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12 COVID-19 Vaccination Strategies for Your CommunityA Field Guide to Support the Work of Health Departments and Community Organizations						Print
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										illustration of four settings: drive through testing, home setting, farm setting, university settingThis COVID-19 Vaccination Field Guide presents 12 COVID-19 vaccination strategies adapted from evidence-based practices implemented nationwide to help increase vaccine confidence and uptake.**Vaccine confidence** is the belief that vaccines work, are safe, and are part of a trustworthy medical system. Without some level of confidence, people will not move toward receiving a vaccine for themselves or their children.
**Vaccine uptake** refers to the proportion of the population that has received a vaccine.This Field Guide also includes examples from communities and organizations that have used these strategies to help increase COVID-19 vaccinations. Each strategy addresses common barriers to getting a COVID-19 vaccine—structural, behavioral, or informational. Refer to pages 6-7 of the complete Field Guide for a list of barriers and their meanings.
When implementing any of these strategies, consider real-world factors by assessing the cost (dollars, time, effort, staffing), involving community leaders in planning and execution, and piloting the effort to measure success before wider execution.
You can also view trends in COVID-19 vaccine confidence in the U.S. to inform your efforts. Fundamental to any strategy is establishing trust with your community of focus by fostering strong partnerships with trusted organizations and communicating responsively.
COVID-19 Vaccination Field Guide: 12 Strategies for Your Community**COVID-19 Vaccination Field Guide: 12 Strategies for Your Community**
Published August 2021
Downloadelderly couple/COVID - 19 Vaccination Field Guide Addendum: Rural Considerations/Vaccine Confidence and Uptake Strategies**Addendum: Rural Considerations for Vaccine Confidence and Uptake Strategies**
Published December 2021
Download
12 Strategies to Help Increase COVID-19 Vaccine Confidence and Uptake
**Health departments and community organizations are encouraged to try a combination of the following strategies:**
1. Vaccine Ambassadors
	illustration of a bandage and heart**Vaccine ambassadors** train community members to disseminate important health information in their communities. Adapted from the lay health advisor model, ambassadors are most effective when they are trusted community members and share similar beliefs and characteristics with their peers. **Anyone can be an ambassador; it is not restricted to community leaders or people in leadership positions.**
**Barriers Addressed:** Equity, Access, Prevailing Social Norms, Mistrust, Mis- and Disinformation, 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.Vaccine Ambassadors Strategy COVID-19 Application Examples:Motivate, Vaccinate, and Activate Campaign**Location:** San Francisco, CA
**Population of Focus:** Latino PersonsThe "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.Learn more how the community implemented this strategy.The culturally tailored initiative was organized through a community-academic-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 and social networks and used a convenient vaccination site. These efforts helped increase vaccinations and overcome misinformation, distrust of institutions, and lack of 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 encourage friends and family members to get vaccinated.**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 people to be vaccinated; and 19% reported that they motivated 6 or more people.
During a 16-week period, the campaign administered 20,792 vaccines at the neighborhood site.Important steps in this strategy included:
Two dedicated staff shared their personal experiences modeling how this could be done.
Staff then encouraged others to share their vaccination experiences with their unvaccinated friends and family to encourage them to get vaccinated.
Staff provided tips on how to handle difficult conversations, provided myth-busting information, and role played.
Philly Teen Vaxx: Encouraging Peer Vaccination**Location:** Philadelphia, PA
**Populations of Focus:** YouthLearn more about how Philly teens are providing the facts to encourage their peers to get vaccinated.Philly Teen Vaxx is a youth-led coalition working to increase vaccine confidence and rates among youth. The partnership between the Children’s Hospital of Philadelphia and the School District of Philadelphia trained 45 Philly teens to serve as vaccine ambassadors. The teens organize vaccination events with the school district and engage in peer-to-peer conversations in person and online.Reached hundreds of teens through social media content and community events.
Vaccinated more than 100 teens at the “Vaxx-it-Ball" basketball and COVID-19 vaccination clinics.
Hosted several back-to-school and fall festival neighborhood vaccination clinics with free food, music, and backpack giveaways.Key Components of Philly Teen Vaxx:
Offer education opportunities for teen ambassadors to learn about public health, vaccination, health communication, and COVID-19 vaccines.
Hold vaccination events where teens can access COVID-19 vaccine information, vaccination, and fun activities.
Facilitate teen-to-teen conversations and debunk vaccine misinformation being spread on social media.Additional resources for implementing this strategy:Community COVID-19 Vaccine Communication Training for Ambassadors – Slide Presentation (San Francisco Department of Public Health)
COVID-19 Vaccine Ambassador Training: How to Talk to Parents (Johns Hopkins University)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 COVID-19 vaccination by 5% to 6%. 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**. For example, one study found doctors trained to announce human papillomavirus (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.illustration of hand with plus symbol

Learn how to increase COVID-19 vaccinations upon discharge from hospitals, emergency departments, and urgent care facilities.Medical Provider Vaccine Standardization Strategy COVID-19 Application Example:Partnership Standardizes COVID-19 Vaccination Practices in Provider Offices**Location:** Arizona
**Population of Focus:** AdultsThe Arizona Department of Health Services Immunization Program in partnership with The Arizona Partnership for Immunization 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 administrationStandardization measures have become routine practice in doctors’ offices and hospitals now that COVID-19 vaccines are widely available. **Standardizing COVID-19 vaccination into routine practice  helps reduce missed opportunities for vaccination**.
Soon after Emergency Use Authorization for COVID-19 vaccines, an Arizona practice received detailed guidance from their county health department that helped them get COVID-19 vaccines and establish an administration protocol. The county health department provided both supplies and weekly instructional webinars to guide practices through the vaccine administration process.
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 vaccine-eligible patients, laying the groundwork for integrating vaccination into routine practice.New York-Presbyterian Hospital Implements Inpatient Vaccine Program**Location:** New York
**Population of Focus:** AdultsIn Spring 2021, New York-Presbyterian (NYP) Hospital received an allotment of COVID-19 vaccines from the state. They quickly assembled a multidisciplinary team to scale up a program for vaccinating their inpatient population proactively, rather than waiting for patients to seek out vaccination. In six weeks, they went from piloting the program at two sites to offering COVID-19 vaccinations to patients at seven of the NYP campuses.
Key Program Components:
Applied multidisciplinary input to troubleshoot program barriers
Integrated COVID-19 vaccine standing order into the NYP electronic health record system
Developed clear eligibility criteria
Responded flexibly to changing eligibility, mandates, and recommendations
Communicated continuously with frontline staffHospitals Vaccinate Patients at Discharge**Location:** Philadelphia, Pennsylvania
**Population of Focus:** AdultsEmergency 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 called on emergency facilities 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 also provided best practices for vaccination during patient discharge.
Additional resources for implementing this strategy:CDC COVID-19 Vaccination Program Provider Requirements and Support
Vaccination: Provider Reminders (The Community Guide)
Vaccination: Standing Orders (The Community Guide)
Standing Orders Templates for Administering Vaccines (Immunization Action Coalition)
COVID-19 Vaccine Use Every Opportunity Implementation Tool (New York City Department of Health)3. Reminder/Recall
	illustration of triangle with exclamation point
**Reminder/Recall** are messages sent to patients to remind them of recommended or upcoming treatment. Messages can be sent by autodialed phone calls, text messages, emails, 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 childhood vaccination rates by using data from the Florida Shots Registry to identify families with upcoming or overdue child vaccinations and **sending them reminders with educational materials through phone calls, letters, and home visits**.
A study in Rochester, New York, showed that when interventions included **patient reminders, provider reminders, and telephone outreach combined**, older adults 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 effective were presented in a professional format and tone—surprisingly not casual  or interactive. The most successful messages reminded patients twice to get their reserved vaccine at their upcoming doctor's appointment.Reminder/Recall Strategy COVID-19 Application Examples:Effective Text Messaging Strategies for Increasing Vaccine Uptake**Location:** Multiple U.S. locations
**Population of Focus:** Adults**Many text-based services are available to help with COVID-19 vaccination.**
CareMessage offers a free model for nonprofit organizations.
V-safe provides personalized and confidential health check-ins via text messages and web surveys so you can quickly and easily share with CDC how you, or your dependent, feel after getting a COVID-19 vaccine. This information helps CDC monitor the safety of COVID-19 vaccines in near real time. It also sends a reminder to schedule a 2nd dose and boosters.Several health departments, including in Michigan, Oklahoma, and Baltimore, Maryland, are using text messages to:
Help people schedule COVID-19 vaccination appointments
Provide education and vaccination site information
Gauge views on vaccination**Certain populations can be reached with text messaging, either based on race, ethnicity, or age, or used in geographic locations with low vaccination rates.** 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.
A study evaluated UCLA Health’s text messaging program that delivers simple reminder text messages to more than 150,000 patients for their COVID-19 vaccine appointments and follow through. Every message led with a focus on scheduling a COVID-19 vaccination appointment and contained a link for patients to immediately sign up for an appointment.
Key Findings:
Text message reminders boosted appointment rates by 6% and vaccination by 3.6% within the healthcare system.
Messages that included ownership language like, “a vaccination is reserved for you” performed the best compared to the control group, as did messages that included an educational video.Email Reminder Strategies**Location:** Pennsylvania
**Population of Focus:** AdultsWell-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 get employees vaccinated against COVID-19, 41% still had not scheduled their vaccination. They conducted a study that showed individually addressed emails containing behaviorally informed messages increased vaccination registration 3% compared to the control group.
The emails had three important components:Learn how the Pennsylvania health system implemented this reminder effort.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 get 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.4. Motivational Interviewing
	illustration of head with arrows inside
**Motivational interviewing** refers to patient-centered conversations designed to increase patient motivation and likelihood of making the health behavior.
**Barriers Addressed:** Misperception, Health Literacy, Uncertainty
**Research Base:** Motivational interviewing aims to support decision making by strengthening a person’s intention to get vaccinated based on their own arguments. The healthcare professional informs the patient about vaccination in alignment with the patient’s specific informational needs and with respect for their beliefs. Motivational interviewing has been shown to increase parents’ vaccine confidence.
A pilot study using motivational interviewing in maternity wards during postpartum stays found the strategy led to:
15% increase in mothers’ intention to get their child vaccinated
7% increase in infants’ vaccination coverage at seven months
9% greater chance of complete vaccination at two years
Motivational interviewing significantly improved HPV vaccination completion among adolescent patients in a study that used 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 may not be billable.Motivational Interviewing Strategy COVID-19 Application Example:Innovative Notification and Motivational Interviewing Strategies**Location:** Western Pennsylvania
**Population of Focus:** AdultsGet scripts for using motivational interviewing with those who may be COVID-19 vaccine hesitant.Motivational interviewing can be a strategy to promote COVID-19 vaccine uptake.
For example, 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.According to the study, 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
7% for pneumococcal vaccinationsPharmacy staff identified the patient, who then received an automated notification about their vaccination status. The staff used motivational interviewing techniques face-to-face or by telephone to engage patients in conversation about getting vaccinated.
**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 implement similar programs.**
Additional resources for implementing this strategy:Communication Skills for Talking About COVID-19 Vaccines (Center to Advance Palliative Care)
Interactive COVID-19 Vaccine Conversations Module for Healthcare Professionals
Using motivational interviewing techniques to inform decision-making for COVID-19 vaccination5. Financial Incentives
	illustration of circle with dollar sign
**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.
**Barrier Addressed:** Inertia
**Research Base:**While evidence supporting the use of incentives to increase vaccine uptake is overall limited, a guaranteed gift incentive. For example, offering a $30 incentive increased vaccination rates at college campus clinics, according to one study, and a study in four North Carolina counties showed a $25 incentive helped encourage equitable vaccine distribution by eliminating financial barriers for low-income individuals.
Two studies of the Ohio COVID-19 vaccine lottery and a study on 24 states with lotteries have been less positive, showing the likelihood that the lottery approach has not increased vaccine uptake.
It is important to note that 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. Thus, the approach and audience may affect vaccine uptake differently.Financial Incentives Strategy COVID-19 Application Examples:Incentives Reward the Vaccinated While Generating Awareness**Location:** Multiple U.S. locations
**Populations of Focus:** Adults and YouthFor ideas on incentives to offer, see the list of state and local government incentives maintained by the National Governors Association.The **Minnesota** “Kids Deserve a Shot” campaign provided families with $200 gift cards if their 5 to 11-year-olds received both doses of a COVID-19 vaccine. More than 22,000 children registered to receive a gift card through the program. This was modeled after the same incentive program for 12- to 17-year-olds. Within one week of launching the 12 to 17 campaign, first dose vaccinations increased by 40%.
In **Louisiana**, the department of health implemented the “Shot for 100” incentive program. Individuals receiving their COVID-19 vaccine at a community-based vaccination centers received a $100 VISA gift card. Over 19 thousand people participated in the program.
People receiving their boosters at city-run vaccination sites in **New York City** were eligible to receive a $100 gift card or tickets to events around the city. Since the program’s inception, vaccination rates rose 25% and the city distributed over 800,000 gift cards.
**Wisconsin** Department of Human Services hosted a month-long incentive program that gave $100 VISA gift cards to people receiving their first dose of a COVID-19 vaccine. They reached over 80,000 individuals, many from the refugee community and disproportionately affected populations.
Additional resource for implementing this strategy:Vaccination Programs: Client or Family Incentive Rewards (The Community Guide)6. School-Located Vaccination Programs
	illustration of school
**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.**School-Located Vaccination Programs Strategy COVID-19 Application Example:Partnerships Bring Vaccine Clinics to Schools**Location:** Missouri and Illinois
**Population of Focus:** School-age youthParkway School District vaccinated nearly 3,000 students through their three school-located clinic events.
The pharmacy partnership was a critical component and paves the way for future vaccination events.Parkway School District in St. Louis County, Missouri held a school-located COVID-19 vaccination event 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 final exams for some students. **School nurses are trusted sources of health information and play an important role in educating students and families about the COVID-19 vaccines.**The Illinois Department of Health took a proactive approach to partnering with school districts and community sites to plan vaccination events for children ages 12 to 17 and 5 to 11 years old. They reached out to every school district and provided guidance for setting up COVID-19 community partner vaccination clinics. During the vaccine rollout for children ages 12 to 17 years, they set up 870 mobile clinics and vaccinated over two thirds of the 12 to 17 population – the highest rate in the Midwest.
While this strategy focuses 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, generally they:Lessons learned from Parkway School District.
Customizable content—letter and newsletter templates, sample social media content, consent forms—for school and childcare-located vaccination clinics.Are easily accessible
Have ample parking
Have both indoor and outdoor spaces available
Are familiar places
Additional resources for implementing this strategy:Resources and Examples for Administering COVID-19 Vaccines at Schools (School-Based Health Alliance)7. Home-Delivered Vaccination
	illustration of house
**Home-delivered vaccination** efforts reach populations where they live; traditionally used when barriers to transportation and access exist.
**Barriers Addressed:** Equity, Access, Inertia, Friction
**Research Base:** Bringing vaccines to people at their homes is an effective means to reach several hard-to-reach populations. This strategy can be applied to homebound people and 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:
People with substance use disorders
Immigrant populations
Older adults
Sex workers
People experiencing homelessnessBoth appointment-based home delivery and canvassing methods may be effective ways to deliver COVID-19 vaccines. When considering a canvassing method, be sure to take your community members’ preferences into consideration. Some may not want to be reached at their home.Home-Delivered Vaccination Strategy COVID-19 Application Example:Partnerships Deliver At-Home Vaccinations**Location:**Multnomah County, Oregon
**Population of Focus:** AdultsGet CDC guidance for implementing homebound and residential living COVID-19 vaccinations.The COVID-19 vaccination effort has shifted from mass vaccination sites to smaller neighborhood and community clinics and includes home-based efforts to give all individuals the opportunity to get vaccinated.
The Emergency Operations Center in Multnomah County, Oregon, partnered with the Multnomah County Public Health Division and County Human Services to provide COVID-19 vaccinations through a mobile program to reach people where they live. Initially vaccinating those in adult care homes, they expanded the project’s scope to include other homebound adults.
**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 provide COVID-19 vaccinations to people in their homes. In one week, the teams reached nearly all care homes and vaccinated more than 900 people.***“Getting to meet people ‘where they are’ and administering a life-saving 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 to respond quickly to inequalities and gaps in vaccine distribution, especially for those who are most vulnerable.”*
*– Dr. Sharon Meieran, a Medical Reserve Corps volunteer*Additional resources for implementing this strategy:Learn how the Mount Sinai Visiting Doctors Program vaccinated hundreds of patients in New York City
Learn how the Medical Reserve Corps is assisting with COVID-19 vaccination8. Workplace Vaccination
	illustration of business buildings
Vaccination clinics held on-site at a workplace removes logistical barriers and creates norms among employees. The clinics 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 workplace vaccination programs 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. Employees reported their top reasons for getting vaccinated at work were that the vaccine was free and convenient, and they didn’t have to miss work to get it. There is evidence that workplace COVID-19 vaccination may have similar uptake success:Locate a pharmacy and request a COVID-19 vaccination clinic on-site or in a retail pharmacy location near you through the Federal Retail Pharmacy Program.A Kaiser Family Foundation studyfound that **77% of those employed stated that they trust their employer for providing reliable information about the COVID-19 vaccines**.
Many counties, such as Clackamas County in Oregon, provide on-site COVID-19 vaccine clinics at local businesses. In Clackamas County, businesses simply complete and submit an online request form.Workplace Vaccination Strategy COVID-19 Application Examples:Food Processor Turns to Grocery Chain to Vaccinate Its Employees**Location:** Midwest
**Population of Focus:** AdultsBy early March 2021, Hy-Vee staff vaccinated over 2,400 employees in Iowa.Tyson Foods is offering on-site COVID-19 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.
By early March 2021, Hy-Vee staff vaccinated over 2,400 employees in Iowa. Workers in the meatpacking industry were hit hard by COVID-19 and were excited for the opportunity to get vaccinated. 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.
In a final effort to prevent additional COVID-related illness and deaths among its 120,000 person workforce, Tyson Foods implemented a COVID-19 vaccine mandate, resulting in a 96% company-wide vaccination rate.Small Business Partners with Health Leaders to Hold Vaccination Events**Location:** Jackson, Mississippi
**Population of Focus:** AdultsAt both Mississippi mobile vaccination events, COVID-19 vaccines were given to all Broad Street Baking Company employees and other attendees who requested them.Small businesses can support on-site vaccination efforts. According to a 2020 Gallup poll, small businesses are one of the most trusted institutions in the United States.
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.
Additional resources for implementing this strategy:Guidance for Planning Vaccination Clinics
Resources for Hosting a Vaccination Clinic9. Vaccination Requirements
	illustration of checklists
**Vaccination requirements** are policies that require employees, students, or patrons to be vaccinated and provide proof of vaccination to comply.
**Barriers Addressed:** Policy, Inertia, Prevailing Social Norms, Politicization
**Research Base:** Vaccine requirements by organizations 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 policies. Exemptions can be offered for specific circumstances, such as medical and religious reasons.
Before COVID-19, vaccination requirements were not often used for adult populations, except for military requirements and for healthcare workers to receive flu shots.
School mandates positively impact uptake for routine childhood vaccines and some studies suggest that vaccination for children and workers, including mandatory vaccination, decreases absenteeism.
A COVID States Project report detailing survey findings from more than 20,000 people across the U.S. revealed **high public support for mandating vaccines**, with 65% of respondents supporting vaccine requirements at the federal, state, and local levels. Respondents also strongly support vaccine requirements for attending in-person school (63%) or university (68%) or getting on an airplane (71%).
**COVID-19 vaccination requirements by employers have been effective****, even with getting those most hesitant vaccinated**. Gallup’s COVID-19 tracking surveyfound that while COVID-19 vaccination mandates can be divisive, the majority (55%) of U.S. workers favor workplace vaccination requirements.Vaccination Requirements Strategy COVID-19 Application Examples:Colleges, Hospitals, and Businesses Implement Vaccine Mandates**Location:** Multiple U.S. locations
**Population of Focus:** AdultsMany employers and more than 1,000 colleges and universities  require staff and students to be vaccinated against COVID-19, with many also requiring booster shots to be considered up to date on their COVID vaccinations. Even though the government’s mandate for businesses with 100 or more employees to implement a COVID-19 vaccine requirement was withdrawn, several large companies still require staff to be vaccinated to return to the office. Many federal and state governments are also requiring vaccination for employees; some with an alternative option to get tested for COVID-19 weekly.
Wesleyan University:
Wesleyan University in Connecticut with 3,200 students was the first higher education institution in the country to require booster shots for students, faculty, and staff. The university’s president announced the mandate in a video released two days before Thanksgiving 2021. To help students get their booster dose, the university held two on-campus booster clinics, distributing 600 shots.
The president stated in his video, “Thanks to our high vaccination rates, mask mandates, and robust testing protocols, the Wesleyan campus community has consistently maintained COVID-19 positivity rates lower than our surrounding area. This remains the case, even as we have seen an increase in positive campus cases. Most importantly, since we have the protection of vaccinations, the COVID-19 cases we’ve had thus far have been asymptomatic or mild.”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.
See the policy and procedures Houston Methodist put in place.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 two-week suspension during which they had another opportunity to 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.Occupational Safety and Health Administration (OSHA)  and Society for Human Resources Management (SHRM) offer guidance and customizable templates for crafting mandatory COVID-19 vaccination policies.Citigroup:
Several large American banks require employees to be vaccinated or be subject to frequent testing. Citigroup required all 65,000 employees to get vaccinated or be placed on unpaid leave or eventually terminated for noncompliance. This policy was effective, resulting in 99% vaccination rate among staff.
Student-Athletes and Coaches:
As many sports involve close contact with others, may be held in poorly ventilated indoor facilities, and require players to be healthy to participate, communities nationwide have implemented COVID-19 vaccination requirements and strong recommendations for students and coaches to participate in team sports. Hawaii and cities and counties in Maryland and Pennsylvania initially had COVID-19 vaccine requirements for public school student-athletes, but now strongly encourage them to get vaccinated. For an example of a guidance document, see Rhode Island Department of Health’s Guidance for Youth, Adult, and School Sports.10. Effective Messages Delivered by Trusted Messengers
	illustration of a shield with checkmark
**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 local doctors, community and faith-based leaders, or local celebrities.
**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 effects they had on participants’ willingness to receive a COVID-19 vaccine. The messages involved themes of:
Patriotism
Harm reduction
Social norms
Scientist recommendation
Physician recommendationThe 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 enables communication campaigns to tailor messages to specific concerns and demographic populations, which is shown to be more effective than generalized messaging.Effective Messages Delivered by Trusted Messengers Strategy COVID-19 Application Examples:Vaccination Communication Campaigns Educate and Empower**Location:** Multiple U.S. locations
**Population of Focus:** AdultsUse **CDC’s quick reference guides** to provide individuals, parents, pregnant people, and patients with information about COVID-19 vaccines.The Black Coalition Against COVID-19, 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 300 videos of Black and Latino doctors, nurses, and scientists talking about vaccine facts and dispelling misinformation and sharing why they got vaccinated.The campaign’s videos have more than 46 million views on YouTube.In addition to the videos, the campaign offers graphics, print media, social media content, and TV and radio public service announcements. The content is free for educational use and communities and organizations are invited to download and use the materials in English and Spanish.
Additional resources for implementing this strategy:Tools and resources for young people to help them have conversations around the COVID-19 vaccine (#NoJudgement)
Learn ways trusted messengers in communities nationwide are building confidence in COVID-19 vaccines
Learn the status of COVID-19 vaccine confidence in the U.S.11. Provider Recommendation
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**Provider recommendation** refers to healthcare professionals recommending that a patient receives a 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 a provider recommendation increases 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 whose providers recommended and offered the flu vaccine during their office visit were 1.76 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.Provider Recommendation Strategy COVID-19 Application Examples:Healthcare Providers Encourage Patients to Get Vaccinated**Location:** New York, New York
**Population of Focus:** AdultsThe *Vaccine Talks* resources include scripts for physicians to talk to their patients and parents of eligible children about COVID-19 vaccines. It also offers tools for physicians to build vaccine confidence with staff and patients.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 patient interaction points.
The health commissioner released a statement promoting *Vaccine Talks*  emphasizes patients’ trust in their healthcare providers and saying that providers’ 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 provides a form providers 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.Health Department Harnesses the Power of Providers**Location:**Washington State
**Population of Focus:**AdultsTo learn more about the POP initiative, go to the POP Community Feature.To address a decline in vaccine demand, Washington State Department of Health (DOH) created the Power of Providers (POP) initiative to **encourage healthcare providers to leverage their influence as trusted voices and promote COVID-19 vaccinations during their routine patient encounters.**
“We are calling on all licensed healthcare professionals to talk to their patients about COVID-19 vaccines. One conversation at a time. One vaccination at a time. It’s opportunities we should not miss at the diabetes check, at the blood pressure check, at the knee repair.”*–*Greg Endler, Washington State DOH Deputy Director of Health Promotion and Education.
Providers enroll in POP by completing an online commitment form to agree to follow a four-step process at every patient encounter to help “SAVE” lives:More than 70,000 of the state’s 212,000 providers have committed to the POP initiative.**S**eek patients’ COVID-19 vaccination status verbally or through immunization records
**A**sk/Educate unvaccinated patients about the vaccines, and offer more information if they’re unsure
**V**accinate patients who agree to be vaccinated, or refer them to a COVID-19 vaccine provider
**E**mpower patients and staff to share their vaccination status with their friends, families, and communitiesParticipating providers have access to clinical and communication resources and patient education materials. To further incentivize providers to have COVID-19 vaccine conversations with their patients, providers can be reimbursed for COVID-19 vaccine counseling, even during visits unrelated to vaccination, by using a newly created Current Procedural Terminology code.
Additional resource for implementing this strategy:How to talk with patients about COVID-19 vaccination
Resources for communicating with parents and caregivers about COVID-19 vaccination for children12. Combating Misinformation
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This strategy consists of tactics used to address and dismantle misinformation and disinformation. **Misinformation** refers to false information shared by people who do not intend to mislead others,  and **disinformation** refers to false information that is deliberately created and disseminated with malicious intent 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 world view.
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
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. Tips for effective corrections include responding with empathy and providing facts, rather than simply saying something is wrong.Combating Misinformation Strategy COVID-19 Application Examples:Physician Uses TikTok to Address Vaccine Misconceptions**Location:** Orlando, Florida
**Population of Focus:**  Black/African American Adults**Stay updated** **on social media misinformation**using the COVID19MisInfo.org Portal and Project VCTR.
**To monitor your local social media**, use the RCA’s Social Listening and Monitoring Tool.Dr. Kristamarie Collman, a family medicine physician, created a TikTok to address COVID-19 vaccine misconceptions and encourage trusted, science-based education. In her 11-second post, she paired a video of herself with upbeat music and text pop-ups addressing common COVID-19 vaccine misconceptions, such as “The COVID vaccine will not give you COVID. Will not change or alter your DNA. Does not have a microchip to track you.” She also used hashtags: #covid #health #learnontiktok #myths #blackdoctors. Her post received more than 60,000 likes, more than 600,000 plays, and nearly 3,000 shares.
“I felt it was my responsibility as a physician to make sure that I was spreading correct information, especially on social media. I want people to know that as a Black woman, as a Black physician, that I hear them and I understand their hesitancy, I understand their concerns,” said Dr. Collman.Learn actions you can take to address health misinformation.
Confront COVID-19 vaccine misinformation on social media using HHS’s pre-made graphics.Dr. Collman has also created TikToks to explain mRNA vaccines, COVID-19 vaccine side effects, and Bell’s Palsy and COVID-19 vaccines in addition to documenting her personal vaccination experiences.
**Disseminating 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, such as Dr. Collman
Using your own social media account to promote accurate informationTask Force Builds Trust to Battle Misinformation**Location:**Tennessee
**Population of Focus:**  Black/African American AdultsTo learn more about the COVID-19 Health Disparity Task Force’s activities, go to the Community Feature.The Office of Minority Health within the Tennessee Department of Health’s Division of Disparities Elimination (DHDE) convened the COVID-19 Health Disparity Task Force, a group of more than 800 partners across the state. The Health Disparity Task Force aimed to address disparities by improving the efficiency and effectiveness of disseminating information to communities they serve. The Task Force includes community and faith-based partners, members of academia, healthcare providers, and public health officials. The group meets weekly to discuss trends, hear from subject matter experts, identify sources of distrust, and address concerns from under-resourced communities.
Through hosting listening sessions and town halls for community partners and Task Force members, the DHDE team learned that no matter which group they engaged, they all had questions and concerns about the vaccine.
“There was a lot of misinformation we had to talk through, beginning with testing and eventually vaccination,” said Dr. Kimberly Lamar, assistant commissioner of Division of Disparities Elimination.
To increase vaccine trust and accessibility in communities disproportionately impacted by COVID-19, the team strengthened connections with small business owners, faith leaders, academia, federally qualified health centers, and other key partners to share vaccine information through as many modes as possible.Field Guide users can submit feedback and strategy examples to confidenceconsults@cdc.gov.
Related Links:Rapid Community Assessment Guide
Ways Health Departments Can Help Increase COVID-19 Vaccinations
6 Things to Know about COVID-19 Vaccination for Children
How to Engage the Arts to Build COVID-19 Vaccine Confidence
How to Tailor COVID-19 Information to Your Specific Audience
How to Address COVID-19 Vaccine MisinformationTop of Page
							
					
							Last Reviewed:  November 29, 2022						Source: 	National Center for Immunization and Respiratory Diseases
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