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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.
What is the Equity-First Vaccination Initiative?
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.
Figure 1. The five EVI demonstration sites and local networks
Anchor partners supporting the CBOs in each city are Open Society Institute—Baltimore Chicago Community Trust Houston in Action United Way of Greater Newark Roots Community Health Center (Oakland).
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
facilitate an inclusive and equity-focused learning community provide technical assistance to counter misinformation and disinformation and develop evidence-based messaging around COVID-19 vaccination support CBOs' data collection and analysis to inform their vaccination approaches and track progress.
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
Why is a hyper-local approach needed?
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.
Figure 2. Communities in Baltimore with the lowest vaccination rates (first) also have the highest social vulnerability (second)
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
What are the challenges of a hyper-local approach?
Hyper-local outreach is time- and labor-intensive, and CBOs typically have small staffs and operating budgets. CBO staff members say that they are running a sprint ("having to go deeper and deeper" into their communities to vaccinate as many people as possible) and a marathon (pursuing health equity) at the same time. One CBO leader noted that although doing the work was uplifting, their staff was completely drained and burned out after months of COVID-19 testing and vaccination events.
Why should COVID-19 vaccination strategies be community-led?
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
What access barriers are EVI partners confronting?
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:
Information There is a lack of accurate, timely, understandable information about where, when, and how to get vaccinated. Physical accessibility Vaccine sites are in inconvenient places, are open only at inconvenient times, and do not accommodate those with mobility limitations. Trustworthiness Institutions and systems administering vaccinations might not be trusted by potential recipients. Technology Vaccine access depends on internet access and solid technological literacy. Cost Individuals can incur costs accessing the (free) vaccine, including transportation costs and missed work hours. How are EVI partners overcoming these barriers?
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).
Figure 3. CBOs are employing multiple strategies to address barriers to vaccination access 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？ Photo by Phil Roeder/Flickr
To be effective, CBOs are tailoring strategies to fit their communities. A strategy that works in Oakland, such as putting a pop-up vaccination clinic at a subway station, might not work in Houston, which is the size of a small state and has fewer public transportation options. Here are several of the multifaceted strategies that the EVI partners are using to promote COVID-19 vaccination equity:
An example from Houston
A Houston-based CBO took advantage of a back-to-school event that was distributing free backpacks. Families were waiting in their cars in a line that snaked around the school parking lot. CBO staff went from car to car, talked to people about the vaccine, showed them data on the impacts of COVID-19 in their community, and asked whether they were interested in getting vaccinated. If people were willing, CBO staff told them that they could get vaccinated just inside the school building after they had picked up a backpack. If they were not ready or did not have time that day, they got an immediate text message in their preferred language with information about where to get vaccinated when they were ready.
An example from Baltimore
A CBO that delivers food to older adults with limited mobility hired local youth to be vaccine ambassadors. The youth helped deliver food door to door in their assigned apartment complexes. At the same time, they talked to residents about getting vaccinated. If the residents were interested, the vaccine ambassadors pulled out their phones, preregistered the residents, made their appointments, and even arranged transportation to and from the site if needed.
What do CBOs identify as critical to their success?
EVI partners identified three organizational characteristics that are essential to the success of their equitable vaccination strategies:
mission-driven, committed staff who reflect or come from the communities they serve deep knowledge of and history in the community agility to respond to the constantly changing pandemic.
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
What else do CBOs need to support their equitable vaccination strategies?
The EVI partners identified four external supports that they need to promote equitable vaccination:
Policy leadership at all levels that makes equitable vaccination a policy priority can generate more funding for the CBOs' efforts, enhance coordination across multiple organizations, and improve the consistency of messaging to the community. Stable and more-flexible funding is essential for implementing, and sustaining, hyper-local equitable vaccination strategies. Most of the CBOs were piecing together funding from multiple sources. Such fragmentation adds administrative burden because each funding source has its own time frame and reporting requirements. Technical assistance can amplify CBO efforts. As part of the EVI, CBOs are supported by partners who provide communication training and assistance with data collection and analysis. To be most useful, technical assistance must be tailored, contextualized, and timely. Access to high-quality data, such as through local health departments, can help CBOs identify neighborhoods and specific populations where vaccination rates are low so that they can better target their outreach. 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
What has the EVI accomplished in its first few months?
EVI partners have made substantial progress since the initiative fully launched in summer 2021. In just the first few months of the EVI, CBOs in the five demonstration sites
held nearly 1,200 vaccine-related events provided assistance more than 42,000 times to get people vaccinated (e.g., transportation, registration) made almost 2 million connections with community members through campaigns and information sessions administered almost 16,000 COVID-19 vaccinations. What lessons have been learned about implementing equity-first initiatives?
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).
Table 1. Overarching lessons for promoting equitable COVID-19 vaccination Build authentic, ongoing relationships to meet community needs before, during, and long after a public health emergency. Amplify and support the CBOs that are doing the grassroots work; don't direct them. As experts in, and on, their communities, they know what strategies will be most effective. Provide a consistent, stable source of funding and ensure that funding opportunities are accessible to CBOs that have limited time or experience with grant-writing. Focus on building capacity within CBOs that will last long after the initiative is over (e.g., to counter vaccine misinformation, to interpret and act on vaccination data, and to apply for grant funding). Co-create messaging and information campaigns and co-design strategies to expand vaccine access in partnership with affected communities. Engage with and listen to communities from the outset, not just when asking for feedback on how something was received. Build bridges across sectors. Vaccination equity intersects with housing, employment, food insecurity, and infrastructure, among other social dimensions. Dig deeply to understand access barriers and hidden costs of vaccination for those without a social safety net; making vaccines available does not automatically mean that people can access them. Partner with various types of trusted messengers in a community. Think creatively with communities about who their trusted messengers are. Apply a harm reduction approach. If individuals are not ready to get vaccinated or do not plan to be vaccinated in the future, share information about how they can protect themselves and others from COVID-19. Reframe the narrative around access barriers and vaccine confidence. Rather than blaming individuals who are not vaccinated, strive to fix the broken systems (e.g., health care) that create barriers and lead people to mistrust them. How can policymakers support equitable COVID-19 vaccination efforts?
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.
Table 2. Actions that can help support equitable vaccination efforts Strategy: Share accurate, trustworthy, and accessible information. Fund CBOs to enable them to identify and collaborate with trusted messengers in their communities and/or hire additional staff. Coordinate messaging and recommendations with CBOs, giving them time to prepare to amplify the message or address concerns. Build communication capacity and networks among CBOs and other local organizations to address vaccine misinformation. Provide resources to primary care providers to equip them for difficult, yet efficient, conversations about COVID-19 vaccination. Strategy: Provide transportation assistance. Collaborate with the private sector (e.g., ridesharing companies) to offer free or discounted rides to and from vaccination sites. Ensure reimbursement by public and private payers to individuals or organizations for transportation. Strategy: Maximize convenience of receiving the vaccine. Provide financial incentives for providers to vaccinate their patient population. Provide accessible, high-quality, real-time data that can help target vaccination efforts, such as where to locate pop-up events. Ensure that pediatricians can be reimbursed for vaccinating adult caregivers who accompany a child to an office visit. Streamline the process for in-home vaccination and offer sufficient reimbursement. Strategy: Streamline registration and appointment processes. Expand funding for community health workers and patient navigators to assist with registration and appointments. Support development of technologies to streamline registration, documentation of vaccination administration, and reporting. Strategy: Offset costs of vaccination. Involve communities in designing incentives that are tailored to the community, have value, and will promote, not hinder, equity. Ensure that paid time off to get vaccinated or to recover from side effects is provided, or provide payments for lost income. Photo by Giselleflissak/Getty Images
How can the EVI contribute to long-term progress?
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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The U.S. Equity-First Vaccination Initiative Dec 20, 2021
Laura J. Faherty @LauraFahertyMD, Jeanne S. Ringel @JeanneRingel, et al.
Research conducted by RAND Health Care
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