Multisector Partnerships and Service Colocation to Increase Adoption of Influenza Vaccines and Address Food Insecurity

Introduction

The development and delivery of safe and effective vaccines to mitigate public health threats from deadly infectious diseases has been one of the most consequential advances in biomedical science. Seasonal influenza viruses are detected year round in the United States and are the cause of respiratory illnesses that increase to epidemic levels almost every winter. Influenza infections can be hazardous for people 65 years and older because of their elevated risk for developing serious flu-related complications. Estimates from national level data (2018–2019) indicate that ∼7 out of 10 adults, age 65 years and older, received an influenza vaccine. ¹

These influenza immunization levels are consistent with national goals (68% in 2019) ² ; however, race and ethnicity-specific data indicate that vaccine uptake among individuals belonging to marginalized racial and ethnic groups is significantly lower. ³

Influenza vulnerability among marginalized populations is often rooted in an inability to address basic needs. Economically challenged groups, including racial and ethnic minorities, may experience greater barriers to accessing medical care, such as lack of health insurance, transportation, or the ability to take time off work, which can limit opportunities to receive influenza vaccinations. ⁴ Although persons aged 65 years and older are Medicare eligible, and thus more likely to be insured, many face similar barriers to care, specifically cost and inadequate transportation. ⁵

The current COVID-19 pandemic has amplified the urgency to increase influenza vaccination rates to reduce the burden of respiratory illnesses on an already over-taxed health care system. Increasing vaccination uptake among marginalized older populations is essential and new models of preventive care are needed. In addition, influenza immunization efforts targeting underserved communities can be expanded to leverage locations that are accessible and familiar to residents. The purpose of this perspective is to describe the current state of disparities in influenza vaccination rates underscoring need for multisector partnerships and service colocation, reducing the burden of influenza among older adults.

Influenza-Related Hospitalizations, Vaccination Rates, and Social Risk Factors

Low or delayed vaccination uptake can lead to higher rates of morbidity and mortality, particularly among older adults. ⁶ A recent age-adjusted analysis from the Centers for Disease Control and Prevention (CDC) showed that compared with White Americans, Black Americans have an influenza-related hospitalization rate that is 80% higher. ³ Vaccines can reduce these disparities; however, data suggest vaccination efforts are not reaching those who would most benefit.

The authors bring additional data to this discussion through their descriptive analysis of medical and pharmacy claims data (2019–2020) from a national insurer, which included individuals who had completed a subset of questions included in the CMS Accountable Health Communities (AHC) Health-Related Social Needs Screening Tool, ⁷ and had continuous Medicare Advantage prescription drug plan enrollment from August 2019 through March 2020 (N = 20,164).

Evidence from this analysis suggests that social risk factors, defined as exposure to adverse social conditions that are associated with poor health, ⁸ may be linked to low influenza vaccination rates, particularly when they occur concurrently. Individuals who reported 2 or more social risk factors had lower influenza vaccination rates than those who reported fewer. When stratified by social risk factor category, were observed slightly lower influenza vaccination rates among those who were food insecure, lacked stable housing, did not have reliable transportation, reported financial strain, and experienced loneliness (Fig. 1).

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FIG. 1.

Influenza vaccination rates by social risk factor category.

Social risk factors often exacerbate barriers that make it difficult to prioritize or access vaccinations. Food insecurity is a significant risk factor as it affects 10.5% of all U.S. households and 34.9% of those households with incomes below the federal poverty level. ⁹ Food is a necessity that is often prioritized over health care, especially preventive services such as vaccinations. Social services such as food banks have become increasingly important in recent years to help address the needs of economically marginalized populations.

Individuals who experience food insecurity can also be subject to unstable housing, transportation, and employment. Food banks can be an important partner in the effort to improve health outcomes among older individuals and other high-risk populations. A recent study indicated diabetes prevention and management interventions conducted with food banks have improved glycemic control among high-risk populations. ¹⁰ Similar programs could be developed to prevent infectious diseases by delivering vaccinations in these trusted locations.

Multisector Partnerships and Service Colocation

Providing preventive services such as vaccinations to those with social risk factors requires broad creative partnerships. ¹¹ There is evidence to suggest connected community networks that leverage multisector partnerships to deploy community health improvement activities are associated with lower rates of preventable mortality. ¹² Multisector partnerships have the potential to mitigate many of the aforementioned barriers to achieving optimal health by pooling resources, coordinating efforts, and reducing duplication, which expands the capacity to support population health activities that address unmet social and health needs. ¹³

Service colocation, a model that facilitates the use of multiple services by offering them in 1 accessible location, is another way to strengthen community networks and support population health. This model can improve access to services, minimize fragmentation, and improve coordination of care. Service colocation as a model became popular during the 1960s when public-sector programs focused on increasing access to services in poor underserved communities. ¹⁴

Currently, colocated health services can be found in a wide range of settings. Primary care services at pharmacy locations, behavioral health services offered in primary care settings, and a variety of HIV care services delivered at a single clinic are common examples. ¹⁴ Colocation can extend beyond traditional clinic settings. The Sickness Prevention Achieved through Regional Collaboration (SPARC) model, recommended by the CDC to expand the delivery of preventive services, strengthens multisector connections by delivering preventive services at new sites such as churches, salons, worksites, and community centers. ¹⁵

Successful implementation of colocated services requires a facilitative payment structure. Multisector partnership and service colocation align to many elements of existing reimbursement models, such as care coordination functions within some Medicare Advantage plans, and care delivery models such as the patient-centered medical home. The AHC model is also designed to stimulate and support similar coordination between clinical and community services, but only in select locations, ¹⁶ leaving many communities without the resources needed to integrate medical and social services. Continued systematic exploration of multisector partnership and service colocation could inform developing policy and advance sustainable service coordination mechanisms.

Low influenza vaccination rates among those with the greatest needs, specifically food insecurity, present an opportunity to think creatively about service colocation. Bringing local health departments and food banks together to offer vaccinations and access to nutritious low-cost foods at a single accessible food pantry site could be an effective approach to increase vaccine uptake and reduce disparities in vaccination rates and food insecurity. This pairing could also optimize the impact of the vaccine itself, as healthy foods rich in essential micronutrients boost the body's immune response, which supports vaccine effectiveness.

Conclusion

The burden of infectious diseases has persisted for centuries, and disproportionately affects racial and ethnic minority groups and vulnerable older adults. Although there is no single intervention to improve health outcomes for vaccine-preventable diseases, the colocation of services that address social risk factors while also increasing access to necessary preventive services, such as vaccinations for influenza, offers the promise of reducing disease burden.