Complex state COVID vaccine guidelines tied to lower uptake

Complex state COVID-19 vaccine eligibility guidelines lead to confusion about eligibility and may contribute to low uptake, according to a population-based study of US adults published yesterday in JAMA Network Open.

Emory University researchers surveyed a probability sample of US addresses from Mar 3 to Apr 21, 2021, to gauge perceived vaccine eligibility by complexity of state guidelines. Of 898 respondents, the average age was 45 years (range, 18 to 89), and 60% were female.

The team used survey data to classify respondents as eligible or ineligible for COVID-19 vaccines based on survey completion date and policy effective date and applied state guidelines to self-reports of age, occupation, health conditions, and residence in a long-term care facility. Guidelines were categorized as high complexity if they contained more than 150 words and more than 30 eligibility criteria.

The authors noted that the study spanned the early COVID-19 vaccine rollout, when states and the US Centers for Disease Control and Prevention (CDC) issued prioritization guidance amid scarce supplies to protect the most vulnerable.

Balancing precision with clarity

A total of 72% of participants correctly indicated their vaccine eligibility, and 79% correctly indicated that they were ineligible. Participants living in states with more complex vaccine guidelines (ie, California, New York, and Pennsylvania) were less likely than those in states with simpler guidelines (ie, Florida, Georgia, and Texas) to correctly indicate their eligibility (61% vs 78%, respectively; odds ratio [OR], 0.44).

Guideline complexity, however, wasn't tied to correct determination of vaccine ineligibility. Adjustment for age, sex, educational attainment, race, health insurance status, and income didn't appreciably change the results (adjusted OR of correct eligibility determination, 0.40).

The study authors urged health agencies to balance information precision with clarity to increase COVID-19 vaccine coverage. "Higher guideline complexity was negatively associated with correct identification of COVID-19 vaccine eligibility during vaccine scarcity in the US," they wrote. "Increased precision may lead to greater complexity and lower target audience comprehension."

The findings, they said, have potentially large public health implications for complex COVID-19 vaccine guidelines, despite the study being limited by ecological design, social desirability bias, and possible miscategorization.

"More complex vaccine guidelines were associated with lower participant comprehension, potentially hindering eligible persons from seeking vaccines during a period of scarcity," they wrote. "To optimize public health communication, brevity and simplicity should not be undervalued."

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