A Conversation on Vaccine Confidence with the Washington State Department of Health

September 07, 2022 | Morgan Jade


Strong public confidence in vaccines leads to higher vaccination rates and fewer illnesses, hospitalizations, and deaths. States and territories work hard to educate and inform the public about the benefits and risks of vaccines to assure the public is comfortable when making decisions about vaccination.

ASTHO spoke with Greg Endler, Deputy Director of Health Promotion and Education, and Michele Roberts, Assistant Secretary, Prevention and Community Health Division—both from the Washington State Department of Health—as they share reflections on working to improve vaccine confidence in their jurisdiction both prior to and during the COVID-19 pandemic.

What are the leading reasons for vaccine hesitancy in Washington State?

Michele Roberts: It really differs because there are people who have vaccine hesitance (or lack of “vaccine confidence") in every community. What’s driving the emergence of vaccine hesitancy is multifaceted and can be connected to someone’s core belief or identity. Vaccine confidence is just one symptom of how polarized we are as a country and how much we believe in individual choice. The drivers are much bigger than just immunization, COVID-19, or even health.

Greg Endler: Those entrenched beliefs are something public health can work to disentangle. Today, people share misinformation through the click of one button and we probably have more hesitancy now because people are paying attention. No time ever in our history has vaccine been in the spotlight for this long and created this much controversy.

What strategies are you using to address vaccine hesitancy? 

Greg Endler: We’ve taken two strategies: one is “mile wide” the other is “mile deep.” We use mass campaigns to hit every corner of the state in a “mile-wide” approach. In our “mile deep” approach, we focus on going into different communities. We have established many relationships with different groups to help us develop a greater understanding and dig into different areas of misinformation and hesitancy. As we have worked with individualized communities, different racial and ethnic groups, socioeconomic groups, regional areas of the state, we’ve learned how to better communicate.

Michele Roberts: Community-driven strategies that are specific for different groups work well. There is not a one-size-fits-all answer. I’m proud of Washington for not only working with partners but also funding community partners to be at the table. That is the key to sustainability. Not just saying “do this on behalf of the state,” but saying “We value you. You have something unique to offer and we want you to be at the table and we recognize it’ll take resources and time for you to be there too.”

What specific messaging have you created to address vaccine misinformation or hesitancy? How has this messaging helped to address health equity?

Greg Endler: In our Mariachi campaign, we worked with the Latinx community to address misinformation and disinformation within the community. We then made the campaign fun by using Mariachi singers to tackle the message through song and it took off. It’s a very interesting concept that we never would have come up without these partnerships that led us to develop something that is able to cut through the clutter.

Michele Roberts: In addition, part of our funding helped community-based organizations partner with us on vaccination events. Partners were the voice of the event, provided education and outreach, set up the vaccine location, and invited the public. We were then able to concentrate on being vaccinators, and it was truly a community driven event.

Is there anything that you would like to do differently in the future to address vaccine hesitancy?

Greg Endler: The COVID-19 pandemic has led to the greatest advancement in the work of immunizations, communication, and health education in decades. We have never had the money or the ability to go this deep. I don’t ever want to downplay the incredible work that was done, but if we would have had more time to be more strategic it would have been helpful, instead of building the plane as we we’re flying it. Although, I am thankful for the whole process. We’ve learned so much that we’ll carry on for decades.

Michele Roberts: We can’t lose the incredible relationships, investments, and partnerships we’ve built. There’s also a piece truly missing, which is we don’t have a consistent way to measure, understand, or describe vaccine hesitancy. The team has started to get back to working on that definition and developing the tools. For example, can we measure vaccine hesitancy like we measure vaccination rates, or could we use a tool like Parent Attitudes about Childhood Vaccines (PACV), as a community measure?

Do you have any advice to share with colleagues or health professionals?

Michele Roberts: Because we’ve been doing public/private multisectoral partnerships for years, having those relationships (academic, community-based organizations, clinical care providers, a spectrum of people coming together) laid a foundation for us. Atop that foundation sat the concepts of focusing on benefits and answering questions to increase vaccine confidence rather than arguing the basics. I would encourage people to think about who these partners are and how to maintain them and do that collaborative work going forward.

Greg Endler: Spend the time to invest in diversity, equity, and inclusion. We learned a lot and it has evolved. We developed materials in 40 different languages and made sure our materials were accessible. I hope we continue to advance our materials and don’t turn back.

Where would you start trying to undo misinformation that is so entwined with technology and social media?

Greg Endler: We are turning back to the basics and rebuilding our public health department brand. People forget the wonderful things that public health does to protect them. We are working to remind them how important public health is, with vaccines being one of them.

Michele Roberts: I agree with Greg. Our hopes for the future include getting back to the basics and establishing common ground.