Advancing shared accountability for meaningful community engagement with socially vulnerable communities: Lessons learned from COVID-19 health education and general outreach in an urban region

Abstract

As COVID-19 public health emergency measures come to an end, socially vulnerable communities have reduced access to resources that address social and health disparities created or exacerbated by the pandemic. Social workers must uphold access to healthcare as a human right in the post-pandemic era by reducing social vulnerability and strengthening community resilience to respond to future health emergencies and natural disasters. This paper draws on the experiences of a team of social work researchers, students, and practitioners engaged in efforts to disseminate information on COVID preventive measures and broker access to local health and social resources. This project, based in one of the fastest-growing metropolitan areas in the United States, formed part of the federal research response to promote community engagement in regions most disproportionately impacted by the COVID-19 pandemic. Through participation in health fairs and community events that targeted persons with limited access to healthcare resources, we gathered critical insights on how to build community capacity for meaningful community engagement. Drawing on a conceptual model for evaluating community engagement strategies, we describe three main barriers to collaborative community outreach: weak organizational communication and coordination, inconsistent strategies for requesting on-site health services, and low neighborhood awareness of outreach events. We advance strategies for improvement that engage community-based organizations, health systems, backbone organizations, and community members in targeted activities to build community resilience. This includes inter-organizational communication during outreach event planning, formal processes to promote greater use of mobile health services, centralized event communication, and grassroots outreach event promotion.

Introduction

On May 5, 2023, the World Health Organization (WHO) declared an end to the COVID-19 public health emergency (PHE). Most countries followed suit and issued similar declarations, effectively ending many government initiatives to reduce virus transmission. Consequently, health care systems and public health departments have significantly less funding for COVID-19 testing, treatments, and vaccines. With the end of special protections to prevent gaps in health care coverage, as many as 14 million people in the United States (US) are projected to lose health care coverage (Cubanski et al., 2023). Safety net providers are anticipating a “tsunami” of persons presenting with health care needs due to long-COVID symptoms (Lledó et al., 2022), gaps in routine and preventive health screenings (Richman et al., 2023; Shukla et al., 2022), limited access to mental health care (Adiukwu et al., 2022), and challenges in healthcare workforce retention (Stievano et al., 2023).

The United Nations and the WHO issued a call to action for including human rights as a critical element of the public health response to the coronavirus pandemic, emphasizing that a failure to address the needs of vulnerable communities subjects them to higher risks of infection, and undermines the effectiveness of other response efforts (United Nations, 2021; World Health Organization, 2020). Consistent with this priority, the COVID-19 pandemic elicited significant public spending on community outreach efforts as a key component of national prevention and promoted vaccine uptake in communities disproportionately impacted by the pandemic (Gilmore et al., 2020). With the end of the PHE and other competing priorities, public health departments and health care organizations have few incentives to allocate funding toward community-based partnerships and initiatives established during the COVID-19 pandemic. As health systems gradually withdraw from active engagement in communities disproportionately impacted by the pandemic, this is likely to further erode low levels of community trust and undermine professional and grassroots networks established through coronavirus-focused partnerships (Page-Tan et al., 2022). Absent other funding, community-based organizations may have limited capacity to invest in communication and coordination efforts that do not directly align with existing programs or structures.

COVID-19 preventive measures and government practices negatively impacted social cohesion and connectedness in several countries (Jewett et al., 2021). Neighborhoods in under-resourced areas and racially marginalized communities experience high levels of social vulnerability and low community resilience, leaving them highly susceptible to future PHEs or natural disasters (Fransen et al., 2022; Wood et al., 2021). However, there is scant research on evaluating community resilience to pandemics (Suleimany et al., 2022). In regions with limited investment in social care and community development activities, social workers played a key role in strengthening community support networks to address material and social needs (Banks et al., 2020). As communities navigate the end of the COVID-19 pandemic, social workers are uniquely positioned to advance human rights through engagement efforts that move beyond superficial or time-limited initiatives and embrace shared accountability by mobilizing resources to (1) minimize harms associated with the withdrawal of PHE protections and public funding for community engagement efforts, and (2) develop targeted activities for sustaining, expanding, and evaluating community engagement efforts that build social resilience for responding to future PHEs and natural disasters.

Building on an ethical imperative to address broader impacts of the pandemic without overlooking persistent vulnerabilities of underserved communities, this article draws on the experiences of a team of social work faculty, practitioners, and students to describe barriers to collaborative community outreach, and explore strategies for building on community engagement efforts established during the coronavirus pandemic. First, we provide an overview of a health education and outreach initiative to reduce COVID-19 misinformation in a large metropolitan area in the Southwestern US. We then apply the Assessing Community Engagement (ACE) Conceptual Model to describe gaps in community capacity for sustained collaboration. Finally, we illustrate promising strategies to improve communication and coordination for maintaining and expanding community engagement through health promotion networks.

Community Engagement Alliance (CEAL)

In the US, the National Institutes of Health (NIH) launched the Community Engagement Alliance (CEAL) program to build long-lasting partnerships through a national research response to the coronavirus pandemic. To accomplish this goal, the NIH established CEAL teams in eleven states across the country to “provide trustworthy, science-based information” to people in communities with disproportionately higher rates of hospitalizations and deaths related to the COVID-19 pandemic (Collins et al., 2023). The Texas CEAL Consortium formed in August 2020 in response to this call. Seven research projects were developed and implemented across five Texas counties selected due to high numbers of COVID-19 cases and high concentrations of racially and ethnically minoritized communities, among other factors (Seguin-Fowler et al., 2022; Thompson et al., 2022). This article draws from the experiences of a supplemental project of the Texas CEAL Consortium that trained teams of students from an academic health science center and a school of social work to develop and disseminate health education and outreach resource content. Located in one of the most rapidly growing and diverse urban counties in the country (US Census Bureau, 2023), the Tarrant County CEAL initiative (TC-CEAL) utilized a shared leadership model across two anchor institutions that included an interdisciplinary team of community-engaged research faculty and graduate students. Over two years, we cultivated a network of community health champions with trusted relationships and expertise in reaching marginalized communities in a southwestern urban metroplex. We capitalized on community outreach events to disseminate evidence-based COVID-19 prevention materials and provide general outreach through graduate-level student health advocates from disciplines including social work, medicine, and biomedical research. This study was exempt from ethics review board approval due to its observational nature and classification as a program evaluation.

Challenges for collaborative community health outreach

The ACE Conceptual Model advances meaningful community engagement (MCE) as a process “grounded in trust, designed for bidirectional influence and information flow between the community and partners, inclusive, and premised on culturally centered approaches” (Aguilar-Gaxiola et al., 2022, p. 6). This model identifies four domains of measurable outcomes for community engagement: strengthened partnerships and alliances, expanded knowledge, improved health and health care programs and policies, and thriving communities. Applying this model, we categorized challenges for MCE observed during TC-CEAL implementation: a lack of inter-organizational communication and coordination, inconsistent processes for service requests, and low community awareness.

Siloed organizational communication

Within the ACE Conceptual Model, strengthened partnerships and alliances reflect “new or improved relational benefits” that carry on into future activities. Local committees provide a forum for outreach staff to learn about upcoming outreach opportunities. In these meetings, we observed many events overlapping in timeframes, geographic location, and target communities. After months of planning, these conflicts were generally not identified until event promotion. This siloed approach to event planning created missed windows of opportunity to learn of available resources, and address shortcomings in organizations with limited marketing capacity and outreach staff. This also restricted expanded knowledge, a domain of the ACE model that emphasizes the creation of outreach tools and strategies derived from collective knowledge and experience in reaching local communities. When participating in community outreach events, organizations must decide which events provide a better return on investment or facilitate greater partnership for their engagement goals, which can contribute to greater disparities in attention and resources shared within underserved communities. Siloed event planning inhibited greater community participation, preventing vendors from disseminating resource information to more diverse audiences.

Inconsistent processes for requesting on-site health services

To improve health and health care programs and policies, the ACE model emphasizes the need for greater alignment between organizations capable of providing on-site health services and the intended users of those services. Many event coordinators lacked knowledge of how to request available health care services, and few events had on-site medical screenings, immunizations, or health providers present. Locally, there are numerous universities, hospitals, and other organizations with mobile initiatives designed for community outreach. However, the lack of consistent and streamlined tools for requesting these services weakened the availability of these services at events aiming to reduce disparities.

Low neighborhood awareness

The ACE model points to thriving communities as the intended outcome of MCE which, in turn, leads to greater community health, well-being, capacity, and connectivity. At neighborhood-based events with a limited turnout, people in geographic proximity were often unaware of events with free screenings, immunizations, and other resources. At one event with the capacity to offer cancer screenings for up to fifty individuals, only four individuals participated. This is a glaring example of awareness as a barrier for outreach events to impact physical and mental health and contribute to community resilience. Attendees voiced hearing about opportunities at church- or school-sponsored events, while others simply saw a crowd and walked to the event. Many noted the lack of a centralized process for learning of upcoming events, highlighting the importance of both greater event promotion as well as geographic accessibility.

Strategies for building community capacity for MCE

Our team identified four strategies to respond to the challenges described: improving inter-organizational communication, formalizing processes to request health outreach services, developing a centralized calendar, and creating a phone bank to notify community members about upcoming events (see Figure 1).

Figure 1:

Capacity-building strategies for meaningful community engagement

Improved communication between organizations

Interorganizational collaborations can facilitate coordination that minimizes co-occurring and geographically overlapping events, integrates community gatekeepers in planning, and encourages shared accountability in achieving intended outcomes. Logistically, coalitions can create structured meeting agenda items that proactively poll members about anticipated events and targeted locations. To nurture transparent communication and establish co-benefits of collaboration, coalitions can survey members to identify incentives and opportunities for coordinated event planning and implementation. This could include, for example, fulfillment of grant deliverables or regulatory requirements, alignment with other organizational priorities, event marketing resources, or participant data collection and evaluation (Greer et al., 2022).

Formalized process for health service requests

To streamline access to the range of community-based health services available, service providers can produce easily accessible standardized forms for event coordinators to request on-site services. This should be clearly visible and accessible on organizational websites, allowing for requests through free or widely used virtual platforms such as Google Forms,^™ Microsoft Forms,^™ or SurveyMonkey.^™ While a few organizations have this available online, this seemingly simple concept is not widely adopted within the county, leaving community organizers struggling to access and navigate local health resources. Our team has taken steps to begin development and implementation of similar forms that are accessible to organizers of health outreach events.

Centralized event calendar

To address limited awareness of upcoming events, anchor institutions can sponsor virtual calendars with centralized event information such as organizations represented, available services, and accessibility information. Recognizing the challenges of sustainability and inter-agency competition for event funding and attendees, it is critical that the calendar be funded and hosted by one or more trusted backbone organizations with widespread partnerships and resources for convening organizational leaders and incentivizing collaboration. This could include local public universities, nonprofit medical centers, local health departments, United Way chapters, and other community-based nonprofit entities. Backbone organizations can develop and disseminate content through existing networks and other service coalitions. Timely communication can improve organizational awareness of upcoming or conflicting events, allowing community members to select events with services that best respond to their existing needs.

Community member phone bank

To promote greater awareness and accessibility for community members with limited access to technology, backbone organizations can establish protocols for developing a phone bank of community members’ contact information for phone-based alerts about upcoming events. These protocols should be developed in partnership with community members to ensure safe and ethical measures for routine collection and maintenance of contact information. We are currently exploring incentives and strategies to cultivate a network of grassroots community members that agree to communicate information within their social networks, upon receiving phone alerts through secure messaging platforms such as Textedly^™ and WhatsApp.^™ As a shared resource, this phone bank can be leveraged during public health emergencies to issue health alerts and facilitate urgent communication.

Conclusion

The end of the COVID-19 pandemic unearthed alarming gaps for meaningful community engagement with socially vulnerable populations. As policymakers roll back social safety net protections in communities with high demand for low-cost or subsidized health services, Schools of Social Work are uniquely situated to elevate human rights as a priority in public health preparedness initiatives. Social work professionals can integrate the recommendations herein presented to develop new or existing community-based field placement agreements that harness students and field supervisors to implement and evaluate community engagement strategies, maximize benefits of participation, and foster shared accountability for building community resilience.

Biographies

Marcela Nava is an Assistant Professor in the School of Social Work at the University of Texas at Arlington, USA.

Caleb Crago is a recent graduate of the Master of Social Work program in the School of Social Work at the the University of Texas at Arlington, USA.

Monica Cañizares is a recent graduate of the Master of Social Work program in the School of Social Work at the University of Texas at Arlington, USA.

Gabrielle Scott is a PhD student in the School of Social Work at The University of Texas at Arlington.

Christian E. Vazquez is an Assistant Professor in the School of Social Work at the University of Texas at Arlington, USA.