Community of Communities: Co-Created Education to Increase COVID-19 Vaccine Uptake

Abstract

Introduction: This paper describes and evaluates the COVAX educational program for Vaccine Acceptance and Access Lives in Unity, Engagement, and Education, Baltimore's vaccine peer ambassador (VPA) initiative, which served to engage the community (including those resistant to vaccination) and increase community knowledge of COVID-19 and COVID-19 vaccination.

Methods: A mixed methods approach was used to describe the effectiveness of the education program for VPA and coordinators. We surveyed VPAs to determine the impact of training and perceived influence in the community. In April and May 2022, we conducted four focus groups of VPAs and coordinators to gain further insights into survey responses.

Results: The engaged approach used in training allowed for a forum where VPAs and coordinators could share their experiences in the field and participate in the learning process. 82% of VPAs and coordinators indicated that they found the training extremely or very useful and 72% perceived their impact in the community to be high. Overall, 53% of VPAs and coordinators felt they were heard and understood by the administrators of the project.

Conclusions: The educational component of the VPA initiative used a variety of pedagogical approaches and allowed for the engagement of VPAs and coordinators. This engaged approach assisted in not only increasing scientific knowledge about COVID-19 and COVID-19 vaccination, but also built trust within a diverse group of VPAs, coordinators, and trainers.

The first COVID-19 vaccines were granted emergency use authorization in December 2020 by the Centers for Disease Control and Prevention, and the State of Maryland implemented a phased allocation plan to provide vaccination to certain groups. The Baltimore City Health Department (BCHD) ambitiously sought to vaccinate 80% of its population. As part of the larger strategy, BCHD identified a need to focus on underserved communities where vaccination rates were low, and distrust of the health system high.¹ Previous flu vaccination rates in the city achieved only 13% coverage, indicating a challenging objective.² The first group to get vaccinated were health workers and other essential personnel followed by older adults. Despite this allocation plan, it became clear that there were significant disparities among groups, with Black and Latinx residents vaccinated at significantly lower rates than white residents.

Place has a significant influence on the health of individuals and communities, and BCHD's COVAX strategy and response emphasized that engaged partners should recognize the history of racism in Baltimore City and the ongoing injustices in the healthcare system and other areas (e.g. food insecurity, financial difficulties, safety concerns, health conditions) that contribute to a person's decision to get vaccinated. As a city and regional institution, communities perceive Johns Hopkins University (JHU) suspiciously because of its extractive history. In general, the relationship between underserved communities and medical institutions is riddled with mistrust; contextually, this skepticism can be linked to practices that have not always been equitable, inclusive, and/or just. In Baltimore, memories persist of JHU's treatment of Henrietta Lacks and the HeLa cell line cultivation.³ These and other historical episodes continue to influence the level of trust between the community and institutions, which became amplified during the coronavirus pandemic.

As a highly segregated city in the United States, certain community statistical areas (CSAs) in Baltimore have lower socioeconomic statuses and are predominantly African American. The historical practice of redlining influences contemporary racial and socioeconomic residential patterns and has resulted in the development of the Black Butterfly, with low-income majority African American neighborhoods making up East and West Baltimore. In contrast to the Black Butterfly, the white L is an area around the Inner Harbor stretching straight North to the wealthy neighborhoods of Homewood and Guilford.⁴ A recent study found an association between historical redlining and present-day health in Baltimore.⁵ Areas of Baltimore that were originally redlined were associated with a 5.23-year reduction in CSA life expectancy.⁵ In addition to the Black Butterfly, the southernmost CSAs of Curtis Bay, Brooklyn, and Cherry Hill were experiencing the lowest percentage of people vaccinated. Curtis Bay/Brooklyn is one of the most polluted CSAs in Baltimore. Cherry Hill is the site of the first and largest planned suburban-style community and was the most striking example of deliberate residential racial segregation in any U.S. city.^6,7 Vaccine peer ambassadors (VPAs) would be on the front lines in these low vaccination areas engaging with the community and working to build trust that would enable the number of individuals getting vaccinated.

To achieve high levels of vaccination in underserved communities, BCHD engaged the International Vaccine Access Center (IVAC) at JHU, The School of Community Health and Policy at Morgan State University (MSU), and Maryland Institute College of Art (MICA) to help address disparities through an educational initiative based in community engagement and co-creation. The Vaccine Acceptance and Access Lives in Unity, Engagement, and Education (VALUE) Baltimore COVAX education initiative identified, engaged, and hired community members as VPAs, and coordinators (managers) to address low vaccination rates, counteract misinformation, increase health literacy, and build trust.¹

Four VALUE Community (VC) groups were established using the life course approach and included older adults, young men, pregnant and lactating women, and youth. Other VCs were more specific and represented populations in Baltimore, including Orthodox Jewish, people experiencing homelessness, Latinx, people living with disabilities and underlying conditions, and immigrants. As members of the Baltimore City community, VPAs and coordinators were a conduit that helped to understand what was happening in the community and were committed to helping improve the health and wellness of others.^8–10 The program was initiated with a series of listening sessions which assisted in designing and implementing the strategy and training.

Following the listening sessions, IVAC developed a curriculum of training to ensure VPAs were both knowledgeable about COVID-19 and vaccination and had the skills to address the concerns of the community. IVAC also trained VPAs on communication techniques informed by research on vaccine suspicion and acceptance and the role they can play in ensuring access and a public voice.^11–15 Training was conducted weekly (Tech Talks and Questions and Coffee), and a key component of the program was feedback from VPAs which assisted in driving the curriculum so it could be adjusted to reflect current community concerns.

The VALUE COVAX educational initiative aimed to provide a virtual space for a culturally and ethnically diverse group of VPAs, coordinators, and trainers who were linked by their dedication to engaging in joint action in geographical locations or settings to inform the community about COVID-19 vaccination. Building community among the VPAs and coordinators was a priority and would have to be sensitive to past and ongoing extractive and discriminatory practices. VPAs were trained to be culturally competent, humble, transparent, accountable, and collaborative so that partnerships and relationships could be nurtured.

IVAC worked with MICA to co-create materials with VPAs through facilitated design sessions. IVAC developed a continuously updated compendium of information to be used by VPAs as a resource for addressing questions on an ongoing basis. MSU facilitated training around resources for social determinants of health to supplement knowledge needed to refer individuals to services that could address broader issues.

This paper discusses and evaluates the VALUE COVAX educational initiative that prepared and supported VPAs and coordinators to work in Baltimore City communities and provide information about COVID-19 and COVID-19 vaccination.

METHODS

A mixed methods approach was used to evaluate the educational component for VPAs and coordinators working with the VALUE Baltimore initiative. Feedback was gathered throughout the project to test VPA knowledge and determine the types of questions they were receiving from the field to adapt training content regularly and address the community's needs.

In April 2022, we evaluated VPA perceptions on the impact of both the VALUE program and training provided by IVAC to ensure VPAs were equipped to educate the community, answer questions and were adept in evidence-informed techniques to respond to people who raised concerns about vaccines. We conducted an anonymous survey using Qualtrics software. We included questions on changes in knowledge and collected feedback on a Likert scale on both questions from the field and VPAs' perceived adaptability of the training to community needs throughout the project's duration (Table 1). We used Spearman rank correlation coefficient test to explore the relationship between training and experiences as a VPA.

In April and May 2022, we conducted four focus groups, two with eleven VPA coordinators and two with 20 VPAs (10 in each group). VPA coordinators selected VPAs who were the most active in the field and regularly attended the training to participate in the focus groups. Broad questions were used to guide the focus group discussion (Figures 1, 2,

Table 1.

Survey Response Rates

and 3). These data were used to contextualize quantitative data. The IVAC team conducted a thematic data analysis which included reading interview transcripts twice and then analyzing using the "cut and sort" processing technique.^16,17 The IVAC team identified sections in the texts relevant to the problem statement and objectives. The IVAC team coded data with the predetermined themes: VC effectiveness, IVAC training evaluation, administration/management, and perceived community impact. There was no data collected from the People Experiencing Homeless Group as this team's work did not continue as part of the IVAC/MSU/MICA component of the VALUE COVAX initiative after December 2021.

This work was reviewed by the Johns Hopkins Bloomberg School of Public Health Institutional Review Board Office which made the determination of public health surveillance and not research requiring institutional review board oversight.

RESULTS

VPA and Coordinator Survey and Focus Groups

85% of VPAs participated in the survey. All 11 of the VPA coordinators and 20 VPAs participated in focus groups.

Figure 1.

Training evaluation.

Figure 2.

Impact and influence.

Figure 3.

Collaborative experience.

Training Evaluation

The survey revealed that 82% of VPAs (including coordinators) found the IVAC training (Tech Talks and Questions and Coffee) very useful (47%) or extremely useful (35%) when interacting with Baltimore City community members. Overall, 92% of the VPAs and coordinators saw themselves as a lot more knowledgeable (42%) and a great deal more knowledgeable (50%) since beginning the program. 69% of the VPAs found the IVAC training personally very useful (43%) or extremely useful (26%). 22% found the training moderately useful (Table 2).

The focus groups supported and provided context for the survey results. VPAs and coordinators discussed how the training increased their knowledge and that it was useful when encountering community members. A unique part of the educational component of the VALUE COVAX initiative was that training was virtual, held weekly and continuous for a total of about 72 sessions over the course of the project. Often referred to as cross training, Many VPAs and coordinators also mentioned how they enjoyed training with other VALUE communities (Figure 1).

PERCEIVED IMPACT AND INFLUENCE

The perceived impact of VPA efforts in their respective VALUE communities was deemed high, with 72% of the VPAs reporting they had a lot or a great deal of impact while 22% thought their impact was moderate. The average mean for groups having an impact on other VALUE communities was 3.69 out of 5 (Table 2).

Qualitative comments corroborated the importance of training to conduct outreach across life stages and communities. VPAs and coordinators self-evaluated themselves as being successful in the field. "trust" and "relationship building" emerged as common themes during the focus groups. VPAs noted they were not always able to get everyone vaccinated, but that the conversations with people were meaningful (Figure 2).

A Spearman rank correlation coefficient test found that those who found the training useful were positively correlated

Table 2.

VPA and VPA Coordinator Survey Responses

to having had an impact on the city (0.44; P < 0.001), understanding the community (0.43; P < 0.001), and the project being influential (0.31; P < 0.05).

Collaborative Experience

As a co-created project, collaboration between VPA (as representatives of the community) and the administration was important. Of the VPAs and coordinators, 53%felt they were heard and understood by the administrators of the project with thirty two percent believing they were heard a lot and 21% believing they were heard a great deal; 30% felt they were moderately heard. Collaborative experience by the VALUE group is provided in Table 2.

Despite the vast majority of VPAs feeling that they contributed to project design, a quarter of VPAs felt they were limited in their impact. For example, VPAs explained that the focus on COVID-19 vaccination limited their ability to address the many needs of city residents (Figure 3).

DISCUSSION

In "Baltimore City: County-Level Comparisons of COVID-19 Cases and Deaths" Kyu Han Lee and Melissa Marx report that Baltimore City was one of the top-performing cities in their peer group when it came to COVID-19 vaccination coverage rates, also faring well in terms of COVID-19 cases and mortality. They suggest that Baltimore City did particularly well after its initial COVID-19 surge.¹⁶ As of February 2024, the total number of persons vaccinated in Baltimore City was 423,693 (72% of the total population 585,708). At the end of the ambassador project (12/31/22) there were a total of 385,200 (65.8%) persons vaccinated. Vaccines for children 5–11 and from six months of age were approved in October 2021 and June 2022, respectively. There are about 99,280 (17%) children under the age of eleven in Baltimore City. The push for childhood vaccination began toward the end of the COVAX ambassador initiative. Table 3 shows that over the course of the COVAX project, while never achieving its ambitious 80% goal, the number and percent of vaccine uptake increased incrementally.^17,18

It can be assumed that ambassadors contributed to the increasing number of individuals getting vaccinated. Community-based interventions represent one public health approach to managing and preventing disease, and community-level strategies are important as many residents may not actively seek and/or be able to access healthcare through traditional settings.¹⁹ These strategies are effective because they can uniquely reach and empower those with the information and resources needed to prevent diseases and provide support for individuals to successfully manage their conditions. Health ambassadors work to empower community residents through education and advocacy. Community health ambassadors can be a comprehensive way to promote multilevel

Table 3.

Number and Percent of Individuals Vaccinated in Baltimore City June 2021 to December 2022

involvement of community leaders and diverse organizations to concentrate on alleviating health disparities.²⁰ VPAs and coordinators made the Baltimore COVAX initiative hyper-local, allowing for the tailoring of messaging and strategies to address access barriers. This hyper-local approach included nonverbal language skills, social/environmental familiarity, and a unique understanding of the community's health beliefs, health behaviors, and barriers to health services.²¹ It was a priority of the VALUE Baltimore COVAX education initiative to bring these perspectives into the learning space.

The modus operandi of many programs is often to produce a proposal and then invite the community to make any adjustments. The Baltimore VALUE COVAX educational initiative was foundationally designed to elicit input from and position communities as equal partners throughout the project lifespan. Through the educational initiative, out of a diverse group of eight VALUE communities, one equitable and inclusive community emerged where individuals felt safe to share their experiences, challenges, strategies, and successes. VPAs and coordinators worked together on the front lines of Baltimore City to assist in making the COVID-19 vaccine not only available and accessible but used by residents. The educational initiative approach focused on diversity, equity, inclusion, and accessibility through community engagement and helped community members take the lead.

The education component of a health ambassador program is important when implementing a lay-health education initiative.¹⁹ A series of VC-specific listening sessions/co-creation exercises was the foundation of the initiative. While these sessions were VC-specific, all communities were linked by their dedication to engaging in joint action in geographical locations or settings to inform the community about COVID-19 vaccination.²² All participants had to be culturally competent, humble, transparent, accountable, and collaborative so that partnerships and relationships could be nurtured. Building community among the VPAs, coordinators, trainers, and administrators was a priority, and all participants were sensitive to past and ongoing discriminatory practices. An assumption underlying the educational approach was that by building an equitable, inclusive, and trusting educational space, a community of communities would emerge and then extend into the communities the VPAs and coordinators served.

Although the initial listening sessions (December 2020 to June 2021) were VC specific, in July 2021, the virtual training space became an integrated virtual venue where all VALUE communities intersected. Sessions were weekly and did not adhere to what Pablo Friere referred to as the banking concept of education where there is an authoritative hierarchy of those doing the training.²³ Rather, training served to tap into the community's strengths and was a participatory space for sharing knowledge and experiences.^23,24 Engaged pedagogies were implemented to create an exciting place of learning. Participatory strategies aligned the course content with the life and field experiences of VPAs and coordinators.²⁵ This made the implementation of the Baltimore COVAX education initiative bottom-up and focused on building individual and community capacity. The bottom-up approach uplifted the field and life experiences of communities and trust.^26,27

The Baltimore COVAX educational initiative worked to keep individuals involved over the long haul.²⁰ It incorporated a human-centered design framework focused on understanding people in their context and from their perspectives.^26–31 Through the co-creation process, VPAs, coordinators, and trainers shared experiences and stories while actively participating, shaping, and developing the curriculum. Throughout the process of working with VPAs and coordinators, trainers had to consciously seek to avoid reverting to the familiar top-down power structures or exploiting the experiences of people who are vulnerable or have survived trauma.³²

Thus, the co-design/creation educational process led to a feedback loop that began with listening sessions and continued with ongoing training to collect VPA and coordinator (community) input (Figure 4). During these sessions, VPAs, coordinators, and trainers shared past and present experiences and stories from the field, as this is crucial to a human-centered design. The co-creation process formed the basis of training design. Feedback was initially sought during listening sessions and as the program progressed, feedback was acquired during training and then applied and integrated into the on-going education. Thus, the educational program was not simply didactic but also used different pedagogical styles for engagement purposes.

The two training spaces where these practices occurred were Tech Talks and Questions and Coffee which alternated weekly. Tech Talks was more didactic in approach in that it was teacher centered and focused on curriculum content and knowledge transfer. VPAs and coordinators were provided with the latest scientific information and policy updates on a bi-weekly basis so that they could relay this information in their engagement. Misinformation about COVID-19 impeded efforts to get the pandemic under control and to rally the public around recommended health and safety measures. Thus, VPAs and coordinators had to have the most up to date information to do their jobs effectively and efficiently. In Tech Talks, assessments were often given to see, not only how well VPAs and coordinators were retaining information, but how the actual training had to be adjusted to accommodate the attendees' needs. The trainers used these assessments to identify areas of confusion. One area of confusion that surfaced in the assessments was the information surrounding booster doses. As a point of confusion, the trainers had to be reflective and think over how information on booster doses was taught and how the pedagogical approach might be improved or altered for improved learning outcomes. In this process, lessons were created that introduced scenarios where ambassadors would have to recall information. This exercise allowed VPAs and coordinators to apply information that they had learned and, in the process, learn from their mistakes. In addition to these scenarios, other fun methods were used for reviewing content such as playing COVID-19 jeopardy in small breakout rooms.

Figure 4.

Feedback loop model.

Questions and Coffee training used different pedagogical approaches and was not didactic. Sessions were learner-centered and used different tools and strategies focusing on the art and process of both teaching and learning. VPAs were front line workers during the COVID-19 pandemic and they were engaging with people in communities and working to increase the vaccination rate in Baltimore City. As front-line workers, they listened to people's stories about why they choose to, or choose not to, get vaccinated. Often this is not about information or the vaccine, but about how to be empathetic, listen and respond to people's concerns. Because of the experience they brought to the learning space, a constructivist approach was used and VPAs, coordinators, and trainers were actively involved in a process of meaning and knowledge construction as opposed to passively receiving information from the trainers. In this manner, VPAs and coordinators were at the forefront and brought their knowledge to the learning space by sharing information about communication, relationship building, and trust.

Questions and Coffee training was also collaborative and cooperative whereby VPAs, coordinators, and the trainers learned with each other, together. It was the VPAs and coordinators, not the trainers, who were actively in the field engaging with the community. Thus, the experience and knowledge of the VPAs and coordinators were central, and the approach was learner centered. Often, trainers had to listen to the experiences of VPAs and coordinators, provide advice based on experience, but also listen to other VPAs and coordinators who may share similar experiences. Thus, there was engagement in the collaborative learning process which capitalized on one another's resources and skills. In this collaborative space, they asked each other for information, evaluated one another's ideas and monetized each other's knowledge and experience. Sessions were also often dedicated to peer teaching, where VPAs and coordinators led sessions on topics such as accessibility, incentives, and working with community-based organizations.

This human-centered approach used in the COVAX VALUE educational initiative allowed for place-based innovation by leveraging Baltimore's existing research institutions/universities and industries (IVAC-JHU, MSU, MICA, and the BCHD) and placing these institutions in an equal partnership with the community (via VPAs and coordinators). This allowed for joint learning and innovation that increased bottom-up grassroots initiatives to enforce the collaborative spirit precipitating the expansion of new alliances and new institutional arrangements.^28,33

As the data illustrate, there were times when VPAs and coordinators felt they were not heard. While the VPAs and coordinators were at the center of the VALUE COVAX educational initiative, they were part of a much larger effort by BCHD. The COVAX initiative began with a small group of people who were quickly overwhelmed with the volume of work. Over time, more people were hired, and the project grew larger. During this process, the community, initially seen as an equal partner (especially when building trust), became decentralized with the approach becoming heavily top-down.

Thus, although the COVAX VALUE educational initiative remained human-centered and bottom up, VPAs and coordinators perceived that their voice was infrequently heard or appreciated in the overall program. During training, VPAs and coordinators expressed how many social determinants of health impacted the Baltimore City population. The educational space permitted project administrators to directly hear community suggestions and concerns, ranging from inequitable medical care access to mistrust of medical and government authorities. As community advocates, VPAs and coordinators understood the contextual challenges and possessed the knowledge about resources to refer people to needed services. However, their emphasis on the community and their needs was sometimes in conflict with the broader vaccination goals set by BCHD, which emphasized the need for vaccination and focused on the clinical aspects of the response and a COVID-only focused message. This often led to both frustration and fatigue. Although VPAs and coordinators were able to find a balance in many situations, using their understanding of communities to meet people where they are, many activities remained solely focused on COVID messaging. COVID-focused messaging included information about the importance of vaccination, the types of vaccines available, and how to access vaccines. VPAs and coordinators expressed that a greater effort was needed to honor the community as equal partners as opposed to numbers who needed to get vaccinated. VPAs and coordinators saw the Baltimore population as people embedded in communities who are often in need of basic resources (food, housing, etc.). Acknowledging and addressing these issues would result in building trust and a greater willingness of people to listen to the COVID-19 vaccine messaging.

VPAs and coordinators were the bridges of communication and served to not only provide information about COVID-19 vaccinations, but also worked to build trust between the Baltimore City Government, the health care sector, and Baltimore City's marginalized communities.³⁴ Of great concern to VPAs and coordinators was their inability to assist people with non-COVID-19 vaccine concerns. This is a valuable lesson learned and, in the future, VPAs and coordinators should be empowered to act as individuals who can connect people to the available services and resources. During training and in the focus groups, VPAs and coordinators often emphasized that having the ability to aid and support those most in need would only serve to build stronger community relationships and establish a higher level of trust.

LIMITATIONS

Although the overall educational program can be measured as a success, there were some limitations. Some VPAs and coordinators failed to complete all three pages of the survey, and thus the sample number decreases by eight for sections (IVAC Training Evaluation and Additional Data). However, this did not impact the independent interpretation of each question. Attendance at training fluctuated throughout the program, although audio recordings and Tech Talks PowerPoint slides were made available to VPAs and coordinators for later access. A compendium was also created and constantly updated so VPAs could have all the information on COVID-19 and COVID-19 vaccines at a user-friendly level.

This paper evaluated the educational component of the VALUE communities. The effectiveness of the program was measured by the participants, VPAs, and VPA coordinators. The evaluation of the educational component did not include a measure of how the greater Baltimore City community perceived the work of VALUE communities. Community surveys would have aided in impact attribution.

CONCLUSIONS

The VALUE COVAX educational initiative was ongoing and focused not only on knowledge transfer, but on engagement in a shared learning space. The evaluation of the program revealed that this engaged approach allowed for a forum where all participants could share their experiences in the field and participate in the learning process. This engaged approach assisted in not only increasing scientific knowledge about COVID-19 and COVID-19 vaccination but also built trust within a diverse group of VPAs, coordinators and trainers.