Ask Me Anything": Lessons learned in implementing a COVID-19 vaccine information initiative in Massachusetts jails.

As a group of medical professionals, faith-community leaders, and jail staff, we launched a COVID-19 vaccine Q&A initiative across Massachusetts county jails to increase COVID-19 vaccine confidence and uptake among detained individuals. Here we describe the lessons learned in developing and implementing this initiative. Published by Elsevier Ltd.

Introduction

Several of the largest COVID-19 outbreaks have occurred in US jails and prisons, leading to substantial morbidity and community spread [1], [2]. The incidence of COVID-19 among detained populations has been five times greater than the US general population, with an age-adjusted mortality rate four times greater [3]. Given the disproportionate detention of Black and Latinx people in the United States, outbreaks in carceral facilities have also exacerbated racial disparities in COVID-19 infection and mortality [4]. Despite high rates of infection and death in carceral settings, only 10 states prioritized early COVID-19 vaccine roll out for detained populations [5]. Early COVID-19 vaccination rates of individuals in federal and state prison varied greatly, ranging from 16 to 79% nationwide as of May 2021 [6].

Public health leaders have recommended that carceral leadership partner with experts and community leaders to increase vaccine uptake in carceral facilities in recognition that effective communication of vaccine availability, effectiveness, and safety to detained populations while respecting their autonomy is imperative [7]. The call for such educational initiatives is supported by recent evidence suggesting that COVID-19 vaccine hesitancy among incarcerated populations is not a fixed phenomenon [8]. Here, we describe a COVID-19 vaccine information initiative designed and implemented by medical professionals, community-faith leaders, and jail staff to increase vaccine confidence among detained individuals across Massachusetts (MA) county jails during the early months of the COVID-19 vaccine rollout (February – March 2021). The lessons learned in developing and implementing this initiative (Table 1 ) may help guide future vaccine information programs in carceral facilities.

Table 1

Lessons Learned in Implementing COVID-19 Vaccine “Ask Me Anything” Sessions in Massachusetts County Jails.

How to…	Lessons Learned
Increase attendance	Q&A sessions should be held in housing units rather than common areas in the jail to allow for a gradual increase in participation and attendance
Increase attendee engagement	Session leaders should disclose their jail affiliation (or lack thereof) at the start of the session, briefly provide information about the vaccine before taking questions from attendees, and minimize distractions in the room.
Build trust	Organizers should proactively recruit session leaders with existing ties to the detained population as well as Black, Latinx, and Spanish-speaking session leaders. Session leaders should initiate an explicit discussion around systemic racism, medical abuse, and individuals’ agency in the vaccination decision process.
Overcome structural barriers to vaccination	Session leaders should work with jail staff before Q&A sessions to clarify the mechanism and timeline of requesting and receiving the vaccine at the jail and ensure that a simple mechanism to request vaccination is available at each session.

“Ask Me Anything” design and implementation

The COVID-19 vaccine information initiative—called “Ask Me Anything” (AMA)—was designed as in-person question and answer (Q&A) sessions for individuals detained in MA county jails. Physicians, community-faith leaders, and medical students were recruited to lead sessions. The objectives of the initiative were to 1) foster an open, non-judgmental dialogue for individuals to share their questions and concerns about the COVID-19 vaccine 2) provide accessible, updated information on COVID-19 vaccines 3) empower individuals to make informed, voluntary decisions regarding vaccination and 4) boost COVID-19 vaccine confidence among detained individuals.

With the guidance of A.W. (co-author and liaison to the MA Sheriffs' Association), we emailed representatives of thirteen MA counties at least twice in early 2021 and offered to host AMA sessions. In one county, we ran a pilot Q&A session in early January prior to vaccination eligibility in MA jails (January 21, 2021). Questions asked during the pilot session were used to design an introductory script and frequently asked questions (FAQ) list for future sessions (Supplemental Material). Of the remaining twelve counties, six counties (seven jails) accepted to host sessions. From February – March 2021, we held AMA sessions in these seven jails.

AMA sessions were organized as half-day in-person sessions. Each half-day was split into three identical one-hour sessions held either in jail housing units or jail common areas (i.e., the cafeteria). Each one-hour session was led by two individuals, at least one of whom was a medical professional. Four session leaders were present for every half-day in each jail, allowing for six one-hour sessions per half-day. The number of attendees per session ranged from about 6–50 individuals. During each half-day in a jail, approximately 50–150 individuals were reached—totaling to about 700 individuals in the two-month period. The introductory script and FAQ list were shared with session leaders prior to each session.

In the initial 10 min of each session, session leaders shared session goals and reviewed fundamental COVID-19 vaccine information with the group. Session leaders then invited individuals to ask questions in the group setting for about 40 min. If one of the leaders was a Spanish-speaker, attendees were given information in Spanish and invited to ask questions multiple times throughout the session. The final 10 min were reserved for individuals to approach session leaders and ask one-on-one questions. This allowed individuals to ask questions that they may not have felt comfortable asking in front of the group (such as effects of vaccination for people living with HIV). Some jails provided vaccine sign-up sheets immediately following the session, while others utilized other mechanisms to request a vaccine, i.e., “sick slips” (medical appointment request) or notifying nursing staff. Attendance at AMA sessions was voluntary and incentives for attendance were not provided. At most jails, AMA sessions were announced by correctional officers within the housing unit. For sessions held within housing units, individuals were encouraged to gather in the unit and televisions were muted. For sessions held in areas outside of housing units, interested individuals were brought to meet session leaders at a common area of the jail (i.e., a cafeteria). Other than one co-author (A.W.) who received salary support from the MA Sheriffs' Association, no presenters received compensation for participation.

Lessons learned

In organizing and implementing the AMA program, we learned several lessons in effectively designing vaccine information sessions (Table 1). We share our group’s reflections to guide the design and evaluation of future public health initiatives in carceral facilities.

Increasing attendance

Sessions held in jail housing units had greater attendance compared to sessions held in a separate common area in the facility. This was likely because when sessions were held in housing units, individuals slowly joined the AMA session as they heard their housemates discuss their experiences with COVID-19 and its vaccine. Vaccinated individuals often shared their motivations for vaccination and experiences with side effects, allowing for peer-to-peer information sharing. For AMA sessions held outside of housing units, while peer-to-peer education was still present, vaccinated peers were not able to pique the interest of individuals who originally chose to not attend the session. Thus, a gradual increase in “late” attendance did not occur.

Increasing attendee engagement

The ability of session leaders to engage attendees was integral to creating an open, non-judgmental space for individuals to share questions. We found that explicitly sharing session objectives—namely to empower individuals to make informed, voluntary vaccination decisions—helped engage attendees. It was also helpful for session leaders to answer several questions from the FAQ list before opening the floor to attendee questions. This helped ground the scope of questions to those related to COVID-19 vaccines and access in the jail. FAQ mirrored questions in the general community (i.e., concerns regarding efficacy, length of immunity, and long-term side effects) and related specifically to the detention experience (i.e., concerns about state-sanctioned medical experimentation on detained populations and the effect of vaccination on court hearings). Moreover, the most engaging sessions occurred when distractions in the room, like television noise, were minimized.

Building trust

We knew that it would be hard to build trust in a one-time encounter. We tried to do this by disclosing our affiliations, emphasizing attendees’ right to deny vaccination, and explicitly initiating a discussion around systemic racism and distrust. We found that disclosing our lack of affiliation with the jail and reaffirming attendees’ individual agency in their vaccination decision helped build rapport. Explicitly discussing how systemic racism and structural violence against detained populations has fueled distrust in medical and carceral systems also helped build rapport. Examples of language used for initiating such a discussion are in the Supplemental Material. Given the disproportionate incarceration of Black and Latinx individuals in MA, recruitment of Black and Latinx leaders as well as Spanish-speaking session leaders helped center the experience of those attending sessions and deepened conversations. For example, an attendee shared with co-author R.S.S. (who leads portions of the sessions in Spanish) that they joined the session after it started because they heard her speaking Spanish.

We also realized that it was vital to leverage existing trust in the community. To do this, we proactively recruited community-faith leaders (such as co-authors and well-known pastors, L.W. and G.W.) and Black medical professionals with existing ties to the population (such as co-author and addiction medicine specialist, E.L.). One individual told G.W. that he was happy to see her because his aunt goes to her church. Another individual approached E.L. after the session because he remembered being treated by E.L. at a community clinic. These connections facilitated rapport-building during sessions.

Overcoming structural barriers to vaccination

Several structural barriers to vaccination in jails were uncovered during our sessions, including limited information regarding vaccine eligibility and unclear processes in requesting vaccination. Individuals’ knowledge of vaccine eligibility and the frequency in which individuals were reminded of their eligibility varied across jails. The method of requesting a vaccine also varied (i.e., sign-up sheet, submitting a sick slip, direct communication with nurse) and several individuals mentioned lack of instruction on how to request vaccination. For example, in several sessions, individuals asked, “Can we still get that [the vaccine]?” or “I think I’m due for the second shot, how can I get it?” We found it important to clarify mechanisms of requesting a vaccine with jail leadership before AMA sessions and to communicate this information to attendees. If request of vaccination continued to be unclear during the session, we directly involved jail staff to clarify and facilitate the request process. Based on immediate feedback from attendees, AMA sessions helped some individuals better understand their vaccine eligibility and an opportunity to request vaccination immediately after each session helped simplify the vaccination process.

Sustainability & future directions

We acknowledge that the sustainability of this initiative depends on the recruitment of volunteers. Although the COVID-19 crisis has demanded community members to fill-in gaps of a fractured U.S. public health system, sustainable vaccine education efforts in carceral settings should be organized by carceral leadership and local Departments of Public Health. Otherwise, depending on voluntary community-led initiatives will lead to inconsistent results nationwide. Given the learned value of including community members in AMA sessions, future efforts should engage trusted community members in jails’ vaccine education programs. While we report the lessons learned in implementing a vaccine information initiative across MA county jails, further research is needed to understand the effectiveness of such sessions in increasing COVID-19 vaccine uptake among detained populations. Future vaccine education initiatives should consider collecting data on the number of attendees who requested and ultimately received a vaccine.

Conclusion

Increasing COVID-19 vaccine confidence and uptake among detained people is needed to mitigate spread in carceral facilities and outside communities [2]. Given the disproportionate detention of Black and Latinx individuals, vaccination efforts also offer an opportunity to advance health equity [4], [9]. This intervention provides an example of a collaboration between medical professionals, community-faith leaders, and jail staff to increase COVID-19 vaccine confidence in jails. As states, jail leadership, and community leaders strive to increase vaccine uptake among detained individuals, we urge organizers to use the lessons we learned to guide future public health interventions in carceral settings.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.