Report
The U.S. Equity-First Vaccination Initiative
Jan 28, 2022
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photo by SDI Productions/Getty Images
As of early November 2021, more than 78 percent of U.S. adults had received at least one dose of coronavirus disease 2019 (COVID-19) vaccine. However, vaccination rates among communities that identify as Black, Indigenous, and people of color (BIPOC) continue to lag relative to their shares of the total population. Even more striking are inequities by race and ethnicity in vaccination rates relative to COVID-19 mortality. For instance, Black non-Latinx Chicago residents accounted for 40 percent of deaths from COVID-19 but only 21 percent of those who are fully vaccinated.
The Equity-First Vaccination Initiative (EVI), supported by The Rockefeller Foundation, aims to reduce racial and ethnic disparities in COVID-19 vaccination rates in the United States and, over the longer term, strengthen the public health system to achieve more-equitable outcomes. Building on prior place-based investments, the foundation committed $20 million over one year to fund five demonstration sites—Baltimore, Maryland; Chicago, Illinois; Houston, Texas; Newark, New Jersey; and Oakland, California (Figure 1)—to plan and implement hyper-local, community-led strategies to increase vaccine confidence and access for BIPOC communities.
The EVI has identified anchor partners in each site that, along with other key partners, have provided subgrants to more than 80 community-based organizations (CBOs). The CBOs are leading the implementation of hyper-local strategies to increase equitable access to COVID-19 information and vaccinations. The anchor partners plan and coordinate CBO efforts in each site (represented in Figure 1 by networks of organizations in each city), track progress, foster communities of practice, and ensure that the CBOs have what they need to be successful.
The EVI has also engaged several additional partners, including the RAND Corporation, to support the CBOs in measuring, evaluating, and scaling up their learning. These partners
This brief focuses on strategies to increase access to COVID-19 vaccination; other products will report on communication and messaging efforts by the CBOs.
We recognize that each community is different.… What you do on the east side of Kashmere Gardens [a Houston neighborhood] may or may not work on the west side of Kashmere Gardens.
A Houston CBO staff member
The maps of Baltimore shown in Figure 2 illustrate a clear overlap between the communities with the lowest percentage of the eligible population that is fully vaccinated and the communities with the highest social vulnerability, which is the potential for external stressors to lead to poor health and other adverse outcomes. This same troubling intersection exists in each of the other EVI demonstration sites.
In addition, a community's composition, culture, norms, and history all affect which vaccination strategies are needed and appropriate. When it comes to tailoring messaging and strategies to address access barriers, there is almost no such thing as too hyper-local.
Zip Code | % of population fully vaccinated | Social Vulnerability Index (0 = lower vulnerability; 1 = higher vulnerability) |
---|---|---|
21201 | 66% | 0.56 |
21202 | 59% | 0.53 |
21205* | 49% | 0.91 |
21206 | 52% | 0.58 |
21207 | 57% | 0.59 |
21208 | 73% | 0.44 |
21209 | 77% | 0.27 |
21210 | 62% | 0.22 |
21211 | 82% | 0.27 |
21212 | 71% | 0.37 |
21213* | 46% | 0.77 |
21214 | 59% | 0.44 |
21215* | 53% | 0.82 |
21216 | 41% | 0.73 |
21217* | 46% | 0.82 |
21218 | 57% | 0.62 |
21222 | 58% | 0.57 |
21223* | 42% | 0.82 |
21224 | 71% | 0.53 |
21225 | 47% | 0.72 |
21226 | 59% | 0.40 |
21227 | 62% | 0.51 |
21228 | 79% | 0.33 |
21229 | 52% | 0.66 |
21230 | 70% | 0.37 |
21231 | 76% | 0.30 |
21234 | 65% | 0.36 |
21236 | 73% | 0.24 |
21237 | 68% | 0.52 |
21239 | 54% | 0.58 |
21251 | 4% | 0.67 |
* = highly vulnerable population
CBOs are closest to the challenges and the solutions in their own local contexts. Community-driven efforts leverage and build capacity among individuals and organizations who know their communities best, promote agency and autonomy, and bring community members' voices to the forefront. Furthermore, CBO staff are trusted messengers about COVID-19 vaccination because they often come from the communities they serve.
We're working with, hiring or recruiting, and deploying people from their own communities. So who better to help us engage a specific community than the actual community members?
A Houston EVI partner
A scan of the academic literature and the media, supplemented by in-depth interviews, identified five types of barriers hindering equitable COVID-19 vaccination across the United States:
EVI partners are using creative, hyper-local strategies to overcome these access barriers. Strategies include sharing information about where and how to access vaccines, making them more convenient by putting sites near where people live or go for other reasons, providing transportation through travel vouchers or car pools, making registration and appointment processes streamlined and inclusive, and offering perks for getting vaccinated. CBOs are using multiple strategies to reach as many people as possible, and each strategy typically addresses several barriers simultaneously (Figure 3).
Information | Physical accessibility | Trustworthiness | Technology | Cost | |
---|---|---|---|---|---|
Sharing accurate, trustworthy, and accessible information | barrier addressed✓ | barrier addressed✓ | barrier addressed✓ | ||
Providing transportation assistance | barrier addressed✓ | barrier addressed✓ | barrier addressed✓ | ||
Maximizing convenience of receiving the vaccine | barrier addressed✓ | barrier addressed✓ | barrier addressed✓ | barrier addressed✓ | |
Making registration and appointment processes streamlined and inclusive | barrier addressed✓ | barrier addressed✓ | |||
Offering incentives | barrier addressed✓ |
EVI partners identified three organizational characteristics that are essential to the success of their equitable vaccination strategies:
EVI partners also identified strong partner relationships as indispensable. All of the EVI partners are building on past successful partnerships and creating new ones to fill gaps. The most important facilitators of these relationships were trust and clear communication, and a collaborative infrastructure supported both. For instance, EVI partners created frequent opportunities to convene as a community of practice both within and across demonstration sites.
We've always positioned ourselves from the beginning as … bridg[ing] the gap between public health and health care delivery. That's a lot of the work that we do, that we've always done. I feel like in this crisis … that has helped us be in a really responsive role at the ground level, because … we've been sitting in that space before now.
An Oakland EVI partner
The EVI partners identified four external supports that they need to promote equitable vaccination:
Every conversation I have about sustainability, I have to say, 'You can't sustain anything without money. I don't care where you are and what you're doing. And so if you're not willing to pay for it, that means that it's really not that important to you.'
A Newark EVI partner
Photo by dragana991/Getty Images/iStockphoto
The EVI partners' work has highlighted several overarching lessons for other initiatives seeking to promote equitable COVID-19 vaccination and address inequities more broadly (Table 1).
Policymakers and public health officials, health care organizations, philanthropic organizations, and the private sector each play a critical role in providing the resources, leadership, and implementation supports for organizations such as the EVI anchor partners and CBOs. Table 2 summarizes selected external supports and policy actions, by type of strategy, that could be implemented in the short term to make equitable vaccination strategies more feasible, scalable, effective, and sustainable.
Photo by Giselleflissak/Getty Images
The inequities in COVID-19 vaccination reflect much broader inequities that the United States has been grappling with for many years. But the EVI is demonstrating a path forward. Achieving the EVI's second goal—building a community-centered public health system—will require significant time, effort, resources, and political will.
The EVI is serving as a real-world example of a hyper-local, community-led approach that is building lasting capacity to address a range of challenges. This initiative will produce insights on what works and what is needed to promote equity in COVID-19 vaccination and beyond.
We take a holistic approach to serving the community.… If someone doesn't have a home, guess what? They don't have food. If they don't have food, nine times out of ten, they have health challenges. If they don't have work, they can't afford a house. It's all connected.
A Newark CBO staff member
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