Innovative Strategies to Make COVID-19 Vaccinations More Accessible Across U.S.

When Shanon Smith, a New Bedford, Mass., epidemiologist, saw there were 10 extra vaccine doses near the end of a health department vaccination clinic, she took to the streets. 

“I put on a vest, grabbed a clipboard, and started knocking on doors and even stopped cars encouraging people to get vaccinated,” said Smith, who works at the city health department through a collaboration with Partners In Health’s U.S Public Health Accompaniment Unit (USPHAU).  

Eventually, with help from residents who pointed out neighbors’ houses and colleagues who called on friends, Smith accompanied enough people over to the clinic for vaccinations. A few even took selfies at the station the department set up to make the experience more fun. It was, Smith said, a small victory: “We did not want those doses to go to waste.” 

Across the United States, public health workers and community leaders, businesses owners and President Joseph Biden are rolling out innovative strategies to gain the attention of people who remain unvaccinated -- and nudge them to roll up their sleeves for the shot. 

A Race Against Time 

From barbershop conversations in Alabama to guest appearances at cupcake-baking classes in Chicago, there is a race-against-time effort underway to increase national vaccine rates and stop the spread of disease. Some approaches might seem a little headline-grabbing, like the Howlin’ Wolf bar in New Orleans promoting its “shot for a shot” night with free drinks for the vaccinated, or Washington State’s, “joints for jabs” with weed as a lure, or Krispy Kreme’s free donuts with a vaccination card. 

But the motives behind these efforts are deadly serious. COVID-19 has killed 600,000 people in the U.S., and while death rates nationally have dropped since their peak, it’s the remaining unvaccinated people who are getting sick and dying. The only path to “normalcy,” experts agree, is by vaccinating most of the public.  

Indeed, the current moment calls for urgent action, and that means getting creative, said Dr. Bram Wispelwey, senior technical lead in charge of clinical operations at the USPHAU. With fewer than 50% of people in the U.S. fully vaccinated, and inequities plaguing the health system in which Black and Hispanic Americans’ vaccination rates are still lagging in almost every state, there is no time to waste. “We're at a crucial moment where cases are lower than they've been in many months and continue to drop,” he said. “So, there's an opportunity here.”   

The USPHAU, collaborating with partners around the country, is seizing that opportunity by helping to support hyper-local efforts aimed at populations facing the greatest barriers to vaccination. 

The Brother’s Chat 

In Montgomery, Ala., where only 35% of residents have had their first shot, Pastor Richard Williams of the Metropolitan United Methodist Church launched the first “Brother’s Chat Round Table Discussion,” at the Legacy Barber and Style shop on a recent Monday night. Six men participated, all of them Black, including the barbershop owner, a local mural artist, two business leaders, and a doctor, who joined via Zoom. For nearly an hour, they talked with the pastor about the pandemic’s toll on their families and community, how long-standing racial and systematic inequities played out over the past year, and the many reasons why some people don’t want the vaccine. “It’s difficult to be able to receive help from a system that doesn’t acknowledge its issues against your existence as a Black man,” said Williams, who also partners with USPHAU on several other vaccine initiatives. 

“I get the point about being hesitant as Black folks and not trusting the government,” said Dr. Ian Moore, attending on Zoom wearing a sweatshirt from his alma mater, Tuskegee University. “But you can’t do stuff like that against your own best interest, and saving your own life, protecting yourself against something you know is killing folks, and it’s killing us disproportionately compared to our white counterparts.” 

By the end of the gathering, two participants who’d been undecided going into the event agreed to get vaccinated.  

Pastor Williams isn’t the only leader thinking about barbershops and vaccines. President Biden recently announced a “month of action” -- including a wide range of activities meant to drive vaccine uptake so that 70% of the population gets at least one shot by July 4. These actions range from “Shots at the Shop,” a vaccination and outreach effort aimed at Black-owned barbershops and beauty salons across the country, to free childcare for parents getting vaccinated and extended evening pharmacy hours to help workers.  

Cupcakes and COVID-19 Shots 

The USPHAU-supported Chicagoland Vaccine Partnership (CVP) was created to combat extreme inequity in the response to COVID-19. For example, while 59% of Chicagoans are Black or Latinx, in the first week that vaccines were available “only 18% of COVID-19 vaccines went to Black or Latinx Chicagoans,” according to city data. That stark gap has closed, but not completely. As of June 13, the official breakdown of fully vaccinated residents was 37% Latinx, 30% Black, 53.9% white, and 52.6% Asian. 

The CVP, a community coalition of more than 135 members--including health, government, philanthropy, and neighborhood leaders, has been working to close those racial and health gaps, ensure access and equity in COVID-19 vaccination distribution, and strengthen the Chicagoland area’s public health infrastructure for the future. When it became clear that the “messengers” delivering vaccine information would be critical to uptake, the Vaccine Partnership created a Speakers Bureau of trained public health professionals who could effectively address a wide range of audiences and community concerns. To date, the speakers have facilitated more than 30 events with over 630 people.  

No venue is considered too small.  

Recently, USPHAU’s Dr. Pranali Koradia, who specializes in emergency medicine, appeared via Zoom at a children’s cupcake-baking class hosted by the community-based organization, It Could be Your Kid, and led by local cook Dominique Lyric. As the young bakers awaited their cupcakes in the oven, Koradia shared vaccine information and answered questions for both the kids and their parents. 

To further engage people in vaccination, Malcolm X City College and the Chicago Department of Public Health, in partnership with the CVP, are also offering a free online training that helps community members speak to their neighbors about vaccination. After taking the course, newly minted Vaccine Ambassadors can earn credits at City College and continue to receive support to bolster their skills and public health training, through an online learning community managed by USPHAU. So far, more than 2,400 people have signed up for the course. 

Call the Aunties 

The USPHAU’s work extends to Toronto, a city with the largest Indigenous population in Canada at over 80,000. The team is partnered with a nonprofit, Seventh Generation Midwives, to support their Call Auntie program, which started as a hotline at the beginning of the pandemic. These urban Indigenous aunties became a COVID-19 information resource for their community, providing culturally safe navigation of public health guidance and problem-solving that is not written for the reality of Indigenous families, 87% of whom live below the poverty line. To date, there have been about 500 calls to the hotline. This partnership expanded, establishing Auduzhe Mino Nesewinong, an Indigenous-specific testing and vaccine clinic providing an integrated public health response to COVID-19. The Aunties continue to provide support, such as food assistance, Indigenous-specific case investigation and contact tracing, and direct support for families who are self-isolating or COVID-19 positive, said Cheryllee Bourgeois, a midwife with Seventh Generation. 

“Using kinship models to center self-determination and extended family well-being, Indigenous people in Toronto always have an Auntie they can call,” she said. 

An All-Hands-on-Deck Moment 

When it comes to vaccination efforts in Pima County, Ariz., the health department is taking an all-hands-on-deck approach, launching events wherever people congregate. There are pop-up clinics at dog racing facilities and casinos, the mall, and even the zoo. To leverage the energy (and social media savvy) of young people, the health department hosted a “Vax Truth Challenge” in which 16- to 24-year-olds submitted videos addressing various vaccine themes for a grand prize of a Nintendo Switch or a Chromebook.  

The winning video, by 23-year-old Amelia Jimenez, was inspired by the TikTok trend juxtaposing images of people getting vaccinated with clips of their favorite memories. This, Jimenez said, “was a representation of that hopeful state of mind that life will one day return back to normal again.” She said the video, which also speaks to the dangers of misinformation shared on social media, has received a mixed response.  

“Going into this competition, I knew that some people wouldn’t like my video,” she said. “But I didn't let that stop me. If I could just impact one person, and that one person decided to get vaccinated because they saw my video, then I have succeeded. No step is too small towards change.” 

Pima County isn’t just trying to appeal to TikTok users. The health department has started offering long-term care recipients the option of requesting a “vaccine house call,” with vaccinators arriving right at the door. 

Similarly, in Newark, N.J., USPHAU has worked with the health department and its partners to send pop-up vaccination sites to homeless shelters and senior housing buildings, communities at particularly high risk for COVID-19.

The Ethics of Incentives 

The range of incentives used by USPHAU and partners is intentionally modest.  

Large cash incentives -- like the $5 million prize lotteries in states such as New York and New Mexico -- could set a dangerous precedent, according to a recent article in The New England Journal of Medicine. “It’s important to consider that booster shots will probably be required down the line,” the authors write. “Offering incentives now may set a costly and undesirable precedent, causing people to expect — and wait for — an incentive the next time around.” 

Ric LaGrange, a vice president at the behavioral science company ideas42, one of USPHAU’s partners on vaccine messaging, said: “Incentives should not be so large as to create coercive influence on an individual's decisions. Free doughnuts are one thing but giving out $100 might cross the line into coercive influence, particularly among low-income populations.” 

So, in Montgomery, where USPHAU is working with Mayor Steven Reed and other partners and leaders on a community-inspired vaccination campaign called “Level Up,” the team recently hosted a food drive and vaccination clinic where people were offered $50 gift cards once they received their first shot. At this and similar events around the city, a total of 200 people were handed a strategically worded ticket which said: “Your second shot is reserved for you.”  

Grace Lesser, USPHAU’s senior lead in Montgomery, said this language was used for a reason. Researchers at the University of Pennsylvania found that telling people a vaccination was “reserved” for them boosted adherence. (The Penn study focused on flu shots, but researchers said the findings held true for vaccinations in general, including for COVID-19.) The idea, researchers suggest, is that telling a person that a particular dose “belongs to them” underscores the notion that if they don’t claim it, they will be losing something important.  

LaGrange added that “vaccine hesitation is complex,” and sometimes seemingly small considerations can shore up the goal of greater vaccination uptake. In Montgomery, for example, “we leveraged behavioral science principles to support integrating a vaccination clinic with a local church’s regularly scheduled food pantry/clinic,” he said. “Appointments were not required, trusted messengers in the community spread the word, and volunteers distributed hot breakfast and dry goods and discussed concerns with visitors. These may sound like small features but reducing potential hassles (like the need to make an appointment or travel to an unfamiliar location) and building trust through one-to-one interactions impact decisions.”  

At the end of the day, each of these initiatives hinges on local connections and trusted relationships built over time.

“There is no one-size-fits-all generic plan that will succeed in addressing all vaccine access issues,” Wispelwey, of USPHAU, said.  “Eligibility for vaccination is not access, and access looks different everywhere.”  

“We are at a stage where the inequity in COVID-19 risk may further increase along the fault lines of poverty, race, and ethnicity unless we can find ways to successfully reach unvaccinated teens and adults in the communities that are both hardest hit and suffer the most limited vaccine access.”