During the p
ast year, the COVID-19 pandemic has highlighted health inequality created by social determinants of health (SDoH) in the United States. SDoH include all aspects of the living environment, social support, safety, well-being, and resource availability, directly or indirectly influencing physical health outcomes. Consideration of SDoH is critical for successful comprehensive COVID-19 vaccine rollout. This post describes how economic, informational, and geographic differences could make it difficult for vulnerable populations to receive vaccinations. We pay particular attention to vaccine distribution in rural areas.
Vaccine Delivery is complex
Delivering mRNA-based COVID-19 vaccines (Pfizer and Moderna) to the public is logistically complex. Both vaccines must be transported and stored in a frozen state until they are ready for use to maintain 95% effectiveness; the Pfizer vaccine requires extreme cooling –70 degrees Celsius. Patients then receive two vaccine doses during separate visits to their care provider. Detailed tracking of vaccinations is important at the individual patient and at the population levels.
The Centers for Disease Control (CDC) [pdf] identifies critical populations at higher risk for catching or spreading COVID-19, including people: from racial and ethnic minorities, tribal communities, incarcerated or detained in prisons, and experiencing homelessness. Similarly, people living in rural communities, with disabilities, and who have limited or no health insurance are identified as critical populations because their access to routine vaccinations is limited. Vaccinating people in these groups will protect individuals and their communities, particularly people unable to be vaccinated due to illness or age. Social, physical, informational, and economic accessibility is required to vaccinate members of critical populations and achieve widespread vaccination coverage to reduce COVID-19 morbidity and mortality.
Information Barriers
Informational and social barriers may complicate vaccine delivery for certain vulnerable groups. The COVID-19 vaccine supply is limited in the immediate future as manufacturing begins. Frontline healthcare workers and people living in long-term care facilities will generally be vaccinated first [pdf]. Members of critical populations will need to know when and where they can be vaccinated. States, health departments, and providers may use virtual communication to share vaccination opportunities, which may create additional barriers. Rural residents have reported lower access to digital technology compared to non-rural populations; in 2019, only 63% of rural Americans reported having a broadband internet connection at home.
Negative personal and cultural experiences with the US healthcare system could also impede widespread vaccine delivery. Nearly 70% of Black Americans report knowing someone who required hospitalization or died from COVID-19 compared to 54% of all Americans. Despite this experience, a poll by the Pew Research Center conducted in November 2020 found only 42% of black adults thought they would get a COVID-19 vaccine compared to approximately 60% of white and Hispanic adults and over 80% of Asian adults. Vaccine hesitancy among Black Americans may be due to past personal or cultural experiences of exploitation or discrimination by healthcare systems. Collaborations with existing social support structures and community leaders to deliver credible vaccination information could help reduce vaccine hesitancy. However, usual community-based preventative care sources such as schools, churches, and non-profit groups may not be operating normally due to COVID-19 restrictions.
Supply-side Barriers
Healthcare is more difficult to get in rural areas because of provider deficits, dwindling care locations, and transportation challenges. Over 60% of primary care Designated Health Professional Shortage Areas are rural. In 2017 an estimated 14 to 17 thousand additional physicians were needed to care for underserved populations in non-metropolitan areas. Rural areas with insufficient healthcare professionals may struggle to meet vaccination targets because medical staff must treat patients.
Beyond clinician shortages, 134 rural hospitals have closed since 2010. The CDC vaccination report [pdf] identified Rural Health Clinics and critical access hospitals as key in vaccinating critical populations, partially because of storage and distribution needs. Typical community pharmacies do not have the necessary cold storage capacity. However, many hospitals, large-scale healthcare facilities, and academic research centers commonly have the required specialty cold-storage equipment. For this reason, the Moderna vaccine or other candidates may be better suited for distribution to rural areas without a local hospital.
Transportation Barriers
Transportation barriers may also be more common in rural areas. Residents of rural areas travel longer distances to get healthcare, increasing travel time and cost. Research also shows that people from racial and ethnic minorities and people with chronic conditions experience more transportation challenges when seeking healthcare. Resources such as travel cost reimbursement and paid leave from work may help people in these groups. Rural communities often have limited public transportation options. This can make it difficult for people who cannot drive to reach their healthcare provider. Elderly Americans, people with disabilities, and people living in low-income households are more likely to depend on public transportation where it is available. A safe and reliable ride to and from vaccination appointments may be the most helpful intervention for these groups. Patients need two carefully timed doses of the vaccine, amplifying transportation barriers.
Economic Barriers
The uninsured population has increased each year since 2017 and in 2019 28.9 million Americans did not have insurance. New federal legislation requires providers to deliver government-purchased vaccines without charging patients. Communication of these recent policy changes to uninsured and underinsured patients may help eliminate any perceived economic barriers to vaccination after these groups experienced surprise billing for COVID-19 treatment. Even with direct costs covered, the indirect costs of vaccination remain for vulnerable groups. The Pfizer and Moderna vaccines require two doses received in a three-week period to reach 90%+ protection against infection. Working adults will need to take time off to receive the vaccine and travel costs remain.
Next Steps
The COVID-19 pandemic emphasizes the impact of social and economic structures on health outcomes and care access in the US. Policymakers must consider addressing the physical, economic, and social obstacles to reach vulnerable and high-risk populations (see an earlier post about the equitable distribution of resources). As local and state leaders formulate vaccine delivery plans, community leaders, businesses, and organizations are vital to community-centered solutions. For example, Lyft, the ride-sharing platform, recently announced a collaboration with Anthem, a major health insurer, to provide rides to vaccination sites for individuals without personal transportation. With thoughtful direction and innovation by political, healthcare, and community leaders, more solutions to facilitate an equitable and comprehensive COVID-19 vaccination campaign may come to fruition. Meeting people’s present needs in critical populations is vital, but ultimately, we should aim to close gaps in SDoH and improve health outcomes overall.
Erin Dobbins
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