Keys to COVID-19 Vaccine Success: Trust and a Healthy Foundation

Article from US News & World Report by Alex Leeds Matthews on June 29, 2021

Many communities with high success vaccinating their residents against COVID-19 also scored well in U.S. News' Healthiest Communities rankings. What can their strategies teach us about the future of public health?

One morning this spring, Moira Cook had a good sort of problem: extra doses of COVID-19 vaccine that she needed to use immediately.

The director of Middlebury, Vermont's local health office got to work immediately, calling 25 local businesses. Cook focused on places like auto mechanics, repair shops and farm retailers: "Folks who don't sit at a desk, who aren't in front of a computer, so it might not be easy for them to go online and register for a clinic in two weeks," she explains.

Cook says she had some takers in Addison County, the community her office serves. But many employers told her, "Everyone here is vaccinated – sorry, we don't have anyone to send you."

"It was fantastic," she says.

With 55% of its population fully vaccinated against COVID-19 as of mid-June, Addison County has been among the most vaccinated counties in the nation. Although Cook attributes much of this to the community's cooperation, there's no evidence that the people of Addison County – or of Vermont, which was the first state to at least partially vaccinate 80% of its eligible population – have an innate love of shots and needles.

Rather, Addison has in common with other highly vaccinated counties a strong performance in community health characteristics that earned it the No. 47 rank in U.S. News' 2021 Healthiest Communities rankings. The annual project assesses nearly 3,000 counties and county equivalents across dozens of factors that fuel and form health and well-being, in categories ranging from equity, the economy and population health to housing, food and nutrition and public safety.

An analysis of Healthiest Communities data alongside Centers for Disease Control and Prevention data on vaccine coverage indicates that many highly vaccinated counties may also be healthier in other ways. As of early June, for example, a quarter of counties in the top 100 of the Healthiest Communities rankings had fully vaccinated at least half their population against COVID-19. Of the more than 2,500 other communities in the Healthiest Communities analysis, only about 100 had reached this milestone.

What's more, fewer than half of the 10 most vaccine-hesitant counties as determined by federal government estimates based on survey data from earlier this year made it into the top 250 of the Healthiest Communities rankings, while among the 10 least hesitant counties, seven were in the top 250 and six were in the top 100.

A U.S. News analysis also found that counties with higher vaccine hesitancy often had higher smoking rates, a higher prevalence of obesity, higher poverty rates and lower median incomes. At the same time, counties with higher vaccine coverage often had higher shares of their populations holding an advanced degree, lower shares of people in medical debt and in general were likely to perform better in the 84 metrics considered for the rankings.

These relationships point to a potential connection between existing characteristics of community health and well-being and a community's willingness to be proactive about their health. And local health officials can be key to fostering both facets.

"What I'm finding in my work as a health officer and what others are finding is that the time to have changed vaccine hesitancy was 10 years ago," says Dr. David Bishai, a professor of public health at Johns Hopkins University and health officer for Harford County, Maryland, No. 259 in the Healthiest Communities rankings and where 48% of residents were fully vaccinated by early June. "Preparedness for a pandemic requires building channels of trust, relationships with the entire county, and you can't build them in the middle of a pandemic – you need to build them for years."

For Leelanau County, Michigan – which placed 73rd in the Healthiest Communities rankings – and neighboring Benzie County, which was No. 319, the first obstacle to vaccination was the number of doses allocated. For the approximately 40,000 residents of the two counties, the local health district was receiving maybe 100 doses weekly, says Lisa Peacock, health officer for the Benzie-Leelanau District Health Department.

But thanks to a partnership with other local health districts in northern Michigan, the department was able to vaccinate its educator workforce at the same time as other counties nearby, despite differing allocations.

The department's staff of just 28 people also needed help scaling up vaccination efforts. Fortunately, both counties are home to highly involved community members, Peacock says. More than 100 volunteers, many of them retirees, pitched in.

Notably, both counties perform well in the Healthiest Communities assessment of community vitality, which includes factors such as voter participation rate and the share of eligible housing units that self-responded to the U.S. Census Bureau's American Community Survey. Leelanau ranks 18th among communities in the category with a score of 85, and Benzie is No. 29 with a score of 80.

With the help of these volunteers, temporary staffers and partnerships with the National Guard and a local federally qualified health center, the department held clinics, did mobile outreach and created "pop-up strike teams" to target unvaccinated populations when vaccine supply began to exceed demand. They reached incarcerated and homebound residents, as well as people at restaurants, bars and festivals. As of early June, Leelanau County had vaccinated nearly two-thirds of its population and Benzie had reached more than half, according to Centers for Disease Control and Prevention data.

As the No. 47 community overall, meanwhile, Addison County achieved its best scores in the Healthiest Communities' food and nutrition and population health categories. Cook, who has worked at the health district for more than a decade, notes initiatives like a vegetable prescription program that has supported food insecure residents and boosted local farmers.

"We don't just care about whether or not you've been immunized or whether or not you've had some reportable illness," Cook says. "We really want you to be healthy and well regardless of your background, your educational attainment or your income."

It's this approach to the community that's allowed Addison to have high coverage not just for COVID-19 vaccinations, but for other immunizations as well, Cook says. Making early investments in the community's health, even when people may not be sick, means there's less convincing to do when it comes time to ask residents to get a jab.

When the pandemic reached Leelanau and Benzie counties, Peacock and her staff began holding weekly community conversations between the health department and other human services organizations and partners.

"Hundreds of people would get on that call every week," Peacock says. "Leelanau County residents want to be informed, they want to be actively involved in improving their community – they want Leelanau County to be a healthy place."

The department also partnered with a migrant council to ensure that migrant agricultural workers in the area received vaccines. And the Northern Michigan Public Health Alliance – the partnership of health districts that helped educators in Leelanau and Benzie get vaccinated – performs community health needs assessments every three years.

This type of engagement plays into a model that's been called "Public Health 3.0."

"Public health is a partnership in the community with the people ... they have to see you because they're working with you on a shared problem," Bishai says. "It's not invisible because the solution doesn't come from some puppeteer out in policyland in a big brick building."

Trust and leadership in public health authorities can only go so far, however. Just as Cook recognized the inherently different needs of office workers from manual and retail workers, a community's underlying demographics also can shape its health behaviors and outcomes, from vaccine uptake to smoking rates and heart disease.

Dr. Octavio Martinez, executive director of the University of Texas' Hogg Foundation for Mental Health and a member of President Joe Biden's COVID-19 Health Equity Task Force, has advocated for equity-focused policies to improve vaccine coverage. He notes that racial minorities may be slow to trust government health authorities, and that there are practical obstacles to consider, like a person's ability to get time off work to make an appointment.

Location also can be a key driver of health, as the Healthiest Communities rankings demonstrate. A Centers for Disease Control and Prevention report in May indicated that disparities in county-level vaccine coverage tied to social vulnerability had widened in suburban and more rural communities in particular as eligibility for vaccinations increased.

Yet effective public health leadership can help address disparities. For Bishai, that meant noticing a gap in vaccine uptake between Black and white residents of Harford County and addressing it by listening to residents.

"We closed the gap with deliberate outreach and we didn't do it the stupid way, we did it the listening way," Bishai says, explaining that they heard residents' concerns and used channels of trust they had, like relationships with Black churches, to take aim at the problem.

From free clinics in Addison to outreach at places like restaurants and festivals in Leelanau, "Public Health 3.0" takes equity as a key goal, rather than a tangential benefit.

"The thing I care about in my research is what can you change about the county," Bishai says. "You can't really change the mix of ages and races and sexes – that's not a policy question."

Photo Credit: Crystal River Outfitters Recreation District