Public Health Policy that Leads with Equity in Rural Appalachia: Recommendations to Confirm Vaccination Status in an Equitable Manner

Abstract

Vaccination is the most important method to control the spread of SARS-CoV-2, the virus that causes COVID-19, and vaccination is key to this goal. This paper highlights considerations for policy development around vaccination attestation and proof requirements, specifically in rural Appalachia. Migrant and immigrant farmworkers are integral to the food and goods supply chain globally; they have been disproportionately impacted by COVID-19, therefore these policies need to take extensive precautions for farmworkers to systematically and easily comply with vaccination status submission procedures. In this paper, we present steps to equitably manage and implement vaccine mandates: (1) Develop and establish policies to support safe workplace standards for everyone, including vaccination policies; (2) Utilize equitable methods to collect vaccine verification; (3) Use effective and inclusive methods to implement the policies by using these techniques; (4) Integrate key populations to develop and strengthen policies to improve health equity.

Vaccination is key to lowering the transmission of SARS-CoV-2. Lowering transmission of this virus will, in turn, reduce the burden of the COVID-19 pandemic on distressed health care systems, such as Appalachia, thereby improving the economic vitality of rural communities. The industrial jobs found in rural Appalachia range from retail trade to manufacturing to farming and forestry.¹ Many of the manufacturing and farming jobs are held by migrant seasonal workers.

Social capital is the backbone of rural Appalachian culture. Social capital is the social support and network of relationships that exist in a person’s life. Social capital is a multidimensional construct comprising community cohesion and social control in the community, along with social relationships between community members.² How trust is built and with whom is an important consideration when identifying key stakeholders towards improving health outcomes. In rural Appalachian communities, churches, family, geographical location and duration, are key relationships that influence social capital. During the COVID-19 pandemic, these relationships have been used to deliver information about all things related to the pandemic.

Immigration policy in the United States (U.S.) impacts the COVID-19 pandemic and public health more broadly as a systemic challenge, and vaccination status is an acute symptom of the larger complexity of society overall and how these systems impact rural communities. It is important, however, to consider the implications of requiring vaccination status with a health equity lens. Vaccination is the most important method to control the spread of SARS-CoV-2, and vaccination requirements are key to this goal. This briefing highlights considerations for policy development around vaccination attestation and proof requirements. This paper aims to provide recommendations that support migrant workers and their jobs through adequately considering an equitable approach to promoting vaccination for COVID-19.

Additionally, an equitable vaccine approach provides many potential benefits to both employers and employees. For example, these benefits include maintaining a healthy workforce by preventing employees from getting COVID-19; protecting clients, customers, and visitors from COVID-19 illness; reducing absences due to COVID-19 illness; improving productivity and morale; building trust, such as being responsive to employees’ needs and cultural norms; preventing COVID-19 illness and long-term complications; reducing absences and doctor visits due to COVID-19 illness; and protecting workers’ families and households from COVID-19 illness.³

Problem Statement

As discussed by the Migrant Clinicians Network, names can be a complex thing for immigrant and migrant workers.⁴ Many workers use pseudonyms in workplaces if they lack documentation to legally work in the U.S. using their birth name. Although this process can lead to short-term benefits for workers, it can also create unexpected problems. Due to recent vaccine requirements, the vaccine card is no longer simply a health document; rather, it is now also a mandatory employment document. Workplace mandates are changing the way we use these cards and have given the names on them new importance.⁵

“The Biden Administration is committed to ensuring that safe, effective, cost-free vaccines are available to the entire U.S. public—regardless of their immigration status.”⁶ According to Liebman et al., Latino/a immigrants have shown distrust of the U.S. government during early phases of the COVID-19 vaccine rollout, and many prefer to stay silent over workplace abuses or personal health concerns rather than expose their immigration status or risk losing their job.⁷ Migrant and immigrant farmworkers are integral to the food supply chain globally; yet, they have been disproportionately impacted by COVID-19. These health and employment policies, therefore need to take into account the important role and immigration status of migrant and immigrant farmworkers and ensure appropriate measure to systematically and easily comply with vaccination status submission procedures.⁸

Policy Recommendations

Here are steps to equitably manage the new federal vaccine mandates.

Step 1: Develop and establish policies to support safe workplace standards for everyone

Step 2: Utilize equitable methods to collect vaccine verification

• • Consider incorporating an Alias strategy. The Migrant Clinician Network recommends that clinicians inquire about Alias names and potentially administer the vaccination record in accordance with this status.

• • Utilize attestation practices to confirm vaccination. Specifically, use the following attestation process for employees:

  • ○ Are you fully vaccinated against COVID-19? Yes or No

  • ○ First Name

  • ○ Middle Name

  • ○ Last Name

  • ○ Alias

  • ○ Which version of the vaccine did you receive?

  • ○ When did you receive your first dose?

  • ○ If applicable, when did you receive your second dose?

  • ○ If applicable, when did you receive your third dose?

  • ○ Facility Name

  • ○ Please upload a photo/image of your vaccine card or confirmation of receipt from a qualified provider

  • ○ I, NAME, attest that all of the information that I have submitted in this survey is true and accurate to the best of my knowledge.

    • ▪ Sign Here

• • Culturally and linguistically appropriate translation is key. For example, the Show Me tool that was developed by Commonwealth of Massachusetts.⁹ Show Me is a suite of tools designed to enhance communication between individuals with communication challenges and public health and emergency management personnel and volunteers during times of emergencies.

Step 3: Use effective and inclusive methods to implement the policies and procedures by using these techniques

• • Make it easy and accessible to comply with the mandate. Whatever the policy and procedure is, it must be easy to use and access. This will make it simple for employees to submit their vaccination certification or update their current status.

• • Communicate with employees and explain the process. Ensuring employees are informed about new vaccination verification policies, procedures, and potential solutions to address compliance will help to establish trust, buy-in, and reduce confusion and friction with implementation. Transparency is key and ultimately leads to better outcomes and understanding.

• • Create a culture of listening and participation. Incorporating the updated policy and procedures into vaccination mandate compliance makes it easier to glean insight and create a more engaged workforce; therefore, it is essential to integrate opportunities for feedback to help the workforce comply with changing requirements.

• • Stay ready for change. If COVID-19 has taught us anything, it’s that changes happen fast and often unexpectedly. Over the next few years, it’s highly likely that vaccination requirements, mandates, and even certifications policies and procedures will change. As decisions change regarding required mitigation methods, having a flexible solution with plug-and-play capability can help organizations and governments to respond at the speed required to keep pace with these changes.

Step 4: Integrate key populations to develop and strengthen policies to improve health equity

Implications for Policy & Practice

Who should consider this policy recommendation?

• • The Presidential Administration, for special consideration with Occupational Safety and Health Administration (OSHA) standards and requirements: The Administration is committed to ensuring that safe, effective, cost-free vaccines are available to the entire U.S. public—regardless of their immigration status.

• • National, State, and Local Public Officials: To eradicate COVID-19 and end this pandemic, vaccination is the leading intervention; therefore, considerations should be made on equitable methods for declaring vaccination status.

• • Business Owners: OSHA mandates that businesses cover costs of employees who are sick and require leave due to COVID-19; therefore, vaccination rates are key to employee retention and presence.

• • Health care Administrators: Burnout of providers in health care is a real threat to the workforce, and high vaccination rates can bolster relief and bring an end to the spike in workload due to the pandemic.

• • Public Health Practitioners and Epidemiologists: Burnout of public health professionals is a real threat to the workforce, and high vaccination rates can bolster relief and bring an end to the spike in workload due to the pandemic.

Discussion

As outlined, these recommended steps can support management and implementation of an equitable vaccine mandated as follows: (1) Develop and establish policies and procedures to support safe workplace standards for everyone, including vaccination attestation and certification policies; (2) Utilize equitable methods to collect vaccine verification; (3) Use effective and inclusive methods to implement the policies and procedures by using these techniques; and (4) Integrate key populations to develop and strengthen policies to improve health equity. Rural Appalachia was and continues to be significantly affected by the COVID-19 pandemic. This includes job loss, loss of hours/wages, loss of health insurance, and many Appalachian residents went without needed medical care during the pandemic.¹⁰ COVID-19 vaccines teach human bodies to develop immunity to the virus that causes COVID-19 without us having to get the illness.¹¹ Employers have a unique opportunity to help increase vaccine uptake among works through providing information about COVID-19 vaccination and establishing supportive policies and equitable practices. To be successful in this, employers need to share clear, complete, and accurate messages; promote confidence in the decision to get vaccinated; and engage employees in plans to address potential barriers to vaccination.¹² Increasing vaccination against COVID-19 can lower the risk of getting and spreading the virus that causes COVID-19 and, therefore, is critical to protecting both the Appalachian workforce and communities.³