Abstract
Vaccination disparities are part of a larger system of health inequities among racial and ethnic groups in the United States. To increase vaccine equity of racial and ethnic populations, the Centers for Disease Control and Prevention (CDC) designed the Partnering for Vaccine Equity program in January 2021, which funded and supported national, state, local, and community organizations in 50 states—which include Indian Health Service Tribal Areas; Washington, DC; and Puerto Rico—to implement culturally tailored activities to improve access to, availability of, and confidence in COVID-19 and influenza vaccines. To increase vaccine uptake at the local level, CDC partnered with national organizations such as the National Urban League and Asian & Pacific Islander American Health Forum to engage community-based organizations to take action. Lessons learned from the program include the importance of directly supporting and engaging with the community, providing tailored messages and access to vaccines to reach communities where they are, training messengers who are trusted by those in the community, and providing support to funded partners through trainings on program design and implementation that can be institutionalized and sustained beyond the COVID-19 pandemic. Building on these lessons will ensure CDC and other public health partners can continue to advance vaccine equity, increase vaccine uptake, improve health outcomes, and build trust with communities as part of a comprehensive adult immunization infrastructure.
Adult immunization uptake differs substantially by racial and ethnic group in the United States. 1 Socioeconomic factors, health care coverage, geography, and interpersonal factors also influence vaccination status. 2 Considering health disparities highlighted by the COVID-19 pandemic in early 2020, the Centers for Disease Control and Prevention (CDC) prioritized vaccine equity. Barriers to vaccinations include lack of vaccine accessibility, mistrust of and lack of access to the health care system, lack of adequate investment in the community-based health workforce, and lack of tailored educational resources for diverse populations.
Deep-seated structural racism drives distrust in vaccines, the health care providers and workers who administer them, and the health care system that recommends vaccination to racial and ethnic populations. CDC has compiled more than 900 published articles on adult immunization and racial and ethnic disparities, 100 of which were published in the last decade, that demonstrate the association between race and ethnicity and the likelihood of vaccination. 2 Data from the National Health Interview Survey from 2010-2019 showed that influenza vaccination coverage differed by race and ethnicity among adults aged ≥65 years (61.4% among Black adults, 63.9% among Hispanic adults, 71.9% among Asian adults, and 72.4% among White adults). 3
Research in immunization, HIV/AIDS prevention, mental health, diabetes, and cancer prevention shows that community partnerships can be effective in narrowing health disparities. In 1 study, a community-level partnership led to an increase in the number of influenza vaccines (from 46% to 80%) and pneumococcal conjugate vaccines (from 35% to 66%) administered from September 1999 to July 2004 among women from racial and ethnic minority populations who initiated prenatal care at a mobile clinic and delivered their babies at the hospital. 4 Engaging the community directly has also been successful in preventing HIV/AIDS. 5 Based on lessons learned from preventing the spread of HIV/AIDS through community engagement, CDC prioritized funding to community-based organizations (CBOs) to understand and address the barriers to vaccination uptake among adults in racial and ethnic communities. 5
Purpose
Partnering with national, state, and local organizations and CBOs, the Partnering for Vaccine Equity (P4VE) program sought to give consistent information to individuals at every level of the sphere of influence in society they might encounter, including health care providers, faith leaders, social media, and other trusted voices.
Methods
Building From Existing Cooperative Agreements
To begin community-driven activities in vaccination in 2021, CDC leveraged the Racial and Ethnic Approaches to Community Health (REACH) program, an existing CDC cooperative agreement that works directly with CBOs. REACH, a program focused on reducing the incidence of chronic disease in racial and ethnic populations, offered CDC a chance to pilot a new vaccine equity program and subsequently designed a funding opportunity to meet future P4VE partners’ needs. Initially, CDC funded 31 health departments, tribes, universities, and CBOs already participating in the REACH program and used their experience to develop additional funding opportunities and partnerships that would ultimately create the P4VE program.
Establishing Partnerships at the National, State, Local, and Community Levels
The P4VE program provided 13 national partners with $156 million for the first year of multiple 5-year cooperative agreements using COVID-19 response funding. The national-level organizations in turn funded 449 CBOs as subawardees, allocating 70% to 75% of the funding they received from CDC across 50 states, which includes Indian Health Service Tribal Areas; Washington, DC; and Puerto Rico. With these funds, CBOs focused on understanding and addressing barriers to vaccine uptake, training trusted messengers, and increasing vaccination opportunities in communities. In addition, 2 of the national partners (CDC Foundation and Urban Institute) were further engaged to manage a learning community and resource hub for partners in the P4VE program.
Offering Technical Assistance and a Peer Learning Network
To support rapid planning and implementation of vaccination activities, CDC provided additional support through data-informed technical assistance, a Learning Community, 6 to serve as an online platform for partners to learn from each other, and The Resource Hub, 7 a material sharing website. Providing data-informed technical assistance empowered partners through tailored maps to visualize populations of focus, potential intervention sites, and local assets to appropriately plan activities based on their populations of interest. The Learning Community is an online platform for group and peer-to-peer learning where partners can join events, hear experts on topics of their choice, connect with others in an online forum, and join affinity groups. Through The Resource Hub, partners can access a curated repository of materials and resources to accelerate implementation, build an evidence base on adult immunization and vaccine equity, and facilitate cross-partner collaboration.
Creating a Reporting Process
To receive regular reporting updates from partners, CDC developed a reporting template in English and Spanish. The data collected under this program received an institutional review board waiver, and it was determined by CDC’s internal clearance and review process that this activity was not human subjects research. To ensure data quality and assurance, CDC also provided trainings to the organizations on the reporting process and collected partner data on performance measures focused on outputs such as reach, language, and number of trusted messengers trained. The performance measure also had qualitative data to input on what CBOs perceived as successful or challenging. CDC analyzed the data and generated reports to share with partners.
Outcomes
While many simultaneous programs and factors at the national, state, and local levels contributed to the narrowing of COVID-19 vaccine disparities, several outcome measures from the P4VE partners program suggest the program’s efforts played a supporting role (Figure).
Estimates of COVID-19 vaccination coverage (≥1 dose) among adults aged ≥18 years, by (A) race and ethnicity and (B) percentage-point differences in coverage compared with non-Hispanic White adults, by race and ethnicity—National Immunization Survey Adult COVID Module, United States, December 2020–November 2021. Reprinted from Kriss et al. 8 Error bars indicate 95% CIs. Abbreviations: AI/AN, American Indian/Alaska Native; NH/OPI, Native Hawaiian/Other Pacific Islander.
In January 2021, CBOs partnered to administer 1.84 million COVID-19 and influenza vaccine doses (Table). Key challenges included reaching unvaccinated people, countering misinformation, improving collection of data on race and ethnicity, and adapting to evolving COVID-19 vaccination and safety guidelines. The 13 national P4VE partners developed 181 vaccine-related educational campaigns. The 4 racial and ethnic minority–led medical and professional organizations (Association of American Indian Physicians, National Council of Urban Indian Health, National Hispanic Medical Association, and National Medical Association) reached 502 745 clinicians and 862 health care organizations to foster culturally relevant vaccination recommendations to populations of focus. For example, the National Hispanic Medical Association held workshops for physicians (majority Spanish-speaking) on media training to effectively amplify trusted messages that emphasized vaccine safety.
Mechanisms and tools used by Partnering for Vaccine Equity (P4VE) program participants and their impact on the community to improve COVID-19 vaccine uptake in the United States, May 2021–June 2022 a
The P4VE program was launched by the Centers for Disease Control and Prevention in 2020 with a focus on increasing equity in adult immunization among racial and ethnic communities. The P4VE program focused on funding and guiding national, state, local, and community organizations to implement culturally tailored activities to improve access to, availability of, and confidence in COVID-19 and influenza vaccines. The program has had a presence in 50 states, which includes Indian Health Service Tribal Areas; Washington, DC; and Puerto Rico, since January 2021. Data source: Data from the P4VE program were extracted from partner progress reports.
Beyond the numbers, various partners’ efforts illustrate how engaging the community directly can be an effective strategy for vaccination programs. It also shows the importance of capturing qualitative data as part of the data collection process, to give a richer picture of the successes and challenges as activities are implemented.
Creating a Network of Public Health Champions
Through the National Council of Negro Women’s program, Good Health Women’s Immunization Networks, CDC was able to reach 300 health departments, foster care systems, schools, libraries, and other nonprofit organizations. From March through May 2021, more than 331 000 trusted messengers attended vaccine events where 12 715 COVID-19 and influenza vaccine doses, tests, and screenings were given to African American participants. During the same period, the social media campaign “Get the Facts, Boost the Trust” produced 1 758 491 social media impressions (the number of times content was displayed) and reached 644 221 people on Facebook and Instagram. Good Health Women’s Immunization Networks partnered with Uber to provide 1582 rides to vaccine sites via the application or an 800 number, presented Vaccine & Voting workshops in communities and to the Congressional Black Caucus, and created public service announcements by the National Panhellenic Council that reached 2.5 million people.
Engaging Local Business Owners in Campaigns
Another example of a successful community engagement is the Bronx Health REACH “I Got Vaccinated for My Mom” campaign in Bronx, New York, which helped increase the vaccination rate among Black and Latino men aged 18-44 years, among whom the fully vaccinated rate was stagnant at 25% in September 2021. Working with F.Y. Eye, a nonprofit media agency, Bronx Health REACH created an advertising campaign to encourage young men in racial and ethnic minority groups to vaccinate against COVID-19 by tapping into their love for their mothers and their instinct to protect their mothers’ health. The advertisements appeared in fall 2021 on bus tails, with an estimated reach of 2.4 million people. A critical factor in the success of Bronx Health REACH’s campaign was the involvement of community businesses, including local barbershops and restaurants. Business owners hosted vaccine events and put flyers in their takeout menus and between barbershop mirrors. They also talked to their customers about vaccine events while cutting their hair or serving food and texted and called regular customers to remind them about the event.
Making Information Accessible and in the Community’s Language
Similarly, the Asian & Pacific Islander American Health Forum (APIAHF) led the establishment of the National AA and NH/PI (Asian American, Native Hawaiian, and Pacific Islander) Health Response Partnership (hereinafter, Partnership) with more than 30 national, state, and local organizations. The Partnership also launched a website, managed by APIAHF, to house COVID-19 and influenza information pertinent to Asian American and Native Hawaiian/Pacific Islander communities, including resources translated into more than 35 languages. APIAHF and community partners have been able to create resources through a feedback loop with community members. These included creating public service announcement videos that addressed common vaccination myths translated into 11 Asian and Native Hawaiian/Pacific Islander languages and partnering with the National Asian Pacific American Bar Association to develop a guide to empower people in the refugee, immigrant, and migrant communities with accurate information to receive their vaccinations.
Another organization, VietLead, whose priority population is the Vietnamese population, used telephone campaigns to translate COVID-19 and influenza vaccine messaging to older adults and limited English–speaking individuals. VietLead used electoral organizing methods, such as voter databases and experienced long-term canvassers, to disseminate COVID-19 and influenza information. Overall, the organization made more than 4713 telephone calls and sent 22 258 texts in Vietnamese to address vaccine hesitancy. VietLead also partnered with Vietnamese-speaking health care professionals to hold monthly webinars to address misinformation and disinformation.
In addition, the Eastern Michigan University Center for Health Disparities Innovation (CHDIS), a CDC REACH recipient, used supplemental funding to develop data-driven strategies tailored to medically underserved communities with a focus on Asian and Arab Americans experiencing health and socioeconomic disparities. They adopted items from the CDC Rapid Community Assessment Guide, 9 developed language-appropriate surveys, and conducted 12 listening sessions. Most survey respondents had limited English proficiency and stated that they did not know how to use the internet to register for COVID-19 vaccines or boosters and how to locate places to get COVID-19 vaccinations. 8 Research by CHDIS also revealed that experiences of racism were associated with greater vaccine safety concerns. 10 The CHDIS Geographic Information Systems team also developed and launched a web-based map 11 that includes the locations, number of vaccines administered, type(s) of vaccines, community partners, and dates of CHDIS mobile clinic events. Recognizing that community health workers are essential frontline public health workers who are trusted members of and/or have a deep understanding of the communities they serve, CHDIS identified, recruited, and trained 164 influential messengers as trusted voices. Based on the survey results, geographic information system mapping, and listening sessions, CHDIS held 48 mobile vaccine clinics in community-accessible locations (eg, community centers, mosques, churches, food distribution sites) that served nearly 4400 people and improved vaccine opportunities for the priority population.
Using Trusted Messengers
In February 2021, the National Alliance for Hispanic Health (the Alliance) established the Vacunas para todos (Vaccines for All) network, led by trusted Hispanic-serving CBOs in 35 communities, as a trusted quick-response infrastructure to close vaccination gaps. The Vacunas para todos network conducted surveys in spring 2021 and 2022 with community members and health care providers to understand and respond to changing health care needs. In the first year of the Vacunas program, the network responded to changing needs by establishing workplace vaccination clinics when workers in meatpacking plants and agricultural fields reported concerns about missing work. The network also implemented mobile vaccination efforts for veterans and older adults who were homebound when communities reported access barriers. When health care providers reported communication barriers, community health workers (promotores) who spoke indigenous languages bridged the gap. Finally, when community residents found that information was lacking, the network developed new resources, including native novela-style videos (National Alliance for Hispanic Health, monthly narrative Vacunas reports to the Health Resources and Services Administration, United States, July 2021–August 2022). In all, from July 2021 to August 2022, the Vacunas para todos network established 661 new vaccination partnerships, trained 7303 trusted community messengers, conducted 3027 informational events that reached 397 674 people, launched bilingual and culturally proficient information campaigns that reached 52.4 million people, and delivered 613 289 COVID-19 and influenza vaccinations in medically underserved communities.
Lessons Learned
The P4VE journey and partners offer multiple lessons about equitable program design, data collection, and community engagement to improve vaccine equity. One success was prioritizing the needs of CBOs before and during the application process for P4VE program funding. This prioritization is indispensable for identifying organizations that may not traditionally partner with federal agencies but are trusted by members of racial and ethnic minority communities.
Another success was supporting partners to provide culturally appropriate and tailored information to meet people in their community and increase vaccine confidence and uptake while combating misinformation and disinformation. This process includes understanding and respecting where an individual is in their vaccination journey to build a trusting relationship. A key piece of the program’s success was training trusted messengers to develop and cultivate relationships in the community and keeping dialogue open between CBOs and community members with differing views about vaccines. By creating an environment in which to share and discuss questions and reservations about the vaccine, CBOs could address misinformation and dispel myths about the COVID-19 and influenza vaccines in a respectful, collaborative environment.
Another way that P4VE partners improved equity was by increasing access to vaccines directly in the communities they serve, such as through mobile vaccination sites in places of worship, schools, or community health centers. A key lesson learned was that communication and education efforts alone are not enough and likely should not be the sole focus of a vaccination effort. Making the vaccine accessible is equally important.
The program also faced challenges, including that the data collected from partners were predominantly outputs (eg, number of events and attendees, number of vaccines administered) and qualitative data, making it difficult to assess long-term impact without formal evaluation. In the future, it will be important to help partners collect and evaluate their own data to support this broader building of the evidence base for what works best to increase vaccine equity in racial and ethnic communities.
A formal evaluation of CDC’s P4VE program activities is underway to understand the impact of these efforts on vaccination rates across populations of focus. While it is difficult to discern the impact P4VE has had on improving vaccination rates given the many efforts occurring simultaneously and the predominantly output data submitted by partners (eg, number of events and attendees, number of vaccines administered), the evaluation of the P4VE program aims to build an evidence base for effective strategies to increase adult immunization uptake and lay the foundation for future evaluations. Once the evaluation is complete, CDC will use these findings to refine its own adult immunization activities and disseminate evidence-based recommendations to partners to support adult immunization uptake.
Ultimately, the strength of the program is the network of partners, each of which brings unique capacities, backgrounds, and skills to the program and supports each other through peer-to-peer learning, which amplifies the impact of CDC’s efforts to reach populations that historically have been medically underserved. The overall program design and strategies implemented by partners can be replicated for other adult vaccinations and in other racial and ethnic populations in the future. Sustaining this progress will require continued investment in communities and accountability for robust and participatory approaches that are essential to designing equitable vaccine programs.
Footnotes
Acknowledgements
The authors thank Theresa Bailey, MPH, and Erin Bernstein, MPH (Deloitte); Amy Parker Fiebelkorn, MSN, MPH, and Megan Lindley, MPH (Immunization Services Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention) for reviewing the abstract and/or the article; and the entire P4VE team for providing programmatic design and support to the P4VE program.
Disclaimer
The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
