Abstract
Refugee and immigrant populations are extremely vulnerable to the consequences of the COVID-19 pandemic. COVID-19 vaccination is a critical tool in mitigating these consequences, but these same communities often lack access to COVID-19 vaccines. We describe the efforts of a community-based primary care clinic in Clarkston, Georgia to provide access to COVID-19 vaccines in a culturally sensitive manner to address this health disparity and vaccine hesitancy.
Although the COVID-19 pandemic has affected everyone, certain populations are disproportionately burdened. African Americans are five times more likely to be hospitalized from a COVID-19 infection than White Americans, and nearly twice as likely to die.1 Although there are insufficient data on how the pandemic has affected refugees, several risk factors increase the likelihood of severe illness from COVID-19 among recently resettled refugees, including higher rates of comorbidities,2 mental health concerns,3,4 health care access, language barriers,1 low socioeconomic status,5–7 and social stressors.8
Clarkston, Georgia, is known as “the most diverse square mile in America” (https://bit.ly/3JQfnpW) as it has served as a refugee resettlement site for the past 30 years. Clarkston has welcomed immigrants seeking refuge from Bosnia, Kosovo, Liberia, Congo, Burundi, Sudan, Somalia, Ethiopia, Eritrea, Iraq, Syria, Bhutan, Burma, Afghanistan, and Pakistan.
Ethne Health was started in October 2018 as a primary care clinic in Clarkston. Ethne Health attempts to meet the diverse medical needs of the community in a culturally sensitive manner. In the past year, Ethne Health has provided COVID-19 testing and vaccinations for the community.
INTERVENTION
As vaccine hesitancy remains a barrier in the struggle to contain the COVID-19 pandemic, one recommended strategy is to directly engage communities through the utilization of community partners with trusted relationships.9 As a culturally sensitive neighbor-centered medical home located in the middle of a diverse community, Ethne Health is uniquely positioned to engage with those community partners to deliver COVID-19 vaccines.
PLACE AND TIME
Data from Ethne Health’s vaccination campaign in Clarkston, Georgia (zip code 30021) were collected from January 6, 2021 through May 28, 2021.
PERSON
During the period of data collection, Ethne Health partially or fully vaccinated 3127 individuals with either the Pfizer or Moderna COVID-19 vaccine. Of these individuals, 2692 were fully vaccinated.
PURPOSE
Our main goal was to provide access to COVID-19 vaccines for the immigrant communities in and around Clarkston in a way that was culturally sensitive and accessible for all. Additionally, because of the scarcity of data on COVID-19 vaccination among refugees, we wanted our local vaccination campaign to serve as a model for future endeavors nationwide.
IMPLEMENTATION
For vaccine administration, four additional full-time staff (vaccine coordinator, nurse, registration coordinator, and community engagement coordinator) were hired, forming a COVID-19 vaccination team. They were buffeted on vaccine distribution days by a large number of volunteers. Staff and volunteers came from a variety of racial/ethnic backgrounds with multiple languages represented. In situations where translation was needed and an in-person translator was not available, telephone translation services were used. Additionally, materials, including Emergency Use Authorization fact sheets, were printed in multiple languages and distributed appropriately.
EVALUATION
During the intervention period, Ethne Health partially or fully vaccinated 3127 individuals with either the Pfizer or Moderna COVID-19 vaccine. Demographic data were collected from 3090 individuals (98.9%). The racial and ethnic demographics of the overall group can be seen in Table 1. The percentages of those who identified as Black or African American, Asian, or White were 46.1%, 19.4%, and 34.1%, respectively. Overall, 3.4% identified as Hispanic/Latino.
TABLE 1—
Racial/Ethnic Demographics of Entire Cohort Partially or Fully Vaccinated by Ethne Health From January 6, 2021, to May 28, 2021: Clarkston, GA
| Race/Ethnicity | No. Partially or Fully Vaccinated (% of Cohort) |
| Black | 1424 (46.1) |
| White | 1054 (34.1) |
| Asian | 598 (19.4) |
| Other | 14 (0.5) |
| Not Hispanic or Latino | 2819 (96.6) |
| Hispanic or Latino | 99 (3.4) |
Of the entire cohort who received at least one dose of either the Pfizer or Moderna vaccine from Ethne Health, 640 individuals (20.4%) had an address in the 30021 zip code. Demographic data were collected from 628 individuals (98.1%). As seen in Table 2, the percentages of those who identified as Black or African American, Asian, or White were 43.3%, 30.1%, and 26.3%, respectively. Those who identified as Hispanic/Latino made up 3.5% of the cohort, and 21 different languages were represented. The racial and ethnic demographics of our cohort vaccinated from the Clarkston zip code closely resembles those of the zip code at large.
TABLE 2—
Racial/Ethnic Demographics of Cohort Living in Zip Code 30021 Partially or Fully Vaccinated by Ethne Health From January 6, 2021 to May 28, 2021: Clarkston, GA
| Race/Ethnicity | No. Partially or Fully Vaccinated (% of Cohort) | Clarkston, GA, Demographics (US Census 2010), % |
| Black | 272 (43.3) | 52.0 |
| White | 165 (26.3) | 28.8 |
| Asian | 189 (30.1) | 16.2 |
| Other | 2 (0.3) | 3.0 |
| Not Hispanic or Latino | 606 (96.5) | 97.1 |
| Hispanic or Latino | 22 (3.5) | 2.9 |
In August 2021, the Prevention Research Center at Georgia State University stated that Clarkston has a “fully vaccinated rate of nearly 42% . . . outpacing neighboring communities that are similarly stressed, with low household income, low literacy and language ability, high density housing, and limited transportation.”10 It highlights Ethne Health’s vaccine distribution as one of the main reasons for success.
ADVERSE EFFECTS
Despite our progress thus far, many challenges still exist in vaccinating our community. Continued efforts need to be made to identify reasons why people remain unvaccinated and to address those concerns.
SUSTAINABILITY
Upon evaluation of the vaccination efforts, we believe that three main factors aided in our outreach to a diverse and sometimes vaccine hesitant population: (1) relationships of trust within the community, (2) multiple avenues of access, and (3) consistent vaccination location and time.
TRUST
Psychological and social influences have been shown to have significant impacts on vaccination rates.11 A community engagement coordinator can help utilize these factors to promote vaccination. With a decade of experience working in the Clarkston community with a refugee resettlement agency, our coordinator leveraged previously established relationships to engage trusted community partners. These trusted and well-respected community partners helped overcome the barriers of distrust and lack of access. Additionally, the coordinator’s experience and relationship with community partners assisted us in developing a culturally sensitive approach to vaccine distribution.
ACCESS
Individualized registration procedures were created that enabled community partners to schedule appointments for their community members without having to navigate registration forms or phone lines. Specifically, our community engagement coordinator worked directly with community partners to assist individuals and groups in registering for and transportation to vaccine appointments. Autonomous community members were able to preregister for vaccines through multiple avenues, including walk-ups and online registration. On vaccinations days, walk-ups were encouraged, and we accommodated accompanying family or friends who were not registered.
CONSISTENCY
We began in January and February 2021 with larger vaccine drives that required significant logistical planning and coordination. By the end of February 2021, we had switched to vaccinating smaller numbers outside of our clinic. This provided a more sustainable endeavor for our vaccine team and clinic, which helps avoid burnout. Additionally, it provided a consistent time and location for community members to find us and get vaccinated. They knew where to find us, when to find us, and that we would vaccinate them if they came.
PUBLIC HEALTH SIGNIFICANCE
Although immunization is not required for resettlement in the United States, overall, refugees are generally immunized. For example, in 2019, 94.6% of 28 478 age-eligible refugee arrivals from 88 countries had at least one documented measles-containing vaccine dose.12 Achieving similar vaccination rates for COVID-19 may be difficult.
As the COVID-19 pandemic continues, COVID-19 vaccine distribution is an utmost priority, especially among vulnerable refugee and immigrant populations. To accomplish this, we have learned that establishing trust, providing multiple avenues of access, and being consistent can minimize many obstacles. Trust can overcome vaccine hesitancy; reducing barriers to access and maintaining a consistent yet sustainable presence can help our community endure this formidable virus. Our vaccination campaign, though small in scale, can offer a model to provide access to COVID-19 vaccines in a way that is effective, sustainable, and culturally sensitive.
ACKNOWLEDGMENTS
We extend a tremendous thank you to the Georgia Department of Public Health for providing us with our vaccine supply. We also thank our many vaccine volunteers who have donated many hours of their time to help us vaccinate our community. Without them, none of this would have been possible.
CONFLICTS OF INTEREST
All authors have no conflicts of interest to disclose.
HUMAN PARTICIPATION PROTECTION
Our team at Ethne Health is only analyzing completely de-identified data and is performing clinical services for a fee that are routinely done for nonresearch purposes.
REFERENCES
- 1.Shen AK, Hughes IVR, DeWald E, Rosenbaum S, Pisani A, Orenstein W. Ensuring equitable access to COVID-19 vaccines in the US: current system challenges and opportunities. Health Aff (Millwood). 2021;40(1):62–69. doi: 10.1377/hlthaff.2020.01554. [DOI] [PubMed] [Google Scholar]
- 2.Centers for Disease Control and Prevention https://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/domestic-guidelines.html2021.
- 3.Porter M, Haslam N. Predisplacement and postdisplacement factors associated with mental health of refugees and internally displaced persons. JAMA. 2005;294(5):602–612. doi: 10.1001/jama.294.5.602. [DOI] [PubMed] [Google Scholar]
- 4.Silove D, Ventevogel P, Rees S. The contemporary refugee crisis: an overview of mental health challenges. World Psychiatry. 2017;16(2):130–139. doi: 10.1002/wps.20438. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Hadgkiss EJ, Renzaho AM. The physical health status, service utilisation and barriers to accessing care for asylum seekers residing in the community: a systematic review of the literature. Aust Health Rev. 2014;38(2):142–159. doi: 10.1071/AH13113. [DOI] [PubMed] [Google Scholar]
- 6.Mangrio E, Forss KS. Refugees’ experiences of healthcare in the host country: a scoping review. BMC Health Serv Res. 2017;17(1):814. doi: 10.1186/s12913-017-2731-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.McKeary M, Newbold B. Barriers to care: the challenges for Canadian refugees and their health care providers. J Refug Stud. 2010;23(4):523–545. doi: 10.1093/jrs/feq038. [DOI] [Google Scholar]
- 8.Fabio M, Parker LD, Siddharth MB. Building on resiliencies of refugee families. Pediatr Clin North Am. 2019;66(3):655–667. doi: 10.1016/j.pcl.2019.02.011. [DOI] [PubMed] [Google Scholar]
- 9.Thomas CM, Osterholm MT, Stauffer WM. Considerations for COVID-19 vaccination on refugees, immigrants, and migrants. Am J Trop Med Hyg. 2021;104(2):433–435. doi: 10.4269/ajtmh.20-1614. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.A Message from the Prevention Research Center on the Progress of COVID-19 Protections in Clarkston, GA. Georgia State News Hub https://news.gsu.edu/2021/08/17/a-message-from-the-prevention-research-center-on-the-progress-of-covid-19-protections-in-clarkston-ga2021.
- 11.Chattopadhyay S, Shinha P. Understanding factors impacting COVID vaccination in India: a preliminary report. Quantum J Med Health Sci. 2021;1(3):18–31. https://qjmhs.com/index.php/qjmhs/article/view/20 [Google Scholar]
- 12.Mitchell T, Dalal W, Klosovsky A, et al. An immunization program for US-bound refugees: Development, challenges, and opportunities 2012-present. Vaccine. 2021;39(1):68–77. doi: 10.1016/j.vaccine.2020.10.047. [DOI] [PMC free article] [PubMed] [Google Scholar]