Championing Change: A Toolkit for Addressing Vaccine Equity Through Community Mobilization

How to Use This Toolkit

This toolkit is intended to be used by state and territorial health agencies, community-based organizations, and local providers looking to implement comprehensive health equity initiatives. Although focused primarily on addressing immunization disparities, a majority of the efforts highlighted in this toolkit can be applied to a diverse range of public health interventions, including those related to chronic diseases, preparedness, and addressing the social determinants of health.

Addressing Systemic Disparities

The COVID-19 pandemic exacerbated many existing health and social inequities present among racial and ethnic minority populations in the United States. In the first few months of the pandemic, it became alarmingly clear that people of color were bearing a disproportionate burden of COVID-19 related cases and deaths. Cumulatively, Indigenous, Latino, Pacific Islander, and Black Americans all experienced mortality rates significantly higher than those of white or Asian Americans, even when adjusting for differences in population age structure. In addition, the pandemic also shed light on the geographical divide between urban and rural areas in the United States—highlighting disparities in rural communities largely driven by social determinants of health such as access to quality healthcare, food, and employment.

As the first COVID-19 vaccines rolled out in late 2020, these inequities persisted with lower rates of uptake among the aforementioned groups. Efforts to alleviate access barriers resulted in moderate improvements, however new challenges arose, including the proliferation of mis- and disinformation about vaccines and significant differences in vaccination rates driven by partisan affiliation.

The culmination of factors affecting access or dissuading COVID-19 vaccination has also contributed to a decline in adherence to routine immunization schedules. From January 2020–July 2021, U.S. adults and adolescents missed an estimated 37 million doses of recommended vaccines. Additionally, the number of Medicare enrollees who missed doses since November 2020 doubled.

Routine vaccination is crucial in preventing and mitigating severe effects of the spread of illness. As outlined in the Healthy People 2030 framework, increasing the proportion of adults aged 19+ who receive recommended vaccines is an emerging priority. As the COVID-19 pandemic recedes, public health agencies should refocus on addressing these longstanding inequities and rebuilding their positions as trusted health providers and messengers in their communities.

Prioritizing Community-Centered Outreach

State and territorial health agencies are routinely tasked with promoting, improving, and maintaining health for all. However, their ability to fulfill these responsibilities—and do so in a sustainable manner—depends largely on public trust in institutions of public health. Recent polling stemming from a collaboration between ASTHO and the Harvard T.H. Chan School of Public Health found that only one-quarter of U.S. adults viewed state and local health departments as highly trusted sources of health information. To effectively address vaccine disparities and implement equitable public health responses in the future, it’s crucial to rebuild trust.

One of the most effective ways to build trust is engaging the communities most affected and leveraging existing, trusted organizations to help address the issues. ASTHO’s Community Action Framework provides a step-by-step outline for doing so, culminating in the creation of a Community Action Team (CAT). CATs are a collective of multidisciplinary partners engaged in similar work and mobilized towards a common goal. By leveraging synergies, CATs allow organizations to expand their networks, organize a systematic approach for change, and enhance their community capacity to sustain a healthy population. Members of CATs may include healthcare providers, faith-based organizations, local non-profits, schools, and most importantly, community residents.

The implementation of ASTHO’s Vaccine Equity Project was structured around the CAT framework to ensure that all vaccine engagement strategies and approaches were community-informed, culturally relevant, and effective. Use this guide to learn more about the structure and outcomes from this project and brainstorm ways to implement similar partnerships that further the pursuit of equity in each jurisdiction.

ASTHO’s Vaccine Equity Project

With support from CDC under the Partnering for Vaccine Equity program, ASTHO, the National Community Action Partnership, and five community action agencies (CAAs) collaborated to increase acceptance and uptake of vaccines among racial and ethnic minority groups and in rural communities. CAAs are local entities that work to reduce poverty and disparities among the populations they serve. Funded through the Community Services Block Grant, CAAs are an ideal complement to public health’s mission to address the social determinants of health and achieve greater equity and improved health outcomes.

Through this project, CAAs built CATs to address vaccine equity in each of their jurisdictions. They partnered with residents, faith-based organizations, local schools and universities, state and local public health departments, and non-profits active in their communities. They also engaged a range of local providers, such as federally qualified health centers, physicians, community health workers, medical and nursing students, and emergency medical technicians. These CATs work together to improve vaccine acceptance and uptake and to customize evidence-based strategies for their own communities and neighborhoods. Partnerships between CAAs and public health departments have been a cornerstone of the Vaccine Equity Project; jurisdictions can learn more about and connect with their local CAAs.

After the five project sites were onboarded, ASTHO conducted an environmental scan of evidence-based practices for increasing vaccination uptake among racial and ethnic minority populations. This scan identified several promising strategies which project sites could choose from and tailor appropriately to their target communities.

Each of the strategies that follow were categorized into one of four categories and further subclassified into those impacting vaccine distribution, administration, or uptake:

• Environmental: Interventions addressing social and cultural norms or health, economic, education, and social conditions related to immunization.
• Community and Clinical: Interventions addressing settings in which social relationships occur, such as a school or neighborhood, or settings where healthcare is provided.
• Interpersonal: Interventions addressing social and personal relationships with neighbors, colleagues, healthcare providers, friends, loved ones, or others.
• Individual: Interventions addressing attitudes, beliefs, and behaviors.

Key strategies included: offering access to vaccines at nontraditional locations and times, partnering with community messengers, and utilizing strategic messaging campaigns.

After selecting their strategies, all community sites developed community action plans—comprehensive outlines detailing WHAT needs to be done, WHO needs to do it, and HOW they would go about accomplishing their goals.

In the next section, read through examples of the standout ways project sites implemented their plans to increase equity in vaccine access and uptake in their communities.

From the Field: Spotlight on State Strategies

Since initiating implementation of their action plans in March 2022, ASTHO’s five project sites have held over 450 events, engaged more than 1.5 million community members in their efforts, and administered at least 5,500 vaccinations including those for COVID-19, influenza, Tdap (tetanus, diphtheria, and pertussis), shingles, and more.

As anticipated, every site took a slightly different approach to implementing their plans to account for the unique nuances in their communities—nuances that are critical to consider before implementing similar initiatives in any jurisdiction. Read through the spotlights that follow to learn more about how project sites leveraged the strength of their agencies, diverse partners, and keen knowledge of community needs to garner success in their vaccine equity work.

Key Themes

As you can see, each CAP took a slightly different approach to equity work in their local jurisdictions. However, all agencies agreed on the following points:

1. The Power of Partnerships

   All sites agreed that spending time establishing and nurturing the strategic partnerships they developed because of this project has reaped far more success than they could have anticipated. Leveraging partners avoids duplication of efforts, spreads out the strain on resources, and most importantly, allows for amplification of reach supported by the attainment of mutual goals (remember the CAT framework?). The potential incited by the maintenance of these relationships has applicability beyond just vaccine equity. The power of these partnerships helps further public health progress across all domains of health and equity, in addition to supporting the sustainability of the work.

2. The Relevance of Social Determinants of Health

   Perhaps the biggest lesson learned throughout this project is that the impact of public health interventions is amplified when agencies cater to the needs of the entire individual. Health, housing, food, education, employment… it is insufficient to address one without addressing the others. Among all CAP sites, teams found exceptional success in pairing the social services they offer daily with the additional offerings of the Vaccine Equity Project. Not only does this address the spectrum of social determinants of health, but it also results in a greater level of trust within communities for the agencies that will be there to help with their most essential needs. It is for this reason that partnership between health agencies and the community action network represents a crucial alliance.

3. The Importance of Sustainable Funding

   The impact of the Vaccine Equity Project has been significant across the targeted communities. In addition to increasing the number of vaccinations provided, the partnerships established have allowed all CAPs to increase the visibility of their agencies as trusted community establishments. However, the future of this effort and similar ones relies on the need for sustainable funding mechanisms. The need to address immunization equity has never been greater. Health agencies can look into ways to collaborate with internal or external partners to blend and braid funding streams in a way that supports sustainable interventions. See the following ASTHO resources that highlight strategies for funding similar programs addressing social determinants of health:

   • Using Your Braiding and Layering Funding to Address Food Insecurity
   • Braiding And Layering Funding for Adverse Childhood Experiences Prevention
   • Braiding and Layering Funding to Address Housing: Older Adults and Persons with Disabilities
   • Braiding and Layering Funding to Address Housing: Individuals with Substance Use Disorders

Advisory Resources

All activities conducted under the Vaccine Equity Project were guided by an ASTHO-led advisory committee of national partners. Each of these representatives serve on behalf of crucial demographics and professional memberships across the United States, including associations of emergency medical technicians, community health workers, physicians, and more. Additionally, in the second year of the project, ASTHO engaged internal subject matter experts to provide guidance on increasing the impact of initiatives for people living with disabilities. Any of the organizations that follow could potentially serve as beneficial partners to the work being done to address health equity in your state or jurisdiction. Here is the full list of the advisory partners engaged in the Vaccine Equity Project:

1. The National Association of Emergency Medical Technicians
2. The National Association of Community Health Workers
3. The National Association of State Offices of Minority Health (NASOMH)
4. The National Medical Association
5. The National Hispanic Medical Association
6. The Center for Healthy Aging at the New York Academy of Medicine
7. The Pacific Island Health Officers’ Association
8. The Association of American Indian Physicians
9. Faith4Vaccines
10. ASTHO’s Preparedness and Disability Integration Team
11. ASTHO’s Immunization Team
12. ASTHO’s Health Equity and Diversity Initiatives Team

At the culmination of this project, advisory committee organizations developed at least one novel tool or resource catered to increasing vaccine access or uptake among racial and ethnic minority populations. While some tools such as flyers may be downloaded and directly used during outreach efforts, others are intended to strategically inform the implementation of future vaccine equity initiatives. In addition, while some are oriented to healthcare providers and public health agencies, others speak directly to community leaders.

Resources for Advancing Vaccine Equity

The following tools are housed by category. Please access these resources as needed when planning or implementing similar work.

Conclusion

The framework and lessons learned from ASTHO’s Vaccine Equity Project can serve as the basis for implementing a health equity approach for countless public health-related interventions. This synopsis of final considerations was derived from the three-year initiative:

• Invest in Trust-Building: Bringing community to the table, lifting up shared decision making, and working alongside trusted institutions is integral to ensuring the success of equity initiatives. Community input is critical, and engagement with community leaders, including compensation for time and expertise provided where possible, should be a key consideration in efforts to advance equity. Establishing and maintaining these relationships early on allows for a more efficient mobilization of resources and information for future public health emergencies.
• Address Root Causes of Inequities: Taking a whole-person approach is essential to effective outreach for immunization or other public health interventions. Interventions that fail to address the social determinants of health and other critical needs of individuals and communities may be limited in their ability to enact positive change.
• Plan for Sustainability: Sustainability should be a primary consideration during the planning stages of program development and throughout project implementation. Braiding and layering funds, utilizing the infrastructure of existing programs, or leveraging partners are all effective ways to support the continuation of work beyond the scope of a single funding stream or grant period.

ASTHO will continue to update the resources available here as applicable through December 2024.