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Utilizing an Educational Intervention to Enhance Influenza Vaccine Literacy and Acceptance Among Minoritized Adults in Southern Californian Vulnerable Communities in the Post-COVID-19 Era

PMCID: PMC11932246

PMID: 40126324

Abstract

Background/Objectives: Since the COVID-19 pandemic began, vaccination rates for preventable diseases, including influenza, have significantly dropped among racially and ethnically minoritized (REM) individuals in the United States. This study explored the effects of a community-based educational intervention designed to improve influenza vaccine literacy and acceptance among vulnerable REM individuals. Methods: The intervention included four 45 min interactive educational sessions on the influenza vaccine. The session attendees (18+) were invited to participate in a pre-/post-intervention study where an anonymous survey measured their post-COVID-19 pandemic attitudes, knowledge, and behaviors regarding the influenza virus and vaccine. To assess the effect of the intervention on vaccine literacy, we used a Mann–Whitney U test to test for differences between the pre-/post-intervention survey responses to seven knowledge-based questions. Descriptive statistics were employed to assess the impact of intervention on vaccine acceptance. Results: A total of 116 participants completed the pre-intervention survey, and 90 (78%) completed the post-intervention survey. All (100%) identified as REM, and 99% lived in highly vulnerable areas. Only 43% believed they were at risk for viral infection before the intervention, but 60% said the intervention helped them reassess their risk. We found significant differences in vaccine literacy when comparing the pre-/post-intervention survey responses, particularly regarding guideline-based vaccine recommendations ( p < 0.05). Before the intervention, 65% of the participants indicated a high likelihood of receiving the influenza vaccine. In contrast, after the intervention, 81% of respondents indicated a high likelihood of being vaccinated, and 72% indicated that they were “extremely likely” to receive the immunization. Conclusions: Community-based educational interventions can have a positive impact on influenza vaccine literacy and acceptance among vulnerable REM populations in the post-COVID-19 era.

Full Text

The coronavirus disease-19 (COVID-19) pandemic has brought attention to the challenges associated with low vaccination rates among vulnerable groups, particularly racially and ethnically minoritized (REM) individuals, which includes American Indian and Alaska Native, Black, Hispanic/Latino, and Native Hawaiian/Pacific Islander individuals [1,2,3,4]. Specifically, during the peak of the pandemic, REM individuals that identified as either Black, Hispanic/Latino, or American Indian and Alaska Native were approximately twice as likely to die from COVID-19 compared with non-Hispanic White individuals [5,6]. Despite the significant impact of the disease on these REM groups, fewer than 60% of Black, Hispanic/Latino, or American Indian and Alaska Native individuals in the US have completed the recommended full vaccination series for COVID-19, and an even smaller percentage has received the recommended updated booster immunizations [7,8].
The COVID-19 pandemic has also been met with the decreased uptake of vaccines for other preventable diseases, including influenza [9,10]. In 2021, hospitalization rates for influenza were nearly 80% higher among REM adults compared with their non-Hispanic White counterparts [11]. Alarmingly, despite rising infection rates and related health complications, REM individuals were 50% less likely to receive vaccinations during the 2021–2022 influenza season than non-REM individuals [11,12]. As a result, vaccination rates reached some of the lowest numbers seen in the last decade [11,12]. This troubling trend is worsened by the fact that REM individuals are disproportionately affected by chronic diseases, such as diabetes, hypertension, and chronic obstructive pulmonary disease (COPD), which can lead to worse outcomes in infectious diseases [13,14,15,16].
There is limited data on the barriers to influenza vaccine uptake among REM individuals in the post-COVID-19 pandemic era. However, existing research points to inequities in social determinants of health (SDoHs) as significant contributors to disparities in vaccination rates [1,17]. Key factors include a lower socioeconomic status (SES), inadequate education, and limited access to healthcare [17,18,19]. In the US, vulnerable communities characterized by a low SES often have a higher concentration of REM individuals, a situation exacerbated by systemic housing policies that have led to residential segregation [18,20]. These low-SES neighborhoods typically offer fewer educational opportunities and have a larger number of individuals who do not complete high school [21,22]. This lack of education negatively impacts health outcomes, as studies indicate that REM individuals are more likely to have limited health literacy (LHL) [23]. Specifically, research shows that 58% of Black individuals and 41% of Hispanic/Latino individuals have basic or below-basic health literacy [23,24].
A downstream effect of overall low health literacy (LHL) is a lack of vaccine literacy. Lorini et al. describe vaccine literacy to be strongly associated with health literacy [25,26,27]. The authors further define vaccine literacy as people’s and communities’ knowledge, motivation, and competencies to access, understand, and critically appraise and apply information about immunization, vaccines, vaccination programs, and organizational processes to access vaccination. This includes the ability to navigate the health system and make informed decisions about vaccines for themselves, their families, and their communities, as well as to understand the larger global impact of vaccines concerning population health.
Of note, a study conducted in the US found that REM individuals were 13% more likely than White individuals to report being unaware of recommendations for receiving the influenza vaccine [28,29]. This lack of vaccine-related information has been linked to low immunization acceptance across REM groups [29,30]. Furthermore, a deficiency in understanding how vaccines work, as well as their safety and effectiveness, has also been associated with a low acceptance and uptake of the influenza vaccine among REM individuals [29,31,32]. These gaps in vaccine literacy may contribute to the perception of influenza as a mild illness that does not require preventative care, as noted in previous studies that examined barriers to vaccine uptake within REM populations [29,33,34,35].
Vulnerable communities also encounter profound challenges related to healthcare access, which may hinder immunization [36]. During the COVID-19 pandemic, research showed that REM individuals residing in areas with high social vulnerability scores had lower vaccination rates than those with lower vulnerability scores [37]. This disparity in vaccine acceptance and uptake is potentially due to the prevalence of “healthcare deserts” and provider shortages within these communities [38]. The lack of access to healthcare providers restricts the availability of trustworthy and culturally relevant vaccine information that can help individuals make informed decisions about vaccinations [39].
Community-based interventions emerged as effective strategies to rebuild trust and address vaccine literacy and acceptance limitations recognized across REM communities [2,40,41]. In 2021, a community–academic partnership was developed between a faith-based organization (FBO) and an academician from a local university to address the low COVID-19 vaccination rates across vulnerable REM communities in San Bernardino County (SBC), located in Southern California [42,43,44]. The community–academic partnership yielded the creation of a community-based educational intervention that consisted of the academician (a pharmacist by training) providing a 45 min PowerPoint presentation on the COVID-19 virus and vaccine at churches located in vulnerable REM SBC communities to enhance knowledge and encourage acceptance of COVID-19 immunization [42,45]. Research that assessed the baseline and post-changes following the educational sessions revealed increased COVID-19-related vaccine literacy among the participants, particularly related to their knowledge of COVID-19 viral risks and the intricacies associated with vaccine development and availability [45]. The research also revealed a 12% increase in vaccine acceptance among community members after attending these educational sessions [45].
Despite the low cost and widespread ability of influenza vaccines through pharmacies or healthcare providers, low uptake rates were reported across vulnerable REM groups across SBC and surrounding counties following the COVID-19 pandemic [46,47]. To address this, the community–academic team developed a community-based intervention to gather insights on the post-COVID-19 pandemic perspectives of vulnerable SBC residents regarding the influenza virus and vaccine. We also provided tailored education on the influenza virus to promote confidence in the vaccinations. Here, we describe the impact of our educational intervention on the attitudes, literacy, and acceptance of the influenza vaccine among these vulnerable REM individuals.
The intervention, a 45 min vaccine education session, took place from September 2023 to December 2023, a time of heightened viral transmission in the Northern Hemisphere. First, a community–academic team, comprised of a project member from the FBO and an academician, collaboratively identified four church locations in highly vulnerable SBC communities, majorly populated by REM groups, to participate in the intervention. To determine these locations, the Centers for Disease Control and Prevention (CDC) Social Vulnerability Index (SVI) was utilized [4]. The CDC SVI uses census tracts (zip code level data) to determine community-level vulnerability. The index uses four themes: socioeconomic status, household characteristics, racial and ethnic minority status, and housing type and transportation, and stratifies social vulnerability into four categories: low, low-medium, medium-high, and high [4].
Upon review of the literature, the community–academic team was unable to identify a survey tool optimized to assess this study’s aims. Therefore, we developed the survey instruments—using existing literature—to collect information on the attitudes, knowledge, and behaviors of the participants at the baseline and following the intervention [29,32,35,48]. The survey tools were reviewed and validated using face validity by experts in the field. The survey tools were also piloted among REM individuals in a vulnerable SBC community one month (August 2023) before the intervention commenced. These individuals were not included in the final analysis of the results, and the Cronbach alpha value obtained from the pilot assessment was 0.71.
The 24-item pre-intervention survey consisted of three sections, and “flu” was used instead of influenza to prioritize the use of plain language throughout the survey. The first section was focused on collecting information about the participants’ perceptions of viral risks, barriers to receiving the vaccine (such as accessibility and the risk of adverse effects), perceived benefits of vaccination, and the perceived prevalence of vaccine uptake within the US and their respective communities. The health belief model was used to guide the development of this section, as it was used previously to explain and predict individual changes in behaviors related to health promotion and influenza vaccine uptake [49,50]. The second section included seven true or false statements that tested knowledge about the influenza virus, the vaccine, and guideline-based recommendations. The final section contained a single vaccine-acceptance-related question that inquired about the participants’ intent to get vaccinated before receiving education. For the questions in the first and third sections, the respondents provided their answers using Likert scales. The wording of the Likert scale response options was adapted to ensure maximum readability. The pre-intervention survey questions are shown in Supplemental Document S1. Only the individuals who completed the pre-intervention survey were allowed to complete the post-intervention survey.
The 19-item anonymized post-intervention survey was also divided into three sections. The first section evaluated the effectiveness of the education session in influencing participants’ attitudes and perceptions about the influenza virus and vaccine. This section also included a vaccine-acceptance-related question that assessed the level of importance that the participants placed on receiving the influenza vaccine after receiving the tailored education. The second section repeated the seven true-or-false knowledge-based statements from the pre-intervention survey. This repetition aimed to assess the impact of the education session on the participants’ influenza vaccine literacy. The third and final section of the post-intervention survey included two vaccine-acceptance-related questions. The first question in the third section evaluated the participants’ intent to be vaccinated, and the second evaluated their willingness to recommend the vaccine to a family or friend after participating in the educational session. The post-intervention survey questions are shown in Supplemental Document S2. Like the pre-intervention survey, the respondents answered the questions in the first and third sections using a Likert scale.
The sample size estimation analysis concluded that for a moderate effect size (d = 0.50), α = 0.05, and 80% power, a minimum of 35 participants for both surveys would be required. The analysis was conducted using R version 4.4.2 [51].
Paper-based surveys were used during the intervention for the convenience of the participating community members. Directly following the intervention, trained individuals inputted the data into Qualtrics for analysis. We used counts and percentages to summarize the demographic data, which include details on race, ethnicity, gender, age, and SVI collected from the pre-intervention survey. Since only the individuals who completed the pre-intervention survey were eligible to take the post-intervention survey, we did not collect demographic data for the latter. Demographic data are shown in Table 1. Alongside the demographic information obtained from the pre-intervention survey, we also report the percentages of the participants’ responses to questions about their perceptions regarding the following topics: the risks of contracting influenza, challenges to vaccination, the benefits of vaccination, and community-level influenza vaccine uptake. Additionally, we report the counts and percentages to the pre-intervention survey vaccine-acceptance-related question, which inquired about the participants’ baseline intent to be vaccinated. All counts and percentages for the responses to the pre-intervention survey questions are shown in Table 2.
From the post-intervention data, we present the average scores to questions related to the reflecting participants’ attitudes about the effectiveness of the education session in reforming their attitudes about the influenza virus and the vaccine. We also provide the percentage of the individuals who responded with a “5” or “extremely effective”. Additionally, we use percentages to summarize the participants’ reported trust in the information provided in the education session. Furthermore, we report the percentages of the post-intervention survey vaccine-acceptance-related questions that inquired about the participants’ intent to be vaccinated and to recommend the vaccine to others after receiving education. We also report the counts and percentages of the individuals who responded with “4” and “5”, indicating a high likelihood. A bar graph comparison of the percentages of individuals who indicated a high likelihood of vaccination in the pre- and post-intervention surveys is presented in Figure 1. The counts and percentages for the responses to the post-intervention survey questions are shown in Table 3.
To assess the impact of the intervention on vaccine literacy, we compared the correct responses to the seven true or false knowledge-based statements in the second section of the pre-/post-intervention surveys. Mann–Whitney U tests were performed to test for statistical differences between the pre- and post-intervention survey correct responses using non-parametric ranking methods. Figure 2 shows a graphical representation of the comparison of the percentages of correct responses to the seven knowledge-based statements included in the pre-/post-intervention survey. Table S1 shows the counts and percentages of the percentages of correct responses to the seven knowledge-based statements included in the pre-/post-intervention survey. All statistical analysis was performed in R version 4.4.2. and statistical significance was determined as a p-value less than 0.05 (p < 0.05) [51].
A total of 116 participants completed the pre-intervention survey, while 90 (78%) participants completed the post-intervention survey. Among the respondents of the pre-intervention survey, the majority identified as non-Hispanic Black or African American (99/116, 85%), followed by smaller proportions identifying as Hispanic/Latino(a) (9/116, 8%), American Indian or Alaskan Native (1/116, 1%), two or more races (4/116, 3%), and other/unlisted (3/116, 3%). The largest age group represented was those aged 65 or older (51/116, 44%), followed by participants aged 55 to 64 (25/116, 22%). Women comprised 70/116 (60%) of the participants, while men accounted for 46/116 (40%). Nearly all respondents (115/116, 99%) were classified as having a high level of social vulnerability. All demographic data on the baseline survey participants can be found in Table 1.
The participants’ perspectives before the intervention revealed varying levels of knowledge regarding the influenza virus and the vaccine. In response to survey questions about their perceived risk of influenza infection, 47/116 (41%) participants believed it was “unlikely” that they would contract the flu, while 32/116 (28%) thought it was “likely”. Most participants anticipated experiencing “mild” (75/116, 65%) or “negligible” (10/116, 9%) symptoms if infected. Additionally, over half (64/116, 55%) expressed that they were “not worried at all” about severe outcomes, such as hospitalization. Regarding the perceived benefits of the influenza vaccine, 54/116 (47%) rated it as “very effective” at reducing complications, such as hospitalization. Furthermore, 48/116 (41%) believed it was “very effective” at reducing symptom severity. When examining perceived barriers to vaccination, most participants found the vaccine “very affordable” (77/116, 66%) and considered the vaccination process “very convenient” (82/116, 71%). However, 20/116 (17%) perceived a “very likely” chance of experiencing side effects. In terms of participants’ perceptions of community influenza vaccine uptake, 65/116 (58%) thought that “many” people in the US received the vaccine annually, but only 52/116 (45%) believed this was true for their local community. When asked about their intent to receive the influenza vaccine if a convenient and easily accessible location were available, 76/116 participants (65%) indicated a high likelihood (choosing “likely”, “very likely”, or “extremely” on the Likert scale) of getting vaccinated. All counts and percentages of responses to questions that assessed the baseline perceptions of the influenza virus and vaccine can be found in Table 2.
Regarding the trustworthiness of the information provided in the educational session, when asked the following question: “How much do you trust the information provided in the presentation about flu vaccines?”, the participants gave a high average score of 4.87, indicating considerable trust in the educational materials. The average scoring of each question and the counts and percentage of individuals that responded with a “5” (the highest scoring option) are shown in Table 3.
In the post-intervention survey, three questions related to vaccine acceptance were posed. When participants were asked, “How important do you believe it is for you to get the flu vaccine?”, a substantial majority (74/90, 82%) selected “5” on the Likert scale, indicating that they felt receiving the vaccine was “extremely important” (average score: 4.6). Additionally, 84/90 participants (93%) expressed a high likelihood of recommending the vaccine to a family member or friend, selecting either “4” or “5” on the Likert scale (average score: 4.7). Furthermore, 73/90 respondents (81%) indicated they had a high likelihood of receiving the vaccine (selection of “4” or “5”), with an average score of 4.5, and 65/90 participants (72%) stated they were “extremely likely” to receive the vaccine by choosing “5” on the Likert scale. Both scoring percentages were higher than those reported in the pre-intervention survey. The average scores for each of these questions, as well as the counts and percentages of individuals who selected “5” (the highest scoring option), are detailed in Table 3. For the two questions that measured the intent to get vaccinated and the intent to recommend the vaccine to others, we also display the counts and percentages of individuals who responded with “4” and “5”, indicating a high likelihood. A bar graph comparison of the percentages of individuals who indicated a high likelihood of vaccination in the pre- and post-intervention surveys is presented in Figure 1.
When comparing the correct responses to the seven knowledge-based true or false statements included in both the pre-and post-intervention surveys, we saw a significant shift in vaccine literacy from the baseline. Notably, awareness that the influenza vaccine enhanced the immune response changed from 75% before the intervention to 94% afterward (p-value < 0.05). Understanding that stronger influenza vaccines are recommended for older adults rose from 47% to 87% (p-value < 0.05). Additionally, fewer participants believed the vaccine caused influenza, where correct responses increased from 58% to 76% (p-value < 0.05). Knowledge also improved from the baseline concerning the statement that the flu vaccine can still reduce the severity and duration of influenza symptoms, even if it does not cover all types of circulating viruses; the correct responses changed from 84% to 96% (p-value < 0.05). Regarding perceptions about effectiveness, the percentage of respondents that indicated that this year’s flu vaccine is less effective than in most years changed from 76% in the pre-intervention survey to 88% in the post-intervention survey (p-value < 0.05). Furthermore, awareness that the flu vaccine is recommended for everyone, regardless of age or health status, improved from 57% in the baseline survey to 87% (p-value < 0.05) in the post-intervention survey. While we did note a shift in the number of correct responses to the statement “The flu vaccine is unnecessary if you haven’t had the flu in several years” (82% vs. 91%, in the pre-and post-intervention surveys, respectively). This shift was not statistically significant, at a p-value of 0.06 (p > 0.05). A bar graph comparison of the percentages of individuals who responded correctly to the seven knowledge-based true or false statements is shown in Figure 1. The counts and percentages of individuals who responded correctly to the seven knowledge-based true or false statements in the pre-and post-intervention surveys are shown in Table S1.
As concerns grow about the spread of dangerous influenza strains, such as H5N1, and their potential impact on vulnerable REM communities, it is crucial to develop strategies that address barriers to vaccine acceptance [52]. Through our community-based educational intervention, we gained valuable insights into the post-COVID-19 era attitudes of REM individuals regarding the influenza virus and the vaccine. We observed significant improvements in influenza vaccine literacy among REM individuals when comparing pre-and post-intervention survey findings. Additionally, a higher percentage of respondents indicated a high likelihood of receiving the influenza vaccine after the intervention, in contrast to the responses received in the baseline survey.
When examining the attitudes toward the risk of contracting influenza, our study’s results were consistent with findings from previous studies on REM individuals. Most survey participants believed they had little to no risk of contracting the illness. Moreover, many thought that if they did contract the virus, it would have a minimal impact on their health, including the possibility of hospitalization due to pneumonia. This perspective is particularly concerning, as it sharply contradicts the actual risks associated with the virus and its effects on REM communities, especially for Black adults aged 65 and older, who comprised the majority of our study’s participants. A recent study based on pre-pandemic influenza data showed that older patients aged 60 and older were more likely to be hospitalized due to viral infection [53]. More specifically, Black individuals reportedly had the highest age-adjusted hospitalization and intensive care admission (ICU) rates [53]. Vulnerability, including low SES and crowded housing conditions, may contribute to higher hospitalization rates. Another study found that individuals residing in areas with high-poverty census tracts were at a higher risk of severe influenza outcomes [54]. This is an additional troubling fact, as 100% of the individuals included in our study resided in an area of medium-high to high vulnerability. Thus, they were likely at an increased risk of infection despite believing otherwise.
Responses regarding the perceived benefits of vaccination also mirrored those reported in the literature, indicating a general lack of confidence in the vaccine among REM groups. Fewer than 50% of participants believed that the vaccine was “very effective” at preventing the disease, alleviating symptoms, or reducing the risk of complications. Previous studies that explored perceptions of the influenza vaccine among older REM adults showed that many individuals in these groups associate the need for vaccination with being acutely or chronically ill [29,32,48]. This notion of “good health”, combined with the belief that the vaccine is either “moderately effective” or “somewhat effective” at preventing influenza, may contribute to apathetic attitudes toward vaccination.
In addition to perceptions of good health and vaccine benefits, social norms—including vaccine-related attitudes and behaviors of immediate family or close friends—also play a role in influenza vaccine uptake for REM individuals. A prior study survey showed that 36% of Black individuals indicated that their spouse or partner was influential in their vaccine decision, and this was closely followed by their children [32]. In our study, 58% of survey participants believed that “many” of the individuals in the US were vaccinated against influenza each season. Nonetheless, only 45% of the survey participants believed that “many” individuals in their communities were immunized against the virus. These results likely reflect participants’ insights from personal conversations with immediate family members and their broader internal community about the influenza vaccine.
Contrary to previous studies, our survey found that participants did not perceive significant barriers to receiving the vaccine, including concerns about adverse events related to vaccination. Most respondents viewed the vaccine as affordable and convenient to obtain, and 51% indicated they were “unlikely” or “very unlikely” to experience side effects. Notably, 44% of the respondents were over the age of 65, making them eligible to receive vaccinations at no charge through Medicare Part B and Part D [12]. This suggests that the vaccination process is likely both affordable and accessible for this demographic. Furthermore, while concerns about vaccine side effects may have deterred some REM individuals before the COVID-19 pandemic, these concerns may have lessened over time. As global educational efforts regarding respiratory viral vaccinations have progressed, many individuals, especially those aged 65 and older, have received multiple doses since 2021 [7]. Therefore, their real-world experiences with respiratory viral vaccinations may have alleviated previous fears.
Although some perceptions about the influenza virus and vaccine from the pre-intervention survey were concerning, the results of the post-intervention survey demonstrate the significant impact that tailored education from a trusted messenger can have on altering virus-related attitudes. In our study, more than 80% of the individuals who completed the post-intervention survey answered that they trusted the information provided “A great deal”. Previous studies showed that education from a trusted healthcare professional can dissuade negative vaccination-related attitudes among REM individuals. In addition to healthcare providers, religious leaders were also shown to be trusted communicators within REM communities [41,55]. Thus, our strategy of coupling a trusted academician, the FBO, and the lead pastors of the churches in executing the intervention may attest to the positive attitudes regarding the influenza vaccine and virus shown in the post-intervention responses. In general, the presentation was well-received by the post-intervention survey respondents and “extremely effective” at making most participants re-evaluate their own risk for infection and increasing their awareness of the seriousness of influenza and its complications. This shift in perspective was crucial, especially since the pre-intervention survey revealed that participants perceived themselves at low risk for viral infection.
Furthermore, the results from the post-intervention survey indicated that 86% of respondents believed the presentation was “extremely effective” at increasing their general knowledge about the influenza vaccine. This improved vaccine literacy was evident when comparing the selected answers to the seven knowledge-based true or false statements included in both the pre-and post-intervention surveys. We observed a positive change in the selection of correct responses for each question. Notably, when comparing the pre- and post-intervention survey results, there was an 18% difference in correct responses to the statement, “The flu vaccine can cause you to get the flu”. Previous studies showed that more than 30% of Black individuals held the belief that the influenza vaccine could cause viral infection [56]. This misconception was found to contribute to lower vaccination rates among this group [56]. However, our findings suggest that targeted education can significantly change this perception.
Research showed that REM individuals may be unaware of guideline-based vaccination recommendations, particularly older REM adults who often lack knowledge about the stronger influenza vaccines recommended for their age group [29,32,35]. Our tailored educational approach, which focused on these important areas, led to a 30% shift in correct responses to the statement, “The flu vaccine is recommended for everyone, regardless of age or health status”, when comparing the pre- and post-intervention results. Additionally, there was a 40% improvement in the selection of correct responses to the statement, “Stronger versions of the flu vaccine are recommended for older adults (65 years and older)”. This highlights the effectiveness of tailored education in significantly improving influenza vaccine literacy around routine immunizations and the importance of receiving them, even in the absence of acute or chronic illnesses.
Past studies showed that vaccine literacy is a strong predictor of vaccine intention, and our study further supported this finding. In addition to the substantial improvements in the number of correct responses to vaccine knowledge-based statements, we also noted that a higher percentage of post-intervention survey respondents reported a higher likelihood of vaccination following the presentation compared with those who completed the baseline survey (65% vs. 81%). While this improvement in vaccine acceptance could have been due to many factors, receiving a strong recommendation from a trusted healthcare provider was shown to encourage vaccine acceptance among REM individuals [39]. Notably, 82% of the participants in our study expressed trust in the information provided, and more than 65% felt that the presentation effectively addressed their misconceptions or myths about the vaccine. This trust, combined with the alleviation of pre-existing fears or misconceptions, likely contributed to the improved vaccine acceptance observed in the pre-intervention and post-intervention survey results.
Furthermore, more than 90% of respondents in the post-intervention survey indicated they had a high likelihood of recommending the influenza vaccine to a family member or friend. Given the impact of social norms on vaccine acceptance and uptake among REM individuals, it is crucial to empower these individuals to advocate for and recommend the vaccine within their immediate and extended communities [32]. These results showcase that providing access to trustworthy information, disseminated through a trusted healthcare provider, can be transformative for vaccine literacy and acceptance within vulnerable REM communities.

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Despite the significant impact of the disease on these REM groups, fewer than 60% of Black, Hispanic/Latino, or American Indian and Alaska Native individuals in the US have completed the recommended full vaccination series for COVID-19, and an even smaller percentage has received the recommended updated booster immunizations [7,8].\"}, {\"pmc\": \"PMC11932246\", \"pmid\": \"40126324\", \"reference_ids\": [\"B9-idr-17-00018\", \"B10-idr-17-00018\", \"B11-idr-17-00018\", \"B11-idr-17-00018\", \"B12-idr-17-00018\", \"B11-idr-17-00018\", \"B12-idr-17-00018\", \"B13-idr-17-00018\", \"B14-idr-17-00018\", \"B15-idr-17-00018\", \"B16-idr-17-00018\"], \"section\": \"1. Introduction\", \"text\": \"The COVID-19 pandemic has also been met with the decreased uptake of vaccines for other preventable diseases, including influenza [9,10]. In 2021, hospitalization rates for influenza were nearly 80% higher among REM adults compared with their non-Hispanic White counterparts [11]. Alarmingly, despite rising infection rates and related health complications, REM individuals were 50% less likely to receive vaccinations during the 2021\\u20132022 influenza season than non-REM individuals [11,12]. As a result, vaccination rates reached some of the lowest numbers seen in the last decade [11,12]. This troubling trend is worsened by the fact that REM individuals are disproportionately affected by chronic diseases, such as diabetes, hypertension, and chronic obstructive pulmonary disease (COPD), which can lead to worse outcomes in infectious diseases [13,14,15,16].\"}, {\"pmc\": \"PMC11932246\", \"pmid\": \"40126324\", \"reference_ids\": [\"B1-idr-17-00018\", \"B17-idr-17-00018\", \"B17-idr-17-00018\", \"B18-idr-17-00018\", \"B19-idr-17-00018\", \"B18-idr-17-00018\", \"B20-idr-17-00018\", \"B21-idr-17-00018\", \"B22-idr-17-00018\", \"B23-idr-17-00018\", \"B23-idr-17-00018\", \"B24-idr-17-00018\"], \"section\": \"1. Introduction\", \"text\": \"There is limited data on the barriers to influenza vaccine uptake among REM individuals in the post-COVID-19 pandemic era. However, existing research points to inequities in social determinants of health (SDoHs) as significant contributors to disparities in vaccination rates [1,17]. Key factors include a lower socioeconomic status (SES), inadequate education, and limited access to healthcare [17,18,19]. In the US, vulnerable communities characterized by a low SES often have a higher concentration of REM individuals, a situation exacerbated by systemic housing policies that have led to residential segregation [18,20]. These low-SES neighborhoods typically offer fewer educational opportunities and have a larger number of individuals who do not complete high school [21,22]. This lack of education negatively impacts health outcomes, as studies indicate that REM individuals are more likely to have limited health literacy (LHL) [23]. Specifically, research shows that 58% of Black individuals and 41% of Hispanic/Latino individuals have basic or below-basic health literacy [23,24].\"}, {\"pmc\": \"PMC11932246\", \"pmid\": \"40126324\", \"reference_ids\": [\"B25-idr-17-00018\", \"B26-idr-17-00018\", \"B27-idr-17-00018\"], \"section\": \"1. Introduction\", \"text\": \"A downstream effect of overall low health literacy (LHL) is a lack of vaccine literacy. Lorini et al. describe vaccine literacy to be strongly associated with health literacy [25,26,27]. The authors further define vaccine literacy as people\\u2019s and communities\\u2019 knowledge, motivation, and competencies to access, understand, and critically appraise and apply information about immunization, vaccines, vaccination programs, and organizational processes to access vaccination. This includes the ability to navigate the health system and make informed decisions about vaccines for themselves, their families, and their communities, as well as to understand the larger global impact of vaccines concerning population health.\"}, {\"pmc\": \"PMC11932246\", \"pmid\": \"40126324\", \"reference_ids\": [\"B28-idr-17-00018\", \"B29-idr-17-00018\", \"B29-idr-17-00018\", \"B30-idr-17-00018\", \"B29-idr-17-00018\", \"B31-idr-17-00018\", \"B32-idr-17-00018\", \"B29-idr-17-00018\", \"B33-idr-17-00018\", \"B34-idr-17-00018\", \"B35-idr-17-00018\"], \"section\": \"1. Introduction\", \"text\": \"Of note, a study conducted in the US found that REM individuals were 13% more likely than White individuals to report being unaware of recommendations for receiving the influenza vaccine [28,29]. This lack of vaccine-related information has been linked to low immunization acceptance across REM groups [29,30]. Furthermore, a deficiency in understanding how vaccines work, as well as their safety and effectiveness, has also been associated with a low acceptance and uptake of the influenza vaccine among REM individuals [29,31,32]. These gaps in vaccine literacy may contribute to the perception of influenza as a mild illness that does not require preventative care, as noted in previous studies that examined barriers to vaccine uptake within REM populations [29,33,34,35].\"}, {\"pmc\": \"PMC11932246\", \"pmid\": \"40126324\", \"reference_ids\": [\"B36-idr-17-00018\", \"B37-idr-17-00018\", \"B38-idr-17-00018\", \"B39-idr-17-00018\"], \"section\": \"1. Introduction\", \"text\": \"Vulnerable communities also encounter profound challenges related to healthcare access, which may hinder immunization [36]. During the COVID-19 pandemic, research showed that REM individuals residing in areas with high social vulnerability scores had lower vaccination rates than those with lower vulnerability scores [37]. This disparity in vaccine acceptance and uptake is potentially due to the prevalence of \\u201chealthcare deserts\\u201d and provider shortages within these communities [38]. The lack of access to healthcare providers restricts the availability of trustworthy and culturally relevant vaccine information that can help individuals make informed decisions about vaccinations [39].\"}, {\"pmc\": \"PMC11932246\", \"pmid\": \"40126324\", \"reference_ids\": [\"B2-idr-17-00018\", \"B40-idr-17-00018\", \"B41-idr-17-00018\", \"B42-idr-17-00018\", \"B43-idr-17-00018\", \"B44-idr-17-00018\", \"B42-idr-17-00018\", \"B45-idr-17-00018\", \"B45-idr-17-00018\", \"B45-idr-17-00018\"], \"section\": \"1. Introduction\", \"text\": \"Community-based interventions emerged as effective strategies to rebuild trust and address vaccine literacy and acceptance limitations recognized across REM communities [2,40,41]. In 2021, a community\\u2013academic partnership was developed between a faith-based organization (FBO) and an academician from a local university to address the low COVID-19 vaccination rates across vulnerable REM communities in San Bernardino County (SBC), located in Southern California [42,43,44]. The community\\u2013academic partnership yielded the creation of a community-based educational intervention that consisted of the academician (a pharmacist by training) providing a 45 min PowerPoint presentation on the COVID-19 virus and vaccine at churches located in vulnerable REM SBC communities to enhance knowledge and encourage acceptance of COVID-19 immunization [42,45]. Research that assessed the baseline and post-changes following the educational sessions revealed increased COVID-19-related vaccine literacy among the participants, particularly related to their knowledge of COVID-19 viral risks and the intricacies associated with vaccine development and availability [45]. The research also revealed a 12% increase in vaccine acceptance among community members after attending these educational sessions [45].\"}, {\"pmc\": \"PMC11932246\", \"pmid\": \"40126324\", \"reference_ids\": [\"B46-idr-17-00018\", \"B47-idr-17-00018\"], \"section\": \"1. Introduction\", \"text\": \"Despite the low cost and widespread ability of influenza vaccines through pharmacies or healthcare providers, low uptake rates were reported across vulnerable REM groups across SBC and surrounding counties following the COVID-19 pandemic [46,47]. To address this, the community\\u2013academic team developed a community-based intervention to gather insights on the post-COVID-19 pandemic perspectives of vulnerable SBC residents regarding the influenza virus and vaccine. We also provided tailored education on the influenza virus to promote confidence in the vaccinations. Here, we describe the impact of our educational intervention on the attitudes, literacy, and acceptance of the influenza vaccine among these vulnerable REM individuals.\"}, {\"pmc\": \"PMC11932246\", \"pmid\": \"40126324\", \"reference_ids\": [\"B4-idr-17-00018\", \"B4-idr-17-00018\"], \"section\": \"2.1. Study Setting and Design\", \"text\": \"The intervention, a 45 min vaccine education session, took place from September 2023 to December 2023, a time of heightened viral transmission in the Northern Hemisphere. First, a community\\u2013academic team, comprised of a project member from the FBO and an academician, collaboratively identified four church locations in highly vulnerable SBC communities, majorly populated by REM groups, to participate in the intervention. To determine these locations, the Centers for Disease Control and Prevention (CDC) Social Vulnerability Index (SVI) was utilized [4]. The CDC SVI uses census tracts (zip code level data) to determine community-level vulnerability. The index uses four themes: socioeconomic status, household characteristics, racial and ethnic minority status, and housing type and transportation, and stratifies social vulnerability into four categories: low, low-medium, medium-high, and high [4].\"}, {\"pmc\": \"PMC11932246\", \"pmid\": \"40126324\", \"reference_ids\": [\"B29-idr-17-00018\", \"B32-idr-17-00018\", \"B35-idr-17-00018\", \"B48-idr-17-00018\"], \"section\": \"2.2. Pre-/Post-Intervention Survey Study\", \"text\": \"Upon review of the literature, the community\\u2013academic team was unable to identify a survey tool optimized to assess this study\\u2019s aims. Therefore, we developed the survey instruments\\u2014using existing literature\\u2014to collect information on the attitudes, knowledge, and behaviors of the participants at the baseline and following the intervention [29,32,35,48]. The survey tools were reviewed and validated using face validity by experts in the field. The survey tools were also piloted among REM individuals in a vulnerable SBC community one month (August 2023) before the intervention commenced. These individuals were not included in the final analysis of the results, and the Cronbach alpha value obtained from the pilot assessment was 0.71.\"}, {\"pmc\": \"PMC11932246\", \"pmid\": \"40126324\", \"reference_ids\": [\"B49-idr-17-00018\", \"B50-idr-17-00018\", \"app1-idr-17-00018\"], \"section\": \"2.2. Pre-/Post-Intervention Survey Study\", \"text\": \"The 24-item pre-intervention survey consisted of three sections, and \\u201cflu\\u201d was used instead of influenza to prioritize the use of plain language throughout the survey. The first section was focused on collecting information about the participants\\u2019 perceptions of viral risks, barriers to receiving the vaccine (such as accessibility and the risk of adverse effects), perceived benefits of vaccination, and the perceived prevalence of vaccine uptake within the US and their respective communities. The health belief model was used to guide the development of this section, as it was used previously to explain and predict individual changes in behaviors related to health promotion and influenza vaccine uptake [49,50]. The second section included seven true or false statements that tested knowledge about the influenza virus, the vaccine, and guideline-based recommendations. The final section contained a single vaccine-acceptance-related question that inquired about the participants\\u2019 intent to get vaccinated before receiving education. For the questions in the first and third sections, the respondents provided their answers using Likert scales. The wording of the Likert scale response options was adapted to ensure maximum readability. The pre-intervention survey questions are shown in Supplemental Document S1. Only the individuals who completed the pre-intervention survey were allowed to complete the post-intervention survey.\"}, {\"pmc\": \"PMC11932246\", \"pmid\": \"40126324\", \"reference_ids\": [\"app1-idr-17-00018\"], \"section\": \"2.2. Pre-/Post-Intervention Survey Study\", \"text\": \"The 19-item anonymized post-intervention survey was also divided into three sections. The first section evaluated the effectiveness of the education session in influencing participants\\u2019 attitudes and perceptions about the influenza virus and vaccine. This section also included a vaccine-acceptance-related question that assessed the level of importance that the participants placed on receiving the influenza vaccine after receiving the tailored education. The second section repeated the seven true-or-false knowledge-based statements from the pre-intervention survey. This repetition aimed to assess the impact of the education session on the participants\\u2019 influenza vaccine literacy. The third and final section of the post-intervention survey included two vaccine-acceptance-related questions. The first question in the third section evaluated the participants\\u2019 intent to be vaccinated, and the second evaluated their willingness to recommend the vaccine to a family or friend after participating in the educational session. The post-intervention survey questions are shown in Supplemental Document S2. Like the pre-intervention survey, the respondents answered the questions in the first and third sections using a Likert scale.\"}, {\"pmc\": \"PMC11932246\", \"pmid\": \"40126324\", \"reference_ids\": [\"B51-idr-17-00018\"], \"section\": \"2.3. Statistical Analysis\", \"text\": \"The sample size estimation analysis concluded that for a moderate effect size (d = 0.50), \\u03b1 = 0.05, and 80% power, a minimum of 35 participants for both surveys would be required. The analysis was conducted using R version 4.4.2 [51].\"}, {\"pmc\": \"PMC11932246\", \"pmid\": \"40126324\", \"reference_ids\": [\"idr-17-00018-t001\", \"idr-17-00018-t002\"], \"section\": \"2.3. Statistical Analysis\", \"text\": \"Paper-based surveys were used during the intervention for the convenience of the participating community members. Directly following the intervention, trained individuals inputted the data into Qualtrics for analysis. We used counts and percentages to summarize the demographic data, which include details on race, ethnicity, gender, age, and SVI collected from the pre-intervention survey. Since only the individuals who completed the pre-intervention survey were eligible to take the post-intervention survey, we did not collect demographic data for the latter. Demographic data are shown in Table 1. Alongside the demographic information obtained from the pre-intervention survey, we also report the percentages of the participants\\u2019 responses to questions about their perceptions regarding the following topics: the risks of contracting influenza, challenges to vaccination, the benefits of vaccination, and community-level influenza vaccine uptake. Additionally, we report the counts and percentages to the pre-intervention survey vaccine-acceptance-related question, which inquired about the participants\\u2019 baseline intent to be vaccinated. All counts and percentages for the responses to the pre-intervention survey questions are shown in Table 2.\"}, {\"pmc\": \"PMC11932246\", \"pmid\": \"40126324\", \"reference_ids\": [\"idr-17-00018-f001\", \"idr-17-00018-t003\"], \"section\": \"2.3. Statistical Analysis\", \"text\": \"From the post-intervention data, we present the average scores to questions related to the reflecting participants\\u2019 attitudes about the effectiveness of the education session in reforming their attitudes about the influenza virus and the vaccine. We also provide the percentage of the individuals who responded with a \\u201c5\\u201d or \\u201cextremely effective\\u201d. Additionally, we use percentages to summarize the participants\\u2019 reported trust in the information provided in the education session. Furthermore, we report the percentages of the post-intervention survey vaccine-acceptance-related questions that inquired about the participants\\u2019 intent to be vaccinated and to recommend the vaccine to others after receiving education. We also report the counts and percentages of the individuals who responded with \\u201c4\\u201d and \\u201c5\\u201d, indicating a high likelihood. A bar graph comparison of the percentages of individuals who indicated a high likelihood of vaccination in the pre- and post-intervention surveys is presented in Figure 1. The counts and percentages for the responses to the post-intervention survey questions are shown in Table 3.\"}, {\"pmc\": \"PMC11932246\", \"pmid\": \"40126324\", \"reference_ids\": [\"idr-17-00018-f002\", \"app1-idr-17-00018\", \"B51-idr-17-00018\"], \"section\": \"2.3. Statistical Analysis\", \"text\": \"To assess the impact of the intervention on vaccine literacy, we compared the correct responses to the seven true or false knowledge-based statements in the second section of the pre-/post-intervention surveys. Mann\\u2013Whitney U tests were performed to test for statistical differences between the pre- and post-intervention survey correct responses using non-parametric ranking methods. Figure 2 shows a graphical representation of the comparison of the percentages of correct responses to the seven knowledge-based statements included in the pre-/post-intervention survey. Table S1 shows the counts and percentages of the percentages of correct responses to the seven knowledge-based statements included in the pre-/post-intervention survey. All statistical analysis was performed in R version 4.4.2. and statistical significance was determined as a p-value less than 0.05 (p < 0.05) [51].\"}, {\"pmc\": \"PMC11932246\", \"pmid\": \"40126324\", \"reference_ids\": [\"idr-17-00018-t001\"], \"section\": \"3.1. Demographics of Pre-Intervention Survey Participants\", \"text\": \"A total of 116 participants completed the pre-intervention survey, while 90 (78%) participants completed the post-intervention survey. Among the respondents of the pre-intervention survey, the majority identified as non-Hispanic Black or African American (99/116, 85%), followed by smaller proportions identifying as Hispanic/Latino(a) (9/116, 8%), American Indian or Alaskan Native (1/116, 1%), two or more races (4/116, 3%), and other/unlisted (3/116, 3%). The largest age group represented was those aged 65 or older (51/116, 44%), followed by participants aged 55 to 64 (25/116, 22%). Women comprised 70/116 (60%) of the participants, while men accounted for 46/116 (40%). Nearly all respondents (115/116, 99%) were classified as having a high level of social vulnerability. All demographic data on the baseline survey participants can be found in Table 1.\"}, {\"pmc\": \"PMC11932246\", \"pmid\": \"40126324\", \"reference_ids\": [\"idr-17-00018-t002\"], \"section\": \"3.2. Pre-Intervention Perceptions of the Influenza Virus and Vaccine\", \"text\": \"The participants\\u2019 perspectives before the intervention revealed varying levels of knowledge regarding the influenza virus and the vaccine. In response to survey questions about their perceived risk of influenza infection, 47/116 (41%) participants believed it was \\u201cunlikely\\u201d that they would contract the flu, while 32/116 (28%) thought it was \\u201clikely\\u201d. Most participants anticipated experiencing \\u201cmild\\u201d (75/116, 65%) or \\u201cnegligible\\u201d (10/116, 9%) symptoms if infected. Additionally, over half (64/116, 55%) expressed that they were \\u201cnot worried at all\\u201d about severe outcomes, such as hospitalization. Regarding the perceived benefits of the influenza vaccine, 54/116 (47%) rated it as \\u201cvery effective\\u201d at reducing complications, such as hospitalization. Furthermore, 48/116 (41%) believed it was \\u201cvery effective\\u201d at reducing symptom severity. When examining perceived barriers to vaccination, most participants found the vaccine \\u201cvery affordable\\u201d (77/116, 66%) and considered the vaccination process \\u201cvery convenient\\u201d (82/116, 71%). However, 20/116 (17%) perceived a \\u201cvery likely\\u201d chance of experiencing side effects. In terms of participants\\u2019 perceptions of community influenza vaccine uptake, 65/116 (58%) thought that \\u201cmany\\u201d people in the US received the vaccine annually, but only 52/116 (45%) believed this was true for their local community. When asked about their intent to receive the influenza vaccine if a convenient and easily accessible location were available, 76/116 participants (65%) indicated a high likelihood (choosing \\u201clikely\\u201d, \\u201cvery likely\\u201d, or \\u201cextremely\\u201d on the Likert scale) of getting vaccinated. All counts and percentages of responses to questions that assessed the baseline perceptions of the influenza virus and vaccine can be found in Table 2.\"}, {\"pmc\": \"PMC11932246\", \"pmid\": \"40126324\", \"reference_ids\": [\"idr-17-00018-t003\"], \"section\": \"3.3. Post-Intervention Survey Responses on the Impact of the Intervention on Influenza Virus and Vaccine Perceptions\", \"text\": \"Regarding the trustworthiness of the information provided in the educational session, when asked the following question: \\u201cHow much do you trust the information provided in the presentation about flu vaccines?\\u201d, the participants gave a high average score of 4.87, indicating considerable trust in the educational materials. The average scoring of each question and the counts and percentage of individuals that responded with a \\u201c5\\u201d (the highest scoring option) are shown in Table 3.\"}, {\"pmc\": \"PMC11932246\", \"pmid\": \"40126324\", \"reference_ids\": [\"idr-17-00018-t003\", \"idr-17-00018-f001\"], \"section\": \"3.4. Post-Intervention Survey Responses to Vaccine-Acceptance-Related Questions\", \"text\": \"In the post-intervention survey, three questions related to vaccine acceptance were posed. When participants were asked, \\u201cHow important do you believe it is for you to get the flu vaccine?\\u201d, a substantial majority (74/90, 82%) selected \\u201c5\\u201d on the Likert scale, indicating that they felt receiving the vaccine was \\u201cextremely important\\u201d (average score: 4.6). Additionally, 84/90 participants (93%) expressed a high likelihood of recommending the vaccine to a family member or friend, selecting either \\u201c4\\u201d or \\u201c5\\u201d on the Likert scale (average score: 4.7). Furthermore, 73/90 respondents (81%) indicated they had a high likelihood of receiving the vaccine (selection of \\u201c4\\u201d or \\u201c5\\u201d), with an average score of 4.5, and 65/90 participants (72%) stated they were \\u201cextremely likely\\u201d to receive the vaccine by choosing \\u201c5\\u201d on the Likert scale. Both scoring percentages were higher than those reported in the pre-intervention survey. The average scores for each of these questions, as well as the counts and percentages of individuals who selected \\u201c5\\u201d (the highest scoring option), are detailed in Table 3. For the two questions that measured the intent to get vaccinated and the intent to recommend the vaccine to others, we also display the counts and percentages of individuals who responded with \\u201c4\\u201d and \\u201c5\\u201d, indicating a high likelihood. A bar graph comparison of the percentages of individuals who indicated a high likelihood of vaccination in the pre- and post-intervention surveys is presented in Figure 1.\"}, {\"pmc\": \"PMC11932246\", \"pmid\": \"40126324\", \"reference_ids\": [\"idr-17-00018-f001\", \"app1-idr-17-00018\"], \"section\": \"3.5. Pre-Intervention Survey vs. Post-Intervention Survey Responses to the Seven Knowledge-Based True or False Statements\", \"text\": \"When comparing the correct responses to the seven knowledge-based true or false statements included in both the pre-and post-intervention surveys, we saw a significant shift in vaccine literacy from the baseline. Notably, awareness that the influenza vaccine enhanced the immune response changed from 75% before the intervention to 94% afterward (p-value < 0.05). Understanding that stronger influenza vaccines are recommended for older adults rose from 47% to 87% (p-value < 0.05). Additionally, fewer participants believed the vaccine caused influenza, where correct responses increased from 58% to 76% (p-value < 0.05). Knowledge also improved from the baseline concerning the statement that the flu vaccine can still reduce the severity and duration of influenza symptoms, even if it does not cover all types of circulating viruses; the correct responses changed from 84% to 96% (p-value < 0.05). Regarding perceptions about effectiveness, the percentage of respondents that indicated that this year\\u2019s flu vaccine is less effective than in most years changed from 76% in the pre-intervention survey to 88% in the post-intervention survey (p-value < 0.05). Furthermore, awareness that the flu vaccine is recommended for everyone, regardless of age or health status, improved from 57% in the baseline survey to 87% (p-value < 0.05) in the post-intervention survey. While we did note a shift in the number of correct responses to the statement \\u201cThe flu vaccine is unnecessary if you haven\\u2019t had the flu in several years\\u201d (82% vs. 91%, in the pre-and post-intervention surveys, respectively). This shift was not statistically significant, at a p-value of 0.06 (p > 0.05). A bar graph comparison of the percentages of individuals who responded correctly to the seven knowledge-based true or false statements is shown in Figure 1. The counts and percentages of individuals who responded correctly to the seven knowledge-based true or false statements in the pre-and post-intervention surveys are shown in Table S1.\"}, {\"pmc\": \"PMC11932246\", \"pmid\": \"40126324\", \"reference_ids\": [\"B52-idr-17-00018\"], \"section\": \"4. Discussion\", \"text\": \"As concerns grow about the spread of dangerous influenza strains, such as H5N1, and their potential impact on vulnerable REM communities, it is crucial to develop strategies that address barriers to vaccine acceptance [52]. Through our community-based educational intervention, we gained valuable insights into the post-COVID-19 era attitudes of REM individuals regarding the influenza virus and the vaccine. We observed significant improvements in influenza vaccine literacy among REM individuals when comparing pre-and post-intervention survey findings. Additionally, a higher percentage of respondents indicated a high likelihood of receiving the influenza vaccine after the intervention, in contrast to the responses received in the baseline survey.\"}, {\"pmc\": \"PMC11932246\", \"pmid\": \"40126324\", \"reference_ids\": [\"B53-idr-17-00018\", \"B53-idr-17-00018\", \"B54-idr-17-00018\"], \"section\": \"4. Discussion\", \"text\": \"When examining the attitudes toward the risk of contracting influenza, our study\\u2019s results were consistent with findings from previous studies on REM individuals. Most survey participants believed they had little to no risk of contracting the illness. Moreover, many thought that if they did contract the virus, it would have a minimal impact on their health, including the possibility of hospitalization due to pneumonia. This perspective is particularly concerning, as it sharply contradicts the actual risks associated with the virus and its effects on REM communities, especially for Black adults aged 65 and older, who comprised the majority of our study\\u2019s participants. A recent study based on pre-pandemic influenza data showed that older patients aged 60 and older were more likely to be hospitalized due to viral infection [53]. More specifically, Black individuals reportedly had the highest age-adjusted hospitalization and intensive care admission (ICU) rates [53]. Vulnerability, including low SES and crowded housing conditions, may contribute to higher hospitalization rates. Another study found that individuals residing in areas with high-poverty census tracts were at a higher risk of severe influenza outcomes [54]. This is an additional troubling fact, as 100% of the individuals included in our study resided in an area of medium-high to high vulnerability. Thus, they were likely at an increased risk of infection despite believing otherwise.\"}, {\"pmc\": \"PMC11932246\", \"pmid\": \"40126324\", \"reference_ids\": [\"B29-idr-17-00018\", \"B32-idr-17-00018\", \"B48-idr-17-00018\"], \"section\": \"4. Discussion\", \"text\": \"Responses regarding the perceived benefits of vaccination also mirrored those reported in the literature, indicating a general lack of confidence in the vaccine among REM groups. Fewer than 50% of participants believed that the vaccine was \\u201cvery effective\\u201d at preventing the disease, alleviating symptoms, or reducing the risk of complications. Previous studies that explored perceptions of the influenza vaccine among older REM adults showed that many individuals in these groups associate the need for vaccination with being acutely or chronically ill [29,32,48]. This notion of \\u201cgood health\\u201d, combined with the belief that the vaccine is either \\u201cmoderately effective\\u201d or \\u201csomewhat effective\\u201d at preventing influenza, may contribute to apathetic attitudes toward vaccination.\"}, {\"pmc\": \"PMC11932246\", \"pmid\": \"40126324\", \"reference_ids\": [\"B32-idr-17-00018\"], \"section\": \"4. Discussion\", \"text\": \"In addition to perceptions of good health and vaccine benefits, social norms\\u2014including vaccine-related attitudes and behaviors of immediate family or close friends\\u2014also play a role in influenza vaccine uptake for REM individuals. A prior study survey showed that 36% of Black individuals indicated that their spouse or partner was influential in their vaccine decision, and this was closely followed by their children [32]. In our study, 58% of survey participants believed that \\u201cmany\\u201d of the individuals in the US were vaccinated against influenza each season. Nonetheless, only 45% of the survey participants believed that \\u201cmany\\u201d individuals in their communities were immunized against the virus. These results likely reflect participants\\u2019 insights from personal conversations with immediate family members and their broader internal community about the influenza vaccine.\"}, {\"pmc\": \"PMC11932246\", \"pmid\": \"40126324\", \"reference_ids\": [\"B12-idr-17-00018\", \"B7-idr-17-00018\"], \"section\": \"4. Discussion\", \"text\": \"Contrary to previous studies, our survey found that participants did not perceive significant barriers to receiving the vaccine, including concerns about adverse events related to vaccination. Most respondents viewed the vaccine as affordable and convenient to obtain, and 51% indicated they were \\u201cunlikely\\u201d or \\u201cvery unlikely\\u201d to experience side effects. Notably, 44% of the respondents were over the age of 65, making them eligible to receive vaccinations at no charge through Medicare Part B and Part D [12]. This suggests that the vaccination process is likely both affordable and accessible for this demographic. Furthermore, while concerns about vaccine side effects may have deterred some REM individuals before the COVID-19 pandemic, these concerns may have lessened over time. As global educational efforts regarding respiratory viral vaccinations have progressed, many individuals, especially those aged 65 and older, have received multiple doses since 2021 [7]. Therefore, their real-world experiences with respiratory viral vaccinations may have alleviated previous fears.\"}, {\"pmc\": \"PMC11932246\", \"pmid\": \"40126324\", \"reference_ids\": [\"B41-idr-17-00018\", \"B55-idr-17-00018\"], \"section\": \"4. Discussion\", \"text\": \"Although some perceptions about the influenza virus and vaccine from the pre-intervention survey were concerning, the results of the post-intervention survey demonstrate the significant impact that tailored education from a trusted messenger can have on altering virus-related attitudes. In our study, more than 80% of the individuals who completed the post-intervention survey answered that they trusted the information provided \\u201cA great deal\\u201d. Previous studies showed that education from a trusted healthcare professional can dissuade negative vaccination-related attitudes among REM individuals. In addition to healthcare providers, religious leaders were also shown to be trusted communicators within REM communities [41,55]. Thus, our strategy of coupling a trusted academician, the FBO, and the lead pastors of the churches in executing the intervention may attest to the positive attitudes regarding the influenza vaccine and virus shown in the post-intervention responses. In general, the presentation was well-received by the post-intervention survey respondents and \\u201cextremely effective\\u201d at making most participants re-evaluate their own risk for infection and increasing their awareness of the seriousness of influenza and its complications. This shift in perspective was crucial, especially since the pre-intervention survey revealed that participants perceived themselves at low risk for viral infection.\"}, {\"pmc\": \"PMC11932246\", \"pmid\": \"40126324\", \"reference_ids\": [\"B56-idr-17-00018\", \"B56-idr-17-00018\"], \"section\": \"4. Discussion\", \"text\": \"Furthermore, the results from the post-intervention survey indicated that 86% of respondents believed the presentation was \\u201cextremely effective\\u201d at increasing their general knowledge about the influenza vaccine. This improved vaccine literacy was evident when comparing the selected answers to the seven knowledge-based true or false statements included in both the pre-and post-intervention surveys. We observed a positive change in the selection of correct responses for each question. Notably, when comparing the pre- and post-intervention survey results, there was an 18% difference in correct responses to the statement, \\u201cThe flu vaccine can cause you to get the flu\\u201d. Previous studies showed that more than 30% of Black individuals held the belief that the influenza vaccine could cause viral infection [56]. This misconception was found to contribute to lower vaccination rates among this group [56]. However, our findings suggest that targeted education can significantly change this perception.\"}, {\"pmc\": \"PMC11932246\", \"pmid\": \"40126324\", \"reference_ids\": [\"B29-idr-17-00018\", \"B32-idr-17-00018\", \"B35-idr-17-00018\"], \"section\": \"4. Discussion\", \"text\": \"Research showed that REM individuals may be unaware of guideline-based vaccination recommendations, particularly older REM adults who often lack knowledge about the stronger influenza vaccines recommended for their age group [29,32,35]. Our tailored educational approach, which focused on these important areas, led to a 30% shift in correct responses to the statement, \\u201cThe flu vaccine is recommended for everyone, regardless of age or health status\\u201d, when comparing the pre- and post-intervention results. Additionally, there was a 40% improvement in the selection of correct responses to the statement, \\u201cStronger versions of the flu vaccine are recommended for older adults (65 years and older)\\u201d. This highlights the effectiveness of tailored education in significantly improving influenza vaccine literacy around routine immunizations and the importance of receiving them, even in the absence of acute or chronic illnesses.\"}, {\"pmc\": \"PMC11932246\", \"pmid\": \"40126324\", \"reference_ids\": [\"B39-idr-17-00018\"], \"section\": \"4. Discussion\", \"text\": \"Past studies showed that vaccine literacy is a strong predictor of vaccine intention, and our study further supported this finding. In addition to the substantial improvements in the number of correct responses to vaccine knowledge-based statements, we also noted that a higher percentage of post-intervention survey respondents reported a higher likelihood of vaccination following the presentation compared with those who completed the baseline survey (65% vs. 81%). While this improvement in vaccine acceptance could have been due to many factors, receiving a strong recommendation from a trusted healthcare provider was shown to encourage vaccine acceptance among REM individuals [39]. Notably, 82% of the participants in our study expressed trust in the information provided, and more than 65% felt that the presentation effectively addressed their misconceptions or myths about the vaccine. This trust, combined with the alleviation of pre-existing fears or misconceptions, likely contributed to the improved vaccine acceptance observed in the pre-intervention and post-intervention survey results.\"}, {\"pmc\": \"PMC11932246\", \"pmid\": \"40126324\", \"reference_ids\": [\"B32-idr-17-00018\"], \"section\": \"4. Discussion\", \"text\": \"Furthermore, more than 90% of respondents in the post-intervention survey indicated they had a high likelihood of recommending the influenza vaccine to a family member or friend. Given the impact of social norms on vaccine acceptance and uptake among REM individuals, it is crucial to empower these individuals to advocate for and recommend the vaccine within their immediate and extended communities [32]. These results showcase that providing access to trustworthy information, disseminated through a trusted healthcare provider, can be transformative for vaccine literacy and acceptance within vulnerable REM communities.\"}]"

Metadata

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