Low-income residents stifling vaccination rate in county

Medi-Cal recipients are receiving vaccinations at a lower rate due to misinformation, distrust of the government and a lack of outreach to white residents

TULARE COUNTY – Low-income residents continue to stifle the vaccination rate in Tulare County, not because they don’t have access to the shot but because they are accessing misinformation about the shot on social media.

More than half (53%) of Tulare County’s population 12 and older has been vaccinated, about 188,000 people, and another 35,000 are partially vaccinated, meaning they have received at least one dose of either the Pfizer or Moderna vaccine. The county’s vaccination rate is only better than nine of 58 counties and tied with three others as the statewide rate is over 75%.

Much of the disparity between the county and the rest of the state is due to the lag in vaccination rates of low-income residents. California’s poorest residents are offered health care coverage through the Medi-Cal program. About 54.6% of Tulare County residents are enrolled in Medi-Cal, the highest in the state, according to the U.S. Census Bureau’s annual American Community Survey.

As of Aug. 22, the latest data available from the Department of Health Care Services (DHCS), which administers the Medi-Cal program, the vaccination rate of low-income residents in Tulare County was between 30% and 45%, compared with 45% to 55% of all residents. Thirty-eight percent of low-income residents have received at least one dose of a vaccine compared with 53% of all residents. The gap exists across all age groups and ethnicities statewide but the greatest disparity is among those ages 18 to 49, which narrows with age.

“While Medi-Cal COVID-19 vaccination rates are gradually improving across the state, the percentage of Medi-Cal beneficiaries with at least one dose lags the population-at-large rate, sometimes by as much as 30 percent,” DHCS stated in a recent report.

The smallest gap is among Hispanics, who make up nearly two-thirds of Tulare County’s population and 45% of the population living in poverty, according to the U.S. Census Bureau’s American Community Survey.

The real pandemic in Tulare County is among low-income white people, who make up 40% of the population living in poverty, have the greatest vaccination disparity statewide (22%) and have a vaccination rate (42.7%) lower than both Asians and Hispanics for getting at least a single dose of a vaccine. Blacks and Native Americans make up less than 2% of county residents living in poverty combined.

Family HealthCare Network provides primary care to many of the county’s underinsured and uninsured. CEO Kerry Hydash said nearly three-quarters of FHCN’s 290,000 patients are Latino but Latinos make up 84% of vaccinations administered at their health centers in Tulare, Kings and Fresno counties. She said she hasn’t seen any hesitancy among the Hispanic population. About 18% of FHCN patients are white yet whites only make up about 14% of FHCN vaccinations. She also noted about 8.5% of patients identify as “other”, a category that only represents 2% of FHCN administered vaccinations.

To complicate matters further, many low-income rural communities have a higher vaccination rate than other, more affluent communities, according to the state. Earlimart, Orosi and Ivanhoe all have a vaccination rate of about 63% while places like Exeter, Three Rivers and Tulare are hovering around 55%. The community with the highest vaccination rate is Lemon Cove at 74%, which has a 0% poverty rate, while the second highest is 65% in Terra Bella, which has a poverty rate of 42%.

Vaccine hesitant

A June report issued by the Kaiser Family Foundation (KFF), a nonprofit focusing on health policy and health journalism, showed unvaccinated adults cite a variety of reasons why they have not gotten the vaccine. About 20% of those surveyed said the main reasons for their hesitancy was the newness of the vaccine, followed by 11% each who said they were worried about side effects, they didn’t trust the government, they don’t think they needed the vaccine, and they just don’t want to get the vaccine.

Hispanic and Black adults are more likely than White adults to cite worries about missing work and having to pay for the vaccine as major reasons for not being vaccinated. In addition, unvaccinated Hispanic adults are more likely than unvaccinated White adults to say they are too busy, would have difficulty traveling to a vaccination site, or are not sure how or where to get the vaccine.

Carrie Monteiro, public information officer for Tulare County HHSA, said promotoras and community-based organizations who have been out canvasing communities throughout Tulare County have found the majority of unvaccinated residents believe either they do not need a vaccination because they already had COVID or that there is not enough information known about the effects of the vaccine and who want to “wait a little longer” for definitive evidence.

Kaweah Health’s Dr. Ryan Gates, a pharmacist and vice president of population health management, attempted to address vaccine hesitancy at a Sept. 2 town hall meeting. Gates said more than 3 billion people across the world have received the vaccine and every day there is more data and more evidence of the safety and efficacy of the vaccines, especially Pfizer which received full FDA approval for ages 16 and older on Aug. 23.

“How are we going to get over COVID? The same way we have overcome every other infectious disease in modern history like polio, smallpox, diphtheria, tetanus, etc., with a vaccine,” Gates said. “We will overcome this, but we can’t do it without the community’s help. We hope that we can convince those who are riding the fence of hesitation for one reason or another to receive it.”

Closing the gap

Tulare County is doing a better job than most of the state in closing the gap between Medi-Cal recipients and the population at large. Tulare County’s gap of 15.7% is smaller than all but six of 58 counties statewide and within a fraction of a percent of five other counties.

Monteiro said Tulare County Public Health is relying on trusted messengers such as promotoras and community-based organizations to canvas communities to educate and inform the public on the COVID vaccine and assist residents in getting registered for vaccination appointments.

“We have assisted in training these trusted messengers to use techniques such a motivational interviewing and this has equipped our trusted messengers with the tools they need to dispel misinformation or increase confidence in the COVID vaccine,” Monteiro said.

One of the most trusted organizations for low-income residents in Tulare County is Proteus, Inc. Since 1967, Visalia-based Proteus, Inc. has offered community, employment, and training programs to farmworkers, foster youth and adults. Randi Espinoza, a community coordinator with Proteus, confirmed many of the concerns regarding vaccines in Tulare County include unwanted side effects and that the government is not being truthful.

“We have done our best to disseminate information about the vaccine and also hear them out about their fears of being unvaccinated,” Espinoza said. “There is not a direct, specific message [that has been successful], just simply offering them information so they can make the best choice for themselves and their families as opposed to forcing it has led to more open minds and captive audiences.”

There are also logistical barriers for the farmworkers to access the vaccine. Espinoza said most vaccination sites require appointments, which farmworkers shared was inconvenient because they had to use a website to schedule the appointment and couldn’t just walk into the office.

That’s where Hernan Hernandez comes in. Hernandez is executive director of the California Farmworker Foundation. Based in Delano, the nonprofit has been providing onsite COVID-19 testing in the fields since last spring and onsite vaccination clinics since January. He said about 15% of farmworkers are unsure if they want the vaccine and another 15% flat out refuse to get the vaccine.

“Access is no longer an issue but rather the main issue is convincing a part of the population that is not interested in the vaccine because of fear,” Hernandez said.

Those fears are both deeply rooted in age old discrimination and new age misinformation. Hernandez said most farmworkers don’t trust the government and are therefore unlikely to go to free vaccination events sponsored by local government or held at government offices. And those are just the more traditional fears. Others heard by Hernandez’s staff include that the vaccine will kill you in four years, that the needles implant tracking microchips under your skin, the vaccine is filled with hormones which will change your sexuality, that it’s made of fetuses and that it will actually make your more sick, possibly by giving you the virus.

“You name it, we’ve heard it,” Hernandez said.

These longtime fears are now being reinforced all day long on Facebook, the preferred social media of farmworkers. Hernandez said many farmworkers use Facebook to stay in touch with families living in different areas and back home in Mexico and it is portable so they can access it through their phone from the fields and packing houses where there aren’t Wi-Fi signals. It is also where they are being bombarded with fake home remedies to cure COVID, myths they can contract the virus by getting tested and false reports of people being deported from a testing site.

“Facebook is one of the biggest disinformation sources for farmworkers,” Hernandez said.

Both Espinoza and Hernandez agreed the most effective approach is talking about the toll the virus has taken on Latinos, their immediate families and their families across the border.

“Residents start to reconsider when they test positive for COVID, or if someone close to them, such as a family members, tests positive,” Espinoza said.


Unfortunately, there are no specific outreach programs targeting low-income white residents. The only way to reach those people is either through their employer or school mandates or by incentivizing them to get vaccinated.

In order to increase vaccinations among low-income residents, Tulare County is using incentive payments announced by DHCS last month.

Beginning this month, the $350 million program will pay primary care physicians, pharmacies, food banks, advocacy groups and faith-based organizations to start-up activities to increase vaccination among their patients, clients or members, such as offering gift cards.

“We’re working extremely hard to improve vaccination rates, but we believe we can do better, and must do better, to prevent further disparities in COVID-19 infection and death among persons served by Medi-Cal,” state Medicaid director Jacey Cooper said.

In addition to statewide incentive programs, Tulare County has held vaccination clinics in partnership with the Visalia Rawhide and the Tulare County Fair where people who get vaccinated get free game and fair entry tickets.

“In overcoming vaccine hesitancy, we have taken a multi-faceted approach and have not found one method that works better than another in reaching our unvaccinated populations, so Tulare County Public Health continues its multi-faceted approach in providing information with trusted messengers to overcome vaccine hesitancy and making our vaccination clinics easily available and accessible to anyone and everyone who chooses to get vaccinated against COVID-19,” Monteiro said.

Tulare County Public Health encourages Medi-Cal patients to visit their primary care doctor or health clinic to get vaccinated for COVID-19 as the vaccine is widely available throughout the county. Individuals can also go to their pharmacy location, as most nationwide pharmacies are now carrying COVID vaccines through the Federal Retail Pharmacy Program. Anyone can find a pharmacy vaccine location online at www.vaccines.gov. Or Tulare County residents can get vaccinated at clinics sponsored by Tulare County Public Health and community partners that are occurring throughout the county. These COVID clinics can be accessed at the statewide COVID Vaccine Scheduling web site myturn.ca.gov or by calling 1-833-422-4255 or 559-685-2260 or simply dialing 211.

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