Vaccine Hesitancy & Communities of Place Report PDF

Understanding vaccine hesitancy through communities of place Abridged report Research conducted by Institute for Community Studies (ICS) UK, the Institute for Community Research (ICR), US, and Boston University, US.  Introduction...

Understanding vaccine hesitancy through communities of place Abridged report Research conducted by Institute for Community Studies (ICS) UK, the Institute for Community Research (ICR), US, and Boston University, US.  Introduction representatives of local community organisations, groups, institutions and systems, held in four case study locations: two in UK and two in US. This report and each full-length case study explores Why look at Beyond this, community organisations know and can have the trust of local community residents, how national and in the case of the U.S., State communities of place so should be part of community intervention policies and practices for vaccine distribution, information, engagement and education have in the context of efforts, particularly on a sensitive subject such as interacted with the sites of distribution, information, vaccination. History, previous studies of welfare vaccine hesitancy? engagement and health response related to vaccine system and policy implementation, a glance at hesitancy at the local level. The report beyond this the news or a brief look at voting behaviours, Introduction is structured as follows. This report presents a summary of the longer study shows that local communities engage with or ‘Vaccine Hesitancy and Communities of Place’. respond to national systems - policy, politics and Section A presents the key concepts, their Whilst the timeliness of this work reflects how messaging - whether invited or not. And the price definitions and terms, that interact and are COVID-19 has changed society, now and for the when communities feel disenfranchised, excluded considered in the study, alongside the research future (0), it is fair to suggest that consideration or discriminated against is high for those trying to questions that informed both the evidence review of the role of communities of place within the drive positive and prosocial behaviours such as and the focused community conversations. delivery of vaccine strategies is long overdue. the acceptance of vaccination, in the intervention Section B presents a short account of the Recent studies have highlighted explicitly that sphere. If they do not have good information; feel literature and evidence review, discussing ‘community engagement remains an underutilised marginalised, just do not agree, or feel disrespected, medical distrust, different socio-economic- approach’ in the context of vaccine hesitancy and communities have been shown to devise their own political contexts, different approaches to consequently, that there is a ‘paucity of literature responses to policy and health strategies which vaccine roll-out, community engagement, and the on community engagement’s effectiveness may be more or less effective. Finally, longstanding expanded SAGE 3-C Model, which informs much on vaccination outcomes’ (1). Yet it is what is reciprocal relationships between government, of the subsequent discussion. happening on the ground: the observable and large institutions and other “official” entities and Section C presents the findings from the four unmistakable role communities and their social, community organisations and residents have been case studies (two from the UK, Tower Hamlets cultural and spatial conditions are playing in the shown to pave the way for better communication, and Oldham, and two from the US, Boston and race of the current COVID-19 vaccine roll-out, that preparation and action in other public health crises, Hartford). Findings are split into generalisable has driven scientists, practitioners and politicians indicating there may be much to learn that could themes observed across all case studies, and to pay greater attention to the need for an evidence support a mass public health strategy such as the context-specific findings, in which case studies base about how to improve vaccine acceptance roll-out of the COVID-19 vaccinations. diverge. that can truly take place-based and community Section D conclusion presents a synthesis of the considerations into account. The research that has produced these reports findings of this study with consideration of the examines the relationship between vaccine hesitancy importance of Community in relation to the 3Cs There are several, connected and primary reasons and communities of place through a participatory model and the SAGE matrix of contextual factors why community is important in relation to mass approach to evidence prioritisation and examination. that affect the 3Cs. vaccination strategies, and to health engagement Alongside traditional search strings and terms of Section E provides relevant policy and public health strategies more broadly. Local reference, community steering groups in the UK recommendations for research and communities are the sites of knowledge and action, and the US, comprised of informed representatives implementation. as well as the physical locations, where interventions of local systems, helped guide our rapid review of Appendix 1 details the research methodology are introduced. To be effective, interventions must literature and evidence to where there were areas of and is followed by Appendix 2 - bibliography of be consistent with community needs and mindful weakness in understanding, and where there could references. of community vulnerabilities; and community needs be rich - even surprising - insights. They guided may be complex if communities consist of diverse us from their experience of what has worked in The full case studies are available as individual groups with different cultural, socio-economic, and vaccine strategies over the last six months since the reports which present the in-depth context and socio-historic backgrounds that mediate relationships COVID-19 vaccinations were available; and what has findings from each case, for consideration alongside with preventative health and immunisation. Research worked in previous crises to build confidence in public this summary report. Each presents a detailed partnerships and open communication channels with - particularly health - policy. This was accompanied by account of a local ecosystem having to respond, policymakers to understand these needs and identify a community-based participatory research approach, innovate, and work during a time of national crisis. how to account for them, is essential. based on in depth interviews and focused community conversations about vaccine hesitancy with diverse 2 © Seventyfour - stock.adobe.com 3  Section A These elements are also integral to how Elements of the rights-based approach are people have experienced the pandemic: in their consistent with the critical public health local neighbourhoods, through local media, perspective that argues that disparities local public services, local economies, and in how communities engage with health local points of contact to health and support - or vaccination - are a consequence of Concepts, terms systems. As the report The Covid Decade (0), inequities that derive from structural and and definitions shows, the local - and the hyperlocal - have been the first points of reference for people social determinants of health. This includes inequalities of representation and participation for researching and communities over the last eighteen - what is sometimes referred to as an “emic” communities of place months since the pandemic first took hold in the UK and the US. The local shapes how perspective, or as representation. Anthropology and sociology are valuable disciplines for in the context of the pandemic has affected peoples’ health, considering vaccine hesitancy alongside vaccine hesitancy wellbeing, and social security. This study health and public policy, as they promote builds on UK and US public health literature understanding of variations in people’s beliefs, that recognises that people, place and power- attitudes and behaviours and recognise that Integral to understanding the relationship based factors mediate residents’ experience they are not irrational. This raises the value of between vaccine hesitancy and communities of of health and participation in accessing of community engagement in the importance of place is consideration of four key elements: health and health care (2). The context of listening - and gaining insight from - diverse communities of place, in the ways in which communities to navigate these behaviours, Place conditions including socio-economic, people interact with health care systems to identify how beliefs, attitudes and values political and historical context. are also inextricably linked to their local are clashing or interacting with information, Social relations including between geographical contexts—to their community. misinformation, power relations and authority, communities, local ecosystems and in delivery of vaccines. authorities; and the connectivity, A rights-based approach participation and engagement that occurs Understanding and addressing the findings between these people, place and system The challenge of vaccine acceptance is often from rights-based, critical framings of why dimensions. discussed in policy and research circles as a ‘one- hesitancy exists is critical to shaping more Community engagement, a term typically way’ relationship: where sceptical, unreasonable inclusive and effective public health responses used to refer to involvement of national, or ill-informed communities must be converted and to enhancing the ability of communities State, and local governmental and private to an ‘informed’ or reasonable position of being to take preventative steps to protect against large institutions with local residential and vaccinated. This study approaches the issue and combat COVID-19. At the time of writing, CBO communities. of vaccine hesitancy and acceptance through the UK and to a greater extent the US are Community mobilization, defined as the lens of a rights-based approach, which some distance from achieving so-called herd the capacity of local communities of recognises that those experiencing profound past immunity1 with vaccine engagement as the organisations and residents to organise the and current structural inequalities will choose principal pathway. The risk of new variants that resources within their boundaries to address whether and when to engage with vaccination. It existing vaccines may not prevent, coupled with a local health issue. recognises that these choices are based on real the challenge of a globalised society in which and legitimate concerns held by communities, the inequalities of distribution and access to These elements - place, social relations, often rooted in distrust of government, medical vaccination and health services interact with community engagement and community and public health authorities that have been the vulnerabilities of different communities to mobilisation - are integral to how the COVID-19 historically exploitative or unresponsive. Finally, COVID-19, means the threat of the pandemic pandemic has affected people, health systems it accepts that these concerns need to be and the need for collaborative insight is far from and health outcomes. They have also proved responded to through immediate and longer-term being over or diminished. integral to the mitigation, intervention and strategies if vaccine acceptance is to be achieved. success or failure of policies, campaigns and health system responses to the spread and 1 Herd immunity can be defined as the indirect protection from an infectious disease that happens when a population is immune either impact of the virus; to the health consequences through vaccination or immunity developed through previous infection (World Health Organisation (WHO), 31st December 2020). WHO supports achieving ‘herd immunity’ through vaccination, not by allowing a disease to spread through any segment of the population, as this of lockdowns and restricted health systems; would result in unnecessary cases and deaths. The WHO estimates herd immunity as occurring between 80% and 95%, depending on the and to the roll-out of the vaccine programme. disease or virus. Double vaccination is seen as one route to achieving herd immunity, as initial studies indicate the vaccine provides strong protection against hospitalisation and serious after-effects of COVID-19. Other routes to herd immunity include natural immunity as a greater proportion of the population catch COVID-19 and/if they recover from it, but vaccination is regarded as a safer, ethical, and targeted approach. 4 © Dmytro - stock.adobe.com 5  Glossary of terms Research questions The research questions for this study are as follows: Community A psychosocial and spatial entity, with connections to belonging and memory as an imagined space, as well as to cultural or national origins. In the context of What are the current, and lasting, this study, it is also a local place where people live, and organise their lives, and health, social, economic, and political where they organise to address health and other issues, where they experience consequences of COVID-19 for different inequities and disparities on the ground and the place where interventions are both developed and implemented, sometimes from inside and sometimes from groups in each of the case study areas? outside and at times in interaction. Are there any place specific conditions or consequences? Place Place is defined as a spatial entity with defined political, administrative, and What are the historic and current environmental boundaries which mediate the application of health and social dynamics of the relationship between policies and the functioning of systems. These socio-political boundaries are not always consistent with a local sociocultural community’s identity and perceived different communities and a) health social, economic, political, and cultural histories. authorities; b) local authorities, and State authorities; c) organisations and groups? Vaccine Whether vaccine is available in a city, town or zone; the degree to which it is What incidences or services / provision availability available to the entire population of a geosocial or sociocultural community; are these founded on? how availability is determined by national, State or local institutional health How do issues of injustice, trust, policies. cohesion and inequality interact with the dynamics around a) health inequalities in Vaccine Whether vaccine is accessible once it is available to all people designated these areas, and b) health engagement, accessibility to receive it. Accessibility is defined by ease of accessing appointments including the current vaccine program? for vaccination; adequate transportation to vaccine; and accessibility of vaccination sites to the populations they are designed to reach. What are the multiple efforts or approaches going on at the present time Vaccine Any delay in accepting vaccination even when a vaccine is available and in the case study areas (Tower Hamlets hesitancy accessible; reluctance to vaccinate even when vaccinated. and Oldham, UK, and Hartford and Boston, US) to improve vaccine engagement, health access and engagement and to Vaccine Active refusal of vaccination when vaccines are available and accessible, due reduce fears and concerns about health refusal to a range of factors; often interacting with ‘anti-vaccination’ sentiments but engagement with specific groups in each not synonymous. area? Who is leading them? What makes these initiatives work? Vaccine Active promotion of vaccine refusal with others. What are the most critical elements in resistance promoting success in the vaccination programs in each area? Where are the gaps in these efforts that Vaccine Approaches and interaction between people, communities and authorities to need to be filled; who should fill them and engagement negotiate decisions about receiving vaccination as and when it is available how? and accessible. What has been the interaction between State/national and local health Vaccine A decision making point where an individual or group agrees to receive (and department/system policies and acceptance promote) vaccination when it is available and accessible. strategies in the roll-out of the vaccination program? Where have the gaps been? 6 © fizkes - stock.adobe.com 7  Section B Experience of medical distrust and compel vaccination - are thus contextualised health discrimination not by irrational unwillingness or anti-social tendencies but by real and compelling lessons Dimensions of vaccine hesitancy, which in the misuse of vaccination as a weapon Literature and is sometimes called ‘scepticism’, can be understood from both historicism and against the weak (11, 12, 13). evidence review contemporary perspectives within communities. Thinking more broadly and globally about In both Britain and North America, widespread vaccine hesitancy offers a more tangible This section provides a review of the main scepticism about vaccination has quite often picture of how particularly complex the issue of themes emerging from existing literature been a product of citizens’ uneasy relationship vaccination has been over the centuries since and evidence on vaccine hesitancy, taking with the State (3, 4). In the United States, its inception in 1790. In the 19th century, the in current and rapidly emerging studies and State-sanctioned medical experiments often British government enacted a series of coercive a historicist approach to understanding the undermined the trust between doctor and and punitive policies designed to vaccinate issue of hesitancy or resistance to vaccination. patient - particularly when those patients were great swathes of the British Empire’s colonised It presents a network diagram of the peer people of colour. The infamous Tuskegee subjects (14). These interventions prompted reviewed and grey evidence found related Syphilis Study, for example, ran for 40 years immediate pushback, read as they were as the to vaccine hesitancy and communities of before anyone thought to question whether controlling, if not punitive, actions of a colonial place, in order to assess areas of strength intentionally withholding treatment from government. In the 20th century, vaccination and weakness in the knowledge base. It poor Black patients with syphilis (even after continued to be compromised by misuse in summarises the key themes and conclusions antibiotic therapy became available) in order policy or through poor delivery, as well as in the evidence base about why communities to study the “natural history” of the disease being met with the rise of media, messaging are hesitant; and what is known in the was a reasonable thing for a State to do to its and mass horizontal communication and evidence about strategies for combatting population. This all took place well within living information spreading within communities. hesitancy and building vaccine acceptance. memory. It was 1972 before the study ended (5, Even the successful eradication campaigns of 6, 7, 8). the WHO over the 1960s and 70s did not affirm, Our review focuses on the common themes in the attitudes and belief systems of certain for why communities are hesitant, sceptical or However, the history of this kind of medical communities, an unambiguously beneficent resistant to vaccination. It is important to note mistrust dates back even further. In the late role for vaccines. Additionally, though the that where this study focused on evidence 19th century, when the English government smallpox eradication campaign was ultimately about strategies, attitudes and experiences tried to make smallpox vaccinations successful, it was also so costly, difficult, and of health engagement, and acceptance of compulsory, they were met with protest (9). labour-intensive that it was by no means a medical intervention and medical care more Vaccines in Victorian England often came given that the WHO would continue with such broadly, we would expect to find different - with debilitating and even deadly side-effects campaigns in future. and more positive - themes, given that where (10). But compulsory vaccination was also individuals and communities seek treatment understood as a tool of an increasingly More recently in the latter part of the 20th and support for illness or disadvantage, rather interventionist government that had fallen century and the advent of the 21st century, than receive preventative intervention, different into the habit of using its legal powers to pharmaceutical companies have run afoul of dynamics between system, service and target various vulnerable groups of people, critics for their pricing practices, which gouge communities tend to be present. Therefore the including sex workers and migrants. Because patients and governments, including the very following themes are the most prevalent and vaccination was also closely linked to the recent antics of Essential Pharmaceuticals, conclusive within the literature about vaccine Poor Law legislation that forced workers and who threatened a 2600% increase in price for hesitancy and communities specifically. their families into the brutalising regime of the one bipolar medication as a bargaining chip in workhouse, its new compulsory status seemed securing a more modest price hike for another. an attempt to extend this same punitive Controversy over pharmaceutical behaviour has attention to the working classes (9). Early 20th fuelled scepticism over vaccines, as well as century concerns over vaccination in both the several notable scandals concerned with side- UK and the US - where it is perhaps best known effects. What is certainly true is that vaccines in terms of the 1905 Jacobson v Massachusetts have been, and remain, political objects that ruling, which upheld the State’s rights to connect the historically problematic ethics of 8 © New Africa - stock.adobe.com 9  pharmaceutical companies to the chequered Individual conditions: confidence, Perceived risks of vaccine- Emerging factors preventable diseases are low; history of institutional racism and sexism complacency, convenience vaccination is not deemed embedded in medicine’s clinical and research a necessary preventive Over the course of the COVID-19 vaccine action. Other life /health practices, to the troubled politics of American The SAGE 3Cs Model for Vaccine Hesitancy is responsibilities seen as more programme, several new factors affecting and British healthcare, and even to the place of the leading model for understanding vaccine important at that point in time. hesitancy have emerged prevalent in real-time each of these countries in the world. hesitancy, emerging in the last decade. As scaled and individual, group and local case well as synthesising the most conclusive studies. We have summarised those particularly evidence about the reasons individuals hold pertinent to community dynamics or to place. Debate, concerns and hesitancy about vaccine hesitancy, it is employed in this study These can be described as: vaccination has never been restricted to the spaces (‘sites’) and the limited interactions to provide a framework for discussion of the COMPLACENCY Disbelief: it was developed too fast and between health practitioners and patients or findings of this study. population, but it has become an increasingly is not sufficiently tested, or there is little, complex picture. Vaccine hesitancy in the 21st The 2014 report of the WHO working inconclusive localised information about it. century can be seen to be heavily influenced by group on vaccine hesitancy developed Trauma: the impact of mass grief, shared by phenomena connected to group dynamics or the now-influential ‘3 Cs’—confidence, the community. what can be seen as ‘communities of interest’ complacency, and convenience—model of CONFIDENCE CONVENIENCE Policy-based distrust: the distrust of the or ‘communities of experience’ - such as vaccine hesitancy, emphasising the critical wider emergency response and lack of trust parenting movements; wellbeing movements; importance of trust in institutions, accuracy on traditional and authoritative sources (17). and online communities around lifestyle of information, and addressing mistrust of choices and regimes, to name but a few. With science (16). The SAGE Model of Vaccine Scepticism related to the side effects: there many individuals seeking, receiving and being Hesitancy (10) categorises the most common are misconceptions related to the effects exposed to growing amounts of information - reasons for vaccine hesitancy or acceptance of vaccine on mental health, fertility or including factual and non-factual information within three key terms: Trust in vaccines, in the Extent to which physical even a cause of other variants of the virus or ‘fake news’ about health and medicine system that delivers availability, affordability, (18), which are shared and discussed in them, and in the policy- willingness-to-pay for, - online, the sites and forms of community Confidence: Lack of trust in safety and makers who decide geographical accessibility, communities of identity and place, online in which vaccine hesitant beliefs, resistant utility of vaccine especially because of which vaccines are ability to understand (language and health literacy) and appeal and in person. needed and when. narratives and honest questions and concerns distrust in providers, medical system, of immunization services Microchip vaccine conspiracy theory: it affects uptake. are raised and debated are multiplying - and government, vaccine producers; quality and implants microchips to control individuals certainly much faster than intervention and safety of vaccine. Beliefs in detrimental (19)2, which is discussed and shared via medical education strategies to combat them. aspects of vaccine. Fig.1 Sage 3Cs Model (SAGE, 2014:11) the same group dynamics as the above concerns about side effects. The issues of medical distrust are being Complacency: Lack of concern about These factors have been evidenced and Relaxed attitudes towards personal health found in rapidly emerging real time studies infection, serious consequences of discussed for how they operate at the individual and well-being: this is more prevalent among to interact heavily with hesitancy about the COVID-19, concern about infecting level, explaining many of the reasons for younger groups who do not feel the need to COVID-19 vaccine. As the scholars Shaun others, perception of low risk delaying vaccine hesitancy for different individuals feel concerned about getting affected (20). Danquah and Marcus Tayebwa have put it or preventing acceptance; belief that and demographics. The SAGE model has not This often, not always, stems from poor in their study of medical scepticism in the other health practices mitigate COVID-19 been tested at the ‘local’ or community level health literacy among these groups. London borough of Lambeth: or prevent infection including healthy to understand how social relations and place behaviours, foods, relaxation etc. dynamics interact with - and could offset An additional factor that is less well “The sensitive nature of the COVID-19 vaccine or exacerbate - the hesitancy influences Convenience: Lack of convenience in examined in peer reviewed studies, but has programme, and the life-or-death situation an individual may be experiencing. Group accessing available vaccine including long been discussed in journalistic studies and that it is framed in can lead to very palpable dynamics and organising by communities can distances, inadequate hours, and days of by communities themselves - is “fear”, in fear across all communities. This fear may, in have a powerful sway over individual choices. service delivery, not available at worksite this case defined as a primary emotion that turn, ostracise those who are already medically This study responds to this gap by testing or school or places where people are weighs risks, heuristic or heard, far more sceptical - especially those within the BAME elements of the SAGE model within the four comfortable to visit (like drugstores). heavily than benefits at a time when anxiety is community - because they may be seen as case studies, asking about the applicability of widely prevalent and authoritative leadership the percentage of the population that are the 3Cs to the way the COVID-19 vaccine was is missing. This can also be understood as preventing progress.” (15). received by communities, in each case study. the ‘risk/benefit’ analysis, which has been 2 https://theconversation.com/reluctant-to-be-vaccinated-for-covid-19-here-are-six-myths-you-can-put-to-rest-165027 10 11  evidenced as a factor in vaccine hesitancy and acceptance by those working with communities around the development of vaccines for HIV, Ebola and Poliovirus. This third factor is dominant in hesitancy concerns for a third group, which also incorporates elements of the first two: those who have been racially or otherwise minoritised, persecuted and stigmatised by majority and dominant groups, and by systems and structural inequalities. Thus ‘Fear’ as a factor within vaccine hesitancy often incorporates elements of the other two factors for these groups. Figure 2: Network Map of what is known from peer reviewed evidence about Vaccine Hesitancy. The network map was formed from collection of data from a Scopus literature review. The dataset included information about 112 distinct pieces of literature, including any author-selected keywords associated with each work. This data was transformed into a network diagram, with keywords as nodes and edges added given two keywords were included in the same work. This initial construction resulted in a network of 261 nodes and 846 edges, split between 1 large and 13 small components. This complete network had an average degree of 6.5, diameter of 7, graph density of 0.025, and average path length of 2.8. Network statistics were also run on the largest component (n = 193; e = 710) of the graph separately, resulting in a slightly higher average degree of 7.4, diameter of 7, graph density of 0.038, and average path length of 2.8. 12 13  The knowledge base: strengths approaches to combatting vaccine hesitancy at and implementation leads to faster, efficient The transmission, as well as content, of and gaps both the system and the individual level. Just decision-making (19) and action. It is also information—and its shadow misinformation— 1.3% of the peer-reviewed evidence focuses typically the case that top-down approaches has also proven key in understanding and It is important to consider the balance of types on place-based interventions or those with derive their measures from previous studies, combatting vaccine hesitancy. Social relations of available evidence and studies related to cross-community considerations, with a further rather than having a more exploratory outlook aspects of community are especially implicated vaccine hesitancy and communities, in order a small number of case studies (15%) that in new situations (22). Thus in the end, while here. Top-down approaches typically rely on to examine where there are evidence strengths consider how individual ethnic communities decision making may be more efficient, delivery one-directional ‘broadcast’ communication and and gaps. The network diagram above interact specifically with, and hold particular may be less effective. Community engagement standardised messaging, delivered through illustrates the field of published (peer and grey) hesitancy towards, public health campaigns approaches can improve the efficiency and official channels and by official representatives, evidence around vaccine hesitancy. or vaccination. There is a particular lack of effectiveness of top-down decision making either from national or State public health bodies qualitative research that goes beyond surveys while accommodating community voice, input or national, devolved or State government. Within the network diagram, the vast majority or attitudinal studies towards vaccination; and tailored action. of the 261 keywords included appear to relate which it is fair to say are typically limited to In a recent overview of the evidence on to what can be called a ‘top-down’ approach examining beliefs at the individual (‘public’) Top-down measures are designed to be effective vaccine rollouts, Razai et al. discuss to combatting vaccine hesitancy. The level and not how hesitancy and/or acceptance uniform, streamlined, simple to implement and the ways in which genuine dialogue with and characteristics and practices of a top-down rationale play out within or across group cost-effective, and very often achieve these within a community can enhance vaccine approach are discussed further below. dynamics, such as communities. aims with a majority part of a population or engagement, citing “lack of communication group (21). Unfortunately, this set of priorities, from trusted providers and community leaders” Towards the lower left of the diagram, the At the system level, gaps exist in the evidence applied universally, may result in the efficacy of as one of a number of Stated reasons for low majority of the red neighbourhood (which understanding how and why coordination, these measures being reduced among smaller, uptake of the COVID-19 vaccine, and suggesting contains, most notably, the large node for partnership and delivery models that work, more marginal vaccine-hesitant populations that integrating communication with trusted, COVID-19) concerns the relationship between function, at local and regional level - and largely due to barriers of the location, quality, local, community sources is an essential public health and the digital spread of vaccine indeed how they are formed and work with or specificity and types of communication and avenue to increasing this uptake(6). Integrated information and misinformation. The cluster supersede national systems. At the individual their relevance to different groups. measures of this type contrast with centrally concerns especially the kind of large-scale level, gaps also exist in understanding how the distributed information campaigns, which make quantitative study (including keywords such 3Cs contribute to localized versions of vaccine In the case of information-based campaigns, both little use of trusted community sources and so as natural language processing, artificial hesitancy, interacting with the dynamics and the format and content may reduce the efficacy may fail to fully engage or increase acceptance intelligence, deep learning, and sentiment belief systems shared in particular, place-based of a campaign. The format of the information in vaccine-hesitant communities. analysis) which has become popular in the communities -;what elements of place interact shared is often not particularly useful, with past decade for understanding general social with the 3Cs; and how consistent or distinctive leaflets noted as a particularly outdated form Conversely, but still with the potential for ‘mass’ trends, but which may elide local, place- these are to each different place or community. of communication. The content of information communication, the diagram shows a growing based community contexts. Both the green is not always available in multiple languages or body of evidence on the role of social media in vaccination and light blue vaccine clusters The following sections discuss what is known in those locations where hesitant populations vaccine information, education and hesitancy. appear largely to concern the efforts of specific from the evidence base that the diagram that need targeting will see it or engage with it. Social media is a leading mode of information vaccination campaigns and the incentives, displays, focusing on particular fields (or Moreover, public health communication content and opinion sharing and represented in a barriers, confidence, and safety of these ‘neighbourhoods’) of knowledge. is often - and often necessarily - concerned with growing body of evidence, with research on measures. The brown influenza neighbourhood, facts and figures, with content heavily reliant on influencers showing that they are emerging to the top right of the diagram, likewise Top-down approaches to addressing statistics in order to provide factual evidence as key agents in behaviour change (19). concerns the efforts surrounding vaccination vaccine hesitancy to support informed decision-making. However There is still limited understanding of how against a specific virus. Other sub-clusters this approach takes in little consideration for the obstructive influence of negative media within the diagram (such as the dark green Traditionally, government-led approaches the statistical interest or literacy of the target messaging affects group interactions with cluster to the top of the network), emphasise and structures to driving vaccine uptake population. The evidence argues that for more vaccination. Deep misbeliefs and false beliefs health communication, but these clusters are and acceptance in the context of mass or tailored communication, there is a need for a were held by people across the four sites often isolated from nodes which appear more targeted vaccination, tend to exhibit a ‘top- narrative and relational approach that takes into studied in this research, as the case studies will closely tied with concepts of community. down’ approach. A top-down approach is more account the fact that most vaccination decisions demonstrate in Section C, below. uniform and is centred on service provision and occur in the social sphere, through discussion, Gaps in knowledge are most significantly in compliance, rather than specificity, adaptation debate and, with communication driven not the lack of studies that capture, understand, and tailoring to local needs (21). This is often through solely statistics or impersonal measures and evaluate the efficacy of local place-based justified by the belief that centralised planning such as leaflets. 14 15  How these negative messages are diffused beyond ‘mass’ to ‘bespoke’ communication. the ways in which historically disadvantaged through social media networks and how they Secondly, the potential for good community populations have borne the brunt of the are challenged or cemented by relations in engagement to shift or counter past negative COVID-19 pandemic (22). Within both the US place, is a subject that would value further experiences that communities have had with and UK, people of colour who have faced the research and a significant gap in the evidence. authorities, for engagement to be ‘dialogic’ acute burden of discrimination for centuries Personal connections, too, with those an and for a testing of which messages are have also face disproportionate case and individual may know offline, can play a key role, received and how. These negative experiences fatality rates throughout the pandemic (23, and may aid in debunking some of the myths could include communities’ experience 24). Among unhoused or poorly housed related to the effectiveness and side-effects of housing policy, gerrymandering or vote populations, implementation of public health of vaccination. As such, while study of social rigging, taxation and development policies, recommendations such as social distancing media dynamics is crucial for understanding and accessibility or infrastructural gaps and isolation indoors becomes impossible the intra-community spread of misinformation, (such as closure of hospitals or health (22). Among more impoverished populations given the important limitations of supra- centres or transfer of health services online, too, with denser housing arrangements and community directed informational campaigns excluded digitally marginalised groups). The a greater need to continue working in largely as described above, it is equally as important implications of these experiences may not be public-facing industries, the social distancing to understand the dynamics of this type of immediately evident but may be cumulative recommendations are less likely to function as information once it begins to circulate within a shocks that have an impact on how far intended (24, 25). Each of these populations given local community. communities practice health engagement also often faces increased comorbidities, regularly, follow local and national such as asthma, which have been associated with an increased risk from COVID-19 (26). Importance of place conditions and government directives, and trust in health These structural and social determinants and community engagement provision and guidance. others interact closely with, and are often most In both the US and UK, histories of inequality, manifest within, geographic spatial inequalities Beyond this, ‘top-down’ communication and discrimination and prejudice, have combined (such as poorer areas with less access to engagement strategies often interact with to generate persistent inequities and public services) - which make place-based discriminatory factors related to integration disparities in health especially in populations considerations a vital consideration of how to or assimilation practices and their impact of colour, or BIPOC in US identification, and support communities through COVID-19 (0). in marginalising or ‘othering’ communities. low-income communities. Many of these Media-related strategies designed to prevent disparities have structural causes. These incorporation of marginalised populations Yet despite ongoing vaccination efforts, many structural factors are persistent and pervasive. into mainstream culture, economy, and individuals, including among those most They affect the conditions of daily living in politics, have implications in how, and how vulnerable as a result of the above factors marginalised local communities. In the early inclusively, messaging about vaccination or and other social factors, have not yet received 2000s, a WHO commission on these ‘social health engagement are a) disseminated and b) a single dose of the COVID-19 vaccine. determinants of health’—or “the conditions received by disadvantaged and discriminated Considering the place factors above, it is in which people are born, grow, live, work, against groups. This is highlighted in the observable this may be the result of vaccine and age”(23)—drew attention to the ways in evidence as important given part of successful availability (whether a vaccine is available which health is more proximately socially health communication involves the right in close proximity in a State, town or zone - determined. These may include such factors medium and the structures of transmission, as related to inequalities of distribution).Equally, as the quality or location of an individual’s well as the right messaging. there are issues of accessibility (whether housing, education, health, employment, a vaccine is accessible once it is available social and community context, and the local to all people designated to receive it; e.g. if Co-morbidities, social determinants appointments can be made, if appointments neighbourhood and built environment. and vaccine uptake can be readily found, if technology required The connection of the social determinants In the COVID-19 context, the relationship to make appointments is available, if of health to the challenge and opportunity between these structural and social factors transportation to a vaccination site is easy to of engaging with communities of place, is and health is especially important. Social find). These factors align with Convenience if on several levels. Firstly, the importance determinants of health have been particularly we consider the SAGE Model. However, where of gaining deep data and specific detail on implicated in increasing the chances of vaccines are both available and accessible in group and individual hesitant cases, that goes COVID-19 infection, with key studies noting the UK and the US, low uptake may instead be the result of vaccine hesitancy. 16 © Pawel - stock.adobe.com 17  Section C Bottom-up: an emerging community policymakers, often discussed in negative However, the quality and accessibility of that engagement model for addressing terms or in the context of seeking to shift their care is influenced by ethnic/racial and linguistic vaccine hesitancy reliance on public service models. A consistent identities, whether people are insured and by what carriers versus uninsured, whether they Case studies and finding across all four of the case studies frequently highlights the importance of national have complex health conditions, and whether A limited but robust field of evidence, largely from vaccine programmes in the Global public health devolving vaccination strategies and working in close alignment and partnership findings they are documented or undocumented. Location is also important especially for South, and Africa and South Asia in particular, with a local ecosystem, recognising community This section presents a brief account of the specialised health care. discusses that unlike the popular top-down relations, knowledge and insight as a strength differences between the two country contexts, approaches, a community-engagement model or asset to building vaccine acceptance. followed by the findings from the four case With regard to strategies for COVID-19 of addressing vaccine hesitancy involves integrating local knowledge into a specific studies. We divide our findings from the case vaccination in both countries, access to targeted intervention, designed to prioritise Summary studies into generalisable findings that were vaccination was determined by age group. impact on a given local community (7). A small significant across all the case studies, to start In the UK, the vaccine roll-out has largely There are significant learnings to be drawn for to build an evidence base for the factors that followed three phases: first, all priority groups but specific body of literature proposes how how (and how not) to involve communities, appear important within all communities of were offered the first dose by mid-April 2021- interventions that incorporate community community leaders and local stakeholders place and vaccine hesitancy; and case specific this included over 50s, care home residents engagement may have transferrable applicability from the tried and tested models in the fields findings which were distinctive to one, or and care home workers, frontline health to vaccine hesitant contexts. This includes the of participatory public health, priority-setting, more, cases, but deserve particular attention. and social care workers, clinically extremely field of participatory public health (27); patient and PPI. But the connection between these In the latter, case-specific, case, this is either vulnerable groups, and those with underlying and public involvement (28, 29), participatory literatures and the issue of vaccine hesitancy because they presented a particularly striking health conditions; the remaining adult research in health, applied research; and the less is currently almost non-existent and it is reason for hesitancy that emerged within a population (aged 18-49) was offered their first explored area of health preparedness (30). evident from the network diagram and the place-based community; or because a case dose by mid-July 2021. A booster programme evidence review that a disconnect exists study demonstrated a particularly innovative is now underway administering a third Community engagement has also been between the different evidence, thematic and or distinctive strategy to addressing hesitancy vaccination shot to all those over 50 years; found as essential to health promotion and methodological fields that discuss community which may provide learning for other contexts. healthcare and keyworkers; and those with to achieving global health goals: the WHO engagement in health contexts. vulnerabilities or underlying health conditions. (2020) published a guide to community Differences between UK and US At each phase, delivery of the vaccine roll-out engagement in the context of global health The emergency context of COVID-19 has started contexts has been devolved via local health systems coverage, citing as it’s principle quote, “A strong to produce an emerging literature on vaccine and local government, with distribution primary health care platform with integrated hesitancy and communities of place - but It is important to acknowledge, firstly, that decided by the national system under Public community engagement within the health there is little indication that the models under within this comparative study are two very Health and NHS England. system is the backbone of universal health study, nor the research approaches used, have different health systems and histories of coverage (31, 32)”. Within a growing field of actively learnt or sought comparison with the community. Despite historical relationships, In the US, national governmental authorities, community engagement methods, the - albeit patient, public and community involvement continuity and similarities at nation State primarily the CDC, vaccinated in cohorts, limited - existing evidence highlights that in in health literature. The field of evidence is and local level, there are differences in the recommending first older adults (75-65, terms of efficacy, the approach of public and currently limited in both case studies and health structures of the two countries, which and 50-65 first) and front-line medical community dialogue (33) is the most important comparative perspectives assessing community affects the dialogue between State/national providers, grocery store workers and some and effective within a bottom-up approach to engagement methods at work in building and local communities around health. The teachers. As more vaccine became available, combatting vaccine hesitancy. vaccine acceptance. Given the interaction of greatest difference is the centralised versus different States prioritised in different ways. the different spatial, social, historic and cultural decentralised US system, with centralisation Connecticut mandated age cohorts, rather A community engagement approach can be conditions of communities with vaccination, this only for those with lower incomes eligible for than priority exposure groups, which meant seen to have similarities to ‘asset based’ public is a much needed gap for further research as government insurance (Medicaid or Medicare, that older white residents were vaccinated health models which seek to understand and it is hard to generalise what will work between VA), those with specific disabilities (SSI). In the first, and for the most part, younger urban accentuate the capacity of communities to and across cases without further testing of UK, primary health care is accessed through residents of colour who were at high risk for identify problems and activate solutions (34), different bottom-up approaches in different a place-based allocation system, whereby an COVID-19 were vaccinated later in spring particularly in addressing health inequalities case study sites. This study is an important start individual’s primary care physician, is selected 2021. This resulted in perceived racial bias (34). This is in opposition to so-called ‘deficit but very much only the beginning of a much- by proximity. In the US, location is also a and resentment. As in UK, in the US, the rollout based’ public health approaches which needed evidence base to support future health significant consideration in accessing health was handled in collaboration with State health frequently categorise communities as having engagement and health crises. care, as people will choose local providers departments, but it also included local larger needs and priorities that ‘need solving’ by 18 19  medical establishments, then federally funded for addressing hesitancy fell primarily to local COVID-19 - thus placing more onus on the community health centres, followed by local authorities and local ecosystems. An additional innovation and collaboration of different types health departments which had fewer resources, but important macro finding that became of organisation at local level. after which vaccine was distributed by many obvious over time, is that the public health collaborating organisations, pharmacies and infrastructure in both countries is insufficiently In the box below, we briefly summarise the other local sites, including door to door and resourced from the national and State level approach to each case study block to block delivery through mobile vans. to enable efficient handling of a crisis like In both countries, the vaccine rollout depended on the ability to deliver vaccine to local sites Tower Hamlets, UK services, preceded and followed by a small This case study combined (1) primary number of in-depth interviews with people and to make it available and accessible. In research from two workshops held with widely representative of the city’s service, all four cases, the primary site of vaccine a total of 43 individuals in Tower Hamlets policy, and advocacy sectors. The primary rollout, engagement, access, and delivery research in workshops and interviews were was the local setting, whether consisting to understand experiences of community leaders in promoting vaccine uptake and informed, designed and co-ordinated by of local departments and systems to Hartford’s Community Research Alliance. broader experiences of the pandemic, promote vaccination, or local hospitals and (2) a review of socio-economic-political Oldham, UK clinics and CBOs. In all four instances, local history, informed by demographic data to communities (boroughs and cities) included This case study uses (1) workshop findings understand the various loci of contention similar groupings of types of stakeholders from two workshops with 35 representatives that have manifested across Tower and institutions, a diversity of faiths and spanning health professionals, local Hamlets’ history, and (3) wider literature intersectional communities, and a shared government and councils, faith and studies with available insight and organisations, equality and diversity sense, as articulated in the case studies, of data about the borough. We used these working groups, and community leaders in belonging to, and recognising a commitment to sources to construct a holistic narrative Oldham, seeking to explore experiences of act for and in that place. around vaccine uptake in Tower Hamlets, encouraging vaccine uptake, challenges, one which frames the vaccine hesitancy and best practice, and (2) an exploration A critical element in the vaccination roll-out within the disproportionate impact of the of literature and data, newspaper and grey was that decision making on availability, pandemic on the Borough, which itself is articles and findings from previous policy nested in a broader substrate of socio- accessibility, information and resourcing (in reviews, charting antecedent and current economic-political marginalisation that has terms of additional funding to support the conditions which set the backdrop to manifested in differing ways. rollout) was led from governance above the Oldham’s COVID-19 experience. local level. The UK’s approach to decision- Hartford, US Boston, US making and allocation was top-down, with less This case study is informed by multiple In partnership with We Are Better Together connection to local organisations - leading sources of information. These include Warren Daniel Hairston Project (WAB2G), to resistance and independent organising for personal observations, newspaper and other we examined community perceptions of delivery. The US approach to allocation was top- media reports on Hartford’s vaccination vaccine distribution efforts in Boston though down led by State, but distribution depended progress and response, State, city and conversations with Black women on a on lateral collaboration of many different other epidemiologic reports, resident sides of community violence. WAB2G is a organisations at different levels. Significantly surveys through community organisations