By Stefanie Friedhoff, Associate Professor of the Practice, and Daisy Winner, Project Manager, Brown University School of Public Health
In our work with community organizations and local and state health authorities, we have found the concept of vaccine demand a useful way to understand where and why vaccination efforts struggled in 2021, and how to apply lessons learned from these struggles to U.S. and global vaccination efforts in 2022 and beyond.
So, what is vaccine demand?
Economists use the term demand to refer to a consumer’s desire to purchase goods and services at given prices at a given time. Changing the features of a product or where one can buy it might increase or decrease demand. If all other factors are constant, an increase in price will decrease demand.
Adapting the concept to public health, vaccine demand refers to a person’s willingness to get a specific shot (such as a Covid-19, flu or shingles vaccine), and their ability and intent to do so given the vaccine’s features, availability, reputation and price. For example, some people might be more eager to get a vaccine via a nasal spray instead of an injection. Some people might want the vaccine if it is delivered close to home. Some people might seek a shot if a family member recommends it. Some people might get a shot because they recently got health insurance, or found a doctor they trust. As such, we conceive of vaccine demand as the number of people who would get a given vaccine right away if it was offered to them.
In economic frameworks, supply and demand are deeply intertwined. Companies have a keen understanding of how changes to the design of a product or its delivery time might impact demand.
In public health, supply and demand are often divorced from each other.
The conversations, funding streams and literature on issues such as setting up distribution through pharmacies are separate from those on issues such as who has access to healthcare or what motivates people to get vaccinated. Recognizing the importance of trust in vaccine demand, and the role of physicians, nurses and other healthcare workers as trusted sources of health information, for example, could have led to an earlier investment in enlisting primary care providers in the vaccination effort.
Moreover, a vaccine demand framework honors the agency and dignity of unvaccinated Americans at a time when they are often dismissed, degraded and disempowered. It acknowledges that people’s choices are shaped by complex psychological, social, structural and other interacting factors.
As a concept in Public Health, vaccine demand incorporates all drivers that contribute to a person getting vaccinated. These include everything from low-quality information and misinformation, to what people think and feel about vaccines due to social factors such as politics and social norms, to structural issues such as transportation, timing, and access to healthcare. The “price” to be paid for the shot includes financial, social and other costs — lost wages due to missed work because of side effects, or a rift with loved ones who are distrustful of authorities and the vaccines they promote.
Today, thanks to vaccines, many of the deadliest infectious diseases are preventable. The availability of effective vaccines has led to dramatic increases in life expectancy. At the same time, paradoxically, as the threat of infectious disease has become less apparent, there is a rise in citizen concerns about the purpose and safety of vaccines. To understand the value and importance of vaccinations, people need to be informed about both the risks of being unvaccinated and the safety and efficacy of vaccinations. The fewer deadly infectious diseases that circulate, the harder it can become to communicate the value of vaccinations.
Key factors in vaccine demand generation — such as how people receive information, how they make sense of the world, and who they trust — have also been affected by dramatic changes driven by both technological and cultural transformations. This has made it harder for people to assess the risks of being unvaccinated or the safety and efficacy of vaccines.
For some Americans, vaccination is also closely connected to individual, collective and intergenerational memory: Black and Brown Americans’ experiences with healthcare and other social goods are different from those of white Americans. Instead of being offered life-saving vaccines or treatments, Black Americans have been coerced into serving as test subjects in medical experiments. To this day, we see stark disparities in the quality of health services offered and delivered by race. Institutions and individuals in medicine and public health have urgent work to do better and earn the trust of these communities.
Addressing these and other barriers to vaccine demand is essential to America’s ability to move past the current vaccination crisis; it is equally essential in efforts to vaccinate the world.
When the Covid-19 pandemic hit, few mechanisms to generate vaccine demand were built into pandemic preparedness and response plans. Vaccine marketing, communications and community mobilization models were outdated and underfunded. And for most experts and public health officials, the volume and intensity of misinformation unleashed by the pandemic came as a surprise.
Amid the rapid pace and competing tasks and priorities of the pandemic response, understaffed and overwhelmed authorities and nonprofit institutions have struggled to meet the massive information needs of American communities. There simply is no playbook yet for anticipating and combating how factors such as the rapidly evolving political climate and deep disparities in the healthcare and social systems affect vaccine demand.
As a result, key opportunities to generate demand were missed, and continue to be overlooked. For example, without clear explanations of staggered vaccine priority, young Americans were told early on that they didn’t need vaccines as much as older people, only to then be suddenly asked to get vaccinated immediately. Some did so happily, others reluctantly, but too many young Americans ended up confused and remain unvaccinated and unconvinced that they need a Covid-19 vaccine.
Similarly, underserved Americans were told the vaccines would be distributed equitably. But then vaccinations were initially not available in ways that fit their needs – for example, without support for sick days or childcare, or without information translated into their language – confirming for these communities that authorities might not really understand — or worse, not care about — them; which in turn contributes to a lack of confidence in authorities and vaccines.
In the absence of more proactive and effective vaccine communications, in each new information cycle in this pandemic, information spaces are crowded with contradictory, inaccurate, polluted and highly emotionalized information rather than clarifying, accurate, compelling information.
In spring 2022, for example, Ivermectin — an antiparasitic drug that is ineffective against Covid-19 but has been widely publicized by disinformation agents as a cure — is well known and driving policy, while Evusheld — an effective antiviral that prevents infection and can save the lives of unvaccinated or immunocompromised people — is hardly known by both doctors and patients.
It is time to focus efforts and apply insights from community and faith leaders, behavioral scientists, communications and misinformation researchers, equity experts and others to increase vaccine access and demand. Such interventions led by community organizations and novel approaches to state and local policy are urgently needed, but remain underappreciated and underfunded. Public health agencies, officials, healthcare providers and communities need new knowledge, new tools, and significantly more resources to do this important work of rebuilding trust in public health.