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Patient Safety, Risk, and Quality—Aging Services, ECRI, Plymouth Meeting, PA
ECRI and Annals of Long-Term Care: Clinical Care and Aging (ALTC) have joined in collaboration to bring ALTC readers periodic articles on topics in risk management, quality assurance and performance improvement (QAPI), and safety for persons served throughout the aging services continuum. ECRI is an independent, nonprofit organization improving the safety, quality, and cost-effectiveness of care across all health care settings worldwide.
With several vaccines against COVID-19 already available through emergency use authorization, others potentially on the way, and a nationwide vaccination campaign to administer the vaccine to as many people as quickly possible, the COVID-19 pandemic continues to transition to new phases. And yet with new hope come new challenges and emerging risks as organizations work to safely care for older adults.
According to the Centers for Disease Control and Prevention, skilled nursing facilities that conducted at least one vaccine clinic during the first month of roll-out administered a first shot to a median of 78% of their residents and 38% of their staff. As the agency points out, the moderately high coverage among residents is counterbalanced by relatively low coverage among staff.1
Why Such Low Vaccination Rates Among Staff?
What accounts for this difference in vaccination rates between residents and staff? Individuals, including health care workers, may decline vaccines for a number of reasons. Regarding COVID-19 vaccination, people who have chosen to take a wait-and-see approach or decline the vaccine altogether have cited concerns ranging from the newness or safety of the vaccine to a lack of evidence-based medicine about COVID-19 and even concerns about the politics involved.2
However, some reasons run deeper than the current vaccination campaign. Reasons for declination can also vary by race, socioeconomics, age, community, culture, and other individual factors.3 For instance, there is a statistically significant difference in vaccination acceptance rates between residents and staff in long-term care facilities—despite the fact that both groups have experienced the very real threat of harm and challenges posed by COVID-19.1
Yet, in spite of these real-life experiences, a significant portion of staff still choose to decline vaccination, giving strong indication that reasons for declination can be deeply held. Perhaps the first lesson to be learned is that vaccination acceptance behavior will differ between groups. With that lesson learned, organizations should then consider the best approaches to address those differences.
Balancing the Greater Good and Individuals’ Rights
One response some organizations are considering to address lagging acceptance rates is mandating the COVID-19 vaccine among aging services staff and other frontline health care workers, based on the argument that the safety and welfare that group immunity brings for the greater good outweighs the individual’s right to decline.
Given the potential harm to older adults and the care-critical necessity of a healthy staff to maintain continuity of care and services, it is perhaps not surprising that such drastic measures might be contemplated. But at what price? And with what unintended consequences? For instance, depending on the reasons for declination—concerns about safety, a lack of evidence-based medicine, or even mistrust of the government’s role in COVID-19 vaccination—moving to mandatory staff vaccination programs in aging services or other parts of society could make some reasons for declination even more entrenched.
Perhaps there is another solution that shifts from approaches that couch the discussion as the greater good or the rights of the individual to choose—ideally an approach that values both the greater good and respect for the rights of the individual. While it is generally understood that time is of the essence to save lives and move us toward some sense of normalcy, COVID-19 vaccination campaigns still carry a large number of unknowns for people being served and for those serving them, now and for the foreseeable future. Illnesses and the medicine employed to combat them are not all equal—and neither are vaccination campaigns, even with the intent to protect from harm.
Vaccination Campaigns: A Process, Not an Event
An effective vaccination campaign has to identify the common reasons for declination and work to overcome those barriers. When organizations or community health systems collect credible declination data, they can use it to develop and amend education materials that address specific declination reasons.4 See “COVID-19 Vaccination Declination Form” for an example form developed by the Los Angeles County Department of Public Health that prompts the individual to indicate their reason for declining vaccination. This approach acknowledges and respects the differences that might exist between stakeholder groups as well as reasons for declination, thereby avoiding the trap of treating all who decline vaccination as being the same.
Such an education approach also becomes an integral part of the informed decision-making process. This helps address concerns regarding the COVID-19 vaccination campaigns, which go beyond those encountered in more established vaccination campaigns, such as those for annual influenza vaccination.
Vaccination programs are meant to be processes and not events and need to be tailored to the stakeholder needs, questions, and concerns about each particular illness and the medicine that treats it. Over time, as evidence mounts regarding the efficacy and safety of new vaccines, barriers would be reduced or overcome for people who declined in favor of a wait and see approach. Viewing vaccination programs as a process rather than an event also allows organizations to identify strategies and integrate them into a comprehensive approach to overcome barriers. For example, carefully choosing who communicates messages about vaccines, and even who administers vaccines, can help address mistrust.
Before rushing to mandatory vaccination programs, organizations should continue to seek an understanding as to why people decline vaccination, educate using the growing body of evidence-based information, and tailor it to help overcome the reasons for declination identified through data collection and analysis. Just as importantly, the nationwide health care system must ensure ongoing access to vaccines so that as reasons for declination are addressed, vaccines can be administered in a timely manner. This includes scheduling additional on-site vaccination clinic dates so that people who have changed their minds can still be vaccinated. As confidence in vaccine efficacy and safety builds, older adults and the staff who care for them will be protected from COVID-19 and quality and continuity of care can be maintained.
Ultimately, each campaign needs to be designed for its specific circumstances. People who are trusted by the different stakeholder groups should deliver messages that speak to all significant and identifiable reasons for declination. Even a perfectly accurate message that fails to get through to its intended audience still runs the risk of behaving like the wrong message.
- Gharpure R, Guo A, Bishnoi CK, et al. Early COVID-19 first-dose vaccination coverage among residents and staff members of skilled nursing facilities participating in the Pharmacy Partnership for Long-Term Care Program—United States, December 2020–January 2021. MMWR Morb Mortal Wkly Rep. 2021;70(5):178–182. doi:10.15585/mmwr.mm7005e2
- Brennan T, Chaguturu S, Graham G. Understanding and addressing vaccine hesitancy: achieving control in the US today. Accessed March 14, 2021. https://payorsolutions.cvshealth.com/sites/default/files/cvs-health-payor-solutions-understanding-and-addressing-vaccine-hesitancy-dec-2020.pdf
- World Health Organization. Vaccination and trust: how concerns arise and the role of communication in mitigating crises. Accessed March 14, 2021. https://www.euro.who.int/__data/assets/pdf_file/0004/329647/Vaccines-and-trust.PDF
- ECRI. Immunization of healthcare personnel. Aging Services Risk Management 2020 May. Accessed March 14, 2021. https://www.ecri.org/components/CCRM/Pages/Infect6.aspx