Abstract
Having a chronic disease is one of the most consistent factors associated with vaccine uptake for adults in the general population, but vaccination beliefs and behaviors specific to those with chronic skin diseases have not been explored. The objective of this study was to explore factors associated with vaccine uptake and barriers to vaccination in adults with psoriasis and eczema. Virtual, video-based semi-structured interviews were performed with adults who self-reported a diagnosis of psoriasis or eczema. Interviews explored themes around healthcare decision making, perceived risks/benefits to vaccination, barriers, and vaccine knowledge. Thematic analysis was used to analyze the data. Of 34 study participants, 25 participants (74%) were females and 9 (26%) were males, with a mean age of 50.8 years (SD: 16.4, range: 24–71 yrs). Half of participants (n = 17) had psoriasis, and half (n = 17) had eczema. Participants recognized both personal and societal benefits to vaccines. Common vaccination barriers identified were access to appointments, concerns about side effects, and misinformation. Physicians, friends/family, and media, including internet resources, were health information resources identified by patients. These results summarize the unique patient perspective around vaccine uptake in adults with eczema and psoriasis and represent an important first step in a multi-pronged approach to improve vaccination rates in adults with chronic skin diseases.
Keywords: Psoriasis, Eczema, Vaccine, Qualitative research, Public health
Introduction
Previous research suggests that adults with chronic inflammatory skin diseases are not receiving the seasonal flu shot and other adult vaccinations as recommended [3, 8, 9, 12, 14, 15]. In the general population, the factors most consistently and strongly associated with receipt of a seasonal flu vaccine are age greater than 65 years and having a chronic disease of any type [21]; however, many patients with chronic inflammatory skin diseases are younger than 65 and without other comorbidities. It is important to understand how adults with chronic inflammatory skin disease consider their skin disease when making health-related decisions, including vaccinations.
During the COVID-19 pandemic, discussions around vaccines recommendations and safety became increasingly common. Despite clear recommendations for all adults to receive a COVID vaccine, significant vaccine hesitancy was reported in adults with psoriasis [1, 5], and not explored in those with eczema, further highlighting the importance of understanding the patient perspective around vaccine decision making. Fully understanding the factors that contribute to a patient’s decision to receive a vaccine is critical for vaccination counseling, to combat misinformation and improve vaccination rates. The patient perspective, specific to adults with chronic inflammatory skin diseases, has not previously been examined qualitatively. The objective of this study is to explore beliefs surrounding vaccinations in adults with psoriasis and eczema.
Materials & methods
Study design
Virtual, video-based semi-structured interviews were performed in adults who reported a diagnosis of psoriasis or eczema, exploring themes around healthcare decision making, perceived risks/benefits to vaccination, vaccine knowledge, and vaccine administration. The Mass General Brigham Institutional Review Board approved the study, and patients provided verbal consent prior to participation.
Study population
A convenience sample of patients was recruited for participation from patient advocacy networks (National Psoriasis Foundation, National Eczema Association) and the dermatology clinics at Brigham and Women’s Hospital. All patients seen in the dermatology clinic for psoriasis or eczema between 1/1/2020 and 5/31/2021 were invited to participate. All adults who self-identified as having a diagnosis of psoriasis or atopic dermatitis/eczema for at least 12 months were eligible to participate, and participants were enrolled and interviewed until saturation of themes was reached.
Data collection
The interview guide was developed based on a review of the literature and the expertise of 4 investigators (JSB, LPC, MHN, AMS), incorporating a freelisting exercise to assess vaccine knowledge. Freelisting is a qualitative interviewing technique that elicits spontaneous response around a theme and is used to understand how a group of people define a topic [7]. The interview guide was pilot tested with simulated interviews and updated based on feedback after each practice interview. Interviews were then conducted by one of the research assistants (AJT, CGL, or MA), with no previous relationship to study participants. All research assistants received formal training in interview technique and performed 4-5 practice interviews prior to performing the study interviews. Interviews were conducted virtually over video conference in three time periods: 3/11/21–3/24/21, 7/20/21–7/28/21, and 9/27/21–10/21/21. Three time periods were necessary due to difficulties with our initial recruitment strategy. All interviews were voice-recorded with the participant’s permission, transcribed, and edited for clarity.
Data analysis
The Health Belief Model was used to guide the interview script development and data analysis. A codebook was created by two senior members of the team (MHN, LPC) by reviewing ten transcripts to identify themes that emerged from the data along with an a priori set of codes developed from the literature and pre-existing clinic knowledge. Each interview was transcribed, edited for clarity, and independently coded by 2 study team members (MA, NG) in NVIVO in batches of 5 transcripts, with clarification and updating of the codebook after each batch. All discrepancies in coding were resolved by consensus between the two coders and a senior team member (MHN), as necessary. After the coded data were sorted by disease type to identify patterns and themes in the data, representative participant quotations were identified for each major theme. The freelisting exercise was analyzed using a saliency index. The salience index ranges from 0 (items with low salience or low recognition) to 1 (items with high salience or high recognition). A saliency index was calculated using the following formula: S = {[(L–Rj+1)/L]/N}, where L is the length of each list, Rj is the rank of item J in the list, and N is the number of lists in the sample. This study follows the Consolidated Criteria for Reporting Qualitative Research reporting guidelines [20].
Results
Of 34 study participants, 25 participants (74%) were females and 9 (26%) were males, with a mean age of 50.8 years (SD: 16.4, range: 23–71) (Table 1). The mean age of participants with psoriasis (mean: 57.6 years (SD: 11.6)) was older than the mean age of participants with eczema (mean:44.0, SD: 19.9) (p=0.01).
Table 1.
Patient characteristics
| Total N = 34 | Psoriasis n = 17 | Eczema n = 17 | |
|---|---|---|---|
| Female, n (%) | 25 (74) | 11 (65) | 14 (82) |
| Male, n (%) | 9 (26) | 6 (35) | 3 (18) |
| Mean age (SD), in years [min, max] |
50.8 (16.4) [23, 71] |
57.6 (11.6) [25, 70] |
44.0 (19.9) [23, 71] |
Table 2 shows the overall frequency of each code and the frequency by skin disease. All participants identified described ways in which their skin disease impacts how they consider their personal health. When asked about benefits and risks to vaccination, most participants recognized both personal and societal benefits to vaccines. Fulfilment of requirements and travel safety were other benefits identified by a few participants. Most of the risks identified by patients were related to safety concerns and side effects, including risk of local reactions, allergic reactions, “flu-like” symptoms, and serious side effect. Some participants discussed concerns about exacerbation of chronic diseases, including their skin disease, and other participants mentioned concerns that vaccines may cause disease/new health problems. Many patients with eczema discussed general safety concerns. For example, one participant expressed their concern by saying, “What if [the vaccine] doesn’t work or it makes you sicker?” Some participants said vaccines were associated with no risks or minimal risks. A participant said, “I don’t think they have any risks. The only risks that we are taking is that we are not taking care of ourselves by not vaccinating ourselves.”
Table 2:
Code frequencies
| Concept | Representative quotation | Total N = 34 N (%) |
Psoriasis N = 17 N (%) |
Eczema N = 17 N (%) |
|
|---|---|---|---|---|---|
| Theme: Benefits of vaccination | |||||
| Personal | “Well, the object of a vaccine is so that you don’t get a deadly disease. Oh, I see that as a pretty big benefit.” | 34 (100) | 17 (100) | 17 (100) | |
| Societal | “I think it’s good for me to know that I’m doing the best I can to take care of myself and to take care of those around me.” | 28 (82.4) | 13 (76.5) | 15 (88.2) | |
| Travel | “The adult vaccinations I take [are] for travel, so it reduces my risk of illness when in a higher risk situation.” | 3 (8.8) | 2 (11.8) | 1 (5.9) | |
| Fulfil requirement | “[Vaccinations] allows you to do thing… like going to college” | 2 (5.9) | 1 (5.9) | 1 (5.9) | |
| Theme: Risks of vaccination | |||||
| General safety concerns |
“I don’t want to tax my immune system if it’s not needed.” “What if [the vaccine] doesn’t work or it makes you sicker?” |
16 (47.1) | 6 (35.3) | 10 (58.8) | |
| Local and/or mild side effects | I’ve had different reactions to vaccines, whether it’s just a sore arm or with the flu vaccine, I actually felt like I had a cold or got a headache.” | 6 (17.6) | 3 (17.6) | 3 (17.6) | |
| Serious side effects | “There are risks like Guillain-Barre, for example, with the flu shot.” | 15 (44.1) | 8 (47.1) | 7 (41.2) | |
| Flu-like reactions |
“I have heard that you can get really lethargic, feverish and have a real reaction because your body is responding to the it.” “… Things like feeling tired or a little bit sick of a couple of days” |
15 (44.1) | 7 (41.2) | 8 (47.1) | |
| Allergic reactions | “I know that there is an anaphylactic reaction to some vaccines.” | 14 (11.8) | 6 (35.3) | 8 (47.1) | |
| Exacerbation of chronic diseases | “I was a little concerned that getting vaccinated would make my psoriasis worse… like flare up.” | 9 (26.5) | 5 (29.4) | 4 (23.5) | |
| Not effective/cause disease | “That they’re just not effective and it might cause some new condition to emerge.” | 8 (23.5) | 4 (23.5) | 4 (23.5) | |
| None/no concerns | “I don’t think they have any risks. The only risks that we are taking is that we are not taking care of ourselves by not vaccinating ourselves.” | 12 (35.3) | 7 (41.2) | 5 (29.4) | |
| Theme: Barriers to vaccination | |||||
| Availability of appointments | “I’m working a job and I’ve got a bunch of like other stuff going on in my life and I don’t have time to think about it or I can’t sacrifice any [time]… I can’t leave work.” | 25 (73.5) | 13 (76.5) | 12 (70.6) | |
| Access | “Vaccine availability obviously, because if it’s not there then you can’t get it.” | 17 (50.0) | 8 (47.1) | 9 (52.9) | |
| Concerns about safety/side effects | “Personally, the only thing that I’m worried about is that I don’t like needles. I get sick and dizzy with needles, so I have a really hard time when I go … to get the vaccine, so that’s my only biggest concern.” | 12 (35.3) | 5 (29.4) | 7 (41.2) | |
| Lack of information about vaccines | “Definitely some knowledge about what the vaccine actually does, feels like a really big barrier.” | 11 (32.4) | 5 (29.4) | 6 (35.3) | |
| Cost | “For most routine vaccines, they’re covered by insurance. If you don’t have insurance, then [cost] can be a barrier.” | 10 (29.4) | 4 (23.5) | 6 (35.3) | |
| Misinformation | “I feel the barriers that existed… were misinformation, conspiracies and scare mongering, all the stuff that’s online and on Facebook… Fear and suspicion. Those are the barriers we faced as a family.” | 9 (26.5) | 5 (29.4) | 4 (23.5) | |
| Lack of trust | “Also, there’s probably for certain populations, a certain sense of whether or not they trust what they’re being injected with.” | 9 (26.5) | 3 (17.6) | 6 (35.3) | |
| Theme: Healthcare information resources | |||||
| Physicians (subcodes: primary care physicians, dermatologists, other specialists) | “I trust doctors the most, like my dermatologist. He’s really good. He explains things. I like somebody who can have a conversation and break it down into normal people terms.” | 31 (91.2) | 16 (94.1) | 15 (88.2) | |
| Other Media (subcodes: TV, newspapers, magazines) | “I watched the news on television. ABC, NBC, CBS, Fox” | 8 (47.1) | 4 (47.1) | 4 (47.1) | |
| Internet (subcodes: blogs, forums, general health information websites, governmental health websites, dermatology-specific websites, news websites) | “I’m always on Reddit because it’s real people like me.” | 15 (44.1) | 9 (52.9) | 6 (35.3) | |
| Friends/Family/Colleagues | “I’m in the biomedical field, so I have colleagues that I can ask” | 12 (35.3) | 5 (29.4) | 7 (41.2) | |
| Pharmacists | “Also, when I get a medication, I talk to the pharmacist and get her views on it.” | 2 (5.9) | 2 (11.8) | 0 (0) | |
| Peer support, including other patients and patient support groups | “I’m trying to join a group of people with psoriasis…so people they have the same interested as me and maybe we could relate.” | 2 (5.9) | 1 (5.9) | 1 (5.9) | |
| Theme: Preferred location to receive vaccines | |||||
| Physician’s office | “I usually go to my primary care doctor. That’s where they always give it to me and it’s available when I’m there. | 28 (82.4) | 15 (88.2) | 13 (76.5) | |
| Pharmacy | “I will get the flu vaccine from CVS or Walgreens, largely because it’s easily available.” | 22 (64.7) | 13 (76.5) | 9 (52.9) | |
| Mass vaccination clinics | “… with COVID I went to Gillette Stadium, because it was easy to get an appointment.” | 6 (17.6) | 4 (23.5) | 2 (11.8) | |
| Community, including work, school, church or community organizations | “As an adult I have to say that I get [the flu shot] at work, I don’t have to go anywhere.” | 5 (14.7) | 3 (17.6) | 2 (11.8) | |
| Grocery store | “In the case of the flu vaccine, our grocery store has a clinic, so we go there while we are shopping” | 1 (2.9) | 1 (5.9) | 0 (0) | |
| Theme: Factors that affect your decision to receive an annual flu shot | |||||
| Personal health benefit |
“I don’t want to die. I don’t want to get the flu” Personally, I have had the flu and it sucks. I don’t want to get the flu.” |
25 (73.5) | 15 (88.2) | 10 (58.8) | |
| Physician recommendation | “My doctor said that I should get the flu shot and that’s what I did every year.” | 11 (32.4) | 7 (41.2) | 4 (23.5) | |
| Benefit to society | “I think with the pandemic, that I have a greater understanding of all of it because [before] nobody ever really said that getting a flu shot is not just about me.” | 11 (32.4) | 7 (41.2) | 4 (23.5) | |
| Requirement | “I do it now because it’s required for work.” | 4 (11.8) | 1 (5.9) | 3 (17.6) | |
| Theme: Factors that affect your decision NOT to receive an annual flu shot | |||||
| Complacency |
“I always get the flu anyway, so I just figured why am I going to get it if I’m just going to get the flu anyway? “I consider myself to be healthy, so I don’t really feel like I need the flu vaccine.” |
7 (20.6) | 1 (5.9) | 6 (35.3) | |
| Dislike needles/shots | “It’s largely because I don’t want to get an injection.” | 3 (8.8) | 0 (0) | 3 (17.6) | |
| Fear of allergy | “When I was younger my mom was hesitant about me taking the flu vaccine because my parents assumed that my eczema was food allergies.” | 2 (5.8) | 1 (5.8) | 1 (5.8) | |
| Dislike doctors | “I don’t like doctors.” | 1 (2.9) | 0 (0) | 1 (5.9) | |
| Theme: Benefits of new vaccines, including COVID | |||||
| Utilize new technology | “The technology is different, and things are more advanced and that seems like a good thing to me.” | 9 (26.5) | 6 (35.3) | 3 (17.6) | |
| High level of testing | “I think they know what they’re doing, and I don’t think the vaccine would be out there if it wasn’t safe or effective despite of how quickly they came out with it.” | 9 (25.5) | 5 (29.4) | 4 (23.5) | |
| Approved by experts | “…and it was being recommended by my doctors. I couldn’t really see any reasons why I shouldn’t get it.” | 8 (23.5) | 3 (17.6) | 5 (29.4) | |
| Increased awareness of other viruses/vaccines | “I think there’s a lot of things that people learned about viruses that we really didn’t think about before, like how you could give [them] to other people…. It brough to my attention that a lot of people actually do die from the flu.” | 6 (17.6) | 3 (17.6) | 3 (17.6) | |
| Theme: Negative aspects of new vaccines, including COVID | |||||
| Lack of long-term data | “Do I know what the results will be 10, 20, 30 years from now? I don’t.” | 15 (44.1) | 7 (46.7) | 8 (47.1) | |
| Potential for Reactions/Side effects | “I would rather take the ones that have been given to people for many years because I felt so sick [after the COVID vaccine] and no one had any explanation.” | 2 (5.9) | 1 (5.9) | 1 (5.9) | |
| Lack of trust | “I don’t know that I trust it. It’s hard to get pure research these days It’s hard to find people who are not connected to money.” | 2 (5.9) | 1 (5.9) | 1 (5.9) | |
| Theme: Impact of skin disease on lifestyle & medical decision making | |||||
| Activities of daily living | “I think from just getting dressed in the morning to washing my hair, depending on what level of disease I have[it] can be an uncomfortable and challenging process.” | 21 (61.8) | 9 (52.9) | 12 (70.6) | |
| Medical decision making | “I get the flu shot because the flu is deadly, and people do die from it. As somebody who’s immune compromised, I feel like it is an important thing for me to try to prevent severe illness. I make anybody that comes into my house also get the flu shot, and now the COVID shot, to protect me.” | 19 (55.9) | 12 (70.6) | 7 (41.2) | |
| Entire life | “I think eczema is something where I have lived with it in my entire life so it’s basically like a part of who I am.” | 18 (52.9) | 9 (52.9) | 9 (52.9) | |
| Mental health, including self-esteem | “Until it was under control, it had a fair impact on my psychologically, because I had these ugly lesions on my legs, arms and back [that] looked like an alligator.” | 14 (41.2) | 6 (35.3) | 8 (47.1) | |
| Diet | “Sometimes I will think about, Oh maybe I shouldn’t eat this or I shouldn’t eat that because it could cause of flare up or cause it to get worse.” | 10 (29.4) | 5 (29.4) | 5 (29.4) | |
| Hobbies and recreational activities | “I don’t swim because it will usually flare my eczema.” | 6 (17.6) | 3 (17.6) | 3 (17.6) | |
| Sleep | “... but it does affect the way I feel specially because when it’s bad I cannot sleep well and that affects like of course all my life, so it does affect definitely” | 6 (17.6) | 1 (5.9) | 5 (29.4) | |
| Interpersonal relationships | “It destroyed my relationship with people around me.” | 4 (11.8) | 1 (5.9) | 3 (17.6) | |
| Pain | “There are definitely some activities I will choose not to do because I know it’s going to hurt a lot.” | 2 (5.9) | 1 (5.9) | 1 (5.9) | |
| Focus/Concentration | “Because eczema kind of interferes with like daily aspects like sometimes it messes with my focus. If I’m like doing something and then I somehow get itchy then I’m kind of like losing track of whatever I was doing or like.” | 1 (2.9) | 0 (0) | 1 (5.9) | |
The most common barriers to vaccination identified were lack of access to available vaccines, lack of time for vaccine appointments, and concerns about side effects. Patients expressed concerns about access to vaccine appointments and a limited supply of vaccines, as was a common concern in the general population during the initial rollout of the COVID vaccine in 2021. A lack of access to information about vaccines, misinformation, cost, and lack of trust were also barriers identified by participants. One participant commented, “Definitely knowledge about what the vaccine actually does, feels like a really big barrier.”
When asked about health information resources, most identified physicians, including primary care physicians, dermatologists, and other specialists, as a source of information. Other common resources identified were the internet, other media, including TV, newspapers, and magazines and friends and family. A minority of patients mentioned the primary scientific literature, pharmacists, and peer support groups. The frequency of themes around sources of health information was similar between those with psoriasis and eczema.
To get a better idea of the familiarity of participants with specific vaccines, we asked participants to list, to the best of their knowledge, all the vaccines recommended for adults in the USA (Table 3). The seasonal influenza was the most mentioned vaccine, followed by herpes zoster, COVID, pneumococcal, and tetanus. We also inquired about seasonal influenza vaccine uptake. In total, 24 of 34 (70.6%) interviewees reported regularly receiving the annual influenza vaccine, 4 participants (11.8%) said they typically do not get the vaccine, and 6 (17.6%) people said they sometimes get the vaccine. Many participants with psoriasis reported receiving a flu shot regularly. Regarding factors that affect an individual’s decision to receive an annual flu shot, most patients mentioned personal health benefits. Other factors described were societal benefits, physician recommendation, and requirements/mandates. Of factors that affect one’s decision NOT to receive a yearly flu shot, participants mentioned complacency about their influenza risk, fear of allergic reactions or needles, and dislike of healthcare providers. A participant mentioned, “I consider myself to be healthy, so I don’t really feel like I need the flu vaccine.”
Table 3:
Free listing of vaccines recommended for adults in the USA
| Vaccine: | Total n = 34 n (%) |
Psoriasis n = 17 n (%) |
Eczema n = 17 n (%) |
Salience index |
|---|---|---|---|---|
| Influenza | 27 (79) | 15 (88) | 12 (71) | 0.55 |
| Zoster | 22 (65) | 14 (82) | 8 (47) | 0.47 |
| COVID | 20 (59) | 12 (71) | 8 (47) | 0.36 |
| Pneumococcal | 14 (41) | 9 (53) | 5 (29) | 0.27 |
| Tetanus (including TdaP & Td) | 14 (41) | 10 (59) | 4 (24) | 0.24 |
| Measles, mumps & rubella | 6 (18) | 4 (24) | 2 (12) | 0.09 |
| Hepatitis (including A & B) | 5 (15) | 4 (24) | 1 (6) | 0.06 |
| Human Papilloma | 5 (15) | 2 (12) | 3 (18) | 0.06 |
| Varicella | 2 (6) | 1 (6) | 1 (6) | 0.05 |
| Meningitis | 1 (3) | 0 (0) | 1 (6) | 0.02 |
Finally, given the acute awareness of participants around new vaccines and vaccine development during the COVID pandemic, we asked study participants their thoughts around new vaccines, like the COVID vaccine. Benefits identified were high level of testing required for approval, utilization of novel technology, increased awareness around other vaccines, and formal approval by experts. Concerns identified were lack of testing or long-term data, potential for an adverse reaction, and lack of trust in the development process. One concerned participant said, “I don’t know that I trust it. It’s hard to get pure research these days It’s hard to find people who are not connected to money.”
Discussion
The results of this qualitative study highlight the varying ways in which adults with psoriasis and eczema consider their skin disease in the context of healthcare decisions and vaccination behaviors. Participants identified both personal and societal benefits to vaccinations, expressed concerns about side effects, and discussed barriers to vaccination including access to appointments, and misinformation. The results of this study should be interpreted in the context of when the interviews were performed. While the participants were instructed to think generally about vaccines, responses were likely influenced by the ongoing COVID pandemic. Specifically, concerns about lack of available vaccine supply and lack of access to vaccine appointments, were unique to the novel COVID vaccine; however, patient concerns about safety and misinformation, highlighted during the pandemic, will likely continue to influence how individuals think about their personal health and all future decisions around vaccines.
Much of the previous research to understand vaccination behaviors in adults with chronic inflammatory disease has retrospectively identified patient-specific predictors of influenza vaccination. Factors that were consistent across studies in the USA and Europe include increasing age, female sex, and a history of chronic lung diseases [6, 9, 11]. The effects of systemic treatments, including disease-modifying antirheumatic drugs and biologics, were mixed across studies [6, 11]. Building upon the patient factors identified in previous retrospective research, this qualitative study provides additional understanding of vaccination motivation for patients with psoriasis and eczema. As expected, most participants recognized that vaccines provide individual protection. Surprisingly, many participants also identified “protecting others” as a benefit to vaccination and motivation to receive a vaccine. While “herd immunity” is certainly not a new concept, there was increasing awareness during the COVID-19 pandemic that high vaccination rates in the general population can help to protect individuals at higher risk and in individuals in which vaccines might not be as effective. [2] The increased awareness around protecting others may become an important motivating factor to utilize in future vaccination campaigns.
Identification of patient-specific barriers to vaccination is a key step in improving vaccination rates. Participants commonly described "scheduling vaccine appointments” as a barrier. Part of this concern, scarcity of the vaccine itself, is likely specific to new vaccines, influenced by the high demand for COVID vaccines after the Emergency Use Authorization in 2021. However, this concern also includes comments about lack of time to make or attend vaccine-specific appointments and difficulties with transportation to appointments. Increasing the availability of vaccines in non-primary care offices, pharmacies and in the community, without the need for vaccine-specific appointments, will increase the convenience of vaccines and may help to reduce this barrier for many patients.
Other common barriers in the existing literature that were also identified by participants in this study were concerns about vaccine side effects, including flaring of psoriasis/eczema and misinformation [5, 6]. Vaccine misinformation contributed to a lower intent to receive the COVID vaccine in the general population and in those with chronic inflammatory diseases [5, 10, 13, 17]. Misinformation and concerns about side effects can be directly addressed in by all physicians in any medical encounter. Studies in the pediatric population show that one-on-one conversations directly addressing concerns help to decrease vaccine hesitancy [16, 18]. Importantly, participants recognized physicians as an important health information resource. This may be even more important for patients with chronic disease who develop longstanding relationships with their physicians.
In addition to one-on-one conversations with physicians, participants recognized media and the internet as frequently utilized health information resources. Public health organizations and the patient advocacy groups should utilize all forms of media, including social media, to serve as a creditable health information resource for patients. For example, The National Psoriasis Foundation developed patient-centered vaccine information about the COVID vaccine that was available for patients on their website [4], updated as additional evidence-based information was available. This model should be expanded to include specific information for other chronic skin disease and extended to all social media platforms, where study participants mentioned they frequently look for health information.
An emerging theme from this study was that lack of information about vaccines was a barrier to vaccination for some, suggesting that disease-specific or medication-specific vaccine education is important to patients. Previous research suggests that many people, including healthcare workers with chronic illnesses, are not aware of recommended vaccines or do not perceive themselves to be at risk [19]. In this study, less than half of participants mentioned being aware of the pneumonia vaccine, a vaccination recommended for all adults 65 year of age and older and certain younger individuals at increased risk. The creation of clear vaccination guidelines for dermatology patients, with recommendations specific to the increased risk associated with dermatology therapies, will help patients and other doctors be aware of necessary vaccines and will ensure dermatology patients have appropriate insurance coverage.
While this study provides a great deal of insight to the patient perspective regarding decisions around vaccines, there are some limitations. First, the study must be interpreted in the context of the qualitative frameworks and relatively small sample size. While a significant effort was made to capture varied patient perspective, ideas expressed in these interviews may not represent the beliefs of all patients with psoriasis and eczema. Complete demographic information and detailed information about disease severity and prior/current treatment were not available for participants and may also have a significant impact on responses. Additional research is necessary to better understand how patient-specific factors influence vaccine uptake.
In summary, the results of this study have identified key themes around vaccine uptake in adults with eczema and psoriasis. This qualitative research represents an important first step in a multi-pronged approach to improve vaccination rates in adults with chronic skin diseases. Dermatologists play an important role in vaccine uptake and can identify and educate patients about recommended vaccines. For patients starting immunosuppressive medications, vaccination education should be incorporated into medication counseling. Utilizing patient information developed by the CDC or the development of dermatology-specific information can help to facilitate this conversation between physicians and patients. Additionally, creating clear vaccination guidelines for dermatology patients will help patients and healthcare provides know what vaccines are necessary for our patients and will ensure dermatology patients have insurance coverage for all necessary vaccines, including those outside of the age-specific recommendations. Finally, increasing the availability of vaccines in non-primary care offices, pharmacies and in the community, without the need for vaccine-specific appointments, will increase the convenience of vaccines and may reduce access barriers. A concerted effort to improving vaccination rates in all adults, but specifically those with chronic skin diseases, will help to decreased infectious complications and improve the overall care for our patients.
Acknowledgements
This study was funded by a K23 Career Development Award (K23-AR073932) from the National Institute of Arthritis, Musculoskeletal and Skin Diseases (MHN). Dr. Scherer also received funding from a K01 Mentored Research Scientist Development Award from the National Institute on Aging (NIA- 1K01AG065440), and Dr. Asgari received funding from a Midcareer Investigator Award in Patient-Oriented Research (5K24AR069760) from National Institute of Arthritis, Musculoskeletal and Skin Diseases.
Author contributions
MHN, JSB, AM, AMS, LPC, MMA and JMG contributed to the study conception and design. MA, NG, CGL and AJT were responsible for data collection. The first draft of the manuscript was written by MN, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.
Funding
This study was funded by a K23 Career Development Award (K23-AR073932) from the National Institute of Arthritis, Musculoskeletal and Skin Diseases (MHN). Dr. Scherer also received funding from a K01 Mentored Research Scientist Development Award from the National Institute on Aging (NIA- 1K01AG065440), and Dr. Asgari received funding from a Midcareer Investigator Award in Patient-Oriented Research (5K24AR069760) from National Institute of Arthritis, Musculoskeletal and Skin Diseases.
Data availability
The datasets generated during and/or analysed during the current study are not publicly available due to privacy concerns assoicated with qualatative research but are available from the corresponding author on reasonable request.
Declarations
Conflict of interest
Maryam Asgari receives royalty payments from UptoDate. Joel Gelfand served as a consultant for Bristol-Myers Squibb, Boehringer Ingelheim, GlaxoSmithKline, Janssen Biologics, Novartis Corp, Regeneron, UCB (Data Safety and Monitoring Board), and Sanofi and Pfizer Inc., receiving honoraria; in addition, he receives research grants (to the Trustees of the University of Pennsylvania) from Abbvie, Janssen, Novartis Corp, Sanofi, Celgene, OrthoDermatologics, and Pfizer Inc., and he has received payment for CME work related to psoriasis that was supported indirectly by Eli Lilly and Company and Ortho Dermatologics. In addition, Joel Gelfand is a co-patent holder of resiquimod for treatment of cutaneous T-cell lymphoma. Arash Mostaghimi has received consulting fees from Pfizer, hims and hers, Digital Diagnostics, Concert, Lilly, Abbvie, Bioniz, Acom, Equillium, Boehringer Ingelheim; equity from hims, Fig 1, ACOM; licensing/royalties from Pfizer, Concert; and research funding from Incyte, Lilly, Aclaris, Concert. Megan Noe has received research grants from Boehringer Ingelheim and Bristol Myers Squibb for projects unrelated to this manuscript. John Barbieri is an Associate Editor for JAMA Dermatology. Joel Gelfand is a deputy editor for the Journal of Investigative Dermatology, receiving honoraria from the Society for Investigative Dermatology, and is the Chief Medical Editor for Healio Psoriatic Disease for which he received honoraria. Arash Mostaghimi is an associate editor for JAMA Dermatology. Megan Noe is senior editor for the Journal of Psoriasis and Psoriatic Arthritis. Marjorie Archila, Lourdes M. Perez-Chada, Nathaniel Goldman, Christina G. Lopez, and Alice J. Tan have nothing to disclose.
Ethical approval
This study was performed in line with the principles of the Declaration of Helsinki and was approved by The Mass General Brigham Institutional Review Board.
Consent to participate
Verbal informed consent was obtained from each prior to participation.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets generated during and/or analysed during the current study are not publicly available due to privacy concerns assoicated with qualatative research but are available from the corresponding author on reasonable request.