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Initial Interview and Survey Results Reveal Vaccine Hesitancy among Veterans and VA Employees

Key Points

  • In November 2020, QUERI requested support from its Rapid Response Teams to evaluate the COVID-19 vaccine rollout undertaken by the National Center for Health Promotion and Disease Prevention (NCP), and to examine causes of vaccine hesitancy among Veterans and VA employees.

  • Early results from three Rapid Response Teams identified target areas to address vaccine hesitancy among VA employees.

  • These three Rapid Response Teams are continuing to engage with and support NCP-led operational activities.

We thank the many members of our RRT-3 for their help with these projects. This work could not be done without them.

As of April 25, 2021, approximately 2.17 million Veterans and 282,000 VA employees have been vaccinated in the Veterans Health Administration (VHA) with one of the three COVID-19 vaccines available in the United States through Emergency Use Authorization.1 While definitely a time for optimism, the vaccine rollout has prompted concerns about widespread vaccine acceptance, across the country and also within VHA. Although COVID-19 is one of the leading causes of death in the United States,2 the percentage of Americans who stated they were somewhat or very likely to get vaccinated declined from 74 percent in April 2020 to 56 percent in December 2020. These declines were observed for both women and men and in all age, racial/ethnic, and educational subgroups.3 As part of the National Center for Health Promotion and Disease Prevention’s (NCP) overall implementation plan, rapid quality improvement projects to identify sources of vaccine hesitancy among VA employees and Veterans, and strategies to overcome these challenges, are greatly needed.  

When QUERI released its request for applications in 2019 for the renewal of existing QUERI programs, and establishment of new programs, an innovative requirement was that the larger programs propose a readily available Rapid Response Team (RRT) that could, quite literally, respond to time-sensitive VHA program office needs for national priorities. Each RRT is expected to have a team comprised of experts in implementation and evaluation to participate in two projects per year, each requiring several months of time and effort. Funding for these projects is built into the QUERI program’s core budget.

In late November 2020, with NCP leading the national vaccine distribution for VHA, QUERI requested support from RRTs to evaluate this implementation effort. The inaugural RRT projects at the Hines VA CARRIAGE QUERI, Durham VA Function QUERI, and Bedford/Boston/Palo Alto VA’s Bridge QUERI mobilized to design six-month projects that evaluate aspects of COVID-19 vaccine hesitancy in conjunction with the NCP vaccine program. Unique to this RRT work is the need for each of the RRTs to collaborate and coordinate efforts, to present a unified package of work products and deliverables to NCP, and to allow for iterative improvements to their six-month implementation plan.

The RRT-3, as the three groups are known, met with NCP in December 2020 to discuss how they could support NCP in their efforts. Launched in January 2021, these projects collectively aim to understand the extent of and reasons for vaccine hesitancy among Veterans and VA employees and to evaluate strategies for communicating with both groups about the COVID-19 vaccine. To answer these questions, the RRTs are leveraging a variety of available data sources, including the national ForeSee survey sent monthly to My HealtheVet users, SHEP VIP (VA Survey of Healthcare Experiences of Patients Program Veteran Insights Panel), and employee surveys administered by VA healthcare systems to plan their vaccine rollout. Each project is collecting additional qualitative data from VA employees or Veterans for a more in-depth understanding of factors contributing to COVID-19 vaccine hesitancy among VA stakeholders as the vaccination program progresses.

Early RRT-3 results have identified target areas to address vaccine hesitancy among VA employees. Results from an employee survey at one VA healthcare system analyzed by our RRT-3 further revealed differences by demographic and work characteristics. For example, Black or multi-racial/ethnic employees were up to four times more likely to indicate hesitancy compared to other minority or White employees, and those who worked in outpatient settings were approximately twice as likely to indicate hesitancy compared to those who work in inpatient settings. Qualitative data collected by the RRT-3 through interviews with employees who were vaccine hesitant illustrate a range of issues related to the mistrust of information from federal sources during the COVID-19 pandemic, concerns about the impact of the vaccines on pre-existing health conditions, and worry about the speed with which the vaccines were developed. Reasons cited for overcoming vaccine hesitancy relate to altruism, such as wanting to receive the vaccine to protect their Veteran patients and elderly family members, as well as having conversations with trusted others, such as their own primary care providers, who are helping these employees understand the data on vaccine safety and effectiveness, and addressing their concerns in a non-judgmental way.

Other RRT-3 projects are focusing on Veterans’ vaccine hesitancy. More recent survey data from Veterans across a broad geographic area of the United States showed that 52.6 percent of Veterans had already received a 2-dose vaccine and 29.4 percent ‘probably would’ or were ‘very likely’ to get a 2-dose vaccine. The most common reasons selected for getting a COVID-19 vaccine were to prevent the respondent from getting COVID-19, to  contribute to ending the pandemic, and so that life could go back to the way it was before the pandemic. Concerns about (immediate and future) side effects and concerns about how quickly the vaccines were developed were the most commonly selected reasons against vaccinating. The top three trusted sources of information about COVID-19 reported by Veterans include their doctor or healthcare provider, the Veterans Health Administration, and science experts like Dr. Fauci. Through the SHEP VIP cross-sectional web-based survey of 1,178 Veterans (83 percent men, 81 percent non-Hispanic white) fielded between March 12 and 28, 2021, 71 percent of the respondents indicated that they were already COVID-19 vaccinated. Of the 29 percent (n=339) not yet vaccinated, those unsure of getting the vaccination were more likely to report fair or poor overall and mental health. Concern about the side effects from the COVID-19 vaccine was the topmost reason for not getting vaccinated among those not yet vaccinated.

Engagement with NCP-led operational activities has been integral to the RRT-3. A member of each RRT attends the COVID Vaccine Weekly Office Hours for Clinical Leaders, a briefing led by Dr. Jane Kim and Dr. Sophie Califano on the status of the vaccine program and any new information. These briefings also provide an opportunity for attendees to ask questions. The RRT-3 also participates in the VHA-wide Integrated Project Team meeting, which provides guidance to the COVID Vaccine sub-workgroups (distribution, policy, prioritization, education, measurement, communications, and vaccine safety) and information on the needs of Veterans, staff, and VHA with respect to COVID-19 vaccine. RRT-3 members are also engaged in individual workgroups such as the COVID vaccine education workgroup, led by Dr. Michael Goldstein, which provides guidance on education materials for Veterans and VA staff. These workgroups have also been a mechanism for sharing and receiving feedback from NCP. RRT-3 has received feedback on data collection tools and sampling strategies from workgroup participants that include NCP.

There are several lessons to be learned for future RRTs based on our collective experience as the RRT-3. RRTs must be able to adapt quickly. VHA conducted a monumental task of rapidly deploying vaccine to all VA medical centers within one week of the Pfizer and Moderna vaccines emergency use authorization respectively. The RRT-3 had anticipated focusing on the initial five VA vaccine pilot sites for data collection; however with rapid deployment of vaccine, this shifted to a broader focus on the larger VA population and a broader set of VA medical facilities. Leveraging additional resources is key to achieving the goals of the RRT. Operational partners will likely be extremely busy and not able to meet separately on a weekly or bi-weekly basis. RRT teams can leverage established workgroup meetings or other teleconferences to obtain input quickly from operational partners and other stakeholders. Finally, collaboration amongst RRTs can bring efficiencies to the process. The RRT-3 share information and data collection tools, with a goal of aligning and triangulating efforts to ensure that the parts produced by each are greater than the whole.

  1. COVID-19 National Summary - VA Access to Care. Accessed April 26, 2021.
  2. Ahmad FB, Anderson RN. “The Leading Causes of Death in the US for 2020,”JAMA. Published online March 31, 2021. doi:10.1001/jama.2021.5469
  3. Szilagyi PG, Thomas K, Shah MD, et al. “National Trends in the US Public’s Likelihood of Getting a COVID-19 Vaccine–April 1 to December 8, 2020,”JAMA 2021; 325(4):396–8. doi:10.1001/jama.2020.26419

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