Partnering for Success: Outreach to Achieve Health Equity

State: MI Type: Promising Practice Year: 2022

Ottawa County Department of Public Health's (OCDPH) mission is to assure conditions in which all people can achieve optimum health. This mission promotes the department's vision of supporting a population of healthy people. OCDPH strives to maintain this vision, in part, by maintaining the responsibility to ensure that all Ottawa County residents have equitable access to healthcare and services in the event of a public health emergency.

Ottawa County, Michigan has a population of 296,200 people and is the 7th most populated county in the state of Michigan out of 83 counties. Ottawa County is the fastest-growing county in Michigan. From 2010 to 2020, Ottawa County's population grew by almost 33,000 residents, a 12.3 percent increase. Approximately 6.7% of the population sits below the poverty line and the median household income is $69,314. The racial makeup of the county is 92.6% white alone, 1.9% black alone, 0.6% American Indian/Alaska Native alone, 3.0% Asian alone, and 2.0% of people are two or more races. Around 10.2% of the population indicates Hispanic or Latino origin. Ottawa County also has one of the largest seasonal farmworker populations in the state, one of only two counties with over 12,000 seasonal farmworkers and household members (in 2013).

Early in the COVID-19 pandemic, several health inequities were identified, including communities experiencing social vulnerabilities and those with an increased risk for COVID-19 infection and poorer health outcomes. In December of 2020, vaccinating members of Ottawa County became a critical component to reduce COVID-19 illness, hospitalizations, and deaths while also helping to restore the proper functioning of our society. Our need to operationalize an effective vaccine response was a challenge due to the complexity of this situation, as COVID-19 was much different than our previous outbreak-related vaccination responses. In addition, Ottawa County faced increasing vaccine hesitancy.

The goal of OCDPH was to utilize all available resources to vaccinate all eligible persons in the public against COVID-19 through an equitable and fair approach. The focus being to increase COVID-19 vaccine uptake in Ottawa County and ensure we were doing so in the most effective and ethical way possible to achieve a high percentage of vaccinated Ottawa County residents.

Next came the approach, to ensure equitable and fair access to vaccines. The approach began with our first objective of community partnerships, but we quickly learned that these partnerships needed to shift. The model needed to shift; it could not be a traditional partnership model. The partnerships had to be reinvented by investigating the past and reinventing the future. OCDPH's primary objectives were to recognize failures, acknowledge mistakes, and have a willingness to change and improve. It would be Partnering for Success: Outreach to Achieve Health Equity. This partnership model with trusted community advisories assisted OCDPH to break through some of the health equity barriers of access to care, language, and hesitancy. These groups held the key to our success in achieving health equity and outreach for community vaccinations. This model is a true example of Public Health 3.0 at its finest, community partners coming together to adapt and change as one.

A variety of activities were implemented throughout the COVID-19 pandemic as part of OCDPH's partnership for health equity model. Mass vaccination clinics acted as centralized locations throughout the county to ensure high numbers of people were vaccinated quickly. While mass vaccine clinics reached a large portion of our county residents, this was not the only way OCDPH would be successful. It was not the best way to reach all residents that may have health access needs. OCDPH needed to ensure that barriers were removed from identified populations, appointment blocks were held to permit more time for a signup, and we needed to promote a greater understanding of vaccination hesitancy. These lessons were all learned through our community partnerships with trusted advisors.

Our partnership model informed us, advised us of changes needed, and guided us through ever-changing territories from limited quantities of vaccines to clients' needs regarding vaccines. OCDPH was a success and resulted in the ability of our organization to embrace critical health equity changes and create a system of partnerships that can be a foundation for future projects, and the continuation of our current health equity and vaccine access project.

The key to much of our success in vaccine distribution was OCDPH team members' ability to be flexible and adaptable to the ever-changing policies and restrictions throughout the pandemic. In addition to adapting our practices to best suit the community, each community partner OCDPH collaborated with during our COVID-19 vaccine response has been critical to our success. These community partners provided volunteers, facilities, and any other resources we needed to create an equitable and effective vaccine response plan. We relied on community feedback and vaccination data to address health inequities in Ottawa County. The data allowed us to see what groups our current vaccine distribution efforts were not reaching, giving us a clear picture of what populations need to be prioritized. These populations included our homebound residents, migrant worker groups, and our Hispanic and Latinx communities. OCDPH connected with leaders in these communities to increase vaccine uptake and reduce health inequities.

Through this ever-changing approach and the willingness to meet the people where they need, OCDPH and its partners have successfully vaccinated 68,633 individuals and held over 422 clinics. To ensure we met the needs of our community members, OCDPH provided a survey to residents who attended our vaccination clinics. Weekly partnership meetings occurred with feedback on clinics and scheduling. Surveys were analyzed for ways to improve vaccine practices. All these actions led to vaccine clinics running more smoothly, in addition to creating a stronger community connection between OCDPH and our partners. OCDPH observed increased community engagement at our vaccine clinics when we were able to utilize community leaders and volunteers to help run our clinics. Through our vaccine response efforts, Ottawa County currently has over 60% of eligible county residents fully vaccinated against COVID-19.

For more information about the OCDPH go to www.miottawa.org.

The target population for Ottawa County Health Equity Outreach was the following:

The Latinx population in Ottawa County has higher hospitalization rates due to COVID-19 compared to the County overall. (approximately 30,212). OCDPH successfully reached 46.3% Completion / 51.2% Initial Latinx for vaccinations.
Workers in food processing, food manufacturing, and agriculture carry a disproportionate amount of risk regarding COVID-19 exposure due to proximity to coworkers, long shifts, and shared transportation to work. (Ottawa County also has one of the largest seasonal farmworker populations in the state, one of only two counties with over 12,000 seasonal farmworkers and household members (in 2013).
Communities in Ottawa County are more socially vulnerable, increasing the risk for COVID-19 infection and poorer health outcomes. (approximately 52,723) - OCDPH successfully reached 47.2% Completion / 52.9% Socially Vulnerable for vaccinations.

The root cause of the problem is systemic and will continue to need attention and development. One concern was trust - some residents did not know who to believe or if they would be safe (concerned of citizenship). Language barriers and understanding of terminology were an issue and concern - residents needed translation services. Additionally, there are ongoing barriers regarding access to healthcare. Finally, residents needed to make a connection to feel comfortable and safe. The safety permitted the message to be communicated and then reduced hesitancy and trust concerns.

Ottawa County Department of Public Health has a long history of leadership and outreach to the Latinx population, and consistently partners with various and diverse organizations when developing and implementing public health interventions such as the 2021 Migrant Health Survey, COVID-19 Vaccine Outreach, Ottawa Food, communicable disease testing, and screening, and the Community Health Improvement Plan to list a few. These organizations include but are not limited to faith-based organizations, academic and health care institutions, non-profit entities, and collaboratives such as the Allegan/Ottawa/Barry Migrant Resource Council who directly and primarily serves Latinx individuals. As a government agency, we serve all Ottawa County residents, and yet because we are a government agency, we recognize that we are not viewed as a key, trusted advisor by all. We continue to work on strengthening trust with the community, and the activities.

Mass vaccination clinics acted as centralized locations throughout the county to ensure high numbers of people were vaccinated quickly. While mass vaccine clinics reached a large portion of our county residents, this was not the only way OCDPH would be successful. It was not the best way to reach all residents that may have health access needs. OCDPH needed to ensure that barriers were removed from identified populations, appointment blocks were held to permit more time for a signup, and we needed to promote a greater understanding of vaccination hesitancy. These lessons were all learned through our community partnerships with trusted advisors.

As the vaccine availability shifted in the community and the demand wanned, OCDPH was challenged to move to a NEW approach for vaccinations: community strike teams. As one member coined, Meeting people where they're at and trying to make it as convenient as possible by going to folks.”

These partners of health equity continued to meet OCDPH on our journey by ensuring support and providing necessary feedback to meet our vaccine goals.

Community strike teams began with OCDPH finding community events, arranging locations, determining need, advertising the clinic, vaccinating at the clinic, educating about the vaccine, and attempting to bring people to the site while vaccinating. This was a large role for 3 to 4 people to handle as a community strike team.

Our partnership for health equity advised that OCDPH needed to focus on core competencies and the community partners provided a shared team support role. We worked collaboratively together, with public health focusing on education of vaccines and vaccinations and partners focusing on scheduling, outreach, communication, and marketing. Community partners already had the TRUST of the community in the neighborhoods that needed the outreach. Together we were able to make a strategic effort as a community.

The model consisted of a shared calendar to determine availability, then the partners would schedule vaccine locations and coordinate setup. Public Health would vaccinate and educate at the events, all while community coordinators would be on-site to market and bring people to the vaccination through prizes, gift cards, incentives, etc.

It was a true demonstration of a community approach to Vaccination: Trusting Relationships that allowed for an Established Connection, which granted Public Health to Provide a Need Service (preventative health) which resulted in what we consider priceless: vaccinations and trust in county government.

Together the group was able to vaccinate 16,650 people plus using the Strike Team methodology at approximately 124 clinics from Feb 2021 thru Nov 2021.

Some of our success:

We have been hosting over 124 pop-up clinics throughout the year at various sites to try and make access easy and to provide education and incentives. We have hosted clinics at local churches, large community events, popular retail businesses, and various cultural festivals.
Community Spoke hired outreach coordinators to assist public health in the vaccination efforts
United Way and Community Spoke were able to assist and provide incentives as an attractive benefit for vaccination
We were able to gather data on the demographics of attendees to ensure our goals were being met: Age, Race, Ethnicity, Gender, Zip Codes
Our overall vaccination rates are difficult to determine because the partnership have been ongoing from the beginning working to ensure health equity and access to care in Ottawa County.
The partners acted as an advisory council to public health
Partners outreach to each of their communities as a trusted advisor on behalf of public health
Successful development of messaging by community partners on vaccinations, videos, and Latinx media developed for weekly outreach.

When vaccination for COVID-19 began, OCDPH aligned our mass vaccination plan with that of the Michigan Department of Health and Human Services, aiming to meet our operational goal of vaccinating 70% of people age 16 years and older for COVID-19 by the end of 2021. Along with this operational goal, we constructed three practice goals to achieve. OCDPH aimed to vaccinate the community as quickly as possible, prioritize those at the greatest risk for severe COVID-19 illness, and Decrease the Extra Burden of COVID-19 on Communities Experiencing Social Vulnerabilities by ensuring equitable vaccine distribution. Following the CDC's recommendations on prioritizing population groups for vaccine allocation, we identified those populations within the community and distributed the vaccine accordingly. OCDPH had three ethical principles guiding our vaccine allocation, as recommended by the Grand Valley State University Health Ethics Advisory Team: maximize the benefits in the community, promote justice and equity, and promote public trust and a sense of community ownership in the process. To ensure our overarching goals were met, the workload was broken down into operational groups of OCDPH team members including incident command, operations, planning, logistics, epidemiology data, and finance and they each had their own objectives to meet. As the pandemic continued and needs in the community regarding vaccinations shifted, objectives for each operational group were adjusted to meet current community needs. Our beginning practice objectives focused on rapid and equitable vaccine distribution; these objectives have evolved and now additionally include objectives to improve our practices and ensure the sustainability of said practices. Incident action plans were routinely updated with details on these new objectives.

The OCDPH COVID-19 vaccination response timeframe was guided by recommendations from both the CDC and the state of Michigan. Our first phase began with vaccinating our priority one population: hospital workers and emergency response systems. We then moved into conjugate living facilities like skilled nursing and adult foster care, first vaccinating staff and then residents with the hopes of preventing outbreaks to protect residents in long-term care facilities. Our third priority group was workers who have direct patient contact. From here we moved on to our second phase came to include people 75 years of age or older that were not included in our first phase. Our third phase included individuals 16 years of age or older that were at high risk of severe COVID-19 infection. This phase was further broken down into group A (individuals age 65 to 74), and group B (individuals age 16 to 64 with a condition that puts them at risk of a negative COVID-19 outcome). Our final phase included other members of the community 16 years of age or older that did not fit in the earlier groups. Our current focus is on vaccinating children 5 to 16 years of age, which has given us an incredible opportunity to strengthen our relationships with schools through Ottawa County.

Throughout each of the phases, OCDPH needed to balance a fair and equitable approach. The Partnering for Success: Outreach to Achieve Health Equity model helped us to achieve this goal. Weekly meetings were established with community partners that were trusted partners within our socially vulnerable populations. Community barriers and problems were discussed weekly. Public health had to swiftly adapt and modify plans to ensure outreach was available to populations. From creating multiple calendar links to ensure that a specific percentage of appointments were held for socially vulnerable populations to having community partners scheduling for those that we're unable to schedule for themselves. This partnership and outreach had to be met with a willingness for change, a recognition of failure, and an effort to rebuild to a better community partner ourselves. Each week this advisory partnership grew and shifted gaining community momentum. Sometimes upwards of 40 partners advised OCDPH on health Equity and Outreach. As the messages changed, the partners assisted in bridging the gaps and sharing the message through a trusted partner. It was a true community effort for vaccination outreach.

As the COVID-19 pandemic progressed, OCDPH found success in increasing COVID-19 vaccine uptake through collaborative partnerships and the creation of community outreach vaccine teams also referred to as strike teams. Key components of successful vaccine uptake in Ottawa County were the community partnerships that had been in place long before the pandemic but strengthened throughout the pandemic. Ottawa County partnered with schools, colleges and universities, fire, Emergency Medical Services (EMS), and law enforcement to create strong support systems that were vital during the COVID-19 vaccine rollout. Key partnerships that were of utmost importance to the success of our vaccination efforts were with the Ottawa County Human Services group and the Community SPOKE/Lakeshore Nonprofit Alliance. As OCDPH identified the need for outreach the Ottawa County Human Services group volunteered to assist with vaccination planning and other efforts to achieve our goal to equitably distribute and vaccinate all eligible persons.

As the vaccine availability shifted in the community and the demand wanned, OCDPH was challenged to move to a new approach for vaccinations: community strike teams. As one member coined, Meeting people where they're at and trying to make it as convenient as possible by going to folks.” To increase our community outreach and target underserved populations, the community strike teams allowed us to conduct pop-up” clinics in areas not close to our mass vaccination clinic areas. OCDPH was able to collaborate with leaders in the Latinx community to provide vaccination clinics via strike teams to our Latinx population in Ottawa County.

With our current focus being on creating equitable access to the vaccine among school-age children (5-16 years of age), we have been able to rely on our community partnerships and school partners around Ottawa County to assist us. OCDPH has conducted kids' vaccination clinics at six different schools in the county, each one being in the evening to accommodate parents; with the assistance of school administration and school volunteers, OCDPH was able to achieve mass vaccination of our county's children.

OCDPH has been able to make mass county vaccination possible through our community partnerships and the grants and federal funds that were available to us.

OCDPH evaluated our practices on a weekly basis through our Partnering for Success: Outreach to Achieve Health Equity meetings. These meetings were focused on the information our partners shared about OCDPH actions and upcoming events, but also on the lessons learned from the week prior. OCDPH did not wait to implement improvements, rather incorporated improvements and changes as the vaccination model were implemented weekly. It also cannot be overstated that the guidance and recommendations our community partners provided to help improve the inclusiveness to vaccine clinics were incredibly valuable we can't thank our partners enough for helping make our strike teams and mass clinics a success.

For example, if the lesson was all the appointments filled up too quickly so individuals without a computer could not make an appointment, OCDPH implemented multiple calendars to hold appointments for those individuals who would call in for appointments and give priority to this population on the top of the list.

Another adaptation from a lesson learned was that OCDPH needed more Spanish-speaking individuals on site. OCDPH adapted by working with the Ottawa County Medical Reserve Corps and staff to increase the number of Spanish-speaking individuals at each site to create a sense of safety and trust for non-English-speaking individuals.

A final example was designating a percentage of appointments for designated populations to ensure OCDPH was meeting health equity in Ottawa County when the appointments were not being filled. OCDPH worked with the community partners to develop outreach mechanisms for calling through trusted advisors to schedule or provide scheduling links.

Another source of data for OCDPH was our Qualtrics surveys that were implemented at the clinics asking individuals to evaluate their experience. This data provided OCDPH with actionable information in a timely manner for adaptation into vaccination clinics that needed to be made or enhanced.

Finally, the vaccination number itself and the percentages have acted as secondary sources for our model.

Together the group was able to vaccinate 16,650 people plus using the Strike Team methodology at approximately 124 clinics from Feb 2021 thru Nov 2021.

Some events vaccinated many people and some a small number. The partnership promoted that if we gave a single vaccine at an event it was a success because we were in the community, creating partnerships and building trust. All of which were underlying goals for Public Health.

The COVID-19 pandemic has provided us with multiple opportunities to improve our current and future practices. Continuous feedback from our Partnering for Success: Outreach to Achieve Health Equity has established an environment at our vaccine clinics that are more accessible and more efficient. Quickly, OCDPH learned we must provide vaccine clinics at multiple different time frames to accommodate all lifestyles from working parents, first and third shift workers, and vulnerable populations that may encounter time restrictions for traditional settings. In addition, the community partners assisted OCDPH with the continual shift of vaccine education and advisements for distribution. The monitoring-built partnership and OCDPH ensured that our messaging would be accurate and designed to meet critical populations in a welcoming manner. This monitoring shows the most effective ways to use the funds provided to us to increase vaccine uptake and distribution.

OCDPH has learned that in this pandemic, it is essential to rely on our community partners and outside companies, to listen to the concerns and address each concern to build our Public Health 3.0 to successfully achieve our goals. Utilizing community/company volunteers gave us the ability to increase our vaccine response efforts and build trusting community relationships simultaneously. While this pandemic has been a top priority at the public health department, there are still other important issues that need to be addressed, so our staff cannot only focus on COVID vaccine response. The community volunteers allowed us to expand our vaccine response while still working on our normal health department practices.

Effective communication between OCDPH and Ottawa County residents has been an ongoing lesson throughout the pandemic. We as a department have learned to provide the most accurate information possible to the community utilizing the data and knowledge that we have at that current moment. Updating the public with information regarding the vaccine has increased community engagement, both positive and negative, on our social media accounts. OCDPH has learned to safely navigate the pushback that we have received from the community regarding the COVID-19 vaccine. By communicating the facts on the vaccine and providing other resources for county residents to use to learn more about the vaccine, we have created a large portion of the community who have increased their trust in our public health department. We have aimed to be a reliable source of information for the community throughout this pandemic. Effective communication between OCDPH and our community partners has been an ongoing lesson as well. Being straightforward on what we can offer our community partners and what we need from them has been key in ensuring all vaccination efforts are running as smoothly as they can.

OCDPH values equity and instituted a health equity committee in 2019. The committee is working to build internal and external capacity by prioritizing policy, customer experience, and training. This advisory council helps build authentic leadership in creating equitable vaccine access because they will be the key advisors, strategic planners, and decision-makers. Through this community member-led partnership, leadership is shared, and power is shifted to the individuals most affected by vaccine disparities. Future OCDPH steering committees can take lessons learned and adopt practices and strategies that proved beneficial for better reaching the Latinx community so that even after we've moved past COVID19, the relationships formed, and the trust built will be sustained. Additionally, the media campaign will help inform OCDPH communication policy and framework to ensure equitable public health communications. Finally, by leveraging technology and customer feedback we can enhance our infrastructure and improve how we promote and deliver services.

Finally, OCDPH is in entering into Phase 2 of the Partnering for Success: Outreach to Achieve Health Equity project through applying for a community grant to assist with the further community outreach for vaccination hesitancy. OCDPH plans to utilize the grant funds for the following activities:

· Create advisory council that will be comprised of Hispanic/Latinx community members (5), community partner agency representatives (5), and OCDPH staff (2). This advisory council will help spearhead all initiatives for improving vaccine rates within the Hispanic/Latinx population and will serve as community-level immunization champions. Advisory council members will be asked to attend at least one community-based clinic per month, assist with the distribution of information and clinic recruitment, and provide support and care coordination to individuals within their networks. Advisory council members will be asked to track progress, attend bi-weekly meetings and they will be compensated for their time. Additionally, OCDPH will hire a part-time team member to help coordinate and facilitate the advisory council.

· Develop a public health media and vaccine education campaign in collaboration with OCDPH communications, emergency preparedness, and agency contractor. Grant funds will be used to specifically target Hispanic/Latinx community members and to increase social media presence using platforms other than Facebook and YouTube, which is what OCDPH primarily currently utilizes.

Increase vaccine access by offering seven, at minimum, community-based vaccine clinics between February and July 2022. Grant funding will be used to offset operational and vaccine (other than COVID-19 vaccine) costs and to improve the functionality of the vaccine appointment reminder system to incorporate reminders in Spanish