key: cord-0778672-phgd3nj3
authors: Fuchs, Joseph R.; Fuchs, Jeffrey W.; Tietz, Sarah E.; Lum, Hillary D.
title: Older adults with limited English proficiency need equitable COVID‐19 vaccine access
date: 2021-02-24
journal: J Am Geriatr Soc
DOI: 10.1111/jgs.17069
sha: 81726a5e3b258bc254235713e2c752540aaf6ab6
doc_id: 778672
cord_uid: phgd3nj3

nan

Luisa, the daughter of an 80-year-old patient in your clinic, calls to ask if you, as his doctor can help her obtain the coronavirus disease 2019 (COVID-19) vaccine for him. Her family has been praying for months for him to receive a vaccine. She tells you her father recently received an email from his health system that included the words "COVID-19," but he could not understand the rest due to his limited English proficiency. Some of his friends have called the health system to obtain information about scheduling their vaccination appointments, but he is too scared to make the call in English. Luisa, who cares for her children and father and is also working full-time since her husband was laid off because of the pandemic, was recently able to log in to the health system patient portal. Her father's link to schedule a COVID-19 vaccination appointment had expired, so she is turning to you for help.

The impact of the coronavirus disease 2019 (COVID-19) pandemic-over 24 million cases and 400,00 deaths in the United States as of mid-January 2021 1 -does not affect all groups equally. There are large socioeconomic disparities in outcomes for persons in racial/ethnic minority groups, including Hispanic, African-American, and American-Indian communities. [2] [3] [4] Furthermore, older adults face far worse outcomes related to COVID-19, with over 80% of COVID-19 deaths in the United States attributed to patients aged 65 and older. 5 One particular population that requires special attention is older adults with limited English proficiency (LEP), who often experience the intersections of geriatric syndromes, racial or ethnic minority background, lower socioeconomic status, multiple chronic conditions, need for family caregiver involvement, and cultural, neighborhood, or legal influences that affect access to health care.

As of 2019, approximately 8.2% of the total United States population and 8.7% of the population aged 65 and older have LEP, defined as individuals who identify as speaking English less than "very well." 6 Importantly, persons with LEP have lower rates of health literacy and poorer health outcomes, 7 which is of particular concern, given recent studies showing that these populations are also at greater risk for COVID-19 infection. 8 With the recent authorization and deployment of COVID-19 vaccines, it is of the utmost importance that we ensure equitable access to vaccines for persons with LEP. The purpose of this commentary is to raise awareness of health system-and clinic-level interventions to promote access to COVID-19 vaccinations for older adults with LEP.

Recent policy-level efforts aim to prioritize older adult populations and minority communities for equitable vaccine distribution. Some states have modified the COVID-19 vaccine distribution recommendations of the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP) to promote more equitable distribution of vaccinations. 9 For example, the Illinois Department of Public Health allows for individuals aged 65 and older to be vaccinated during phase 1b rather than the recommended age criterion of 75 years by the ACIP to account for the disproportionate number of deaths from COVID-19 in younger black and brown residents. 10, 11 This policy-level intervention promotes timely distribution of COVID-19 vaccines in a way that attempts to further exacerbate disparities in the most at-risk populations. However, it is important to note that the majority of early vaccination efforts relied on health system planning and delivery, rather than the availability of coordinated and broadly accessible public health infrastructure.

At the health system level, some institutions have started utilizing online patient portals to facilitate sign-up for COVID-19 vaccination appointments. 12 Although these electronic health record-based portals provide a centralized option that may reduce time spent on phone calls to schedule appointments and can display appointment availability in real time, they are often inaccessible or burdensome to access and use for many patients, especially older adults. For example, recent results of the National Poll on Healthy Aging have noted 45% of patients 65-80 years of age had not set up an account with their health provider's patient portal. 13 Patient portal access is also difficult for persons with LEP, with one study showing only 4.1% of Spanish-speaking patients activated a patient portal that was offered only in English. 14 Patient portals require patients to have appropriate technology, adequate internet access or data plans, and sufficient English proficiency and health literacy-all of which can be barriers for older adults with LEP. As an example, when one of our health systems conducted an early pilot of sending COVID-19 vaccine scheduling invitations via the patient portal to a random sample of older adults aged 70 and older, we identified clear disparities in the rate of scheduling for vaccine appointments. Ten days after the portal-based invitations were sent, 831 (32.6%) of the 2550 patients aged 70 and older seen in the past year within a geriatric clinic had scheduled a vaccine appointment. Yet among the 254 patients in this clinic who have LEP, only 27 (10.6%) had scheduled a vaccine appointment. Additional health system-and clinic-level efforts are needed to ensure that older adults with LEP receive equitable opportunity to obtain COVID-19 vaccination.

While examining the experiences of older adult patients with LEP during the COVID-19 vaccination process to date, we propose the following measures to promote equitable vaccine access at the health system and clinic levels (Table 1) . At the clinic level, older adults with LEP should be contacted with an interpreter via telephone (or in-person in the context of clinical care) to determine whether they are interested in receiving the vaccine and their preferred location to access the vaccine when multiple options are possible (i.e., clinic/health system, assisted living facility/nursing residence, community location). Patients who choose to receive their vaccine through a larger health system should be offered assistance with scheduling. All patients should have the opportunity to ask questions regarding the vaccine and be provided with accurate information in their preferred language, especially given the high rate of myths about COVID-19 vaccination. These efforts can promote autonomy by allowing patients and their families to independently discuss and evaluate the decision to receive the vaccine. This allows patients to seek clarification and receive education about the vaccination process that may otherwise only be available in English. With early and proactive outreach, patients may be able to appoint a trusted family member, friend, or caregiver who can assist them in scheduling their vaccination when it is offered to them. This is especially important for older adults with LEP who are more likely to have cognitive, vision, or hearing impairments compared with younger populations and those who are proficient in English. 15 Family or caregiver involvement in vaccination scheduling may allow for better support of older adults with LEP who have multifactorial geriatric issues and social determinants of health needs.

Health system-level efforts to work within patients' communities are also critical to ensure equitable vaccination access. First, we recommend that patients with LEP be provided patient education materials in their preferred language regarding the COVID-19 vaccine. Some of these resources already exist and are ready for distribution, including the Emergency Use Authorization Fact Sheets for the Pfizer-BioNTech and Moderna vaccines, which are currently available in over 20 languages on the FDA website. 16 Second, health systems should engage community organizations, churches, and other faith-based organizations for vaccine education and distribution through partnerships such as mobile, community-based vaccine clinics, and free, accessible, virtual panels with trusted community experts. This allows for a second access point for information about the vaccine in an environment that may be more comfortable, trusted, and accessible for older persons and their family caregivers. With these measures, we can help ensure that older adults with LEP are provided numerous resources and opportunities to receive the COVID-19 vaccination.

Although we applaud efforts that provided over 12 million individuals with their first dose of the COVID-19 vaccine in the United States by mid-January 2021, there is considerable work to be done to ensure the process of COVID-19 vaccine distribution does not further exacerbate health disparities. 17 By collaborating with older adults with LEP and their family caregivers, both at the health system and clinic levels, we can help reduce inequities in vaccine administration. Although these recommendations emphasize the specific needs for older adults with LEP at this stage of COVID-19 vaccine distribution, many of these ideas (and lessons we are learning through rapid, iterative, implementation) can apply to all persons with LEP of any age, other underserved communities, and older adults with complex needs including those with cognitive, vision, or hearing impairments. Integrating these initial proposals is a necessary step toward a more equitable path to recovery from the COVID-19 pandemic, and sustaining measures that effectively serve persons with LEP can help address other public health emergencies and situations that exacerbate social disparities.

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COVID-19 and African Americans

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Illinois will Make Coronavirus Vaccine Available to Residents 65 and Older in Next Phase of Inoculations

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45% of Adults Over 65 Lack Online Medical Accounts, Which Could Affect COVID-19 Vaccination

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Older adults with limited English proficiency need equitable COVID-19 vaccine access

The authors report no conflicts of interest related to this work.

All authors contributed to the article concept and recommendations. All authors contributed to the manuscript preparation.

ORCID Hillary D. Lum https://orcid.org/0000-0001-5637-3912 TWITTER Hillary D. Lum @HDayLum