As a medical student, I (P. K. M.) was interested in approaching the COVID-19 public health crisis from an equity lens to ensure that vulnerable populations had access to vaccinations. I reached out and began working with a physician in Cook County who was a member of an Illinois Department of Public Health (IDPH) working group seeking to vaccinate homeless populations throughout the state. As Cook County and the Chicago Department of Public Health embarked on groundbreaking and comprehensive initiatives to reach their dense metropolitan homeless populations, the IDPH working group focus was on statewide interventions. In the end, we ensured that all shelters in Illinois had access to COVID-19 vaccines and provided education and outreach, support, and events for any shelters that needed help.
There are several lessons I have learned about addressing health care inequities from my work on the IDPH homeless vaccination initiative, as described in the sections to follow.
UNDERSTANDING THE LAY OF THE LAND
Our research on the state landscape and population needs allowed us to develop informed strategies for this large, complex state health initiative. Mapping social vulnerability, COVID-19 burdens, and homeless population densities and shelters highlighted key areas of focus. We researched higher-order regional entities involved in the care of homeless populations, such as continuums of care. We designed and distributed a COVID-19 needs assessment survey to shelters as a means of garnering insight into existing efforts, barriers, and challenges to inform our interventions.
ESTABLISHING AN INTERAGENCY WORKING GROUP
Another important strategy was facilitating collaboration between local (e.g., local health departments, shelters, health systems, community partners), regional (e.g., continuums of care), state (e.g., IDPH, Illinois Department of Children and Family Services, Illinois Emergency Management Agency), and national (Department of Housing and Urban Development) leadership. Coordination optimized efficiency and, importantly, created an opportunity to form lasting relationships for future public health initiatives.
WORKING WITH THE COMMUNITY
Rather than a “top-down” approach, such as sending in national guard units to set up one-off mass vaccination events, working from the ground up with local health departments and community-based organizations proved essential in developing effective community-directed interventions. Trusted community members were a key factor in vaccine uptake.
EDUCATION AND OUTREACH
Vaccine hesitancy was a major barrier to vaccination of homeless populations. The most common request for assistance in our shelter survey was educational materials for clients and staff. We provided flyers, presentations, and Web site materials from the Department of Housing and Urban Development and other organizations that were screened for literacy and content. One of the most effective strategies was having advocates engage with the community at housing projects, soup kitchens, and other local events. Word of mouth was important for community trust. Events were also posted on social media, and town halls were held to answer questions. In addition, we engaged in educational outreach to specific populations such as those with mental illnesses, those in domestic violence shelters, and the youth population. Education and outreach efforts for each of these populations were targeted toward their specific needs.
CARE BEYOND SHOTS
As medical students and trainees, we were passionate about connecting patients with health care resources beyond vaccination. Homeless populations often have multiple chronic conditions but limited access to health care and basic necessities. Partnerships with local health care entities such as Federally Qualified Health Centers and public health departments led to the provision of mobile medical units and informational materials and helped connect people with health care resources. Mobile units conducted blood pressure screening, naloxone training, and testing for HIV and other sexually transmitted diseases. Basic necessities addressing social determinants of health (e.g., food, water) and counseling resources for housing assistance and government programs were also provided on site. This approach provided holistic care and built trust between people and public health officials.
CONCLUSIONS AND REFLECTIONS
Through my experience working with IDPH, I learned about critical strategies for crafting successful public health interventions addressing health care inequities, as follows:
Develop a diverse team and encourage collaborative brainstorming (such efforts should include students, who have a different perspective and are willing to learn and help; our team included residents, medical students, and public health students and interns).
Ask community members directly what they need, what they are already doing, and barriers and challenges they are facing.
Work with community partners and support local efforts, which fosters trust. Do not take a “top-down” approach.
Bring together leadership from different organizations to facilitate communication and planning and to serve as an investment in future public health initiatives.
Prioritize education and outreach.
Provide resources that address the social determinants of health.
Reflecting on this project, I was surprised by the challenges in health care delivery to homeless populations. I noticed that shelters often did not have established relationships with their local health departments or health care systems (e.g., Federally Qualified Health Centers) and that there was a need for collaboration between community-based organizations, national partners, and regional or local partners. Within the context of this project, I learned how important it was to develop relationships between all of these partners to allow for communication of population needs (local level), resources available (local, state, and federal levels), and coordination of delivery (local, state, and federal levels). I gained an appreciation for the importance of a health care system that supports vulnerable populations by facilitating such partnerships; however, I also realized that this infrastructure needs to be further developed to provide sustainable long-term care for these populations. This is something I hope to focus on in my future career.
Working on this project opened my eyes to the value of engaging with community partners. Talking with community organizations highlighted the depth of knowledge they have about their community, what works within the community, and the resources available. For example, I was surprised to see the lack of buy-in from younger populations, who often stated that they were healthy and not worried about COVID-19. We would not have known how to best engage young people without insight from the community, which informed us of how to connect with a local rapper who could promote the importance of vaccination at her concerts and events. Community members also showed us local hang-out spots and encouraged us to include food and music at our events as a means of engaging young people to be part of this initiative.
My work with IDPH allowed me to engage with public policy and implement impactful interventions to provide health care to vulnerable populations. I felt that my insight and perspective on this interdisciplinary team were valued, and I learned from more experienced public health officials, physicians, and members of the community. As a medical student, I was particularly encouraged by the strong mentorship on this project and the leadership of physicians in public health. I will take the lessons I have learned to future public health initiatives that I am a part of. I encourage students who are interested in public health measures to reach out and work with public health officials.
ACKNOWLEDGMENTS
We acknowledge the leadership and support of Catherine Counard and Ngozi Ezike of the Illinois Department of Public Health.
CONFLICTS OF INTEREST
The authors declare no conflicts of interest.