Coalition of Faith Leaders, Community Organizations, and Governmental Organizations to Implement a COVID-19 Campaign in a Latino Neighborhood, Baltimore, Maryland, 2020–2021

Abstract

The disproportionate impact of COVID-19 on low-income Latinos with limited access to health care services prompted the expansion of community-based COVID-19 services. From June 25, 2020, to May 20, 2021, we established a coalition of faith leaders, community organizations, and governmental organizations to implement a Spanish-language hotline and social media campaign that linked people to a COVID-19 testing site at a local church in a high-density Latino neighborhood in Baltimore, Maryland. This retrospective analysis compared the characteristics of Latinos accessing testing in community versus health care facility–based settings. (Am J Public Health. 2022;112(S9):S913–S917. https://doi.org/10.2105/AJPH.2022.307074)

Latinos are twice as likely as non-Hispanic Whites to be hospitalized or die of COVID-19.¹ Evidence suggests that this risk is heightened among undocumented immigrants and Latinos with limited English proficiency because of ineligibility for unemployment benefits or stimulus checks, high-risk essential worker status, and crowded housing conditions.^2,3 For many low-income immigrant Latinos ineligible for health care coverage through the Affordable Care Act, access to conventional health care facility–based testing has been hampered by a lack of health insurance or of a primary care doctor.^2,4 In addition, difficulty in navigating the health system, immigration status, language barriers, stigma, and lack of trust in health care institutions are barriers to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing and COVID-19 care.^2,5

INTERVENTION AND IMPLEMENTATION

As part of the Rapid Acceleration of Diagnostics-Underserved Populations (RADx-UP) initiative, we established a coalition of faith leaders (Baltimoreans United in Leadership Development), community organizations (Esperanza Center), and governmental organizations (Mayor’s Office of Immigrant Affairs) to implement a social media campaign that encouraged testing at an outdoor free SARS-CoV-2 testing site at a local church in a high-density Latino neighborhood (Sacred Heart Church testing site).^6,7 In addition, we established a COVID-19 Spanish-language hotline hosted at a local organization (Esperanza Center) that linked people to testing at the Sacred Heart Church testing site or, when community testing was unavailable, to the Johns Hopkins Health System (JHHS) COVID-19 testing facilities. The Esperanza Center hotline number was disseminated through our social marketing materials. People could preregister for testing at the Sacred Heart Church site, but walk-ins were also encouraged. All patients with a positive test result tested at Sacred Heart Church or referred to JHHS testing through the Esperanza hotline were contacted by bilingual community health workers and referred to clinical and social services, such as cash and food assistance or referral to isolation hotel, as needed. In addition, patients could request letters for their employers (isolation and return to work letters).

PLACE, TIME, AND PERSONS

We conducted 42 free testing events at the Sacred Heart of Jesus Church in Highlandtown, Baltimore, Maryland, between June 25, 2020, and May 20, 2021. Testing events were staffed with Spanish–English bilingual health workers and designed to serve Latinos with limited English proficiency. However, testing was offered to anyone who sought services at this site without restrictions. Analysis was restricted to Latino adults (18 years and older).

PURPOSE

This program aimed to improve access to SARS-CoV-2 testing and support services for Latinos with limited access to health care or difficulty navigating the traditional medical system.

EVALUATION AND ADVERSE EFFECTS

To assess whether the Sacred Heart Church testing site improved access to SARS-CoV-2 testing for Latinos, we conducted a retrospective study comparing the characteristics of Latinos tested for SARS-CoV-2 at the Sacred Heart Church testing site or referred for testing to JHHS through the Esperanza hotline to those tested at the Johns Hopkins Bayview Medical Center (JHBMC), which is located in the catchment area of our project. We extracted data on patient demographics and testing from the JHHS electronic medical record system and a Research Electronic Data Capture database. We compared characteristics of patients tested at JHBMC or Sacred Heart Church and referred to JHHS through the Esperanza hotline using the t test or χ² test (Table 1). From June 25, 2020, through May 20, 2021, 3982 Latinos, of whom 3117 (78.3%) had limited English proficiency, were tested at these sites. Among them, 1791 (45%) were tested at the RADx-UP community site, 164 (4.1%) were referred to JHHS through the Esperanza hotline, and 2027 (50.9%) were tested at JHBMC-based facilities. Patients tested at the Sacred Heart Church community site were more likely to be male (47.3% vs 39.6%; P < .01) and speak Spanish (88.2% vs 70.7%; P < .01) than were those tested at JHBMC. Patients referred to JHHS testing from the Esperanza hotline were most likely to speak Spanish (93.3%), be uninsured (94.5%), or not have a primary care doctor (92.1%). Insurance and primary care doctor information were not routinely collected at the Sacred Heart Church testing site, but based on existing data in the electronic medical record, we found that only 8.4% of patients had a primary care doctor. SARS-CoV-2 positivity rates were lower among patients tested at the Sacred Heart Church (32.1%) than those tested at JHBMC (43.3%) or referred to JHHS testing from the Esperanza hotline (50%; Figure 1). Positivity rates declined slightly over time as testing volume increased (Figure A, available as a supplement to the online version of this article at https://ajph.org).

TABLE 1—

Characteristics of Latino Patients Tested for SARS-CoV-2 at JHMBC Versus Those Tested at the RADx-UP Community Initiatives: Baltimore, MD, June 25, 2020–May 20, 2021

Characteristic	JHBMC (n = 2027), No. (%) or Mean ±SD	Sacred Heart Church (n = 1791), No. (%) or Mean ±SD	P a	Esperanza Hotline (n = 164), No. (%) or Mean ±SD	P a
Female	1225 (60.4)	944 (52.7)	< .01	101 (61.6)	.88
Age, y	37.3 ±15.2	34.0 ±16.3	< .01	42.5 ±12.2	< .01
Language preferenceb
English	582 (28.7)	198 (11.5)	< .01	11 (6.7)	< .01
Spanish	1433 (70.7)	1517 (88.2)	< .01	153 (93.3)	< .01
Other	12 (0.6)	2 (0.1)	.03
Interpreter needed	1417 (69.9)			151 (92.1)	< .01
PCP
Has a PCP	777 (38.3)	154 (8.4)	< .01	7 (4.3)	< .01
No PCP	1030 (50.8)	717 (40.0)	< .01	151 (92.1)	< .01
Unsure/missing	220 (10.1)	920 (51.4)	< .01	6 (3.7)	< .01
Insurance group
Private	570 (28.1)			3 (1.9)	< .01
Medicaid	185 (9.1)			4 (2.4)	< .01
Medicare	86 (4.3)			2 (1.2)	.06
No insurance	1186 (58.5)			155 (94.5)	< .01
SARS-CoV-2 positive	878 (43.3)	575 (32.1)	< .01	82 (50.0)	< .01

Notes. JHBMC = Johns Hopkins Bayview Medical Center; PCP = primary care provider; RADx-UP = Rapid Acceleration of Diagnostics-Underserved Populations; SARS-CoV-2 = severe acute respiratory syndrome coronavirus 2.

^aWe calculated P values from the Student t test, the Pearson χ² test, and the Fisher exact test for small sample sizes using the JHBMC testing site as reference for each pairwise comparison.

^b Self-reported language preference at Sacred Heart Church information was missing from 74 individuals (denominator is 1719).

FIGURE 1—

SARS-CoV-2 Positivity Rate by Site: RADx-UP Initiative, Baltimore, MD, June 25, 2020–May 20, 2021

Note. JHBMC = Johns Hopkins Bayview Medical Center; RADx-UP = Rapid Acceleration of Diagnostics-Underserved Populations; SARS-CoV-2 = severe acute respiratory syndrome coronavirus 2. Monthly positivity rates are shown as solid lines by site. Statistically significant differences (P < .05) in monthly positivity rates were evaluated across sites with one-way analysis of variance. This included an omnibus analysis of variance comparison with significance (P < .05) resulting in correction for multiple pairwise comparisons using the JHBMC site as reference. Multiple post hoc pairwise comparisons (Tukey test) of each group (Sacred Heart Church, Hotline/Esperanza Center) to the JHBMC reference group also demonstrated significant differences (P < .05 for each pairwise comparison).

SUSTAINABILITY

Community testing at the Sacred Heart Church was implemented early in the pandemic, when access to testing was very limited, especially for individuals without a primary care home. Testing costs were covered through the Coronavirus Aid, Relief, and Economic Security Act, which has now expired. Once COVID-19 vaccinations were approved, the infrastructure established for testing (i.e., hotline, social marketing, staff) was used to expand access to COVID-19 vaccination for low-income Latinos, and the Maryland Department of Health supported it through the Health Services Cost Review Commission.

PUBLIC HEALTH SIGNIFICANCE

The overall success of the US COVID-19 pandemic response strategy relies on an inclusive approach to all people living in the United States, regardless of immigration status. This study demonstrates that SARS-CoV-2 testing beyond conventional health care settings and paired with a community engagement strategy increased access to testing for Spanish-speaking Latinos and provides essential insights for programs aiming to improve SARS-CoV-2 testing equity. Despite having a well-resourced hospital in the catchment area of our study, almost half (45%) of testing during this period was performed at the Sacred Heart Church community testing site.

SARS-CoV-2 positivity rates were much higher than the Maryland SARS-CoV-2 positivity rate (state seven-day average ranged from 2.07% to 9.47% during this period) in all sites, underscoring the disproportionate impact of COVID-19 among Latinos.⁸ However, the lower positivity at the Sacred Heart Church suggests that this site expanded access to testing for people who may not have sought facility-based testing. High positivity rates reflect ongoing transmission and undetected cases. Our approach, with close community health worker follow-up, facilitated testing contacts, which is critical for epidemic control. More men were tested at the Sacred Heart Church than at facility-based testing; it is significant that Latino men are more disenfranchised from the health system.⁹

Pairing the social marketing campaign with a bilingual hotline was especially important for Spanish speakers without health insurance or usual source of care and may have mitigated the digital divide. Finally, low insurance rates and not having a source of primary care at all sites underscore structural challenges that low-income Latinos face, especially immigrants ineligible for health care coverage under the Affordable Care Act. Access to care is one of many critical factors that must be addressed to reduce health disparities in this population.

Our model relied heavily on trusted bilingual and bicultural community health workers, volunteers, flexible appointment scheduling, and community organizations; it used a high-touch and low-tech approach (i.e., in-person outreach, hotline, Spanish-language media, and word of mouth). Partnering with trusted community leaders and organizations is crucial for reaching immigrants, especially those who are undocumented, as concerns about deportation can dampen health care utilization.¹⁰ Street outreach and word-of-mouth referrals helped identify Latinos at high risk for COVID-19 with limited access to health care. Community-based COVID-19 initiatives with bilingual and bicultural capacity are critical for addressing health disparities. Such initiatives are labor intensive and require adequate funding, including institutional and governmental support.