Theme 1. Conflicting perceptions about HBV risk and the CDC recommendation for adults with diabetes.

Physicians’ opinions differed where risks of contracting HBV were concerned. The majority (63.6%) believed that people with diabetes were at an “increased risk” of HBV exposure, referring to sharing of devices or, to a lesser extent, sharing of insulin syringes.

I know of people within the same family that share the same glucose monitoring devices…-P4

Other physicians were convinced that not all people with diabetes were at an increased risk and said: “…it depends, I think, on how their diabetes being treated…” -P3

HBV infection was also associated, to a greater extent, with other risk factors such as employment, travel, or risky behaviors.

…any risks that they would have, either employment wise or personal decision wise, whether they would be increased risk for hepatitis B transmission. -P1

With regards to the CDC recommendation, physicians that said people with diabetes are at an increased risk for HBV were also the ones that agreed with the recommendation: “I do agree that they should be given the recommendation.”(P10), while those that didn’t think there was an increased risk were skeptical of recommending it to everyone with diabetes.

…most individuals are not necessarily at increased risk for hep B transmission by lifestyle choices. -P1

Theme 2. PCPs don’t perceive hepatitis B vaccination as important as other adult vaccines and prioritize vaccination based on risk exposure.

The importance of HepB vaccination among people with diabetes was perceived to be less of a priority compared to other vaccines, with one physician stating:

…we’re often talking about shingles vaccines or pneumococcal vaccines, flu vaccines, certainly COVID vaccines now. And then hepatitis B falls to the wayside. -P1

With the HepB vaccine recommendations in mind, physicians tended to recommend the HepB vaccine to patients considered high-risk due to factors other than their diabetes status.

…we typically would use the hepatitis B vaccine for patients who are higher risk… -P2

Physicians also mentioned that individuals at risk include “anybody that’s around healthcare (P2)” or that “handles blood or blood products (P6)”, but did not associate these situations with individuals with diabetes, although they utilize healthcare settings and occasionally handle blood.

Physicians approached the recommendations to people with diabetes to get the HepB vaccine the same way as other vaccines. They mentioned the increased risk of contracting HBV and explained why people with diabetes should receive the HepB vaccine.

I would just talk about like I do with the other vaccines that are recommended. No, this is recommended for people with diabetes because of their increased risk by getting more needle sticks. -P3

Theme 3. PCPs’ perceived barriers to hepatitis B vaccination among adults within diabetes.

Subtheme 3.1: Physician-Level Barriers. 3.1.1. Lack of Physician Knowledge of CDC Recommendation. Physicians mentioned that some physicians might be unaware of the recommendation for people with diabetes, with one physician saying:

…part of it is physicians. I think that not everyone is necessarily familiar with the recommendation… -P8

One physician mentioned a “lack of knowledge”(P9), while another physician suggested that a barrier could be physicians themselves: “Obviously if a lot of doctors aren’t recommending it…” (P2)

3.1.2. Limited Electronic Medical Records (EMRs) Alerts. Physicians indicated that EMR systems did not prompt them to offer patients with diabetes the HepB vaccine or that a follow-up vaccine was needed.

They don’t automatically say, “Hey, did this person get their?” But they do it for other things like their eye exams, their foot exams, things like that. It’s not included in that type of recommendation in the recommendations pad, panel. -P8

Two physicians said that patient vaccinations could be found in a specific section in the EMR system, but it requires physicians to go there and review the information, which could be time-consuming.

So pretty much the practice is to just look. So, you look for every patient and see what do they due for, and whatever they due for, you recommend. -P9

A lack of EMR system follow-up reminders contributes to patients and physicians forgetting about follow-up vaccines despite people with diabetes seeing physicians every 3–6 months. One physician said:

You would think it would be easier given someone with diabetes is coming back fairly regularly… -P10

Follow-up vaccines were also challenging to complete if not scheduled in advance, leading to physicians and patients forgetting again. One physician mentioned lack of reminders being sent to patients and said:

…We don’t have the record, or the schedule where we send our reminder to our patients. -P7

3.1.3. Competing Priorities. Time constraints lead to physicians prioritizing information and treatment topics concerning diabetic care and education. This leads to physicians focusing on vital information and the HepB vaccine discussion falling by the wayside.

more attention towards other things related to their health… other aspects of their care, just their plain diabetes management, their other comorbid health condition management… -P1

One physician declared it’s not a priority since it’s more considered for those at higher risk.

…is just we’re not thinking about it as much as a priority. Cause again, traditionally, training for most docs is that it’s more just certain high-risk populations. -P2

Subtheme 3.2: PCPs’ Perception of Patient-Level Barriers. 3.2.1. Lack of Insurance Coverage. Physicians mentioned costs associated with getting the vaccine, and one physician stated: “insurance companies won’t cover it for most people” (P6). Some physicians said that patients may “worry about whether their insurance is going to pay” (P4) for the vaccine or whether a co-payment would be necessary, while others did not know whether insurance would cover HepB vaccines.

I will admit that I don’t have a good sense of insurance coverage for hepatitis B vaccinations…-P3

3.2.2. Patient Beliefs and Vaccine Hesitancy. Physicians stated that patients exhibit vaccine hesitancy across the board and that it’s most likely due to “a fear of the needles” (P7) or side effects, health literacy, and misinformation.

Vaccine hesitancy has also been exacerbated by the COVID-19 vaccine controversies during the global pandemic, with one physician stating: “there are some people that have become more vaccine hesitant overall because of COVID vaccines” (P3) and another saying: “It’s got everybody concerned about the safety, what’s in these vaccines. A lot more people hesitant to want to get it (P10). It has also made it harder for physicians to recommend any vaccines. Vaccine fatigue because of COVID was also mentioned by physicians and can be described as the effect multiple vaccine recommendations have on people’s ability to take action.

…there’s like a sense of vaccine fatigue right now from patients, because it’s so prominent and present…-P2

3.2.3. Lack of Patient Knowledge and Health Literacy. According to some physicians, patients may not be aware of HBV and why they need to vaccinate against it. Patients may push back or think they don’t have to worry about HBV since they don’t consider themselves at high risk.

…patient themselves not understanding why it’s necessary…-P6

One physician also mentioned that there might be “a knowledge gap” (P4) in understanding the importance of HepB vaccinations, while another said that “health literacy is a major challenge” (P7) and that individuals may not understand their diabetes and therefore do not understand “what is hepatitis B or why is that important?” (P7)

3.2.4. Socio-demographics. Lower education was mentioned as a barrier, with physicians linking lower education to being uninsured or underinsured. These patients experience barriers to accessing care, which may cause them to utilize multiple healthcare resources, leading to inconsistent care. This could explain why individuals are unvaccinated or have incomplete vaccinations.

…those with less education, they’re more likely to be uninsured or underinsured and, therefore not have access to preventative health and seeing a primary care provider–P1

Age was also mentioned, with most physicians stating that younger individuals would be more likely vaccinated against HBV due to childhood immunizations and that older individuals may have been left by the wayside.

I think the younger groups would have gotten the hepatitis B as part of their childhood immunization… Whereas, I think the older population, there would be some that haven’t gotten it when they were children…-P7

Two physicians stated that older adults are more reluctant to receive vaccines, with one saying: “patients as they age are probably less likely to take the vaccine” (P9), while another believed older adults are more receptive to vaccinations than younger individuals: “the older population is more receptive to vaccinations in general, and it’s definitely more of the younger population that I do have more challenges with” (P2)

Other demographic characteristics mentioned as barriers to getting the HepB vaccine were religion, gender, race, and socioeconomics, with one physician stating that:

I would say gender not so much… Race maybe in lower SES status groups, which may tend to be certain races, just in general. But I don’t know if it’s more the race, or it’s more the socioeconomic status piece. My suspicion is it’s more the SES piece, and not the race directly. -P2

Theme 4. Physician recommended strategies to increase hepatitis B vaccination among adults with diabetes.

4.1. Physicians’ Strategies. Some physicians suggested “educating primary care physicians” (P1) about the CDC recommendation and why it’s necessary to recommend the HepB vaccine to patients with diabetes. One physician said: “reinforcing and giving more education at the provider level first” (P2) was needed, while another stated:

…we need more physician education… I don’t think it’s widely understood as to why this is being recommended. -P6

Another strategy mentioned by physicians was implementing a “quality measure” to encourage physician adherence in recommending the HepB vaccine. One physician said that their office uses quality metrics to help keep track, but that HepB vaccination wasn’t one of them and recommended:

…getting that added into our quality measures and into our checklist that we do with diabetic patients… -P3

In addition, physicians mentioned different resources to help them recommend the HepB vaccine. Multiple physicians suggested programming EMR alerts to prompt HepB vaccine recommendations and would serve as reminders for physicians. In addition to EMR alerts, one physician suggested including it in the guidelines:

I think it would be really good if it is included in the guidelines… -P7

One physician suggested including it in diabetes education to educate patients at the practice, while another two physicians suggested including medical assistants in reviewing information and processing the HepB vaccine before the physician sees the patient.

…having it within a diabetes education visit may be a more beneficial process where the nurse or the dietician doing the diabetes education have that as part of their education… -P1

if we had a care protocol that allowed our nurses to propose the order because there was a care gap identified, the physicians would be more willing to sign that … -P4

4.2. Patient Strategies. Physicians also mentioned multiple strategies to improve HepB vaccination among people with diabetes. One physician suggested using information resources like brochures, flyers, and videos for patients at the practice, while others suggested using advertisements and creating awareness on social media.

… a flyer or a brochure. If we could develop some kind of a video or something, they can watch, they can explain… -P7

If you put it on T.V., on commercials and say, "This is something you should do, ask your doctor," -P6

One suggestion was to get insurance companies to incentivize their clients to get the HepB vaccine. Reducing insurance costs for clients who use vaccines or other preventative medicine may persuade people to receive recommended vaccines.

What will work is economic incentive… An insurance company that says, oh yeah, we’re going to drop your rates if you do this…-P9

Another strategy was to have pharmacies promote the vaccine more, while one physician suggested getting community organizations involved, organizing community fairs to educate individuals, or doing vaccination clinics.

…organizing community camps regarding, let’s say preventative thing, vaccinations for pneumonia, for hepatitis B…-P5