Wake County, North Carolina is the largest county by population in North Carolina, with just over 1.1 million residents and is one of the fastest growing counties in the US (Demographics, n.d.; U.S. Census Bureau, 2021.) The recent census indicates that 67% of residents identify as White, 21% identify as Black or African American, <1% identify as American Indian and Alaska Native, 8% identify as Asian, and 10% of residents identify as Hispanic or Latino. Wake County Health and Human Services (WCHHS) serves these residents utilizing more than 1600 staff members in nine locations across the county. The Wake County Public Health Division is housed within WCHHS and plays a critical role in protecting and improving the health of communities across Wake County. As such, WCHHS has led the county in innovative COVID-19 mitigation strategies, which have kept COVID-19 rates among the lowest in the State while also ensuring health equity. Specifically, WCHHS has worked to address health disparities intensified by COVID-19 and accelerate services to communities most impacted by COVID-19 through a comprehensive COVID-19 vaccine equity strategy.

Across the US, COVID-19 has exacerbated existing health inequities rooted in structural racism, injustice, and systemic barriers. This holds true in Wake County, North Carolina where Black/African American and Hispanic/Latino communities have been disproportionally impacted by COVID-19, as seen by heightened mortality and case rates adjusted for population (NC DHHS, n.d.-a). To address these inequities, WCHHS developed a strategy to identify testing deserts, which utilized real-time data to immediately adapt testing locations to ensure that the hardest hit communities were reached through access to mobile testing. Building upon this model in early 2021, WCHHS developed a vaccine equity strategy that prioritizes census tracts in the county experiencing disparities related to COVID-19.  In almost all instances, areas of the county that report the highest COVID-19 case rates also report the highest level of disparities related to healthcare access, availability to transportation services, and correlate with higher scores on the social vulnerability index.

The COVID-19 vaccine equity strategy aims to ensure that underserved communities experiencing health inequities have both access to COVID-19 vaccines and information needed to make informed decisions regarding vaccinations through trusted community partners. The strategy was developed so that it could be easily replicated for future health campaigns, with the long-term goal of ensuring more equitable access to health services in Wake County. The specific practice of implementation was multipronged and included:

·        Background data analysis and mapping of all census tracts in Wake County.

·        A community engagement strategy that utilized trusted partners and community health workers.

·        Mobile vaccination sites at high-traffic community points in selected census tracts.

·        Geo-targeted communication efforts. 

·        Continuous adaptation of vaccination sites based on real-time evidence.

In the census tracts that were selected for mobile vaccinations and complimentary outreach through the vaccine equity strategy, vaccination rates of Black/African America and Hispanic/Latino increased significantly as did access to vaccination/health services among these groups.

Structural inequities and historical discrimination have led to greater disparities in social determinants of health in Black/African American and Hispanic/Latino communities, as well as overrepresentation in occupations classified as frontline workers (Casura et al., 2020). At the start of the vaccination campaign in Wake County, 23% of all COVID-19 cases reported in Wake County were among Hispanic/Latino individuals, though population estimates show that 10% of residents are Hispanic/Latino (U.S. Census Bureau, 2021). Corollary to this, 31% of all deaths attributed to COVID-19 in the county were among Black/African American individuals (NC DHHS, n.d.-a), whereas only 21% of the county’s population identifies as Black/African American. These COVID-19 disparities were most evident in certain census tracts across Wake County; often those with less access to healthcare, higher social vulnerability index, and those that live in more densely populated areas.

Addressing Inequities and Serving Those Most Impacted by COVID-19

Long-standing inequities became increasingly apparent during the first few months of the COVID-19 pandemic in Wake County. As previously mentioned, to immediately address disparities, WCHHS began using geocoded data to locate testing deserts and deploy mobile testing sites. Given the positive impact of the testing program, WCHHS developed a vaccine equity strategy that replicated best practices from the testing program. The initial goal of the strategy was to address inequities surrounding COVID-19 vaccinations and enhance wrap-around services by increasing access to these services in communities across Wake County. WCHHS accomplished this by placing mobile vaccination sites in census tracts with low COVID-19 vaccination coverage, limited access to health services, and those experiencing disparities related to social determinants of health. In addition to health access, WCHHS aimed to reduce inequities in health literacy and bolster trust in communities both where mobile vaccination sites were placed and across the county. WCHHS utilized trusted community messengers, community partners, and innovative community engagement strategies (e.g., townhalls) to address these inequalities.

To address the needs of populations most impacted by COVID-19, WCHHS initially created a vaccine equity strategy that prioritized zip codes across the county for vaccination in January 2021. However, by February 2021 it became apparent that zip codes were not granular enough to fully ensure equity, so WCHHS shifted to data analysis at the census tract level. This shift was congruent with the North Carolina Department of Health and Human Services (NCDHHS) plan to prioritize 25 census tracts in Wake County for vaccination through equity doses for groups, classified as historically marginalized populations by NCDHHS, experiencing disparities, (NC DHHS, 2021b). The effort supported by NCDHHS was implemented through May 2021, at which point WCHHS developed a refined vaccine equity strategy that shifted to intensified support of four priority census tracts, for three-month time periods.

·        By focusing on four of the census tracts with lower access to healthcare services, lower vaccination coverage, and higher social vulnerability index, WCHHS was able to offer tailored support to communities. Additional detail is provided within the section of ’Quality Improvement’.

·        Through this strategy, WCHHS decided to remain in a census tract for three months to garner community trust through consistency and relationships with key community partners such as religious organizations, businesses, and affiliates that included Historically Black Colleges and Universities (HBCUs.)  

·        Mobile vaccination sites in the four selected census tracts were placed at sites selected through community feedback, which were high traffic. Examples of locations selected include Hispanic/Latino supermarkets, parks, churches, and barbershops.

WCHHS also recognized that complimentary efforts to placing a vaccination site in a community were necessary to serve the needs of that community, examples of which are as follows.

·        Community health workers and partner organizations often supported canvassing in conjunction with mobile vaccination sites. Multilingual canvassers engaged in door-to-door activities as well as tabling at mobile sites to address the concerns and questions of community members most impacted.

·        Strategies for each census tract were unique, based on the demographics of that census tract and the needs as relayed by community leaders.

·        To further ensure equity, disaggregated vaccination and survey data were reviewed every two weeks to inform strategies. This allowed WCHHS to quickly adapt, measure impact, and to select new census tracts after three months.

The COVID-19 vaccine equity program in Wake County brought together a variety of stakeholders and community partners to implement an innovative, evidence-based strategy to reduce health disparities. COVID-19 brought public health to the forefront of American life, thus resulting in an increase of available resources including personnel, financial, and even physical (e.g., mobile vaccination vans). These resources allowed WCHHS to utilize real-time, highly granular data to inform decisions for all programing and to support mobile outreach in a way that was unparalleled. Though this practice is not new to the field of public health, combining geocoded data, community outreach, and service delivery in this way, at a census tract level is unique. The microplanning involved in this work allowed for greater health equity and was utilized to establish partnerships that will be carried forward to ensure greater health equity in all WCHHS programming.

Adaptability

The vaccine equity strategy supported by WCHHS was also unique due to the programs unique ability to adapt. The strategy utilized an evidence-based approach that incorporated weekly case and vaccination analysis, to ensure that interventions were placed in the right locations. A combination of securely held individualized and publicly available data aggregated to actionable geographic units was key to the success of this program; allowing community stakeholders to support informed decision making. A crucial portion of the evidence-based approach included the use of GIS expertise supported through the Wake County Long Range Planning team. The ability to visually compare data across census tracts informed programming to bolster vaccine equity on an at-will, real-time basis.

EVIDENCE- BASED

The strategy in Wake County is founded in best practices for equitable vaccine distribution as noted by the HHS and CDC. The use of geospatial data to inform programming has been utilized in a variety of public health interventions including by UNICEF.

Community Engagement Strategy and Partnerships

As noted above, WCHHS quickly recognized the increasing infection, hospitalization, and death rates of COVID-19 disproportionately affecting Black/African American and Hispanic/Latino communities. WCHHS also recognized the importance of community partners in outreach, prevention, and mitigation strategies to control the spread of COVID-19. To ensure collaboration with community partners to mitigate the spread of COVID-19 and ensure health equity, WCHHS developed the following community engagement goals/strategies in late 2020:

·        Decrease disproportionality in COVID-19 infections, hospitalizations, and deaths in Black/African American and Hispanic/Latino communities.

·        Increase testing opportunities in vulnerable communities.

·        Increase willingness to receive the COVID-19 vaccine once it becomes available.

·        Ensure there is equitable access to the COVID-19 vaccine for Black/African American and Hispanic/Latino communities.

·        Increase access to health and wrap-around resources in Black/African American and Hispanic/Latino communities.

·        Increase compliance with local, state, and federal guidelines and orders designed to mitigate the spread of COVID-19

Building upon this community engagement strategy, WCHHS partnered with over 50 community-based organizations (CBOs), including churches, non-profit organizations, HBCUs, physicians’ networks, health equity community coalitions, social justice organizations, Black Greek entities, and youth leadership organizations. Through this network of community partners, WCHS was able to quickly pivot to support testing and vaccination events, which expanded outreach in prioritized ZIP codes and (ultimately) census tracts identified through background GIS mapping. Community outreach was key to the success of the vaccine equity strategy, with community partners supporting vaccination events to bolster trust within areas prioritized by WCHHS. Community outreach focused on door-to-door registration campaigns, partner-led community events, and multilingual information sessions. These outreach events utilized trusted community leaders and influencers to help provide information, connect communities to resources, and increase access to vaccination opportunities. Specific strategies and partner networks included:

·        Faith Partners - Existing faith partnerships, by regions and/or denominational conferences, were engaged to help disseminate culturally appropriate information to their congregations and the communities in which they served. Faith partners were also engaged to provide community-based testing and vaccination sites in underserved communities. Faith partners were able to help provide transportation services in areas of limited access, particularly in rural areas.

·        Physicians Network - A network of African American and Latino physicians was assembled to provide culturally appropriate and relevant information on COVID-19 and the vaccine to faith communities and community organizations. Physicians from the network participated in virtual town hall meetings where participants were able to write in to “ask the doc” questions.

·        CBOs - WCHHS utilized CBOs to support testing and vaccination strategies. For the vaccine equity strategy two organizations, Southeastern Health Care and El Centro Hispano, supported community engagement activities while mobile vaccination events were occurring. Other community partners were engaged in community vaccine bootcamp sessions.

·        University Partners - WCHHS worked with two HBCUs to support vaccination efforts and innovative communication efforts surrounding vaccinations. These organizations will also support monitoring and evaluation of vaccination efforts through grant funding in the coming months.

Interdepartmental Collaboration

In addition to external partnerships which were expanded and refined through the vaccine equity strategy, interdepartmental collaboration was also deepened.  The Long-Range Planning Division, which falls within Wake County Planning, played a critical role in GIS support including geo-coding for selected census tracts.  Wake County Information Services supported the public health division in the analysis and dissemination of crucial COVID-19 information, supporting evidence-based decisions surrounding vaccine equity. In addition, Live Well Wake, a unit of the public health division, supported activities geared towards improving social determinants of health.

The vaccine equity strategy utilized data to strategically inform the planning stages of how to increase the percentage of the population vaccinated, along with five formal assessments at key timepoints to inform iterations as the program progressed, to increase the likelihood of engaging the populations that were under-vaccinated, lacked convenient access to vaccine locations, were historically marginalized, and /or were vaccine hesitant. In particular, the use of GIS expertise and mapping software, in conjunction with public and proprietary data, enabled WCHHS to conduct microplanning within the census tracts of interest.  

Examples of publicly available information that was utilized in conjunction with GIS software to create detailed maps that informed the planning stages include:

·        Locations of historically marginalized & uninsured populations based on census data

·        Block group level social vulnerability index, similar to CDC’s census tract level index

·        Vaccine hesitancy - based upon US Census Bureau Household Pulse Survey data that was published by the US CDC at the Public Use Microdata Area (PUMA) level.

·        Vaccine deserts – based upon determining the location of every pharmacy, county provider, and private practice (including hospitals) that could administer vaccines and then placing a 3-mile buffer around them. The resulting areas not covered by the buffers enabled a clear understanding of the role geography has with regards to healthcare access.

·        Site planning for mobile vaccination clinics based upon areas of high traffic and/or locations that could be utilized as focal points of engagement to interact with the community.

Several proprietary datasets are also available to WCHHS and were utilized in the planning stages. Specifically, WCHHS has a dynamic dataset of every COVID-19 case and person vaccinated against COVID-19 that maintains a residence within the county. Each case and vaccinated person has individualized demographic data (e.g., age, gender, race/ethnicity), along with their provided address that was subsequently geocoded. Examples of detailed maps that were created include:

·        Percentage of population vaccinated across different demographics by census tract and municipality

·        Case rates by census tracts and by municipality across different time frames.

As a tool for increasing the number of people vaccinated, WCHHS deployed canvassing teams to go door-to-door to educate communities surrounding the importance of being vaccinated, as well as administer vaccines at peoples’ homes. To guide canvassing teams to areas of the most unvaccinated individuals, a new metric was developed during the planning stages utilizing proprietary data in conjunction with US Census data to classify subdivisions, apartment complexes, and mobile home parks into categories that represented differing amounts of unvaccinated individuals likely to be in these aggregated locales. This information was then input into GIS software to enable the canvassing teams to have a quick understanding of where to focus their efforts with the intent of visiting areas classified as having a higher number of unvaccinated individuals to allocate time/resources.

Several improvements were made during the implementation process based upon the use of data, mapping, and formal assessments. These include:

·        Identification and prioritization of specific census tracts based upon presence of historically marginalized populations, high social vulnerability index, low vaccination rates, and limited access to vaccine providers.

·        Improved efficiency of the canvassing team by directing canvassers to specific locations that had a higher probability of unvaccinated individuals and reducing repeat interactions with those that were vaccinated.

·        Refined focus for where to setup mobile vaccination sites.

Several inequitable health outcomes improved because of the methods utilized (previously described). They include:

·        Boosted vaccination rates for Hispanic/Latinos and Black/African Americans, as well as the age groups spanning 18-24, 25-39, and 40-54 in the four prioritized census tracts.

·        Improved equitable vaccination access for demographic groups that included Hispanic/Latinos and Black/African Americans, as well as the age groups spanning 18-24, 25-39,40-54 in the prioritized census tracts.

·        Built trust with community members at some repeat vaccine sites, which led to an increase in word of mouth being utilized to attract more people to get vaccinated. 

Although outreach & vaccination efforts have been countywide this practice of focusing on census tracts led WCHHS to focus human, financial, logistical, clinical, and technical resources towards a specific geography.

The meaningful public health impact of the vaccine equity project was wide ranging and included:

·        An increase in vaccination in underserved areas.

·        Improvement in vaccine equity among historically marginalized populations & youth demographics.

·        Community partnerships were built, strengthened, and expanded, which have positioned WCHHS to utilize them for other initiatives that expand well beyond COVID-19 engagement.

Several key lessons were learned from the vaccine equity strategy. They include:

·        Determined that food/retail/grocery locations were better sites for repeat walk-up mobile vaccination clinics.

·        Determined that parks were better sites for single special event mobile vaccination clinics, not as effective/efficient as repeat sites.

·        Determined that faith locations were better sites for scheduled/appointment mobile vaccination clinics, not as walk-up vaccination sites.

·        Indicators that were vital in assessing the progress of the county’s community engagement to increase vaccination were: 1) the average number of vaccine doses administered per mobile vaccination event  enabled WCHHS to assess the effectiveness of mobile vaccine events at specific locations over time as well as set a threshold of the number of doses that should be administered per event; and 2) the ratio of doses administered for each canvassing shift, which assessed the effectiveness of canvassing overall across different demographics and geographies within the prioritized census tracts.   

Aspects of the program that will be incorporated into future programs post-pandemic include:

·        Enhanced coordination between community engagement, operations, communications, and epidemiology/data teams at WCHHS on health equity planning & analysis.

·        Utilization of GIS expertise and mapping for health equity planning & analysis, including an expanded partnership with the Wake County Long Range Planning Department.

·        Mobile vaccination site selection will be driven by different types of public and proprietary data, which include vaccination coverage and case rate, location type, mobility information, population/demographic data from the US Census Bureau, as well as Wake County neighborhood-level information.