key: cord-1043988-rfug6ibn
authors: Feifer, Richard; Bethea, LaShuan; White, Elizabeth
title: Racial Disparities in COVID-19 Vaccine Acceptance: Building Trust to Protect Nursing Home Staff & Residents
date: 2021-07-21
journal: J Am Med Dir Assoc
DOI: 10.1016/j.jamda.2021.07.006
sha: 0081ec7c9aa5e326e039701eb46cff93386e9614
doc_id: 1043988
cord_uid: rfug6ibn

Vaccines are critical to protect both nursing home residents and staff from COVID-19, but some staff have expressed reservations about being vaccinated. In this brief report, we describe interventions that Genesis HealthCare, one of the largest US long-term care providers, implemented after recognizing mid-way through vaccinations that racial and ethnic disparities existed in vaccine uptake among employees, with Black and Hispanic employees having significantly lower rates of vaccination than their peers. Specifically, Genesis engaged its Diversity, Equity, and Inclusion (DEI) Committee to identify ways to augment its already comprehensive vaccine education campaign in order to build confidence among employees from minority communities. Interventions implemented beginning in late January 2021 included adding DEI representatives to information sessions to facilitate culturally sensitive discussions; holding information sessions at all times of day and night, and inviting employees’ family members to join; increasing availability of multilingual educational materials; and featuring DEI representatives in social media campaigns. Between the end of January and beginning of March, 2021, we observed statistically significant improvements in the likelihood of Black and Hispanic employees being vaccinated relative to White employees, calculated as the relative risk of vaccination, suggesting a reduction in vaccination disparity. Whether these trends are directly related to the organization’s efforts, or rather reflect individuals needing longer to become comfortable with the vaccines, is difficult to discern in the absence of a formal pragmatic trial. Still, these findings support the continuation of targeted educational and engagement efforts to improve vaccine uptake among staff, and the critical need to ensure that nursing homes have ongoing access to vaccine supply to continue their vaccination programs.

Vaccines are critical to protect both nursing home residents and staff from COVID-19, but some 37 staff have expressed reservations about being vaccinated. In this brief report, we describe 38 interventions that Genesis HealthCare, one of the largest US long-term care providers, 39

implemented after recognizing mid-way through vaccinations that racial and ethnic disparities 40 existed in vaccine uptake among employees, with Black and Hispanic employees having 41 significantly lower rates of vaccination than their peers. Specifically, Genesis engaged its 42 Diversity, Equity, and Inclusion (DEI) Committee to identify ways to augment its already 43 comprehensive vaccine education campaign in order to build confidence among employees from 44 minority communities. Interventions implemented beginning in late January 2021 included 45 adding DEI representatives to information sessions to facilitate culturally sensitive discussions; 46 holding information sessions at all times of day and night, and inviting employees' family 47 members to join; increasing availability of multilingual educational materials; and featuring DEI 48 representatives in social media campaigns. Between the end of January and beginning of March, 49 2021, we observed statistically significant improvements in the likelihood of Black and Hispanic 50 employees being vaccinated relative to White employees, calculated as the relative risk of 51 vaccination, suggesting a reduction in vaccination disparity. Whether these trends are directly 52 related to the organization's efforts, or rather reflect individuals needing longer to become 53 comfortable with the vaccines, is difficult to discern in the absence of a formal pragmatic trial. 54

Still, these findings support the continuation of targeted educational and engagement efforts to 55 improve vaccine uptake among staff, and the critical need to ensure that nursing homes have 56 ongoing access to vaccine supply to continue their vaccination programs. 57 58 J o u r n a l P r e -p r o o f More recent data suggest that staff vaccination rates have improved over time, although as of 69 mid-June 2021, 15 states still had fewer than half of nursing home staff vaccinated. 1 70 Genesis HealthCare is one of the largest long-term care providers in the U.S. As of the 71 end of January, midway through its vaccination clinics, Genesis had vaccinated 61% of staff and 72 84% of residents across nearly 300 centers. 3 However, from vaccination data and conversations 73 with center leaders and direct care staff, organizational leaders identified disparities in staff 74 vaccination rates by race and ethnicity, with Asian employees having the highest rates, and Black 75 and Hispanic employees the lowest. This mirrored similar patterns reported in the general 76 population, where Black and Hispanic adults have reported more often than Whites wanting to 77 wait and see how the vaccines affected their peers before deciding to be vaccinated 78 themselves. 4,5 Although many factors contribute to individual decisions regarding vaccination, 79 the systemic historical inequalities and medical mistreatment that many minority communities 80 have faced only further exacerbated concerns and fears around vaccine safety. 6,7 81

In this brief report, we describe a series of interventions that Genesis implemented to 82 improve vaccine confidence among employees, particularly Black and Hispanic colleagues, 83 along with an initial evaluation of these efforts. 84

Genesis center leaders, with support from senior and regional leadership, started 86 educating residents, staff, and families about COVID-19 vaccination in September 2020, months 87 before the first vaccines were authorized or available. These efforts, prioritized by senior 88 leadership and coordinated by the organization's Vaccine Acceptance Steering Committee, 89 included hosting "Ask a Doc" sessions where staff could ask questions and receive factual 90 information from experts; providing multilingual educational materials; and leveraging trusted 91 peer influencers within centers and in local communities. Prior to the emergency use 92 authorizations of the vaccines beginning in mid-December 2020, educational efforts focused on 93 the science behind vaccine development, and sought to establish trusted communication channels 94 for information moving forward (Supplementary Table S1 ). As more detail on safety and 95 efficacy of the specific vaccines became available, this information was also incorporated. 96

Leadership also modified messaging as needed to address common concerns raised by frontline 97 staff, received through direct feedback, or from focus groups and surveys conducted by 98 researchers with whom the organization collaborated. 8 99

Vaccination clinics began in mid-December 2020, and each center was scheduled for 100 three clinics that lasted through mid-March 2021. By the end of January 2021, when the initial 101 clinics had finished and the second clinics were underway, it became evident that lower vaccine 102 uptake existed among Black and Hispanic colleagues. At this point, the Vaccine Acceptance 103

Steering Committee engaged the organization's Diversity, Equity, and Inclusion (DEI) 104 J o u r n a l P r e -p r o o f Committee to build additional support for the existing vaccination campaign. The DEI 105

Committee is comprised of 20-25 employees who are diverse with regards to race, ethnicity, 106 religion, cultural background, sexual orientation, age, disability status, and military service. 107

Committee members reside and work throughout the country. 108

The Vaccine Acceptance Steering Committee held four listening sessions with the DEI 109

Committee between December 2020 and March 2021 to help inform the organization's education 110 strategy. During these sessions, members discussed how individuals from various communities 111 access information, providing insight into some of the factors that influence vaccine uptake. 112

These sessions proved valuable in exploring and developing strategies to reach individuals from 113 diverse backgrounds. From these, the committees identified a set of priority areas for supporting 114 center leaders, and developed specific interventions that the DEI Committee members helped to 115 implement beginning in late January 2021. These are summarized in Table 1 . Publicly recognize and highlight vaccine experiences of trusted co-workers and community leaders via social media and center-specific communications.

• Diversity, Equity, and Inclusion (DEI) Committee representatives were added as copanelists for the "Ask the Doc" information sessions in order to help facilitate culturallysensitive discussions. Where possible, multilingual physicians were also leveraged. • "Ask the Doc" sessions were hosted throughout the day and night, enabling employees to log in from home and invite members of their family to participate, because the DEI Committee emphasized that family and friends can be influential in Black and Hispanic individuals' decisions related to vaccine acceptance. • DEI Committee members were involved in the #ThisIsOurShot education and social media campaign. This campaign highlighted employees' personal journeys towards vaccine acceptance and gave a voice to the unique decision-making process of individuals from diverse backgrounds. • A "Vaccine Acceptance" page was added within the company's DEI intranet site. This page, which promotes resources from the Kaiser Family Foundation and the Black Coalition Against COVID, includes a link to a library of more than 50 videos where Black and Hispanic healthcare professionals provide factual information about the COVID-19 vaccines in both English and Spanish. Educational information from the CDC was also made available in multiple other languages. • Nursing leaders from racially-diverse backgrounds visited centers to offer small group discussions and one-on-one conversations with individuals to answer questions on culturally-sensitive topics that impact decision making related to vaccine acceptance. Table S1 . Educational areas addressed starting in September 2020, before any COVID-19 vaccines received emergency use authorization

• The history of vaccine safety and the success of vaccination programs in the United States. • The role of center leaders, providers, and clinical staff in promoting vaccine acceptance. • Acknowledging the flood of sometimes conflicting information about vaccines, and establishing trusted communication channels for information going forward. • The research and approval process, related to safety and efficacy. • How vaccines work, including background on mRNA vaccines, to begin to build confidence in the new technology. • The possibility of side effects, and the fact that most of them are simply reflections of a functioning immune system and a favorable vaccine response. 

Centers for Disease Control and Prevention 176 National Healthcare Safety Network

Coverage Among Residents and Staff Members of Skilled Nursing Facilities 180 Participating in the Pharmacy Partnership for Long-Term Care Program -United States

Genesis HealthCare Announces Resident and Staff COVID-19 Vaccine 183

Vaccine Monitor

Lessons learned from frontline skilled nursing 193 facility staff regarding COVID-19 vaccine hesitancy

What Contributes to COVID-19 Vaccine Hesitancy 196 in Black Communities, and How Can It Be Addressed? : RAND Corporation

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