Engaging With Communities - Lessons (Re)Learned From COVID-19

"Community engagement and partnerships are at the heart and core of public health, are essential for achieving health equity, and are most dramatically needed during pandemics such as we now face."

Pandemics and epidemics, including COVID-19, are most dangerous to people who are already at risk. Vulnerabilities due to underlying health conditions and/or deeper racial, structural, and systemic inequities explain why Black, Latino, American Indian, and Pacific Islander individuals and their communities in the United States (US) suffer age-adjusted mortality rates 2 or 3 times greater than that of White residents. Among the reasons: a long-term mistrust of government, research, and healthcare institutions make it less likely that some racial/ethnic communities and historically marginalised communities will trust public health messaging or believe they will receive equal access to testing, treatment, and vaccines. In the context of such disparities, this article argues that responses to COVID-19 require partnerships that use a health equity lens, build on community strengths, and use community engagement strategies to respond, build trust, and advocate for health for all.

Despite and often because of COVID-19 disparities in the US, community-based organisations (CBOs), Native American tribes, state and local health departments, hospitals, and universities with histories of collaboration have responded to COVID-19 using intentional, stepwise engagement with marginalised communities. Here are just a few examples, across diverse communities:

• In New Mexico, a partnership across academia, local and state government, nonprofits, primary health care clinics, and others have used the community-based participatory research (CBPR) model as a planning and evaluation tool. Partners first identified a short-term goal of encouraging homeless people not to leave shelters. They created a rapid-cycle CBPR process of surveying elderly homeless people on their perceived barriers to staying at the shelter, returning the results through town hall dialogues and responding to the recommendations. After the first 3 weeks, the proportion of elders who stayed in the shelter after sleeping there grew from 20% to 75%, with no one testing positive for COVID-19.
• In Solano County, California, the Solano Pride Center is conducting virtual emotional support and practical information sessions for lesbian, gay, bisexual, transgender, and queer (LGBTQ) youth and older adults and has opened a chat service and other safe spaces in response to the social isolation and limited emotional support accentuated by the COVID-19 crisis.
• In New Brunswick, New Jersey, the response has been channeled through peer-to-peer interaction and networks of partnerships. For instance, community health ambassadors serve as the cultural bridge between CBOs, health care agencies, and their respective communities. In addition, Saint Peter's University Hospital conducted an informal geo-mapping of infected New Brunswick residents and found that close to 100% of New Brunswick residents infected with COVID-19 lived in 2 predominately Latino neighbourhoods whose census tracts have the most substantial health and social disparities in the city. In response, the hospitals put together care kits that included masks, soap, and public service announcements (in English and Spanish) on proper prevention methods, which the hospitals and community partners disseminated in these neighbourhoods. Other announcements addressing COVID-19 health concerns and underlying structural inequities (inability to isolate in home settings) are promoted by using community outreach and a website, mobile app, and social media outlets.
• The HealthStreet Community Engagement Program at University of Florida, which has been working to build community trust, pivoted from being a face-to-face community health worker model to a telephone-based programme to continue to assess the needs of their 12,000 members and link them to needed services.

These and other examples shared in the article highlight that:

• Engagement with communities early on and throughout a crisis is critical, especially communities of colour and other marginalised groups who require a public health response that is not channeled through discriminatory systems and structures and does not perpetuate inequities.
• Awareness of the various cultures of a community and other factors affecting diversity needs to shape the planning, design, and implementation of community engagement approaches.
• Partners must be prepared to release control of actions or interventions to the community and be flexible enough to meet its changing needs.

The article reviews lessons from past health emergencies, including AIDS and severe acute respiratory syndrome (SARS), suggesting that effective public health roles should include:

• gathering data on those affected;
• building on community strengths and priorities to shape the actions of collecting, sharing, and interpreting data with the communities;
• developing plans with community leaders;
• co-creating and communicating risk and harm reduction strategies through existing communication methods; and
• rapidly tracking and adjusting plans as the epidemic progresses.

Specifically, the following steps are recommended for public health organisations seeking to engage with communities and partners in times of crisis:

• Learn - for example, train staff in health equity, using local resources or national training, and gather information about effective multisector partnerships.
• Partner - for example, gather, share, and interpret data with affected communities, working with community members and leaders, and with analysis by race, ethnicity, language, location (zip code or census tract), and social factors.
• Work collectively:
  • Design and implement with a priority placed on equity.
  • Co-create with cross-sector partners, such as CBOs, clinicians, universities, medical centres, housing and transportation sectors, and schools of public health, especially those located in or partnered with racial/ethnic communities (recognise that students, including in public health, medicine, and nursing, have much to contribute and learn).
  • Collectively define the problem and create a shared vision to solve it.
  • Focus on outcomes, not just on activities or processes.
  • Use data to continuously learn, adapt, and improve.
  • Develop and deliver health risk messaging that is culturally and linguistically appropriate, relevant to vulnerable communities, and delivered through trusted sources.
  • Move beyond information delivery to community conversations that encompass knowledge, beliefs, attitudes, and behaviour.
  • Build a culture that intentionally fosters relationships, trust, and respect across participants.
• Share - for example, gather and distribute stories and data both of initial failures and of solutions found.
• Advocate - for example, engage with partners in coordinated efforts to advocate for immediate support for communities that are most affected, for removal of barriers, for support of programmes that address the root causes of health inequity, and for a diverse public health and healthcare workforce that works together in partnership with its communities.

In conclusion: "Although public health holds a leadership role during the epidemic response, it needs the engagement, partnerships, and trust of communities in shaping, communicating, implementing, and disseminating recommended strategies. Trust can only be built when government and academic collaborators are themselves trustworthy and engage communities as partners in addressing what matters to them, including inequities in testing, treatment, and potentially future access to vaccines....We must also learn how to effectively communicate the need for long-term investment in the infrastructure required for healthy, productive communities, including public health, health care from primary care through hospitals, and community partners."