key: cord-0744525-agvdjdkx authors: Faherty, Laura J.; Schulson, Lucy; Gandhi, Priya; Howell, Khadesia; Wolfe, Rebecca; Ringel, Jeanne S. title: Promising Practices for Ensuring Equity in COVID-19 Vaccination: The Devil’s in the Details date: 2022-05-02 journal: Public Health Rep DOI: 10.1177/00333549221086579 sha: 93e7da4c5cd389191203682103c508281273d7d1 doc_id: 744525 cord_uid: agvdjdkx nan The vaccine rollout has been a massive undertaking, and pent-up demand far outpaced supply during the initial months of rollout. More recently, as expected, the pendulum has swung; we have entered a new phase in which demand has declined dramatically, and most people who wanted the vaccine and could easily access it have gotten vaccinated. In this new phase, public health officials and health care institutions, faith-based organizations and youth-led nonprofit organizations, small businesses and huge national companies, tech startups, and many more are getting the chance to apply well-established public health principles that we all (think we) know so well 4 : engage the community, understand their barriers, use trusted messengers to get the word out, and provide information using the channels that communities actually use, in the languages they actually speak. These principles, while not new, have never been more urgently needed, particularly given the explosion of misinformation and disinformation about COVID-19 vaccines. What is new is the unprecedented speed, scale, and complexity of what the nation is attempting to do: vaccinate as many people as possible in the shortest amount of time. Across the country, hundreds of organizations at the federal, state, local, and hyperlocal levels are using promising strategies to overcome the many barriers that populations that have been historically marginalized-particularly those in BIPOC communities-confront in accessing COVID-19 vaccination (and health care more generally). The Rockefeller Foundationfunded Equity-First Vaccination Initiative is supporting more than 100 community-based organizations in 5 US cities to lead efforts to increase access to COVID-19 vaccines and accurate information about them. 5 As a learning partner for this initiative, focusing on access to and delivery of vaccines, our team conducted an environmental scan to identify promising practices for overcoming access barriers and promoting racial and ethnic equity in COVID-19 vaccination. Importantly, ensuring access to evidence-based information to build vaccine confidence and counter misinformation is outside our scope but is a crucial part of the overall initiative. Starting in early April 2021, we conducted repeated online media searches to identify strategies being used across the United States to promote equity in COVID-19 vaccination. 6 We initially conducted these media scans 3 times per week and then decreased the frequency of our searches to weekly, then monthly, through June 14, 2021. We also monitored social media channels, including Twitter, Facebook, Instagram, and Google (through an automated alert), daily to identify additional promising practices. We screened 777 media articles, leading to a total of 228 included articles that (1) described approaches to overcoming access barriers to COVID-19 vaccination and/or (2) contained results of interventions to increase COVID-19 vaccination rates. We excluded articles that only identified barriers to vaccination access without discussing solutions to address them or focused exclusively on overcoming vaccine hesitancy. From those 228 included articles, we abstracted into a Microsoft Excel spreadsheet the following information: the organization(s) leading efforts to address vaccine equity, their location, the target population, the barriers to vaccine access the organization was tackling, interventions used to address those barriers, challenges encountered and solutions to those challenges, and measures of effectiveness, if any. Using a qualitative descriptive approach, in which we sorted the data to identify patterns and synthesized findings into meaningful groups, we organized the most common access barriers into 5 broad categories: information, physical accessibility, trustworthiness, technology, and cost. To do so, we drew on an existing conceptual model of health care access 7 that integrates the supply side (accessibility of services) with the demand side (the person's ability to access those services), adapting the model to the unique COVID-19 context (Table 1) . Similarly, the strategies organizations are using to address barriers to access and promote COVID-19 vaccine equity can be organized into 5 categories: Information Lack of accurate, timely, understandable information about where, when, and how to get vaccinated (including knowing the vaccine is free) because information is not disseminated through the channels used by the community, the information is not available in appropriate languages, and/or the information is not accessible by people with visual or hearing impairments. Physical accessibility Vaccine sites are placed in inconvenient locations (eg, far from public transport or only in affluent neighborhoods) or in locations without accommodations for those with poor health or mobility limitations. Vaccine sites are open during hours that do not meet the needs of the community. Trustworthiness Institutions and systems administering the vaccine may not be trusted, reflecting current and historical systemic racism and xenophobia. Technology Vaccine access depends on consistent internet access and high levels of technological literacy (eg, registering for a vaccine, making an appointment, using apps to schedule rides to vaccine site). Cost Although the vaccines themselves are free, individuals may incur other costs from accessing them, including transportation costs or missed work hours and lost income due to vaccine appointments or side effects. a Adapted from Faherty et al. 6 and Levesque et al. 7 19 and food 20 during regular distribution events. • Organizations are also working to meet people where they are. Boston Healthcare for the Homeless has taken the vaccine "to the street" 21 to vaccinate those experiencing homelessness and has provided individuals with a 24-hour hotline to call with any questions about side effects from the vaccine. • Growers, agricultural producers, and county farm bureaus throughout California have hosted clinics at local farms and processing plants for agricultural employees during regular work hours. 22 Largescale employers 23 -including Amazon, Ford Motor Co, and Chobani-have partnered with local health systems to offer workplace vaccination. Making registration and appointment processes streamlined and inclusive • Several organizations lowered the barriers to vaccination by allowing walk-ins and expanding hours. For instance, the Black Doctors COVID-19 Consortium in Philadelphia offers appointments and a walk-in, first-come, first-served system to meet the needs of the community. 24 Other organizations have increased access by operating into the evening 25 We illustrate examples of efforts in each type of strategy (Table 2) . For example, the United Way of Cincinnati used a 2-1-1 line to arrange transportation to vaccination appointments. 12 Additionally, growers, agricultural producers, and county farm bureaus throughout California have hosted clinics at local farms and processing plants for agricultural employees during their regular work hours. 22 Although these vaccination strategies are inspiring and represent just a sampling of the work that is occurring every day around the country, it was clear from this national scan that in some situations, even the most well-intentioned strategies for equitable vaccine distribution encountered challenges as they were implemented in the real world of a vast, complicated, and urgent vaccine rollout ( Table 2 ). Organizations discovered that even small missteps were thwarting their efforts. Here are just a few examples, organized by the 5 types of strategies: • • Sharing information: Organizations are making a huge effort to provide written and nonwritten information about where and when to get vaccinated to communities in their preferred language(s). However, it can be challenging to ensure that once individuals who are non-English speakers get to the vaccination site, they are able to navigate the site, understand the anticipatory guidance of the potential side effects, and make an appointment for a second dose if needed, if no one at the vaccination site speaks their language. • • Providing transportation: Expanding access to ridesharing companies is a promising way to provide transportation, but some people encounter operational challenges. For instance, to use the app-based service (Uber also offers a telephone-based service to request a ride), the user must have a smartphone, be able to download and use an app that may not be available in their primary language, and have a credit card. Riders were not always accustomed to the service, so connecting with the driver at the designated location could also be a challenge. • • Maximizing convenience: Lack of coordination among the multiple organizations working to maximize the convenience of vaccination in a community could lead to multiple pop-up vaccination sites being inadvertently located a few blocks from one another on the same day, while leaving other parts of neighborhoods without convenient access. Organizations encountered several challenges: access codes intended to be given to communities of color for appointments were shared on social media and misused, forcing some vaccination sites to pause operations temporarily or switch to walk-in only; and, in one organization, well-intentioned volunteers called people to confirm appointments or schedule second doses, but those individuals did not know their telephone numbers had been shared, causing fear and mistrust. • • Offering incentives: Several organizations indicated that locally tailored incentives can be a useful tool, but they are concerned that if incentives are not deployed equitably, they may have little impact on inequities and, worse, may solidify people's skepticism about and mistrust of the vaccine. People may think that if the vaccine were safe and effective, people would not need to be paid to receive it. As these unintended consequences show, the devil is truly in the details when it comes to equitably delivering COVID-19 vaccines in the context of historic and current structural racism, xenophobia, worsening politicization, and declining trust in institutions. 38 In other words, a strategy that seems reasonable and sounds like it should succeed may not be effective if policy makers and implementers do not have the full, detailed picture of the local context in which the strategy is being deployed. Based on the experiences of exemplary organizations at various levels, the first few months of the COVID-19 vaccination rollout showed us that even as we celebrate our progress, public health officials and other policy makers at the federal, state, local, and hyperlocal levels must recommit to closing persistent equity gaps, learning from these early missteps, and sustaining progress toward health equity beyond the pandemic. To do so, structural changes are needed to maximize the chances that the strategies we described will be successful. Specifically, policy makers may consider several actions as they seek to address inequities in COVID-19 vaccination ( Table 3) . As we put our public health principles into practice, we need to continuously and critically examine proposed solutions to overcoming access barriers. These solutions should be designed by members of historically marginalized communities, and their input should be put front and center when implemented and adapted to local contexts. If we fail to do this, our "solutions" at best will not help those they are intended to reach and, at worst, will exacerbate existing inequities in COVID-19 vaccination. Table 3 . Policy actions to support hyperlocal efforts to promote equitable COVID- 19 vaccination Policy actions that could support implementation of hyperlocal vaccination strategies Invest in BIPOC-led communications and graphic design organizations, which can create locally and culturally tailored informational materials and know best how to help individuals who speak languages other than English navigate the complex vaccination process. Builds capacity in local organizations that understand the community and the local context and so are best positioned to develop content that will resonate and be effective. Increase health insurance reimbursement rates for various transportation options and support the use of transportation vouchers. Supports organizations to address transportation barriers that communities may face in getting to vaccination appointments. Provide sufficient paid sick leave and pursue options to make childcare more affordable so that individuals do not have to choose between their employment and their health. Addresses key barriers to vaccination faced by low-income populations. Making vaccination as low cost and convenient as possible can increase uptake. Invest in public health data infrastructure in local communities so that public health entities can support community-based organizations to develop data-driven hyperlocal planning around where and when to organize vaccination sites or events. Granular data can help local organizations identify neighborhoods or populations that are particularly vulnerable and/or have low vaccination rates, allowing them to tailor and target their outreach and access strategies. Involve communities in designing incentives that are tailored to the community, have value, and will promote rather than hinder equity. Engaging the community in developing policies and programs that affect them can improve implementation and effectiveness because the policy addresses the specific community needs and context. Abbreviation: BIPOC, Black, Indigenous, and People of Color. COVID data tracker: COVID-19 vaccinations in the United States Mapping and recontextualizing the evolution of the term Latinx: an environmental scanning in higher education Latest data on COVID-19 vaccinations by race/ethnicity Best practices in public health risk and crisis communication Creating vaccine equity: with equity-focused practices, we can improve COVID-19 vaccination rates among communities of color. 2021. Accessed The U.S. Equity-First Vaccination Initiative: Early Insights. RAND Corporation, 2022 Patient-centred access to health care: conceptualising access at the interface of health systems and populations 7 things that could reduce health disparities for Blacks, Latinos hit hardest by pandemic. The Greenville News Tribes are racing ahead of vaccination curve. Indian Country Today COVID-19 Vaccine Equity Plan. 2021. Accessed Vaccine equity in action COVID-19: Black residents get new access to vaccine at churches, clinics. Cincinnati Enquirer Find your state COVID-19 vaccine and eligibility information Vaccines for all: announcing free or discounted rides to vaccination sites Walgreens in Chicago aim to vaccinate more than 10,000 residents with houses of worship. Chicago Tribune COVID-19 vaccination event at Mesa market aims to improve Asian American vaccine access. Arizona Republic Amid access hurdles, grassroots efforts underway to get COVID-19 vaccine to at-risk people of color. USA Today Black hustlers mutual aid and freedom boutique Downtown clinic provides COVID-19 vaccine to St. Louis' homeless population. St. Louis Post-Dispatch Local health, social service organizations plan COVID-19 vaccines for the homeless. The Daily News Boston Health Care for the Homeless Program. Important COVID-19 MASS & CASS update Farmers maintain vaccine efforts for employees. AgAlert A jab on the job: companies, unions offer COVID-19 vaccines Make an appointment at the Center for Health Equity Coronavirus in California; vaccine rollout slows down as county works to improve access; over the last week, health officials see a 24% drop in number of shots administered COVID vaccine sites to open, expand hours across Connecticut on Monday COVID-19 vaccine Groups work to get Latino residents vaccinated: advocates get creative to help community make appointments. Austin American Statesman COVID-19 vaccine incentives DoorDash donates $2 million in community credits to support the White House's COVID-19 vaccination efforts Facing his July 4 vaccination deadline, Biden touts a major campaign, including free child care through big providers. The New York Times These companies are paying their employees to receive the COVID-19 vaccine. CNN Business Target's paying frontline team members to get the COVID-19 vaccine-here's how How to get promotions, prizes and freebies with your COVID-19 vaccine Vaccines made available to Cargill front-line employees in protein facilities across multiple states: essential protein workers in Kansas, Michigan and Nebraska among first to receive vaccine 19-employee-vaccinationevents-across-arkansas 37. Golden R. Dollar General to pay employees to receive COVID-19 vaccine. HR DIVE The authors thank their RAND colleagues, Kiera Addair, Paul Koegel, and Ninna Gudgell, for their contributions to this work. The authors also thank Boston Medical Center, Del Valle Community Coalition, Growing Coachella Valley, iFoster, Neighborhood Outreach Access to Health, the Rhode Island Department of Health, Sandhills Pediatrics Inc, the San Diego Unified School District, the Seward Vaccine Equity Project, and the University of Pennsylvania Health System, who agreed to be interviewed for this project and provided invaluable insights that informed this work. The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The Rockefeller Foundation. Laura J. Faherty, MD, MPH, MSHP https://orcid.org/0000-0002-8953-8856 The findings and conclusions contained in this article are those of the authors and do not necessarily reflect positions or policies of The Rockefeller Foundation.