Achieving Vaccine Equity through Data and Collaboration

The Fairfax County Health Department (FCHD) serves the most populous jurisdiction in Virginia and the Washington, D.C. metropolitan area, encompassing 390 square miles including Fairfax County and the Cities of Fairfax and Falls Church. With an estimated 1,148,433 people, the county is diverse and serves a large ethnic minority population. Almost 50 percent of county residents (49.2%) represent an ethnic or racial minority group. Thirty percent of the population is foreign-born, two-and-a-half times more than the state average, with 37.9% of residents ages 5 and over speaking a language other than English at home. Almost 10 percent of residents are African-American, 20 percent are Asian, 16 percent are Hispanic, and nearly 4 percent are multiracial (two or more races). Within the public school system more than 54,000 (29 percent of the total population) of students are eligible for free and reduced-price meals.

While all areas of the county are diverse, there are geographic areas with higher concentrations of racial and ethnic minorities, particularly in the Bailey's Crossroads/Culmore, Reston/Herndon, and the Route 1 Corridor areas, which also experience higher rates of poverty and linguistic isolation. In Bailey's Crossroads, 20.4% of residents live in poverty and 68.5% speak a language other than English at home.  In Hybla Valley, along Route 1, 13.7% of residents live in poverty and 55.2% speak a language other than English at home.

Public health Issue: Ensuring vaccine equity for residents with socio-economic, cultural and language barriers.

Model Practice: Since May 2020, FCHD has convened a High Risk Communities Task Force (HRCTF) to inform public health response and resources for residents of the county experiencing disproportionate rates of COVID-19 disease, anticipated vaccine hesitancy and barriers to accessing vaccine. In January 2021 as vaccines became available the HRCTF implemented strategies to support vaccine decision making and vaccine equity throughout the county.  Anchor vaccinators such as local federally qualified health centers, safety net clinics, cultural health care serve organizations, academic training providers, and a federal pharmacy provider were identified and supplied with public health vaccine supplies until other distribution channels were available. Vaccine Equity Clinics were established at trusted community locations and multi-cultural partners were engaged to help register older adults and essential workers for vaccine appointments at dedicated clinics not available through general population appointment portals. Vaccine equity clinics continue as more residents become eligible for vaccine.

HRCTF Goals: Enable containment of COVID-19 disease in high risk communities through access to education, testing and vaccination. 

Objectives: 

1.       Continued promotion of protective behaviors in targeted communities 

2.       Promote awareness of testing at fixed sites for symptomatic residents with limited resources. 

3.       Enhance vaccination of underserved residents by identifying factors to promote action and addressing barriers for essential workers, Hispanic, black/African American and/or older adults 

a.     Reduce barriers to vaccination to increase choice and ability to be vaccinated, recognizing barriers maybe related to: 

               i. individual perceptions and need for more information,  

               ii.cultural factors,  

              iii.logistical 

b.     Explore, share insights, refine and address what we understand for our targeted residents: 

               i.Essential workers - minority - critical infrastructure, basic needs services 

              ii.Hispanic - generally more acceptance of vaccination, less hesitancy, culturally central America - less vaccine hesitancy 

             iii.Black/AA - distrust in communities  perception, culture and logistics;  

             iv.Older high-risk adults, Age 75+ - hesitancy less, perception barriers in white community lower 

Metrics: 

1.     % vaccinated 

             i.         Early roll-out of vaccine: We only had denominator for 75+ (not essential) measure of vaccine update to use as marker and proxy for success 

            ii.         Vaccination rates by zip code

           iii.         Vaccination rates by race and ethnicity

2.      Reach where vaccinated live, are there holes in the community? Where do we reach them?  

Actions: 

1.       Create and enable wide-spread conversations in the community about getting vaccinated 

                i.            Work with and through influencers 

               ii.            Virtual Town Halls about vaccination 

2.       Establish Vaccine Equity Clinics for targeted populations and neighborhoods

3.       Create High Value Target Reports from state vaccination registry data applied to land parcels coded by population density to determine percent unvaccinated in land parcels across zip codes.

4.       Collaborate with community outreach to assess if high value target area would benefit from place-based vaccine equity clinic or assignment of vaccine navigators.

5.       Prepare monthly vaccine equity data reports for elected and administrative leadership.

Results/Outcomes: Fairfax County's population is 16.2% Latino, with 16.7% of all vaccinations received by Latino residents; 9.2% of the population is black, with 8.1% of all vaccinations received by black residents.

Specific Factors that led to success: The formation of a cross agency High Risk Communities Task Force (HRCTF) that consisted of population health, a multi-cultural outreach team, epidemiologists, communications, public health strategists, vaccine navigators and cross-county equity and community development partners. Weekly meetings of the task force offered pandemic status updates, cultural and population group barrier dialogues, epidemiologic data reports and recommendations, identified challenges and priority objectives for the week ahead. Task force members held weekly regional huddles with trusted community partners to recommend, plan outreach and establish pop-up vaccine equity clinics. Innovative strategies to support vaccination were celebrated.

Public Health impact: Fully vaccinated rates of people over 18 years old is 79.6% across the Fairfax Health District, and 70.2% of all residents including children and youth are fully vaccinated.

Level or Type of Community Engagement: Community partners and informal community champions helped to identify locations, recommend operating days and hours, provide language interpretation and conduct outreach to inform neighbors of vaccine clinics. Medical Reserve Corps volunteers have staffed over 600 vaccine equity clinics in roles such as pre-clinic outreach neighborhood canvassing, registration, site assistants, flow control and post vaccination monitoring.

Steps taken to address and reduce health inequities: Data review and establishment of targeted strategies towards population group and communities with lower vaccination rates. Continuous engagement and delivery of community input to shape communication messages delivered through formal and organic messaging platforms. Regularly operating vaccine equity clinics in evening hours and on Saturdays and Sundays.

Website: https://www.fairfaxcounty.gov/health/novel-coronavirus; COVID-19 Vaccine Equity reports are found on https://www.fairfaxcounty.gov/topics/one-fairfax

The target population for the vaccine equity strategies were the racial and ethnic groups who experienced higher rates of disease throughout the pandemic. Within Fairfax County's estimated 1,148,433 resident population, nearly 50 percent of county residents (49.2%) represent an ethnic or racial minority group. Almost 10 percent of residents are African-American, 20 percent are Asian, 16 percent are Hispanic, and nearly 4 percent are multiracial (two or more races). Within the public school system more than 54,000 (29 percent of the total population) of students are eligible for free and reduced-price meals.

While all areas of the county are diverse, there are geographic areas with higher concentrations of racial and ethnic minorities, particularly in the Bailey's Crossroads/Culmore, Reston/Herndon, and the Route 1 Corridor areas, which also experience higher rates of poverty and linguistic isolation. In Bailey's Crossroads, 20.4% of residents live in poverty and 68.5% speak a language other than English at home.  In Hybla Valley, along Route 1, 13.7% of residents live in poverty and 55.2% speak a language other than English at home.

Root causes that existed to challenge vaccine equity included limited English language and literacy skills, transportation barriers, low-income hourly wage earners, lack of trust in government initiatives and misinformation. Initial barriers to vaccine equity included complex web-based registration portals, English language registration portals, and distant locations to obtain vaccine. The multi-cultural outreach team members of the HRCTF had many pre-pandemic community relationships established, which allowed us to host vaccine decision making town halls and engage community champions and partners in the shared objective to reduce disease and improve quality of life within the population groups and neighborhoods.

Previous Health Department analysis found that persons living in overcrowded conditions (i.e., six or more people living in household) were 67 percent more likely to test positive for COVID-19 at Health Department testing locations compared to persons living alone. For economic reasons, persons living in apartments are more likely to need to live in overcrowded conditions as compared to single-family homes.

A primary tool that contributed to the successful outcomes of the model practice was the creation of High Value Target Reports for select zip codes with higher social vulnerability indexes, higher case rates, lower vaccination, and more language barriers. Epidemiologists on the team conducted geospatial analysis and population denominator estimates at parcel level which were provided to the Health Department by Fairfax County's  Department of Information Technology, and the Economic, Demographic and Statistical Research Unit.

Analysis within ArcGIS to calculate percent of persons vaccinated by parcel was completed using Fairfax County produced parcel population estimates and immunization data from the Virginia Immunization Information System. A high value opportunity for outreach was defined as a parcel with an estimated resident population of more than 50 persons who were less than 50 percent vaccinated against COVID-19.

To target resources and seek to reach 70% vaccination rates within every neighborhood across a zip code, the regional vaccination outreach teams were provided high value opportunity reports to help them better prioritize and reach vulnerable populations within each ZIP Code analyzed. (HIPAA data was removed prior to sharing reports with community partners.) Working with community partners recommendations were submitted to establish a vaccine equity clinic at a location and hours that lowered barriers for the community. Door-to-door canvasing supported the notice to residents of the vaccination opportunities. Trusted partners helped to register residents for vaccine appointments that were not available on publicly searchable platforms. To lower additional barriers the vaccine equity clinics converted to walk-up vaccination opportunities before other general population clinics did so in the county.

Of the 873,830 Fairfax Health District residents who have been vaccinated as of November 21, 810,120(93%) have race and ethnicity included in the Virginia Immunization Information System. Overall, from December 2020 through November 2021, Hispanics comprised 16.5% of Fairfax Health District residents vaccinated, Black or African Americans comprised 8.1%, Asian and Pacific Islanders comprised 21.6%, non-Hispanic Whites comprised 44.6%, with 9.3% reporting another race and ethnicity.

The current practice of a cross-department task force that meets weekly to share county-wide disease and vaccination updates, community concerns and questions from the multi-cultural outreach team, epidemiological findings, evidence based research, vaccine equity clinic recommendations, communications and marketing, and vaccine navigation challenges has accelerated an agency-wide demonstration and recognition of how to lead with equity. Cross discipline relationships within the public health agency and across the community have been fostered and strengthened. This practice is better as we have developed more robust data informed decision-making tools that complement community based knowledge and the distribution of limited resources to achieve vaccine equity goals.

Evidence Base:

The Community Guide: Vaccination Programs: Community-based Interventions Implemented in Combination

https://www.thecommunityguide.org/findings/vaccination-programs-community-based-interventions-implemented-combination

• The Community Preventive Services Task Force (CPSTF) recommends using a combination of community-based interventions to increase vaccination rates in targeted populations. Interventions may aim to increase community demand, enhance access to vaccination services, or reduce missed opportunities by vaccination providers.”

CDC: Ways Health Departments Can Help Increase COVID-19 Vaccinations

https://www.cdc.gov/vaccines/covid-19/health-departments/generate-vaccinations.html

• Discusses strategies and resources for LHDs  to generate demand for vaccination, building trust, addressing misinformation, and tailoring messages. Explicitly discusses reaching people where they live, work, learn, pray, play, and gather.

Assistant Secretary for Planning and Evaluation – Office of Health Policy Research Report: Overview of Barriers and Facilitators in COVID-19 Vaccine Outreach

https://aspe.hhs.gov/sites/default/files/2021-08/Vaccine%20Outreach%20Research%20Report%208-27-2021%20FINAL.pdf

• Addresses multiple points of HRCTF – multi-pronged strategies, tailoring messages, outreach strategies, community-based vaccination programs.

Local Health Department and Community Collaboration:

Goal: Enable containment of COVID-19 disease in high risk communities through access to education, testing and vaccination. 

Objectives: 

1.       Continued promotion of protective behaviors in targeted communities 

2.       Promote awareness of testing at fixed sites for symptomatic residents with limited resources. 

3.       Enhance vaccination of underserved residents by identifying factors to promote action and addressing barriers for essential workers, Hispanic, black/African American and/or older adults 

a.     Reduce barriers to vaccination to increase choice and ability to be vaccinated, recognizing barriers maybe related to: 

          i. individual perceptions and need for more information,  

          ii.cultural factors,  

         iii.logistical 

b.     Explore, share insights, refine and address what we understand for our targeted residents: 

           i.Essential workers - minority - critical infrastructure, basic needs services 

         ii.Hispanic - generally more acceptance of vaccination, less hesitancy, culturally central America - less vaccine hesitancy 

        iii.Black/AA - distrust in communities – perception, culture and logistics;  

         iv.Older high-risk adults, Age 75+ - hesitancy less, perception barriers in white community lower 

What did you do to acheive goals and objectives? Time frame?

Since May 2020, FCHD has convened a High Risk Communities Task Force (HRCTF) to inform public health response and resources for residents of the county experiencing disproportionate rates of COVID-19 disease, anticipated vaccine hesitancy and barriers to accessing vaccine. In January 2021 as vaccines become available the HRCTF implemented strategies to support vaccine decision making and vaccine equity throughout the county.  Anchor vaccinators such as local federally qualified health centers, safety net clinics, cultural health care serve organizations, academic training providers, and a federal pharmacy provider were identified and supplied with public health vaccine supplies until other distribution channels were available. Vaccine Equity Clinics were established at trusted community locations and multi-cultural partners were engaged to help register older adults and essential workers for vaccine appointments at dedicated clinics not available through general population appointment portals. Vaccine equity clinics continue as more residents become eligible for vaccine.

Numerous stakeholders have been involved in the work as the High Risk Communities Task Force engaged with multi-sector partners throughout the community. These partners include community based organizations, nonprofit advocacy organizations, public school parent liaisons, resdential property managers, house of worship, businesses, grocery, food distribution organizations, elected office staff, medical reserve corps, transportation partners, regional community developers and others. Epidemiological data informed the hyper-local planning and showed results from vaccination efforts. 

Steps taken to ensure equitable, meaningful and representative collaboration included regular communications and conversations with target populations. These conversations occurred in barber shops, at food distribution lines, and in community zoom meetings organized by school principals and community based social service organizations. The feedback received from residents informed the development of communication tools and messages. Specific examples of actions to communicate and collaborate with targeted populations include:

·       In the African American community, FCHD outreach staff have implemented the Real Talk for the Culture” campaign to promote confidence in younger Black adults in making a vaccine decision and to continue to grow and nurture partnerships beyond the pandemic. This campaign was recently featured on FOX 5. The key components of the campaign include ‘Real Talk' conversations in small groups and ‘Real Talk' infographics. Key partners include local Black barber shops/salons, Black-owned businesses, and nonprofits serving the Black community.  

·       In the Hispanic community, we have engaged with over 40 organizations that serve the Hispanic population; been frequent contributors to Telemundo and Univision; developed extensive Spanish language media assets including a Spanish website, Spanish blog, Spanish Facebook page and live broadcasts, and Spanish language videos; as well as engaging with faith-based and other trusted community leaders and organizations to provide information and support decision-making by individuals in their communities.   

The work of the High Risk Community Task Force has been operated in-kind throughout the pandemic. The original task force team consisted of 17 health department cross agency staff, but it has grown to include 73 health department, contract navigator and county agency partner staff.  All vaccine equity clinics are held in locations that are donated space, vaccinators administer vaccine without charge to the county, and support staff are largely medical reserve corps volunteers.

The High Risk Community Task Force members each contributed public health expertise to operate as a cohesive team in support of its objectives to enhance vaccination of underserved residents by identifying factors to promote action and addressing barriers for essential workers, Hispanic, black/African American and/or older adults. Working with the community we sought to reduce barriers to vaccination, to increase choice and ability to be vaccinated, respect individual perceptions and need for more information, appreciate cultural factors, and apply innovative and supportive approaches to address unique logistical, language and staffing needs for hundreds of vaccine equity clinics delivered as pop-up, mobile and established locations

Reducing barriers to vaccination was possible through establishing vaccine equity clinics with trusted partners, reducing location barriers, language barriers, offering vaccine during evening hours and on weekends.

Primary Data: Vaccination rate data was obtained from the Virginia Immunization Information System. Population data is obtained from the American Community Survey.

ZIP Codes with low vaccination rates, high case rates, and areas with known vulnerable populations were selected to identify high value opportunities for vaccination outreach by the Health Department and external partners. A high value opportunity for outreach was defined as a parcel with an estimated resident population of more than 50 persons who were less than 50 percent vaccinated against COVID-19.

Analysis within ArcGIS to calculate percent of persons vaccinated by parcel was completed using Fairfax County produced parcel population estimates and immunization data from the Virginia Immunization Information System (not shown to protect confidential health information).

Vaccination outreach teams were provided high value opportunity reports to help them better prioritize and reach vulnerable populations within each ZIP Code analyzed.

From March to August 2021, 4.5% (n=55,200) of all COVID-19 vaccine doses administered to Fairfax Health District residents have been administered at an equity clinic. Contributing to these numbers were 28 locations, including 5 on-site vaccination clinics, that were identified by the high value opportunities report that received outreach services. Outreach to additional locations is ongoing.

As of early October 2021, 41% of all ZIP Codes in Fairfax Health District have been analyzed to identify high value opportunities for vaccination outreach. Among these ZIP Codes, 57% have undergone a second or third round of analysis to help assess vaccination progress and direct efforts to parcels with an ongoing need.

During vaccination outreach, staff provide residents with vaccination education in multiple languages, make appointments for residents at a nearby vaccination equity clinic, or provide instructions on where the nearest clinic is located.

Combining the efforts of equity clinics and identifying high value opportunities for outreach, has allowed the Health Department and our partners to help make faster progress towards vaccine equity in Fairfax Health District. As of September 27, 2021, 82.6 percent of vaccine eligible persons who identify as Hispanic in Fairfax Health District have received at least one dose as compared to 74.7 percent of Hispanics in the rest of Virginia.

Detailed monthly COVID-19 Vaccine Equity strategy reports are provided to the County Executive and elected Board of Supervisors. These reports are publicly posted on the One Fairfax program page, which details the County's racial and social equity policy. www.fairfaxcounty.gov/topics/one-fairfax

The multi-discipline and data informed collaboration to address vaccine equity has established appreciation and recognition of the value of performing as a 21^st century public health agency.  The pandemic provided a crisis of opportunity to implement a collaborative model that successfully achieved vaccine equity within our Hispanic resident population and closed the gap in achieving equity within our African American resident population. The expert contributions of all members of the High Risk Community Task Force accelerated vaccine equity.  Community partners and champions are engaged as true partners in public health. We are confident of our ability to sustain the collaborative and data informed practice and excited to meet the challenges of the future as we lead with equity.