Greene County’s low vaccination rates spur door-to-door visits from public health workers

A little after 2:15 p.m. on Feb. 1, Cody Hyde and Jordana Vera gathered near the foot of a driveway at the end of a block near McDaniel Park to trade notes after an hour spent surprising residents with questions about vaccinations.

The two Springfield-Greene County Health Department community health advocates visited 36 homes in the Delaware neighborhood that afternoon, informing anyone who answered the door that they were with the health department and wanted to talk about COVID-19 precautions.

Because they cover ground separately, because each of these canvassing sessions inform the next one and because the conversations can get heavy, they take time after canvassing to debrief.

Hyde had started on the west side of the avenue that day, with Vera taking the east. But she ended up knocking on a few westside doors while Hyde spoke with an unvaccinated woman. The discussion lasted about 10 minutes.

“That’s the longest conversation you’ve ever had,” Vera said.

“Yeah, one of them,” Hyde responded.

“Was it good?”

His short answer: “Yeah.” His longer answer was that it touched on topics that often lead discussions about vaccination hesitancy to abruptly end or never begin — Chinese surveillance, George Soros, a cashless society. Government distrust, mRNA suspicions and emergency use authorization concerns emerged as well.

But this conversation was civil. It ended with Hyde handing her educational material that the health department had produced to allay some concerns she specifically mentioned, and with her thanking him and saying she’d share it with other members of her family, many of whom were unvaccinated.

“That was one of those things where it was productive,” Hyde said.

A productive conversation counts as a positive outcome at a time when unvaccinated people make up the overwhelming majority of those hospitalized with COVID-19 in Greene County — a place where the vaccination rate was so low last summer that federal health officials sent a specialist from Centers for Disease Control and Prevention (CDC) to help find out what was going on. Last July, as the Delta variant spread through Springfield, the specialist told local health officials something that has stuck with Cara Erwin: stop treating the decision to vaccinate like it's a now or never one, because the urgency pushes people away.

“We need to give people the grace to be able to take their time in making the decision,” Erwin, communications and outreach manager for the Springfield-Greene County Health Department, said.

Will it lead someone who reads that material Hyde handed out to join the nearly 53 percent of Greene County residents who, as of Feb. 1, were fully vaccinated? While that is a hope of the door-to-door canvassers participating in the health department’s Finish Strong 417 initiative, it is not a data point they will directly track. The door-to-door effort, Vera said, is partially to let people know that vaccine appointments are readily available and that there are financial incentives to getting them.

But more than that, she said it is to meet face-to-face and hear people out about what has become a highly politicized issue both nationwide and in a county where the vaccination rate lags roughly 11 percentage points behind the national one.

Why some locals don’t (or do) vaccinate

“We need to do one about the chip again,” Vera said, after speaking with a woman who mentioned concerns about tracking devices.

“Oh, the chip,” Hyde said. “See, I don’t even know how to, like, battle that. What do you say?”

He quickly formed an answer to his own question, that you could say smartphones and social security numbers and other things already track you, or that you could try Socratic questioning.

A recent master’s of public health graduate from Missouri State University, Hyde first began canvassing in mid-July. Back then, he was on a fact-finding mission, part of a student team conducting interviews with vaccine-hesitant residents at a time when Springfield was the national epicenter of the delta variant surge.

The effort was in collaboration with the health department, the CDC and the MSU-based Ozarks Public Health Initiative, where Hyde then worked as a grad assistant in a health-related arm. In response to a request for assistance from Missouri officials, the CDC in July sent a team to Springfield that included a researcher who’d previously examined public health crises in Haiti, Iraq and West Africa.

In Springfield, he helped analyze the information that about 45 residents provided about their hesitations to get vaccinated. A PowerPoint provided to state and local officials summarized each of the major themes, including:

• Excessive self-efficacy. (“I’m bulletproof.”)
• Autonomy. (“I alone will decide, but I can’t with such conflicting information.”)
• Fatalism. (“Since I’m not sure, leave it up to fate or God.”)

The information gathered during those mid-July interviews serves as a snapshot of beliefs from that time, said Erwin. But it also provided a building block for the health department canvassing effort that has continued across the county. While the Delta variant surge is seemingly in the rearview mirror, COVID-19 is not.

CoxHealth CEO Steve Edwards called January “the most demanding month of this pandemic,” citing the 840 COVID-positive admissions to the hospital system last month.

And so, after a temporary suspension of canvassing efforts during the projected peak of the Omicron variant spread, the community health advocates are hitting the pavement again.

How door-to-door vaccine conversations play out

Each time that someone answered the door, Vera greeted them with a cheerful “Hi,” a flyer and her message.

“We’re with the Finish Strong 417 initiative, and we’re just in your neighborhood talking to people about what kind of things you are doing to protect yourself during these COVID times all over again,” she said. “What kinds of things are you doing, like vaccination or masking?”

Vera and Hyde have come to expect people to answer that question in any number of ways. Joyce Smith, the first person to open a door on Hyde’s side of the street, said she couldn’t think of anyone in her circle of family or friends who was unvaccinated, and pointed out that One Call Care Center, her employer who has encouraged her to work from home, “is awesome.” Still, Hyde left a flyer with information about the nearby vaccine clinic because maybe she’d think of someone who could use it.

Across the street, Vera walked up to one front porch after another, hanging flyers on the doors that never opened and passing them quickly to anyone who answered them.

“Yeah, I’ve had my vaccinations, I’ve had my booster,” Gloria Murrill said.

“Awesome, awesome,” Vera responded. “Do you know anybody who hasn’t had a vaccine yet?”

“Not off the top of my head,” she said, but Vera left her a flyer anyway and encouraged her to mention the $50 gift card incentives to anyone she met that hadn’t had a first or second dose. Then she punched in some information about the visit to a SurveyMonkey questionnaire open on her smartphone as she headed to the next door.

After Vera left, it occurred to Murrill during a conversation with a Daily Citizen reporter that an older family member and her husband hadn’t been vaccinated yet, and that a woman her hairdresser knew had already been hospitalized due to COVID, but “for some reason, she's got the impression the shot will kill her.”

Why Springfield petitioned for the CDC’s help

On July 30, 2021, a pandemic era-high of 113 patients with COVID-19 were hospitalized in critical care in Greene County. That month, 75 people died due to COVID-19 complications. When the Delta variant began surging earlier that summer in southwest Missouri, the Missouri Department of Health and Senior Services (DHSS) turned to the CDC for help.

DHHS asked the CDC to send team members to Springfield to assist with three goals, according to a CDC statement sent to the Hauxeda. One was to work with local officials in addressing the area's low vaccination rate and vaccine hesitancy. To help with that, the CDC sent Richard Garfield, Team Lead for Assessment, Surveillance and Information Management in the CDC’s Emergency Response and Recovery branch.

Since joining the CDC, Garfield has taken part in rapid responses to public health disasters across the globe — the 2010 hurricane in Haiti, the mid-2010s Ebola epidemic in West Africa and others in Cuba, Liberia, Nicaragua and elsewhere. In Springfield, grad students and health officials who worked with him said Garfield approached the situation here with curiosity.

“He just was really a sponge and wanted to know everything that we had already been doing, why we were doing it, how it was going,” Erwin said.

Garfield worked with local officials to build a team to conduct on-the-street interviews with people about their vaccination decisions. After a swift mid-July training session, groups of Missouri State University master’s of public health students visited northwest Springfield and the nearby town of Ash Grove. The students targeted those locations for precise reasons. In 2021, DHSS contracted with Deloitte Consulting to provide data and mapping resources that analyzed vaccination gaps across the state. That May, Deloitte began providing census tract-level data to Springfield-Greene County Health Department officials that showed which county tracts were the least vaccinated. At the time, residents in two neighboring northwest Springfield tracts were the city's least vaccinated, and Ash Grove was the least vaccinated area outside the city limits.

“We had these two excellent, nationally known organizations that were wanting to look at Springfield, learn about our community and help us develop and deploy messaging to help reduce that vaccine hesitancy,” Erwin said. “At what was a very frantic time, it was great to be able to have that additional support from those organizations.”

How canvassers counter vaccine hesitancy

In teams of two, the students visited the three tracts and stood in church and grocery store parking lots. They visited parks, farmer’s markets, flea markets and vaccine clinics as well. At each locale, they asked people questions about vaccinations, and about any reasons they maintained for hesitancy in receiving them.

Reached by email, Garfield said he was not authorized to talk about his visit to Springfield. The emails obtained by the Missouri Independent included one Garfield wrote to a state health department official after spending two weeks in Springfield working with the health department and the MSU research team. He wrote important lessons had been learned that the CDC could apply in other areas of the country, adding that “now its (sic) clear that where people Live is far less important than where they Shop and Worship and hang out……”

Emily Fessler, who in July was an Ozarks Public Health Institute graduate assistant, agreed. Fessler, who is finishing her masters of public health at MSU, led the interview training process for the participating students, and also conducted numerous interviews, including at churches where parishioners had come from different corners of the city to worship.

In an article about the research published in the Greene County Medical Society journal, Fessler wrote about the three general themes that emerged from the conversations with the vaccine-hesitant, the ones mentioned in the PowerPoint Garfield prepared. Garfield’s PowerPoint included potential responses to people who expressed vaccine hesitancy:

• To people who said they don’t get sick (excessive self-efficacy), he suggested offering testimonies of other healthy people who fell ill.
• To those who expressed distrust in the government, or confidence that people in their age group wouldn’t get it (autonomy), he suggested having reliable information at the ready to counter what can be found on social media.
• To those who described their fate in God’s hands, he suggested pointing out that people have been given tools to combat other diseases and enhance their immune systems.

The recommendations were presented to the Springfield-Greene County Health Department, where the outreach team had been canvassing neighborhoods since May 2021 and was already working on communications material that emphasized some of these points. Erwin said the findings reinforced their belief that they were addressing key points. The Ozarks Public Health Institute team was then asked to shift focus from the census tracts to a different population with a low vaccination rate, 18-22-year-olds, and worked with a team of MSU communications students to create presentations delivered to fellow students.

Listening to vaccine-hesitant residents is key

To Fessler, who majored in anthropology as an undergraduate and now works as the project manager for #HealthierMO, the community conversations conducted as part of the summer survey, and the ones that have been conducted as part of the health department’s neighborhood canvassing effort, are steps in the right direction for the public health field, which she said is deeply data-oriented.

“Data is critical, because data is what allows us to drive our decision-making and make sure that our decisions are evidence-based,” Fessler said. “But there does come a point when we know what the decision is, and we know what we need to do and what our goals are. And at that point, that's when we have to have those community conversations. Meeting people where they are, I think that's so important because data can't provide you that value.

“People want connection. They want to be heard. They want to be listened to and they want to feel that their concerns matter. And so talking through people with that is going to provide you better data in the long run.”

Understanding where people are coming from will go a long way in furthering conversations around getting vaccinated, said Fessler. As will recognizing that, while scientific evidence overwhelmingly points to vaccines improving defenses against COVID-19, many have reasons that can’t be dismissed for distrusting public health officials, she said. In her article, she pointed to one reason in particular expressed by several Black respondents who she interviewed on Sunday morning outside of Turning Point Church.

“Especially among the African-American community, distrust of government and local public health agencies was the most common reason for vaccine hesitancy, with many citing the Tuskegee Experiment,” she wrote, referring to the decades-long U.S. Public Health Service study that began in 1932, in which researchers withheld penicillin from hundreds of Black men suffering from syphilis even after it became the treatment of choice for the infection.

“Tuskegee actually wasn't that long ago,” Fessler said. “It's really fresh, it's really raw. The amount of people that mentioned Tuskegee to me was quite high.”

Canvassers are locals, too

Hyde was with Fessler outside Turning Point Church that day. He grew up on the south side of Springfield, and said that going to Missouri State helped him get out of his geographic bubble. Canvassing, he said, has burst it entirely. He’s now been to all corners of Springfield, and said he feels like he knows his community better and has strengthened his public health knowledge in the process.

“I definitely like to engage with people in the community,” Hyde said. “And I'm passionate about public health. So I kind of want to be able to be on the front line and be that person who can talk to people, go through their hesitancy, hopefully change their mind, but also just learn what the community is thinking.”

And, he said, he wants to be prepared to respond to their thoughts. He keeps up not only on research about COVID-19, but also how it’s being presented on social media, particularly TikTok.

“I follow a lot of people who are doctors who are responding to misinformation,” he said. “So I find that to be helpful to explain certain things that I may not find super easy to explain. (Then) the algorithm is definitely like, ‘OK, let me throw some actual misinformation to you.’”

Rather than thumb past misinformation, he tends to study it, too. It can lead to sleepless, scrolling nights, but he said that’s how he first watched someone blame vaccine boosters for causing the new variants of COVID-19. He took that with him to work, where educational material was created to explain how a virus has more opportunities to mutate the more that it spreads, replicates and changes over time. Hyde carries the material with him in a black binder that he brings on his door-to-door trips, and it includes handouts that address mRNA vaccines, vaccines and fertility, the process of FDA approval and emergency use authorization and other topics that have come up. When vaccine hesitant residents bring up unease about the science and safety surrounding the shots, Hyde handpicks documents that address them. When people enter the chat with conspiracy theories, Hyde said, he tries to move past them and build a connection between the two people on each side of the doorway.

Latino community vulnerable to tracking concerns

After introducing herself and the Finish Strong 417 initiative, Vera asked Kym Barnett what precautions she was taking. Barnett answered that she started masking again during the Omicron wave, but that she did not get the vaccine.

“Do you mind if I ask what’s your hesitancy?” Vera said. “What is the reason you don’t want to get the vaccine yet? Feel free to tell me whatever.”

“OK,” Barnett responded. “I just feel like it’s evil. I feel like it’s got a chip in it. And I feel like that’s the way of keeping track of people. I just feel like that’s how they keep track of people. You know, everybody that I know that has not gotten it hasn’t gotten sick. People that have gotten it have gotten sick.”

Vera, who has lived here for two decades and co-founded the nonprofit Alliance for Leadership, Advancement and Success to improve Latino students’ access to higher education, said later that she had heard this refrain about the chip before, but not from a white person.

“In the Latino community, the Latinx community, the chip discussion, it’s pretty much everything,” she said.

The reason: a tracking chip plays into fears of people who are or who know undocumented citizens, Vera said. Like Hyde, Vera tells people with those concerns that if someone wanted to find you, they could have used your smartphone signal to do it already. But she said she understands that “probably 90 percent” of your decisions — from scheduling vaccinations to grocery runs — are based on avoiding attention if you don’t have your documents.

To Barnett, Vera said, “That’s your right to decide what you want to do,” and offered her the door hanger, pointing out information about the gift card incentives for the first and second doses.

“If you ever change your mind, we have a vaccine clinic where we are giving $50 gift cards to those who get the first or second dose if you are interested in getting it,” she said, and told Barnett the clinic is where the old Toys ‘R’ Us used to be after she asked.

“Sounds like a plan,” Barnett said. “Thank you so much.”

After Vera left, Barnett, who uses a wheelchair, said she appreciated the door-to-door conversation in part because she doesn’t often get out, and also because Vera was “polite and friendly.”

Empathy matters

In public health, Vera said you need both data and empathy for the people you’re presenting it to.

“You can have all the science, but if you're not nice or empathetic, it won't work,” she said as she waited at another door. Nathaniel Foster opened it.

Vera introduced herself and asked what he was doing to protect himself during the latest surge. Foster said he wasn’t the homeowner, and Vera said it was OK, that she still wanted to know if he was willing to share. And he did. He said he was wearing masks again, and using hand sanitizer.

“What about vaccination?”

“No,” he said.

“Do you mind if I ask you what's the reason,” she said.

“I just don't know the outcome. Maybe it turns into something, maybe not, I don’t know.”

She asked where he had gathered information, and he said YouTube, the news and from people who had received the shot.

“It's going to come down to, that we have to take it in order to get work, but I don't think that's fair,” he said. “That's what it's looking like, and if that's the case, then I don't know. Maybe in the long run. I don't want to be a test dummy, you know?”

Vera headed across the street to handpick some information from Hyde’s binder to give to Foster. She had to backtrack the block, because Hyde was still talking with a woman whose door he’d knocked on several minutes prior.

‘We’re part of this community’

Rhonda Trotter said she assumed that the young man at her front door was a Jehovah’s Witness.

“I thought I was gonna have to save them,” she said. “But now I find that they’re trying to save me. I said, OK, well let me talk to you. Because I’ll talk to you. That’s the problem with some people.”

After introducing himself as part of the Finish Strong 417 initiative, the conversation took numerous turns. Her concerns about Chinese surveillance and political motivations to bypass FDA approval were interspersed with anecdotes about family members who were not vaccinated, and had been fine so far and one who had been, and was sick after receiving it. Hyde gave her information on how emergency use authorization works, asked her to imagine the short period of time her vaccinated relative was sick and compare that to getting COVID-19 at a time where hospital beds are at a premium and pointed on the door hanger to the health department’s website for vaccine information.

Hyde said later that, whether you’re vaccinated or not, your immediate sphere of influence — your family, friends, neighbors and community — shape and reinforce your decisions. An outside influence can hit people in an “us versus them” way. Outsider pressure is a point of contention that numerous people brought up when he started talking to them about vaccines in July, and it’s one he has heard from scores more since. So this canvassing effort has become one in which the canvassers are trying to show, by showing up, that they are in fact in this together.

“We are part of this community,” Hyde said. “We're trying to bring you information about your own community. That's why I told her, there's 260 people, right now, in the hospital, from our community. So even if you think the federal government is corrupt, and BS, at least look at how it's impacting us right now and that can maybe help people consider it more. I'm not sure if that's actually had an impact.”

That’s for the people on the other side of the doors to decide. Trotter said it would be wrong of her not to share the material Hyde provided her with her family and said she’d do so.

“You need to know your options, or if you believe in the options,” she said. “So I will talk to them about it and say something.”

“I appreciate that a lot,” Hyde said.

“Well, I feel like you believe in what you're doing, so that does help,” she said. “The health department is part of the government, but there are good people that do work at the health department. I do know that.”

Cory Matteson

Cory Matteson moved to Springfield in 2022 to join the team of Daily Citizen journalists and staff eager to launch a local news nonprofit. He returned to the Show-Me State nearly two decades after graduating from the University of Missouri-Columbia. Prior to arriving in Springfield, he worked as a reporter at the Lincoln Journal Star and Casper Star-Tribune. More by Cory Matteson

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