Federally qualified health centers (FQHCs) care for low-income, racially and ethnically diverse, medically underserved populations disproportionately affected by COVID-19 and its associated health inequities.1 As trusted, accessible entities, FQHCs may mitigate further inequities by providing access to COVID-19 vaccination in communities most affected by COVID-19 that have often been least likely to have access to vaccines.2 The objectives of this study were to examine (1) COVID-19 vaccination administration rates at US FQHCs by race and ethnicity and (2) the racial and ethnic equity in vaccine receipt at FQHCs.
We conducted a retrospective cohort study using biweekly Health Resources & Services Administration Health Center COVID-19 Survey data from January 8 to July 2, 2021,3 of all FQHCs in the US. The data reported counts of vaccinations per FQHC by race and ethnicity with an average biweekly response rate of 81%. Patients self-identified as Hispanic, non-Hispanic American Indian and Alaska Native, non-Hispanic Asian, non-Hispanic Black, and non-Hispanic White (hereafter, American Indian and Alaska Native, Asian, Black, and White) individuals, or as individuals of other race (the other category includes the following races and ethnicities or multiple races: Hawaiian, Other Pacific Islander, and multiracial). The secondary data source was the 2019 Uniform Data System, which includes annual FQHC-level data reported by all FQHCs that capture information on patient, organizational, and performance characteristics of the FQHCs. We excluded FQHCs reporting data for less than 80% of all biweeks (n = 234), those located in US territories (n = 32), and those with fewer than 10 vaccinations per week (n = 22). Boston University’s Institutional Review Board deemed the study exempt and waived the requirement for informed consent because data were publicly available. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guideline.
The unit of analysis was the FQHC biweek. The outcomes of interest were (1) the cumulative percentage of initiated vaccines administered at FQHCs according to the recipient’s self-reported race or ethnicity and (2) the vaccination equity ratio of the number of observed cumulative, initiated vaccinations within a racial or ethnic group divided by the number of expected vaccinations within the group, where the expected number is based on the percentage of the FQHC population that belongs to that racial or ethnic group. We used linear probability models to estimate the association between calendar time (biweeks) and the 2 outcome measures, which were estimated separately for each self-reported racial group. All models applied population-size denominator weights and produced robust SEs clustered at the FQHC level.
P values were 2-tailed, and statistical significance was set at α = .05. Analyses were performed using Stata, version 17.0 (StataCorp, LLC).
Among 1096 FQHCs in the study sample that served 25.9 million patients (14.6 million [56%] female and 11.3 million [44%] male individuals; 181 090 [0.7%] American Indian and Alaska Native, 750 230 [2.9%] Asian, 4.5 million [17.5%] Black, 10.9 million [42.0%] Hispanic, and 9.0 million [34.9%] White, and 517 400 [2.0%] other race individuals), 5 606 679 initial vaccinations were administered to patients with a known race or ethnicity (race and ethnicity were unknown in 18.7% of patients who received COVID-19 vaccines) during the study period. The cumulative proportion of patients who received vaccines at FQHCs and self-identified as Black or Hispanic increased over time (Figure 1). By July 2, 2021, 61.4% of all cumulative, initiated vaccines administered at FQHCs were to patients who self-identified as American Indian or Alaska Native (30 852), Asian (618 024), Black (684 792), Hispanic (2 181 502), or other race and ethnicity (116 683; other included the following races and ethnicities or multiple races: Hawaiian, Other Pacific Islander, and multiracial). Of this proportion, less than 1% of vaccines were administered to American Indian or Alaska Native patients, 5.1% in Asian patients, 15.6% in Black patients, 38.5% in Hispanic patients, and 1.5% in patients of other or multiple races.
When accounting for the racial and ethnic composition of FQHC populations, American Indian or Alaska Native, Asian, and non-Hispanic White patients were initially more likely to receive the vaccine, whereas Black and race Hispanic patients were less likely to receive the vaccine (Figure 2). However, equity changed over time, and by April 16, 2021, all racial and ethnic groups experienced statistical equity (ratio ≥1.0) except for Black patients, who, by July 2, 2021, had an equity ratio of 0.94 (95% CI, 0.88-0.99).
Federally qualified health centers have provided critical access to COVID-19 vaccinations for patients from diverse racial and ethnic groups. As of July 2021, FQHCs administered 61.4% of their vaccines to patients of races and ethnicities other than White compared with 40% administered to racial and ethnic minority groups in the general US population.4 Vaccine administration at FQHCs was equitable for American Indian or Alaska Native, Asian, and Hispanic populations, but there were inequities for the Black population, although these inequities were smaller compared with those of the general US population.2 Initial inequities in vaccine administration in the Hispanic population were likely driven by state-dictated, age-based vaccine eligibility.
The present study suggests that governments should continue to sustainably fund and prioritize the use of FQHCs as major vaccine administration sites to improve vaccination equity through the Health Center COVID-19 Vaccine Program.5 This includes direct allocation of vaccines; use of FQHC-based mobile clinics, pop-up vaccination sites, and school-based sites; and targeted outreach for Black and Hispanic patients, including pediatric populations.6 Study limitations include the use of facility-level data without individual-level characteristics, such as age. In addition, equity ratios are sensitive to measurement error in smaller racial and ethnic populations, and missing racial and ethnic data may bias findings. Nonetheless, as policy makers work toward increasing COVID-19 vaccine equity, they must invest in and learn from FQHCs by meeting patients where they are geographically and continuing outreach by trusted community clinicians.
Accepted for Publication: November 11, 2021.
Published: January 10, 2022. doi:10.1001/jamanetworkopen.2021.42698
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Cole MB et al. JAMA Network Open.
Corresponding Author: Megan B. Cole, PhD, MPH, Department of Health Law, Policy, and Management, Boston University School of Public Health, 715 Albany St, Talbot Building, 240W, Boston, MA 02118 (mbcole@bu.edu).
Author Contributions: Dr Cole had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Cole, Raifman.
Acquisition, analysis, or interpretation of data: Cole, Assoumou, Kim.
Drafting of the manuscript: Cole, Raifman, Assoumou.
Critical revision of the manuscript for important intellectual content: Cole, Assoumou, Kim.
Statistical analysis: Cole.
Obtained funding: Cole.
Administrative, technical, or material support: All authors.
Supervision: Cole.
Conflict of Interest Disclosures: Dr Raifman reported receiving grants from the National Institutes of Health’s National Institute of Mental Health, Boston University Clinical & Translational Science Institute, and Robert Wood Johnson Foundation during the conduct of the study. Dr Assoumou reported receiving grants from the National Institutes of Health’s National Heart, Lung, and Blood Institute and National Institute on Drug Abuse and Boston University School of Medicine Department of Medicine Evans Career Investment and Evans Junior Faculty Merit Awards during the conduct of the study.
Funding/Support: Dr Cole reported receiving support for this work from the National Center for Advancing Translational Sciences, National Institutes of Health, through Boston University Clinical & Translational Science Institute (grant No. KL2TR001411) and the Peter Paul Professorship.
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.