Journal of Community Medicine & Health Education
Open Access

Townhall meetings; COVID-19 education; COVID-19 vaccination; Education; Latino

In the United States (U.S.), these populations disproportionately experienced higher rates of morbidity and mortality from COVID-19: Latinos, Black non-Hispanic, American Indians, Alaska Natives, and people with socio-economic disadvantage. [1]. These populations’ significant inequities in Social Determinants of Health (SDoH) primarily explain why their COVID-19 mortality and morbidity are excessive compared to non-Latino Whites. Robust COVID-19 vaccination uptake is crucial for protecting the general population [2,3]. And since these racial and ethnic groups and people with financial hardships are at even greater risk for COVID-19 complications, getting vaccinated is imperative to address these disparities. Among these populations, multiple barriers impede vaccination adoption, including fears about adverse effects, job loss, costs, and deportation. Vaccination myths, misinformation, and distrust are other major factors in vaccination hesitancy [4- 6]. Community Health Workers (CHWs) are vital to improve vaccination rates in these communities. Extensive evidence shows that lay CHWs can enhance community health outcomes and reduce health disparities [7]. As trusted community members, they provide credible health information, healthcare access navigation and education about resources.

The Centers for Disease Control and Prevention reported in late 2022, that 87.5% of the United States Latino population have had at least one dose of the primary COVID-19 vaccination series. Further, the Latino population vaccination rate for at least one dose had improved to 89.1% at the last reported date of March 2023. However, the national Latino primary series completion rate was static at 84%. But the national updated bivalent booster rate improved from 8.6% to 25.6% in 2023 [8].

In the Latino population of Omaha, NE, primary vaccination series completion rates are lower than the national rate at 67%, as of September 10, 2023 [9]. In contrast, locally the non-Latino White population of Douglas County, Greater Omaha, in 2022 was 407,990 and had a 59% primary series completion rate, also as of September 10, 2023. Thus, the Latino vaccination rate exceeds that of the non-Latino Whites. The Latino population in 2022 was 81,347 [10]. But 33% of the Latino population in Omaha (26,845 individuals) lack the primary series vaccinations.

The purpose of this paper is to summarize a Latino Community Health Workers (CHWs) COVID-19 vaccination education, training, and community outreach program in Omaha, Nebraska. These Latino CHWs or “promotoras/res” were part of a cadre of CHWs previously trained and certified by Creighton University’s Center for Promoting Health and Health Equity (CPHHE) [11,12]. CHW effectiveness in addressing community health disparities and inequities is why the CPHHE has educated, trained, and overseen a cadre of CHWs since 2014 [12,13]. CPHHE has referred to these CHWs as “Community Health Advocates (CHAs)'' and “Community Health Advisors (CHAs),” terms common in the literature. The current efforts by the promotoras/res were part of CPHHE’s broader CHA vaccination promotion to diverse communities through personal community encounters and town hall meetings. Bilingual Latino CHAs, worked primarily in South Omaha with Latino families and individuals. CHA community encounters were in English or Spanish as needed.

CPHHE’s COVID-19 Project had 2 phases. Phases 1 and 2 aimed to reduce disparities in COVID-19 infections and vaccination, respectively, including the Latino population. In Phase 2, specific aims for CHA education and training were to show CHA trainees how to (1) overcome vaccination hesitancy and misinformation, and (2) disseminate relevant information, given language barriers and cultural beliefs and customs contributing to vaccine hesitancy. Douglas County Health Department (DCHD) in Nebraska funded Phases 1 and 2.

Creighton University funds CPHHE through distributions of state of Nebraska Tobacco Settlement funds LB692. Figure 1 illustrates CPHHE’s CHA programmatic evolution from 2014 through the 2021 COVID-19 programs [14].

Figure 1: CPHHE-CHA Historical project development

Phase 1 of CPHHE’s CHA COVID-19 program involved training CHAs to educate their respective communities on COVID-19 infection prevention and transmission. Phase 2 CHA education and training about vaccination promotion complemented Phase 1 prevention training. Phase 2 training employed a train-the-trainer approach. All CHAs in the program were experienced in collaborating with community members and had well-established community trust and rapport.

The training's main objective was to ensure that these CHAs understood scientific aspects of COVID-19 infection, transmission, and vaccination effectiveness and development, including CDC information in English and Spanish. For the promotoras/res and their audiences, scientific information was translated and discussed in plain Spanish to ensure that they fully understood and could confidently communicate the facts.

Curriculum development and CHA training

For the overarching project, collaborating contributors included Omaha community organizations, Creighton University, and local governmental agencies. Project leadership met weekly. Community partners were Latino and Maya community CHAs, Nebraska Center for Healthy Families (NCHF), Lee Brown and Associates (Healthcare Consulting Firm), African American churches, Urban League of Nebraska, Omaha, Charles Drew Health Centers, OneWorld Community Health Centers, and Omaha (Public) Housing Authority (OHA) [12]. Program design, implementation, evaluation, and management details are described in our overview article [14].

The promotoras/res in the Latino community were educated and trained in 2021 during the pandemic’s height. The weekly topics included, over 8 weeks: local and national COVID-19 data by population (morbidity, mortality, and vaccination rates), COVID-19 vaccinations development process and clinical trial outcomes, how vaccines boost the immune system, and overcoming vaccine myths and misinformation. Particularly for promotoras/res and their communities, other topics included various fears (see below), costs, and cultural considerations like language barriers that can contribute to vaccine hesitancy. Case studies complemented didactic presentations. Small groups discussed hypothetical cases involving practical COVID-19 issues. All participants then regathered to share and reflect on small group reports. A bilingual facilitator guided Latino CHAs in their small group. CHA topics also included lists of community resources like vaccination and testing sites, food pantries, clinic locations and hours, and information on prevention measures like masking and hand sanitizing. The bilingual (Spanish and English) academic partner monitored and addressed Latino CHA understanding of the presentation.

All Latino session materials were translated into Spanish. A Latino expert in translation of materials verified accuracy and culturally sensitive language. The featured medical and public health speakers presented in English. A local Latino community lay leader and Latino academic partner translated into Spanish as needed. The scientific information was translated and discussed in plain Spanish to ensure that the CHAs (“promotores/ras”) understood fully the facts during the eight-week training so they could explain and disseminate this information correctly, in simple terms, and with confidence to their circle of influence.

Town halls

Practices: To prepare 2 town halls, practice sessions were held with the CHAs. Practices helped overcome CHA nervousness and assure information accuracy. Also, Author ISS individually met with 2 of the promotoras to rehearse presentations, ensuring comfort and quality. Prior to the first Town Hall, Authors ISS and JRS met to ensure presentation of scientific information in Spanish was linguistically appropriate. To prepare for the second town hall, Author LV helped a CHA presenter update local COVID-19 statistics and showed them how to explain their significance to the Latino population.

Presentations: Themes addressed attendee needs, informed by CDC guidelines [14]. Two CHAs and a health expert discussed vaccine facts, population specific data, vaccine science, myths, and misinformation. All materials were presented in Spanish. Moderators were a local Latino lay leader and a Latino Academic Partner.

During the town halls, moderators first introduced CHA and expert presenters. A moderator then detailed county COVID-19 data (morbidity, mortality, and vaccine rates for the Omaha Latino community). Next, the health expert addressed COVID-19 vaccine development (clinical trials basics and immune system effects), CDC guidelines including mask wearing, hand sanitizing, social distancing, vaccine side effects, allergies, COVID-19 variants, and prior infection. CHAs then presented other facts regarding vaccine myths (effects on pregnant or menstruating women, post-vaccine mask wearing, and vaccine safety). Other CHA topics were disproportionate Latino COVID-19 morbidity and mortality, including comorbid diseases like diabetes, high blood pressure, and obesity. It was stressed that chronic diseases increase vulnerability to worse COVID-19 outcomes.

CHAs also addressed Latino vaccine hesitancy regarding:

• Fear of being identified as undocumented,

• Costs concern,

• Fear of job loss for taking time off for vaccination,

• Side effects and manipulation of their own DNA,

• Religious beliefs and prohibitions regarding alleged fetal stem cell use in vaccines,

• Relentless concern that the vaccine could lead to COVID-19 infection,

• Belief that prior COVID-19 illness provided permanent infection protection (voiding vaccine need), and

• Fear that vaccine side effects are worse than the disease itself.

Finally, attendees were encouraged to ask questions of the presenters and then responded to an online evaluation survey available in Spanish and English.

Communication: Community-wide communications over 6 months involved collaboration with community-based organizations and county media outlets. Messaging included prevention measures like masking, social distancing, and vaccination promotion. Communication modalities were social media, radio, TV, newspaper, newsletters, music, bulletin boards, billboards, and public zoom meetings in English and Spanish [14]. The overarching goal of the town hall meetings and community encounters was to provide a forum for community members to discuss pandemic relevant topics and question CHAs, experts and panelists. The main objective was to help attendees and community members overcome vaccine hesitancy, understand the scientific validity of vaccine development, and dispel myths and misinformation.

Project communications were tailored culturally and linguistically. Town hall meetings lasted 1.5 hours, 12 over 6 weeks (July 2021-August 2021). Two of 12 were Latino community meetings. For Latino audiences, communication materials were translated into Spanish. During town hall meetings, communication leaders used a conference call number to troubleshoot issues during the town hall meetings.

Community encounters: CHA community encounters were informal and customized health education sessions with one or more community members in contrast with the more formal setting of the town hall meetings. CHA training included:

• The use of tablets to complete data collection forms during community encounters,

• Linguistically translating content to match community members' health literacy, and

• How to facilitate these community encounter discussions. An example is using reflective listening skills and summarizing what was heard, then educating in response to help overcome vaccine hesitancy. These skills are grounded in motivational interviewing methods [15].

Evaluation: Two Qualtrics evaluation surveys were developed, each in Spanish and English. One survey assessed CHA training outcomes and was completed by CHA attendees. The other assessed town hall session outcomes and was completed by community attendees. Variables assessed during outcome evaluation for town hall meetings were information organization and comprehension, helpfulness, interest in encouraging others to receive the vaccine because of attendance, and the value of clarifying facts and dispelling myths. A link to the online survey was provided in Zoom chat.

CHA training

Of the total project involving 65 CHA’s, 9% (6 individuals) were Latino CHAs (promotoras). These Latino CHAs were educated and trained during 8 weekly sessions on the vaccine development processes, overcoming vaccine hesitancy and clarifying disinformation found in myths and facts about COVID-19 vaccines. Latino CHAs were also trained to conduct community encounters. Of 1,333 overall project CHA encounters, 108 encounters involved Latino community residents. Also, 2 CHAs were trained to present information at each Latino Town Hall meeting on the Myths and Facts about COVID-19 vaccinations.

Town hall meetings

There were 2 town hall meetings held for the Latino population. The first town hall meeting was on Zoom and Facebook with an attendance of 30 and 3,000, respectively. The second town hall meeting was also on Zoom and Facebook. Topics presented included viewing and interpreting the Douglas County Health Department’s dashboard data (local statistics by population), vaccine science and safety, mask wearing, variants, and answers were provided to anticipated questions around allergies, and side effects. Whether vaccination causes “COVID-19 infection” was also discussed. Two CHAs presented facts that discredited myths surrounding vaccine hesitancy. Question and answer sessions concluded each town hall meeting.

Communications

Flyers and brochures were adapted to Spanish and disseminated in the communities. Other communication strategies were also culturally and linguistically adapted. For example, the project newsletter was translated to Spanish and reviewed by a Latina project leader. Communication strategies employed, with the total number of items disseminated, included: flyers in Spanish (50); brochures (200); posters (20); banners (1); billboards (1); newsletters (5 minimum); newspaper articles (2); pocket guide booklet (1); magazine article (1) church bulletins (6 minimum); and Facebook postings.

Evaluation

As indicated in the final report submitted to the funder, Douglas County Health Department, survey results showed that most respondents viewed the events positively and would use the information with their neighbors [16]. However, a minority of respondents would not use the information to change their minds regarding vaccination. One participant indicated they changed their mind and would seek vaccination.

Of the English language survey respondents, 91.8% indicated they had taken the COVID-19 vaccine, while 65% of the Spanish language survey respondents indicated they had taken the vaccine. However, 95% of Spanish survey respondents indicated they would help spread the COVID-19 vaccination promotion message of encouraging people to take the vaccine, while 100% of the English language survey respondents were in the affirmative. Also, 93.2% of English language survey respondents indicated they gained new information and 95.8% of Spanish language survey respondents answered “yes” (Table 1).

Table 1: Town hall meeting post-event “Yes” survey responses for both English and Spanish language surveys

Our overall project included 6 Latino CHAs among the total cadre of 65. Aside from the town halls, these 6 Latino CHAs educated over 100 community members in direct person-to-person educational encounters (one-on-one or a small group). And these 6 Latino CHAs reached many more individuals through the town hall meetings. Thus, the burden of disseminating urgent vaccine promotion messages to the Latino community fell squarely on a small group of trained Latino CHAs.

Future project planning should have extensive pre-project collaboration with Latino community members, including strategies for promotoras/res recruitment and training if funding allows. Reasons for this planning strategy include that the overall project planning did not adequately consider some linguistic, cultural, and logistical challenges as detailed below. However, the pandemic’s emergent nature required rapid planning and implementation. Also, limited funds for recruiting and training Latino CHAs constrained project scope.

The town hall meetings posed complex technical needs that were partially unmet; attendees through the Facebook (FB) platform were unable to complete evaluation surveys as the link was not made available through FB, whereas Zoom participants could complete the survey by clicking on the chat link. Given this complexity, one individual could not satisfactorily monitor all streaming platforms. Thus, at least 2 individuals are needed to monitor technology platforms during presentations and town hall meetings.

Other technology challenges included user discomfort with the project team’s selected Zoom platform for the Town Hall meetings. Instead, users in the Latino community mostly preferred Facebook (FB) streaming rather than Zoom. Because we did not anticipate the predominant FB presence, two-way communications with that audience were unavailable during the town hall meetings. Again, enhanced pre-planning with the CHAs might have averted these issues. Thus, a project of this overall size, and the Latino subset participation, posed several technological needs. A team approach of shared expertise with community input would better anticipate such challenges.

Impact evaluation should assess vaccination rates due to CHA promotoras/res encounters, attending town hall meetings, and impact of other communications (e.g. catchy promotional phrases like “Don’t hesitate, vaccinate,” billboards and rap music). However, such outcome determinations require significantly enhanced project funding. Our project did not include that financial support.

Latino communities include communities with varied cultural practices. To ensure cultural alignment, pre-planning consultation with members of these diverse communities can help customize messaging and potentially improve long term impact. For example, effort should be made to translate materials and presentations to Spanish to ensure clarity and accuracy among Spanish-speaking attendees from different regions. Despite the dialectical differences in the 21 countries and 4 continents where Spanish is spoken, there is a standard version that most of Spanish-speaking individuals can understand. This version should be preferred and selected to accommodate the needs of a broad Spanish-speaking audience. Other cultural considerations could include (1) vaccination hesitancy related to curanderismo (traditional medicine) and (2) a deeper exploration of needs for micro-cultural adaptations. Given this project’s urgent nature and COVID- 19’s rapid transmission, we were unable to explore such cultural adaptations. However, to address cultural variations, the CHAs infused their cultural knowledge into their presentation of the myths and facts surrounding vaccinations. Further, and as noted in Methods, communitywide communications were culturally and linguistically adapted.

Whether the program participants were subsequently vaccinated was not evaluated. Culturally sensitive impact evaluation surveys 3 months or 6 months after project completion would assess project-related vaccination responses. Thus, we reemphasize seeking funding to include this impact assessment.

The evaluation process overall needed more planning for this population. Specifically, to improve response rates for outcome evaluation measuring knowledge and attitudes toward vaccination, guidance on survey completion is crucial. For example, facilitators could explain how participants can choose options in response to each question.

Latino CHAs promoted COVID-19 vaccinations through virtual town hall meetings and community in-person encounters. Funding for recruiting more Latino CHAs would have enhanced their reach into the Latino community. The Latino population favored Facebook participation for the town hall meetings. Since post program evaluation omitted Facebook, outcome evaluations were incomplete. Given the project size and multilayered needs, we recommend a team technology approach adapted for Latino technological availability, capability, and preferences. Project data management and evaluation processes should be developed during project pre-planning, including adapting for diverse populations. Impact evaluation should assess vaccination rates due to CHA encounters, attending town hall meetings, and diverse communications such as billboards, musical jingles, or newspaper articles. Project planning, when not urgent, must include extensive collaboration with Latino community leaders prior to project design and implementation.

The authors have no competing interests to declare.

This journal article, “The Latino Community Experience Promoting COVID-19 Vaccination through Community- Academic Partnership,” is supported in part by proceeds from the Nebraska Tobacco Settlement LB692 to Creighton University and the COVID-19 CARES Act Fund to Douglas County Health Department, Omaha, Nebraska.

The Douglas County Health Department in Omaha, Nebraska has endorsed no part of this publication.

We thank the Community Health Advocates for collecting data and participating in town hall meetings. In addition, the Latino community in Omaha, Nebraska, engaged from the planning stage through implementation monitoring, assessment, and evaluation, Mr. Luis Marcos (Maya Community coordination) and Ms. Phebe Mercado Jungman for copy editing the document.

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