Using a Harm Reduction Model to Reduce Barriers to Vaccine Administration

"Community vaccine outreach programs and relationship-based care can increase vaccine uptake through improved health literacy and associated behavioral changes including greater vaccine acceptance."

Socioeconomic factors, social policies, and historic and persistent experiences of racism and discrimination are among the barriers to vaccination access and acceptance in the United States (US). This article makes the case that midwives and women's health clinicians are in a position to provide vaccine information and recommendations that are relevant to clients during clinical encounters. The article presents strategies that can support clinician involvement and leadership in improving community health through vaccination.

The article is grounded in a harm reduction framework, which encourages clinicians to review a client's vaccination status, identify barriers to vaccination, and seek opportunities for vaccine education. Harm reduction refers to strategies that work to minimise the negative health, social, and economic consequences of lifestyle or health behaviours, in part by identifying and addressing the root causes of specific behaviours. These approaches are based on meeting people where they are in their lives and valuing each client as an individual who lives within the context of a particular culture and community. Clinicians practicing harm reduction - including in the case of vaccination - work in partnership with their clients to create a plan that is consistent with the client's beliefs, abilities, and priorities.

Among the barriers to vaccination that can be recognised and addressed through this process:

• Client barriers: For example, barriers to health care, such as geographic isolation and presence or absence of public transportation, are markers of interlocking structural inequalities that are magnified when combined with limited educational and employment opportunities, racism, discrimination, and stigma. When a clinician views a patient's vaccination status from a personal responsibility framework, this perspective can result in blame for the client's situation being placed on the client, rather than on the embedded social structures that constrain the client. In a 2019 national (US) study, vaccine hesitancy was associated with lower educational levels and household incomes of less than 400% of the federal poverty level. Understanding the root causes of vaccine hesitancy for each client is necessary to develop effective strategies that address the issues directly. Although designed to increase vaccine uptake, vaccine mandates can actually act as a barrier to vaccination when they create resistance to vaccine recommendations.
• Health system and healthcare provider barriers: For example, the absence of a common electronic health record system that allows review of immunisation status across health practice sites can result in a lack of collaboration, inefficient coordination of services, and missed opportunities to vaccinate. However, healthcare provider actions or vaccine policies designed to ensure that no client falls through the gaps can be perceived as coercive or judgmental. Providers who ignore or dismiss client concerns about vaccine safety can cause continued resistance to vaccination, rather than increasing acceptance rates. Healthcare personnel behaviours such as being arrogant or obtaining perfunctory signatures without providing adequate information for genuinely informed consent can affect client willingness to share sensitive health and social information and cause mistrust that can lead to a breakdown in the client-clinician partnership.

The authors argue that using a harm reduction approach can mitigate these barriers and actively improve client-clinician partnerships through strategies including:

• Engaging clients as experts on their own lives - The authors reference the Global Initiative for Asthma (GINA), which provides guidance for developing effective client-clinician partnerships. GINA stresses the need for individualised care that meets each person where they are, takes into consideration personal preferences, and is grounded in shared decision-making. Recommendations to engage with clients include encouraging clients to express their expectations and concerns and retaining cultural humility when considering the client's ability and willingness to participate in what the health care provider considers appropriate self-care. Engaging with clients can be the first step in identifying barriers to vaccination.
• Respecting individual autonomy - Though providers should be mindful of the effect of nonvaccination on the population at large, the principle of autonmony is a cornerstone of the US medical system. A provider can express respect for individual autonomy by being attentive and responsive to each client's cultural and societal norms that are reflective of ethnicity, race, and family dynamics. Use of open-ended questions such as "What are your thoughts about vaccination since last time we spoke?" versus "Are you still against immunisation?" reflect the clinician's respect for the client and a willingness to hear what the client has to say. Also, respect for individual autonomy within a harm reduction framework recognises that clients who make decisions that are discordant with healthcare recommendations can continue to be provided with the same high-quality care, compassion, and dignity as other clients.
• Providing culturally congruent care - Reducing health disparities and improving equity requires recognition of the diversity of clients, including physical and mental ability, gender identity, ancestry, ethnicity, and language needs. For example, thoughtful selection of the words and images used in vaccination outreach education materials can affect the relevance of the information to the viewer. Ideally, racial and cultural images on posters or brochures, the language(s) used, and concordance of the wording, images, and message reflect the populations to be served. Furthermore, the authors stress that, for the value of vaccines to be recognised by people of colour, historical and current violations of trust by the healthcare community must be acknowledged and mitigation efforts actively and visibly initiated. The availability of community health workers, clinicians, and health personnel who participate in vaccination outreach from within minority/diverse populations can improve cultural congruence of vaccine-related care.

The article outlines a number of implications for practice. For instance, in order to address client concerns about vaccine safety and administration, each clinician is expected to be knowledgeable about vaccine benefits, recommendations, side effects, and potential adverse reactions. Vaccination programmes hosted by health professionals such as midwives or primary care providers with accurate and up-to-date knowledge can contribute to public confidence in vaccination. Midwives and primary care providers can also participate in community activities that spread a culture of proactive health behaviours, such as vaccination, and that build trust in community health workers. Infectious disease awareness activities can range from vaccination education programmes for teachers and students in secondary schools, to provision of disease and vaccine information during prenatal care and birth preparation classes, to community programmes about vaccination access for the general public.

Community engagement is a key harm reduction strategy discussed here and involves, for instance, midwives and other clinicians engaging people who are leaders in their communities as active collaborators to increase the credibility of community vaccination programmes. The presence of respected individuals who bring the community together and who are seen as leaders, such as aunties, teachers, tribal leaders, religious leaders, community organisers, and volunteers, can aid in effective planning and implementation of vaccine outreach programmes. These individuals can play a part in messaging, participate in vaccination support tasks, and if they desire, can publicly receive their vaccination to demonstrate their confidence in the vaccine and the immunisation process. This type of social accountability can be further enhanced by signaling vaccine acceptance through a marker of some kind, such as "I got my shot" stickers or vaccine selfies. Visible symbols of vaccine acceptance can cue others about evolving social expectations and local vaccine access.

In conclusion: "The effectiveness of vaccination as a public health measure is dependent on vaccine uptake. Outreach programs can be instrumental in reducing health disparities through improved vaccine access and vaccine acceptance. Clinicians and community members can partner to create robust vaccination outreach programs that are relevant to the communities to be served, meet the need for vaccination, and highlight the health and social benefits of vaccination."