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.
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)
% of population fully vaccinated
Social Vulnerability Index (0 = lower vulnerability; 1 = higher vulnerability)
* = highly vulnerable population
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:
There is a lack of accurate, timely, understandable information about where, when, and how to get vaccinated.
Vaccine sites are in inconvenient places, are open only at inconvenient times, and do not accommodate those with mobility limitations.
Institutions and systems administering vaccinations might not be trusted by potential recipients.
Vaccine access depends on internet access and solid technological literacy.
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
Sharing accurate, trustworthy, and accessible information
Providing transportation assistance
Maximizing convenience of receiving the vaccine
Making registration and appointment processes streamlined and inclusive
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 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).
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.
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.
This report is part of the RAND Corporation Research brief series. RAND research briefs present policy-oriented summaries of individual published, peer-reviewed documents or of a body of published work.
Permission is given to duplicate this electronic document for personal use only, as long as it is unaltered and complete. Copies may not be duplicated for commercial purposes. Unauthorized posting of RAND PDFs to a non-RAND Web site is prohibited. RAND PDFs are protected under copyright law. For information on reprint and linking permissions, please visit the RAND Permissions page.
The RAND Corporation is a nonprofit institution that helps improve policy and decisionmaking through research and analysis. RAND's publications do not necessarily reflect the opinions of its research clients and sponsors.
Faherty, Laura J., Jeanne S. Ringel, Malcolm V. Williams, Ashley M. Kranz, Lilian Perez, Lucy Schulson, Allyson D. Gittens, Brian Phillips, Lawrence Baker, Priya Gandhi, Khadesia Howell, Rebecca Wolfe, and Tiwaladeoluwa Adekunle, Early Insights from the Equity-First Vaccination Initiative. Santa Monica, CA: RAND Corporation, 2021. https://www.rand.org/pubs/research_briefs/RBA1627-1.html.
Faherty, Laura J., Jeanne S. Ringel, Malcolm V. Williams, Ashley M. Kranz, Lilian Perez, Lucy Schulson, Allyson D. Gittens, Brian Phillips, Lawrence Baker, Priya Gandhi, Khadesia Howell, Rebecca Wolfe, and Tiwaladeoluwa Adekunle, Early Insights from the Equity-First Vaccination Initiative, Santa Monica, Calif.: RAND Corporation, RB-A1627-1, 2021. As of January 14, 2022: https://www.rand.org/pubs/research_briefs/RBA1627-1.html