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Targeted or open to all? COVID-19 vaccine equity clinics in N.H. have tried to do both.

A person receives a COVID-19 vaccine at a barbershop.
Gaby Lozada
La Fama, a Latinx barbershop in Nashua has held COVID-19 vaccine clinics for patrons. The first clinics took place over the summer. One of the shops locations recently held another clinic, where some people got booster shots and others got their first shots.

From churches to state parks, over 1,600 New Hampshire COVID-19 vaccine “equity clinics” have tried to take the vaccine out of traditional medical settings and meet Granite Staters where they are.

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The clinics are often hyper-specific and tailored to community needs by local public health workers. And the stakes were high – these clinics were the centerpiece of state health officials’ goal to “mitigate inequities in health care access and health outcomes” by specifically focusing on outreach to racial and ethnic minorities, and other at-risk populations, including unhoused people and those living in economic hardship.

As 3 in 10 Granite Staters remain unvaccinated, per CDC data, the clinics are still happening. But, a year later, it’s still unclear if they’ve mitigated inequities in COVID-19 outcomes, like hospitalizations and deaths.

And the clinics are changing. Many equity clinics have become less focused on the vulnerable populations they were supposed to serve and are now for any Granite Stater.

It’s hard to know how well these efforts have worked in New Hampshire, largely due to gaps in COVID-19 data collection, pre-existing barriers in access to health care, and a long underfunded public health infrastructure.

As the Granite State aims to reduce health disparities across the state with other health initiatives, the effort's shortcomings and successes could provide important insight into future public health initiatives.

A year later, not everyone sees the need for more equity clinics amid fears of alienation 

Over 12 months after the vaccine became available, the need for equity clinics still exists, but demand for vaccines has dropped. The politicization of the vaccine is pervasive and fueled by misinformation that at times, has reached all the way to the State House.

As hundreds of locations still offer the vaccine, some stakeholders say people have already been able to get the shot elsewhere. Some who have held past clinics don’t see a need for additional efforts.

Schools face strong pushback from parents who oppose the vaccine, said Scott Schuler, the incident commander of the Seacoast COVID-19 complex. They’ve coordinated dozens of vaccination clinics in the region.

“Schools are saying we've done these big clinics. People have had access. We want out,” Schuler said.

But in other cases, like Lamprey Health Care, which sees patients in Nashua, Newmarket and Raymond, holding more clinics is too resource-intensive with too little payoff.

Lamprey works with many low income and uninsured patients, and the organization has coordinated vaccine clinics. CEO Gregory White said recently they’ve slowed those efforts due to a precipitous drop in demand.

Lamprey doesn’t have the resources to pursue poorly-attended clinics, White said.

Those conditions are different from a year ago. Back then, holding a clinic at a time when people are off work and offering services in languages other than English meant dozens of unvaccinated people would come in for a shot.

But many accessibility issues haven’t gone away.

Lilo Almonte has hosted vaccine equity clinics at his Nashua barbershop and said language barriers resurfaced for some Spanish-speaking patrons when booster shots became available.

Robert Ortiz, a bilingual community health worker with the Nashua Division of Public Health and Community Services, agrees vaccine access issues persist, even if fewer people are actively seeking a shot.

Successful COVID-19 vaccine equity work today, Ortiz and other public health workers say, addresses issues of vaccine access and vaccine hesitancy. They find talking to people in person is crucial because that interaction can cut through disinformation.

But individual conversations and face-to-face engagements are difficult to do at scale.

And other health care workers feel their time and energy on those efforts should be conserved, especially when conversations about vaccination can be alienating. If building trust with patients is their goal, they say talking about the COVID-19 vaccine isn’t going to do it.

The dynamic means vaccine equity efforts often fall on local public health workers and community members, who are often unpaid.

Measuring the success of equity clinics isn’t easy 

And while New Hampshire’s equity clinics have brought the vaccine into hundreds of locations, it's unclear how successful they’ve been at increasing vaccination rates among vulnerable populations or reducing disproportionately severe outcomes of the virus.

“Data is somewhat limited because of the well-known issues that we've had in rolling out our immunization registry,” said Patricia Tilley, director of the Division of Public Health Services for the New Hampshire Department of Health and Human Services.

She said the state also relies on anecdotes from local public health workers and others involved in this work to provide context about the effectiveness of the state’s vaccine equity strategy.

That insight is especially important for assessing how the state is reaching populations that aren’t part of its official data collection, like LGBTQ+ Granite Staters and those with disabilities, Tilley said.

But it’s still been hard to evaluate the state’s progress on one of the equity clinic's original goals: addressing the disproportionate impact that the pandemic has had on people of color.

New Hampshire isn’t publicly reporting racial or ethnic data on some important COVID-19 outcomes, like hospitalizations. While the state does report case and mortality rates across race and ethnicity on its COVID-19 dashboard, that data doesn’t account for age, an important indicator in COVID-19 outcomes.

But state health officials knew Granite Staters of color – people at high risk of severe outcomes from COVID-19, like hospitalization or death, also might have difficulty getting vaccinated.

In the pandemic’s first eight months, racial and ethnic minorities in New Hampshire were hospitalized at nearly 4 and a half times the rate of white residents and dying from the virus at 1 and a half times the rate of white residents, when age was accounted for according to state officials.

But in the last year, the state appears to be struggling to close gaps in vaccine coverage for these groups.

As of Feb. 16, about 39% of Black residents and 49% of Latino residents have at least one shot in New Hampshire, compared to about 56% of white residents, according to state data. The numbers are likely a significant undercount because state data is missing thousands of doses administered by pharmacies.

Still, analysis from the Kaiser Family Foundation suggests that these gaps between racial and ethnic groups are larger than national averages.

State data shared with NHPR in June 2021 showed, at least initially, the equity clinics were reaching a more racially and ethnically diverse group of patients than the state's broader vaccination program.

But equity clinics reached a much smaller number of people overall. NHPR has requested more recent data about the racial and ethnic makeup of people who have been vaccinated at equity clinics to date, and the state has said they’re working on providing more information soon.

But other details provided by state health officials show New Hampshire’s efforts shifted away from clinics geared toward racial and ethnic minorities and other at-risk populations in the summer of 2021.

Between February and July 2021, more than 70 clinics occurred across the state with a focus on vaccinating racial and ethnic minorities. But between July and December, just 16 clinics were held with the same focus, according to state equity clinic data shared with NHPR.

And as the state oversaw a steep decline in equity clinics targeting racial and ethnic minorities, more “general access” equity clinics occurred — in other words, clinics that were open to anyone.

Why the state shifted to more “general access” clinics

One reason is the introduction of the state’s mobile vaccine van, which started work during the summer. The van’s clinics are tracked as a part of the equity clinic initiative, but the van goes where it’s invited, in an effort to reach the unvaccinated or unboosted, wherever they may be, whoever they are.

Sometimes those clinics attempt to reach a population included in the state’s early equity clinic goals, like a visit to Seacoast Family Promise, which works with people experiencing housing insecurity. But other times, the van travels to places like Bear Brook State Park, in the middle of the workday – which likely wouldn’t find people the equity initiative tried to reach.

The rollout of boosters and vaccines for kids 5-11 also caused the shift away from some of the more targeted equity clinics.

Pharmacies and other private sector actors were initially overwhelmed by the public’s demand for these shots. Many of the same health workers coordinating booster equity clinics had to spend months helping the state reach the general population by coordinating school-based clinics and booster events.

 One of New Hampshire's mobile vaccine vans at Bear Brook State Park on August, 18, 2021.
Alli Fam
Over the summer, New Hampshire's mobile vaccine van held mobile clinics at state parks, where were tracked as a part of the equity initiative. Clinics like these, are part of the approach of having an "open door" to all Granite Staters who may not be up-to-date on their COVID-19 vaccines.

But Tilley says general access clinics are meant to reach everyone in the community, including Granite Staters of color or other at-risk populations, even as fewer clinics focused on reaching racial or ethnic minorities happen.

She says equity considerations for some of these clinics aren’t evident from the “general access” label. That can include efforts from community health workers, who may be helping people they work with go to a general access clinic.

NHPR has requested data about age-adjusted COVID-19 related hospitalizations and deaths in an effort to better understand what, if any, impact the state’s vaccine equity efforts have had on reducing health disparities for racial and ethnic minorities. But again, we are still waiting for that information.

That lack of information is part of why it’s so hard to track success, as are long-standing health inequities that will take more than one health initiative to overcome.

Public health in New Hampshire looks ahead at an uncertain future 

Many regional public health networks and city departments have worked closely with local stakeholders, to help hold equity clinics.

Health officials say they hope to build on those relationships, but maintaining them takes work and resources.

More paid community health workers who often connect their communities and the health system, could be a part of making that happen.

Over the past year, New Hampshire health centers and departments have increased their number of community health workers.

But as public health leaders look ahead, they say adequate funding from the state is not guaranteed. Millions of dollars in federal money for vaccination work stalled last fall in the wake of anti-vaccine mandate protests. 

State funds were also recently cut for health centers that serve low-income women and families.

Health leaders also say this year's legislative agenda is an attack on public health and their work. There are bills to limit the state’s vaccine registry and weaken vaccine requirements at schools, including non-Covid diseases like measles and tetanus.

Kris van Bergen, who has spearheaded dozens of equity clinics in the North Country, is one of many concerned public health workers.

”There's been some decided focus on undermining the public health infrastructure that makes it less stable” she said.

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