The U.S. Equity-First Vaccination Initiative: Impacts and Lessons Learned

Overview

The one-year U.S. Equity-First Vaccination Initiative (EVI), officially launched in April 2021, aimed to reduce racial inequities in coronavirus disease 2019 (COVID-19) vaccination across five demonstration cities (Baltimore, Maryland; Chicago, Illinois; Houston, Texas; Newark, New Jersey; and Oakland, California), and over the longer term, strengthen the U.S.'s public health system to achieve more-equitable outcomes. Nearly 100 community-based organizations (CBOs) and other local partners led hyper-local, place-based, holistic work to increase vaccination access and confidence in communities of people who identify as Black, Indigenous, and People of Color (BIPOC). In each demonstration city, an anchor partner (and in two cities, an additional key partner), selected and subgranted funding from The Rockefeller Foundation to a diverse coalition of CBOs in their city. Anchor partners and key partners provided leadership, tracked progress, and ensured that the CBOs had what they needed to be successful. Various EVI learning, communication, and advocacy partners supported and amplified the work of the CBOs. Building on an interim study that was released in January 2022, these two studies together answer the following research questions:

• What has been learned within and across the five demonstration sites about the most-effective hyper-local and equity-first delivery models to increase access to COVID-19 vaccination for marginalized populations?
• What are implementation practices that make such models more feasible, acceptable, effective, scalable, and sustainable?
• To what extent do available data indicate that the equitable COVID-19 vaccination efforts have been successful?

To address these questions, this study describes:

• Activities of the CBOs that comprise the EVI, including the local COVID-19–related context in which they were working, how that context changed over time, and what these organizations did to promote equitable COVID-19 vaccination in their respective cities
• How those activities affected individuals, organizations, and the broader community
• Implementation challenges and lessons for implementers and policymakers in advancing an equity-first approach
• Specific policy recommendations for how to support, and sustain, this hyper-local, community-led approach, as well as overarching recommendations for beginning to tackle the longer-term goal of strengthening the public health system in the United States.

Approach

We used a combination of quantitative and qualitative data and approaches for this analysis. Over the course of the EVI, we conducted virtual semistructured interviews with organizational leaders and staff from the anchor and key partners, collected monthly reflections about their work through an online survey or brief discussion, and interviewed a subsample of CBOs. We also reviewed informal notes taken by the RAND Corporation team during the community of practice meetings. To supplement these interviews and notes, we collected screen captures of flyers, photos, and other public posts from the social media pages of the EVI CBOs.

We conducted descriptive analyses of four metrics that anchor partners reported monthly to RAND to track the activities of the EVI in their demonstration sites and modify their hyper-local strategies as needed. We compiled and conducted descriptive analyses and mapping of community-level COVID-19 cases, hospitalizations, deaths, and vaccinations by type and by race and ethnicity in each city. We accessed these community-level data through a combination of public sources (e.g., COVID-19 dashboards) and data requests from state and local departments of health. Although the results of our analysis provide important insights that are relevant beyond these five communities, it is important to not overgeneralize the findings to all BIPOC populations in all settings. Rather, the lessons learned need to be tailored to the specific contexts and populations to which they will be applied.

Key Findings

Impacts

We found that the EVI had the following impacts:

• There is evidence that the EVI reached its target population and played a role in improving vaccination equity.
• The CBOs that participated in the EVI were working in cities with longstanding inequities. Over the course of the EVI, rates of those who were fully vaccinated rose substantially among Latinx residents across the five demonstration sites, but there was less progress for Black residents. Those receiving booster doses were disproportionately White.
• Despite these entrenched inequities, CBOs that previously did not work in the fields of public health and health care (as traditionally defined) proved that they could quickly and effectively pivot to address barriers to COVID-19 vaccination, thereby playing a critical role in the country's pandemic response.
• At the national level, the number of first and second doses of COVID-19 vaccines given per month steadily declined; over the same period, vaccinations through the EVI continued to trend upward.
• Collectively, the CBOs that participated in the EVI held over 4,500 events where vaccination occurred, provided assistance to get vaccinated almost 155,000 times, gave nearly 65,000 vaccinations, and made almost 15 million connections with people to provide accurate vaccination information.
• The EVI's primary impact on anchor partners and CBOs was the capacity these organizations built and continued to strengthen over time, including building health communication infrastructure and skills; establishing relationships, networks, and communities of practice in their cities; and advocating for equitable policies in their communities.

Implementation Challenges and Lessons Learned

These were the challenges and lessons learned:

• The initiative encountered challenges related to (1) the need to move quickly to address this urgent public health crisis, and (2) the use of an equity-first approach.
  • For instance, it was a challenge to define and communicate partner roles within the complex initiative and efficiently distribute funding to anchor partners and CBOs. In addition, The Rockefeller Foundation and the EVI supporting partners navigated challenges with addressing the trauma, loss, and burnout that the CBOs were experiencing themselves; minimizing the burden on anchor partners and CBOs; and tailoring resources and tools offered by the supporting partners to what the anchor partners and CBOs actually needed.
• These challenges and insights from EVI participants pointed to a set of promising practices for implementing hyper-local, community-led, equity-first vaccination and other public health interventions.
• Approaches for promoting equitable vaccination include:
  • Dig deeply to understand access barriers and hidden costs of vaccination.
  • Reframe the narrative around access barriers and vaccine confidence away from blaming the individual and toward fixing the broken system.
  • Approach vaccination holistically, recognizing the intersectionality of structural barriers to achieving health equity, (e.g., unemployment, food insecurity).
  • Apply a harm-reduction approach; if people are not ready to get vaccinated or do not plan to be in the future, share information about how they can protect themselves and others.
• Approaches for building relationships include:
  • Form authentic, ongoing partnerships built on trust.
  • Build bridges across sectors.
  • Partner with various types of trusted messengers. Think creatively with communities about who their trusted messengers are.
  • Harness the power of communities of practice for emotional support, technical assistance, and shared problem-solving.
• Approaches for working with CBOs include:
  • Amplify, support, but do not direct, the CBOs that are doing the grassroots work.
  • Build lasting capacity within CBOs through resources, trainings, and technical assistance.
  • Co-create messaging and information campaigns and co-design strategies to expand vaccination access in partnership with affected communities.
  • Constantly assess and reassess the burden that participating in such initiatives as the EVI places on CBO partners.
  • Acknowledge and address the grief, burnout, trauma, and stress—direct results of the pandemic and of doing this work—among partners. Demonstrate flexibility and adaptability to meet the needs of the partners.

Recommendations

The EVI CBOs played an essential role in addressing inequitable access to public health services that were laid bare by the pandemic. However, the COVID-19 pandemic and the intensity of community-based work have taken an extraordinary toll on these organizations, and they worried that the EVI was a unique opportunity that provided an exceptional level of support that they might not receive again.

To sustain this work, not just for COVID-19 but for other emerging or longstanding issues affecting communities, CBOs should not be seen as stopgaps used to plug holes in an emergency. CBOs need to be incorporated into the public health system on a day-to-day basis and consistently and adequately supported with both funding and technical assistance. Policymakers and public health officials at all levels of government, health care organizations, philanthropy, and the private sector play an important role in providing the resources, leadership, and implementation supports for community-based organizations to successfully implement hyper-local public health interventions.

To build an equitable and community-centered public health system of the future, we must expand our definition of the public health workforce to include those that are outside the fields of health care and public health as traditionally defined, and we must provide those nontraditional partners with:

• adequate, consistent, and flexible funding to meet the needs of communities as the pandemic evolves and other crises emerge
• resources that are allocated equitably, (e.g., according to disease burden)
• access to high-quality, race-disaggregated, hyper-local, and timely data to inform their work
• resources, technical assistance, workforce capacity-building, and infrastructure to focus on public health communication and be able to disseminate coordinated, evidence-based messaging to the public and policymakers.