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In the depths of the Covid-19 pandemic, community health workers played a significant role in increasing vaccine uptake in hard-to-reach New York City communities, a new study has found.
Community health workers are public health workers with close connections to the communities they serve, and often act as intermediaries between local residents and health systems or social services. Across the country, many regions invested in community health worker initiatives as part of pandemic response efforts. But the workforce is particularly vulnerable to public health’s boom and bust funding cycle.
Quantifying the impact of community health workers who don’t work in clinical settings has long been challenging, said Dr. Maureen Miller, an epidemiologist and contractor with the New York City Department of Health and Mental Hygiene. But the data that emerged from the pandemic — and the Health Department’s significant investment in community health workers — offered an unusual opportunity to show their value, she said.
In the study, recently published in the American Journal of Public Health, Miller and other researchers affiliated with the Health Department found that community health workers, in partnership with the agency and community-based organizations, helped drive sharp increases in vaccination levels among local residents.
In 75 ZIP codes targeted for public health interventions, residents were primarily Black and Latino — demographics that had experienced disproportionately high mortality rates in the early weeks of the pandemic. At the beginning of the initiative in July 2021, 44% of all residents had completed their primary series Covid-19 vaccination. By June 2022, vaccine uptake rose to 76%. The majority of those communities received high levels of engagement from community health workers, defined as interactions during at least 11 months of the year.
Over the course of that year, community health workers also provided vaccination information to local residents more than 18 million times and participated in more than 22,000 outreach events, according to the study. They made 800,000 linkages to Covid-19 vaccination appointments, created more than 200,000 referrals to testing sites, distributed 17 million face masks and handed out 73,000 at-home antigen tests. They also helped residents tackle other issues, from food insecurity to housing instability.
In an interview this week with Healthbeat, Miller discusses the study, the role of community health workers, and why their approach to community engagement proved so effective. This interview has been edited for length and clarity.
Take us back to where New York City was in the pandemic when this project began. What motivated this research?
I was hired just as [the Covid-19 variant] Omicron was taking off, as were all of my colleagues. It was a very crazy period in the pandemic. Although vaccines were increasingly available, they were kind of challenging to get in New York City. You had to make appointments through computers and online. Not everyone knows how to operate that, not everybody has access to that, and we were also in the communities that had been left behind already by vaccines, by treatments. People had already died.
The statistics are astounding: Almost half of the people who died in the pandemic in New York City died in the first month or two. That’s staggering, and I think we’ve swept that loss under the rug because it’s enormous. It has affected all of us.
Against that background, people were mistrustful. They said, ‘You want us to take this vaccine now, we don’t understand it. We hear bad things about it.’ There was already a great deal of misinformation and skepticism on the part of community members that we were working with. So the idea was not, as the city Department of Health, to go in and say, ‘Get vaccinated.’ It was to partner with community-based organizations who hire people who are centered in the community. We provided funding for the community-based organizations to hire community health workers who we would help train and keep updated on all the new variants, the new vaccines, the boosters.
The community health workers and the community-based organizations developed a lot of their own methods of interacting with the community. We would provide the information, but they would make up songs and get them on the local radio, they’d have flyers. They would do videos and put them on social media. We had biweekly meetings with community members and with community-based organizations. We had a series of trainings for community health workers. It was probably the largest effort that the New York City Department of Health has ever made to integrate community with government in the city.
How did you set up this study?
One of the reasons that community-based community health workers get no respect is because it’s been extremely difficult to find a database that shows the impact of population-level change. We wanted to change entire communities, not just one person at a time. We didn’t interact with every single person in the community, yet our impact was felt, as evidenced by the huge increase in vaccine uptake over time.
We had an outcome: how many people had received the full series of vaccinations. We had that data, and it was collected on a weekly basis for everyone who became vaccinated. I can’t even tell you how unusual that is in the world of public health — but so is a pandemic. This provided a unique opportunity to look at the outcomes and then to see how our work with the community was impacting our objective, which was vaccine uptake.
We didn’t interact with every single person in the community, yet our impact was felt, as evidenced by the huge increase in vaccine uptake over time.
— Dr. Maureen Miller
The contracts were based on X number of outreach engagements, X number of handing out materials and documentation. You had to satisfy a minimum set of criteria in terms of engagement that you would then get paid for. That’s unique in my experience, but it was extremely effective, because the community-based organizations wanted to help the community in any way they could. So most of the time they exceeded [the goals].
What were the main findings of your research?
I was shocked — I hadn’t looked at the data until things started to settle down with the pandemic. I wondered: Well, how big of an impact did we have? And we had an enormous impact. I don’t know of vaccine uptake that has happened so quickly for any other disease.
Within one year, from the initiation of the project in July 2021 through June 2022, we had a 30% increase in vaccine uptake in a community that is under-resourced, marginalized, distrustful, and disinvested. People went out and got vaccinated.
One of the projects that we did was a storytelling project. We wanted to know, ‘Why did you get vaccinated? Why are you encouraging others to get vaccinated?’ And it was all about family. It was about, ‘I’m going to protect my family.’ It was about community. In an individualistic society such as ours, it was really heartening to hear that that was a fundamental reason why people were choosing to get vaccinated and to convince others to get vaccinated. Not only were our community health workers acting as advocates for vaccination, eventually so were community members.
How do community health workers’ efforts to help residents with other issues, like food insecurity or housing instability, connect to the broader goal of increasing vaccine uptake?
The Health Department wanted people to get vaccinated right away. And the community came back and said, ‘Listen, my kid doesn’t have diapers. I’m not getting a vaccine before I can get diapers.’ There was such a great deal of need — and there continues to be need — for food, for housing, for money for child care, for elder care. There is just so much need in these communities that they can’t afford to think about the Health Department’s priority of getting people vaccinated and not spreading Covid.
People really wanted help, and they didn’t necessarily want the help that we came in with — to provide vaccines. They wanted help with daily living needs that were not being met, and in fact, were exacerbated by the pandemic. So we started providing referrals. We pulled together a list of organizations where people could go to get food. We partnered with the Department of Homeless Services to provide vaccine information and opportunities to make reservations to get vaccinated, and also to find housing for people. Community-based organizations also corralled their networks of food pantries and other resources so that we could amplify their ability to refer others to these services.
That’s how we build trust. We need to pay attention to what it is you need and want; it’s not only about getting vaccinated. It’s dealing with community priorities to ensure that when we would like to do an important health intervention, we’ve already built up the trust.
Eliza Fawcett is a reporter covering public health in New York City for Healthbeat. Contact Eliza at efawcett@healthbeat.org.
