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Equitable Vaccine Distribution for Older Adults Requires a Tailored Approach and Key Principles

As the COVID-19 vaccine rollout bumps along and vaccinations for older adults have begun on a large scale, it is clear that, although supply is a problem, a bigger problem is that some older adults in the communities hardest hit by COVID-19 are not able to access the vaccine due to other barriers.

Lucy is 104 years old and entirely homebound. She has survived cancer twice and relies on two caregivers daily. After the announcement that adults 65 years and older in her state would be eligible for the COVID-19 vaccine, her family called multiple agencies and hotlines trying to secure an appointment for her. At each turn, they encountered the same response: nothing was set up for homebound people like Lucy.

Stories like Lucy’s are unfortunately far too common as older adults across the country struggle to get vaccinated. As we predicted in December, the vaccine distribution process is riddled with barriers to obtaining the vaccine, from technology and transportation to logistics and language.

Compared to Lucy, Quynh was lucky. Even though she has limited access to technology and limited English proficiency, a tech savvy friend helped the 71-year-old snag her first vaccine appointment. The mass vaccination site did not offer interpretation nor did it provide materials in her native Vietnamese.  She muddled her way through the process but left without knowing the vaccine required two separate doses and did not schedule her second appointment.

Some barriers are a result of a medical system that has fostered significant distrust among communities of color due to historical and present-day racism and disrespect in medical settings. Darryl originally had his doubts about the COVID-19 vaccine. He had some skepticism about how effective the vaccine would be in fighting the virus, and he did not know many other people who had gotten it. But after he saw a friend, another Black man, at his homeless shelter successfully get vaccinated, he became interested in learning more, especially after a recent outbreak at the shelter. However, when he tried to register with the mobile clinic nearby, he was told that at 59 years old, he did not meet the age criteria and needed to “wait his turn.” This experience added to his lack of confidence in the health care system.

 

A natural instinct is to advocate for a specific community given the devastating health and economic impacts of the COVID-19 pandemic. Such instincts can prevent meaningful cross-movement coalition building and distract from the underlying question of who is most at risk of serious illness and death.

Successful vaccine strategies must inherently recognize that older adults are not a monolith community and as such one-size-fits-all solutions, like mass vaccination sites, will likely not work for many of the older adults who have been disproportionately impacted by the COVID-19 pandemic. Early data suggest these one size solutions in fact are not working. Far too many COVID-19 vaccine allocation plans fail to address the barriers at the intersection of age and other characteristics like race/ethnicity, disability, English proficiency, zip code, and income resulting in inequitable access to the vaccine for the communities who face the greatest risk of infection and mortality. In observing the vaccine rollout nationally, Justice in Aging continues to champion the following principles for states and local health departments as best practices to center equity for older adults in the vaccine process:

  • Create as many channels and sites for vaccination as possible. Vaccine confidence can be addressed by creating vaccine sites in partnership with trusted community messengers, like senior centers and adult day health programs. This also includes strategies to provide vaccinations at home for homebound individuals, like Lucy, and setting up sites and mobile clinics in areas where older adults tend to congregate, like senior housing buildings, while also leveraging health care providers, health plans, and aging service providers as key messengers in linking people to appointments.
  • Ensure there are multiple ways to register for an appointment. Just like having a variety of ways to receive the vaccine, the registration process should include multiple routes and should not be limited to the use of an app or website to register. Older adults should be able to call hotlines with an option to leave a callback number, and they should also be able to work with trusted messengers to register through a ticketing process. Call centers should be well-staffed to answer logistical questions and quickly schedule appointments so older adults can receive their vaccine promptly.
  • Properly compensate community-based organizations for their partnership. Community-based organizations serve as trusted messengers in helping older adults register for appointments, addressing vaccine confidence for people like Darryl, and collaborating as sites for mobile clinics, among other vital tasks. Even prior to the vaccine rollout, many of these organizations have been burdened by taking on additional unpaid work during the pandemic, many times limiting their ability to provide their usual services. Proper compensation sends the right message that their partnership is valued and also allows them to maintain non-vaccine related services for their communities.
  • Make the process accessible from start to end. Vaccine sites must be physically accessible, providing seating, wheelchair accessibility, designated parking, available and accessible restrooms, and other accommodations. Webpages and consumer-facing materials should at a minimum include short statements in non-English languages about the availability of free language assistance services and be accessible for blind users and individuals with visual disabilities, call center hotlines should be able to provide telephonic interpretation and individuals should be advised of their right to an interpreter on-site. These best practices not only better serve older adults with limited English proficiency (LEP) like Quynh and others with disabilities, but also comply with federal and state law.
  • Vaccine prioritization is an opportunity to build cross-movement coalitions and should not pit high-risk communities against each other. In a fixed-pie world like this one where vaccine supply is so scarce, a natural instinct is to advocate for a specific community given the devastating health and economic impacts of the COVID-19 pandemic. Such instincts can prevent meaningful cross-movement coalition building and distract from the underlying question of who is most at risk of serious illness and death. In answering that question, we encourage policymakers to employ an intersectional approach that looks at risk linked to compounding impacts across multiple factors, like age, race, disability, and whether the individual resides in a multigenerational household or in a congregate setting. For example, Darryl’s risk of exposure and adverse health outcomes is heightened as a result of his race, age, setting, and homelessness, but straight adherence to an age-only approach ignores the nuances and varied experiences of older adults like him.
  • Prioritizing older adults in vaccine allocation is meaningless if they are also not consistently prioritized in the operationalization. Although federal guidance rightfully recommends prioritizing older adults in state vaccine allocations, the prioritization is nothing more than an empty promise if states and local health officials do not target older adults in their outreach and operationalization. One-size-fits-all solutions on a first come, first serve basis will fail to meet the needs of older adults most impacted by the virus. These include mass pop-up vaccination sites and smartphone apps used to register for vaccine appointments. Prioritizing older adults in allocation must come with parallel, targeted investments in building a vaccine infrastructure that meets their needs.   
Following these principles creates a foundation for a more equitable response to a pandemic that has ravaged the country and its older adults in the most inequitable of ways. While most states have COVID-19 trackers on public websites, few are reporting disaggregated data showing which populations have received the vaccine. Making transparent the data about who is getting the vaccine allows for greater accountability to that goal. These principles do not solve the problem of vaccine scarcity, but they help ensure people who have been most impacted, like Lucy, Quynh, and Darryl, have access to a vaccine that may save their lives. If implemented, these principles ensure that not only the needs of many older adults are met in the process, but also many others in their communities, regardless of age.

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