Vaccine Trust in Marginalized Communities With Children's National Hospital

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Tom Haederle
Parents will do anything to keep their kids healthy. Yet many children remain unvaccinated for COVID 19 due to ongoing questions and concerns about the safety of the vaccines. COVID 19 will continue to be a part of our lives for the foreseeable future, so we can't lose sight of the importance of the vaccines for keeping our kids safe and healthy.

00;00;37;03 - 00;01;09;20
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA Communications. In this series on Pediatric COVID 19 vaccine confidence, we'll speak with leaders from children's hospitals from across the country about their vaccine confidence efforts. Today's podcast is a conversation between the AHA's Julia Resnick, director of Strategic Initiatives, and Dr. Claire O'Connell Boogaard, medical director of the COVID-19 vaccine program and a pediatrician at Children's National Hospital.

00;01;09;22 - 00;01;21;20
Tom Haederle
They discussed Dr. Boogaard's efforts to build trust in the vaccine, particularly in the historically marginalized communities in the Washington, D.C. area. Now over to Julia and Dr. Boogaard.

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Julia Resnick
Claire, thanks so much for joining me today. To kick things off. Can you tell me a little bit about your hospital and the community you serve and in your role at the hospital?

00;01;30;12 - 00;01;59;19
Claire O'Connell Boogaard
Sure. So I am a pediatrician who works at Children's National Hospital in Washington, DC, our nation's capital. And it's a unique, large academic center because of its location in Washington, D.C.. Washington, D.C., as you guys know, is a large city, but it's not a state and it's closely surrounded by Virginia and Maryland. So our hospitals, these patients, from what we call the DMV, which is District of Columbia, Maryland, and Virginia.

00;01;59;22 - 00;02;09;14
Claire O'Connell Boogaard
And we see patients for everything from preventative visits to urgent and emergent care specialty visits, and then inpatient and ICU care if needed.

00;02;09;17 - 00;02;10;25
Julia Resnick
And your role there.

00;02;10;27 - 00;02;17;07
Claire O'Connell Boogaard
So I was the COVID 19 vaccine medical director for our patient and families.

00;02;17;10 - 00;02;29;19
Julia Resnick
Excellent. So you're the perfect person to have this conversation with. So can you talk a little bit about the general attitudes towards the COVID 19 vaccine in your community, and you know how that's changed since the vaccine was released?

00;02;29;21 - 00;02;51;03
Claire O'Connell Boogaard
Sure. So the community we take care of is very large. But I think what we saw locally in our region was what people were seeing all over. And that's that there's really three types of people when it came to vaccines, There were the unworried or maybe even eager who were ready to get it, or if it wasn't their priority, would get it with a little bit of convincing.

00;02;51;06 - 00;03;07;12
Claire O'Connell Boogaard
And then there were the skeptical that really wanted to ask important questions and talk to people that they trusted. And then there's still like a smaller ideological group of people that just don't believe in vaccines or don't think that is a healthy way to combat an illness.

00;03;07;14 - 00;03;16;19
Julia Resnick
Yeah. So for those skeptics and the people who were less confident in the vaccine, how did you respond to their concerns when they brought this to you?

00;03;16;21 - 00;03;39;15
Claire O'Connell Boogaard
Sure. I think the hospital responded based on the time during the pandemic that we were talking about. So the vaccine became available to children after it became available to adults and older people, which in our region was around March of 2021. When it first rolled out it was only really available for people who had chronic disease on top of it.

00;03;39;17 - 00;04;00;18
Claire O'Connell Boogaard
This was also a time where some people were waiting and eager to get it, and others, even though they qualified, were still very nervous to get it. And there were hundreds of thousands of people at this point who had died of the COVID 19 infection. And so the hospital had to make choices on how to deliver this scarce resource at the time.

00;04;00;20 - 00;04;23;02
Claire O'Connell Boogaard
And what they chose to do was to really have an equitable approach, which was to offer it to the people that were highest at risk and to schoolteachers actually to help people get back in school. And so that was the first big vaccine event they had in March of 2021. And quickly, with each new development or each change in the vaccine, we were able to offer it to more and more people.

00;04;23;04 - 00;04;43;21
Claire O'Connell Boogaard
And the strategy of being able to offer it to the communities most impacted first was something that was kept throughout the process and also with a goal to get kids back in school and back into their regular routine. I can go into more detail on how that looked throughout the pandemic, but those were the two general approaches from a system standpoint that we took.

00;04;43;24 - 00;04;59;19
Julia Resnick
That's great that you really kept equity front and center. And I know as part of your your organization's greater equity work, you have robust partnerships with community stakeholders. So how did you work with those partners to build trust in the vaccine?

00;04;59;21 - 00;05;18;15
Claire O'Connell Boogaard
It's a great question, and I'm not sure we mastered it if you look at the data. But what I can tell you is we were really proud about a year after offering the vaccine, the majority of people that had received the vaccine from our hospital were people of color, people that lived in high risk neighborhoods. And that was intentional.

00;05;18;17 - 00;05;37;19
Claire O'Connell Boogaard
All of our mass vaccine events had an offering or were only primarily offered in those areas. And any time at the beginning of the pandemic, when we actually had to prioritize all solicited patients, we started with those zip codes as well, because we wanted to get to the families, into the communities that were most impacted by the disease itself.

00;05;37;22 - 00;06;04;04
Claire O'Connell Boogaard
I'm also pediatrician and I see patients in Ward 8, which is essentially like a neighborhood in D.C. That's how we describe them, as wards. And for you guys that can't see me, I am a white woman and I work with a primarily black population. And so I think I have firsthand knowledge of how important trust is to build that relationship, especially that therapeutic relationship around trusting something new.

00;06;04;07 - 00;06;38;24
Claire O'Connell Boogaard
We know from history the black community, especially in America, has been treated completely unfairly and unjustly and the medical community has taken advantage of black patients. And that is known and is very much at the forefront of a lot of people's minds. So what we did from a system standpoint at the hospital was as soon as we could get it available in a convenient fashion, we wanted to get it into the hands of the primary care doctors who had built relationships with patients over time so that they could have these one on one conversations with the parent and the kids in the room.

00;06;38;26 - 00;06;51;29
Claire O'Connell Boogaard
Because what we know from the science but what we actually know anecdotally, too, is that each each parent has a different concern. And you want to be able to address the one that's important to that individual to help them make that choice.

00;06;52;02 - 00;07;01;04
Julia Resnick
So in those communities that you were working in, what messages were resonating and what were those strategies that you were using to really build that trust?

00;07;01;06 - 00;07;22;07
Claire O'Connell Boogaard
Great question. I think no matter what community you're in, including the community I work in, you're talking to a bunch of parents. And parents love their kids and they want the best for their kids. And so the primary things that came up were safety and what we call efficacy  - or how good the vaccine works. Each parent had a different concern related to that, right, like some.

00;07;22;10 - 00;07;46;10
Claire O'Connell Boogaard
And it changed throughout the pandemic because we remember the virus changed throughout the pandemic. So the risk that you could contract the virus would change with each individual family and with each, frankly, almost every month. Right. It would change on what that meant. I mean that by, you talk to a family whose whole family just had COVID 19 and they all had mild symptoms and they're doing fine.

00;07;46;13 - 00;08;10;04
Claire O'Connell Boogaard
There was even a point during the vaccine rollout that you wouldn't recommend that vaccine right away to that family, and you would recommend that later. However, if you were talking to a family who was very anxious and didn't want their kid back in school or sports and their kids were having mental health concerns and they had high risk individuals at home and a lot of mistrust, you would definitely change how you approach that conversation.

00;08;10;06 - 00;08;34;09
Claire O'Connell Boogaard
The strategies we use are pretty basic, but it's really listening to the family and empathizing. I'm a parent myself, and so it's really not hard to empathize with parents who are concerned about giving a new vaccine or try a new strategy to keep their baby safe. And honestly, I don't...whatever community you're in...I worked in various communities over my career.

00;08;34;11 - 00;08;56;14
Claire O'Connell Boogaard
It's the same concerns as wanting to make sure that you keep your kid as safe and as healthy as you can. The problem with the pandemic, though, was that there was risk benefit to every decision you were making, and that risk benefit ratio changed over time. And that was something that we did as a global community, but also something that each individual family, their risk would change the time.

00;08;56;18 - 00;09;08;00
Claire O'Connell Boogaard
And so there really needed to be this broad public health approach, but also really an intimate approach with each family so that they could understand their risks and benefits and be able to answer their own individual questions.

00;09;08;02 - 00;09;23;06
Julia Resnick
Absolutely. And such a universal concern that we all just want to keep our kids safe and understanding what the best way to do that is. The vaccine for kids has been out for a while now. Have you heard changes in what the concerns are? Like, what are you hearing now?

00;09;23;08 - 00;09;52;26
Claire O'Connell Boogaard
The vaccine for children became available for the children 5 to 11 right before the Omicron wave, which was the biggest wave of infections in our country. However, that was also the time at which the vaccine switched from something that was mostly a lower respiratory illness and therefore causing more morbidity and mortality to more of an upper respiratory illness, which is more contagious and therefore could spread easier.

00;09;52;28 - 00;10;14;24
Claire O'Connell Boogaard
But when people got it, they tended to not get sick. This was also a time that was due to the nature of how we develop vaccines, that we give it to the least vulnerable first. And so kids being vulnerable, we tend to offer things to last. People were trying to engage back in their communities. If you remember, you know, just over a year ago and many kids were back in school.

00;10;15;00 - 00;10;37;01
Claire O'Connell Boogaard
And so a lot of families by then had also encountered the virus themselves. There was certainly a lot of fatigue around having to isolate and be inside and a lot of eagerness to get back to regular schedules. And so there were a lot that played in to the decision around children getting vaccines. Not only was it new that was now going to children, but how effective was it going to be?

00;10;37;01 - 00;10;55;27
Claire O'Connell Boogaard
How many doses? Kids don't like any needles. And there were also some system constraints, right? Like your child can't take themselves to the doctor. You have to be able to take off of work and do other things. So I'd say initially it was a lot on safety and efficacy or even what's the point? We all got it. We heard a lot of that.

00;10;55;27 - 00;11;15;22
Claire O'Connell Boogaard
What's the point? We all just got over it. What's the point? It's not as bad now anymore. I heard this vaccine doesn't work as well as that vaccine because there are multiple options. And I was a parent of a five year old at the time that came out. And then I had one like she was older than that, but I had one that also still had to wait.

00;11;15;22 - 00;11;52;10
Claire O'Connell Boogaard
So my family was still split and we didn't even get the freedom if we got that first one. And there were many families like that. So just a lot of exhaustion. And remember, with each new cohort that got it, that that allowed other people to feel safe around you. So if you were one of the the families that had younger kids and still felt like you should isolate either for your own personal preference or for the public preference or the public safety, there was now a lot more temptation out there because people were getting together and convening and restaurants and schools were opening that it just didn't seem as important to stay inside socially, isolate,

00;11;52;10 - 00;12;17;13
Claire O'Connell Boogaard
wear masks, and then the vaccine was part of that, right? Like, what's the point? I can say now we're having more conversations now around the COVID vaccine that remind us of the influenza vaccine discussions that we have annually as pediatricians. Assessing risk is hard for people. The flu virus causes death in like tens of thousands of people a year.

00;12;17;16 - 00;12;41;11
Claire O'Connell Boogaard
But there are many people every year that don't get the flu vaccine, adult or child. And that's because we are used to this being a risk that we have in our environment. COVID 19 is certainly still present, can still morph and change, but we're hoping that when it does, it still stays less virulent or doesn't cause as much damage as previous strains have.

00;12;41;13 - 00;13;02;14
Claire O'Connell Boogaard
But again, this is one of those things that's not mandatory in most states, not mandatory for most schools. So there is an option for the parent to opt in or out. And the parents make that decision sometimes based off of what they're most comfortable with, which is like, fine, I'll do the vaccines you're making me do, but I don't want to do the other ones because I already feel pushed in that direction.

00;13;02;17 - 00;13;23;20
Claire O'Connell Boogaard
Some of them are like, Sure, I understand how vaccines work and I want my kids to have everything, even if it's not that good of a vaccine. I want to get it this year. And I think that the the conversations now are very different than we had a year ago. Year ago, we were still trying to teach people how vaccines work and combat misinformation.

00;13;23;20 - 00;13;34;07
Claire O'Connell Boogaard
I think now we're more in the routine of trying to teach people what their choices are and why it's still a good idea to get, though the risk that people feel is much lower.

00;13;34;10 - 00;14;03;04
Julia Resnick
As you were talking about, I think we're really moving on to a new phase of the pandemic with the public health emergency ending in the spring. So as we're looking forward to you know, this future where we're just living with COVID, what are the the key lessons or takeaways that you learned that you would be helpful to other hospitals and communities as they're still working with their parents and with their patient populations to make sure that people realize how important this vaccine is to enable us to gather into to live in our new normal.

00;14;03;07 - 00;14;22;21
Claire O'Connell Boogaard
I think the hospital systems have to take a public health approach, which means they have to look at who's most at risk and then help them first. That's called health equity. And you can look at that through a bunch of different lenses. With the COVID 19 pandemic, it happened to show disparities around racial lines or neighborhood lines.

00;14;22;21 - 00;14;49;13
Claire O'Connell Boogaard
And that was important to address right away. It's not fair to give protection for people that are lower at risk. So I think that was one thing that everyone needs to consider. The other thing is the importance of recognizing the autonomy of a patient or the family in making this choice and recognizing that we are information givers, but the parent and family are the decision makers.

00;14;49;16 - 00;15;07;15
Claire O'Connell Boogaard
And so our goal is really to listen and provide good information. And I think we all know that, like, you can't force trust. You can't force someone to do anything they don't want to. So just meeting people where they are and saying, I have a knowledge base or I've been trained on something that I can share with you.

00;15;07;17 - 00;15;34;02
Claire O'Connell Boogaard
You don't have to make a decision today if you don't feel comfortable, but I know that you want to keep your child safe and you want to keep them healthy, and so do I. And I think this is by far the better option than the other. And let me tell you why. So the long and short of that, I would say the summary to that is just really recognizing our role as information giving as opposed to like what sometimes the public views us as which is pushing vaccines.

00;15;34;02 - 00;16;08;00
Claire O'Connell Boogaard
And I would say most most providers know this. But from a public perspective, too, that's not what we see our job as. Our job is to teach you why the science shows this is a better option. And frankly, if it's not, we need to be honest and tell you that. And hopefully people listening to this had providers throughout the pandemic that could talk through the nuances and let them feel comfortable that they weren't just making a blanket statement on comfort, but they really looked at the positives and negatives of each choice and made a smart decision on offering the vaccine.

00;16;08;03 - 00;16;28;23
Julia Resnick
Very well put. That human to human connection is just so important in building the trust, and I hope that everyone listening has had that kind of relationship with their provider and has a space to ask those questions and get those get those fears assuaged. So, Claire, thank you so much for joining us today. This is a really wonderful and important conversation.

00;16;28;23 - 00;16;30;21
Julia Resnick
I really appreciate your taking the time.

00;16;30;23 - 00;16;33;24
Claire O'Connell Boogaard
Thank you for having me. It was a delight to be here.

00;16;33;27 - 00;16;44;14
Julia Resnick
Absolutely. For more information about vaccine confidence efforts, visit www.aha.org/vaccineconfidence.

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Tom Haederle
This podcast was funded in part by a cooperative agreement with the Centers for Disease Control and Prevention. The contents of this resource do not necessarily represent the policy of CDC or HHS and should not be considered an endorsement by the federal government.