Lessons in Equity From the Front Lines of COVID-19 Vaccination

We are what we do, especially what we do to change what we are.

Eduardo Galeano

Beginning in late 2020, many health care organizations in the US took on a new public health role: meeting the urgent, unprecedented challenge of COVID-19 vaccination. Without a coordinated national strategy, health systems needed to design and implement their own vaccination strategies to deliver the COVID-19 vaccine equitably and efficiently, first to their own employees and then to patients.¹ As our own health care system took on this new mission, it confronted many challenges to equitable care, and novel forces for organizational change emerged. This experience—within a large Massachusetts health care system—shows how positive transformation can occur rapidly when an organization urgently realigns its work to serve the public health. We present 5 lessons that our regional health care system learned from this experience.

Health systems need accurate demographic data to target their strategies and reach patients. As our health care system worked to identify eligible patients from within its population of 1.6 million patients, demographic information, including preferred language and race/ethnicity, was often found to be incomplete and inconsistent. To identify eligible patients and optimize the ability to reach them, the Information Systems team was able to integrate data from multiple electronic medical record systems and from population health management systems. The team also developed new electronic tools to invite patients by text and email to book vaccine appointments, which may prove useful for addressing future population health needs. The experience created new urgency and significance for efforts within the organization to ensure consistent and reliable demographic information for all of our patients. Stratified data regarding vaccination drove greater accountability in addressing health care disparities.

In the context of vaccine scarcity, it became clear that an institution’s approach to engaging patients can reinforce or reduce structural inequities.² Appointment scheduling relied heavily on digital outreach but did not use a patient portal strategy, given the known digital divide in portal uptake.³ Instead, the team sent personalized links using text messages in addition to email, which greatly increased success given the broader availability of smartphones. Nonetheless, a solely digital outreach strategy is bound to produce inequities—particularly with the added complexity of patient attestation.⁴

Computer-assisted outgoing phone messages were deployed in targeted languages, with live phone outreach to eligible patients in some highly impacted communities. This strategy began with outreach to all eligible patients associated with selected community health care centers, followed by all eligible patients in towns and neighborhoods within the health care system service area with the highest cumulative COVID-19 incidence, followed then, on a randomized cohort basis, by eligible patients across Massachusetts. The approach is now being expanded through place-based registration and vaccination in collaboration with local community stakeholders.⁵ Racial/ethnic, digital, and linguistic disparities in vaccination rates diminished in the areas that were intentionally prioritized and were more prominent in those we had not.

This vaccination effort has required complex communication with patients in a changing environment. Early results revealed that vaccine appointments were not being booked as effectively for patients with limited English—prompting reevaluation of the approach to these patients. It is a challenge to make messages clear, accessible, culturally meaningful, short, and multilingual, but these characteristics, combined with outreach from trusted messengers, help reduce disparities in vaccination.⁶ The campaign prompted our organization to identify a more streamlined workflow for translations. Thoughtful discussions about a more comprehensive system strategy regarding language access and literacy are now underway.

Organizing a vaccine campaign requires empowered collaboration among many leaders and content experts. Racial/ethnic and language disparities were powerfully relevant to decisions made about what to prioritize, where to place vaccination sites, and how to approach patient communications, yet Black and Latinx voices are underrepresented at multiple levels in our health care system. Successes and failures reflected in daily data highlighted the importance of including diverse staff perspectives and engaging community health leaders. This experience has strengthened the organization’s commitment to bring more diverse patient voices, community-based organizations, and diverse leadership into decision-making.

Over the summer of 2020, in the wake of the nation witnessing George Floyd’s death and widespread social unrest, the health care system chief executive officer explicitly articulated his support for advancing antiracism and health equity. A Diversity, Equity, and Inclusion Task Force assembled recommendations, incorporating input from listening sessions involving thousands of employees. This backdrop, along with the extreme health disparities observed during the COVID-19 pandemic, made the issue of health equity both more familiar and more urgent within our organization. In this context, diverse faculty and staff with different voices could speak up, be heard, and shape decision-making. For example, as the hospitals grappled with disparate uptake in vaccination, faculty conferences engaged new experts—medical assistants, nurses, and physicians of various backgrounds who shared powerful personal stories demonstrating that vaccine hesitancy and deliberation often occur in the context of ongoing experiences of racism and discrimination.⁷ Greater transparency and dialogue about these challenges will build a more inclusive and trusting culture.

Vaccinating the US population against COVID-19 will require an unprecedented ongoing public health campaign. Large health care systems are receiving crash courses in public health implementation, engaging with upstream structural determinants of health, and reassessing which problems require attention and whose input is valuable. Sustaining this positive momentum will rely on the shared understanding that when it comes to health, we are all in this together.

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Fernández L et al. JAMA Health Forum.

Corresponding Author: Leonor Fernández, MD, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA 02215 (lfernan1@bidmc.harvard.edu).

Conflict of Interest Disclosures: None reported.