The main objectives of the Covid-19 Vaccination Program for the San Francisco Department of Public Health was to efficiently and equitably distribute and administer Covid-19 vaccines within our local population with minimal disparities in vaccine administration by race, age, income or housing status. Given the health outcomes of the first 10 months of the pandemic demonstrating the highest case rates, hospitalizations and deaths among Black/African American, Latino/a, and Asian residents of San Francisco, relative to their population representation, we were particularly focused on ensuring the vaccine effort could help to reduce the impacts of Covid on those communities. We anticipated disparities in COVID-19 vaccine access, confidence, and uptake and for social and structural barriers to factor into vaccine administration rates across different race/ethnicity groups in SF and sought to mitigate and reduce these disparities through intentional planning, partnerships and continuous improvement efforts centered around community voices and feedback. We identified three core principles based on public health and community best practices to guide this program:
1. Center community voice and leadership in the design and implementation processes. Both quantitative and qualitative input and feedback is critical in designing and evaluating systems that work for diverse communities.
2. Address structural barriers to accessibility of care based on community feedback. Whether enabling physical proximity to a needed resource, ensuring language accessibility, or reaching people by phone or social media, we must understand the systems and structures of our patients' everyday lives to best incorporate health interventions that meet their needs.
3. Enhance trust (and the likelihood of accepting a health intervention) through transparent and accountable practices such as regular meetings with partners to share data and plan program priorities and adjustments.
A. Local Historical Impact of the Covid-19 Pandemic and Goals for Improvements
During the early months of the pandemic, we recognized the disproportionate burden of COVID-19 infection on Latinx, Black and other socially and economically marginalized groups. In April 2000, a large-scale, census tract-focused testing effort in the Mission led by our partners at UCSF and the Latino Task Force revealed high infection rates in the Latinx community and highlighted key social and structural determinants of health that increased risk for infection. These included income insecurity and the need to continue in person, essential work during shelter in place, as well as overcrowded housing. Over 40% of those tested were not already linked to primary care and many feared immigration enforcement when accessing government services. These same determinants would need to be addressed to overcome predisposing, enabling and reinforcing barriers to COVID-19 vaccination and ensure equitable vaccine access. Several of these barriers also were cited by members of the BAA community during focus groups and weekly COVID-19 Learning community discussions, and were exacerbated by a legacy of anti-Black racism and mistreatment in health care that has led to and sustained profound mistrust in government- led services. In addition, disinformation about the vaccines’ safety and efficacy on social media and the perceived speed of vaccine rollout has increased hesitancy, particularly among youth.
B. Innovative Design to Address Community-identified Barriers
Based on surveys and focus groups with community members both before the vaccine roll-out and iteratively throughout, we identified possible areas to target interventions, as listed below:
1.Structural Barriers to Access
a. Site Selection in community hubs
b. Allocation of Vaccine and logistical support to trusted, community-based providers
c. Digital literacy, language and scheduling support via call-center and in-person supports
d. Drop-in access and flexible hours
e. Mobile vaccination teams: including in-home support and roving, street-based teams
2. Information Barriers to Interest, Beliefs and Attitudes
a. Identifying trusted community messengers to overcome historical mistrust
b. Identifying trusted, BIPOC experts (physicians, pharmacists, nurses) to answer questions
c. Multi-lingual and multi-approach social media campaign and in-person approaches with youth and other key groups
d. Regular meetings with public health operations to share impact of disease, vaccination progress, and hear ideas for improvements for the response as well as to plan for how to address health inequities in the future
C. Data-informed improvement efforts and outcomes
Historically, influenza immunization rates among BAA populations in SF have been low (41.2% compared to 58.5% among all races among SFHN patients). As such, in planning the vaccination effort, we tracked demographic data captured at time of vaccine administration. We developed dashboards that broke-down vaccination trends by age, race/ethnicity, and geo-spatially at the neighborhood and census tract levels to inform the efforts of neighborhood-based teams. The initial, phase-based eligibility system implemented by the California Dept. of Health (CDPH) based on age and occupational category presented an early unique challenge to accurately visualize the disparities in vaccination rates. However, during the phase 2 expansion for the general population in early April 2021, we were able to more reliably gauge the level of disparity. At that time, the data clearly showed that Black and Latino/a residents were being vaccinated at lower rates than any other race/ethnicity group, as follows: Asian: 53% Black or African American: 37% Hispanic or Latino/a, all races: 42% White: 46%. Through continuous efforts and community-based improvements, by October 2021, we had substantially narrowed the disparity in vaccination rates by race and ethnicity as follows: Asian: 79%, Latino/a: 78%, Black/African American: 70%, White: 70%. (See supplemental material)