Astrid Eriksen^1,2, Ruth Waitzberg^1,2

¹Berlin University of Technology, Germany

²European Observatory on Health Systems and Policies

 Introduction

During the 2020 pandemic, scientists developed a vaccine against COVID-19 in a record time (Machingaidze & Wiysonge, 2021). By late 2020 and early 2021, countries around the world started rolling out COVID-19 vaccines to their populations. A successful rollout depends on the availability of enough vaccine doses, the workforce that gives the jab, and the uptake of the vaccine by the population (Waitzberg & Davidovitch, 2021). Vaccine uptake can be undermined by hesitancy or misinformation. This was particularly relevant in the case of the COVID-19 vaccine because some of them were based on new technology (Dror, et al., 2020; Machingaidze & Wiysonge, 2021). As governments began to roll out their vaccination programmes, they have had to reassure the public that the vaccines are safe and also stress the importance of taking the vaccine on both an individual and community level, such that a high coverage of vaccination is crucial for mitigating the pandemic. After the initial phase, when willing individuals got their jabs, the pace of vaccination started declining in most countries. Some population groups remained with lower vaccination rates (Brown, et al., 2021).

To encourage vaccine uptake among adults, some countries have moved to making vaccines mandatory for certain professionals, such as for health workers in France, Germany, and Italy (Paterlini, 2021; Wise, 2021) or the adult population, such as in Austria (Weise, 2022). At the time of writing, the vaccine's effectiveness diminishes after several months, and booster doses are needed. In some countries, vaccination coverage has declined because the uptake of boosters is not as high as the uptake of the first two doses, and they can therefore no longer be considered "fully protected". Other countries are struggling to get the last part of the population to take the first two vaccinations.

High vaccine coverage is important to avoid future virus mutations as it continues to spread and are key to reducing the need for non-pharmaceutical interventions, such as physical distancing, the use of face-masks, movement restrictions, and lockdowns. To achieve a high vaccine coverage, it is therefore important that governments continue to have availability of the doses and the necessary workforce to give the jabs and communicate with the public to further increase uptake.

A good, tailored communication strategy is likely to increase the willingness of population groups to take the jab (Ayers, et al., 2021). This snapshot examines communication strategies using two countries as case studies, Denmark and Israel. Although these countries differ in age structure, population size, minority groups, culture, health system structure and resources (Table 1), both have a high-performing health system (Rotenberg, et al., 2022). Denmark and Israel were selected because they both had high vaccinations rates during the early rollout and had to cope with population groups, who had lower vaccination rates compared to the general population. As such, they present a rich comparison with diverging experiences and various examples. The goal is not to evaluate the communication strategies, but rather to distil lessons for other countries looking to enhance their own communication strategies.

 The snapshot is structured according to the following research questions:

1) Which population groups have shown lower rates of vaccination?

2) What are the reasons for the low vaccine uptake among these groups?

3) What has the country done to communicate with these population groups and increase vaccine uptake?

This snapshot analyses the communication content and method of communication. It is important to note, that the focus is on official campaigns from the government and public health authorities. This means that any vaccine endorsements from well-known personalities or organisations outside of the official communication strategy is not captured in this analysis. This analysis covers the period up to December 2021.

 Denmark and Israel developed innovative communication strategies tailored to their different population and health system characteristics
Both Denmark and Israel have relatively small populations, but Denmark’s area is much larger than Israel’s, meaning that there are populations in more remote areas. Denmark is located in Northern Europe and Israel in the Middle East. The Israeli population is younger than the Danish. Both populations have a similar level of education. Both countries have a dominant culture and religion to which about 75% of the population belong. In terms of health system, Denmark spends more than Israel on health both per capita and as a percentage of GDP, but when adjusted for age and expenses on long-term care, these differences are less marked (Rotenberg, et al., 2022). Denmark collects funds for the health system through general taxation while Israel combines general taxation with statutory health insurance, where four competing, nation-wide health plans are responsible for the provision (not only payment) of health services to their members (See Table 1). Nevertheless, both countries opted for a centralized (national) vaccination planning, and a decentralized vaccine rollout. 

Despite these similarities and differences, both countries developed interesting communication strategies to attract population groups with a lower vaccination uptake to get the jab. Some of the strategies were implemented by both countries, while others were implemented only in one country but not the other (see Table 2).

There were population groups with lower rates of vaccination in both countries

Denmark’s vaccination campaign was launched in late-December 2020 and by March 2021, 10% of the population had received their first dose. By May, there was 30% vaccination coverage which reached 50% by July 2021 (Statens Serums Institut, 2021). Despite the increasing vaccination rate, there was a slightly lower uptake among young adults and in certain areas of the country.

Israel’s vaccination campaign was also launched in late-December 2020, and within 2.5 weeks, 20% of adults had received their first dose. Afterwards, the pace slowed such that it took an additional 4 weeks to increase to 40% coverage and yet another 6 weeks to increase to 60%. Initially, uptake was low among young adults, and two religious, cultural minority groups - Ultra-orthodox Jews (UOJ) and Israeli Arabs, but their uptake increased markedly over time (Rosen et.al, 2021). As can be seen in Figure 1, on 7 January 2021, the vaccination rate with the first dose for those aged 60+ among the general Jewish population of 73% (i.e., non OUJ) was higher than that of UOJ and Arabs (66% and 48%, respectively). By the end of March 2021, after efforts to communicate with the public and also to reduce access barriers, the differences among the groups had narrowed considerably: 96% among non-OUJ, 91% among UOJ and 89% among Arabs (Rosen et.al, 2021). 

Despite these similarities and differences, both countries developed interesting communication strategies to attract population groups with a lower vaccination uptake to get the jab. Some of the strategies were implemented by both countries, while others were implemented only in one country but not the other (see Table 2).

There were population groups with lower rates of vaccination in both countries

Denmark’s vaccination campaign was launched in late-December 2020 and by March 2021, 10% of the population had received their first dose. By May, there was 30% vaccination coverage which reached 50% by July 2021 (Statens Serums Institut, 2021). Despite the increasing vaccination rate, there was a slightly lower uptake among young adults and in certain areas of the country.

 Israel’s vaccination campaign was also launched in late-December 2020, and within 2.5 weeks, 20% of adults had received their first dose. Afterwards, the pace slowed such that it took an additional 4 weeks to increase to 40% coverage and yet another 6 weeks to increase to 60%. Initially, uptake was low among young adults, and two religious, cultural minority groups - Ultra-orthodox Jews (UOJ) and Israeli Arabs, but their uptake increased markedly over time (Rosen et.al, 2021). As can be seen in Figure 1, on 7 January 2021, the vaccination rate with the first dose for those aged 60+ among the general Jewish population of 73% (i.e., non OUJ) was higher than that of UOJ and Arabs (66% and 48%, respectively). By the end of March 2021, after efforts to communicate with the public and also to reduce access barriers, the differences among the groups had narrowed considerably: 96% among non-OUJ, 91% among UOJ and 89% among Arabs (Rosen et.al, 2021). 

Both countries had tailored communication strategies for young adults

In August 2021, it was observed that adults aged 20-29 years old had the lowest uptake in Denmark with over one quarter (27%) having not responded to their vaccine invitation (Sundhedsstyrelsen, 2021b). This can be partially explained by the fact that there had been large outbreaks of infection among this age group, and that previously infected persons already had a valid “Corona pass”, along with a perception that there was no need for a vaccination after recovering from COVID-19 (Sundhedsstyrelsen, 2021c).

To increase the vaccine uptake in this age group, a nationwide information campaign was launched to inform them about the vaccines and the importance of getting vaccinated. The information was, among other places, displayed on screens in educational establishments, metro stations, shopping centres, and cafés across the country. Furthermore, the campaign was also communicated on social media platforms, including Facebook, Instagram, Snapchat, and Tinder (Sundhedsstyrelsen, 2021d). Companies and organisations have also, in collaboration with the Danish Health Authority, offered their members to be vaccinated at work and increased the information available to employees, especially young people in this age group (Sundhedsstyrelsen, 2021e). 

As in Denmark, Israeli young adults (aside from those at high risk due to their occupation or underlying health status) were less inclined to get vaccinated than other age groups. One of the possible reasons is that it was perceived by this population group that COVID-19 symptoms and health risks are substantially lower for young adults than for older adults, thus, the benefits of vaccination are lower for them. Young adults in Israel were concerned about the vaccine’s safety and side effects, particularly over unsubstantiated potential long-term effects on fertility (Rosen, et al., 2021). 

Israel addressed vaccine hesitancy via a mix of messaging, incentives, and extensions to the initial vaccine delivery system. Communication was key to increase uptake, and the most important content of messages was reliable and transparent information: The main messages contained scientific evidence about the benefits and safety of the vaccine, transmitted by health workers and well-known medical figures such as hospital directors, the Minister of Health or health researchers. The Ministry of Health also published daily updates on vaccination coverage by age group and locality and disseminated a steady stream of findings from Israeli studies that demonstrated the real world effectiveness of the vaccine beyond the clinical trial setting. Political and health care leaders also communicated a vision of how widespread uptake would enable a return to normal in the foreseeable future (Rosen, et al., 2021).

Note: [1] In Denmark, the population has received an official invitation (and reminders) for the COVID-19 vaccine over e-Boks, which is an online digital mailbox where citizens can receive mail from the public authorities.

Israel tailored communication strategies for cultural minorities

In Israel, UOJ, Bedouins and some Arab groups initially had a slower uptake of the vaccine. Besides the concerns with side effects and vaccine safety mentioned above, these cultural minority groups more often mistrust the government, which contributed to a higher resistance to get the jab. Their relatively limited levels of secular education, and their limited exposure to the mass, mainstream media prevented them from accessing key sources of reliable information on new scientific developments and important communication channels used by the Ministry of Health and public health authorities. 

Efforts were put in place to tailor messages and reach out to these groups. Since they differ culturally in beliefs and way of life, messages had different content and were transmitted by different means. For example, for young adults among the Jewish population, mass and social medial communication campaigns were launched via videos and text. Some of the UOJ do not have access to mass or social media (Waitzberg, et al., 2020). Therefore, communication media specific to the UOJ population were used, including magazines, newsletters, recorded phone messages, and billboard posters. These were written using adapted discourse, wording, and language (i.e., Yiddish in addition to Hebrew) tailored to the community. For example, many of the communications cited relevant Biblical verses, such as “Take good care of your life” (Deuteronomy 4:15) and “Do not stand idly by when your colleague is at risk” (Leviticus 19:16) (Rosen, et al., 2021). 

Anti-vax messaging and misinformation was widespread in the Arabic-language social media, which significantly exaggerating vaccine risks (particularly regarding fertility) and promoting distrust in government. The pro-vaccine messages – emphasizing vaccine efficacy and safety – was put in place via Arabic-language mass and social media, and via individual outreach by the health plans and Arab physicians. Muslim religious leaders and various voluntary organisations also played an important role in the messaging effort. The messages themselves were also tailored to the Israeli Arab population and culture. For example, a clip of a woman wearing a traditional headscarf saying that it is permissible to get vaccinated during the Ramadan fast. Other exhortations to get vaccinated cited traditional Arab proverbs on the importance of honouring the elders of the community (Rosen, et al., 2021). 

Governance efforts helped tailor outreach to cultural minorities: the Ministry of Health established a special task force charged with focusing on the population of UOJ and another special task force focused on the Israeli Arab population. These task forces were established in consultation with leaders of the relevant communities and included medical professionals from within those communities. They partnered with community leaders (e.g., rabbinic and communal leaders were recruited to encourage uptake throughout the vaccination campaign). In addition, senior physicians who had close ties to UOJ communities (and who were highly respected by them) were enlisted to counter concerns about vaccine safety, and family physicians were mobilized to do vaccine promotion outreach among their patients (Rosen, et al., 2021). 

Denmark tailored communication strategies for specific geographical areas

In Denmark, in June 2021, the vaccination uptake in some parishes were lower compared to the national average (Figure 2). Parishes should be read here as a geographical, statistical delimitation, and not as a religious group or area. An evaluation of a pilot project (explained below) for increasing vaccine uptake found that some of the reasons of hesitancy in these areas were 1) uncertainty about side effects of the vaccine, 2) uncertainty about the different vaccine types and their effects, 3) uncertainty due to confusing and changing information from public authorities, 4) lack of information/knowledge about the COVID-19 vaccines, and 5) access barriers such as distance to vaccination site and language (Sundhedsstyrelsen, 2021f). 

The Danish Health Authority, in collaboration with the relevant municipalities and regions, launched a pilot project (which was later extended in some areas) in mid-June 2021 to try to overcome some of the barriers (Sundhedsstyrelsen, 2021). The aim was both to reduce access barriers (like distance to vaccination points) and to increase targeted and extensive communication efforts to raise awareness of the benefits of vaccination (like information on the importance of getting vaccinated and how to get vaccinated), towards increasing uptake. The municipalities involved a range of internal actors (health and social administration) and external actors (housing organisations, civil society organisations, religious communities, associations, and leisure clubs) in their communication efforts (Sundhedsstyrelsen, 2021f). The communications channels used by municipalities included posters, flyers, social media, direct conversations (through phone calls, text messages and face-to-face contact), local media (newspaper, daily newspapers, radio), information on municipal websites and information meetings. The communication materials consisted largely of information on the national vaccination effort, including rollout, information on the production of the vaccines, and the impact of the vaccines on getting back to normal, and possible side effects (Sundhedsstyrelsen, 2021f). For example, some municipalities have been in dialogue with local faith communities, informing them about the vaccination efforts for example at Friday prayers (Sundhedsstyrelsen, 2021g).

Conclusion and policy recommendations

Despite differences between Denmark and Israel in terms of both population and health systems characteristics, we have identified communication strategies common for both Denmark and Israel, which can be useful to other countries. Furthermore, we have identified different strategies that are context specific to Denmark and Israel. Countries should develop some other communication strategies tailored to their own needs. The case studies can serve as inspiration (see Table 2).

We recommend these 7 steps to develop tailored communications strategies focusing on population groups with lower vaccination uptake than the general population.

1. Identify population groups that have lower vaccination rates
2. Understand and be sensitive to the populations’ concerns: vaccine importance, efficacy, safety, long term side effects
3. Understand social or cultural factors that might be a barrier for vaccine uptake in certain population groups
4. Identify sources and content of dis- or mis-information and respond to them
5. Work with local authorities (e.g., municipalities), community or religious leaders to find the effective messages and the means to reach out to the population
6. Tailor the communication methods, language and content of messages to different groups
7. Respond to unique needs and lifestyles (e.g., co-habitation of many generations in the same household, community ties, frequency of social encounters)

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