As the Omicron surge that began in late 2021 demonstrated world-wide, not prioritizing the older old in national vaccinations strategies can result in devastating surges amongst the entire population [13]. Further, recent data shows that even vaccinated and unboosted elderly are dying of COVID at higher rates than unvaccinated adults under the age of 49 [14]. As the largest integrated healthcare system in the United States, and one that serves a disproportionately large percentage of racial and ethnic minorities as well as a large population of individuals with lower socioeconomic means, [15] the VA has an opportunity to serve as an essential access point for COVID-19 vaccinations to the broader population. Although the VA has fully vaccinated more than 2 million Veterans, [16] many more Veterans and their families remain unvaccinated. This study allows VA to better understand barriers to vaccination among some of its most vulnerable Veterans, and the potential role of geriatric primary care programs to optimize their vaccination program.
The three most commonly cited factors influencing vaccine hesitancy in the literature are convenience, confidence, and complacency [14]. These factors have been validated in recent studies of COVID-19 specific hesitancy [17]. In understanding vaccine hesitancy as a continuum, [3] this study illustrates key factors concerning confidence and convenience that emerged to help understand the success of VA in its early vaccination efforts in this GeriPACT sample. The high level of trust reported by both White and African American Veterans enrolled in their VA GeriPACT programs, along with the long-term relationship described with both their current team and the VA, contribute to the VA being a trusted source of healthcare for many patients, bolstering confidence in information received about the vaccine, even when that information is cursory. As important, familiarity with the VA system facilitated easy and rapid registration for and completion of the vaccination process, decreasing barriers around convenience.
The Veteran who presented concern around the vaccine and his Guillain–Barre’ syndrome offers an example of where more interaction with the clinical care team could potentially relieve hesitancy. Concern around Guillain–Barre’ syndrome and the flu vaccine is understandable, and the healthcare community has accordingly dedicated efforts to inform the Guillain Barre community that the COVID vaccine is safe [18].
The primary reasons cited for not receiving the vaccine through VA, or explicitly rejecting early vaccination opportunity, amplify the overwhelming desire to be vaccinated alongside the importance of convenience; technological barriers such as the VA’s online vaccination registration site and the strong desire to be able to get the vaccine with their caregiver, i.e. their spouse. Accessing the internet has been well explored as a barrier to COVID-19 vaccination, [5, 19] and future efforts will require healthcare systems to provide alternate access points for vaccine registration. While initially a limitation, the recent passage of the SAVE LIVES Act [20] now allows for vaccination of Veterans’ caregivers and family members and has tasked the VA with expanding eligibility from 9 million to more than 33 million individuals in the United States [21].
Even in this limited sample, addressing complacency through active outreach efforts by healthcare providers is evident. As noted, the risks to this population exist even though they are often homebound, and herd immunity cannot be achieved without moving many individuals along the continuum to vaccination. The role of healthcare providers in pushing individuals along the vaccine hesitancy continuum has been recognized, [2, 3, 17] and in conjunction with other vaccination promotions, it can serve as a powerful tool.
Our study has limitations. COVID-19 adoption varies by state, and although the project included states representing five distinct regions, acceptance rates may differ in other states. Selection bias may be present since practitioners selected patients for us to interview, and some individuals refused to be interviewed. Although our sample included individuals who declined the vaccine, we did not indicate specific parameters for the practitioners about who to select for the study, so study participants could have been weighted more heavily toward those inclined toward vaccination. Future studies should include individuals from additional states, including rural and other regions where vaccine hesitancy is greater. In addition, VA’s efforts to vaccinate individuals beyond its traditional patient population of eligible Veterans should be examined. Given VA’s nationwide scope and its mandated responsibility to assist the US in times of emergencies and disasters, [22] a successful rollout of efforts to vaccinate these individuals could serve as a model for vaccination efforts when needed for future public health emergencies.