As COVID-19 Vaccine Hesitancy Decreases, Boosting Access Will Be Critical to Reducing Inequity in the DC Metro Area

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The Washington, DC, metropolitan area has suffered during the COVID-19 pandemic. According to data from the DC, Maryland, Virginia, and West Virginia dashboards, about 430,000 residents of the metro area experienced infections, and 7,000 lost their lives. Similar to national trends, the coronavirus has disproportionately affected people of color, exacerbating inequities that existed long before the pandemic hit because of deeply rooted structural racism.

 Vaccination efforts are well underway. More than 1.4 million COVID-19 vaccines have been administered in the greater DC metro area as of March 23, 2021, and by our calculations, 745,000 residents—mostly those in age and occupation groups at higher risk—are fully vaccinated.

 Vaccine availability is increasing, but demand still outstrips supply. And concerns about equitable distribution remain. Many reasons contribute to inequities in vaccine distribution, but much of the focus has been on vaccine hesitancy, particularly among communities of color. In February, for example, Maryland governor Larry Hogan attributed disparities in vaccine take-up to communities of color “refusing” to get vaccinated. But at that time, many Marylanders reported wanting to get vaccines, but faced challenges obtaining them. Moreover, hesitancy should not be confused with refusal. Though some may have reservations about COVID-19 vaccines, many are still deciding and can be persuaded. To reduce inequities, evidence supports focusing on improving vaccine access instead of faulting reluctance for racial and ethnic disparities in vaccination rates.

Vaccine hesitancy rates are decreasing among Black nonelderly adults in the DC metro area

 Nationwide surveys have found higher rates of vaccine hesitancy among Black respondents, likely related to a history of exploitation of Black bodies in medical research and the persistence, even today, of racism in the health care system. But recent Urban Institute research found vaccine-hesitant Black adults seemed more open than their white counterparts to changing their minds. And although, on average, they are more likely to plan to get vaccinated, the majority of vaccine-hesitant Americans are white.

 Multiple data sources find vaccine hesitancy falling nationally, and new data from the US Census Bureau’s Household Pulse Survey shows declines in hesitancy overall and among Black residents in the greater DC region. In the first half of January, 23 percent of Black respondents reported they “probably” or “definitely” would not get vaccinated; by late February, this rate had decreased to 10 percent. This reduced hesitancy occurred as receipt of vaccinations also increased among this group (from 5 to 28 percent; data not shown).

Bar chart showing the share of Black nonelderly adults in the DC metro area who would probably or definitely not receive a COVID-19 vaccine decreased between January and February 2021
 
Improving access could help reduce inequities

Increasing vaccinations in the DC metro region and closing equity gaps will require focusing on easing barriers keeping those who want a vaccine from getting it. At a recent Urban event, Travis Gayles of the Montgomery County, Maryland, Department of Health and Human Services; George Jones of Bread for the City; and Urban’s Jennifer Haley and Monique King-Viehland explored several strategies.

  • Eliminate technological barriers. Not everyone has a computer and internet access and the ability or time to navigate online appointment systems, so nontechnological alternatives can help more people secure appointments. Virginia has established a phone hotline to assist, and DC has begun door-to-door outreach to register eligible people in the hardest-hit areas of the city.
  • Improve accessibility of vaccine distribution sites. Maryland has reserved some vaccine doses at its mass vaccination site in Prince George’s County for county residents, who have one of the lowest vaccination rates in the state despite suffering the highest infection burden. But as Gayles indicated, simply locating vaccine distribution in an underresourced neighborhood does not necessarily lead to more equitable distribution. Equally important is communicating vaccination options, addressing transportation challenges, and directly reaching out to those unable to visit. Baltimore County arranges Uber rides to vaccination locations and vaccinates homebound residents in their homes, and DC has established clinics in high-traffic areas in its hardest-hit zip codes and provides buses for eligible residents.
  • Increase convenience of vaccine availability to accommodate people’s other responsibilities. Flexible hours for vaccine administration—including on weeknights and weekends—can help busy adults balance vaccine appointments with work and caregiving responsibilities. Gayles noted that Montgomery County is working with employers to ensure people can take off work without penalty to get their shots.
  • Improve communication for non-English speakers, and assure immigrant families that obtaining vaccinations will not jeopardize their status. Language access remains a challenge, as has been documented in Maryland and Virginia, and panelists recommended working with translation services and providing multilingual materials. Ensuring undocumented immigrants are never turned away or reported to immigration authorities when seeking vaccinations is essential. Holding vaccine clinics in conjunction with trusted immigrant-serving organizations could help immigrant families feel safer seeking vaccines.
  • Coordinate efforts with trusted, culturally effective community partners. Anecdotal and empirical evidence suggests that as people see more of their acquaintances vaccinated, they reassess the likelihood of side effects and become more receptive to vaccination. This is especially true with trusted community leaders, who can serve as ambassadors. DC Health (the city’s Health Department) allowed Bread for the City to remove itself from DC’s registration portal as a vaccine site when mostly white residents were coming in for the vaccine, rather than their usual clientele. This allowed them to reach out to community residents for appointments, and Jones said vaccinated residents spread the word, increasing uptake.
Ensuring future crises don’t hit people with low incomes and people of color hardest will require a commitment to dismantling structural racism

More broadly, meeting financial, housing, health, and other needs would help families of color and families with low incomes weather the uncertainty. Montgomery County is partnering with a variety of community-based organizations to pair their pandemic response with social supports, what Gayles referred to as a “whole person health model.”

But addressing these problems is also necessary for long-term improvements so the region can be prepared for the next crisis. An analysis of past flu vaccination efforts shows that people with low incomes and people without health insurance and/or a usual source of care are less likely to receive vaccinations, suggesting that addressing health care access and health-related social needs could also reduce vaccine inequities. Moreover, uprooting systemic racism, which limits economic opportunities and leads to inequities in income, education, and health, would mean we approach future emergencies on more equal footing.

Moving forward, regional policymakers and stakeholders across a variety of sectors should plan for future crises with racial equity at top of mind. The greater COVID-19 infection and death rates among people of color has revealed a “second public health crisis” of structural racism, according to Jones. Direct attention on improving vaccine access to communities of color—not explaining away lack of access as refusal—can help counter inequities now and in the future.


The Urban Institute has the evidence to show what it will take to create a society where everyone has a fair shot at achieving their vision of success. 

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