Equity in Healthy Aging: A Data-Driven Movement Led by Trusted Ambassadors

Health and Well-being is one of ASA’s priority areas, and from July 18 to 22 we are hosting a Generations Forum on “Promoting Health Equity in Aging.” Please register here.

When the Catholic Charities of Northern Nevada, a National Council on Aging (NCOA) partner, held a food pantry outreach event, Tammy, a community outreach worker and nurse, met 67-year-old Maria as she was picking up food for her multigenerational household.

Tammy offered to check Maria’s blood pressure and asked about her COVID-19 vaccine status. Maria mentioned she had received her Pfizer shot, but when Tammy inquired about the status of her second shot or booster, Maria was surprised. She didn’t know she needed two shots, let alone three. It had been several months since Maria’s first dose, so Tammy gave her instructions on how to get her second shot.

This is just one example of the thousands of on-the-ground partners working to transform relationships and systems to create the conditions for everyone to thrive under an initiative called Communities RISE (Reach, Immunizations, System Change for Equity).

In the project’s first phase, RISE trained 3,000 community vaccine ambassadors and got 183,000 people vaccinated.

RISE is advancing an equitable response to the pandemic through immunizations, while meeting social and health needs today and creating civic capacity for a better tomorrow. It is funded in part under the American Rescue Plan via the U.S. Department of Health and Human Services (HHS) Health Resources and Services Administration (HRSA) and housed within the Community-based Workforce for COVID-19 Vaccine Program.

RISE builds on the civic muscle of more than 2,400 community-based organizations, with decades of investments in direct service, support and community outreach in the country’s most economically vulnerable communities. It connects these community organizations with local public health networks to overcome vaccine hesitancy and misinformation and connect individuals to the supports they need.

Leveraging Community Ecosystems

What makes RISE unique is its focus on community workforce ecosystems that have built trust for decades, and in some rural areas for more than a century. Local connections with community outreach workers and vaccine ambassadors, translation services provided by partners, connections to health and community resources and linguistically responsive messaging sensitive to cultural vulnerabilities guide the effort as it reaches out to Black, American Indian, Hispanic/Latino, Asian American/Pacific Islander, immigrant/migrant and low-income older adults in 200 counties in 29 states.

The approach works. In the first phase of the project, RISE trained 3,000 community vaccine ambassadors and got 183,000 people vaccinated. Each community created unique outreach plans, both online and on-the-ground. In total, the effort reached 824,599 individuals directly and more than 40 million indirectly.

Beyond vaccines, RISE sought to ensure the well-being and social support of each individual. Through the program, 212,587 people also were connected to public benefits, such as the Supplemental Nutrition Assistance Program, to help them pay for daily needs.

NCOA, in partnership with other key aging network partners, leveraged Benefit Enrollment Centers, Area Agencies on Aging, senior centers and other partners. Examples of local activities included:

  • Deploying community outreach workers fluent in multiple spoken languages and American Sign Language,
  • Organizing mobile vaccination clinics for farmworkers,
  • Partnering with Black churches to build vaccine confidence, and
  • Implementing culturally and linguistically appropriate outreach campaigns.

This collaborative effort called upon some of the nation’s most trusted messengers to dive deep into hard-to-reach communities to get the most vulnerable people vaccinated, but with an intentional strategy of not leading with that message. Instead, “outreach” meant beginning a dialogue with community members about health in general, and the health of their loved ones—to build trust and credibility.

Ensuring Empathetic Data Implementation

This road was not always smooth given the history of inequity and racial oppression that many have experienced firsthand. RISE took a different approach at the onset by baking in transparency and honest assessments of what historical challenges these communities have experienced around access, lack of trust and barriers to social mobility.

‘RISE partners are now able to collect data, see data, and use it to the betterment of their communities.’

Empathetic data collection and implementation made a difference. Partners who faced questions from community members about why it was necessary to collect data were able to communicate in culturally responsive ways about how and why their data would be used.

Cultural values of privacy, mixed immigration status in multigenerational households and other situations required a person-centered approach incorporating key pillars of equity and education for messengers and community members both. Using a restorative justice framework lessened understandable fears due to historical oppression and lack of access based on race, religion and socioeconomics.

RISE partners are now able to collect data, see data, and use it to the betterment of their communities. As the next iteration of the collaboration continues, it is less about how a “rising tide lifts all boats” and more about focusing on those most in need and implementing specific strategies steeped in culture, heritage and history to make lasting change. The civic muscle inherent in this effort provides partners all they need to succeed—training, a trusted network and an opportunity to address their well-being, so they can better serve their community.

RISE National Partners:

  • Center for Popular Democracy
  • Chromatic Black
  • Hawai’i Public Health Institute
  • Latino Health Access
  • Meals on Wheels America
  • Migrant Clinicians Network
  • National Council on Aging
  • National Indian Health Board
  • Public Health Institute
  • The Center for Popular Democracy
  • USAging
  • Well-being and Equity (WE) In the World
  • Well Being In the Nation (WIN) Network

To read more about NCOA’s work on health inequities related to chronic disease, click here.

Ramsey Alwin is National Council on Aging president and CEO, and Somava Saha, MD, is Well-being and Equity (WE) in the World executive lead and Well Being in the Nation (WIN) founder and executive lead.