Healthcare worker perspectives on system-level barriers to hepatitis B birth dose vaccination: An analysis in five urban U.S. hospitals

ABSTRACT

Despite three decades of recommendations, hepatitis B birth dose vaccination coverage remains suboptimal at 81.5% nationally, falling short of other routine immunizations and public health targets. This study examined implementation practices across five Washington, DC birthing hospitals through semi-structured interviews with 36 healthcare workers representing professional roles. While providers demonstrated strong support for vaccination, with 94% routinely recommending the birth dose for newborns, significant system-level barriers emerged that impede optimal delivery. Only 69% consistently recommended vaccination for premature infants, revealing concerning practice variability and knowledge gaps regarding weight-based guidelines. Critical infrastructure deficiencies included widespread unawareness of vaccination tracking systems (64% uncertain), complete absence of designated vaccine champions, minimal leadership engagement, and severely limited provider training – with only 19% receiving regular education on birth dose importance and 86% lacking training to address vaccine hesitancy. Electronic reminder systems were absent (17% utilization), despite proven effectiveness. Although parent education showed better implementation with literacy-appropriate materials and multi-modal communication strategies, the disconnect between robust provider support and weak institutional systems represents a fundamental implementation failure. Addressing these modifiable barriers through systematic quality improvement initiatives, enhanced monitoring infrastructure, and comprehensive workforce development could substantially improve vaccination coverage and advance perinatal hepatitis B elimination goals.

Introduction

Perinatal hepatitis B virus (HBV) transmission represents a critical global health challenge, with infected newborns facing a 90% risk of developing chronic infection and subsequent complications including cirrhosis and hepatocellular carcinoma.¹ The hepatitis B birth dose vaccine, administered within 24 h of delivery, stands as one of modern medicine’s most effective interventions for preventing vertical transmission, demonstrating 75–95% efficacy when implemented optimally.²

Since the Advisory Committee on Immunization Practices (ACIP) established universal newborn vaccination recommendations in 1991, the United States has achieved remarkable progress, with acute hepatitis B infections among children and adolescents declining by 98%.³ Under the Vaccines for Children program and Affordable Care Act mandates, hepatitis B vaccines are available at no cost regardless of insurance status, ensuring universal access.⁴

Despite these profound public health achievements, substantial implementation challenges persist across the healthcare delivery continuum. Current Centers for Disease Control and Prevention surveillance (CDC) data reveal that only 81.5% of infants born during 2019–2020 received timely hepatitis B vaccination – a coverage rate that falls below the 90% threshold achieved by other routine childhood immunizations and remains short of the Healthy People 2030 target of 85%.³ Notably, the COVID-19 pandemic did not significantly disrupt inpatient neonatal hepatitis B vaccination uptake,⁵ suggesting that systemic gaps predate the pandemic. Achieving global hepatitis B elimination – a key World Health Organization (WHO) target by 2030 – will require sustained efforts to reach 90% vaccination coverage.⁶

Contemporary evidence suggests that successful birth dose implementation requires sophisticated understanding of hospital-level factors including organizational culture, leadership engagement, infrastructure capabilities, and quality improvement initiatives.⁷ However, the extent to which these evidence-based practices have been adopted across diverse healthcare settings remains poorly characterized, particularly in urban environments serving demographically complex populations.

From an implementation science perspective, the persistent gap between evidence and practice suggests that traditional approaches focused primarily on clinical guidelines and provider education have proven insufficient to address the multifaceted barriers operating within healthcare delivery systems.⁸ Theoretical frameworks such as the Consolidated Framework for Implementation Research (CFIR) emphasize that successful intervention adoption requires alignment across multiple domains including intervention characteristics, outer setting factors, inner setting organizational attributes, individual provider characteristics, and implementation processes.⁹

Given these considerations, comprehensive assessment of current implementation practices across diverse institutional contexts is essential for identifying modifiable barriers and developing evidence-based improvement strategies. This study aimed to examine hepatitis B birth dose implementation across Washington, DC’s major birthing hospitals, systematically investigating institutional protocols, provider practices, and multilevel facilitators and barriers through a research approach grounded in implementation science theory.

Methods

Study design and theoretical framework

We employed a concurrent embedded mixed methods design grounded in the CFIR to examine multi-level factors influencing hepatitis B birth dose delivery.⁹ This approach enabled simultaneous collection of quantitative metrics and qualitative insights to comprehensively assess implementation contexts across participating institutions, with quantitative survey data as the primary component and qualitative data providing contextual depth.

Setting and participants

The study was conducted across five major birthing hospitals in Washington, DC: Sibley Memorial Hospital, George Washington University Hospital, Georgetown University Hospital, MedStar Washington Hospital Center, and Howard University Hospital. These facilities collectively account for approximately 15,000 annual births, representing approximately 75% of all hospital births in the District of Columbia. The participating hospitals serve demographically diverse populations with varying socioeconomic characteristics. Washington, DC was selected to provide a concentrated healthcare delivery system serving diverse populations within a defined geographic area, enabling comparative analysis while controlling for state-level policy variations.

Eligible participants included healthcare workers directly involved in perinatal care: neonatologists, pediatricians, obstetricians, nurses, nurse practitioners, pharmacists, and medical trainees. We employed purposive sampling to ensure representation across professional roles and institutions, followed by snowball sampling to identify additional key informants.

Survey development and validation

The survey instrument was developed through systematic processes incorporating literature review, expert consultation, and pilot testing with five healthcare workers from different professional roles, resulting in three amendments to improve clarity and feasibility. The final 30-item instrument was structured around CFIR domains: (1) intervention characteristics, (2) outer setting factors, (3) inner setting organizational attributes including structural characteristics and implementation climate, (4) individual provider characteristics, and (5) implementation processes including training and quality improvement initiatives. Response formats included 5-point Likert scales, multiple-choice questions, and open-ended prompts for contextual elaboration.

Data collection procedures

Data collection occurred between November 2024 and April 2025 via synchronous videoconferencing interviews lasting 15–20 min. The survey instrument was developed and administered in English only, as all healthcare worker participants were English-proficient medical professionals practicing in the participating institutions. After obtaining verbal informed consent, trained research assistant administered the survey while simultaneously recording responses in a structured database. Participants provided quantitative responses while offering spontaneous qualitative elaborations captured verbatim.

Nonparticipation occurred due to: scheduling conflicts (36.9%), declined without reason (22.0%), unable to contact (12.8%), and ineligibility due to limited newborn care involvement (2.8%). Response rates varied by professional role, with nurses showing higher participation compared to physicians.

Participants received a modest Amazon eGift Card for their time. The study protocol was reviewed by the George Washington University Institutional Review Board and determined exempt (Protocol # NCR245913).

Statistical analysis

Quantitative data were analyzed using IBM SPSS Statistics version 29. Descriptive statistics characterized participant demographics and response distributions. Chi-square tests examined associations between hospital characteristics and implementation practices, with Fisher’s exact test applied for cell counts <5.

Qualitative data were analyzed using thematic analysis in ATLAS.ti (version 23). A team member (SS) independently developed a coding framework based on CFIR constructs and refined the codebook through iterative review. For independent coding, coder 1 (SS) created a duplicate file for coder 2 (JS), retaining the selected quotations but removing all prior codes. Coder 2 then independently coded the excerpts. Interrater agreement was assessed, with an initial coding agreement of 87%. Discrepancies were resolved through team discussion, resulting in 100% consensus. Emerging themes were examined in relation to CFIR constructs. Finally, quantitative and qualitative data were integrated using comparison matrices and narrative weaving to provide a comprehensive understanding of implementation contexts.¹⁰

Results

Participant characteristics

Of 141 healthcare workers contacted, 36 (25.5%) completed interviews. Participants represented all five hospitals: Howard University (n = 9, 25%), Georgetown (n = 9, 25%), GWU (n = 8, 22.2%), Sibley (n = 5, 13.9%), and Washington Hospital Center (n = 5, 13.9%). The sample was predominantly female (83.3%) and racially diverse. Registered nurses constituted the majority (n = 22, 61.1%), followed by neonatologists (n = 12, 33.3%). Notably, 31 participants (86.1%) provided direct newborn care. Table 1 presents detailed demographic characteristics by professional role.

Table 1.

Participant demographics by professional role.

Role	n	Age Distribution	Race/Ethnicity	Gender
Neonatologist	12	35–44: 7 (58.3%); 45–54: 3 (25.0%); 55–64: 2 (16.7%)	White: 3 (25.0%); Black: 1 (8.3%); Asian: 6 (50.0%); Other: 2 (16.7%)	Female: 9 (75.0%); Male: 3 (25.0%)
Registered Nurse	22	25–34: 6 (27.3%); 35–44: 8 (36.4%); 45–54: 7 (31.8%); 55–64: 1 (4.5%)	White: 11 (50.0%); Black: 7 (31.8%); Asian: 2 (9.1%); Other: 2 (9.1%)	Female: 21 (95.5%); Male: 1 (4.5%)
Other*	2	25–34: 1 (50.0%); 45–54: 1 (50.0%)	White: 2 (100%)	Female: 1 (50.0%); Male: 1 (50.0%)

*Includes one nurse practitioner and one neonatology resident.

Provider-level vaccination practices

Nearly all participants (n = 34, 94.4%) reported “always” or “usually” recommending hepatitis B vaccination for healthy term infants, with only 2 (5.6%) reporting they “never” recommend vaccination. However, recommendations for premature infants^11,12 showed substantially greater variability – only 25 participants (69.4%) always/usually recommended vaccination for premature infants, while 7 (19.4%) occasionally recommended, and 4 (11.1%) never recommended, revealing a concerning 25% point gap between healthy and premature infant vaccination recommendations.

Spontaneous comments revealed weight-based decision-making as the primary driver of practice variation, with concerning inconsistencies in guideline interpretation. As one neonatologist from an academic medical center explained: “Our protocol is clear – infants under 2 kilograms don’t receive the birth dose unless the mother is HBsAg-positive. But there’s confusion about whether this applies to all NICU (neonatal intensive care unit) admits or just those meeting the weight criteria.” Additional responses highlighted temporal considerations: “It depends on the weight. If the newborn is less than 2 kg or 30 d of life, we don’t give it” (Neonatologist, University Hospital). This suggests potential conflation of weight and age criteria that may lead to inappropriate vaccination delays.

Regarding ordering responsibilities, 26 participants (72.2%) identified pediatric providers as primarily responsible, while 2 (5.6%) cited obstetric providers, 1 (2.8%) noted registered nurses, and 7 (19.4%) cited shared responsibility models across provider types.

Hospital infrastructure and policies

Analysis of order set utilization revealed marked differences between healthy and NICU infant populations. Admission order sets predominated for healthy newborns (n = 25, 69.4%), while NICU infants showed fragmented approaches including discharge order sets, standing orders, and facility-specific protocols.

Substantial infrastructure gaps emerged. Most participants (n = 23, 64%) were unaware whether their hospitals tracked vaccination rates, with only 10 (27.8%) confirming active tracking and 3 (8.3%) stating no tracking occurred. Table 2 reveals concerning institutional knowledge gaps – only one participant across all five hospitals confirmed vaccination rate tracking, while hospital-specific hepatitis B policies were confirmed by just 10 participants (27.8%) overall.

Table 2.

Hospital-specific implementation characteristics by institution.

Hospital	Track HepB Vaccination Rates (n, %)	Have HepB Vaccine Policy in Place (n, %)	Leadership/QI Projects (%)	Training/Hesitancy Training (%)	Term/Premature Recommendations (%)
Sibley Memorial (n = 5)	0 (0%)	2 (40%)	0%/0%	20%/20%	100%/60%
Howard University (n = 9)	0 (0%)	2 (22%)	11%/22%	11%/11%	89%/78%
George Washington (n = 8)	0 (0%)	3 (38%)	0%/25%	25%/13%	100%/75%
Georgetown (n = 9)	0 (0%)	3 (33%)	11%/0%	22%/11%	100%/56%
Washington Hospital Center (n = 5)	1 (20%)	0 (0%)	0%/0%	20%/20%	80%/80%

No participants identified a designated “hepatitis B champion,” with 26 (72.2%) confirming this role’s absence and 10 (27.8%) uncertain across all institutions. Evidence-based strategies showed poor adoption: delivery room availability (n = 7, 19.4%) and electronic reminder systems (n = 6, 16.7%) were rarely implemented, despite strong evidence supporting these interventions.

Participants identified systematic vaccination strategies with variable implementation: standardized post-delivery protocols (n = 29, 80.6%), staff training (n = 28, 77.8%), parent education (n = 28, 77.8%), and maternity ward vaccine availability (n = 25, 69.4%). However, evidence-based strategies showed poor adoption: delivery room availability (n = 7, 19.4%) and electronic reminder systems (n = 6, 16.7%) were rarely implemented, despite strong evidence supporting these interventions.

Additional hospital-level strategies showed broader endorsement: checklists (n = 28, 77.8%), leadership advocacy (n = 27, 75%), discharge policies (n = 26, 72.2%), and family communication protocols (n = 25, 69.4%).

Quality improvement and training

Leadership engagement was notably limited across all institutions (Table 3). Only 2 participants (5.6%) reported department chair involvement, 7 (19.4%) noted hospital leadership engagement, and just 1 (2.8%) indicated quality improvement/quality assurance (QI/QA) participation.

Table 3.

Leadership and quality improvement engagement by hospital.

Hospital	Department/Division Chair Involvement	Hospital Leadership Role	QI/QA Role Engagement
	No	Yes	No
Sibley Memorial	5 (100%)	0 (0%)	5 (100%)
Howard University	8 (89%)	1 (11%)	7 (78%)
George Washington	8 (100%)	0 (0%)	6 (75%)
Georgetown	8 (89%)	1 (11%)	6 (67%)
Washington Hospital Center	5 (100%)	0 (0%)	5 (100%)
Total	34 (94%)	2 (6%)	29 (81%)

Only 5 participants (13.9%) reported awareness of quality improvement projects targeting hepatitis B vaccination. Regular training on birth dose importance was reported by only 7 participants (19.4%), despite nearly half (n = 17, 47.2%) believing additional training was needed. Standardized training to address vaccine hesitancy was particularly lacking: 31 participants (86.1%) reported no training for addressing staff concerns, and 24 (66.7%) lacked training for parent concerns.

One nurse manager from a community hospital noted: “We get extensive training on other vaccines, but hepatitis B is often assumed to be routine. New staff might not understand why timing matters so much or how to respond when parents have questions.”

Parent education and communication

Parent education showed relatively better implementation. Most participants (n = 23, 63.9%) confirmed educational materials in admission packets, though 13 (36.1%) were uncertain. Nearly all reported parent refusals occurred only “occasionally” (n = 34, 94.4%).

Communication strategies¹⁰ included multiple modalities: face-to-face discussions (n = 35, 97.2%), consent forms (n = 34, 94.4%), and printed materials (n = 33, 91.7%). Washington Hospital Center was the only facility where participants reported fewer than three communication strategies.

Importantly, 31 participants (86.1%) reported education materials were tailored for diverse literacy levels. As one participant explained: “We have materials in multiple languages and use pictures to explain the vaccine’s importance. The challenge isn’t the materials – it’s finding time for meaningful conversations during the hectic post-delivery period.”

Direct patient care provision

Table 4 illustrates care responsibilities across professional roles, highlighting nurses’ predominant role in newborn care delivery. With 31 of 36 participants (86.1%) providing direct newborn care, this finding underscores the critical importance of nurse-focused training and engagement strategies for successful implementation.

Table 4.

Direct newborn care provision by role and hospital.

Hospital	Role	Performs Direct Care	Performs Newborn Care
		No	Yes
Sibley Memorial	Neonatologist	0	2
	Registered Nurse	0	3
Howard University	Neonatologist	0	4
	Registered Nurse	2	3
George Washington	Neonatologist	0	1
	Resident	0	1
	Registered Nurse	1	5
Georgetown	Neonatologist	0	3
	Nurse Practitioner	0	1
	Registered Nurse	2	3
Washington Hospital Center	Neonatologist	0	2
	Registered Nurse	0	3

Hospital-specific implementation patterns

Table 2 further reveals substantial variation in implementation characteristics across hospitals. Washington Hospital Center was notable as the only institution where any respondents confirmed vaccination tracking (20%), though policy awareness was paradoxically lowest (0%). Georgetown University Hospital showed the largest practice variation, with a 44% point gap between term and premature infant vaccination recommendations. Howard University Hospital demonstrated the highest engagement in quality improvement initiatives (22% of respondents). Notably, no hospital achieved comprehensive implementation across all measured domains.

Discussion

This study provides critical insights into the complex implementation landscape surrounding hepatitis B birth dose vaccination in a major metropolitan area. Despite strong provider endorsement and established clinical guidelines, substantial system-level barriers impede optimal vaccine delivery.

Alignment with national best practices

Our findings reveal complex interactions across CFIR domains that collectively impede optimal birth dose implementation. While individual characteristics showed strong provider support (94% recommendation rates), inner setting structural characteristics and implementation climate emerged as primary barriers. The absence of designated champions, electronic reminder systems, and systematic monitoring represents critical infrastructure gaps that prevent systematic improvement.¹³

The marked variation in practices between term and premature infant populations suggests confusion about weight-based guidelines that could be addressed through standardized protocols and enhanced training. However, the minimal leadership engagement and absence of quality improvement initiatives indicate that successful interventions will require comprehensive organizational commitment rather than individual-level education alone.

The premature infant challenge

The 25% gap in vaccination recommendations between term and premature infants warrants particular attention. While CDC guidelines appropriately recommend deferring vaccination for infants <2,000 grams born to HBsAg-negative mothers, our qualitative findings suggest confusion about applying these criteria. This uncertainty may lead to missed opportunities among eligible premature infants >2,000 grams or unnecessary delays for those approaching discharge.

Recent evidence suggests structured protocols and weight-based order sets can minimize inappropriate deferrals while maintaining clinical safety.^14,15 The variation in order set utilization between healthy and NICU populations suggests opportunities for standardization that could reduce practice variability.

Infrastructure and quality improvement gaps

Perhaps most concerning was the widespread lack of monitoring infrastructure and quality improvement initiatives. With 69% of participants unaware of vaccination tracking at their hospitals (Table 2), institutions lack fundamental data for identifying improvement opportunities. This finding aligns with research showing only approximately 40% of birthing hospitals regularly monitor birth dose rates.¹⁶

The minimal leadership engagement documented in Table 3 – with less than 20% hospital leadership involvement and virtually no QI/QA participation – represents a critical barrier to systematic improvement. Successful QI initiatives require executive sponsorship and dedicated resources, elements notably absent across participating institutions.

Training and workforce development

The striking absence of systematic training programs – with only 19% receiving regular education and 86% lacking hesitancy-focused training – reveals a fundamental workforce development gap.¹⁷ This finding gains significance considering emerging evidence linking provider confidence to vaccination rates.¹⁸

The predominance of nurses in direct newborn care (Table 4) underscores the importance of nurse-focused training initiatives. Effective programs should address both clinical knowledge and communication skills, with simulation-based training showing particular promise.

International context and lessons

While the primary barriers to timely hepatitis B birth dose administration vary by context, the strategies to address them are frequently comparable. In many low- and middle-income countries (LMICs), the main barriers are structural – high proportions of out-of-facility births, intermittent vaccine supply and cold-chain gaps, limited maternal HBsAg screening, and workforce shortages.¹⁹ Programs that have raised hepatitis B birth dose to ≥90% in LMIC contexts typically pair simple, standardized protocols with point-of-care delivery (maternity-ward administration within 24 h), outreach for home births, and basic monitoring (facility registers with monthly review).²⁰ Where allowed, temperature-flexible handling policies and task-sharing to midwives or community health workers further reduce missed opportunities.

High-income countries (HICs) face a different bottleneck profile.²¹ With financing and supply largely solved, underperformance is most often tied to hospital system factors – order-set design, role clarity at the bedside, absence of unit-level champions, weak feedback loops, and inconsistent training on special populations (e.g., <2,000 g infants). HICs that sustain >90% timely hepatitis B birth dose commonly share three features: embedded Electronic Health Record (EHR) prompts, routine ward-level dashboards with leadership oversight, and standing protocols that cover both well-baby and NICU workflows.²²

Bidirectional lessons follow. The U.S. can borrow LMIC strengths in simplicity – uniform, one-page protocols, bedside checklists, and outreach thinking for births that fall outside standard pathways. Conversely, LMIC programs can adapt U.S. practices – universal maternal screening with linkage to case management, basic electronic or paper dashboards, and protected time for a vaccine champion – to accelerate both coverage and equity.

Implications for practice and policy

Our findings illuminate a critical implementation paradox that demands immediate and coordinated action across multiple organizational levels. The disconnect between robust provider support and failing institutional infrastructure suggests that traditional educational interventions alone will be insufficient to improve birth dose coverage. Instead, hospitals must prioritize the development of comprehensive monitoring systems that leverage electronic health record capabilities to provide real-time vaccination tracking and automated performance feedback to clinical teams. Such systems have demonstrated the ability to increase vaccination rates by approximately 15% in similar contexts and provide the foundational data necessary for continuous improvement efforts.²³

The complete absence of designated vaccine champions across all participating institutions represents a particularly actionable opportunity for rapid improvement. Evidence from successful hepatitis B vaccination programs demonstrates that empowered clinical champions, when provided with protected time and institutional support, can drive substantial increases in coverage through peer education, protocol standardization, and sustained advocacy.^24–26 This leadership role becomes especially critical for addressing the concerning variability in premature infant vaccination practices, where clear weight-based protocols integrated into admission and discharge order sets could eliminate current confusion while maintaining appropriate clinical safeguards.

Beyond structural changes, our findings underscore the urgent need for systematic workforce development that moves beyond sporadic in-service training to comprehensive competency-based education. Institutions should mandate regular education that integrates clinical knowledge with evidence-based communication strategies. A presumptive approach, paired with listening, and pre-bunking, can improve vaccine acceptance. Trust-building, value-aligned messaging, and social norms further boost confidence. While some parents may initially decline, ongoing dialogue increases the chance of future acceptance.²⁷ This training investment must be coupled with visible executive leadership engagement, as the current absence of department chair and hospital leadership involvement creates a cultural vacuum that undermines frontline improvement efforts. Finally, the limited focus on quality improvement initiatives for birth dose vaccination highlights a missed opportunity to apply well-established healthcare improvement strategies. Hospitals are encouraged to adopt structured Plan-Do-Study-Act cycles to test and refine interventions, fostering a learning environment that shifts current practices toward dynamic systems capable of achieving and sustaining the 90% coverage rates needed for hepatitis B elimination.²⁸

Limitations

Several limitations merit consideration. First, our small sample size and low response rate limit the generalizability of our findings and may introduce selection bias, potentially overrepresenting engaged providers while systematically excluding perspectives from less engaged healthcare workers.

Second, the cross-sectional design prevents causal inference about factors influencing vaccination practices. Third, our reliance on provider awareness rather than objective institutional data sources such as electronic health records or policy documents limits our ability to distinguish between actual absence of systems and provider unawareness of existing systems. This represents a limitation in our ability to make definitive assessments of organizational capabilities.

Fourth, we did not include comparative measures for other routine newborn interventions, limiting our ability to determine whether identified implementation barriers are specific to hepatitis B vaccination or reflect broader systemic challenges in perinatal care delivery. Fifth, our focus on hospital births completely excludes out-of-facility birth experiences, which account for 1–2% of US births but may represent populations at higher risk for suboptimal vaccination coverage.

Finally, our reliance on CFIR as the primary theoretical framework may have introduced confirmation bias toward identifying institutional barriers while potentially overlooking community-level influences that fall outside the framework’s scope. The framework’s emphasis on stable organizational characteristics may underestimate the importance of resilient systems capable of maintaining performance despite workforce volatility characteristic of perinatal care environments.²⁹

Future directions

Future research should prioritize linking provider practices to vaccination outcomes through EHR integration. Prospective intervention studies testing champion-led initiatives, enhanced training programs, or systematic quality improvement approaches could provide causal evidence for effective strategies. Additionally, examining implementation in out-of-facility settings and parent perspectives could illuminate barriers not captured in our provider-focused approach.

Conclusion

Despite decades of universal recommendations, significant implementation gaps persist in hepatitis B birth dose delivery across Washington, DC birthing hospitals. While individual providers strongly support vaccination, system-level barriers including inadequate monitoring infrastructure, limited training opportunities, minimal leadership engagement, and absence of quality improvement initiatives impede optimal coverage. The marked variation in practices between term and premature infant populations, coupled with inconsistent order set utilization, highlights opportunities for standardization. Addressing these modifiable factors through evidence-based interventions could substantially improve vaccination rates and progress toward eliminating perinatal hepatitis B transmission. As hospitals adapt to incorporate new perinatal interventions,³⁰ strengthening foundational immunization systems becomes increasingly critical for ensuring comprehensive neonatal protection.

Biography

Y. Tony Yang, ScD, LLM, MPH, is an endowed professor of Health Policy and Associate Dean for Health Policy and Population Science at the George Washington University School of Nursing, with a joint appointment at the Milken Institute School of Public Health. He leads Cancer Control and Health Equity programs at the GW Cancer Center and holds affiliations with numerous institutions, including the District of Columbia Center for AIDS Research and the GW Trustworthy AI Initiative. Dr. Yang’s prolific scholarship focuses on the intersection of law, policy, and healthcare delivery, with over 200 peer-reviewed publications featured in top journals like NEJM, JAMA, The Lancet, and Health Affairs. He is lead author of Vaccine Law and Policy (Springer, 2023) and sole author of Achieving Health Equity: The Role of Law and Policy (Wiley, 2024). Recognized internationally for his expertise, Dr. Yang serves on the WHO Technical Advisory Group for tuberculosis vaccines and as Co-Editor-in-Chief of Health Policy and Technology. His accomplishments include prestigious awards such as the APHA Early Career Award and over $7 million in federally funded research grants as principal investigator (including various projects on vaccination), underscoring his impactful contributions to vaccine law, health equity, and public health policy.

Funding Statement

Supported in part by a research grant from Investigator-Initiated Studies Program of Merck Sharp & Dohme LLC [MISP #102182]. The opinions expressed in this paper are those of the authors and do not necessarily represent those of Merck Sharp & Dohme LLC.

Disclosure statement

JS reports advisory board consulting and speaking fees from GSK and Pfizer, unrelated to the current work. All other authors declare no conflicts of interest.

Data availability statement

De-identified data supporting the findings of this study are available from the corresponding author upon reasonable request and with appropriate institutional agreements.

Ethics statement

The study protocol received ethical approval from the Institutional Review Board of The George Washington University Office of Human Research (Protocol # NCR245913). All procedures were conducted in accordance with the committee’s guidelines and the principles of the Declaration of Helsinki.