Supporting Health Equity Through Data-Driven Decision-Making: A Local Health Department Response to COVID-19

Abstract

COVID-19 highlights preexisting inequities that affect health outcomes and access to care for Black and Brown Americans. The Marion County Public Health Department in Indiana sought to address inequities in COVID-19 testing by using surveillance data to place community testing sites in areas with the highest incidence of disease. Testing site demographic data indicated that targeted testing reached populations with the highest disease burden, suggesting that local health departments can effectively use surveillance data as a tool to address inequities. (Am J Public Health. 2021;111(S3):S197–S200. https://doi.org/10.2105/AJPH.2021.306421)

The Marion County Public Health Department (MCPHD) used COVID-19 incidence data to place and promote community testing sites in the highest-need areas, allowing MCPHD to reduce barriers to testing among populations disproportionately affected by the pandemic.

INTERVENTION

MCPHD used a data-driven approach to select sites equitably for COVID-19 testing. We matched positive case reports from private and public laboratories to electronic health records and integrated them into a community-based dashboard.¹ We used these to establish testing sites near populations with higher disease burden. Given the novel and dynamic nature of the pandemic, we based resource allocation decisions on assessments of multiple COVID-19 disease statistics and trends among demographic subpopulations rather than predefined criteria.

PLACE AND TIME

The initial MCPHD community testing site opened on April 2, 2020, in Indianapolis, Indiana, with the first day dedicated to essential personnel. As test availability increased, we opened additional community testing sites. After the launch of the first site, MCPHD staff began to examine trends in COVID-19 incidence by location, race, ethnicity, and other demographics, and we targeted areas with the highest COVID-19 morbidity for expanded testing to mitigate the disproportionate spread of COVID-19. As COVID-19 hotspots emerged, MCPHD sought input from and maintained regular contact with long-standing partners with community influence among inequitably affected groups (notably, Black, Latinx, and Burmese populations). Partners helped determine targeted testing site locations in communities disproportionately affected by the pandemic. In May, we opened testing sites at the largest, predominantly Black church on Indianapolis’s Eastside and an educational campus with a large Latinx population. Over time, we established a centrally located main site and opened and closed additional sites in response to changes in incidence. Through the end of 2020, MCPHD operated at least three community sites at a time, with additional short-term, temporary sites used in response to COVID-19 surveillance trends.

PERSON

Anyone could receive free COVID-19 testing at MCPHD testing sites. To ensure equitable access to testing, we located sites near populations with disproportionately high COVID-19 incidence, and community organizations promoted these using flyers, mixed media (e.g., radio ads, webinars, and social media posts), and door-to-door campaigns. MCPHD supported partner promotion efforts with flyers, graphics, and prevention materials such as masks and sanitizer. Most sites were located in areas with a high density of racial and ethnic minorities, a pattern consistent with other urban areas examining morbidity.²

PURPOSE

Health inequities disproportionately affecting historically marginalized populations existed long before the COVID-19 pandemic but have been highlighted by it.³ These inequities are likely an outcome of systemic racism, which is also independently associated with poorer mental, general, and physical health.⁴ People facing health inequities are less likely to have a primary care provider, health insurance, or regular access to health care, including COVID-19 testing and treatment.^5,6 In response, MCPHD sought to ensure equity in its COVID-19 testing strategy.

IMPLEMENTATION

MCPHD established ongoing surveillance of COVID-19 in March 2020, including data on number of tests administered, positive tests or case reports, health care use, and deaths. We tracked trends and relative rates by age, race, ethnicity, gender, and location (i.e., by zip code or census tract). We minimized missing data by merging interview, laboratory, death, and other clinical data.

MCPHD worked with community partners to identify and address challenges related to COVID-19 testing. We addressed language and literacy barriers by translating testing materials into languages primarily spoken by affected subpopulations (Spanish and Burmese), establishing a Spanish-language telephone registration system for COVID-19 testing, and working with partners to deliver mixed-media messaging and advertisements about testing site locations. In particular, direct messaging through trusted community leaders and media sources stating that MCPHD did not report to immigration services attempted to allay fears of deportation for some community members accessing testing services.

To increase access to MCPHD testing sites, onsite registration was available for those unable to register in advance because they did not have Internet access, they were unfamiliar with online or call-in registration systems, or English was not their first language. We considered access to public transportation when selecting drive-through site locations, and a walk-up option was available. Sites held weekend hours to accommodate different work schedules.

Figure 1 shows the daily COVID-19 case rate per 100 000 residents by race/ethnicity, and Figure 2 shows COVID-19 testing rates per 100 000 residents by race (Latinx ethnicity testing data were not available). Early in the pandemic, Black residents were disproportionally diagnosed with COVID-19 (April 10, 2020 peak: 23 cases/100 000 Black residents vs 9.7 cases/100 000 White residents), prompting the testing site at the Eastside church, which has an extensive network throughout the county and especially attracted older adults. The rapid increase in Latinx case rates in May (May 10, 2020 peak: 37 cases/100 000 Latinx residents vs 5.5 cases/100 000 White residents) prompted the opening of two testing sites convenient to Latinx residents. The Southside clinic testing site opened in response to an increase in COVID-19 incidence among Burmese residents; testing among Burmese residents increased following this site’s opening. Within two months of each of these efforts, the respective case rate gap decreased or disappeared entirely.

FIGURE 1—

COVID-19 Cases per 100 000 by Race/Ethnicity: Marion County, IN, March 6, 2020–January 27, 2021

Note. A = Eastside church (Black), B = educational campus (Latinx), C = Westside racetrack (Latinx), D = Marion County Public Health Department (MCPHD) main site, E = Southside clinic (Burmese [Asian]), F = Westside commercial, G = county fairgrounds. Dotted vertical lines indicate opening dates of MCPHD community testing sites. This figure does not include temporary testing sites, which usually lasted less than 3 days.

FIGURE 2—

COVID-19 Testing Rates per 100 000 by Race: Marion County, IN, March 6, 2020–January 27, 2021

Note. A = Eastside church (Black), B = educational campus (Latinx), C = Westside racetrack (Latinx), D = Marion County Public Health Department (MCPHD) main site, E = Southside clinic (Burmese [Asian]), F = Westside commercial, G = county fairgrounds. Dotted vertical lines indicate opening dates of MCPHD community testing sites. This figure does not include temporary testing sites, which usually lasted less than 3 days. Testing data by Latinx ethnicity are not available.

EVALUATION

Figure 1 shows that rates of new cases declined for focal racial groups after targeted testing sites and information campaigns began for Black (A), Latinx (B and C), and Burmese (E) residents. Figure 2 shows the notable increase in testing among the county’s relatively small Asian population after the Burmese-focused testing site opened (E). The impact of the Eastside church on the countywide testing rate for Black residents is smaller, given the county’s large number of Black residents. Countywide testing rates for Latinx residents were not available.

ADVERSE EFFECTS

We are not aware of any adverse effects from this intervention that are not inherent to testing (e.g., discomfort of nasal swab).

SUSTAINABILITY

The testing site intervention will not be sustained past the COVID-19 pandemic, but MCPHD will continue to stratify health statistics by demographics to detect and address disparities.

PUBLIC HEALTH SIGNIFICANCE

Because COVID-19 is frequently transmitted by individuals without symptoms, mitigation strategies require rapid identification and follow-up with infected individuals so they can isolate and their contacts can isolate or quarantine.⁷ Targeting testing resources in areas with disproportionate risk ensures efficient and equitable use of resources and decreases disease spread among marginalized populations.

In addition to higher rates of COVID-19 infection and related death, Black and Brown Americans bear a disproportionate burden of chronic illnesses—associated with worse COVID-19 outcomes—and experience greater barriers to accessing quality health care.³ One role local health departments can serve in countering outcomes of systemic racism is monitoring for and directing resources to address inequitable disease distribution among the population. Populations at highest risk of disease or experiencing inequitable morbidity should receive emphasis in local health department services.

This intervention relied on partnerships that MPCHD built with community organizations, specifically those in historically marginalized communities, over many years through consistent communication and collaboration; financial support of clinics, community centers, and skills-building services; and providing wraparound services.

The Public Health 3.0 framework emphasizes increased use of electronic data to inform the actions of public health agencies. This intervention used a community-based, integrated system designed to capture comprehensive data on COVID-19 infections, hospitalizations, and mortality. Local health departments can use health systems’ existing data infrastructure to inform their strategies for addressing health challenges, including COVID-19, that disproportionately burden Black and Brown communities.