Understanding and improving COVID-19 vaccine uptake: A patient-engaged & community-informed approach

the team had asked us to talk about um some of our covid-19 vaccine work um this topic came up recently because um another Junior Investigator reached out about flu vaccine hesitancy um and and this brought up sort of the idea of the fact that we had done this um project around the pandemic um but we think a lot of the lessons learned from this project could be applied to other um other things like flu vaccine hesitancy and so I think it's still relevant even though the pandemic seems like so long ago um so hopefully you guys all find this to be relevant too um we've given this talk several times um so apologies if you've heard this before um but given that we only have five minutes we're going to keep this super high level um talk a little bit over the slides that we have um so if you have questions at the end um we're happy to answer questions or talk offline um we have no conflicts of interest and this research was supported by two grants um from Asel um so they had a covid-19 rapid science grants program um which was a pilot grants program during the pandemic and then um we also applied for administrative supplement um specifically to address covid-19 vaccine hesitancy um so uh the first grant that we actually got was actually looking at something completely different um it was around understanding disparities and covid-19 outcomes around multiple domains um but then the vaccine became available and so we quickly pivoted um to also try and understand parent beliefs about the covid-19 vaccine for their kids um really briefly and I I put the uh reference here for our uh article about this if you're interested but we surveyed 1449 caregivers of children of at neor of diverse backgrounds um and you can see here we asked about intention to vaccinate their children against covid-19 um and about a third of parents were unsure if they would vaccinate their children against covid-19 at that time again this was be right before um the vaccines came out um and uh we saw higher uncertainty rates among parents of black children we also asked questions about covid-19 beliefs Guided by the health belief model um and there were clear disparities here too um and you can see those here so in particular um parents from communities of color and communities with fewer opportunities um were less likely to believe that the vaccine was effective and safe um and parents from rural communities um were less likely to believe that covid-19 would cause serious illness um and finally parents of younger kids um were less likely to to believe many things um including that their child would get covid-19 um that it would cause serious illness um and that the vaccine was safe for their child uh finally we asked about cues to action so that's part of the health belief model um and by far Health experts and doctors um were the people who parents thought would affect their decision to vaccinate their child against covid-19 um so all of this together showed us that we really needed to do work to educate but also to motivate parents to vaccinate their children against covid-19 um and that we really needed to tailor any intervention to the beliefs of the community and also leverage trusted Messengers going to pass it on to Paul all right so because we wanted to make sure that we were um trying to reduce disparities and promote Equitable uptake of the covid-19 vaccine we wanted to make sure that we were incorporating The Voice the communities that we were trying to serve into the research process so uh at the kind of the outset of one of our projects we had um engaged with uh some people within numores and also some trusted Partners in the community um including uh friends over at Christiana um to try and identify uh different partners across Delware who we should engage throughout the resource research process um I'm not going to kind of go through all of these groups uh individually but we wanted to make sure that we included Partners from the community um including the communities of histor who are historically underserved within Delaware um also our healthcare partners because we know that they're important to actually getting the vaccines um and to you know actually administering them uh and then continue to engage in with an advisory committee um who could help us uh you know guide us on how to engage with our Community Partners um uh throughout the process and next slide thank you uh so here's kind of a highlevel um framework that we used to co-create the intervention uh and engage with our partners um so we started just by talking about what we were trying to accomplish got their input on kind of what our objectives were and modified them a little bit to make sure that uh everyone was kind of on the same page then we talked a little bit about kind of what they were seeing in their communities to brainstorm intervention ideas um and then we turn took and we kind of went uh separately and developed uh some prototypes uh for intervention so that was things like handouts that um would help educate families about the covid-19 uh vaccine um topics for videos things uh to educate uh pediatricians about how to talk to families about the vaccine and then we brought them back to our family Partners um and we asked them what do you guys think um is this kind of meeting the needs of your community or there anything different that we should be doing um and we use that feedback to kind of iteratively develop them um until everything was good to go um and you know this process took uh uh multiple meetings over a couple months um so it's it's very busy and if anyone's interested in doing that we're happy to talk a little bit more about kind of what that process was like and how to um how to make it happen next slide so uh as we were talking with our partners uh in the community and our HealthCare Partners uh we received a lot of feedback both on kind of what would work with regards to intervention um and also um uh things that we should be considering so uh the broad themes were things like uh from the community they wanted interventions that targeted not only parents but also youth um at that time a lot of uh youth were actually talking to their parents and saying I want to get the vaccine for X Y andz reason and so that could be really uh uh compelling to a parent uh to decide to get their child vaccinated they also wanted local families and providers um so people who are from their communities not necessarily like a an athlete or some Superstar like um uh you know you might see in other ads they wanted to make sure that any of the content was tailored again to what the specific concerns and motivators families had um and then just to leverage uh the pediatric clinics um no more is I think um uh privileged in the fact that we're really you know embedded throughout the communities um and so you know utilizing that um in the kind of those trusted uh Healthcare centers um with regards to the healthcare uh providers um uh side you know we there everyone's very busy um especially during Co everyone was incredibly busy so we wanted to make sure that whatever we were doing was as unive as possible um we wanted to make sure that we could provide more consistent guidelines and educate providers because you know things were changing so rapidly that oftentimes there was just inconsistent knowledge about what was and was not okay um making sure that their vaccine was tently offered um and then just making sure that um we whatever we were doing was incorporated into the culture of individual practices next slide so our we developed kind of a four component intervention um that we rolled out in four phases that LE will talk about in the next slides um so the first was just culturally tailored fact sheets and fers um so all of these things that are listed um were concerns or motivators that our family Partners said were really important they approved the language they approved some of the imagery all of that great stuff next slide um we also had some uh some motivational posters uh that included just yeah like that so those are local youth at um and I'm blanking on the name of the the location Le you remember uh the warehouse the warehouse thank you um so it's it located in Wilmington so these are teens who attend the warehouse um we were actually fortunate that's some of the leadership for the warehouse were part of our Community Partners and they helped make this happen um and these were all hung up in clinic next slide we also created some videos that featured local Youth and providers talking about a variety of different things um that occurred during the covid-19 pandemic next slide um specific to the healthcare side we educated or created some uh kind of brief education around uh you know more family centered communication strategies around the vaccine so um we created kind of dos and don'ts that providers could read very quickly could be posted up in provider workspaces um we also shifted people instead of asking do you want to get the vaccine using kind of more of like the sliding scale so you know where do you fall on this scale how ready are you to talk to your provider about the vaccine um uh to try and you know use motivational interviewing strategies to get people more on board with actually getting vaccinated next slide and then last but not least um we had an amazing team of community health workers who joined us uh for this project um so uh these are our four community health workers and they were doing Outreach to families before their pediatricians appointments um to uh try and help educate them about the vaccine and get them on board with maybe getting vaccinated I'll turn it back oh um and so we developed all this stuff and then to just make sure that everything we did was uh copesthetic with our families we actually went back we recruited um Hispanic uh Black and Hispanic youth and caregivers of unvaccinated Youth um and we showed them all of the intervention materials that we had developed and we got their feedback on them um generally it was really positive people really liked it we did get some really good feedback though on things with the family centered communication um specifically around how we asked families about uh the vaccine so you know they really did not want to saying your child is due for the vaccine because it felt like it was something they had no choice over but instead framing the question around you know uh how ready are you to talk to your provider about the covid-19 vaccine because that felt a little bit less um like threatening a little bit more palatable right and so um once we had developed the intervention we tested it um in a cluster randomized control trial um we selected uh two primary care clinics um in northern Delaware and T in Southern Delaware um to be the participating clinics for this um and our primary outcome was percent of eligible unvaccinated patients with a clinic visit who then received the covid-19 vaccine um we implemented this in four phases so each of the things that Paul just mentioned we implemented over four phases um and you can see here the vaccination percentages across phases of the study um so both groups had a decline which unfortunately we saw with the pandemic right that people who wanted the vaccine got it early and then over time people just got more hesitant and more resistant to getting the vaccine and those were the the families that we were trying to reach with this intervention um but you do see that with the intervention group um there was an increase um in vaccination rates um in phase three and um sustained higher vaccination rates in phase four um which again where when we sort of implemented things with communication in the clinic and with community health workers um and then when we looked across race and ethnicity um we saw that these effects um were the same across all Races and ethnicities and especially um with our Black and Hispanic families community health workers and conversations with pcps um seem to be most effective we continued our community health worker Outreach after this fact um after this study um with some additional funding um and we saw that Community Health work Outreach reached a larger percentage of black Black and Hispanic children um and children whose parents did not speak English so I know we're a few minutes over um but I think our takeaways from this and that you can apply to any research whether covid-19 or not um is that really understanding first where and why disparity exists in your patient population and the communities you serve is an important First Step so really really working with Community Partners really understanding what patient are experiencing before you like develop an intervention um and then working with them to develop that intervention um is really key to promoting Equitable outcomes um and then um lastly promoting delivery of culturally relevant messages by trusted Messengers and using shared decisionmaking um can be really important too for Behavioral interventions like ours that's a that's a quick overview um happy to provide more details or answer any questions and these are all the people that it took to make this happen