Racial, Ethnic, and Rural Disparities in US Veteran COVID-19 Vaccine Rates

Background Race, ethnicity, and rurality-related disparities in coronavirus disease 2019 (COVID-19) vaccine uptake have been documented in the United States (US). Objective We determined whether these disparities existed among patients at the Department of Veterans Affairs (VA), the largest healthcare system in the US. Design, Settings, Participants, Measurements Using VA Corporate Data Warehouse data, we included 5,871,438 patients (9.4% women) with at least one primary care visit in 2019 in a retrospective cohort study. Each patient was assigned a single race/ethnicity, which were mutually exclusive, self-reported categories. Rurality was based on 2019 home address at the zip code level. Our primary outcome was time-to-first COVID-19 vaccination between December 15, 2020-June 15, 2021. Additional covariates included age (in years), sex, geographic region (North Atlantic, Midwest, Southeast, Pacific, Continental), smoking status (current, former, never), Charlson Comorbidity Index (based on ≥1 inpatient or two outpatient ICD codes), service connection (any/none, using standardized VA-cutoffs for disability compensation), and influenza vaccination in 2019-2020 (yes/no). Results Compared with unvaccinated patients, those vaccinated (n=3,238,532;55.2%) were older (mean age in years vaccinated=66.3, (standard deviation=14.4) vs. unvaccinated=57.7, (18.0), p<.0001)). They were more likely to identify as Black (18.2% vs. 16.1%, p<.0001), Hispanic (7.0% vs. 6.6% p<.0001), or Asian American/Pacific Islander (AA/PI) (2.0% vs. 1.7%, P<.0001). In addition, they were more likely to reside in urban settings (68.0% vs. 62.8, p<.0001). Relative to non-Hispanic White urban Veterans, the reference group for race/ethnicity-urban/rural hazard ratios reported, all urban race/ethnicity groups were associated with increased likelihood for vaccination except American Indian/Alaskan Native (AI/AN) groups. Urban Black groups were 12% more likely (Hazard Ratio (HR)=1.12 [CI 1.12-1.13]) and rural Black groups were 6% more likely to receive a first vaccination (HR=1.06 [1.05-1.06]) relative to white urban groups. Urban Hispanic, AA/PI and Mixed groups were more likely to receive vaccination while rural members of these groups were less likely (Hispanic: Urban HR=1.17 [1.16-1.18], Rural HR=0.98 [0.97-0.99];AA/PI: Urban HR=1.22 [1.21-1.23], Rural HR=0.86 [0.84-0.88]). Rural White Veterans were 21% less likely to receive an initial vaccine compared with urban White Veterans (HR=0.79 [0.78-0.79]). AI/AN groups were less likely to receive vaccination regardless of rurality: Urban HR=0.93 [0.91-0.95];AI/AN-Rural HR=0.76 [0.74-0.78]. Conclusions Urban Black, Hispanic, and AA/PI Veterans were more likely than their urban White counterparts to receive a first vaccination;all rural race/ethnicity groups except Black patients had lower likelihood for vaccination compared with urban White patients. A better understanding of disparities and rural outreach will inform equitable vaccine distribution. Graphical Image, graphical

Examining Pregnant Veterans' Acceptance and Beliefs Regarding the COVID-19 Vaccine.

BACKGROUND: Pregnant persons have received mixed messages regarding whether or not to receive COVID-19 vaccines as limited data are available regarding vaccine safety for pregnant and lactating persons and breastfeeding infants. OBJECTIVE: The aims of this study were to examine pregnant Veteran's acceptance of COVID-19 vaccines, along with perceptions and beliefs regarding vaccine safety and vaccine conspiracy beliefs. DESIGN AND PARTICIPANTS: We conducted a cross-sectional survey of pregnant Veterans enrolled in VA care who were taking part in an ongoing cohort study at 15 VA medical centers between January and May 2021. MAIN MEASURES: Pregnant Veterans were asked whether they had been offered the COVID-19 vaccine during pregnancy, and whether they chose to accept or refuse it. Additional questions focused on perceptions of COVID-19 vaccine safety and endorsements of vaccine knowledge and conspiracy beliefs. Logistic regression was utilized to examine predictors of acceptance of a vaccine during pregnancy. KEY RESULTS: Overall, 72 pregnant Veterans were offered a COVID-19 vaccine during pregnancy; over two-thirds (69%) opted not to receive a vaccine. Reasons for not receiving a vaccine included potential effects on the baby (64%), side effects for oneself (30%), and immunity from a past COVID-19 infection (12%). Those who received a vaccine had significantly greater vaccine knowledge and less belief in vaccine conspiracy theories. Greater knowledge of vaccines in general (aOR: 1.78; 95% CI: 1.2-2.6) and lower beliefs in vaccine conspiracies (aOR: 0.76; 95% CI: 0.6-0.9) were the strongest predictors of acceptance of a COVID-19 vaccine during pregnancy. CONCLUSIONS: Our study provides important insights regarding pregnant Veterans' decisions to accept the COVID-19 vaccine, and reasons why they may choose not to accept the vaccine. Given the high endorsement of vaccine conspiracy beliefs, trusted healthcare providers should have ongoing, open discussions about vaccine conspiracy beliefs and provide additional information to dispel these beliefs.

Addressing COVID-19 Vaccine Acceptance Within a Large Healthcare System: a Population Health Model.

BACKGROUND: The COVID-19 pandemic, and vaccine hesitancy, pose a significant public health threat. The Veterans Health Administration system is uniquely situated to provide insights into the implementation of a population health approach to vaccine acceptance. AIM: We describe the VA Connecticut Healthcare System's (VACHS) quality improvement project to improve rates of vaccine uptake. SETTING AND PARTICIPANTS: VACHS consists of eight primary care sites with 80 primary care providers delivering care to 47,000 enrolled veterans. PROGRAM DESCRIPTION: Our program involved identification of a local champion, education sessions, development of vaccine acceptance tools (including the templated "COVID-19 Prevention Letter" and the "COVID-19 Prevention Telephone Note"), and application of a population health approach (use of a prioritization scheme and playbook) by primary care patient-aligned care (PACT) medical home teams. PROGRAM EVALUATION: We found increased rates of vaccination at VACT compared to the surrounding region 6 months after implementation (65.16% vs 61.89%). Use of vaccine acceptance tools were associated with a statistically significant increase in vaccination (24.1% vs 13.6%, P = 0.036) in unvaccinated veterans. DISCUSSION: A population health approach to vaccine acceptance using EHR-based tools can impact vaccination rates, and this approach may be of practical utility to other large healthcare systems with EHR.

Veterans' Perinatal Care and Mental Health Experiences During the COVID-19 Pandemic: An Examination of the Role of Prior Trauma and Pandemic-Related Stressors.

Background: Many pregnant and postpartum Veterans have experienced multiple lifetime traumas, including military sexual trauma, intimate partner violence, and combat trauma. These women may be particularly vulnerable to increased post-traumatic stress disorder and other mental health problems following additional trauma exposures or stressful events, such as Coronavirus disease 2019 (COVID-19). This study sought to examine the impact of prior trauma exposures on the lived experience of pregnant and postpartum Veterans during the COVID-19 pandemic. Materials and Methods: Pregnant Veterans at 15 VA medical centers were surveyed at 20 weeks of pregnancy and 3 months postpartum asked about their COVID-19-related perinatal and mental health experiences, as well as the stressors that impacted them as a result of the COVID-19 pandemic. Results: Overall, 111 women Veterans completed both the pregnancy and postpartum surveys that included COVID-19 items. Sixty percent of our sample had experienced at least one potentially traumatic lifetime event, with 22% of our sample experiencing two or more of the included exposures. Women with a trauma history had 3.5 times increased odds of reporting their mental health as "much worse" compared to before the COVID-19 pandemic (95% confidence interval [CI]: 1.06-11.75) and were more likely to report that COVID-19 negatively affected their mental or emotional health "a lot" compared with women without a trauma history (odds ratio: 8.5; 95% CI: 1.93-37.48). Conclusions: COVID-19 has had a significant impact on pregnant and postpartum Veterans' mental health. Obstetricians should consider strategies to ensure women have access to mental health care during pregnancy, especially as the COVID-19 pandemic continues. Hospitals should also consider the importance of labor support companions during the COVID-19 pandemic and examine adjusting policies to allow for at least one labor support companion during labor and delivery.

Optimizing the Impact of Pragmatic Clinical Trials for Veteran and Military Populations: Lessons From the Pain Management Collaboratory.

Pragmatic clinical trials (PCTs) are well-suited to address unmet healthcare needs, such as those arising from the dual public health crises of chronic pain and opioid misuse, recently exacerbated by the COVID-19 pandemic. These overlapping epidemics have complex, multifactorial etiologies, and PCTs can be used to investigate the effectiveness of integrated therapies that are currently available but underused. Yet individual pragmatic studies can be limited in their reach because of existing structural and cultural barriers to dissemination and implementation. The National Institutes of Health, Department of Defense, and Department of Veterans Affairs formed an interagency research partnership, the Pain Management Collaboratory. The partnership combines pragmatic trial design with collaborative tools and relationship building within a large network to advance the science and impact of nonpharmacological approaches and integrated models of care for the management of pain and common co-occurring conditions. The Pain Management Collaboratory team supports 11 large-scale, multisite PCTs in veteran and military health systems with a focus on team science with the shared aim that the "whole is greater than the sum of the parts." Herein, we describe this integrated approach and lessons learned, including incentivizing all parties; proactively offering frequent opportunities for problem-solving; engaging stakeholders during all stages of research; and navigating competing research priorities. We also articulate several specific strategies and their practical implications for advancing pain management in active clinical, "real-world," settings.