Investing in Public Health and Community Partnerships Reduced COVID-19–Related Disparities

In 2023 the Centers for Disease Control and Prevention and the National Network for Public Health Improvement (NNPHI) joined forces to lead publication of this AJPH supplement: “Lessons Learned From the Centers for Disease Control and Prevention’s National Initiative to Address COVID-19 Health Disparities Among Populations at High-Risk and Underserved.” The sponsors’ goal was to feature state, tribal, local, and territorial public health agencies’ firsthand reports of achievements and lessons learned via the National Initiative to Address COVID-19 Health Disparities Among Populations at High-Risk and Underserved, Including Racial and Ethnic Minority Populations and Rural Communities Health Disparities Grant (HDG) and thus expand the evidence base for mitigating COVID-19–related health disparities.

More than 80 abstracts were submitted for consideration. The articles chosen for the supplement reflect a small subset of the effective, creative, and community-building work that public health agencies and their partners collaborated on to create equitable public health structures, processes, and programs that addressed well-known, persistent inequities and those laid bare by the pandemic. In presenting a select group of articles, this supplement captures only a snapshot of organizations’ early lessons learned, successes and challenges, and insightful program evaluation the HDG made possible. The volume of insights submitted exceeded the issue’s length.

Also missing from these pages is a description of NNPHI’s “behind-the-scenes” support and technical assistance for public health agencies and prospective authors who worked intently to write their stories. Eager to report their accomplishments, they drafted articles while still experiencing the effects of the pandemic, chronic underfunding, workforce shortages, and burnout on their ability to sustain core public health programs.¹ NNPHI offered technical assistance, including writing coaching, for all prospective authors. Many of them expressed gratitude for that support. The guidance ensured that submitters, especially those who are not scholars or experienced with AJPH publication standards, could succeed throughout the editorial and peer review familiar to established authors. Thus, the HDG and the NNPHI-assisted journalistic process promoted equity among communities and the public health workforce.

This supplement details strategies that further the paradigm shift to center communities to guide local public health efforts. Through this first of its kind funding opportunity, HDG programmatic funds could focus on expanding more effective public health strategies to meet communities where they are. Editorials, notes from the field, research articles, and commentaries in this supplement demonstrate that most health departments implemented multiple interrelated community-focused approaches to strengthen their public health infrastructure. Their collective purpose was to advance sustainable and effective public health partnerships, programs, and outcomes.

VALUING COMMUNITIES

In their lead editorial, Dauphin and Liburd (p. S540) describe the HDG’s goal to enable health departments’ implementation of four specific strategies: strengthening public health infrastructure, mobilizing collaborators and partners, bolstering prevention and mitigation services, and collecting and disseminating data. They also highlight strengthening the local public health ecosystem, centering health equity, and building trust between health departments and their communities as significant contributors to the HDG’s success in mitigating disparities.

CREATIVE FUNDING

Health departments in North Carolina and Texas demonstrated how infrastructure strengthening resulted from creative funding mechanisms that ensured that community members share authority for public health strategy development and implementation. Specifically, Stanley et al. (p. S554) note that when local health department resources were dedicated to increasing their capacity to strengthen commitments to community partners, the North Carolina communities most in need had better uptake of public health program interventions.

Similarly, Johnson et al. (p. S562) demonstrate that when Texas’s county health departments modified their subcontracting process to increase the upfront funding community-based subrecipients could receive, more community-based organizations had the resources to serve the communities most disproportionately affected by COVID-19. Subsequently, with the shift to receiving up to 40% of grant funding upfront, more smaller community-based organizations that staff the most trusted messengers in the community were also able to meet the infrastructure capacity needed to access federal and other funding sources.

COMMUNITY PARTNERSHIPS

Many grantees understood the roles community health workers (CHWs) serve as trusted messengers in the public health workforce and highlighted their use of HDG funding to employ CHWs, positioning them as force multipliers and bridge builders in their programs. To implement local health equity action teams in 20 counties, Kansas hired, trained, and certified CHWs (including those who identified as immigrants, refugees, disabled, or previously unhoused) using HDG funds to activate tailored COVID-19 interventions for the most vulnerable in their communities (Finocchario-Kessler et al., p. S570).

Parrella et al. (p. S566) demonstrate increased effectiveness by staffing CHWs as a trusted workforce in New York City; they describe the COVID-19–related health disparities mitigated among communities of color that have experienced historical disinvestment. CHWs helped people schedule COVID-19 vaccination appointments, enroll in the Supplemental Nutrition Assistance Program, and complete housing applications, and they addressed many other inequities. Von Alexander et al. (p. S543) describe how CHWs in territories and freely associated states supported effective prevention and mitigation efforts—including COVID-19 testing, vaccination, case management, and treatment—and provided in-home visits and more accurate data collection.

CLOSING GAPS

Nevada and Arizona undertook additional public health mitigation approaches that focused on meeting communities where they are. Jamerson et al. (p. S558) used data combined with community insights to strategically place vending machines with multilingual registration for COVID-19 testing in rural Nevada. This reached the communities effectively and nearly tripled test distribution. Koch et al. (p. S546) share how this dedicated funding was necessary to tailor vaccination strategies (e.g., mobile vaccination units) to a wide variety of otherwise marginalized or overlooked communities with the highest risk of COVID-19, such as agricultural workers from Mexico and tribal and rural communities in Arizona.

Toews et al. (p. S590) describe reductions in COVID-19 transmission among people experiencing sheltered homelessness in Chicago, Illinois. The collaboration of multiple sectors used a whole community approach to facilitate this success, as COVID-19 HDG resources enabled comprehensive prevention and treatment strategies to meet people where they are.

PLANNING, EVALUATION, AND INSIGHTS

Two research articles present the promises and potential pitfalls of applying data-driven approaches to reducing inequities. Cardoso et al. (p. S599) explain how Massachusetts deployed the Community COVID-19 Impact Survey to guide interventions for some specific undeserved population groups and those with intersectional identities whose vulnerability is often missed using standard surveillance tools.

That approach was effective for parents and for Asian, Native Hawaiian, and Pacific Islander communities. However, data capture on Black, Latinx, and other groups was deficient. Using zip code–level analysis of social vulnerability guided Rhode Island to designate Central Falls as its first priority area for COVID-19 vaccine distribution, thereby reducing the communities’ COVID-19–related disparities. Fortnam et al. (p. S580) also recognize the potential shortcomings of the state’s approach, noting that early prioritization may have similarly benefited other socially vulnerable regions. Acknowledging that without an adequate vaccine supply this allocation was not possible underscores how critical it is to invest in public health.

CONCLUSIONS

As Dauphin and Liburd emphasize, the public health system depended on federal funding to focus strategies on populations that experienced the greatest burden of COVID-19; this is particularly important given the chronic resource constraints public health departments face. This collection of articles illustrates that the HDG initiative was a crucial resource across state, tribal, local, and territorial public health departments. It made possible effective community engagement strategies, creative funding, and data-informed prevention and mitigation strategies, and it established CHWs as essential members of the public health workforce.

In honor of all public health practitioners and researchers who took time to submit accounts of their efforts, we recognize that this supplement is only a snapshot of the amazing work the HDG supported. Your lessons exemplify reasons to be optimistic about the future of public health, especially when implemented through community-led solutions. We must couple that optimism with an ongoing push for adequate and sustainable funding to ensure that public health systems at every level of government can achieve the best health outcomes for all.