Risk communication and community engagement for COVID-19 vaccination: implementation tool

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All images ©WHO Address requests about publications of the WHO Regional Office for Europe to: Publications, WHO Regional Office for Europe, UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office website (http://www.euro.who.int/pubrequest). The introduction of COVID-19 vaccines happens in the context of overall pandemic response, often including staff that has not worked in immunization before. This implementation tool serves as a bridge between risk communication and community engagement (RCCE) principles and evidence-based vaccine acceptance and uptake initiatives. Clear understanding of RCCE approaches can foster coordination and collaboration between experts in RCCE, external relations and vaccine science at every level of the response, including in preparation for adverse events following immunization (AEFI). Art-direction and layout: www.freightdesign.co.uk COVID-19 VACCINES RISK COMMUNICATION AND COMMUNITY ENGAGEMENT VACCINE ACCEPTANCE AND DEMAND CRISIS COMMUNICATION ADVERSE EVENTS FOLLOWING IMMUNIZATION Document number: WHO/EURO:2022-2756-42514-59053 © World Health Organization 2022 KEYWORDS ABSTRACT Risk communication and community engagement for COVID-19 vaccination Implementation Tool Contents Acknowledgements iii 1.0 Introduction 1 2.0 Background 2 Key considerations for RCCE interventions 3 Timing 4 3.0 Goals and objectives 7 3.1 Transparency and early announcement 9 3.2 Coordinate communications for clarity and 10 consistent messaging 3.3 Listening through two-way communication 10 3.4 Develop and distribute key messages through 13 appropriate channels 3.5 Communicating about AEFI 16 Annex 1 – Outcomes and actions 17 Annex 2 – Communicating about adverse events following COVID-19 vaccination 20 Communication tips 23 References 25 ii © WHO Acknowledgements This document was developed by Martha Scherzer (Consultant, WHO Regional Office for Europe, Health Emergencies, Risk Communication and Community Engagement), Siff Nielsen and Catharina Reynen de Kat (WHO Regional Office for Europe, Vaccine-preventable Diseases and Immunization programme), Mario Mosquera, Sergiu Tomsa and Viviane Melo Bianco (UNICEF Europe and Central Asia Regional Office). It was reviewed and improved by Cristiana Salvi (WHO Regional Office for Europe, Health Emergencies, Risk Communication and Community Engagement) Katrine Habersaat (WHO Regional Office for Europe, Behavioural and Cultural Insights Unit) and Siddhartha Datta (WHO Regional Office for Europe, Vaccine- preventable Diseases and Immunization programme). iii Risk communication and community engagement for COVID-19 vaccination Implementation Tool 1.0 Introduction The WHO Regional Office for Europe and the UNICEF Europe and Central Asia Regional Office, in consultation with several groups of regional experts, created a series of operational guidance documents to address key focus areas for successful COVID-19 vaccine deployment and implementation (1). The operational guidance on vaccine acceptance and uptake (2) includes an emphasis on planning and implementing risk communication, community engagement and crisis communication. Staff in this Region that has been working in risk communication and community engagement (RCCE) throughout the COVID-19 response at the country level will likely also be deeply involved with media requests, message development and other demand- generation activities related to COVID-19 vaccines but may have never worked in this area before. Purpose This implementation tool is meant to act as a bridge between general RCCE principles that have guided actions throughout the response and vaccine acceptance and uptake activities being initiated as COVID-19 vaccines become available. Clear understanding of RCCE approaches can foster strong coordination and collaboration between experts in RCCE, external relations and vaccine science at every level of the response, including in preparation for adverse events following immunization (AEFI). Audience Communication and RCCE focal points, Communication for Development (C4D) specialists and others working on the COVID-19 response and COVID-19 vaccination at country level in the WHO European Region and UNICEF Europe and Central Asia Region are the target for this tool. Information provided may be applicable globally. © WHO Vaccine acceptance and uptake is a unique area of work embedded in vaccine introduction and routine immunization programmes; what is unique to COVID-19 vaccines is that they are being introduced in the context of the overall pandemic response. 1 Risk communication and community engagement for COVID-19 vaccination Implementation Tool 2.0 Background To be fully effective, vaccination must reach and be accepted by the intended target groups in each country. While it is challenging to introduce any new vaccine, ensuring uptake of COVID-19 vaccination presents additional complexities: • multiple vaccines became available for use concurrently and in record time; • both supply of and demand for vaccination may fluctuate; • prioritization of recipients may be confusing; • the evidence about the virus is continuously advancing and new SARS CoV-2 variants potentially complicate the situation; • a mass vaccination of this type with a new vaccine is prone to vaccine safety events that can erode vaccine confidence; • social media channels are being used increasingly to spread misinformation on COVID-19 vaccines. For many people, vaccines bring heightened expectations of a quick return to normalcy. However, this is a time for continued compliance with all protective behaviours, as vaccination is primarily aimed at reducing hospitalizations and deaths, while its impact on virus transmission is still being assessed. In addition, individuals, governments, health systems and health workers are exhausted and frustrated after enduring more than a year of this global pandemic. This growing fatigue and stress caused by long-term restrictions and uncertainty, along with varying risk perceptions, increasing misinformation and declining trust in government responses are all taking a toll on community cohesion and willingness to follow recommended behaviours (3,4). Compelling evidence shows that knowledge is just one of many factors affecting vaccination perceptions and behaviour, and a strategy aimed at providing information alone is not likely to be effective (5). Rather, the RCCE strategy should be multifaceted and based on a comprehensive understanding of the current epidemiological situation, behavioural insights and appropriate societal, cultural and economic considerations. Importantly, RCCE interventions should be integrated within the overall effort to ensure high COVID-19 vaccine acceptance and uptake, and demand management. This document should thus be used along with other key documents related to this key focus area for COVID-19 vaccine deployment. The COVID-19 pandemic and the restrictions put in place to contain it have had extensive public health, social and economic implications. A safe and effective vaccine represents a critical opportunity to help end the pandemic. 2 Risk communication and community engagement for COVID-19 vaccination Implementation Tool These include the following: • Operational guidance: acceptance and uptake of COVID-19 vaccines, January 2021. Copenhagen: WHO Regional Office for Europe; 2021. (2) • Health workers in focus: policies and practices for successful public response to COVID-19 vaccination. Strategic considerations for Member States in the WHO European Region. Copenhagen: WHO Regional Office for Europe; 2021. (6) • Behavioural considerations for acceptance and uptake of COVID-19 vaccines: WHO Technical Advisory Group on Behavioural Insights and Sciences for Health, meeting report, 15 October 2020. Geneva: World Health Organization; 2020. (7) • Covid-19 vaccines: safety surveillance manual. Geneva: World Health Organization; 2020. (8) • Vaccine misinformation management field guide: guidance for addressing a global infodemic and fostering demand for immunization. Public Good Projects, First Draft, Yale Institute for Global Health and UNICEF; December 2020. (9) • Countering Online Misinformation resource pack. UNICEF Regional Office for Europe and Central Asia; August 2020. (10) • Vaccine messaging guide. Yale Institute for Global Health and UNICEF; December 2020. (11) Key considerations for RCCE interventions Collection and use of social listening data Understanding key target audiences through the collection of data on behavioural insights is essential for tailoring COVID-19 vaccine communication. Many countries in the WHO European Region have collected data related to the COVID-19 pandemic and response, with the use of tools such as behavioural insights studies (12), the HealthBuddy+ web device (13) and smartphone application (14), qualitative research protocols, UNICEF U-Reports, community feedback mechanisms and other social listening methods. There may be existing research in each country that can help authorities better understand overall vaccine hesitancy. All elements of society should be included, especially those who are marginalized, excluded or at risk, such as migrants and refugees, internal migrants, internally displaced people, and people with disabilities. Gender equity is also an important consideration when collecting data. Maintaining trust Experience from routine immunization, new vaccine introductions, emergency response and extensive research highlight the role of trust in vaccines and in the authorities delivering them (15). The way governments communicate risks, listen to and engage with different population groups – including health- care workers – to sustain trust is of crucial importance for positive behaviours, including vaccine acceptance. It is also essential to identify trusted stakeholders and engage them by strengthening and expanding alliances and partnerships at national and community levels. Consideration of the communities and contexts in which vaccination occurs and what discourages or motivates people to participate will be important considerations for COVID-19 vaccine uptake. All segments of the population should receive information that they can understand and act upon, including those who speak minority languages, are visually impaired or have other special needs. © WHO 3 Risk communication and community engagement for COVID-19 vaccination Implementation Tool Managing expectations As vaccines become available to all, supply and demand my vary over time. This might shift the focus from demand generation to demand management. The public should be prepared for this possibility through clear information and the rationale about procurement and distribution plans that underline fairness. Depending on the vaccine, audiences may need reminders to return for a timely second shot. Everyone will need to continue preventive measures until enough people are vaccinated and the pandemic has been controlled. Focusing on health workers As vaccine recipients, providers and champions, health workers are essential for successful uptake. Behavioural insights surveys conducted using the WHO Regional Office for Europe’s behavioural insights survey tools (12) confirm that in many countries, health workers are the most trusted source of COVID-19- related information, and it is documented that health workers can influence patients’ vaccination decisions. However, health workers are also individuals who may have their own concerns and fears about vaccination, and should have access to information appropriate for their perspectives and education level. For in-depth background, policy and recommended actions to empower and engage health workers as advocates for vaccination, see Health workers in focus: policies and practices for successful public reponse to COVID-19 vaccination (6). A new library of COVID-19 vaccine video explainers (16) targeted at health workers is now available as well. Countering mis/disinformation Effective management of what WHO has called the “infodemic” is also essential for vaccine uptake. Concerted and coordinated efforts will be needed to provide trusted, evidence-based information on COVID-19 vaccines and vaccination to counter mis/disinformation, avoid confusion, address legitimate questions and concerns (9). While many people will welcome the arrival of COVID-19 vaccines, many also have understandable concerns about the new vaccines that need to be addressed so that they can make evidence-informed decisions for themselves and their families. Relatively few people are adamantly opposed to vaccination in general or COVID-19 vaccination in particular. Whereas proactive, consistent and targeted provision of accurate and relevant information to the public is absolutely key, it is recommended that countries carefully consider whether to engage in direct communication or debate with the minority group of what can be called vaccine deniers. Research related to routine immunization and science denialism in general has shown that repeating misinformation even while proving it wrong can backfire. Calling undue attention to this group can also contribute to the creation of a skewed social norm of vaccine refusal (if the others do not want it, I do not want it either). WHO has provided guidance on how to unmask the tactics of denialism when needed (17). An additional resource is the COVID-19 vaccine communication handbook & Wiki (18), a product of the SciBeh Forum (19). Timing Three phases of communication activity are needed as vaccines are developed and approved, made available to priority groups and eventually to all. Health workers remain a key target audience throughout the process as individuals who should get vaccinated themselves, administer vaccines and advocate for vaccination. Each phase requires a specific and targeted approach to communications and community engagement, and each phase draws on the core capacities of RCCE. © WHO Risk communication and community engagement for COVID-19 vaccination Implementation Tool4 1. Planning When planning all vaccine distribution activities, focus on transparency and building trust. Know the facts about COVID-19 and the specific vaccines available. Work with technical experts to communicate the facts clearly. Increase knowledge and motivation among health workers, inform the public about safety, engage with the media to ensure ethical reporting, manage public expectations, build consensus about prioritization, prepare for a communication response to any possible adverse event. Establish or re-establish communication working groups for coordination. Collect data for two-way listening using behavioural insights studies (12), the HealthBuddy+ web device (13) and smartphone application (14), social media and other social listening, such as setting up feedback and complaints mechanisms and rumour management systems. Also reinforce the need for continuing public health and social measures (handwashing, mask-wearing, physical distancing, etc.). 2. Roll-out to priority groups Throughout distribution to priority groups, continue engaging health workers, communicating about and clarifying prioritization categories, and managing expectations among those initially not targeted for vaccination, building demand in priority groups, and managing any adverse events. In this phase, it is important to listen closely to reactions and voices in communities (including health workers) expressing thoughts and feelings about vaccination. Create a rumour log and generate periodic reports to direct possible responses to rumours and misinformation as appropriate (linking to infodemic management [IDM] systems and efforts), including managing potential perceptions of unequal distribution between and within countries. At the same time, maintain and strengthen public trust and confidence in COVID-19 vaccines, including through transparent communications about safety and routine immunization. Reinforce the need for continued public health and social measures. Data collection on knowledge, attitudes, perceptions and concerns among various segments of the population and specific groups such as health workers should be ongoing to inform the response. 3. Wider roll-out As countries move towards broader population vaccination, it is important to build strong demand for and confidence in COVID-19 vaccines. It is important to manage the communication response to adverse events, respond to concerns, rumours and misinformation to maintain public trust and confidence in vaccines and immunization, and to reinforce the need for appropriate public health and social measures, as relevant to the pandemic response stage. Efforts should also continue to specifically listen to, engage, motivate and build capacity in health workers and other key groups, institutions and networks. © WHO 5 Risk communication and community engagement for COVID-19 vaccination Implementation Tool © WHO Objectives: 1. Public trust is maintained at high levels in the overall response and vaccine roll-out process. 2. Effective coordination ensures consistent communication about COVID-19 vaccines and vaccination within and across sectors, organizations and levels (national, local). 3. Behavioural insights and social listening data are regularly collected and findings inform vaccine communication and other activities. 4. Strong community engagement and empowerement facilitate ongoing two-way communication through listening and responding to concerns raised. 5. A motivated health workforce is prepared to be vaccinated themselves, advise patients and advocate for vaccination widely. 6. Response teams are ready to manage communication related to AEFIs. 7. Public expectations are managed: · Well-informed individuals are ready to accept vaccination when eligible/available and non-priority groups understand prioritization needs. · Uptake of prevention behaviours continues at high levels both before and after priority groups are vaccinated. 8. Rumours and misinformation are addressed through effective communication of factual information relevant to users’ perceptions. Risk communication and community engagement for COVID-19 vaccination Implementation Tool © WHO This implementation tool is in support of national vaccine strategies. The goal of a national RCCE vaccine strategy is that all persons in the country have the knowledge, skills and motivation to protect themselves and their communities from COVID-19 through vaccination and uptake of public health and social measures. 3.0 Goals and objectives 7 Box 1. Four core capacities of RCCE Risk communication and community engagement for COVID-19 vaccination Implementation Tool The WHO Regional Office for Europe identifies four RCCE core capacities as part of the 5-step package for emergency risk communication (20). These contribute to building and maintaining trust through transparency and early communication, coordination, understanding and listening to target audiences, and communicating through appropriate channels and influencers. Each of these capacities has a direct application for COVID-19 vaccine communication. 8 Using the RCCE core capacities to build and maintain trust, the following recommended approaches and actions can help achieve these objectives. 3.1 Transparency and early announcement The development of vaccines against COVID-19 has been widely discussed and anticipated for months. As countries begin to receive and distribute a range of these new vaccines, it is essential to communicate with the public in a timely and transparent way. Supply of and demand for vaccines may vary between countries and over time. Different groups will be prioritized according to national plans that must be clearly communicated. Some people who want the vaccine immediately will not be eligible. Access and registration systems will need to be clearly communicated to avoid confusion and manage expectations. Timely, relevant and transparent communication about potential risk to the public continues to be essential for building trust. Remain proactive in your communication about vaccine availability, the prioritization process and longer-term distribution plans as well as vaccine safety. Recommended actions: • Plan communication for vaccine roll-out early. • Communicate continuously with the public about the national and sub-national plans to build confidence in the process while awaiting delivery of vaccines. • Communicate clearly what is known now about these vaccines, what is not yet known and what is being done to learn more. • Proactively communicate directly with health workers to prepare them to get vaccinated themselves, administer vaccines and advocate for vaccines broadly. (See Box 3 for details, including training for health workers.) • Ensure that all persons in the country, including refugees, asylum seekers, internally displaced people and migrants, people living with disabilities, etc. understand the criteria for choosing and distributing vaccines, and that they understand the characteristics of the vaccine they will be offered. • Ensure that everyone understands the criteria for group prioritization (see below “Listening through two-way communication”), and knows where vaccines are provided, to whom, at which times and how to access information in all relevant languages. If vaccines are offered free of charge, this should be clearly communicated. • Communicate uncertainty and manage expectations. • Emphasize at all possible opportunities, especially in press briefs and public announcements, that this situation is changing rapidly, that vaccine supply and demand may not always match, and what is being done (or is planned) to address the issue. • Remember that every communication event is an opportunity to build trust by showing competence, objectivity, fairness, consistency, sincerity and empathy (see Box 2) (15). Box 2. Elements of Trust Competence you possess knowledge and expertise Objectivity you are not influenced by stakeholders with an agenda Fairness you include all relevant opinions Consistency your messages and actions are predictable and aligned Sincerity you are transparent, honest and open Empathy you listen, understand and sincerity want the best for them 9 Risk communication and community engagement for COVID-19 vaccination Implementation Tool 3.2 Coordinate communications for clarity and consistent messaging Coordination of communication across government agencies, between national and sub-national levels, and among national and international partners is crucial and becomes even more important as vaccine distribution begins. COVID-19 vaccination may involve individuals, government agencies and organizations that do not normally work on immunization programmes and do not have a history of working together. Strong coordination and following the lead of vaccination experts is essential. Recommended actions: • Establish, re-establish or reinvigorate COVID-19 RCCE response coordination groups – including across sectors and levels in government as well as with United Nations (UN) agencies and nongovernmental organizations (NGOs) – to specifically address vaccination. • Ensure integration of RCCE efforts into the vaccine acceptance and demand focus area for maximum contribution to the overall deployment effort. • Create and agree upon plans for regular meetings. • Facilitate the sharing of data, insights from social listening mechanisms, materials, messages and campaigns, and plans to avoid duplication of efforts or confusion among the public. • Define a clear process for clearance of messages/ products and identify who will be responsible in a timely manner. • Define and align plans and interventions based on social and behavioural data to prevent duplication and ensure efficient use of resources. 3.3 Listening through two-way communication • Collect social listening data and incorporate findings into the response • Identify, understand and respond to key target audiences Effective communication begins with listening and understanding key target audiences. Ongoing listening and feedback about the vaccination experience (including among those who must wait weeks and months for their turn) can inform every future step in the process of vaccine deployment. This can be done in many ways, including through a range of data collection and social listening efforts and through regular, ongoing community engagement with priority groups, hard-to-reach communities/individuals and broad outreach. Collect data and incorporate findings into the response: The WHO Regional Office for Europe and the UNICEF Regional Office for Europe and Central Asia have invested in a variety of systems to better understand the needs of specific target audiences, including in the behavioural insights studies (12), the HealthBuddy+ web device (13) and smartphone application (14). Each country may have other research, organized by universities, national or international organizations or private market research companies. Telephone hotlines can also be an excellent source of information about callers’ current concerns through the collection of frequently asked questions. Interviews and focus group discussions with audiences of interest are additional ways to understand more about how people perceive COVID-19 vaccines. Community feedback mechanisms and other social listening mechanisms, including through social media, can also provide valuable insights to shape your response. It is important to understand what motivates people to either accept or reject vaccination – what are the barriers to and drivers of vaccine acceptance? This allows for tailoring of not only communication but also policy and implementation of vaccine distribution. For example, the cost of the vaccine or how easy it is to access the service might be as important for some as their perceived risk of getting infected with COVID-19. © WHO Risk communication and community engagement for COVID-19 vaccination Implementation Tool10 Data should be collected on a regular basis to understand changes and trends in perceptions and behaviours, especially as vaccination reaches more people. Recommended actions: • Engage with health workers early to understand what is needed to elicit their support from the beginning as vaccine recipients, providers and champions. • Engage with communities and individuals, including marginalized and vulnerable groups, to listen to their concerns and understand their barriers to and drivers of appropriate vaccine uptake. • Leverage/establish social listening mechanisms that allow the collection of insights into the public’s questions and concerns about COVID-19 vaccines on a continuous basis. Identify, understand and respond to key target audiences: Each country will follow its own process for identifying and prioritizing specific target groups to receive the initial vaccine doses in the context of limited supply. Using the social listening data collection tools mentioned above, gain an understanding of each of these groups to learn how best to target communication for them. © WHO 11 Risk communication and community engagement for COVID-19 vaccination Implementation Tool Recommended actions: • Focus on communication with people who are prioritized for early vaccination; ensure that they know how to register for or access vaccination services. • Give special consideration to those who are not on the priority schedule so they understand when they can expect to be vaccinated and why they must wait. Consider that people in this group can also influence those in the priority group to get vaccinated. • Manage expectations in line with supply and demand in your country. As vaccine roll-out begins, there will be more demand than there are vaccines to reach everyone who wants it. • As vaccines become more widely available, consider specific groups identified through data collection as less likely to vaccinate and create additional messages, materials and activities for them. • Before communicating to any target audience, test messages/visuals/products and make sure they are disseminated through the appropriate channels. Different audiences may require messages and communication approaches tailored to their needs. • Give special consideration to groups that are marginalized or more vulnerable, such as people with disability, minorities, refugees, etc. • Emphasize that protective behaviours (handwashing, mask-wearing, physical distancing) need to be maintained, even by those who receive the vaccine. Box 3. Key target group: health workers Research shows that health workers’ perceptions and knowledge, their communication and recommendations regarding vaccination, and their own vaccination behaviours, have a powerful influence on the vaccination behaviour and acceptance of their patients (21–23). Fully leveraging the positive influence of health workers for COVID-19 vaccination is not simple, as health workers may require support for communicating information related to vaccination with patients and they may have concerns about vaccination themselves. Three intended behaviours of health workers (6): • accepting the vaccine for themselves; • administering vaccines to patients in a way that promotes uptake and makes patients feel safe, respected, comforted and informed; • recommending the vaccine to patients and others, regardless of whether they work with vaccination directly or not. See the document Health workers in focus: policies and practices for successful public reponse to COVID-19 vaccination (6) for more details, suggested activities and links to resources. Training materials are available for health workers on interpersonal communication: Communicating with patients about COVID-19 vaccination: evidence-based guidance for effective conversations to promote COVID-19 vaccine uptake (24) in addition to other technical training available through OpenWHO (25) and the UNICEF ECARO Interpersonal Communication Training Package (26). © WHO Risk communication and community engagement for COVID-19 vaccination Implementation Tool12 • Communicate and engage broadly because all eligible individuals should ultimately be vaccinated. • Renew or continue community engagement that has been ongoing throughout the pandemic. • Review partnerships and consider whether you can expand into any new areas, such as networks of care homes or civil society and community-based organizations in order to reach more vulnerable people. 3.4 Develop and distribute key messages through appropriate channels Using data from a range of sources as described above, develop messages that not only inform but also motivate toward positive behaviours, based on shared values. Partnerships with influencers and community engagement are critical to delivering trusted messages. Recommended actions: • Develop messages based on an understanding of peoples’ perceptions and the barriers and drivers they experience. Specific/tailored messages are required for specific groups, along with specific communication channels and platforms. This should be informed by evidence. • Test messages with the intended audience before broader use. This can be done online or through video calls if physical distancing requirements do not allow for gathering in person. Message testing is extremely important. If resources and time are constraints, testing may be done by consulting experts who know the audience very well or through rapid interviews and focus group discussions with representatives of target audiences. • As vaccines become more widely available, tailor communication plans to key audiences according to perceptions about vaccination. After vaccination is started for priority groups, vaccine communication plans should be developed or revised based on vaccine acceptance: • Those who strongly agree with vaccination should remain motivated. As with all other groups, make sure they have all the necessary information on scheduling, what to expect, where to go and who to contact with questions. • Those who are undecided can be targeted with appropriate outreach, messaging and motivation to help persuade them of the benefits of vaccination. As more people are vaccinated and share positive personal stories, this will likely help others to decide to do the same. • Those strongly against vaccination can also be targeted at the appropriate time by investing time in outreach and dialogue. However, this requires considerable effort, and priority should be given to those more likely to agree to vaccinate. • Remember that health workers are also individuals and members of communities. They may have the same concerns as others and may also belong to the categories above of strongly agreeing to be vaccinated themselves, being undecided, or being against vaccination. Messages and communication strategies can be designed according to these distinctions for health workers as well. Using behavioural insights and other data, determine the channels most used and trusted by your target audiences. • Assess the information/media consumption patterns of your different audiences. Depending on your assessment, you may want to consider traditional media such as television and radio for reaching older audiences, social media for reaching younger ones, as well as proactive outreach to local authorities, community leaders and groups, religious leaders and others who can help persuade diverse audiences to vaccinate at the appropriate time and to continue prevention behaviours. 13 Risk communication and community engagement for COVID-19 vaccination Implementation Tool • The media plays a critical role in communicating information that can make the difference between life and death. Media outlets are key public health players, shaping perceptions about vaccines and influencing communities’ health decisions. Consider engaging the media as partners to reinforce vaccination norms and remind people of the benefits of vaccines through accurate, balanced, ethical and responsible reporting. • Social media can be positively used for reaching large numbers of people with extremely up-to- date information. Social media has also been highlighted as a major channel for mis-and disinformation about COVID-19 generally and COVID-19 vaccines in particular (27). One of the main priority groups for the vaccine is older people, who may not be very active on social media. Consider prioritizing older adults through targeted channels, including traditional media, phone calls, home visits. It may also be possible to reach younger family members through social media, who can then help their elders access services. In addition, it is important to communicate with young people about vaccine distribution as well so that they may wait patiently for their turn and accept vaccination when the time is right, while adopting public health and social measures, such as handwashing and mask-wearing. • The social media landscape is complex and fast-changing. Be sure you are using the social media apps that your target audiences are using. © WHO Risk communication and community engagement for COVID-19 vaccination Implementation Tool14 • Always ensure that it is clear who the sender is, that a source is official. • Review the Debunking handbook (28), social media debunking guidance (publication pending, conact nielsens@who.int) , and the Misinformation management guide (9). • Trusted community figures have high potential to influence positive behaviours based on a deep understanding of community dynamics and interactions and because they are perceived to be part of the group. • Youth can influence their peers by establishing a positive norm of vaccine acceptance as a responsibility vis-à-vis older family members. While young adults with no comorbidities are not among the prioritized groups for the first deployment phase of vaccines, they have a key role to play in sharing accurate messages and information with their families and communities, and in managing the digital space, especially in helping older relatives access online systems for vaccine registration. • Faith-based organizations are highly trusted. As such, they are vitally positioned to support vaccination and engage communities to take it up by reconciling the scientific soundness and religion/cultural relevance of the messages. • Health workers are among the most trusted influencers: you may consider leveraging the social media accounts of trusted health professionals and/or promoting them as champions of vaccination through other channels and interactions. • Consider engaging or re-engaging with influencers on social media and other platforms to extend reach. Revisit influencers who have already supported COVID-19 protective measures in the past year and identify new ones to join the response. When mapping digital influencers consider not only the number of followers these people might have, but also the type of engagement they have on health-related topics. Relationships with social media influencers must be carefully managed to ensure that they are not promoting values that do not align with those of national health authorities. However, engaging audiences through existing channels is generally preferable to developing new social media channels specifically for COVID-19 vaccines, which takes time and tends to attract those already interested in the topic. Box 4. Use storytelling to convey messages Accepting or declining vaccination can be related to emotional and moral perspectives in addition to or even rather than scientific evidence, which can be difficult to understand or internalize for the general public. Using stories to share information can be especially effective for COVID-19 vaccination. Based on a range of data you collect to understand your target audience, you might consider amplifying stories of individuals who have had positive experiences of COVID-19 vaccination. This might take the form of videos or print media human interest stories of health workers who decided to vaccinate early and what it has meant for them or an older adult who feels safer after vaccination. Such stories may have more impact than sharing statistics and efficacy rates. © WHO Adapted from the Vaccine messaging guide (11), developed by Yale Institute of Global Health, UNICEF Demand for Immunization Team, and Facebook (Insights for Impact and Global Strategic Partnership Program). 15 Risk communication and community engagement for COVID-19 vaccination Implementation Tool 3.5 Communicating about AEFI In the context of a global synchronized roll-out of vaccines, adverse events following immunization (AEFIs) will happen. Every vaccine may produce some known side effects, which are mostly mild and clear up quickly. Any other unexpected or serious medical occurrence following immunization should be reported and investigated, even if it is likely to be coincidental and unrelated to vaccination. A number of factors specific to COVID-19 vaccination might increase the possibility of adverse events. For example, priority groups include older adults and those with chronic illnesses in whom coincidental events could be more likely. The unprecedented scale of global mass vaccination also increases the possibility of identifying very rare vaccine product- related events or administration errors. Some vaccines may also be more suitable for specific population groups. Be aware of the specificities of each vaccine available in your country and communicate clearly about any contraindication or increased risk of side effects among certain groups. Any and every serious AEFI must be responded to quickly and efficiently, including by transparently communicating about the event and progress of the related investigation. WHO recommends that countries invest in preparedness to ensure a rapid and effective programmatic and communcation response. See Annex 2 for a detailed template on preparing for AEFI communication. Rarely has this kind of quick, coordinated response to potential vaccine safety signals been more important. With the whole world watching vaccine roll-out, even a seemingly unrelated or isolated event could rapidly become a focus of international attention. Preparing early to respond to AEFIs is essential. Communicators should work closely with experts from other technical areas to plan for and coordinate the investigation and communication following any serious potentially safety-related event. AEFI risk communication should always place an event into the context: provide background on occurrence of the event in the specific population group. Information about risks of very rare product adverse events should always be accompanied by clear information on risks of disease in those not vaccinated. The scope of this document does not allow for detailed description of the response, but the WHO Regional Office for Europe offers tools and support for addressing AEFIs. See the Vaccine safety communication library (29) for access to many documents and guidance. © WHO Risk communication and community engagement for COVID-19 vaccination Implementation Tool16 Desired outcomes • Public trust in the vaccine development, approval and roll-out processes. • High uptake of COVID-19 vaccines among health workers and other priority groups. • A motivated and vaccinated health workforce is prepared to vaccinate patients and to advocate for vaccines. • High uptake of COVID-19 vaccines among general population. • The public has realistic expectations regarding vaccines, variants and ending the pandemic. • Regular behavioural insights and social listening data collected and findings applied to the response. • Effective coordination between all COVID-19 response stakeholders. • Strong community engagement and partnerships. • Prepared communication team ready to respond to any potential adverse events following immunization (AEFI). • Continued high uptake of prevention behaviours, such as handwashing, wearing a mask and physical distancing. • Mis-and disinformation addressed and less likely to spread. Actions Emphasize transparency to build trust Focus on communicating uncertainty and keeping people informed of all new developments related to the vaccine(s); prioritize direct communication with health workers. • Communicate early and clearly all developments related to the vaccine(s) available in the country. • Proactively communicate directly with health workers to encourage them to be vaccinated themselves, to administer vaccines and to advocate for vaccines broadly. • Ensure that the public understands the criteria for prioritizing vaccination and changes to eligibility. • Communicate any changes/updates to the vaccination strategy/plan to the public. • Clarify the processes required to access vaccination services. • Prepare the public for known side effects and inform them how to report any unexpected symptoms. • Remember that every communication event is an opportunity to build trust by showing competence, objectivity, fairness, consistency, sincerity and empathy. Coordinate communications for clarity and consistent messaging Establish or refresh coordination mechanisms for communication. Ensure that all organizations involved in COVID-19 vaccination are included. The effort to distribute these vaccines includes stakeholders who may not have participated in immunization activities before, and their participation in coordination groups is very important. • Initiate or continue regular coordination between communication staff of stakeholder organizations. • Ensure coordination at the highest technical and political levels about all public communication and messaging related to vaccination. • Involve communication staff in all discussions about the vaccination process, including vaccine distribution, transportation and storage to ensure that the full picture of the roll-out can be communicated clearly. • Strengthen and expand partnerships with appropriate government ministries and community-based organizations, such as elder care homes, health worker professional associations, and groups working with marginalized and vulnerable populations. Annex 1 Outcomes and actions 17 Risk communication and community engagement for COVID-19 vaccination Implementation Tool Listen through two-way communication Effective communication begins with listening and understanding key target audiences. Ongoing listening and feedback about the vaccination experience (including among those who must wait for their turn) can inform every future step in the process of vaccine deployment. Health workers are the highest priorty target audience for information, motivation and trust-building. • Collect and/or review behavioural insights data with health workers and the general population and incorporate into the response using tools such as: • behavioural insights surveys • HealthBuddy+ web device and app • telephone hotlines • rumour logs • social media listening tools • existing research data from partner organizations (universities, government, international and national organizations). • Identify, understand and respond to key target audiences: • Using these insights, identify elements of culture, history, social norms, beliefs and values that can be emphasized to motivate vaccination, being patient while waiting to get vaccinated and continuing protective measures. • Consider specific groups identified through data collection as less likely to vaccinate and create additional messages, materials and activities for them. © WHO Risk communication and community engagement for COVID-19 vaccination Implementation Tool18 Develop and distribute key targeted messages through appropriate channels, influencers Using insights from your social listening efforts, develop targeted messages and interventions to address the questions and concerns of specific groups. As more people become vaccinated, consider focusing on personal stories of the experience to motivate others on an emotional level. As uptake increases, those who remain unvaccinated will largely be people who feel negative toward the vaccines and will require more tailored communication. Creative approaches will be needed for messaging and channels, including working with peers, social care workers and others who are trusted by under-vaccinated groups. Across all target audiences and channels, reaffirm the importance of protective behaviours and explain why it is needed even after vaccination: physical distancing, handwashing, wearing a mask as well as testing and contact-tracing. Channels • Using behavioural insights and other data, determine the media channels most used and trusted by your target audiences. • Establish, re-establish relationships with the media and provide/continue training on COVID-19 vaccines. • Conduct or revise social media scan to ensure that you use the channels that your target audiences’ use. Influencers • Identify new or existing influencers to partner with on vaccine campaigns and communication. • Consider social media for younger audiences, but also influential health workers, neighbourhood or work/school leaders, nationally or locally famous personalities, religious leaders or others. Community engagement • Renew or continue community engagement that has been ongoing throughout the pandemic. • Proactively reach out to health worker professional associations to establish relationships, share materials and strengthen ongoing dialogue. • Review partnerships and consider if you can expand into any new areas, such as networks of care homes or civil society and community-based organizations in order to reach more vulnerable people. • Actively reach out to include marginalized and vulnerable groups that may have difficulty in accessing information and/or services through community-based groups or through key community leaders. • Engage with young people who have a key role to play in sharing accurate messages and information and managing the digital space, especially helping older relatives access online systems for vaccine registration. Prepare communications response to potential adverse events following immunization (AEFIs) • Identify in-country stakeholders to be engaged to respond to any vaccine safety event(s). • Identify in-country stakeholders to be engaged to respond to any potential vaccine-safety-related event(s). • Identify a communication team to manage communications linked to any potential vaccine-safety-related event(s). • Prepare the public and media for known side effects and the potential for AEFIs. Make sure the public and health workers know how to report any unexpected or serious symptoms following immunization. • Maintain regular contact with stakeholders to join the response to any potential vaccine safety event. • Meet regularly with the team that will manage communications linked to a potential safety event. • Identify (and train) additional spokesperson(s) as needed. • Revise/refresh model holding statements based on need and experience. • Strengthen information-sharing and rumour-monitoring mechanisms. • Ensure that every AEFI that could be a potential vaccine safety signal is handled transparently for the local/national population but also for international audiences; the whole world is watching and could exaggerate or misrepresent an event if information is not shared transparently and widely. 19 Risk communication and community engagement for COVID-19 vaccination Implementation Tool Annex 2 Communicating about adverse events following COVID-19 vaccination This document aims to support health authorities, and health care professionals, in ensuring an immediate communication response to any potential crisis related to COVID-19 vaccination. This will be critical to sustain trust in the immunization programme by addressing any concerns in a transparent manner. Please note that any communication linked to the potentially vaccine-safety-related event should be carried out in close collaboration with relevant technical experts responsible for case investigation and causality assessment. The following actions are not necessarily in chronological order, as some will need to be carried out in parallel immediately following the event. © WHO Risk communication and community engagement for COVID-19 vaccination Implementation Tool20 ACTIONS Get prepared Before vaccination starts • Identify in-country stakeholders to be engaged to respond to any potentially vaccine-safety-related event(s). • Identify a communication team to manage communications linked to such an event. • Identify (and train) spokesperson(s). • Develop model holding statements (see sample message below). • Strengthen existing or establish information sharing and rumour monitoring mechanisms. Validate event and assess impact Validate the event immediately (within 24 hours of receiving the information) • Check the source of information and basic details on the event: What? Where? When? • Assess the potential impact of the event: the event can be assessed as low-, medium or high-impact* Coordinate and engage Engage response group immediately (within 24 hours of reporting of the event) • Convene a rapid response team/group and initiate coordination mechanisms. • This should include experts from vaccine safety, regulation, vaccination programme, pandemic response, communication, behavioural insights and more. • Nominate a spokesperson. Inform all key stakeholders Inform media and key stakeholders Immediately (within 24 hours) issue a ‘holding statement’ to the media (outlining what is known, what is not known, and what is being done to fill in the gaps (see the sample messages below). • Plan for further communication in consultation with the Ministry of Health and other stakeholders. • Inform in-country stakeholders: Ministry of Health, national immunization programme, Institute of Public Health, National Immunization Technical Advisory Group, national regulatory authority, COVID-19 response coordination group, partners, other. 21 Risk communication and community engagement for COVID-19 vaccination Implementation Tool Prepare the response Technical team to investigate and conduct detailed causality assessment initiate as soon as possible (within 24 to 48 hours) • Determine if the event is solitary or part of a cluster. • Confirm the diagnosis, timing and the outcome of the safety event(s). • Identify details of the vaccine administered. • Document the health status of other recipients of the same vaccine. • Review the quality of services and operations of the immunization programme delivering the services. • Conduct a detailed causality assessment. • Provide information to the communication response team as it becomes available to be included in messaging Identify and segment key audiences • Those directly affected by the event. • Those who may shape opinions: community leaders, media, politicians, other influencers. • Health workers: always a key audience who need to uphold trust in the vaccine and to be able to answer questions. Define the objective(s) • The outcome: what do you want those targeted to do or understand? • All future actions and messages should be shaped in the light of these objective(s) and in line with the out- come of the investigation of the event including the causality assessment. Communicate Prepare messages • Use the sample draft messages below to develop holding statements. • Revise/adapt messages according to the communications objective, information gathered through the investigation, knowledge of the target audiences and input from the rapid response team/group. • Monitor public opinion to guide preparation of messages; Gather information from media, social media, health workers and other allies. Engage effective influencers • Engage spokesperson and alliances that are trusted, have the necessary knowledge and are able to convey complex messages in understandable language. Ensure credibility and trust • Demonstrate honesty, express empathy, show respect, promote action and competency. Assess the impact Monitor the impact and revise • Assess the impact of communication messages/strategy to inform next steps/potential changes based on the collected information (new) or as evidences emerges. * Guidance to assess an event as low-, medium or high-impact: https://www.euro.who.int/en/health-topics/disease-prevention/vaccines-and-immunization/publications/2017/ how-to ensure-a-context-specific-response-to-events-that-may-erode-trust-2017 ** Relevant key technical documents related to adverse events following immunization: https://www.who.int/vaccine_safety/initiative/investigation/New_aide-memoire_AEFI.pdf https://www.who.int/vaccine_safety/initiative/investigation/New_aide_mem_causal_assmt.pdf?ua=1 Risk communication and community engagement for COVID-19 vaccination Implementation Tool22 Communication tips • Build trust of the population through transparency, empathy, objectivity and competence. • Consider different channels and spokespersons for different audiences. • Convey what you know (the facts), what you do not know (yet) and when you will share information next. • Describe the actions taken to gather more facts and to support those affected. • Convey clear recommendations linked to continuation of the vaccination programme. • Keep media informed; consider the media an important ally, not an enemy: build relations, trust and mechanism for regular updates. Sample holding messages (Please tailor the messages to your setting) • Death or serious illness: • It is with great distress and sadness that I/ we learned about the illness/death of [insert name, where appropriate] in the [..days] following their immunization against COVID-19 . On behalf of the Ministry of Health, I/we would like to express my/our sincerest condolences to the family and relatives in this difficult moment. [Every death is a tragedy]. • All necessary measures are being taken by the [name of Ministry of Health] to investigate this event and identify what caused it. While the investigation is ongoing, the [Ministry of Health] is undertaking all necessary measures to ensure safe and uninterrupted COVID-19 vaccination services in the country. • In the large-scale vaccination campaigns, it is routine to signal adverse events following vaccination. This does not necessarily mean that the events are linked to the vaccination. We do know that [this type of condition] can be caused by [several different factors] and do occur [X adults of certain age/population group per moths/week]. COVID-19 vaccination will not reduce illness or deaths from other causes. • As of now, we are collecting all necessary evidence to find whether the event has been caused by in any by the vaccination or by other coincidental factors. • Vaccination is a critical tool to help prevent further illness and death from COVID-19 and to control the pandemic; [… people have lost their life due to COVID-19 disease in our country so far]. • As the investigation into the cause of the death/illness continues, I/we will make sure to communicate any new findings as soon as they become available. • As the investigation into the cause of the death/illness continues, I/we will make sure to communicate any new findings as soon as they become available.© WHO 23 Risk communication and community engagement for COVID-19 vaccination Implementation Tool © WHO • Allergic reaction: • It is with great distress and sadness that I/we learned about the illness/death of [insert name, where appropriate] in the [..days/hours] following their immunization against COVID-19 . On behalf of the Ministry of Health, I/we would like to express my/our sympathy and full support to the family and relatives in this difficult moment. [Every death is a tragedy]. • Extreme reactions to vaccination are very rare, but they can occur. While many people will experience only minor, if any, reactions following COVID-19 vaccination, a very small number of people may have an allergic or other severe reaction following receipt of the COVID-19 vaccine. • Health care professionals in [insert name of country] are trained to watch for and recognize the symptoms of any severe and serious reactions so they can be promptly treated if needed. • [… Covid-19 vaccine] is safe and [XX millions] of people have received it in [our country/in neighboring countries and around the globe]. The benefits in protecting people against severe diseases and death caused by COVID-19 far outweigh the very rare potential risks [… people have lost their life due to COVID-19 disease in our country so far]. • All necessary measures are being taken by the [name of Ministry of Health] to investigate this event and to assess whether proper procedures were in place and strictly followed. While the investigation is ongoing, the [Ministry of Health] is undertaking all necessary measures to ensure safe and uninterrupted COVID-19 vaccination services in the country. I/we will make sure to communicate any new findings as soon as they become available. Risk communication and community engagement for COVID-19 vaccination Implementation Tool24 References 1. Operational guidance to support Member States in preparing for and implementing COVID-19 vaccination. 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Yale Institute for Global Health and UNICEF; December 2020. (https://www.unicef.org/media/93661/file/ Vaccine%20messaging%20guide.pdf). 12. Survey tool and guidance: behavioural insights on COVID-19, July 2020. In: WHO Regional Office for Europe; 2020 [website] (https://apps.who.int/ iris/handle/10665/333549?search-result=true& query=Vaccination+and+Trust&scope=10665%2 F107131&filtertype_0=author&filter_relational_ operator_0=equals&filter_0=World+Health +Organization.+Regional+Office+for+Europe& rpp=10&sort_by=score&order=desc&page=5). * All references were accessed 20 July 2021 25 Risk communication and community engagement for COVID-19 vaccination Implementation Tool 13. HealthBuddy+ web device. In: healthbuddyplus [website]. WHO Regional Office for Europe and UNICEF Regional Office for Europe and Central Asia; 2020 (https://healthbuddy.plus/index). 14. HealthBuddy+ Smartphone Application. Enhancement to COVID-19 mobile app rolled out across WHO European Region. 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(https://hackmd. io/@scibehC19vax/home). 19. SciBeh [website] (https://www.scibeh.org). 20. Emergency risk communication (ERC) 5-step capacity-building package. Copenhagen: WHO Regional Office for Europe; 2017 (https://www. euro.who.int/en/health-topics/health- emergencies/pages/whos-work-in-emergencies/ risk-communication-in-emergencies/national- health-emergency-risk-communication-training- package). 21. Karafillakis E, Dinca I, Apfel F, Cecconi S, Wurz A, Takacs J et al. Vaccine hesitancy among healthcare workers in Europe: a qualitative study. Vaccine. 2016;34:5103–20. doi:10.1016/j. vaccine.2016.08. 029. 21. Simone B, Carillo-Santisteve P, Lopalco PL. Healthcare workers’ role in keeping MMR vaccination uptake high in Europe: a review of the evidence. Euro Surveill. 2012;17:ii=20206 (https://www.eurosurveillance.org/ content/ 10.2807/ese.17.26.20206-en, accessed 25 January 2021). 22. Paterson P, Meurice F, Stanberry LR, Glismann S, Rosenthal SL, Larson HJ. Vaccine hesitancy and healthcare providers. Vaccine. 2016;34(52):6700– 6. doi:10.1016/j. vaccine.2016.10.042. 23. Communicating with patients about COVID-19 vaccination: evidence-based guidance for effective conversations to promote COVID-19 vaccine uptake. Copenhagen: World Health Organization Regional Office for Europe; 2021 (https://apps.who.int/iris/handle/10665/340751). 23. COVID-19 vaccination training for health workers. OpenWHO: WHO interactive knowledge transfer platform (https://openwho.org/courses/covid-19- vaccination-healthworkers-en). 24. Interpersonal Communication for Immunization: training for front line workers. UNICEF Europe and Central Asia Regional Office; November 2019 (https://www.unicef.org/eca/reports/ interpersonal-communication-immunization). 25. Immunizing the public against misinformation. Geneva: WHO; August 2020 (https://www.who.int/ news-room/feature-stories/detail/immunizing- the-public-against-misinformation). 26. Lewandowsky S, Cook J, Ecker UKH, Albarracín D, Amazeen MA, Kendeou P. The debunking handbook 2020 (https://www.climatechange communication.org/debunking-handbook-2020/). 27. Vaccine safety communication library. Copenhagen: WHO Regional Office for Europe (https://www.euro.who.int/en/health-topics/ disease-prevention/vaccines-and-immunization/ publications/vaccine-safety-communication- library). Risk communication and community engagement for COVID-19 vaccination Implementation Tool26 Risk communication and community engagement for COVID-19 vaccination Implementation Tool World Health Organization Regional Office for Europe UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark TEL +45 45 33 70 00 FAX +45 45 33 70 01 EMAIL eurocontact@who.int WEB www.euro.who.int The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves. Member States Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czechia Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Israel Italy Kazakhstan Kyrgyzstan Latvia Lithuania Luxembourg Malta Monaco Montenegro Netherlands North Macedonia Norway Poland Portugal Republic of Moldova Romania Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan Turkey Turkmenistan Ukraine United Kingdom Uzbekistan Document number: WHO/EURO:2022-2756-2514-59053