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Health Equity
March 19, 2021

Inequities in Technology Contribute to Disparities in COVID-19 Vaccine Distribution

Author Affiliations
  • 1Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
  • 2Section of Geriatrics and Palliative Care, Department of Medicine, University of Chicago, Chicago, Illinois
JAMA Health Forum. 2021;2(3):e210264. doi:10.1001/jamahealthforum.2021.0264

As states have begun administering COVID-19 vaccines to those 65 years and older and essential workers, they face substantial challenges. These challenges include the race against more contagious virus variants; the continuing death toll, particularly in vulnerable subgroups1; concerns about vaccine supplies; and insufficient funding for vaccine distribution. The National Academy of Medicine and the Centers for Disease Control and Prevention’s Advisory Council On Immunization Practices (ACIP) have emphasized the need for equitable vaccine allocation and urgent prioritization of subgroups most negatively affected by COVID-19.

Because of social distancing measures, vaccine scheduling has predominantly relied on technology such as mobile apps and internet portals. Despite ongoing efforts to ensure equity, longstanding systemic disparities in technology access and literacy are hindering equitable vaccine distribution and raising bigger questions about how technology disparities may be affecting social and health disparities. A recent JAMA editorial offered several important recommendations to promote equity in the distribution of COVID-19 vaccines.2 However, national guidelines and expert recommendations have not proposed solutions to technology-related equity challenges. Ameliorating these inequities will require a deeper understanding of how technology may exacerbate disparities in vaccine access and to consider potential solutions.3

Internet Connectivity and Access to Technology

In 2019, more than 40% of older adults did not have broadband in their homes, and more than one-quarter did not use the internet. Both broadband and cellular coverage vary significantly across geographic locations; the largest dead zones more frequently occur in rural areas, lower-income neighborhoods, and minority communities. Beyond connectivity, disparities in ownership of computers and tablets further contribute to the digital divide among vulnerable groups. Although most adults 65 years and older own a cellular phone, nearly half do not have a smartphone. Within this older age group, those with advancing age, presence of disability, or low income and those who are Black or Hispanic are more likely to lack access to computers connected to the internet.

The pandemic has made clear that technology can be a powerful tool for those with access, as technology quite literally enabled social distancing across the US in order to “flatten the curve.” However, what was previously a digital divide has now become a digital chasm. Despite state-based efforts to improve connectivity and technology access in response to the CARES Act, connectivity deserts and limited technology resources remain among disadvantaged groups, limiting their access to health care resources. Policies to promote universal connectivity are overdue, and more efforts like this one in Chicago are needed to inform policy.

Technology Usability and Literacy

Simply having access to technology does not ensure usability when seeking COVID-19 vaccines. Usability concerns include complicated websites for registering, requiring email addresses for registration, needing to frequently monitor appointment availability, and narrow windows for scheduling appointments. The heavy reliance on technology to access COVID-19 vaccines is problematic for many of the groups hit hardest by COVID-19. In a Chicago Tribune op-ed, we highlighted the critical need to address technology literacy when implementing technology-based health interventions, because at least one-quarter to one-third of the population faces significant challenges to engaging in such interventions.4

Even for those with access to technology and skilled in its use, the first-come, first-served model for scheduling internet- and portal-based vaccine appointments introduces additional challenges. In some states, successful scheduling of appointments often takes multiple devices, multiple individuals, and repeated attempts over hours, days, or even weeks. For individuals who lack these resources or essential workers without time to dedicate to this process, this quest for a vaccine appointment unfairly favors those with more resources, including time, money, and larger social networks.

Solutions to Promote Equity in Vaccine Access

Although websites can provide vaccine scheduling options, they will continue to contribute to disparities if utilizing first-come, first-served processes for vaccine registration. The use of preregistration followed by lotteries to create waves with easy access to central appointment scheduling drastically improves equitable access. Appointments would be released in waves to give people the opportunity to identify resources to help them use offline or online navigators. Ensuring multilingual support is available for all scheduling strategies will increase equitable access, and offering vaccine administration options that are geographically accessible or include mobile units, transportation, or even home visits will help to reach the one-fifth of community-dwelling older adults or millions living with disabilities who need some help leaving the home.5

Live navigators have been applied to COVID-19 testing, whereby 24/7 hotlines have allowed access to advisors to help individuals identify nearby testing facilities with timely availability. This approach also would work well if applied to vaccine scheduling, so someone on the phone could assist individuals to learn about their eligibility and, when applicable, assist with securing vaccine appointments. States could then pair the hotline with a complementary technology navigator, such as Zocdoc. Zocdoc consolidates information and makes a one-stop option available to identify vaccine appointment opportunities. A live navigator could help direct individuals to the site and/or assist them by phone if the individual cannot navigate to the site on their own.

In an ideal implementation process, steps would be taken to ask those in vulnerable groups how to make vaccine access easier. Given the heterogeneity of technology adoption, nuanced, tailored approaches are needed. The use of participatory design,6 or codesign, has successfully enabled those least likely to use new technologies to benefit from them.7 National guidelines and resources guiding implementation of COVID-19 vaccinations must promote equitable distribution and address the heavy reliance on technology as a means of access to vaccines.

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Article Information

Open Access: This is an open access article distributed under the terms of the CC-BY License.

Corresponding author: Valerie G. Press, MD, MPH, Section of General Internal Medicine, Department of Medicine, University of Chicago, 5841 S Maryland Ave, MC 2007, Chicago, IL 60637 (vpress@bsd.uchicago.edu).

Conflict of Interest Disclosures: Dr Press reported receiving consulting fees from Vizient and Humana and research funding from the National Institutes of Health (NIH) and American Lung Association outside the submitted work. Dr Huisingh-Scheetz reported receiving funding from the NIH and the Carol and George Abramson Fund for Aging and Longevity during the conduct of the study. Dr Arora reported receiving funding from the NIH and being a board member of the Joint Commission and the American Board of Internal Medicine.

Acknowledgment: The authors acknowledge and thank Mary Akel for her help preparing this manuscript for submission.

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    1 Comment for this article
    Supporting Equitable COVID-19 Vaccine Distribution at VA
    Ernest Moy, MD, MPH | Veterans Health Administration Office of Health Equity
    The observations of Drs. Press, Huisingh-Scheetz, and Arora in their March 19, 2021 commentary, “Inequities in Technology Contribute to Disparities in COVID-19 Vaccine Distribution,” mirror our experience with patients at the Veterans Health Administration (VHA).

    In anticipation of the COVID-19 vaccines, and with research showing greater vaccine hesitancy among minorities during past pandemics, we held listening sessions with Veterans of Color late summer/early fall 2020. From these sessions, we learned that information aimed at helping them overcome hesitancy would need to:

    • Come from a trusted source (physician, fellow Veteran);
    • Address specific
    concerns, such as the infamous Tuskegee study;
    • Be delivered via technology and/or media they already used; and
    • Link directly to a specific action, such as scheduling a vaccination appointment..

    In response, VHA doctors began discussing the benefits of vaccination with Veterans months before the first vaccines became available. Additionally, VHA developed targeted messaging aimed at addressing issues such as medical mistrust and Tuskegee. We also issued Internet-connected devices to the many Veterans who lacked them and distributed information through less bandwidth-intensive channels such as VEText. Once vaccines became available, many VHA facilities leveraged our centralized electronic health records to identify eligible Veterans, contact them by phone, and, if they were agreeable, schedule appointments.

    By anticipating vaccine hesitancy and engaging with Veterans of Color early on, VHA greatly reduced the potential for disparities in vaccination. To date, we’ve seen no differences in uptake by White, Black, and Hispanic Veterans. Direct and honest dialogue with Veterans kept us focused on their specific concerns, thereby enabling us to provide the information they needed in the way they needed it, and help them make sound vaccination decisions for themselves and their families.