Introduction

In January 2021, the American Academy of Family Physicians (AAFP) began work on the quality improvement (QI) project Improving Adult Immunization Rates Within Racial and Ethnic Minority Communities. The project is funded by a grant from the Centers for Disease Control and Prevention (CDC) National Center for Immunization and Respiratory Diseases. The QI project aims to increase adult immunization rates in racial and ethnic minority communities by:

• Assessing current adult immunization rates

• Identifying barriers that affect vaccination rates

• Educating physicians and health care teams about adult immunizations

• Addressing misinformation and myths about vaccines

• Overcoming systemic barriers to vaccination

• Implementing evidence-based interventions to improve vaccination rates and measure success

Twenty-four family physician practices participated in the project using the QI process and other evidence-based improvement strategies, such as Plan-Do-Study-Act (PDSA) cycles, to increase immunization rates in adult patients from racial and ethnic minority communities. Family physicians who provide continuity of care within the communities they serve are ideally suited to address gaps in immunizations.

This two-part supplement series shares information and lessons learned by our participating practices on their journey to improve immunization rates in racial and ethnic minority communities. Part one (appearing in the May/June 2022 issue of FPM) highlighted QI processes to reduce vaccine disparities, identified recommended adult vaccines, and discussed their importance among racial and ethnic minority communities. This part focuses on practical strategies to communicate about immunizations, and overcoming myths, misinformation, and barriers to improving vaccine confidence and vaccination rates within these communities.

Strategies to Communicate About Immunizations

Patient visits are an ideal opportunity to discuss the critical importance of vaccines. Through meaningful conversations with their patients, physicians and other clinicians can address patient concerns about vaccination and review vaccine benefits and potential risks. The following are strategies and tips one practice incorporates to communicate vaccine information effectively.

Team-Based Care

Our practice incorporates a team-based approach to vaccination. Front office staff will contact patients due for immunizations and schedule patient visits with a physician and sometimes a nurse depending on the purpose of the visit. Check-out staff will schedule future appointments when vaccines are due, according to the adult immunization schedules provided by the AAFP and CDC.

Negative language should be avoided when administering vaccines. For example, we avoid statements such as, “It’s too bad you have to get a shot today.” Instead, our medical assistants encourage the patient and share their support for vaccines. Our staff is encouraged to answer questions openly and honestly and refer to the physician when unsure how to reply.

We hold monthly huddles to discuss vaccine data, immunization needs, and educational resources to promote vaccine confidence. We review the CDC’s Vaccine Information Statements (VIS), and the staff is familiarized with the content to discuss during patient visits. We provide the VIS sheets to patients for recommended vaccines, even if they are not receiving the immunization. This allows open discussion between patients and our medical team. These steps have increased immunization rates among our patients.

Conversations About Vaccines and Safety

Annual wellness visits are another excellent opportunity to discuss vaccinations with patients. For patients 65 years and older, we discussthe CDC’s recommendation for the pneumococcal vaccine. The patient will typically ask whether it is necessary to receive it if they received the COVID-19 vaccine. This is a perfect moment to illustrate the differences between pneumonia and COVID-19 pathogenesis. This is also an opportune time to explain how vaccination against each disease minimizes the patient’s risk of becoming severely ill and prevents hospitalization. We can then segue our discussion into the influenza vaccine.

Physicians should remind patients that although influenza isn’t discussed as much in the media due to the saturation of coverage of COVID-19, it does not mean the flu has been eradicated. There is still a benefit to being vaccinated against the flu. Our takeaway message for patients is that more vaccination means more protection.

While having a dialogue with your patient, the issue of vaccine safety almost inevitably arises. When addressing their concerns, it is beneficial to communicate the following key points:

• Objections to thimerosal resulted in its swift removal from most vaccines (few multi-dose flu vials still contain it as a preservative).¹

• Nearly all vaccines have been reported to the CDC as a cause of loss of consciousness; most common are the human papillomavirus (HPV), meningococcal conjugate, and tetanus, diphtheria, pertussis (Tdap) vaccines. Researchers believe fainting results from the immunization process and not the vaccine itself, given that the ingredients of all three of these vaccines are different.²

• Influenza is highly contagious, and patients who are pregnant are among the most vulnerable to the virus. Changes in immunity during pregnancy make expectant patients more susceptible to infections and, thus, complications. People who are pregnant also have a higher risk of complications from influenza than people who are not pregnant. The flu vaccine is recommended and safe during pregnancy and breastfeeding, and the vaccine does not result in congenital disabilities.³

• Similar to some medications, vaccines can have mild side effects (i.e., low-grade fever, pain, and/or redness at the injection site) that go away within a few days. An individual is more likely to be seriously harmed by a vaccine-preventable disease than a vaccine. For example, tetanus can cause lockjaw, blood clots, and muscle spasms; Haemophilus influenzae type b can cause intellectual disability; congenital rubella infection can cause congenital abnormalities; hepatitis B virus can cause liver cancer; and measles can cause blindness and/or encephalitis.^4,5,6

• Although adverse reactions may occur after vaccination, they are extremely rare. For example, the flu vaccine has a slightly increased risk of Guillain-Barré syndrome (GBS), but the benefits of immunization far outweigh the potential risk of GBS.⁷

Describing vaccine components and how they work to improve the patient’s health status is also helpful during visits. When discussing immunizations, clinicians should inform patients that vaccines can contain antigens (weakened or inactive forms of either the virus or bacteria), adjuvants (immune response boosters), preservatives (ensure the vaccine doesn’t become contaminated and stays effective), and stabilizers (prevent chemical reactions and keep the vaccine components from sticking to the vaccine vial). These all work together to enable an individual to form antibodies as an immune response when a vaccine is given. Through these antibodies, the individual’s immune system remembers the disease and how to fight it if the individual is exposed to the illness in the future.⁸

Being well-informed and making a strong recommendation for vaccination are more likely to result in acceptance. Most individuals (79%–85%) indicated they were more likely to accept an immunization if their health care professional recommended it.⁹ Patients were also more willing to trust information from physicians who took the time to listen and address their concerns regarding vaccine safety.

An approach that effectively addresses patient questions is Singer’s CASE method. This method involves four aspects¹⁰:

• Corroborate: clinician acknowledges concerns and identifies a point to agree on, which will set a positive tone

• About me: clinician details their expertise and knowledge base

• Science: clinician offers scientific facts about vaccines

• Explain/advise: clinician strongly recommends based on science

The CASE method can be applied to COVID-19 vaccine hesitancy as the approach incorporates evidence-based guidance with an empathy-based educational approach.¹⁰ It provides talking points that allow for an open environment, enabling positive communication between patients and physicians. Although these discussions take time, they are worth it, and your patients will appreciate them.

Overcoming Myths, Misinformation, and Barriers

People are continually exposed to false, inaccurate, or misleading vaccine information. Misconceptions cause confusion and lead to vaccine hesitancy or refusal, a rejection of public health measures, and a belief in unproven treatments, which can contribute to outbreaks of vaccine-preventable diseases. Vaccine misconceptions are nothing new. In many ways, they are understandable, given the ease of accessing myths and misinformation.

Family physicians should keep in mind that lower vaccination uptake, especially among Black and Hispanic/Latino/Latina populations, is not just due to the mistrust of the medical system but also mistrust of its institutions. There are various reasons for certain patient populations to mistrust institutions. Studies have shown how the implicit biases of health care professionals and others toward African American patients shape the treatment they receive and their health outcomes.¹¹

The following are approaches a couple of practices implement to address vaccine myths, misinformation, and barriers.

Staff and Patient Engagement

Our clinical staff meet weekly and monthly to remind, reinforce, and discuss how better to provide accurate information to our patients about vaccines. We have a recall and reminder procedure called the daily report, which includes the list of patients due for the shingles vaccine and any pneumonia vaccines, along with other gaps in care. These daily reports are available to all primary care offices within our medical group. Our goal is to have all vaccines due listed on the daily report.

We also use numerous learning aids, including PatientPoint,^® a patient engagement product that offers take-home pamphlets, wallboards, and wall-mounted interactive screens in each patient room that provide information on vaccines and other health information.

Overcoming Barriers and Finding Solutions

We encountered a barrier to the new recommendation for the HPV vaccine, which caused confusion. Historically, HPV vaccines were targeted toward young patients via advertising and social media campaigns. It has been a challenge to explain the importance of the vaccine to adults since it was initially targeted toward young patients.

Another barrier to vaccine coverage we’ve experienced is capturing vaccines administered at pharmacies but not reported to our office or the state’s Immunization Information System (IIS). Pharmacies in some states are not mandated to update vaccine administrations to the state website, and most patients are unaware of the exact vaccine they may or may not have received at the pharmacy.

A barrier another practice is overcoming is standardizing documentation. Our office accepts Medicare Part D insurance for vaccines. We run these claims through the TransactRx program. This has been an efficient opportunity to offer the shingles vaccine during a same-day office visit. We are working on standardizing our documentation process when vaccines are declined, including information about why patients are refusing them.

Dispelling Myths and Misinformation

Social, cultural, and political contexts play a vital role in vaccine acceptance or refusal. Anti-vaccine messages about vaccine safety circulate rampantly on social media platforms, increasing vaccine hesitancy or refusal. Misinformation and anti-vaccine behaviors can affect any single vaccine effort. Even worse, they can lead to vaccine hesitancy or refusal of all vaccinations.

Efforts to dispel myths and misinformation about vaccines should involve a multi-pronged approach to increase the acceptance of vaccines. For example, implement the following approaches to help assure patients of vaccine safety and build confidence about vaccines:

• Communicate clearly and use lay language to help patients understand any health-related information about vaccines.¹²

• Frame and articulate vaccine information to its targeted audiences when addressing vaccine hesitancy. One effective approach is to meet ethnic and racial minority groups where they are, such as in their populations’ online forums and in physical locations, such as churches, mosques, tribal gatherings, faith-based institutions, barbershops, hair salons, and other trusted community-based locations.^13,14

• Ensure vaccine information reaches these communities by following up with groups to answer any questions regarding vaccines.¹⁵

• Develop talking points before patient engagement. This will help initiate conversations and prepare you to address myths or misinformation, ultimately leading to improved vaccination rates, increased vaccine adherence, and overcoming barriers to building vaccine confidence.¹⁵

Global health agencies, such as the World Health Organization (WHO) and United Nations Children’s Fund (UNICEF), along with health care professionals, vaccine advocates, and the media, play a crucial role in addressing misinformation, especially in online settings, where it is most easily spread.^16,17 The best advice clinicians can provide their patients is always to take information from reliable sources and not pay attention to powerful but misleading social media posts.

Conclusion

In the second part of this two-part supplement series, we’ve identified the strategies and communication efforts used by family medicine physicians and their practices to increase immunization rates among adult racial and ethnic minority patients. A few key strategies and communication efforts to achieve their immunization goals include:

• Empower health care teams to identify and address missing immunizations using daily huddles, immunization reports in the electronic health record (EHR), state immunization registries, standing orders, and strong messaging to patients regarding how vaccines work and the importance of vaccines.

• Use the AAFP Office Champions Quality Improvement Model by utilizing PDSA cycles to implement interventions to improve immunization rates, assess the effectiveness of the interventions, and adjust to meet the quality benchmarks the practice has set.

• Stock all recommended adult vaccines in the practice.

• Collect race, ethnicity, and language (REAL) and social determinants of health (SDoH) data to accurately identify racial and ethnic minority patients who need immunizations.

• Provide culturally and linguistically appropriate educational material on vaccination.

• Leverage partnerships with trusted organizations and leaders in racial and ethnic minority communities to promote vaccination.

• Address vaccine myths, misinformation, and hesitancy with patients to build vaccine confidence.

To help your practice improve immunization rates among patients from racial and ethnic minority communities, the AAFP’s performance improvement (PI) continuing medical education (CME) activity Increasing Adult Immunization Rates Among African American Communities addresses the specific needs of this patient population. The activity includes self-guided exercises to evaluate your practice’s current performance with immunizations, implement a plan to improve immunization rates, and measure the improvement plan and interventions, and an educational webinar on strategies to improve immunization rates in African American communities.

This publication is supported by a cooperative agreement (6 NU66IP000681-02-01) with the Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services.