Latino vaccination rates are high in one Maryland county. A cartoon grandmother helped.

Devora Guerrero, a coronavirus outreach volunteer in Montgomery County, Md., saw five family members, including her grandmother, get the virus last year. She herself tested positive in December - and despite it all, Guerrero was afraid to get the vaccine.

The 23-year-old's friends had nearly convinced her that the vaccine was not safe - but then she met Abuelina.

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This animated character commissioned by Montgomery County's Latino Health Initiative (LHI), Por Nuestra Salud y Bienestar, a community partner focused on reaching the Latino population, reminded Guerrero of her own abuela - a short, hard-working and wise Chilean 74-year-old grandmother.

Abuelina speaks with a Salvadoran accent, places her hands on her hips and reminds viewers to mask up, use hand sanitizer and get vaccinated.

Abuelina won Guerrero over. She eventually scheduled a vaccine appointment for herself, two of her friends, her stepfather who works as a warehouse worker and his seven co-workers.

"She's everyone's grandmother," Guerrero said. "You doubt your mom, but not your grandmother. In the Latino community, grandmothers are wise and magical. We have a lot of respect for them and we know we should listen."

Like for other communities of color, vaccination rates for Latino residents have lagged behind White residents across the country. Public health experts and local officials have sought out ways to reach this community that has been especially hard-hit by the pandemic, with many who work in front-line jobs, live in multigenerational houses and can be harder to reach due to language or other barriers.

In Montgomery County, over two-thirds of the covid-19 cases in July 2020 were among the Hispanic community, and Latinos lagged behind non-Hispanic White residents in vaccinations by 20 percentage points in February. Latinos make up about 20% of the county's population as of 2019.

Now the vaccination rate among the Latino and Hispanic population is 9.2% higher than the rate for non-Hispanic White residents, reaching 74.2% for Hispanics compared to 65% for non-Hispanic White residents as of Thursday. The county's rates are based on the 80% of vaccination records in which race and ethnicity information was available.

Beyond the long-standing partnership with the Latino Health Initiative and the county's emphasis on multilingual coronavirus resources, many attribute the county's success in boosting those rates to Abuelina - a combination of abuela, or grandmother in Spanish, and the name Lina - and her red-rimmed glasses, gray bob haircut and commanding presence on Facebook, WhatsApp, posters in grocery stores, health centers, testing sites and television commercials.

The concept of Abuelina was intended to reflect the "heart of the people," said Mynellies Negron, marketing director of Communication Shop, a public relations company that designed the character.

The illustrators aimed to have Abuelina look like a modern grandmother - so no hair in a bun, oversized glasses or bulky purse. "We didn't want her to be the stereotypical abuelita," Negron explained.

And they wanted her speech to be reassuring and familiar, which led to Abuelina's voice actress elongating the middle syllable in tranquilo, or calm, as reflected in Salvadoran accents, for example.

She was inspired by an elderly Dominican woman who had attended the focus group sessions led by the design team.

"She would listen to everyone and when she said something it was not imposing," Negron said. "And everyone would simply be quiet and listen, not just out of respect, but because they knew she had great things to say based on her experience."

County Council Vice President Gabe Albornoz, D-At Large, whose parents are from Chile and Ecuador, said he thought the campaign hit the right notes.

"It brings together everything we've learned about authentic community engagement," Albornoz said. "You have to go much deeper and be repetitive and consistent in order to really be able to break through. And that's what this initiative has proven to be."

Albornoz said Abuelina reminded him of his tía, or aunt, Luli, and his mother, who, like Abuelina, have authority through their calm, caring and stern demeanors.

"My family was very proud of the campaign. I think some campaigns in the past missed the mark because they were not really culturally appropriate or - maybe without intending to be - somewhat condescending," he said. "But [Abuelina] wasn't that."

And as the pandemic rolled on, the design team created new characters, like Abuelina's male partner Don Carlos, who was meant to appeal to the county's large Colombian demographic. Later, the campaign featured Abuelina's grandchildren, 12-year-old Valentina and 16-year-old Alex, to reach a younger audience.

Senior manager of LHI Sonia Mora said the county is in the process of copyrighting Abuelina and her family members to ensure they are not used for commercial purposes. The county, however, is willing to share strategies and lessons learned with other agencies, she added.

"She's incredible, but really we feel very strongly that she is part of the whole effort of having all these services," Mora said. "When people come to our testing sites, they are going to be received in a culturally and linguistically competent manner by staff that knows the community."

On one Wednesday at the Mary's Center coronavirus testing site in Silver Spring, cardboard cutouts of Abuelina were in the waiting room and propped up next to the tent outside.

Isaac Vasquez, 36, came to the center to get his 9-year-old daughter Martina, who had the sniffles, tested for the virus. Vasquez, who has diabetes, got vaccinated earlier this year at the request of his doctor at the center.

Vasquez recognized Abuelina from the advertisements across the county and said he appreciated the deliberate choices made in creating her character. He also said he thought the initiative was helpful in getting information to the Spanish-speaking community.

"Most of the information available to Spanish speakers made available on social media scared me, and because of that I stopped paying attention to the news," Vasquez said through an interpreter. "But I think this initiative was smart in reaching the community."

Sandra Crouse Quinn, a senior associate director at the Maryland Center for Health Equity, School of Public Health, said the campaign reflects a model for successful outreach.

Quinn contributed to a Johns Hopkins study that recommended public health policies for communities of color to combat vaccine hesitancy.

"Montgomery County, it is very much in keeping with some of the work we're doing. Having a deep knowledge of the communities in which we work is vital," Quinn said.

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