Addressing Inequities in SARS-CoV-2 Vaccine Uptake: The Boston Medical Heart Well being System Expertise

Communities of colour have been disproportionately affected by the COVID-19 pandemic. In the USA, Black and Latino individuals are dying at roughly twice the speed of White individuals (1, 2) but stay much less prone to be vaccinated (3). Causes for decrease vaccination charges amongst Black individuals embrace distrust of the well being care system, which can have resulted from historic occasions, such because the involuntary experimentation within the U.S. authorities–funded examine of untreated syphilis on the Tuskegee Institute (4), in addition to newer destructive experiences with the well being care system (5, 6).

Medical facilities can play an essential position in addressing vaccine uptake disparities. Boston Medical Heart (BMC) leveraged its established partnerships within the surrounding communities to construct confidence in SARS-CoV-2 vaccines and improve entry to vaccination in a few of the hardest-hit communities (7). This mannequin may function a blueprint for different medical facilities. On this article, we describe the technique BMC utilized in its vaccination program and current outcomes, challenges, alternatives, and classes realized from this system.


The BMC Well being System is the biggest safety-net well being system in New England and an essential accountable care group for Massachusetts Medicaid (7). As a safety-net hospital, BMC cares for sufferers no matter their capability to pay or their immigration standing (8). BMC strives to ship high quality well being companies via an fairness lens and facilities its organizational tradition round group engagement and outreach. Its surrounding neighborhood and catchment space are marked by hanging well being care inequities. As a metropolis by which 95% of wealth is concentrated amongst White households, Boston claims each the best per-capita Nationwide Institutes of Well being (NIH) funding (9) and the biggest racial gaps in well being outcomes (10, 11) in the USA. In early 2020, greater than three quarters of individuals with COVID-19 admitted to BMC recognized as folks of colour (8). Boston residents of colour have continued to be disproportionately affected throughout subsequent surges, with Black and Latino individuals contaminated at roughly 1.5 instances the speed of White individuals (12, 13).

BMC COVID Response Program Description

The BMC COVID Response Program was knowledgeable by the conceptual framework for group engagement in interventions that was developed by Brunton and colleagues (14). This framework synthesizes the advanced and diversified constructs vital for profitable engagement of communities in public well being interventions. Desk 1 describes the appliance of the framework to the BMC vaccination program.

Desk 1. Software of the Conceptual Framework Guiding Neighborhood Engagement in Intervention Dimensions to the BMC COVID Response Program

Table 1.

BMC was nicely positioned to extend equitable entry to vaccination within the hardest-hit communities by offering entry to vaccines at community-based websites, at cell occasions, and on the BMC medical campus (Determine). Key features of BMC’s group engagement efforts included established partnerships with group leaders and group well being facilities (CHCs), in addition to the Commonwealth of Massachusetts, the Massachusetts Division of Public Well being, and the Boston Public Well being Fee. Different key elements included a communication marketing campaign that includes trusted messengers and a deal with well being fairness. Along with the aforementioned mediators, we used sturdy analytics to determine “vaccine deserts” for strategically positioned cell vaccination websites. Key programmatic parts are detailed within the following sections.

Determine. Key parts of BMC’s program to offer equitable entry to vaccination within the hardest-hit communities.

The purpose of the BMC vaccination program was to offer equitable entry to vaccination in a few of the hardest-hit communities. BMC opened community-based vaccination websites, applied cell vaccination occasions, and supplied vaccination in its outpatient vaccination clinics. Key mediators included group engagement, and essential course of measures had been a data-driven method and using an fairness lens whereas leveraging established processes and infrastructure. BMC = Boston Medical Heart; CHC = group well being heart; SVI = Social Vulnerability Index.

Partnerships and Approaches to Convey Vaccines to the Neighborhood

BMC’s historical past of group engagement facilitated an method geared toward bringing vaccines to the group as an alternative of anticipating folks to return to the medical heart. When provide was restricted, BMC ensured the supply of vaccines in communities with the best Social Vulnerability Index (SVI) rating. The SVI makes use of 15 measures of social vulnerability to determine communities which might be most in danger for poor well being outcomes (15). Deciles of the SVI vary from 0 (lowest vulnerability) to 10 (highest vulnerability). At a time when many mass vaccination websites had been situated in suburban areas with restricted entry to public transit, BMC opened websites in extremely susceptible city areas, together with 7 websites in church buildings and group facilities (Appendix Determine 1). Many places had been co-branded with Boston-area CHCs, and BMC supplied operational assist to run the amenities. As trusted and acknowledged manufacturers which might be strongly conscious of group wants, CHCs helped to tailor messaging, and so they additionally vaccinated sufferers at their facilities and directed sufferers to group vaccination websites. The partnership between BMC and CHCs was additionally vital when vaccine provide turned restricted, as CHCs contributed the availability they’d acquired from the Well being Sources and Companies Administration (HRSA) (11).

Appendix Determine 1. Vaccination websites prioritized in response to SVI.

This determine reveals the places of BMC-affiliated vaccination websites. The colours on the map signify estimates of the SVI in numerous geographic places within the larger Boston space. Excessive SVI scores correspond to increased danger for poor well being outcomes. BMC used SVI scores to prioritize the location of vaccination websites on the following places: Twelfth Baptist Church, Roxbury; 17 Corinth Road, Roslindale; St. Nectarios Greek Orthodox Church, Roslindale; Menino YMCA, Hyde Park; Morning Star Baptist Church, Mattapan; Codman Sq., Dorchester; and the BMC medical campus group vaccination web site (85 East Harmony Road). BMC = Boston Medical Heart; SVI = Social Vulnerability Index.

Whereas the preliminary section targeted on group vaccination websites, the later interval beginning in June 2021 engaged unreached folks. BMC’s current infrastructure allowed for a strong analytical course of that recognized vaccine deserts to tell placement of cell vaccination websites the place individuals in excessive SVI classes (deciles 8 to 10) lived. This section additionally concerned collaboration with state and native well being departments to develop a complete vaccination plan. As the speed of weekly vaccinations decreased, the technique pivoted from giant group websites to embedding BMC groups in communities the place the unvaccinated inhabitants was highest. Smaller cell vaccination occasions occurred in faith-based organizations, faculties, local people occasions, grocery shops, and residence complexes. For example, collaboration with the management of Boston Public Colleges, together with superintendents and principals, improved entry to vaccines locally. Every cell occasion occurred in collaboration with a group associate and concerned a minimum of 2 occasions separated by 21 or 28 days for administration of the primary and second vaccine doses. If an individual obtained their first dose on the second occasion at a specific location, they got an appointment for his or her second dose both on the BMC medical campus or at one other upcoming cell vaccination session. Occasions had been marketed utilizing flyers, social media, print, radio, and tv, with some appearances that includes authorities officers such because the governor, mayors, state senators, metropolis councilors, and members of Congress. Details about occasions was additionally shared via the BMC web site. Efforts additionally included door-to-door canvassing and home-based vaccination (16, 17). This method diminished perceptions of alternative value, corresponding to the necessity for transportation and time without work from work, and created areas for dialogue with skilled well being care staff. Lastly, to complement efforts locally, BMC secured vaccination appointments on the medical campus for older adults and individuals with underlying medical situations who had been already scheduled for medical visits.

Operational Concerns, Deal with Fairness, and Communication Technique

BMC supplied operational assist to group websites. This system capitalized on established processes and infrastructure, targeted on data-driven resolution making, and used an fairness lens. Neighborhood-based vaccination efforts required a longtime logistical and operational infrastructure that BMC may present as a big well being system. Coordination occurred with numerous departments, together with not solely pharmacy and nursing but in addition provide chain, data know-how, authorized, finance, safety, medical workflows, and an infection prevention. As well as, BMC performed month-to-month affected person surveys for views on vaccination, which knowledgeable the general technique. For instance, when surveys early within the pandemic confirmed that Black sufferers had been extra involved about doable adversarial results, the medical heart labored with collaborators and its various group to adapt its communications to handle this concern.

As well as, BMC’s long-standing equity-focused lens underpinned this system’s implementation, as mirrored by a dedication to addressing inequities by creating partnerships within the surrounding group and management positions particularly tasked with this purpose, in addition to recruitment and retention of a various workforce that mirrors the affected person inhabitants and the encompassing group. Earlier than the pandemic, BMC established relationships inside the group. Senior management members, together with the Vice Presidents of Neighborhood Engagement and Mission, labored to develop long-term group partnerships and deal with structural elements affecting the group’s well being. BMC additionally prioritized the recruitment, improvement, and retention of a various workforce given rising proof of improved outcomes. For instance, a examine confirmed that race concordance was related to improved adherence to drugs amongst Black sufferers and language concordance improved outcomes amongst Spanish-speaking sufferers (18).

BMC’s vaccination program was supported by a communication initiative that includes a various group of trusted messengers. Well being professionals and group leaders participated in dialogues utilizing social media, print, tv, and radio (Appendix Desk 1). Well being professionals disseminated details about the science of vaccines and in addition shared their private causes for getting vaccinated. BMC additionally supplied coaching to all clinicians on helpful strategies to extend vaccine acceptance amongst sufferers.

Appendix Desk 1. Neighborhood Conversations to Enhance Vaccine Confidence

Appendix Table 1.
Analysis Strategies

We analyzed BMC programmatic knowledge from 13 December 2020 to twenty-eight November 2021 to know the consequences of the vaccination program on key implementation science domains, significantly adoption and attain. To explain program adoption by group companions, we current numbers of group vaccination websites and cell vaccine occasions in addition to data on staffing, together with annual full-time equivalents (FTEs) and hours of operation. To summarize attain, we current descriptive statistics, together with the variety of vaccinations administered and self-reported race/ethnicity of vaccine recipients. Moreover, we characterize the distribution of vaccinations from our microtargeting occasions stratified by race and SVI decile. We additionally present outcomes from BMC affected person surveys that knowledgeable the communication technique. All knowledge had been analyzed in Excel 2018 (Microsoft) and R (R Basis for Statistical Computing). The Boston College Medical Campus Institutional Overview Board accepted this examine.


In the course of the examine interval, BMC established 7 community-based vaccination clinics (Appendix Determine 1) and performed 99 particular person cell vaccination occasions along with offering vaccination alternatives on the medical campus. Most websites had been open 6 days per week and had been staffed for a median of 8 hours per day (Desk 2). Initially, vaccination slots had been accessible by appointment, however extra walk-in choices turned accessible as provide improved. Neighborhood vaccination websites in church buildings and group facilities had been developed to accommodate giant turnouts. Cellular websites included a workers of roughly 12 annual FTEs, with group well being staff, nurses, a supervisor, a director, and an occasion coordinator. In distinction, group vaccination websites had been bigger operations, fluctuating between 20 and 100 annual FTEs relying on native wants (Desk 2).

Desk 2. Website Traits at BMC-Affiliated Vaccination Amenities

Table 2.

The 9 core Boston neighborhoods served by BMC embrace roughly 400 000 folks, and as of 28 November 2021, roughly 109 938 first doses had been administered (Desk 3; Appendix Desk 2). Vaccinations peaked at 17 730 per week in late April 2021. After vaccination charges decreased by 77% between Could and June 2021, the technique advanced from bigger group websites to smaller cell occasions. Roughly 72% of vaccines administered at cell occasions got to individuals approached and registered on the day of the occasion, with 89% being first doses.

Desk 3. Traits of Individuals Receiving First Doses of Vaccines at BMC-Affiliated Amenities (n = 109 938)

Table 3.

Appendix Desk 2. First and Second Doses Administered at BMC-Affiliated Websites Between 13 December 2020 and 28 November 2021

Appendix Table 2.

Neighborhood vaccination websites reached the biggest proportion of individuals, with 94 703 (86%) first doses (Desk 3). With 2466 (2%) first doses, cell websites vaccinated the fewest individuals and led to the best proportion of discarded vaccines however reached a extra various and youthful group of Boston residents. For instance, the median age of individuals vaccinated at these occasions was 19 years, in contrast with 44 years at BMC’s outpatient ambulatory clinics. The imply SVI decile for individuals vaccinated at cell occasions was additionally increased than estimates from different amenities. As well as, 61% of individuals vaccinated at cell websites recognized as Black/African American or Latino (Appendix Determine 2). By way of value, BMC spent roughly $12.1 million on the vaccination program, of which $10.4 million was coated by insurance coverage corporations and HRSA funds. Given limitations of the reporting methodology, we weren’t capable of disaggregate prices for every particular person program, however by November 2021, BMC secured grants totaling roughly $300 000 particularly targeted on the cell vaccination program.

Appendix Determine 2. Racial/ethnic and SVI composition of individuals vaccinated at cell websites, November 2021.

Nearly all of folks vaccinated at cell websites self-identified as folks of colour, with 36% figuring out as Black, 25% figuring out as Latino, and a couple of% figuring out as Asian. Individuals vaccinated at cell websites additionally lived in places with the best SVIs. Excessive SVI scores correspond to increased danger for poor well being outcomes. SVI = Social Vulnerability Index.

Vaccine-related communication efforts had been knowledgeable by affected person surveys (Appendix Desk 3). For instance, survey knowledge in February 2021 revealed {that a} majority of respondents (60%), particularly Black and Latino individuals, had been most involved about adversarial results. The communications group used these knowledge to switch its messaging to incorporate useful details about what to anticipate by way of adversarial results. The group additionally shared extra assets for individuals who wanted extra data.

Appendix Desk 3. Sufferers’ Responses to a Survey Query About Their Most important Issues Associated to SARS-CoV-2 Vaccines, February 2021 (n = 793)

Appendix Table 3.

BMC improved entry to vaccines via community-based clinics, cell websites, and vaccination on its medical campus. Between 13 December 2020 and 28 November 2021, BMC administered greater than 100 000 first doses and reached folks dwelling in areas with the best SVIs. Though cell websites recorded the fewest vaccinations in contrast with different places, these occasions reached greater than 2000 folks and had been vital in offering entry to youthful individuals in places with the best SVIs. Latest knowledge present that vaccination amongst youthful individuals trails vaccination amongst older adults, and cell websites present a possible resolution to handle this hole. Our outcomes present that by deliberately specializing in growing entry to vaccines in communities which have been disproportionately affected by the pandemic and transferring past often-secluded bubbles, medical facilities may deal with disparities in outcomes by creating group partnerships to achieve well being fairness objectives in traditionally disinvested communities.

Distrust of well being organizations and pharmaceutical corporations was an essential barrier. Many individuals expressed skepticism about vaccines usually and SARS-CoV-2 vaccines particularly. Moreover, packages contemplating related efforts must be conscious that sturdy logistical and operational infrastructures are vital. Monetary forecasting was additionally difficult. It was not clear on the outset that this system could be financially self-sustaining. BMC used HRSA funds, reimbursement from insurance coverage corporations, and grants to cowl the operation. By March 2022, BMC acquired grants totaling roughly $1 million to particularly cowl bills associated to cell vaccination efforts, and as of August 2021, the cell vaccination group was totally funded via grants.

The 4 most essential classes realized from this system had been as follows. First, to handle disparities, efforts ought to deal with reaching folks the place they’re as an alternative of anticipating them to return to the medical heart. Second, BMC’s outcomes exhibit the significance of management and a workforce dedicated to well being fairness and group engagement. Present management, together with the Vice President of Neighborhood Engagement, enabled the fast improvement of impactful packages that served as the muse for future health-related initiatives. This consists of BMC’s Well being Fairness Accelerator, which focuses on eliminating race-based fairness gaps, such because the discovering that Black girls are 3 instances extra prone to die of pregnancy-related causes than White girls (19, 20). Third, an adaptable method that shortly pivots relying on altering situations can also be key. For instance, this system advanced from vaccinating in church buildings and group facilities to a microtargeted method utilizing SVI and cell occasions. Lastly, constructing vaccine confidence takes time. It’d take a number of encounters for folks to resolve to get vaccinated, and our expertise reveals that vaccine deliberation shouldn’t be everlasting. With entry to dependable data, many individuals who initially waver may resolve to get vaccinated.

Different U.S. packages have additionally targeted on participating the group to extend entry to vaccination. For instance, the Vaccine Collaborative for Black Communities in Philadelphia partnered with the group to handle structural boundaries, corresponding to the placement of vaccination clinics (21). As well as, a program in San Francisco labored with group leaders to enhance entry to vaccination within the hardest-hit communities, and a program led by the College of North Carolina Well being System engaged the group to enhance entry to care (22, 23). Our program used the same group engagement method whereas additionally emphasizing a partnership with CHCs and state and native well being departments.

Our examine is proscribed by our use of programmatic knowledge. As well as, our findings are from a well being system in an city setting with entry to well being care assets, which can restrict generalizability. Additionally, given BMC’s mission as a safety-net well being system, emphasis was positioned on investing in vaccination as a purpose to enhance the well being of the group, no matter sufferers’ capability to pay.

In conclusion, the BMC expertise underscores that an intentional group partnership may assist shut the hole in vaccination charges. BMC is now leveraging this infrastructure to handle different essential health-related points. As well as, the establishment is now a part of the NIH’s Neighborhood Engagement Alliance, which goals to extend vaccine confidence and engagement in analysis (24).


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