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Carrying Equity in COVID-19 Vaccination Forward: Guidance Informed by Communities of Color

One-size-fits-all vaccination campaign strategies won’t be successful and ignore opportunities for systems change


Seven months into the COVID-19 vaccination campaign in the U.S., nearly 50% of Americans have been vaccinated. This is notable, but a significant amount of work remains to be done.

CommuniVax, a national rapid research coalition of social scientists, public health experts, and community advocates, released a report, Carrying Equity in COVID-19 Vaccination Forward: Guidance Informed by Communities of Color, with recommendations for state and local officials to better serve groups with persistently low vaccine coverage—particularly low-income persons and communities of color.

Since January 2021, local research teams have worked with Black and Hispanic/Latino communities in Alabama, California, Idaho, Maryland, and Virginia. The teams assessed community infrastructure; listened to community members, public health officials, and government leaders; and coordinated engagement activities to understand how to best promote awareness of, access to, and acceptability of COVID-19 vaccines.

Co-chair of CommuniVax and co-author of the report, Monica Schoch-Spana, PhD, MA, of the Center for Health Security breaks down some of the report’s key points in this Q&A.

The report points out that it’s problematic to blame low vaccine coverage entirely on hesitancy. Why is that?

First, “hesitancy” is a simple explanation for a complex set of circumstances, and if we do not accurately identify the problem, then we cannot apply the most appropriate solution.

Vaccine hesitancy—in its popular sense—involves a range of concerns about vaccines that can vary in detail and severity from person to person. In speaking with 10 people, it is possible to hear 10 very different types of concerns that, even when similar, differentially influence the decisions of the persons expressing them. One-size-fits-all communication strategies won’t have their intended effect in these circumstances.

Vaccine hesitancy, too, is often considered an “either-or” prospect, but in the local research, individuals routinely related the dynamic nature of their decision-making. Their assessments of vaccination changed over time as they were exposed to new information—accurate or not.

For some individuals, their evaluation of COVID-19 vaccines continued even after they were vaccinated. For example, some expressed regret for receiving the Johnson & Johnson vaccine following the pause, and others, frustration at learning about the possibility that vaccinated persons could still contract COVID-19. Sustaining people’s confidence in COVID-19 vaccines is important.

Second, and even more seriously, mischaracterizing the causes for low vaccination rates within particular groups can conceal issues of access, including those due to structural racism. This can result in a failure to fix the real problems as well as instances of victim-blaming.

Since the very beginning of the COVID-19 vaccine rollout, access to vaccines has been a significant barrier for many marginalized groups. The same socioeconomic and structural obstacles that have contributed to the uneven impacts of COVID-19 by socioeconomic status and by race/ethnicity have also kept people from getting vaccinated.

Barriers identified in the local research included a lack of transportation to vaccination sites (especially in rural areas), limited hours at vaccination sites, and inability to take time off work for vaccination appointments or to take time off if vaccination resulted in sickness. In Hispanic/Latino communities, additional barriers included a lack of multilingual speakers at call centers and vaccination sites.

These are practical hurdles that require reconfiguring vaccine delivery and communication strategies, rather than overcoming perceived deficits in a person’s feelings, thinking, or even moral fiber.

Another “critical error” is assuming that all communities of color face the same circumstances. What are some suggestions for correcting this harmful misperception?

We should all resist the urge to generalize about the end users of COVID-19 vaccination, in the interest of expedient, easy answers to more complicated realities.

For instance, regarding public health communication about COVID-19 vaccines, no single message can reach all white individuals; the same holds true for all other demographic groups, including Black and Hispanic/Latino persons. Characteristics other than racial and ethic identity also shape a person’s interactions with and understandings of the world around them, including age, gender, political identity, religious identity, attachment to place, education, and socioeconomic status.

At the same time, certain commonalities can exist, which vaccination planners should also account for. Black and Hispanic/Latino persons share the burden of racial inequalities, although their experiences of racism may differ due to factors such as language, culture, and historical experiences with certain institutions (e.g., immigration and law enforcement).

Vaccine promoters should pause and think about real people and how their lives are organized: For instance, where might young Hispanic/Latino congregate in their free time, and how can we reach them as a group there and with what information? Regardless of race/ethnicity, what barriers to access do “essential workers” working at grocery stores or as caretakers for children/elders face when trying to get vaccinated?

As vaccination becomes more widespread, new outbreaks are occurring in ever smaller and more local clusters such as particular communities within cities or counties. The report found that “hyperlocal responses” actually work better than blanket national campaigns. How can groups respond quickly and in a targeted way to prevent new outbreaks?

To reverse the COVID-19 vaccination campaign’s current slowdown and persistent unevenness in vaccine coverage, it should support more peer-led and neighborhood-based opportunities for community conversation and for convenient vaccine access.

Health systems and health departments should develop and/or strengthen their collaborations with community-based organizations (CBOs), faith-based organizations (FBOs), and community health workers (CHWs) and, importantly, commit to maintaining these relationships after the COVID-19 pandemic subsides.

CBOs, FBOs, and CHWs should play a key role in identifying reasons for low vaccination coverage and should be involved in developing interventions to address those issues, such as providing vaccines at locations community members perceive as safe, familiar, and convenient.

CBOs, FBOs, and CHWs who have roots in specific underserved communities and who have common life experiences—both ups and downs—have the local knowledge and trusted inroads into the community that can help make the campaign more personal and its delivery and communication strategies more precise.

The report says that “humanizing delivery and communication strategies” is crucial for vaccines, and cites collaborations between health systems and the communities they serve as an example of this. Can you talk about what that might look like, or give an example of a successful campaign?

Community partnerships have been used with great success throughout the pandemic.

In the Mission District of San Francisco, for example, the Latino Task Force was instrumental in organizing a community hub for food distribution and other wraparound services.

The Task Force, in an alliance with Unidos en Salud, the University of California San Francisco, and the public health department, went door-to-door to promote COVID-19 testing, which resulted in 70,000 tests overall, and provided a platform for the community’s eventual vaccination efforts.

By late June, 67% of the Hispanic/Latino population in San Francisco had been vaccinated.

COVID-19 vaccinations provide opportunities for people to come into contact with public health systems they might otherwise never consider. How can these encounters be maximized so that people are getting not just vaccines, but perhaps access to other needed services?

Vaccines cannot stand on their own as an intervention to stop COVID-19’s direct and indirect effects.

Public agencies, hospitals and health systems, nonprofit social service providers, CBOs, FBOs, and CHWs should align themselves around a “whole person” model of pandemic recovery to multiply the benefits of each vaccination encounter.

COVID-19 vaccinations and culturally and linguistically appropriate information about them should be provided alongside other critical goods and services, such as food, housing, and job opportunities. Vaccination sites could be resource centers, or hubs, in partnership with CBO and FBO staff to provide holistic support.

This type of wraparound service approach provides the sense of safety and security that is essential for informed health decision-making. Also, treating people’s well-being holistically can generate trust in health and governmental systems—these institutions are proving themselves as trustworthy by caring about “whole persons” and not just vaccination rates.

The pandemic has opened up all sorts of conversations around health equity. How could COVID-19 vaccine campaigns lend themselves to larger, systems-level changes to address gaps?

Humanizing delivery and communication strategies for COVID-19 vaccines can lead to broader vaccine coverage in groups with high rates of COVID-19 cases, hospitalizations, and deaths; jumpstart ongoing and consistent delivery of services that improve the health and well-being of underserved populations; and begin the work of repairing the structural and interpersonal racism experienced with medical, public health, and governmental systems.

Anchoring COVID-19 vaccination for hard-hit areas in a holistic recovery process can enhance health and wellness among the worst-off survivors of the pandemic now, and it can prompt advances in the social determinants of health that strengthen quality of life as well as community resilience to extreme events.

A more highly evolved COVID-19 vaccination campaign can accelerate development of a national immunization program to protect people throughout the life course. It can enable broader coverage for COVID-19 vaccines and the 13 other vaccines urged for some or all adults, and it can raise immunization rates for racial/ethnic minority adults whose vaccination rates trail those of white adults.

The community health workforce is essential to the COVID-19 vaccination’s campaign efforts, particularly among low-income communities of color. Greater efforts to formalize and sustainably finance CHWs—who advance goals of disease prevention, health promotion, and social justice—can lead to better health outcomes, improvements in the social conditions of health, and communities’ having control over the trajectories of their own health and wellness.

Monica Schoch-Spana, PhD is a senior scholar at the Center for Health Security and a senior scientist in Environmental Health and Engineering.