People of color face multiple barriers to vaccine access — including ‘skepticism of a system that has treated them poorly’

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With early vaccination data in Philadelphia showing racial disparities, leaders from Penn Medicine, Mercy Catholic Medical Center and the community launched three clinics in a church, a high-school gym and a recreation center in predominantly Black neighborhoods.

The sheer number of patients vaccinated at these clinics — at least 3,800 — belied concerns about vaccine hesitancy among people of color, said Nida Al-Ramahi, a Penn Medicine administrative fellow who co-authored a NEJM Catalyst commentary article about the clinics.


Some vaccine recipients have told the team, ‘Had you not been here, I wouldn’t have gotten vaccinated.’

“The demand is there,” she said. “We think it’s more of an access problem, rather than people are just downright not interested in receiving the vaccine.”

The clinics owe their success, in part, to a “no/low-tech” approach that used automated text messages and phone calls to schedule appointments rather than a website (a 102-year-old was able to sign up, Al-Ramahi said); the location of these clinics being close to where people reside; and partnerships with grassroots organizations and faith leaders.

Some vaccine recipients have told the team, “Had you not been here, I wouldn’t have gotten vaccinated,” Al-Ramahi said. Many have also said on patient-satisfaction surveys, “I feel dignified.”

“That can mean different things to people, but that repetition of that sentence being shared with us by people we’ve vaccinated is important,” she said. Part of this, she added, may stem from “us prioritizing and recognizing that there’s need and inequity in vaccine access.”

Hesitancy declines, but structural barriers remain

The Philly-focused effort is one of many vaccine-equity initiatives across the country aimed at boosting vaccination levels among people of color — who, despite being hit disproportionately hard by the coronavirus, have been getting vaccinated at lower rates.

Recent polls suggest U.S. vaccine hesitancy has declined overall, with Black Americans — an early target of outreach efforts by healthcare professionals due to historical medical experimentation and racial inequality that persists today — showing the biggest jump in vaccine enthusiasm. Republicans and white evangelicals are the groups most likely to say they won’t get vaccinated, according to recent KFF polling.


‘We talk about Black communities being hesitant, but I think they have a healthy level of skepticism of a system that has treated them poorly historically.’


— Melody Goodman, the associate dean for research and an associate professor of biostatistics at the NYU School of Global Public Health

“We talk about Black communities being hesitant, but I think they have a healthy level of skepticism of a system that has treated them poorly historically up until the present-day moment,” said Melody Goodman, the associate dean for research and an associate professor of biostatistics at the NYU School of Global Public Health who studies health disparities.

Still, Black and Hispanic Americans across states continue to receive lower shares of vaccinations in comparison to their burden of COVID-19 cases and deaths, as well as their shares of the population, according to a recent analysis by KFF. As of April 19, the share of white people in 43 states who had received at least one vaccine dose was 1.6 times higher than the corresponding shares of Black and Hispanic people.


A longstanding set of underlying structural inequities have likely created increased barriers to vaccine access for people of color and underserved groups.

While survey data points to a high degree of willingness to get vaccinated across racial and ethnic groups and shows that willingness has increased over time, a longstanding set of underlying structural inequities have likely created increased barriers to vaccine access for people of color and underserved groups, said Samantha Artiga, the director of KFF’s racial equity and health policy program.

A recent Morning Consult poll of 30,000 U.S. adults showed, among other findings, that white adults who wanted to be vaccinated were more likely to report getting their shots than their similarly willing Black and Hispanic counterparts, even when controlling for income — suggesting that “vaccine access is at least as big of a problem as vaccine hesitancy.”

Initial vaccination efforts centered on tackling hesitancy, “in some ways to the detriment” of addressing structural barriers, which didn’t receive as much visibility until more recently, said Georges Benjamin, the executive director of the American Public Health Association.

With that said, “there is still hesitancy out there, and we need to do work to make [people] vaccine-confident,” he added.

Barriers to accessing the vaccine

Barriers to accessing the vaccine include more limited access to technological resources for navigating online scheduling systems; less flexibility in work and caregiving schedules to be able to search for appointments or take whatever appointment might be available; limited transportation options restricting the range of viable vaccination locations; and potential linguistic barriers, Artiga said.

People of color are uninsured at higher rates, she added, meaning they may be more likely to have concerns about the vaccine’s cost if they don’t know it’s available for free. This may be particularly confusing because some vaccine providers request insurance information in order to bill administrative costs to insurance providers, though they aren’t allowed to charge patients out of pocket or deny vaccination on the basis of coverage status.


Barriers to accessing the vaccine include more limited access to technological resources for navigating online scheduling systems; less flexibility in work and caregiving schedules.

Households with an immigrant family member may question whether they’re eligible to receive the vaccine (they are), fear a potential impact on their immigration status, or face challenges supplying proof of identification or residency requested by vaccination sites, Artiga added.

It will be hard to pinpoint the true barriers to access for marginalized people until COVID-19 vaccines are freely available and supply is no longer a constraint, Goodman said. Though every state has now expanded vaccine eligibility to all adults in accordance with President Biden’s April 19 target, she said it’s still too early to know. 

“Right now the main barrier is availability — and that impacts all populations, although some have better access when things are scarce,” Goodman said. “But I think that’s changing.”

Efforts at the federal, state and local levels

The Biden administration has launched a COVID-19 health-equity task force, established federally run community vaccination centers in areas disproportionately impacted by the virus, dispatched hundreds of mobile clinics, and sent doses to local pharmacies and community health centers “that disproportionately serve vulnerable populations.” 

People of color represented a majority of coronavirus vaccine recipients at community health centers between January and April, a recent KFF analysis found, and health centers seem to be reaching people of color at higher levels than broader vaccination efforts — “pointing to their longstanding role serving these communities,” Artiga said.


People from wealthier, predominantly white neighborhoods were grabbing up vaccine appointments available in lower-income and minority communities hit hard by the pandemic.

The administration also announced last month it would spend close to $10 billion on efforts to boost both access and vaccine confidence in underserved communities, largely funded by the $1.9 trillion American Rescue Plan.

Meanwhile, pharmacy chains have partnered with ride-hailing companies (Walgreens
WBA,
+2.24%
with Uber
UBER,
+0.84%
; CVS Health
CVS,
+2.30%
with Lyft
LYFT,
+1.06%
) to help facilitate equitable transportation access for vaccinations. 

Some states have also sought to tackle racial inequity in vaccinations through strategies like allocating extra vaccine doses to hard-hit areas, setting up hotlines for scheduling appointments, and situating clinics in underserved communities, a KFF review shows.

A lot of what we’re seeing in terms of successful efforts is when local community-based organizations are really leading vaccination efforts, because they can design them in a way that meets the needs and preferences of the population they serve,” Artiga added. 

Not all vaccine-equity efforts have proved successful: Reports from the early months of the country’s mass-vaccination campaign, for instance, suggested that people from wealthier, predominantly white neighborhoods were grabbing up vaccine appointments available in lower-income and minority communities hit hard by the pandemic.

The Philadelphia team aimed to address that possibility by asking prospective appointment-takers to acknowledge that the clinic was intended “to address the vast racial inequity in COVID outcomes and vaccine distribution by vaccinating our West & Southwest Philly *Black and Brown* communities hit hard by COVID,” and providing a list of zip codes being targeted. 

Some 36% of people stopped trying to sign up after this was disclosed, the researchers said. 

Building trust in communities

After determining that not many minority residents were getting inoculated at a mass-vaccination site on campus, officials at the Ohio State University Wexner Medical Center quickly stood up a second location at a hospital in an underserved area, said Beth NeCamp, the center’s executive director of civic and community engagement and co-lead of Ohio State’s vaccine disparities work group. 


While the campus site remained open to anyone in Ohio, appointments at a new location were reserved for people from underserved zip codes.

While the campus site remained open to anyone in Ohio, appointments at the new location were reserved for people from underserved zip codes, so “they weren’t fighting with the whole city to get them,” NeCamp added. “We were trying to free up access to the vaccine for the folks that were having the most difficult time getting it,” she said.

To tackle the time, digital-literacy and linguistic obstacles often associated with online scheduling, NeCamp’s group also launched a program to invite community organizations to sign up their clients or members for vaccine slots, with her team plugging in people’s information “on the back end.” So-called patient navigators help address needs such as transportation and interpreters. 

“We really think it’s this kind of extra navigation service, as well as simplified sign-up service, that’s really helping us to reach more of the hard-to-reach,” NeCamp said.

Maryland’s Vaccine Equity Task Force, led by Maryland National Guard Brig. Gen. Janeen Birckhead, works with local health departments and fields requests from community and faith-based organizations to bring clinics and mobile vaccination units to places with the greatest need.

The task force identifies vulnerable communities based on variables like age, income, unemployment, educational attainment and minority composition. Its efforts serve Black and Hispanic people, as well as other underserved populations including poultry-industry workers and rural residents, Birckhead added — “putting shots in people’s arms where they are.”

“I hope that we’re building trust in the communities in times like these, and no one is going to be left behind,” she said.

Also read: Dr. James Hildreth: Here’s how to instill vaccine confidence among people of color



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