Though they might sometimes be thought of as the “funny pages,” cartoons and comic strips aren’t just for jokes and laughs. Graphic literature has a long history of being highly effective for delivering important messages about difficult topics.
That’s why an outreach group at the University of Cincinnati (UC) College of Medicine is using art-based educational materials to encourage vaccination in economically and historically marginalized communities in Cincinnati as part of the AAMC’s Building Trust and Confidence Through Partnerships grant program. Another grant awardee, Meharry Medical College in Nashville, takes a different approach, producing a “choose-your-own-adventure” website to distribute health messaging to community members.
Both aim to increase confidence in COVID-19 vaccines.
Funded by a cooperative agreement with the U.S. Centers for Disease Control and Prevention, the AAMC grant program supports efforts to encourage COVID-19 vaccination in local communities surrounding several academic medicine centers that have partnered with community organizations to build trust in the COVID-19 vaccines. The AAMC program directs resources to culturally sensitive and high-impact projects designed to meet locals where they are along their journey to vaccination. Leveraging connections with local faith-based organizations and other community partners helps reinforce that the information being offered can be trusted.
UC College of Medicine
Here, the AAMC grant is supporting a program led by John Kues, PhD, associate dean for research evaluation and professor emeritus of family and community medicine and Melinda Butsch Kovacic, MPH, PhD, associate director for community outreach and engagement at the UC Cancer Center. In collaboration with the Cincinnati Health Department and First Ladies for Health, a faith-based community organization, project stakeholders aim to increase communication and education about COVID-19 vaccines in African American and/or Black and Latinx communities in Cincinnati.
The partnership stemmed from work Butsch Kovacic, a biochemist and epidemiologist by training, has been doing since 2018 to increase health literacy within those communities using graphic stories depicting a robust cast of characters talking about important public health issues to help convey their message.
More recently, the group has directed its energies toward improving understanding of COVID-19 and the vaccines against it. When COVID-19 hit, the team asked their community partners what they needed to support vaccination efforts.
“They felt like they wanted to do something about COVID-19 in their community and then they also asked for training on stories and how to become advocates for their communities,” Butsch Kovacic says.
Those two concepts came together as the graphic stories that form a key aspect of We Engage 4 Health, an outreach effort to under-resourced communities in Cincinnati who were made more vulnerable to COVID-19.
They worked with the Health Department of Cincinnati to develop a list of frequently asked questions related to COVID-19, which then formed the basis of an FAQ graphic story they co-developed with individuals in the communities they most wanted to reach.
This list of FAQs allows community advocates to get to the heart of what’s preventing someone from getting vaccinated.
Co-designing the materials with community members has been a big component of why the campaign is working since it helped embed important and appropriate cultural elements into each story right from the beginning.
Then a script was developed that explains complex science concepts clearly for a third- to fifth-grade reading level. The visuals were built in Comic Life, an app for comic creation.
Each story was refined through lots of feedback and a back-and-forth process. Once the group had a story that seemed useful, they would test it with a small group of individuals in the target community.
One story shows how two characters — one, a teen named Jazzy, and another, a middle-aged woman named Miss Georgia — learn about the COVID-19 vaccines and work through their hesitations for getting one. The characters presented in the booklet and an accompanying COVID FAQ list — which directly responds to common reasons why people hesitate to vaccinate with information explaining why such concerns are unfounded or misconceptions — all have unusual skin tones (greens, blues, and oranges) and vibrant hair colors.
To disseminate the information, community advocates read the story out loud with an individual or group they’re working with. With this approach, all parties become more active participants in learning the information, “and when you talk about the stories and characters, you don’t have to talk about yourself, which means you don’t have to feel defensive,” says Butsch Kovacic.
“We call it a low-stakes conversation,” she continues. “People can share their beliefs and you can try to give information without actually saying, ‘you’re wrong’ or having an argument.”
Making the stories memorable and sharable is also an important aim; the hope is that the individuals who encounter these stories will remember them and tell them to other people they know.
The community advocate volunteers, who Butsch Kovacic refers to as “champions,” are local folks who have been vaccinated and want to encourage health in general in their communities.
“It’s a specific kind of person … you need to promote vaccination, because people are sometimes afraid to get push back,” Butsch Kovacic says. “They don’t want to argue, so you need someone who can welcome a discussion and is OK with people disagreeing.”
The idea is to offer clear, scientifically accurate information, have a discussion around it, and allow the individual to make their own decision.
When looking for champions in the target communities, First Ladies for Health became an obvious choice of partner. The UC team had collaborated with First Ladies in the past on other health literacy campaigns. They also connected with Santa Maria Community Services, a nonprofit that supports the Greater Price Hill community of Cincinnati.
Working with the city’s health department also helped open doors in communities with lower vaccination rates.
“They’re already going to be in the homes of people and they’re going to ask whether they’re vaccinated or not,” Butsch Kovacic says. “Our goal is to get these low-cost, low-stakes conversations happening so that people can start to think about considering vaccination.”
Across the whole effort, Butsch Kovacic says it’s important that UC truly partners with its community advocates.
“I don’t want to be the expert coming into a community and saying, ‘this is what you need.’ The whole point of developing this program was to increase health literacy and help [community advocates] be better partners.”
Some of that networking and collaborating has also helped the team continually revise and improve the materials they’ve developed.
For example, the materials are printed in both English and Spanish, but in certain neighborhoods and congregations, a dialect of Spanish may be a much more impactful means of communicating.
“We talked with some of these people who were using [the standard Spanish version] and they said they tweak the general translation a little bit when they’re talking to these groups,” Kues says. “So, we decided that because they’re cartoon books, we’ll leave some of the [speech] bubbles open. The people who are doing the training can write in the correct translation for the people they’re talking with and then they can give them the materials.”
As the pandemic continues to shift and evolve, the UC program will adapt accordingly, Kues says.
Meharry Medical College
In Tennessee, a team at Meharry Medical College has also developed unique content aimed at helping assuage vaccine fears and dispel misconceptions among community members.
The project is led by two Meharry Medical College faculty: Jennifer Cunningham-Erves, PhD, MPH, MAED, MS, associate professor at Meharry Medical College, and Jamaine S.C. Davis, PhD, assistant professor in the department of biochemistry, cancer biology, neuroscience, and pharmacology. Other Meharry staff members and an outside communications firm also contribute to the effort.
The team collaborates with Congregational Health and Education Network, a consortium of more than 90 churches in middle Tennessee that’s working to improve social determinants of health and reduce health inequities in the African American and/or Black and Latinx communities.
Better Options TN, a community-building nonprofit organization focused on improving health outcomes among immigrant and other communities that do not have enough resources in middle Tennessee, is also involved in the program.
“We have a lot of multidisciplinary backgrounds who are at the table in this effort,” Cunningham-Erves says. “I think between all of us we have been able to create a program that is culturally appropriate and also very much at the level of health literacy that we believe all communities can understand.”
At the center of the team’s efforts is a comprehensive website, yourcovidfacts.com/en, that allows users to select their primary concerns — such as how the vaccine was developed so quickly, why boosters are needed, and possible side effects — and be taken to another page where each concern is thoroughly and directly addressed.
“People have valid concerns that weren’t being addressed,” Davis says. “And when we talk with the public in different forums, we typically learn something new each time. So, this gave us the idea of really collating this and putting it together to address all those concerns.”
In building the website, the team worked to drill down on every possible concern someone might raise and to provide clearly worded responses and additional resources for every single issue.
“It took several iterations of trying to get this together so that people can walk away with a basic but firm understanding of the factors associated with why vaccines are important,” Davis says.
Cunningham-Erves adds that because of her work in encouraging HPV vaccine acceptance, she knew that “hesitancy is really complex,” she says. “So, we knew going into this project that we could not develop a website that was what you typically see with pages that are very comprehensive — people get lost in those pages because it’s so much information.”
Instead, they decided to make the information more accessible.
“I think with the design of this webpage, we really wanted people to be able to identify what their concerns were and go directly to it instead of having to search and get that unwanted information that wasn’t relevant or concerning to them,” she says.
A series of meetings with community leaders helped the team identify the concerns that needed addressing.
“I think that really shows us the importance of our communities being at the table when it comes to information programming, so that we can make sure that we get it right so they can make an informed decision about the vaccine,” Cunningham-Erves says.
She notes that it’s OK to have concerns about the COVID-19 vaccines.
“We all have them,” she says, “but we really want people to reach out and take a look at this site to get answers to their questions.”
A six-month marketing campaign to direct people to the website, which is currently ongoing, has rolled out in several phases, kicking off with radio ads over the first month or two. Those spots were followed by billboards and other visual marketing tools, such as bus stop bench wraps and newspapers ads. Ads and posts that target the neighborhoods and congregations the team is looking to connect with most followed next on Facebook, Instagram, and Twitter.
Additional efforts include partnering with local health care providers to distribute printed information.
“We know that different channels are needed to reach people where they are,” Cunningham-Erves says. “We are hoping that through these different channels we’ll be able to reach people and give them this trusted information source so they can make an informed decision around COVID-19 vaccination.”