring-vaccines/

List of hospitals and health systems that are requiring vaccines for workers.

https://www.beckershospitalreview.com/workforce/hospitals-health-systems-mandating-vaccines-forworkersjune17.html

Morgan Stanley to Require Vaccinations to Enter N.Y. Offices.

https://www.bloomberg.com/news/articles/2021-06-22/morgan-stanley-tells-staff-they-ll-need-vaccinesto-enter-office

The deadline for Houston Methodist’s vaccine mandate was June 7. How did it go?

https://www.beckershospitalreview.com/workforce/the-deadline-for-houston-methodist-svaccine-mandate-was-june-7-how-did-it-go.html#:~:text=Post%2DAcute-,The%20deadline%20

for%20Houston%20Methodist’s%20vaccine%20mandate%20was%20June,How%20did%20it%20

go%3F&text=Houston%20Methodist%20employees%20had%20a,24%2C947%20workers%20being%20

fully%20vaccinated.

Mandatory Vaccination Policy Lawsuit Update: Nurses Take a Shot Against Hospital, But Judge Jabs Back in 

Texas.

https://www.natlawreview.com/article/mandatory-vaccination-policy-lawsuit-update-nurses-take-shotagainst-hospital-judge

Additional Resources for Implementing this Strategy

Several legal organizations offer guidance and templates for crafting vaccine requirement policies:

https://www.fisherphillips.com/services/emerging-issues/vaccine-resource-center/index.

html?tab=overview

https://www.shrm.org/resourcesandtools/tools-and-samples/policies/pages/vaccination-policymandatory-covid19-coronavirus.aspx 

https://www.themcdispatch.com/wp-content/uploads/2021/02/HUB-SAMPLE-Employee-COVID-19-

Vaccine-Policy.pdf 

Houston Methodist Vaccine Requirement Policy 

https://hrportal.ehr.com/LinkClick.aspx?fileticket=WbwcMj8SRPg%3d&portalid=78 

Strategy 10: Effective Messages Delivered by Trusted Messengers

Research Base 

Assessing the state of vaccine confidence in the United States: recommendations from the National Vaccine 

Advisory Committee.

https://journals.sagepub.com/doi/abs/10.1177/003335491513000606

Committee, N. V. A. (2015). Assessing the state of vaccine confidence in the United States: 

recommendations from the National Vaccine Advisory Committee: approved by the National Vaccine 

Advisory Committee on June 10, 2015. Public Health Reports, 130(6), 573-595.

The COVID-19 States Project: A 50-State COVID-19 Survey Report #36: Evaluation of COVID-19 Vaccine 

Communication Strategies.

https://news.northeastern.edu/wp-content/uploads/2021/01/COVID19-CONSORTIUM-REPORT-36-

VACCINE-COMM-Jan-2021.pdf

Appendix A
39

Examining the effect of information channel on COVID-19 vaccine acceptance.

https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0251095

Piltch-Loeb, R., Savoia, E., Goldberg, B., Hughes, B., Verhey, T., Kayyem, J., ... & Testa, M. (2021). Examining 

the effect of information channel on COVID-19 vaccine acceptance. Plos one, 16(5), e0251095.

More Information about the COVID-19 Examples

Greater Than COVID helps individuals take charge of their health during the evolving COVID-19 public health 

crisis. Tailored media messages and community tools will address information needs about the new vaccines.

https://www.greaterthancovid.org/theconversation/ 

Additional Resources for Implementing this Strategy

Resources for building vaccine confidence and CDC vaccine confidence insight reports. 

https://www.cdc.gov/vaccines/covid-19/vaccinate-with-confidence.html#reports

Vaccine communication tips from deBeaumont Foundation. 

https://debeaumont.org/changing-the-covid-conversation/vaccineacceptance/covid-vaccine-pollvaccine-communications-tips/

Strategy 11: Provider Recommendation

Research Base 

Recommendations and offers for adult influenza vaccination, 2011–2012 season, United States.

https://doi.org/10.1016/j.vaccine.2016.04.061

Benedict, K. M., Santibanez, T. A., Black, C. L., Ding, H., Graitcer, S. B., Bridges, C. B., & Kennedy, E. D. (2017). 

Recommendations and offers for adult influenza vaccination, 2011–2012 season, United States. Vaccine, 

35(9), 1353-1361.

Longitudinal predictors of human papillomavirus vaccine initiation among adolescent girls in a high-risk 

geographic area.

https://doi.org/10.1097/OLQ.0b013e3181f12dbf

Brewer, N. T., Gottlieb, S. L., Reiter, P. L., McRee, A. L., Liddon, N., Markowitz, L., & Smith, J. S. (2011). 

Longitudinal predictors of human papillomavirus vaccine initiation among adolescent girls in a high-risk 

geographic area. Sexually transmitted diseases, 38(3), 197–204.

More Information about the COVID-19 Examples 

The New York City Department of Health and Human Hygiene created a resource called Vaccine Talks which 

emphasizes the importance of healthcare provider recommendations in increasing COVID-19 vaccination 

rates.

https://www1.nyc.gov/site/doh/covid/covid-19-providers-vaccines-communication.page

The statement the NY health commissioner released promoting Vaccine Talks that place emphasis on the trust 

patients have in their healthcare providers.

https://www1.nyc.gov/assets/doh/downloads/pdf/covid/providers/coh-letter-vaccinecommunication-04272021.pdf

COVID-19 Vaccine Use Every Opportunity Campaign Implementation Tool.

https://www1.nyc.gov/assets/doh/downloads/pdf/covid/providers/covid-19-vaccine-use-everyopportunity-tool.pdf 

Here is an example of the Philadelphia Department of Public Health putting a call out to emergency facilities in 

the city to begin recommending and administering COVID-19 vaccines to patient upon discharge.

https://vax.phila.gov/index.php/notices/vaccinate-patients-upon-discharging/

Here is an example of the Philadelphia Department of Public Health using CDC Best Practices for Vaccinating 

Appendix A
40

Upon Discharge in addition to Vaccine eligibility.

https://vax.phila.gov/index.php/notices/cdc-best-practices-for-vaccinating-upon-discharge/

Additional Resources for Implementing this Strategy

CDC offers 5 suggestions on how to talk to your patients about COVID-19 vaccine. 

https://www.cdc.org/vaccines/covid-19/hcp/engaging-patients.html 

The American Medical Association’s (AMA) COVID-19 Vaccine FAQs includes statements physicians can use 

when talking with patients. 

https://www.ama-assn.org/system/files/2020-12/covid-19-vaccine-physician-faqs.pdf 

Strategy 12: Combating Misinformation

Research Base

Debunking: A meta-analysis of the psychological efficacy of messages countering misinformation.

https://journals.sagepub.com/doi/full/10.1177/0956797617714579

Chan, M. P. S., Jones, C. R., Hall Jamieson, K., & Albarracín, D. (2017). Debunking: A meta-analysis of the 

psychological efficacy of messages countering misinformation. Psychological science, 28(11), 1531-1546.

Effects of fact-checking social media vaccine misinformation on attitudes toward vaccines.

https://doi.org/10.1016/j.ypmed.2020.106408

Zhang, J., Featherstone, J. D., Calabrese, C., & Wojcieszak, M. (2021). Effects of fact-checking social media 

vaccine misinformation on attitudes toward vaccines. Preventive Medicine, 145, 106408.

Misinformation and its correction: Continued influence and successful debiasing.

https://journals.sagepub.com/doi/pdf/10.1177/1529100612451018

Lewandowsky, S., Ecker, U. K., Seifert, C. M., Schwarz, N., & Cook, J. (2012). Misinformation and its 

correction: Continued influence and successful debiasing. Psychological science in the public interest, 13(3), 

106-131.

The Swiss cheese model for mitigating online misinformation.

https://www.tandfonline.com/doi/full/10.1080/00963402.2021.1912170

Bode, L., & Vraga, E. (2021). The Swiss cheese model for mitigating online misinformation. Bulletin of the 

Atomic Scientists, 77(3), 129-133.

More Information about the COVID-19 Examples

PGP (The Public Good Projects) is a public health nonprofit specializing in large-scale media monitoring 

programs, social and behavior change interventions, and cross-sector initiatives.

https://publicgoodprojects.org/about

How data scientists and influencers are joining forces to fight against dangerous COVID-19 conspiracy theories 

online.

https://www.msn.com/en-us/money/other/how-influencers-are-fighting-dangerous-conspiracy-theoriesabout-covid-19-as-people-shun-experts-warnings/ar-BB1c8Zf6

Additional Resources for Implementing this Strategy 

Weekly briefings highlighting trends in vaccine misinformation. 

https://www.viralityproject.org/weekly-briefings

Additional Resource

The Guide to Community Preventive Services (The Community Guide) lists evidence-based interventions to 

improve vaccination rates in an easy-to-use table. 

https://www.thecommunityguide.org/sites/default/files/assets/What-Works-Factsheet-Vaccination.pdf

Appendix A
41

Appendix B

Strategy Matrix Table

Common Barriers

Strategy Barriers Population Location

1. Vaccine Ambassadors Equity, access, prevailing 

social norms, mistrust, 

misinformation, cultural 

relevance

Hispanic or Latino Adults and 

Black Adults

San Francisco, CA 

Philadelphia, PA

2. Medical Providers

Standardize Vaccination

Policy, mistrust, health literacy Adults Multiple U.S. locations

3. Medical Reminders Equity, access, forgetfulness, 

friction, health literacy, lack of 

adequate information

Adults Multiple U.S. locations

4. Motivational Interviewing Misperception, health literacy, 

uncertainty

Adults Western Pennsylvania

5. Financial Incentives Inertia College Students Multiple U.S. locations

6. School-Located

Vaccination Programs

Access, friction, prevailing 

social norms, uncertainty, lack 

of adequate information

School-aged Youth St. Louis County, MO

7. Home-Delivered

Vaccination

Equity, access, inertia, friction Adults Multnomah County, OR

8. Workplace Vaccination Access, cost, prevailing social 

norms, friction

Adults Midwest; Jackson, MS

9. COVID-19 Vaccine 

Requirements

Policy, inertia, prevailing social 

norms, politicization

Adults Multiple U.S. locations

10. Effective messages

delivered by trusted

messengers

Mistrust, health literacy, 

misinformation, lack of 

adequate information

Adults Multiple U.S. locations

11. Provider

Recommendations and Offers

Inertia, friction, mistrust, 

uncertainty, mis- and 

disinformation, lack of 

adequate Information

Adults New York, NY; 

Philadelphia, PA

12. Combating Misinformation Misperception, mis- and 

disinformation, lack of 

adequate information

Adults Multiple U.S. locations
42

Appendix C

Diagnostic Tool
43

Appendix C
44

Appendix C
45

Appendix C
46

Appendix D

BeSD Framework

The Behavioral and Social Drivers (BeSD) Framework

Source: The WHO BeSD working group. Based on Increasing Vaccination Model (Brewer et al., 2017)

An expert working group chaired by the World Health Organization (WHO) developed a behavioral 

framework specific to COVID-19 vaccination uptake titled the Behavioral and Social Drivers (BeSD) 

of COVID-19 Vaccination Uptake. The framework demonstrates that the following drivers are 

associated with COVID-19 vaccination: 

 What people think and feel

 Social process

 Motivation

 Practical issues

Each driver can be measured through regular data collection to understand and act on individuals’ 

barriers and enablers to COVID-19 vaccine uptake. Factors at many levels—individual, community, 

societal, and policy—affect someone’s decision to get vaccinated. Some of these factors are 

within control to address, and some are not. Understanding this framework provides an additional 

way to understand people’s thoughts and behaviors related to their decision about receiving 

the COVID-19 vaccine.
47

Acknowledgments

Timely production of this guide would not have been possible without strong leadership from CDC 

staff, insightful technical input and review from advisory committee members, and hours of work by 

contractors. We gratefully acknowledge each contributor. 

We are thankful to the National Association of County and City Health Officials (NACCHO) members 

who reviewed the draft and provided feedback from the perspective of those we hope will use the 

information in this Field Guide. 

The Little Jab Book: 18 Behavioral Science Strategies for Increasing Vaccination Uptake, developed by 

Busara, Common Thread, and Save the Children, was the inspiration to develop a U.S.-oriented resource 

and became the template for this work.

Advisory Committee

Ann Aikin, MA

Office of Infectious Disease and HIV/AIDS Policy

U.S. Department of Health and Human Services

Washington, D.C.

Meredith Allen, DrPH

Health Security

Association of State and Territorial Health Officials

Arlington, VA

Noel T. Brewer, PhD

Department of Health Behavior

Gillings School of Global Public Health

University of North Carolina – Chapel Hill

Chapel Hill, NC

Alison Buttenheim, PhD MBA

Department of Family and Community Health

University of Pennsylvania School of Nursing

Philadelphia, PA

Michelle Cantu, MPH

Infectious Disease and Immunization

National Association of County and City Health Officials

Washington, D.C.

David Hopkins, MD

Guide to Community Preventive Services

Office of the Associate Director for Policy and Strategy

CDC

Portland, OR

Amy Lansky, PhD

Guide to Community Preventive Services

Office of the Associate Director for Policy and Strategy

CDC

Portland, OR

James Tseryuan Lee, MD

Immunization Services Division

CDC

Atlanta, GA

Saad B. Omer, PhD

Yale Institute of Global Health

Yale University

New Haven, CT

Marcus Plescia, MD

Medical Officer

Association of State and Territorial Health Officials

Arlington, VA

Elana Safran, MS

Office of Evaluation Sciences 

U.S. General Services Administration

Washington, D.C.
48

Acknowledgments 

CDC Leadership

Neetu Abad, PhD

Global Immunization Division

CDC

Atlanta, GA

Kimberly Bonner, PhD

Epidemic Intelligence Service

CDC

Atlanta, GA

Stephanie Griswold, MPH

National Center for Immunization and Respiratory Diseases

CDC

Atlanta, GA

Elisabeth Wilhelm, MA

Global Immunization Division

CDC

Atlanta, GA

Writing and Design Team

Kelly Clay, MS, CHES®

Karna, LLC

Alia Hiller, CHES®

Tanaq Support Services, LLC

Roderick Hopkins, MPH

Karna, LLC

Alange Jacobs

Karna, LLC

Lorraine L. Janeczko, MPH

Karna, LLC

Sarah Morris Hummer, MA

Tanaq Support Services, LLC

Carly Ng, MPH, CHES®

Tanaq Support Services, LLC

Aparna Ramakrishnan, MA, MSW

Karna, LLC

Torey Repetski, MPH

Karna, LLC

Leslie Rodriguez, PhD

Karna, LLC

Randall Simpson, MPH, PMP

Karna, LLC

Bryan Sorenson, MPH

Tanaq Support Services, LLC

Nicole Weinstein, MSW

Karna, LLC