[Download] The digital solution framework for achieving health equity
COVID-19 starkly highlighted new and existing health inequities in our country. Dr. Aditi Mallick, the Outgoing Director of North Carolina’s COVID-19 Response Command Center, worked at the crossroads of COVID-19 and health equity, managing the state’s rollout with a focus on providing resources and access equitably to the state’s residents. We sat down with Dr. Mallick to learn more about her work, how she reduced health inequities during COVID-19, and how leaders can improve healthcare for low-income communities and communities of color in the future.
I was responsible for overseeing multiple aspects of North Carolina’s COVID-19 response: integrating epidemiology and emerging trends to determine when, where, and how the state built, bought, and deployed resources for vaccination, testing, case investigation, and contact tracing. All of these efforts were done with the overarching goal of being as equitable and efficient as possible in our response.
I spent much of my time dealing with the most immediate, pressing issues of any given day or week, whether it was outbreaks on university campuses or surge testing in the hardest hit counties. During my tenure, I led the deployment of over 3 million rapid antigen tests, spearheaded vaccine allocation and distribution, and managed our FEMA vaccination clinic hub and spoke sites. I also worked with my colleagues to lay the foundation for the state’s response to future public health emergencies.
When we looked at the race and ethnicity of the initial wave of people being vaccinated in North Carolina, we saw that those being vaccinated didn’t reflect the demographics of the local communities, even when we accounted for who was eligible for vaccines at the time (nursing home residents and staff, healthcare workers, people over age 65). Even in areas with a high proportion of Black, Latinx, Asian, American Indian, or Alaskan Native populations, the majority of people getting vaccinated were non-Hispanic White. Time and again, we were hearing that low-income people and people from communities of color could not navigate the system. We came to understand that they were asking questions like: Am I eligible? Who in my area is giving vaccines? How do I make an appointment to get one? We also heard anecdotes from our community partners that immigrants and refugees were hesitant to get vaccinated out of fear that they would be asked to show some ID or documentation that would put themselves or their families at risk.
The four main areas we focused on to address these inequities were designed to reduce misinformation and barriers to care in order to increase vaccination rates among communities of color and low-income communities.
The first thing we did was to create and communicate clear, reliable, and fact-based information about the vaccines, including how they were developed, how they work, how they had been studied in diverse populations, and what their safety profiles were. Our NCDHHS team created “Vaccine 101” materials and a dedicated website and used community outreach, print and radio, digital marketing, social media, buck slips, door hangers, and more to disseminate vaccine information as widely as possible throughout the state.
The next thing we focused on was forging partnerships with community leaders and organizations because we knew that these partnerships could and would underpin our information campaigns. For many BIPOC communities, the state and federal government is not a trusted source of information. Instead, communities look to community health workers, local federations, and churches, among others, for guidance.
When we were launching the state FEMA site, for example, we engaged 175 community organizations to promote the site and assist in scheduling and outreach. These organizations included the Hispanic Federation, Black Votes Matter, HBCUs, Black fraternities and sororities, county school boards, school- and community-based athletic organizations, faith-based organizations, AARP, and more. This initial round of engagement formed the basis for NCDHHS’ Healthier Together: Health Equity Action Network, a public-private partnership that included grants to community-based organizations to help increase vaccinations among BIPOC and other historically marginalized populations (HMPs) across the state.
While we focused on ensuring communities had accurate, trusted information about the vaccine, we also turned our attention to the question of whether community members had a place in their neighborhood for them to receive the shot. We used data to create a map of vaccination rates and social vulnerability index (SVI), made that mapping publicly available, and tracked it regularly to ensure we had vaccination sites set up equitably across the state. From late April to late May 2021, vaccination rates had increased by 50% in 89 of the state’s most underserved counties, defined as those with high SVI and low vaccination rates. Underpinning all of this was a requirement for all vaccine providers to record the race and ethnicity of every person receiving a vaccine to measure our performance against equity goals; North Carolina was one of the first states in the country to do this, leading the national charge for data on vaccine equity.
In addition to setting up vaccination sites in underserved communities and measuring our performance, we wanted to remove any remaining barriers to access, so we investigated transportation needs, physical accessibility, language spoken, and appointment access.
To reach HMP communities where they live and work, we held mobile vaccination clinics at community centers, churches, public parks, and HBCU campuses in high-SVI areas, all near major transportation lines, and in some cases, rerouted local bus lines and added shuttles to make the sites more accessible. We partnered with United Way and Lyft to offer free rides across sites, and for our main hub site, we offered free bus passes to anyone who reported having a transportation barrier while they were making their appointment.
To improve equitable appointment access, we kept sites open nights and weekends, so people working non-traditional hours and those with children could have greater convenience in getting vaccinated. Based on our earlier experience, we knew that appointments would go quickly once released online and we knew that many members of HMP communities couldn’t make appointments online because of lack of reliable Internet or smartphone access, lack of digital literacy, and other reasons. Recognizing this digital divide, we set aside 50% of our appointments at our FEMA site to be accessible only through our community partners or through our bilingual English-Spanish call center. Recipients received bilingual email and plain text SMS confirmations. We offered in-person Spanish interpreters, signs in English and Spanish, American Sign Language and video remote interpreting, and phone interpreters for dozens of other languages.
As a result of these efforts, more than 35% of people vaccinated at our FEMA hub site identified as Black, African American, or Hispanic/Latinx, and at our FEMA spoke sites, nearly 60% of people vaccinated identified as Black, African American, or Hispanic/Latinx. North Carolina continues to track share of vaccinations relative to share of total population, and the state is building equity into every aspect of vaccine distribution in order to close the vaccination equity gap.
Health systems must convey to the communities they serve that they are here for the community in the long-term. Health systems need to show that they’re more than an emergency room or ambulatory care site – they need to be trusted partners that are invested in making the community healthier in partnership with community organizations. This idea can play out in different ways: it could be partnering with local businesses to bring healthier food options to a community, supporting violence reduction and response initiatives inside and outside hospital walls, investing in creating more affordable housing options, working with school nurses and community health workers to keep high-risk patients out of the ER, and much more.
Another big component of being a trusted partner is also hiring from the local community. Health systems are often among the largest employers in their regions. The demographics of the people working at the health system should reflect the demographics of the community they’re serving. Research has shown that patients are more likely to have a positive healthcare experience if they’re cared for by people who look like them.
Health systems also need to examine how they’re viewing health equity as an organization. If health equity is siloed to one part of an organization, then the results will also be siloed. It’s essential to infuse health equity – and accountability for improving health equity – into every area of the organization and build it into the health system’s model, strategy, and budget in order to truly move the needle.
If health equity is siloed to one part of an organization, then the results will also be siloed.
First, it’s important to acknowledge that certain digital tools are not equally accessible to all. Many American households lack stable broadband access – somewhere between 21 million and 42 million by latest estimates, and broadband access in Black and Latinx households trails that in White households by 10-15%. Black and Latinx adults are more likely to be dependent on smartphones for Internet access and also more likely to have cellphones that are not smartphones.
The good news is digital can be a tool of progress in health equity when used properly. There are a wide range of digital tools that can help provide more equitable care. On the provider side, I’ve seen successes with the following tools:
On the patient side, commonly used tools are:
The two biggest areas where I see potential for impact beyond COVID-19 are in intentional partnerships and seeking and using data effectively. COVID-19 is not unique in being a disease that disproportionately affects communities of color – diabetes, hypertension, kidney disease also have a greater impact on these communities. We need to put the same level of effort as we did for COVID-19 into tracking the data around who is getting these diseases, how accessible care is for different people, and what the outcomes of care are. That data helps inform the community partnerships necessary to reach communities and provide the support and care they need.
My favorite piece of advice came from Dr. Marcella Nunez-Smith, who is President Biden’s COVID-19 Equity Task Force Chair: Equity is a team sport. We all have a role to play. When I was working in North Carolina, partnerships between local, state, and federal governments, community-based organizations, health systems, payors and others were vital to the COVID-19 work that we did. Our progress in reducing health inequities would not have been possible without this cooperation.