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The Voices on Vax Campaign: Lessons Learned from Engaging Youth to Promote COVID Vaccination
Background: The Voices on Vax campaign was a collaborative effort that engaged youth to create an interactive website and social media presence to increase COVID vaccine confidence and uptake among African American families in Baltimore, Maryland.
Objectives: To describe lessons learned and offer recommendations for future health communication campaigns involving youth ambassadors and virtual platforms.
Methods: We collected website analytics and limited data from pop-up surveys on the Voices on Vax website, as well as reflections from the youth ambassadors about their experiences.
Lessons Learned: Challenges included difficulties engaging the priority population and methodological limitations of our campaign’s impact evaluation. Successes included our focus on youth and adaptive engagement strategies.
Conclusions: We recommend using techniques to maximize engagement by the priority population, conducting in-person outreach, incorporating mixed methods data collection, and providing a mix of structured training and creative freedom to youth ambassadors.
Youth engagement, COVID vaccine, Social media, Community health partnerships
Due to impacts of structural racism, African Americans are at higher risk than White Americans for COVID infection, hospitalization, and death, as well as COVID-related economic and social adversities.1–6 African Americans also have lower COVID vaccine uptake, due both to access barriers and safety concerns.5 Unvaccinated African American individuals, however, are more likely than their White American counterparts to be open to vaccination.7 Large-scale community assessments conducted by the Johns Hopkins Institute for Vaccine Safety indicated that 52% of the African American individuals surveyed wanted more information before deciding whether to obtain the COVID vaccination.8
The Voices on Vax (VoV) campaign was designed to increase COVID vaccine confidence and uptake among African American families in Baltimore, Maryland. At the start of the project in May 2021, only 19% of Baltimore residents had been vaccinated; fewer than 10% of African American residents had been vaccinated,9 highlighting the urgent need for culturally sensitive public health strategies to engage this community. We developed an interactive website and Instagram page to increase vaccine confidence and uptake among African American families in Baltimore. We partnered with African American adolescents and young adults in the development and implementation of VoV, including youth ambassadors who helped develop the website and social media content. We [End Page 345] used music and visual arts to engage our priority population in learning about COVID vaccination.
OBJECTIVES
This paper explores lessons learned from the VoV campaign. We discuss project challenges and successes, using data from website analytics and pop-up surveys, as well as reflections from our youth ambassadors. Based on our experiences, we offer recommendations for future health communication campaigns that include youth ambassadors.
METHODS
Partnership
Initiated in March of 2021, this project represents a collaboration among six key partners: the Johns Hopkins Center for Adolescent Health (CAH), a Centers for Disease Prevention and Control-funded Prevention Research Center of 30 years with long-standing partnerships in Baltimore; the Johns Hopkins Institute for Vaccine Safety (IVS), which provides independent and objective assessments of vaccine safety to guide decision makers and educate physicians and the public; Hip Hop Public Health (HHPH), an organization that promotes health behavior change through hip hop music; HeartSmiles, a Baltimore-based nonprofit organization that provides youth leadership training; Baltimore City Public Schools (City Schools); and the Baltimore City Health Department (BCHD). CAH had well-developed relationships with the other five partners before the current project. Drs. Mendelson and Powell at CAH were awarded funding for the project through a Centers for Disease Prevention and Control COVID Vaccine Supplement available to Prevention Research Centers. Partners at IVS, HHPH, and HeartSmiles were engaged as co-investigators.
Partners from CAH, IVS, HHPH, and HeartSmiles met weekly through most phases of the project to collaborate on campaign planning and implementation. Drs. Mendelson and Powell also attended weekly meetings with City Schools and, separately, with BCHD, to coordinate the integration of the VoV campaign with other citywide COVID response strategies. Ad hoc meetings and regular emails were used to communicate and make decisions across all partners. The Johns Hopkins Bloomberg School of Public Health Institutional Review Board determined that the current project did not meet criteria for human subjects research.
Campaign Design
The VoV campaign design was informed by two theories of behavior change. The Child-Mediated Health Communication (CMHC)10 framework proposes that tailoring intervention messages for youth is an effective avenue for changing youth and parent behavior. Youth are trained to identify the signs and symptoms of a health issue and execute the steps needed to seek help for their caregivers. This framework has been supported by research showing increased health literacy among parents following training of youth health messengers.11,12 The Multisensory Multilevel Health Education Model (MMHEM) highlights the value of art and culture for enhancing health communications.13 It comprises three major domains—art, culture, and science—and eight subdomains (e.g., aesthetic design, cultural tailoring, social norms, cognitive strategies, evidence-based methods).
Consistent with CMHC, we identified youth as primary messengers of our health communication efforts. Based on CMHC and MMHEM, we engaged youth as health ambassadors and developed interactive “edutainment” content on the VoV website featuring visual art, hip hop music and science-based information about vaccination. Campaign materials were designed to provide clear, evidence-based information and spark conversations about the vaccine in homes and within friend groups. All content reinforced our central message: vaccination is a powerful tool that can help keep you, your family, and community protected. The campaign was organized as “mobile first” to ensure content was easily accessible to cellular and tablet users.
Youth Engagement
Young people were engaged early and often in the process of developing and implementing the campaign. Initially, youth from the CAH’s Youth Advisory Board (YAB) were consulted to create a name for the campaign. The CAH YAB contains 25 youth members; all members are African American and range between 16 and 22 years old. The YAB meets twice per month to advise CAH on projects to promote youth health equity and to generate their own projects in this area. A member from the CAH study team attended one of the YAB’s regularly [End Page 346] scheduled meetings, described the goals of the project and requested YAB members’ feedback regarding a name. More than 20 ideas were submitted, with VoV ultimately selected by the partnership. Next, youth were consulted about the design and content of the website both before and during development.
Finally, three youth from HeartSmiles, who were also YAB members, were invited to join the team and serve as youth ambassadors (ages 16, 18, and 19). They were paid for this work and received training in basic scientific concepts relevant for understand the COVID virus and vaccine and in principles of effective health communications. Their responsibilities included attending team meetings, interviewing peers about their vaccine journeys, creating content for the VoV social media page, speaking to the press about the VoV campaign, and hosting two online contests for youth to create music videos or other artistic products containing information about COVID vaccination. Because all Youth Ambassadors were also YAB members, the larger YAB was regularly updated on the campaign and assisted campaign activities during twice monthly meetings.
Campaign Launch and Activities
With input from all partners, the VoV website (voicesonvax.com) and Instagram account (@VoicesOnVax) launched on October 1, 2021. The VoV website contained five pages in addition to the Home page: Learn, Create, Share, About and Contest. The Learn page provided answers to commonly asked questions about the COVID vaccine and included a series of six animated videos, entitled Community Immunity, created by HHPH, rap artists, and HeartSmiles with information about the vaccine. Visitors could submit questions on the website to be answered on the site and VoV Instagram page. The Create page invited visitors to create their own videos using vaccine facts provided on the website to share with their communities. The Share page invited visitors to tell their vaccine journey stories and featured brief videos in which the youth ambassadors interviewed other young people about the process leading to their decision to get the COVID vaccine (https://voicesonvax.com/share/). The About page described the purpose, intended audience, and creative partners involved in the VoV campaign. The Contest page provided detailed instructions and deadlines for submitting entries for the VoV contests, in which contestants were asked to create a short music video or audio track using one of the beats provided and to include at least three vaccine facts. Two contests were held during the VoV campaign period, one in January 2022 and another in April 2022. Contest winners were chosen by the audience during live online sessions; both were rappers.
Instagram was chosen as the primary social media by the YAB because this was the most used the social media outlet among their peers in Baltimore. Instagram posts were made daily. Youth Ambassadors monitored engagements and began making posts during times with the most engagement. As the project continued and Tik Tok became a more prominent [End Page 347] social media outlet among their peers, the Youth Ambassadors created Tik Tok videos to post on Instagram. Initially, the youth ambassadors met frequently with the CAH Communication Specialist to review posts and seek feedback. As the campaign continued, the Youth Ambassadors were more capable of assessing and adjusting their posts with little guidance. They learned that funny meme’s encouraging COVID vaccination and vaccine awareness performed best. Instagram live sessions where invited experts to answer questions or had other youth discussing their vaccination journeys were most popular.
Monitoring and Evaluation
Our monitoring and evaluation efforts were informed by the RE-AIM (i.e., reach, effectiveness, adoption, implementation, and maintenance) framework,14–16 which has been used to examine implementation of other vaccination interventions. Reach was assessed using website analytics (e.g., individuals accessing the site, number of visits, time spent onsite) and monitoring our Instagram audience size and engagement over time.16 Effectiveness was explored through onsite pop-ups; adult visitors to the website were asked to complete a brief survey to assess basic demographic characteristics and key metrics related to attitudes about the COVID vaccine, perceived norms regarding vaccine uptake by the community, intentions to receive the vaccine, access to the vaccine, and vaccine uptake. Sample questions included, “How important do you think getting a COVID-19 vaccine is to protect against COVID-19?”, “If eligible, has your child/children received at least one dose of a COVID-19 vaccine?”, and “Many things might make it difficult to get a COVID-19 vaccine. Select all that apply to you.”
All first-time visitors received these evaluation questions; after the first visit, questions were provided in randomly selected subsequent visits. Visitors were informed that all data would be collected and analyzed anonymously. Adoption was tracked using the pop-up survey items on vaccine uptake, as well as monitoring the BCHD’s COVID Dashboard to track the number of non-Hispanic African American residents who received the COVID vaccine monthly. Implementation was measured by tracking website visits of Baltimore residents, average duration of site visits, and content accessed during site visits; we also identified campaign strategies associated with increased visits to the site. Maintenance was assessed as repeated use of the website using website analytics.17
LESSONS LEARNED
Challenges
Audience Engagement
All partners identified audience engagement as a key challenge to campaign reach, implementation, and maintenance. According to the US Census Bureau, the estimated population of Baltimore, Maryland, is 593,490. African American families in Baltimore comprise 62% of the city’s population (approximately 373,899 residents). Of the 2,573 unique website visitors, 606 (24%) were Baltimore residents as assessed by website analytics, highlighting a challenge in reaching our priority population. With respect to site usage, sessions averaged 48 seconds, and approximately 10% of visitors returned after their first visit.
The Instagram page achieved 258 followers. However, the 138 Instagram posts, 312 stories, 38 videos, and 6 live sessions reached 22,299 Instagram accounts, suggesting that reach extended far beyond the followers alone. The youth ambassadors struggled at times with the amount of time and energy needed to maintain fresh and well-timed social media content to maximize views (see Table 1 for representative quotes). Content had to be refreshed frequently, which meant that even posts the youth had worked particularly hard on had short shelf lives. Relatedly, new content had to present the same basic message in a somewhat different way to maintain viewer interest. Careful thought and planning were needed to tailor content to viewers to communicate factual vaccine information effectively and engagingly.
Evaluation
Because this was not a research study, evaluation strategies were limited to monitoring site traffic and usage and offering a brief pop-up survey to site visitors. To receive this survey, visitors were required to identify as being age 18 or older and residents of Baltimore. We were unable to survey youth due to the difficulty in this context of obtaining parent permission, although we anticipated that more youth would visit the site than adults. Most visitors meeting eligibility criteria to receive pop-up surveys chose not to complete them. A total of 112 visitors completed the survey from October 1, 2021, to August 31, 2022. Because identifying [End Page 348] information was not collected on non-respondents, we were unable to determine how many visitors were 18 years or older and eligible to take the survey. Due to budget constraints and the fact that we were not approved to conduct research, we were unable to compensate visitors for completing the pop-up survey, nor could we collect identifiable data on visitors over time. Future researchers seeking to address these challenges may consider requested additional time and financial support to fund the planning process and participant payments.
Of the initial responses obtained, 84% of respondents (n= 94) believed that vaccination was important for protecting against COVID. Over 90% (n = 105) reported having received [End Page 349] one dose of the COVID vaccine. Of the 67 respondents with children, 73% (n = 49) reported that their child had received at least one dose of the vaccine. These high reports of vaccination suggests that our sample may not reflect African American families in Baltimore, who were less likely to be vaccinated at the time of the study. Alternative strategies may be needed to reach the most vulnerable groups, such as in-person or peer-based efforts. While these data provide a cross sectional snapshot of adult visitors who volunteered to complete the items, they do not permit causal inferences about the effectiveness of the campaign for increasing vaccine confidence and uptake in Baltimore. In addition to its methodological limitations, the VoV campaign was conducted in the context of multiple Baltimore City efforts to increase COVID vaccinations, complicating attempts to isolate the impact of any one strategy.
Successes
Youth Focus
Engaging youth in research allows them to critically reflect on issues, establish new relationships with community members and researchers, and drive community change.18–20 All partners agreed that the robust engagement of youth ambassadors in the VoV campaign helped produce a vibrant youth-relevant site and Instagram account. Based on our extensive conversations with City stakeholders, it was evident that, while several other Baltimore groups were working with young people to promote COVID awareness, VoV was the only COVID campaign in Baltimore for which youth helped develop a website and produce social media content and contests. The youth ambassadors felt well qualified to connect with a youth audience and were pleased with their communication efforts (see Table 1).
Adaptive Engagement Strategies
Given the range of organizations providing vaccine information, our team had the opportunity to explore different strategies for engaging the priority population and to learn about best practices. We found that having other city stakeholders spread the word about VoV was helpful. For example, when a site on COVID vaccination created for Baltimore adults (bmorevaxxed.org) included a link to the VoV website, our site traffic increased. The youth contests VoV sponsored, in combination with targeted media promotion, proved to be our most successful strategies. Contestant ages ranged from 13- to 24-years-old. Most contestants were high school students with one being in middle school, two reporting attending local community colleges or universities and one who is an active member of the military.
Data showed that website traffic increased during contest periods and their promotion in the media, and usage shifted from desktop to mobile devices. After the Homepage, the Contest page was the most visited page on the website. Table 2 displays Instagram and website analytics from October 1, 2021, to August 31, 2022. As shown in Table 1, the youth ambassadors noted success of the contests for increasing traffic and the engagement benefits of other strategies they developed, including use of humorous video posts on Instagram and payment of small honoraria ($20) to incentivize content development by other young people (“Content Creators’ Lab”), including artwork and TikTok videos. These responses were gathered during a regularly scheduled meeting with Youth Ambassadors.
Youth Development Opportunities
The VoV campaign afforded opportunities to the youth ambassadors for training, professional development, media exposure, and creative expression (see Table 1). The Youth Ambassadors worked with the CAH’s Communications Specialist on what makes a good post, how to evaluate what types of posts are working best and how to continually work to expand your reach. They also held two informational meetings with an outside social media expert. As noted above, youth ambassadors also received training regarding the COVID virus and vaccines and health communications at the start of their involvement. They appeared on the local news and radio stations to address COVID vaccine confidence and promote contests. They also had an opportunity to further develop skills in interviewing and video editing by creating a series of interviews with peers about their decisions to get vaccinated, which were featured on the website. In addition, each week, they created social media content and explored what content and posting times were most effective and were able to meet with a social media strategist who provided instruction in this area. They worked together as a team and found ways to organize workload equitably and efficiently.
CONCLUSIONS
Based on our experiences with VoV, we suggest three recommendations for future health campaigns that involve [End Page 350] young people. First, provide oversight and training for youth ambassadors that includes room for creative freedom. Second, explore a range of online techniques to engage priority populations. Finally, incorporate in-person outreach. Each of these recommendations are described below in detail.
Provide Oversight, Training, and Creative Freedom
Engaging young people in research offers unique opportunities for learning from youth and providing educational and growth opportunities to youth.21,22 Youth not only learned technical knowledge related to the COVID virus and vaccine, but they also learned about health communication. Providing structured training and setting clear expectations was important. It was equally important to allow youth to have creative control over their social media posts. Our initial process required all youth ambassador content to be reviewed by an expert before posting. This approach slowed the process of sharing content and did not align with our values of trust and transparency. Ultimately, following a request from our youth ambassadors, the adult partners allowed the ambassadors to share content without prior approval from an expert. This increased the rate of content creation and empowered young people to assume greater control of the creative process. All posted content aligned with the training the youth ambassadors had received.
Explore a Range of Online Techniques
Consistent with previous successful social media campaigns, it is necessary to foster social connections among the priority population.23,24 Our priority was to run a robust and high-quality communications program that was deployed consistently over time. To do this, youth ambassadors used a range of online techniques to increase engagement on our social media site, including leveraging contests and existing partnerships and connections with organizations to increase engagement. They also invited followers to create posts by sharing ideas through direct messages. This approach allowed followers to contribute to content creation and led to the expansion of our reach to followers’ networks. Future teams may also consider paid strategies, such as advertisements and boosting posts, to engage social media audiences.
Enhance In-person Outreach
Online campaigns may be less likely than in-person efforts to reach those who are unvaccinated. A systematic review of vaccination related campaigns found few used social media as a part of their campaign.25 Of the social media campaigns, many raised awareness of the issues, but failed to increase vaccination rates. Thus, social media campaigns, alone, may not be sufficient to improve vaccination rates. Although we visited three schools to promote the VoV campaign, our ability to conduct in-person outreach at schools and community settings were limited due to constraints on youth ambassadors’ schedules, but this would have likely increased awareness in the local population. Future teams desiring to extend their reach might consider regularly scheduled (e.g., weekly or twice monthly) in-person outreach as a complement to their digital presence. They might consider scheduling visits with schools in after-school settings where youth ambassadors can present to other young people. We also recommend developing partnerships with schools and youth organizations in which youth ambassadors facilitate student engagement with the online material. For instance, ambassadors could develop activities or games that incorporate youth visits to the digital spaces to [End Page 351] find information or comment on existing posts. Structured activities have the potential to both increase engagement and awareness of a health campaign, as well as educate students on health topics.
Social media campaigns provide broad-reach and convenience for promoting freely available health information.26 Our multidisciplinary and multisector team encountered both challenges and successes in our implementation of the VoV campaign. Notable challenges included difficulty attracting and maintaining website visitors and Instagram followers, as well as significant methodological constraints on our capacity to evaluate the program’s impact. Successes included meaningful involvement of young people in the development and implementation of the campaign, resulting in youth-relevant content, being adaptive in our strategies to attract our priority population, including youth contests, and expanding skills, leadership potential, and professional development for our youth ambassadors. We hope that our recommendations can assist other researchers interested in working with youth on health campaigns.
REFERENCES
1. Zelner J, Trangucci R, Naraharisetti R, Cao A, Malosh R, Broen K, et al. Racial disparities in coronavirus disease 2019 (COVID-19) mortality are driven by unequal infection risks. Clin Infect Dis. 2021;72(5):e88–95.
2. Centers for Disease Control and Prevention. Atlanta: Risk for COVID-19 infection, hospitalization, and death by race/ethnicity. Available from: https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-race-ethnicity.html. Updated 2022.
3. Centers for Disease Control and Prevention. Atlanta: COVID data tracker [updated 2022; cited 2022Sep 30]. Available from: https://covid.cdc.gov/covid-data-tracker/#datatracker-home.
4. Price-Haywood EG, Burton J, Fort D, Seoane L. Hospitalization and mortality among Black patients and white patients with covid-19. N Engl J Med. 2020;382(26):2534–43.
5. Millett GA, Jones AT, Benkeser D, Baral S, Mercer L, Beyrer C, et al. Assessing differential impacts of COVID-19 on black communities. Ann Epidemiol. 2020;47:37–44.
6. Khanna N, Klyushnenkova EN, Kaysin A. Association of COVID-19 with race and socioeconomic factors in family medicine. J Am Board Fam Med. 2021;34(Suppl):S40–7.
7. Dudley MZ, Schwartz B, Brewer J, Kan L, Bernier R, Gerber JE, et al. COVID-19 vaccination status, attitudes, and values among US adults in September 2021. J Clin Medicine. 2022;11(13):3734.
8. Salmon D, Kan L, Shwartz B, Bernier R, Brewer J. Understanding diverse communities and supporting equitable and informed COVID-19 vaccination decision-making: Findings after wave 1. 2021. Available from: https://www.naccho.org/uploads/downloadable-resources/Wave-1-Preliminary-Findings-Memo-Report-final.docx.pdf
9. Baltimore City Health Department. Baltimore city COVID-19 vaccination dashboard [updated 2022; cited 2021 May 20]. Available from: https://baltimore.maps.arcgis.com.
10. Williams O, Leighton-Herrmann E, Hecht MF, DeSorbo A, Gerin W, Hedmann M, et al. Child-mediated health communication: A conceptual framework for increasing stroke literacy in hard to reach populations. J Health Dispar Res Prac. 2016;9(4):7.
11. Williams O, DeSorbo A, Noble J, Shaffer M, Gerin W. Long-term learning of stroke knowledge among children in a high-risk community. Neurology. 2012;79(8):802–6.
12. Williams O, DeSorbo A, Noble J, Gerin W. Child-mediated stroke communication: findings from hip hop stroke. Stroke. 2012;43(1):163–9.
13. Williams O, Swierad EM. A multisensory multilevel health education model for diverse communities. Int J Environ Res Public Health. 2019;16(5):872.
14. Gaglio B, Shoup JA, Glasgow RE. The RE-AIM framework: a systematic review of use over time. Am J Public Health. 2013; 103(6):e38–46.
15. Glasgow RE, Vogt TM, Boles SM. Evaluating the public health impact of health promotion interventions: the RE-AIM framework. Am J Public Health. 1999;89(9):1322-7.
16. Asare M, Popelsky B, Akowuah E, Lanning BA, Montealegre JR. Internal and external validity of social media and mobile technology-driven HPV vaccination interventions: systematic review using the reach, effectiveness, adoption, implementation, maintenance (RE-AIM) framework. Vaccines. 2021; 9(3):197.
17. Stephens AB, Wynn CS, Stockwell MS. Understanding the use of digital technology to promote human papillomavirus vaccination–a RE-AIM framework approach. Human Vaccin Immunother. 2019;15(7–8):1549–61.
18. Pavarini G, Lorimer J, Manzini A, Goundrey-Smith E, Singh I. Co-producing research with youth: the NeurOx young people’s advisory group model. Health Expect. 2019;22(4):743–51.
19. Offiong A, Willis K, Smith BD, Lewis Q, Portee-Mason D, Glover D, Burton M, Powell TW. Maintaining Community-engaged Research with Young People in A Virtual setting. Prog Community Health Partnersh. 2023;17(2):329-337. doi: 10.1353/cpr.2023.a900213.
20. Ozer EJ. Youth-led participatory action research: overview and potential for enhancing adolescent development. Child Dev Persp. 2017;11(3):173–7.
21. Lerner JV, Bowers EP, Minor K, Boyd MJ, Mueller MK, Schmid KL, et al. Positive youth development: processes, philosophies, and programs. In: Lerner RM, Easterbrooks, MA, Mistry J, Weiner IB, editors. Handbook of Psychology, 2nd ed. Somerset: John Wiley & Sons, Inc.; 2012.;6.
22. Ozer EJ, Douglas L. The impact of participatory research on urban teens: an experimental evaluation. Am J Community Psychol. 2013;51(1-2):66–75.
23. Kostygina G, Tran H, Binns S, Szczypka G, Emery S, Vallone D, et al. Boosting health campaign reach and engagement through use of social media influencers and memes. Social Media Soc. 2020;6(2):2056305120912475.
24. Edney S, Bogomolova S, Ryan J, Olds T, Sanders I, Maher C. Creating engaging health promotion campaigns on social media: observations and lessons from Fitbit and Garmin. J Med Internet Res. 2018;20(12):e10911.
25. Argyris YA, Nelson VR, Wiseley K, Shen R, Roscizewski A. Do social media campaigns foster vaccine adherence? A systematic review of prior intervention-based campaigns on social media. Telematics Inf. 2022:101918.
26. Rayward AT, Vandelanotte C, Corry K, Van Itallie A, Duncan MJ. Impact of a social media campaign on reach, uptake, and engagement with a free web-and app-based physical activity intervention: the 10,000 steps Australia program. Int J Environ Res Public Health. 2019;16(24):5076.