People who identify as American Indian (AI) or Alaska Native (AN) make up just 1.1% (nearly 4 million) of the U.S. population.¹ Yet despite their small footprint, these communities face a far bigger share of negative health outcomes compared to other racial and ethnic groups.

This unsettling truth was never more apparent than during the COVID-19 pandemic, which ravaged Native communities at staggeringly disproportionate rates. Data shows that at the height of the pandemic, AI/AN people had COVID infection rates 3.5 times higher than non-Hispanic white people. They were 3.2 times more likely to be hospitalized for COVID and more than twice as likely to die from the virus.² COVID hit Native elders with even more ferocity, depriving Tribes of their cherished storytellers and tradition keepers.

If there was one sliver of light piercing the darkness of the COVID crisis, it was that it brought renewed attention to vaccine-preventable illness in Native communities. And it sparked action.

In fact, while COVID vaccine uptake has been low in the U.S. overall, vaccination rates have been consistently higher than average in Native populations. As of April 2021, 32% of AI/AN people had received at least one dose of a COVID vaccine, compared to 19% of white people, 16% of Asian people, 12% of Black people, and 9% of Hispanic people.³ By February 2023, the percentage of AI/AN people who had received at least one dose was higher than any other group in the U.S. at 78%.⁴

Why have Indigenous communities done so well in getting their people vaccinated?

Much of this success can be attributed to innovative, culturally informed vaccination strategies that tie getting vaccinated to what’s most important to Native populations: a deep love of their family and friends and respect for their elders, who play a vital role in the community.

Community-led vaccination efforts are a key priority of the National Council of Urban Indian Health (NCUIH), which is dedicated to improving the health of the 70% of Native people who live off Tribal lands in urban areas.¹ NCUIH is also a subgrantee for the NCOA Vaccine Uptake Grant Initiative, working with partners nationwide to improve COVID and influenza vaccination rates among urban Native elders. They work with Urban Indian Organizations (UIOs) both remotely and on the ground to provide technical assistance, training, toolkits, and reporting support for local vaccination initiatives.

We spoke with Kimberly Fowler, Ph.D., Vice-President of the Technical Assistance and Research Center at NCUIH, about the disparities AI/AN communities face—and how her organization is elevating outreach and education focused on older adults and vaccines.

Why does COVID disproportionately affect AI/AN communities?

Fowler shared some of the many factors behind health disparities in AI/AN populations, which contribute to delays in diagnosis, treatment, and prevention efforts for both COVID and the flu. They include:

• Barriers to health care access: In urban areas, Native communities’ health care needs are served by 41 UIOs located across the nation. Unfortunately, since they’re a subset of the chronically underfunded Indian Health Service (IHS), there simply aren’t enough UIOs to meet the demand. “Underfunding of these organizations is a huge issue,” Fowler explained. “More is needed to provide the facilities and the care these communities need and deserve.” Even if someone has private insurance and can go elsewhere, Fowler said, they’re not assured of receiving culturally sensitive care. “If you’re an American Indian or Alaska Native, you want to be seen by people within your community,” she explained. “Being able to stay in your community affects whether you feel comfortable seeking and receiving health care.”
• Medical and institutional mistrust: Increasing vaccine uptake requires your target audience to have basic trust in the system. But, studies show AI/AN people often have high levels of mistrust in Western medicine and less satisfaction with health care compared to non-Hispanic white people. This distrust may stem from providers’ lack of cultural competency in treating these populations, historical trauma (including medical experimentation), and systematic underrepresentation in clinical trial research. As for the COVID vaccine, Fowler said many Native people initially doubted its safety: “They didn't understand how the vaccine was created in such a short time. They thought it hadn't been tested enough, that the outcomes and effects on their community were not truly known.”
• Living conditions: American Indians and Alaska Natives are more likely to live in substandard, overcrowded housing in urban areas, often with multiple generations co-existing. This promotes more rapid disease transmission, makes it harder to practice social distancing, and puts vulnerable older adults at much higher risk.
• Chronic diseases: AI/AN communities suffer disproportionately higher rates of underlying health conditions such as diabetes, heart disease, asthma, obesity, and other chronic diseases that boost the risk for severe COVID and flu infections. Limited access to health care services and resources only compounds the problem.

How did UIOs respond to help their elders stay healthy at the start of COVID?

Vaccinations were initially a struggle due to delays in receiving supplies of the COVID vaccines. However, when UIOs began receiving those first doses in December 2020, they were ready to move.

A case in point is Native Health in Phoenix, Arizona, which wasted no time in trying to reach those at highest risk. This NCUIH member called, texted, and emailed local elders about upcoming vaccine clinics and contacted churches and elder groups to ask for their help in spreading the word. Centrally located pop-up clinics were held regularly, indoors and outdoors, including drive-thru vaccine clinics for the Pascua Yaqui Tribe. More than 300-800 people received vaccines during each drive-thru event.

Once Native Health received more vaccines and clearance to vaccinate additional groups, they pivoted to create new, tailored outreach methods and marketing. Their efforts made an impact: In the first year of COVID vaccine distribution, the UIO provided over 16,000 vaccines.

How has a community-centered approach helped to promote vaccine acceptance among urban AI/AN elders?

Culturally competent messaging from trusted sources has been a key driver in increasing vaccine uptake among Native people of all ages. One example is NCUIH’s Be a Good Relative campaign, which centered on community responsibility to encourage vaccination for COVID, the flu, and RSV. With its tagline "For the elders. For the youth. For the future,” this campaign also helped combat vaccine hesitancy by dispelling common myths surrounding the vaccine’s safety and efficacy. Fowler noted they created various iterations to reflect different target audiences and even different seasonal times of the year. 

"We wanted to send the message that 'you're doing this for your elders,'" Fowler said. "We had animated videos to explain who is at high risk for COVID and how getting the virus without being vaccinated is dangerous."

Be a Good Relative messaging was disseminated through pamphlets, social media, podcasts, tribal newspapers, and national outlets to help drive people to local vaccine clinics held by UIOs. Native people also shared personal testimonials about how getting vaccinated helped their families.

Another way the message was getting out was through partnerships with local universities. The University of Maryland Baltimore, for instance, worked with IHS and local clinics to help reach and vaccinate American Indians living outside of UIO networks. Through that effort alone, they provided more than 65,000 vaccinations.

Fowler said Native elders themselves have played an essential part in these outreach campaigns.

Conversations with our elders was and still is important,” Fowler said. “We need to include them in events and decisions and use their storytelling ability to share how the COVID vaccine has helped them.”

She cited community events such as talking circles playing a key role in vaccine acceptance. These settings offer a safe, trusted space where people can come together with family, friends, and neighbors to share their perspectives and concerns about the vaccine.

What barriers still exist to vaccination for American Indian and Alaska Native elders?

Misinformation is still a big problem, according to Fowler, and distrust continues to be an obstacle within Native communities. NCUIH and its partners are still creating messaging to validate concerns and correct misconceptions about COVID and the vaccines.

Funds are another persistent barrier, with UIO funding accounting for just 1% of the IHS budget. Many vaccine clinics have had to rely on funding from additional sources to cover expenses like PPE, staffing, and vaccine incentives.  

If history has taught us anything, however, it’s that Native people are resilient—and so are the organizations working hard to advance their health and well-being. The success urban Native communities have had in vaccinating their people provides valuable lessons to draw from. These insights can not only inform vaccination efforts for older adults; they serve as a blueprint for other underserved communities throughout the country.  

"We know that our communities look out for one another—from our next generations to our elders,” said Francys Crevier, CEO of NCUIH. “Native communities were among the most impacted by COVID-19, and it is still costing Native lives. We applaud our urban Indian health clinics for being vital lifelines during the pandemic and beyond. Our elders are our storytellers, so it is important that we have the education and access to vaccines so we can help protect the stories for our next generations by keeping our elders healthy.”

Sources

1. U.S. Department of Health and Human Services, Office of Minority Health. American Indian/Alaska Native Health. Found on the internet at https://minorityhealth.hhs.gov/american-indianalaska-native-health

2. National Council of Urban Indian Health. American Indian/Alaska Native Data on COVID-19. Found on the internet at https://ncuih.org/wp-content/uploads/COVID-AI-AN-Info-doc_NCUIH_D072_V4.pdf

3. KFF. COVID-19 Vaccination among American Indian and Alaska Native People. April 9, 2021. Found on the internet at https://www.kff.org/racial-equity-and-health-policy/issue-brief/covid-19-vaccination-american-indian-alaska-native-people/

4. KFF. COVID-19 Cases, Deaths, and Vaccinations by Race/Ethnicity as of Winter 2022. March 7, 2023. Found on the internet at https://www.kff.org/coronavirus-covid-19/issue-brief/covid-19-cases-deaths-and-vaccinations-by-race-ethnicity-as-of-winter-2022/