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

May 01, 2024 | Shalini Nair

This toolkit introduces the power of partnerships and community-based mobilization in addressing vaccine equity. By sharing lessons learned from ASTHO’s flagship Vaccine Equity Project and providing a database of evidence-based tools, this evergreen resource informs state and territorial efforts to advance equity in public health initiatives.

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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.

Do you have a CAA in your community?

Find Your Local Agency

Found one? This could be a great opportunity to familiarize your agency with the services provided by your local CAA and identify potential areas of synergy for the implementation of public health improvement activities.

Map 1: ASTHO-CAA Partnership Locations

ASTHO selected and had the opportunity to work with five CAAs targeting nine counties in the United States. Each of the CAAs represent a target area or county in which vaccination rates were lower, and rates of social vulnerability were higher than those seen on the national level at the time of the project’s inception.

A map of the United States dipicting the five community action agencies representing a target area or county in which vaccination rates were lower, and rates of social vulnerability were higher than those seen on the national level.

green location iconCommunity Action Partnership of Kern (CAP Kern)
Kern County, CA

Light blue location iconCommunity Action Program for Central Arkansas (CAPCA)
Faulkner, Cleburne, & White Counties, AR

Medium blue location iconPickens Community Action
Pickens County, AL

orange location iconEnrichment Services Program, Inc.
Troup and Stewart Counties, GA + Russell County, AL

navy blue location iconPalmetto Community Action
Berkeley County, SC

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 planscomprehensive 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.

Interested in developing a community action plan for your agency?

Utilize a step-by-step planning template.

Get the Template

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 communitiesnuances 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.

Partnering with Health Care and Public Health

Site: Palmetto Community Action Partnership (Palmetto CAP)

Notable Partners Engaged:

The town of Cross is an unincorporated community located in rural northwestern Berkeley County, South Carolina, that falls within the target range of Palmetto CAP’s vaccine equity efforts. This rural town has very limited access to healthcare services and healthy food. The only community health center in town is operated by Fetter Health Care, a regional federally qualified health center with sites across southeastern South Carolina. Identifying a need to address these disparities, Palmetto CAP worked to engage Fetter as a critical partner in their efforts to vaccinate Berkeley County. Fetter began administering vaccines on behalf of the Vaccine Equity Project at their clinic locations, while Palmetto CAP worked directly with Fetter to reimburse for the cost of vaccine administration, but also bridge gaps for individuals needing access to wraparound services such as food, housing, or utility assistance. In addition to targeting rural areas, Palmetto CAP also engaged with partners who were already doing the work in the vaccination space – including The Medi Covid Alliance, Berkeley County EMS, and the South Carolina Department of Health and Environmental Control (SCDHEC). SCDHEC proved to be an invaluable partner in Palmetto’s efforts to provide access to vaccine and vaccinators at their community events, and SCDHEC has documented a notable increase in vaccine uptake in the South Carolina Lowcountry since the partnership with Palmetto CAP began.

Meeting People Where They Are with Fact-Based Messaging

Site: Enrichment Services Program

Notable Partners Engaged: 

At one point during the COVID-19 vaccination rollout, Russell County, Alabama—a target county served by Enrichment Services—had the lowest uptake of COVID-19 vaccinations in the entire state at just 17%. At the inception of the Vaccine Equity Project, all three counties targeted by Enrichment Services had adult vaccination rates lower than 35%. Site staff observed challenges related to the spread of vaccine-related conspiracies and misinformation. They needed to ensure community members had access to vaccines and reliable information that supported an informed decision to be vaccinated. As a result, Enrichment Services centered their vaccine equity strategy around comprehensive, fact-based messaging. Pairing vaccine clinics with community events, Enrichment Services hosted or attended school supply distributions, field days, and other unique events such as their “Shots for Shots” event at a local high school basketball game, where they provided on-site vaccines and access to a variety of merchandise and messaging materials related to vaccination.

By rooting their campaign in health education, Enrichment Services reached a greater number of community members and diversified the outcome of their efforts. In some situations, playing the long game and fostering continuous, longer-term discussion was critical when it came to engaging with community organizations who had strong influence, but were wary of directly promoting uptake of vaccines, particularly for COVID-19. In these instances, rather than shifting focus from these communities entirely, Enrichment Services was able to offer to simply distribute their printed materials at events without the accompanying on-site clinic. This method exemplifies meeting communities where they are and leveraging organizational strengths to advance efforts. The impact of the Vaccine Equity Project reaches far beyond just shots in arms and highlights the importance of working from the ground up to cultivate long-term trust community by community. In this example, Enrichment Services printed their vaccine education points on paper fans that were distributed to a local congregation for use on a hot day!

Leveraging Existing Programming and Partnerships to Expand Reach

Site: Community Action Program for Central Arkansas (CAPCA)

Notable Partners Engaged:

Based in Conway, Arkansas, CAPCA serves a diverse audience through their range of social services. When CAPCA joined the Vaccine Equity Project, they began with a data-gathering survey to better inform how to target their efforts and track progress over time. The survey addressed individual perceptions about vaccination, helped identify barriers, and solicited preferences related to location and timing of vaccine events.

Interested in learning more? Access CAPCA’s data gathering survey.

Once CAPCA began hosting events, two of their strongest clinic bases stemmed from populations they already engaged through their internal HeadStart/Migrant HeadStart and Project Homeless Connect programs. By leveraging the existing trust with families of young children who already attended CAPCA’s HeadStart programs, the team was able to recruit families to attend vaccine events, where attendance was often further bolstered by word of mouth. Similarly, CAPCA also utilized their existing monthly distribution events catered towards individuals experiencing homelessness to meet multiple needs at once by also providing vaccinations on site.

In many instances, CAPCA found that people did not have any explicit reasons for not getting vaccinated. However, they chose to get vaccinated after receiving more information or talking to others who had been vaccinated at events. In other cases, including in responses to CAPCA’s perceptions survey, many identified that the greatest barriers to vaccination were cost and fear of citizenship documentation requirements. By providing free vaccines through the Vaccine Equity Project and leveraging their strong ties with internal migrant HeadStart staff to effectively message around requirements for vaccination, community members expressed that CAPCA was able to successfully address these concerns. Since the start of the project, several participants have reported positive attitude change about vaccination over the course of implementation.

The CAPCA team was adamant that the success of their outreach efforts would not have been possible without collaboration from partners. Their local federally qualified healthcare center, ARcare, as well as the Arkansas Department of Health both aided in providing vaccines and scheduling events.

Empowering Culturally Competent Community Partners

Site: Community Action Partnership of Kern (CAP Kern)

Notable Partners Engaged: 

The diversity of California’s Kern County is represented across several demographic categories, from age to race and ethnicity. The county is home to bustling communities of Hispanic and Latino residents, who make up over 50% of the population and speak a variety of languages from Spanish to Indigenous Mixteco Alto. In addition, Kern also hosts notably higher proportions of Asian and American Indian or Alaska Native residents than the rest of the United States. For CAP Kern, door-to-door, culturally competent outreach and expansion of nontraditional clinic hours and locations was key to engaging residents and supporting equitable access to vaccination.

When CAP Kern joined the Vaccine Equity Project, they focused on identifying and connecting with partners in the community who were already doing the workpartners with similar goals whose momentum could be further amplified through mutual support. CAP Kern enlisted two subcontractors: South Kern Sol and the Bakersfield American Indian Health Project (BAIHP). South Kern Sol is a youth-led media initiative aimed at highlighting and dismantling the disparities and systems oppressing communities of color in Kern County. South Kern Sol’s deep knowledge of the community allowed CAP Kern to reach their target populations while appreciating the vast cultural and linguistic diversity present even within those groups. BAIHP is an outreach and referral center funded by the Indian Health Service that serves the over 220 represented tribes currently residing in Kern. Their approach to healthcare services focuses on contributing to the health and vitality of the community in a respectful manner with high regard for cultural values, Tribal affiliation, spiritual and personal values of individuals.

In total, BAIHP and South Kern Sol have hosted dozens of vaccine events through the Vaccine Equity Project. Their events have engaged countless community organizations, including radio outlets, Head Start programs, their state and local departments of health, food banks, the Dolores Huerta Foundation, and more. Both organizations found great success in disseminating information about their events through targeted city-level social media campaigns, and by using repetitive tactics to get the message across that their organizations can be trusted to show up when the community need arises. CAP Kern’s approach in empowering their community partners emphasizes the idea that vaccine equity initiatives don’t always have to be a ground-up effort. It is important to fully understand the current local landscape and help identify partners who are already doing the work!

Identifying and Engaging Trusted Community Messengers

Site: Pickens Community Action

Notable Partners Engaged:

Pickens County, a rural area located in west-central Alabama, is home to a population of just under 90,000 residents. Of those, nearly 40% are African American and additional 6% are Hispanic or Latino. Early on, the Pickens team identified several sub-demographics to target through their efforts: residents aged 65+, faith-based communities, and the most challenging for them, those aged 18-45. Pickens identified government distrust as a multigenerational issue among community households but also noticed a unique lack of urgency around vaccination and health maintenance particularly among younger adults. To address these challenges, Pickens turned to their community to engage trusted messengers in their outreach.

Prior to joining the Vaccine Equity Project, Pickens had existing partnerships with several organizations engaging homebound individuals, seniors, and people living with disabilities that they were able to efficiently leverage in their vaccine efforts. To reach those heavily involved in faith-based networks, Pickens assembled a Faith-Based Advisory Committee comprised of 12 churches of different denominations across the county. To reach younger adults, the team recruited local respected leaders including a retired professional football player, a local Congresswoman, and several other local government officials to film media clips encouraging vaccination. Additionally, they also partnered with local football powerhouse the University of Alabama, who provided support to many of their events. To encourage the persistence of these relationships, Pickens conducts continuous outreach to new businesses or agencies in their area to get the word out about their vaccine equity work and how to get involved. The work being done at Pickens Community Action highlights the relevance of knowing one’s audience and tailoring strategies accordingly to help achieve equity.

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.

  1. 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.

  2. 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:

COMMON THREADS: Every site participating in ASTHO’s Vaccine Equity Project cultivated partnerships with their state or local health department to aid in their outreach efforts. These relationships can transcend into other areas and stages of public health interventions. Consider connecting with similar organizations in your own community to help amplify existing efforts or bring them to the table when contemplating new ones.

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.

Cross-Sector Partnerships
Culturally Relevant Outreach
Resources for Older Adults and People Living with Disabilities
Community-Based Resources and Sample Materials
Additional Resources


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.

The construction of this toolkit and all activities completed under the Vaccine Equity Project were supported by CDC, under Grant Number NU21IP000598. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of CDC.