Vaccines remain the most effective way to significantly reduce the risk of severe illness, hospitalization, and death from COVID-19, of which Black, Indigenous, and people of color (BIPOC) communities bear a disproportionate burden.

With more than 76 percent of US adults fully vaccinated against COVID-19, public health efforts are increasingly focusing on the people who remain unvaccinated. Some have described this reticence to get the jab as “vaccine hesitancy.”

In many ways, this term is reductive. It implies being unvaccinated is solely attributable to personal preference, ignoring the structural barriers some face, especially those from BIPOC communities, and how social determinants of health across all aspects of a person’s life influence health behaviors and create disparities in vaccination rates.

What are the social determinants of health?

Evidence shows clinical care contributes only 10 to 20 percent to a person’s health, while other factors, often broadly referred to as the social determinants of health, account for 80 to 90 percent (excluding genetics).

The Office of Disease Prevention and Health Promotion defines the social determinants of health as “the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks” and groups them into five areas:

• education access and quality
• economic stability
• social and community context
• neighborhood and built environment
• health care access and quality

How do social determinants of health influence COVID-19 vaccine uptake?

Through our work with a range of community-based organizations participating in the Partnering for Vaccine Equity (P4VE) project, we’ve seen how the social determinants of health affect vaccination access and uptake:

Lack of transportation

Transportation barriers can lead to missed health care appointments and delayed care, which may lead to poor health outcomes. A lack of access to public transportation—which is part of the built environment—disproportionately affects certain demographics; women, young adults ages 25–29, Black workers, and low-income workers tend to use public transportation for commuting more than other groups.

If public transportation is not available or reliable within a community and a person doesn’t own or have access to a car, it can be challenging to visit a COVID-19 vaccination site even if that person wants to get vaccinated. Therefore, placing vaccination sites in convenient, accessible locations may boost vaccine uptake.

To address this challenge in their communities, Centro Campesino, a farmworker advocacy organization in South Florida, hosts vaccination pop-ups at nurseries, farms, and migrant villages where many farmworkers work and live. The Mississippi Immigrants Rights Alliance (MIRA) developed partnerships to host vaccination events at locations such as poultry plants, churches, and community centers.

Language barriers

A growing evidence base identifies health care providers’ linguistic competence as a key component of health care access and quality, with language competence contributing to decreases in health disparities.

If a community has a large Spanish-speaking population but few Spanish-speaking providers and few health education materials in Spanish, it can be difficult for people to ask providers questions or access evidence-based information about the safety and efficacy of vaccines.

Further, public health information isn’t translated into some languages at all or, when it is translated, it’s done poorly, creating confusion with imprecise or incorrect wording.

Community-based organizations can help address these language barriers. Community health workers with Fresno Interdenominational Refugee Ministries are proficient in a variety of languages and host vaccination events in languages used by community members, such as Arabic, Hmong, Lao, and Ukrainian.

Luke’s House, a clinic in New Orleans that serves a large Hispanic community, offered trusted messenger training in Spanish to support recruiting health ambassadors who speak the language and understand the culture and values of the people they are working to reach.

The P4VE Vaccine Resource Hub and the National Resource Center for Refugees, Immigrants, and Migrants provide vaccine information examples and templates in many languages to help organizations get started on this work.

Other needs aren’t being met

Organizations working in the health care space are increasingly adopting a whole-person care approach, coordinating physical health, behavioral health, and social services to address social and community factors that affect health outcomes.

Supporting access to basic human needs, such as fresh and healthy food, child care, and flexible clinic operating schedules, can lessen the burdens of accessing health care and give people the psychological space to prioritize their health, including vaccination. A parent with low income will be more likely to get the shot if they do not need to worry about where and whether they can buy groceries, take time off from work, or leave their children in a safe place with trusted people.

Considering health and social factors outside vaccination can increase community trust in the organization and result in creative approaches to meet people where they are. Atlanta’s Refugee Women’s Network provided child care and transportation to encourage participation in a community peer-group workshop for unvaccinated Eritrean and Ethiopian mothers, where they discussed vaccination.

The Bay Area Women’s Coalition (BAWC) in Mobile, Alabama, partners with other organizations to bring vaccination opportunities and education to food and toy drives. When engaging community members, BAWC health ambassadors discuss not only vaccination but also how to sign up for assistance programs, such as the Supplemental Nutrition Assistance Program.

Why does this matter?

Inequities related to the social determinants of health aren’t new—COVID-19 simply shed more light on and exacerbated them in many places and among many groups, especially BIPOC communities. Addressing the social determinants of health needs in these communities is essential to advance health equity and improve health outcomes for all.

As the country continues to combat COVID-19, organizations working to promote vaccine confidence and uptake can be aware of these determinants, use their knowledge to address vaccine and health care access barriers, and work with partners to sustainably address broader, systemic challenges.