Date of Award

January 2025

Document Type

Open Access Thesis

Degree Name

Master of Public Health (MPH)

Department

School of Public Health

First Advisor

Lucian L. Davis

Abstract

Objective: To identify system-specific barriers and facilitators to COVID-19 vaccination among older adults (≥65 years) within a large academic healthcare system and to inform future strategies to enhance vaccine uptake.

Methods: This mixed-methods study included six semi-structured interviews with healthcare leaders and staff, a large-scale survey of 42 clinical leaders across 52 ambulatory sites (20 responses), and analysis of administrative data from Yale New Haven Health (2020–2024). Interviews and survey responses were thematically analyzed. Quantitative data on vaccination rates for COVID-19 and influenza were analyzed by age group and year using descriptive statistics and t-tests.

Results: The semi-structured interviews with healthcare leaders and frontline staff across the Yale New Haven Health System provided nuanced insights into the multifactorial challenges affecting COVID-19 vaccine uptake among older adults. Several key themes emerged: (1) Vaccine hesitancy; (2) Logistical challenges; (3) Insurance and Cost Limitation; (4) Physical Patient Barriers; (5) Workforce and documentation errors; (6) Staffing and Training Constraints; (7) Vaccine Access and delivery limitation; and (8) Specialty care specific limitation. In addition to identifying these barriers, interviewees proposed strategic approaches to improve vaccine uptake: (1) On-Site Vaccine Delivery; (2) Staff and workflow optimization; (3) Insurance and financial reform; and (4) Education and trust building. Insights from the interviews informed the development of survey questions that were later distributed to healthcare professionals. From the large-scale survey, four primary challenges to COVID-19 vaccination among older adults were identified: (1) Patient Hesitancy; (2) Challenges Related to Staffs; (3) Operational and Logistical Barriers; and (4) Policy and Financial Constraints. The findings from the quantitative analysis provide support for the patterns observed in the qualitative interviews. Both older (≥65) and younger (18–64) adults exhibited a significant decline in vaccination per visit from 2021 to 2024. For older adults, the vaccination rate significantly declined from1.18 vaccinations per visit in 2021 to just 0.39 in 2024.

Conclusions: Future work should expand on this study through comparative analyses of COVID-19, influenza, and RSV vaccination trends by age and time period. GIS mapping and visit-type stratification could uncover spatial and operational disparities to better inform targeted interventions. An implementation pilot using Plan-Do-Study-Act (PDSA) cycles is planned to improve vaccine delivery in subspecialty clinics. This study was limited to one health system with a small sample size and lacked key demographic data, reducing generalizability and the ability to assess disparities. External vaccine data (e.g., pharmacy-administered doses) were also not captured, and patient perspectives were not included.

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This is an Open Access Thesis.

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