Take These Steps To Increase Vaccine Adherence-The HSB Blog 2/7/22
Our Take:
We need to broaden the use of culturally appropriate tools, expand the use of digital tools as a source of vaccine knowledge and increase representation through broader use of digital clinical trials to improve vaccine acceptance as we move from Pandemic to endemic. While the initial COVID vaccines were developed in under a year, vaccines were not widely accepted for a number of reasons including (but not limited to) the politically infused tradeoffs between personal liberty and public health, confusing communication by public health around various mandates, historic distrust of the healthcare establishment, particularly in communities of color around the safety and efficacy of the vaccine. However, as we move forward we need to do a better job of actively taking into account the social perspectives and cultural backgrounds of underserved communities by utilizing stronger grassroots listening and education campaigns (in the place of mildly informative and effective PSAs). Embracing and changing reimbursement that allows clinicians to do a better job of 1:1 education and care for the disaffected, such as proactive telehealth extension, broader education, and recruitment through digital trials, and leveraging virtual prenatal care would help increase vaccine adoption as we move from pandemic to endemic over time.
The Problem:
While the first two COVID vaccines to earn emergency use authorization (EUA) in the U.S. were developed in under a year, the approval process itself was shrouded in the fog of politics and then held up as a litmus test of loyalty to political philosophy (and some would argue a political party). For example, there was tremendous pressure on the FDA to grant approval and speed up the pace of its review. In addition, once the vaccines were granted emergency authorization, distribution was plagued by delays and there were initial reports of initial adverse reactions to the shots increasing a sense of apprehension. As a result, there was clear public confusion. Public health authorities appeared to lack the ability to craft a coherent and consistent message as information was imperfect and in a flexible situation. While this persisted, the Biden Administration instituted various government mandates to increase vaccine adoption which simply fanned the flames of the philosophical debate. All the while, efforts to educate the underserved around the factors that contributed to the rapid development of the vaccine were lacking. In addition, challenges surrounding the resistance to the vaccine among many in underserved communities who were healthcare workers, teachers and, students (and thus subject to the mandates) appeared to have been shoved to the side thus creating a backlash.
In addition to the mandates, public health officials also enacted incentives to increase vaccination rates which included such things as prepaid debit cards or gift cards to local attractions or establishments. Although these have been successful, they did create a sense of inequality for those who felt like they were doing their civic duty by getting their shots with nothing in it for them. As we move forward, strict regulation on compliance will be an active means of protecting oneself and others by preventing the spread of the virus and it appears there will have to be some consequences for those who choose not to get vaccinated (many European countries have successfully enforced mandates and brought about strong vaccine adherence). However, with the shortage of healthcare workers and with variants like Omicron being highly contagious some sort of COVID vaccine is likely to be with us for some time.
The Background:
Assessing a new health threat while keeping the public calm is an arduous and delicate task in and of itself, especially in the digital age where conspiracy theories and fake news are ever present. During this pandemic, poor communication and constant changes in rules and regulations are the main culprits. The Centers for Disease Control and Prevention (CDC) has been highly criticized for failing to be more proactive in its actions against COVID and create a more coherent and consistent plan for protecting the public. During the early phases of the Pandemic, the public received conflicting perspectives and uncoordinated government communications from both state and federal leaders. Many have argued that the CDC is not designed for this role and was poorly equipped to take it on once COVID hit. They have called for the creation of a new public health authority to be responsible for monitoring and alerting the public to risks such as COVID.
This is particularly true as the access to and understanding of public health terminology and assessing personal risk is not easily definable for the general population. For example, according to an article entitled “An Analysis of Government Communication in the United States During Covid-19 Pandemic: Recommendations for Effective Government Health Risk Communication”, “conflicts within governmental agencies are key factors that often trigger social disorder, and in the United States, [these] sparked increased societal hostilities between public sectors with different political orientations…[leading to] negative health outcomes (illness, suffering, and deaths) during the COVID‐19 crisis situation.” This was further complicated by a lack of real-time, coordinated public health systems that could help collect and disseminate relevant data.
As noted earlier, there is significant distrust in underserved communities based on some historical precedents. This stems from the lack of trust in governing officials, discomfort related to the lack of diversity in clinical trials, and fears of hidden agendas. According to, “The views of ethnic minority and vulnerable communities towards participation in COVID-19 vaccine trials”, “Ethnic minority communities have 10–50% higher mortality risk compared with those of white ethnicity in the UK and USA”, yet were dramatically underrepresented in the vaccine trials as a percentage of total participants. In addition, often accompanying or compounding this vaccine hesitancy in communities of color many women of childbearing age had specific concerns around preterm birth and potential birth defects that were difficult to address early on due to the risk of running trials on pregnant women. However, once the initial safety of the vaccine was established these trials could be run to address these issues. For example, a study in the CDC’s Morbidity and Mortality Weekly Report (MMWR) “found no significant risk or association for preterm births, infants that were born small for their gestational age (SGA), or for those that received a COVID-19 vaccine dose(s) in comparison to unvaccinated pregnant women,” yet many would argue the CDC has not done a good job publicizing this information in terms that are accessible to many and significant misinformation still exists.
Nevertheless, many are optimistic about recent developments and the potential for an annual single-dose COVID vaccine that would be effective against a range of variants. However, even with a so-called “single-jab” vaccine, there are likely to be many who will refuse to get even one dose of the vaccine because they question its efficacy. As a result, we have to look at new and alternative vehicles to get the message out and that more effectively combat vaccine hesitancy and misinformation.
Implications:
To achieve improved compliance with COVID 19 vaccination, policymakers need to take social, cultural, and political perspectives into account in order to better understand and acknowledge the fears of the vaccine hesitant. While significant resources have been poured into rebutting the fears of those anxious about getting the vaccine (and even those opposed to getting the vaccine at all) we need to do a better job of listening and acknowledging those concerns. This is where digital apps and tools which provide culturally appropriate care may play a pivotal role as these solutions cater to minority groups who may be unable to comprehend information due to a language or cultural barrier. Culturally appropriate education, support, and resources on the COVID vaccine, its benefits (and risks) should be addressed and accessible to everyone, especially underserved communities. Interventions such as these that engage with communities in a meaningful way play a key role in not only educating but in helping communities feel heard as their doubts are answered and not simply downplayed.
This is where telehealth and other digital tools could play a significant role. With the dramatic increase in telehealth during the Pandemic, communicating with your doctor, typically a family’s most trusted health advisor, became significantly easier and more convenient. Yet a study by the New York University School of Global Public Health found just over ⅓ got their information about the Pandemic from doctors or medical authorities while an almost equivalent amount (29%) got their information from traditional media channels (13.6%), new media (9.8%) and (5.8%) from family, friends, or colleagues. The study noted, “In contrast, those with the lowest level of COVID knowledge preferred informal sources like social media or family and friends.” It is clear that we need to empower and reimburse clinicians to address these issues. At the very least, personal physicians are in a position to address vaccine hesitancy in the context of a patient’s personal history and are in a good position to counter any vaccine misinformation.
In addition to a more proactive use of virtual care tools, actively recruiting more participants from underserved communities and enabling more convenient participation in clinical trials by using digital clinical trials would combat myths about side effects and increase the credibility of vaccines. Seeing more information about participation (and possibly even knowing a trial participant) by people who are more representative of the underserved will provide reassurance that getting vaccinated will be beneficial for the average person’s health. Moreover, successful clinical trials with significant BIPOC panel participation can demonstrate that the vaccine is not dangerous and in fact, is effective at preventing patients from contracting or suffering serious illnesses from COVID. This would give the vaccine credibility and help dispel many of the myths and misinformation currently out there. More than anything we need a transparent and thorough breakdown of vaccine-related information and clinical procedures so we can increase vaccine participation as we move from pandemic to endemic.
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