A Matter of Trust: Building COVID-19 Vaccine Confidence among Diverse Communities in Canada and the United Kingdom - Final Full Report to The British Academy

Over the course of the COVID-19 pandemic, the virus has undergone many mutations. Governments must continually update their health policies – often in seemingly contradictory terms – to protect the public from illness and death, and health systems from collapsing. This means persuading millions of people, not just once, but twice and three times each, to be vaccinated, while the virus and the messaging about it are in flux. 
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\nThe purpose of our ongoing research, in Canada and the United Kingdom (UK), is to learn what methods to date have worked to improve COVID-19 vaccine confidence among the public throughout the pandemic and to share this information with policymakers, public health officials, community decision-makers and contributors to public discourse. Our goal is to better understand how policy changes and mis/disinformation are experienced in communities with low vaccine confidence and to identify community level interventions that can be used to develop vaccine confidence. 
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\nFor this multiple methods study, our teams analysed and compared societal reception to COVID-19 vaccination policies, in particular the communication of those policies, across two distinct areas and populations, one in the UK and the other in Canada. Both areas studied had areas with lower vaccination rates and similar kinds of demographic subpopulations. We have characterized the evolution of relevant public health policies in terms of their content, context, actors and processes, seeking to learn more about how people understood and acted – or not – on COVID-19 health policy changes over time. We wanted to study which communication channels were used and how various populations responded to public health information and regulations; what other “unofficial” channels they may have used, for better or worse; and what community efforts might have built vaccine confidence among rural and urban communities. 
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\nWe, firstly, examined the policy evolution through a desk review. Our data sources included government websites and official social media, which were used to identify operational COVID-19 policy documents, guidelines, laws and regulations. Search results were indexed, extracted and inserted into a spreadsheet for each country, then policy categories were devised based on how the policies were framed. Secondly, we characterised response to these policies through a series of individual interviews conducted in the East Midlands region of England and in Waterloo, a small, southern-Ontario city in central Canada. Finally, we compared our policy review to our qualitative analysis to gain insights into the influence of policy on vaccine programme equity and coordination.
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\nFindings from the desk review indicated that Canada and the UK were able withstand uncertainty and fluctuations created by the global COVID-19 pandemic through adopting a proactive stance. They ensured that their respective populations were able to access vaccines through creating actors dedicated to overseeing vaccine specific policy, such as the vaccine task forces, and by adopting a multisectoral response with targeted funding.
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\nHowever, our findings also indicate that both Canada and the UK would have benefitted from more co-ordinated, consistent, and clear vaccine communications. When health policy makers tried to find the “perfect” way to communicate complex, changing information to the public, they tended to sow confusion and mistrust, creating vaccine hesitancy. Communicating evidence and data in widely accessible ways was important for engendering trust in the policies and processes. The believability of vaccine messages depended on the level of trust in who the messenger was. This varied between Canada and the UK and among different population groups, depending on the level of trust that was shown for politicians vs scientists vs public health doctors. Messaging had to be adapted and targeted for different communities, considering cultural and language differences. While community understanding mattered, approaches that explained the evidence and adopted a compassionate approach that emphasized individual benefits, as well as benefits for those close to an individual, were perceived as being more effective over the longer term than emphasizing community benefits to vaccination. 
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\nIn both countries, adopting an approach that was open, responsive, shared information and created autonomy was seen as more effective than handing policies down from a traditional, rigid hierarchy. In the UK, the framing of vaccination policy as “protect the NHS” had the unintended consequence of worsening access to health care in already deprived communities; doctors abandoned routine activities to prioritise the vaccination programme. Funding of “community championship” schemes in the UK was not proactive, undermining the effort needed to keep vaccine acceptance levels high. At the same time, the UK commissioned key studies that were very valuable in informing vaccine schedules, booster programmes and vaccination of pregnant people, among others, including in other countries such as Canada. 
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\nWith trust for the source and spokesperson at the centre of whether an individual would accept vaccine advice, we see a need for investment in public health outreach work that promotes good relationships with, and among, communities that may have low engagement with vaccination and other health care opportunities. Governments need to have transparent policies on vaccine approval processes that lay people can access and understand. Authentic, ethical statements about what vaccines can and cannot deliver need to be conceived and delivered in good faith. Transparency and open dialogue between the government and historically excluded groups must also be ongoing, as the sudden prioritizing of vaccination raised worries and mistrust in some. 
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\nWe suggest that further study is needed to interrogate the role of trust, especially trust in policy actors. Specifically, how can we expand our understanding of who is a trustworthy leader, especially if they are not in health care, the civil service or elected government? Which potentially important community actors are missing from the COVID-19 story? We have seen in this study that religious leaders can be trusted by many, for example, but what about the influence of women on health care action in communities? And at what point do people switch from wanting to do their duty as citizens of a country, to making a vaccine decision about themselves as individuals? 
\nWe also suggest that health policy makers prioritise the widest possible global sharing of the best, clearest and most up-to-date scientific information about COVID-19 – and whatever virus comes next – to help reduce the mis/disinformation that spreads like wildfire on social media, creates mistrust and limits vaccine uptake. COVID-19 continues to show us that no individual is immune, even if they are vaccinated,

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