Could Dollar Stores Be the Answer To Expanded Covid Vaccine Access?

The footprint of deep discount retailers like Dollar Stores corresponds to the regions with some of the lowest vaccination rates. 

And as big pharmacy chains have learned, vaccinations drive other business. JL 

Mario Patino and Jackie Gu report in CityLab:

Distributing vaccines through Dollar General could dramatically increase vaccine availability in low-income areas and some communities of color. Vulnerable regions are also where Dollar General and other discount stores like it tend to cluster. Vaccine-hesitant people would be willing to get vaccinated, if only they could go somewhere convenient — and perhaps familiar enough to instill trust.

It was midway through a remote meeting on vaccine accessibility in rural America that A. Toni Young, co-founder of the Rural Health Service Providers Network, brought up an idea to expand the Covid-19 vaccination campaign: “You’re going to think I’m crazy but here it is: Dollar General.”

Her slidedeck transitioned to a map of the U.S. covered with thousands of dots. The dots represented the more than 17,000 Dollar General locations that make the discount chain one of the largest retailers in the country. By comparison, CVS and Walgreens each have fewer than 10,000 locations. Dollar General’s footprint is particularly prominent outside of big urban areas, where its number of stores has been steadily increasing over the last decade, as has the other dominant chain, Dollar Tree.

Dollar General Locations Per Year

The retail chain has expanded everywhere, particularly outside big urban areas

• Large metro
 
• Suburb
 
• Medium metro
 
• Small metro
 
• Small town
 
• Rural

Note: 64 stores couldn’t be mapped to a code in the CDC urban/rural classification scheme

Sources: Jerry Shannon, professor of geography at the University of Georgia; Centers for Disease Control

In fact, distributing vaccines through Dollar General was something the U.S. Centers for Disease Control considered, too, before deciding in May not to pursue a “formal partnership,” according to a CDC spokesperson. But such a collaboration might be just what’s needed to vaccinate some of America’s hardest-to-reach populations, according to research by Judith Chevalier, Jason Schwartz and their colleagues at the Yale University schools of management and public health.

Such a partnership could dramatically increase vaccine availability in low-income areas and some communities of color, the authors found in their working paper, which hasn’t yet been peer reviewed.

“The dollar store footprint ... lends itself to thinking about this broader aim of making vaccines available right where people are located, and the people that are disproportionately under-vaccinated in so many of our cities and communities right now,” said Schwartz, a professor of public health at Yale.

Even beyond Covid-19, Young makes the case that dollar stores could be key access points for reaching vulnerable populations who have limited access to health care services, and sometimes lack trust in the system.

The researchers’ national analysis compared the locations of pharmacy retail chains that are currently partnering with the government through the Federal Retail Pharmacy Program to the locations of Dollar General stores, depicted in the map below (with a caveat: not all FRPP affiliated pharmacies actually distribute vaccines). They then analyzed state vaccine sites in the 21 sites where data was accessible.

Where Dollar General Stores Expand Vaccine Access

The percent of low-income population within one mile of a vaccine site increases the most in rural states with Dollar General stores

Increase in vaccine access for low-income

population after adding Dollar Generals

No Dollar

Generals

+5 or less

+5-10

+10-20

+30 percentage points or more

+20-30

AK

ME

VT

NH

MA

WA

ID

MT

ND

MN

WI

MI

NY

CT

RI

OR

NV

WY

SD

IA

IL

IN

OH

PA

NJ

CA

UT

CO

NE

MO

KY

WV

MD

DE

AZ

NM

KS

AR

MS

TN

VA

NC

OK

LA

AL

GA

SC

HI

TX

FL

Note: Includes only data on pharmacy participants in the Federal Retail Pharmacy Program, not state vaccination sites.

Source: Judith Chevalier, Jason Schwartz and colleagues

The White House announced on June 22 that it would narrowly miss its goal of getting 70% of U.S. adults at least one dose of Covid-19 vaccine by July 4. As of July 2, 67% of adults are at least partially vaccinated, with important regional disparities. States in the Northeast tend to be ahead of the 70% threshold. In the South these numbers are much lower: 55% in South Carolina, 50% in Alabama and 46% in Mississippi (the lowest nationally), according to a data analysis by the New York Times.

“There is far more vaccine supply than demand,” Schwartz said. “We knew we would hit that tipping point some time in April. And we also knew then, and know now, that not everyone who isn’t vaccinated right now is vaccine-hesitant.” Schwartz’s argument is geared at the people who would be willing to get vaccinated, if only they could go somewhere convenient — and perhaps familiar enough to instill trust.

Those in more vulnerable communities tend to be the least vaccinated, the data shows. Chevalier and Schwartz use a metric called the Social Vulnerability Index (SVI) in their analysis, which compiles a wide range of variables including income, education, housing type and transportation.

County Vaccination Rates and Social Vulnerability 👆

The higher the Social Vulnerability Index decile, the more vulnerable the county

• Average vaccination rate

Note: Filters out counties that are less than 80% complete in reporting home addresses of vaccinated individuals. Percentages are calculated for fully vaccinated individuals out of the total population 12 and older. Data as of July 1st.

Sources: CDC; Texas Department of State Health Services; Commonwealth of Massachusetts

The researchers found that in the most vulnerable decile, the number of retail pharmacies that are eligible to provide vaccines through the Federal Retail Pharmacy Program is the lowest. But these vulnerable regions are also where Dollar General and other discount stores like it tend to cluster.

As former Dollar General CEO David Perdue put it in an interview with the Wall Street Journal in 2017: “We went where they ain’t” (referring particularly to Walmart). The chain’s strategy is based on opening stores in deprived spaces, sometimes making it the closest option for groceries. “We seek to locate our stores in close proximity to our customers,” an annual company report states, “which helps drive customer loyalty and trip frequency, and makes us an attractive alternative to large discount and other large-box retail and grocery stores.”

Critics argue that the dollar store’s very business model may do other harm to public health. Before 2019, Dollar General stores offered little fresh produce and dollar stores have been reported to increase obesity in the communities they serve. Some politicians and activists believe Dollar General is actually driving out other grocery stores and retailers that offer healthier foods and have proposed blocking new dollar stores in their communities. But the company says it now offers fresh produce in 1,300 of its stores and plans to continue expanding. And whether it’s a cause or effect that results in their dominance in vulnerable areas, Chevalier and Schwartz document how dollar stores currently fill substantial retail gaps — in some regions far more than others.

“States vary considerably in the extent to which their vaccine sites provide substantial proximity to low income people,” the study finds. In New Jersey, for example, 39% of low-income households are located within less than a mile of a state vaccination site, and this share is propelled to 79% upon adding pharmacy partners. Adding Dollar General Stores doesn’t add much: It ramps up access by a mere 2 percentage points.

But in Arkansas, where the researchers estimate that only 27% of low-income households are within a mile of a state-run vaccination site, adding pharmacy retailers only increases the percentage to 31%. It increases to 48% when adding Dollar General locations to the pool.

Within a 15 minute drive...

to a Dollar General

to a state vaccine site or pharmacy

to both

vaccination sites and dollar store locations

Springdale

Fayetteville

Fort Smith

Conway

Little Rock

50 mi

60 km

Note: Map does not include areas within driving distance of an out-of-state vaccination site or Dollar General

Sources: Judith Chevalier, Jason Schwartz and colleagues; Mapbox

Despite their accessible locations, there are other challenges to administering vaccines at dollar stores. One big one is the lack of employees qualified to administer the vaccine.

That’s why Clay Marsh, West Virginia’s appointed Covid-19 vaccine czar, thinks mobile clinics are a better solution for filling access gaps than any fixed location like a dollar store.

“To me there is a group of vaccine hesitant, people who don’t have access, and may not have the energy to go seek vaccines,” said Marsh, “but if the vaccine was brought to them, then at least from what we’re seeing in our surveys, they would be open to being vaccinated.”

One option, Marsh suggests, might also be to use dollar store parking lots as prime locations for mobile clinics.

“We are really very enthusiastic about trying a number of things and making vaccines very accessible,” said Marsh, “because the access is at least what we hear in our survey results as a critical issue for many people.”

Dollar General has already provided Covid-19 tests in some of its stores, and a spokesperson says the company is continuing to explore other partnerships, including potentially with state and local governments.

To Young, the rural health services advocate, the presence of Dollar General stores in vulnerable areas suggests a potential broader role for the retailers in improving public health.

“There’s a way for [Dollar General] to expand this, make more money, and change [its] brand in communities,” says Young, who lives in West Virginia. She argues it could be a way for Dollar General to show itself as a “good corporate citizen.”

Young thinks criticisms that dollar stores are driving out other retailers offering healthier foods overlooks the economic realities in many rural communities.

“Some people will say: Did they create the food desert, or are they a response to the food desert?” said Young. “And I think it’s a little bit of both. Not that many big box stores are going to open stores in rural communities, because there’s not enough traffic. Is that enough traffic for a Dollar General? Yes.”