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

CoumminVax National Report #2 - Carrying Equity in COVID-19 Vaccination Forward: Guidance Informed by Communities of Color
Brunson EK, Schoch-Spana M, Carnes M, Hosangadi D, Long R, Ravi S, Taylor M, Trotochaud M, Veenema TG, on behalf of the CommuniVax Coalition
Date posted:
July 14, 2021
Publication type:
The Johns Hopkins Center for Health Security

Seven months into the COVID-19 vaccination campaign in the United States, nearly 50% of the American population has been vaccinated. While this is a monumental accomplishment, there is still much work to do.

In the coming months, the country will face a series of vaccination challenges including serving groups with persistently low vaccine uptake (due to, for example, low/no access, vaccine hesitancy, or a combination of factors), expanding COVID-19 vaccination to children (particularly those whose parents may be less willing to vaccinate their children than to get vaccinated themselves), and orchestrating a potential booster dose campaign (with its own hesitancy issues). As the COVID-19 vaccination campaign continues, lessons from the vaccine rollout to date can help provide direction moving forward.

One challenge that deserves closer attention and more refined solutions is the campaign’s limited success at delivering vaccines to low-income persons and communities of color. During the pandemic, these populations have experienced significant physical, financial, and psychological harms at a disproportionate rate. The continued emergence and spread of new SARS-CoV-2 virus variants and the resumption of routine social, commercial, and educational activities across the country amplify the risks that COVID-19 poses to these groups.

This report provides specific guidance on adapting COVID-19 vaccination efforts to achieve greater vaccine coverage in underserved populations and, through this, to develop sustainable, locally appropriate mechanisms to advance equity in health.

In the first half of the report, we outline findings from local, ethnographic research conducted within Black and Hispanic/Latino communities in Alabama, California, Idaho, Maryland, and Virginia. Since January, local research teams have been assessing community infrastructure; listening to community members, public health officials, and government leaders; and coordinating engagement activities to understand how best to promote awareness of, access to, and acceptability of COVID-19 vaccines. In the second half of this report, we present the policy and practice implications of the local research. The Working Group on Equity in COVID-19 Vaccination—an advisory body of community advocates, public health experts, and social scientists—developed the recommendations, eliciting local team feedback.


  1. Naming vaccine hesitancy as “the problem” obscures a more complex set of realities
    The now popular term “vaccine hesitancy” glosses over diverse concerns about vaccines, COVID-19, and health authorities. Rather than a perceived moral failure of being “hesitant” or “noncompliant,” a lack of vaccination is often an external reality related to lack of access to vaccines. The same socioeconomic and structural forces that contribute to the disparate impacts of COVID-19 have also created persistent barriers to accessing vaccines. A myopic focus on vaccine hesitancy can conceal access issues, including those due to structural racism. Vaccine decision making is ongoing, dynamic, and interpersonal, rather than a straightforward process of an individual, alone, digesting educational materials and then moving to action.

  2. Assuming communities of color are homogeneous is a critical error
    Common experiences among communities of color do exist, particularly the shared burden of economic and racial inequalities. Where the communities live can also create similar experiences; for example, urban areas often have more developed internet and transportation infrastructure compared to frontier and rural locations. Despite these similarities, differences between and within local communities make them unique and result in different experiences. Black and Hispanic/Latino persons experience racism differently due to factors such as language, culture, and historical experiences with certain institutions (eg, immigration and law enforcement). Within communities, demographic characteristics like age, gender, and political party affiliation greatly influence and differentiate individuals’ experiences and perspectives.

  3. Hyperlocal responses to the pandemic result in better health outcomes
    Community led, organized, and advocated measures have closed COVID-19 response gaps. Grassroots groups already have the trust of community members and understand the socioeconomic and cultural realities of their lives. Governmental public health agencies and healthcare systems do not always have such assets to the same extent or depth. Such trust is important. Vaccination moves at the speed of public trust; without trust, education campaigns, national messaging campaigns, and other pro-vaccination efforts fall flat.


Urgent Actions: Take immediately to improve vaccine coverage within underserved communities

  1. Humanize delivery and communication strategies for COVID-19 vaccines
    To reverse the vaccination campaign’s current slowdown and persistent unevenness in vaccine coverage, the campaign 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), FBOs (faith-based organizations), 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. Groups and people communicating about COVID-19 vaccination should target as many social settings as possible—in person, on air, and on screen—to create multiple opportunities that prompt peer-to-peer conversations about vaccination. Individuals do not make their decision alone, even if they make the final decision about getting the vaccine.

  2. Anchor COVID-19 vaccination for hard-hit areas in a holistic recovery process
    First, public agencies, hospitals and health systems, nonprofit social service providers, CBOs, FBOs, and CHWs should align themselves around a “whole person” model of recovery to meet underserved communities’ self-identified needs (eg, food, housing, jobs, mental health support) and to multiply the benefits of each vaccination encounter. A wraparound service approach provides the sense of safety and security important to informed health decision making. Second, local and state jurisdictions should take immediate steps to plan for long-term recovery and community resilience by: (a) convening a cross-sector council of stakeholders, including Black and Hispanic/Latino leaders, CBOs, FBOs, and CHWs to apply a whole-of-community, whole-of-government approach; and (b) engaging existing data-driven coordinating bodies that already facilitate disaster recovery, economic development, and other long-range planning.

    Essential Actions: Execute steadily to create systems-level changes and advance health equity broadly

  3. Develop a national immunization program to protect people throughout the life course
    During the COVID-19 vaccination effort, public health authorities and government leaders at federal and state levels should capitalize on an already highly successful national immunization program for children, building out systems to provide broader coverage for COVID-19 vaccines and the 13 other vaccines recommended for some or all adults. Tasks include reconfiguring funding systems to support a life-course (versus childhood-only) approach to immunization, facilitating the integration of adult immunization with other health systems and priorities, and developing systems to monitor program progress and measure social and economic impacts. The funding support must be adequate to ensure health departments have sufficient staffing to oversee progress in enhancing adult immunization uptake and can take corrective actions if progress is judged to be inadequate.

  4. Rebuild the public health infrastructure, properly staffing it for community engagement
    Political leaders at all levels should allocate steady core funding for the public health infrastructure, sustaining its capacity to respond to future emergencies and address prevalent health challenges (eg, diabetes, heart disease) that affect communities of color in greater numbers. A mandatory national investment of $4.5 billion per year in a public health infrastructure fund will ensure a predictable minimum capacity at state and local levels. State and local officials should provide steadfast support to agencies that protect the health of their populations. Furthermore, state and local health departments should commit to the strategic goals of promoting equity in their ranks at every level, including their boards of health, and strengthening human-centric competencies through the recruitment of more social and community proficient professionals, such as health educators/promoters, risk communicators, language translators, social media strategists, and sociobehavioral researchers.

  5. Stabilize the community health system as the backbone for equity and resilience
    Federal, state, and local leaders should take steps to formalize and finance the country’s struggling, but promising, community health system. Through community roots and shared experiences, CHWs build trust with clients while navigating health and human services systems, bridge client and provider cultures to adapt service delivery and better meet needs, and advocate for system-level changes that will improve clients’ access to care and overall health. In consultation with local, regional, and national CHW networks, federal and state officials should create sustainable financing strategies (including Medicaid reimbursement) for community health work on disease prevention, health promotion, and social determinants of health. To generate opportunities and a career ladder, state legislators should authorize a CHW workforce development plan; public health officials should work with human resources systems to create positions at varying levels of experience. To acknowledge the deep social assets and community organizing abilities of CBOs, FBOs, and CHW-led organizations, public and private funders should provide grants directly to these entities, adapting funding processes and eligibility criteria to create an environment where communities with the greatest need benefit from funding first.



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