Community Engagement of African Americans in the Era of COVID-19

Community Engagement of African Americans in the Era of COVID-19

Summary

What is already known on this topic?

African Americans are more likely to contract coronavirus disease 2019 (COVID-19), be hospitalized for it, and die of the disease when compared with other racial/ethnic groups. Psychosocial, sociocultural, and environ- mental vulnerabilities, compounded by preexisting health conditions, ex- acerbate this health disparity.

What is added by this report?

This report adds to an understanding of the interconnected historical, policy, clinical, and community factors associated with pandemic risk, which underpin community-based participatory research approaches to ad- vance the art and science of community engagement among African Amer- icans in the COVID-19 era.

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What are the implications for public health practice?

When considered together, the factors detailed in this commentary create opportunities for new approaches to intentionally engage socially vulner- able African Americans. The proposed response strategies will proactively prepare public health leaders for the next pandemic and advance com- munity leadership toward health equity.

Abstract African Americans, compared with all other racial/ethnic groups, are more likely to contract coronavirus disease 2019 (COVID-19), be hospitalized for it, and die of the disease. Psychosocial, so-

ciocultural, and environmental vulnerabilities, compounded by preexisting health conditions, exacerbate this health disparity. In- terconnected historical, policy, clinical, and community factors ex- plain and underpin community-based participatory research ap- proaches to advance the art and science of community engage- ment among African Americans in the COVID-19 era. In this commentary, we detail the pandemic response strategies of the Morehouse School of Medicine Prevention Research Center. We discuss the implications of these complex factors and propose re- commendations for addressing them that, adopted together, will result in community and data-informed mitigation strategies. These approaches will proactively prepare for the next pandemic and advance community leadership toward health equity. Community Engagement of African Americans in the Era of COVID-19

Introduction Racial/ethnic minority populations have historically borne a dis- proportionate burden of illness, hospitalization, and death during public health emergencies, including the 2009 H1N1 influenza pandemic and the Zika virus epidemic (1–4). This disproportion- ate burden is due to a higher level of social vulnerability — “indi- vidual and community characteristics that affect capacities to anti- cipate, confront, repair, and recover from the effects of a disaster” — among racial/ethnic minority populations than among non- Hispanic White populations (5). These characteristics include, but are not limited to, low socioeconomic status and power, predispos- ing racial/ethnic minority populations in general and African Americans in particular to less-than-optimal living conditions. Some racial/ethnic minority populations are more likely than non- Hispanic White populations to live in densely populated areas, overcrowded housing, and/or multigenerational homes; lack ad- equate plumbing and access to clean water; and/or have jobs that do not offer paid leave or the opportunity to work from home (6,7). These factors contribute to a person’s ability to comply with

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the mitigation mandates of the coronavirus disease 2019 (COVID- 19) pandemic established to reduce risk for infection, such as physical distancing and sheltering in place (8).

The COVID-19 pandemic presents new challenges for public health evaluators, policy makers, and practitioners, yet it mirrors historical trends in health disparities and poor health outcomes among African Americans. African Americans are more likely to contract, be hospitalized, and die of COVID-19–related complica- tions (9–12). Social vulnerability is often compounded by preex- isting health conditions, exacerbated during times of crisis (13–17).

Public health leaders are now at a critical juncture to advance health equity among vulnerable African Americans. To advance this health equity, we must first have a comprehensive understand- ing of the factors that create health disparities and the factors that can contribute to an effective, multilevel response. With this un- derstanding, we can then deploy effective mitigation strategies based on a community-based participatory research framework that fosters and sustains community leadership in the assessment and implementation of culturally appropriate and evidence-based interventions that enhance translation of research findings for community and policy change (18,19). The objective of this com- mentary is to 1) detail the interconnected historical, policy, clinic- al, community, and research challenges and considerations central to comprehensively advancing the art and science of community engagement among African Americans in the COVID-19 era; 2) describe The Morehouse School of Medicine Prevention Research Center (MSM PRC) pandemic response strategies, driven by community-based participatory research (CBPR); and 3) discuss community-centered implications and next steps for public health action.

Challenges and Considerations Historical context

Racial/ethnic health disparities have always existed in the United States. Differential health outcomes between African Americans and non-Hispanic White Americans have been part of the Americ- an landscape for more than 400 years (20). Many measures of health status have been used to assess differences among racial/ ethnic groups; more recently, health researchers have advanced concepts and constructs of health equity and social determinants of health (21). Reaching back to the mid-20th century, the US gov- ernment documented that African Americans were far more likely than non-Hispanic White Americans to have a wide range of po- tentially fatal illnesses, including noncommunicable diseases such as type 2 diabetes, asthma, end-stage renal disease, and cardiovas- cular disease (21). In 1985, the US Department of Health and Hu-

man Services published the landmark Report of the Secretary’s Task Force on Black and Minority Health, better known as the Heckler report (21). The report documented an annual excess 60,000 deaths among African American and other racial/ethnic minority populations. These underlying determinants can only res- ult in disproportionately adverse health outcomes for racial/ethnic minority populations during the COVID-19 pandemic.

The COVID-19 pandemic is intensified by the long-standing in- come inequality between non-Hispanic White people and racial/ ethnic minority populations. Economists use the Gini coefficient to measure income inequality. Values for this measure range from 0 to 1, with higher values representing greater income inequality. From 1990 to 2018, the Gini coefficient in the United States rose from 0.43 to 0.49 — an increase in income inequality. When in- come disparities exist along with other disparities (eg, health in- surance, employment, education, social justice, access to quality health care), public health pandemics marginalize racial/ethnic minority groups, and this marginalization requires a strong and strategic response (22).

Policy landscape

Racial/ethnic minority populations are disproportionately affected by COVID-19 (23), as they are by many diseases. In the United States, African Americans, Hispanics/Latinos, Native Americans, Native Hawaiians, and Pacific Islanders are more likely than other racial/ethnic groups to die of COVID-19 (24). The pandemic has not affected all populations equally for several reasons, including social, behavioral, and environmental determinants of health. In addition, economic and social policies have not benefitted all pop- ulations equally. Obesity, asthma, depression, diabetes, heart dis- ease, cancer, HIV/AIDS, and many other disorders that put vulner- able populations at greater risk of dying of COVID-19 can often be linked to a policy determinant (25). Air pollution; climate change; toxic waste sites; unclean water; lack of fresh fruits and vegetables; unsafe, unsecure, and unstable housing; poor-quality education; inaccessible transportation; lack of parks and other re- creational areas; and other factors play a large role in overall health and well-being (26). These factors increase a person’s stress and limit opportunities for optimal health (27). Too often, public health researchers and practitioners stop at the social determinants of inequities. These social determinants do, indeed, play an out- sized role in these human-made inequities, but underlying each one is a policy determinant that should be addressed to improve health equity.

Consider, for example, the problem of asthma among many racial/ ethnic minority populations. One community, in East Harlem, one of Manhattan’s poorest neighborhoods, found that a bus depot caused the high rates of asthma among children who lived near it

PREVENTING CHRONIC DISEASE VOLUME 17, E83 PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY AUGUST 2020

The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions.

2 Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2020/20_0255.htm

 

 

(28). Six of 7 bus depots in Manhattan are located in East Harlem, and East Harlem has the highest rate of asthma hospitalizations in the country (29–31). In another community, the exhaust and dust from the vehicles traveling a major highway that cut through the middle of the community was found to contribute to the high rates of asthma among residents who lived near it (32). In both of these examples, an underlying policy determined the placement of the bus depots and the highway, which led to the eventual health in- equities.

Examples of how legislative and policy change can immediately affect the social determinants of health are demonstrated in gov- ernment and public responses during the first 3 months of the COVID-19 pandemic in the United States. Federal, state, and loc- al policies were implemented to stimulate local economies and in- fuse communities with free food and direct revenue, including in- creases in SNAP (Supplemental Nutrition Assistance Program) be- nefits and expanded unemployment benefits. These initiatives have helped communities and individuals during the crisis. Des- pite these programs, however, some marginalized African Americ- an communities have not benefitted. As the nation adjusts to the “new normal,” it is imperative that the social, economic, and health gaps in these communities also conform to a “new normal” that is driven by new or expanded and sustained policies.

Clinical mechanisms, chronic conditions, and increased risk of COVID-19

African Americans are twice as likely as non-Hispanic White Americans to die of heart disease and 50% more likely to have hy- pertension and/or diabetes (33,34). This elevated risk increases the likelihood of other complications and death from COVID-19 (35,36). Let us consider, for example, people living with diabetes. Their immune system is depressed overall, because their blood glucose is not well controlled (hyperglycemia) (37). It is hypothes- ized that hyperglycemia causes an increase in the number of a par- ticular receptor in the lungs, pancreas, liver, and kidneys; this in- crease impairs the function of white blood cells, which are de- signed to fight off infections (37). This impairment predisposes the person living with diabetes to an increased risk of bacterial and viral infections. When severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) enters the lungs by way of this par- ticular receptor, it overwhelms the alveoli (air sacs) in the lungs and disables the exchange of oxygen and carbon dioxide (38). As a result, some people with diabetes may need supplemental oxy- gen, intubation, and/or admission to an intensive care unit (37). Hyperglycemia in combination with a disease such as COVID-19 makes recovery difficult (37). People with diabetes who are in good mental health, know the names and dosages of their medica- tions, and know their blood pressure, blood glucose, and other laboratory values, such as hemoglobin A1c, tend to have better

control of their disease and have lower levels of illness and death (16,37). Emphasizing the importance of good blood glucose con- trol to prevent diabetes complications and associated COVID-19 risk is more important now than ever (36–38). Mental health plays a major role in a person’s ability to maintain good physical health and optimally manage their chronic conditions, and mental ill- nesses may affect the ability to participate in health-promoting be- haviors (39).

Mental and behavioral health

The constellation of stressors triggered by the COVID-19 pandem- ic undermines the nation’s mental health (40–42). Various disrup- tions in daily life, coupled with the threat of contracting the deadly virus, is leading some people to experience anxiety and depres- sion, sometimes to the extreme. Reports of family violence and use of suicide prevention hotlines have increased (43,44). Physic- al distancing, shelter-in-place orders, business and school closures, and widespread unemployment have radically changed ways of life and contributed to a sense of hopelessness, isolation, loneli- ness, helplessness, and loss (45,46). Pandemic-related factors, in- cluding quarantine, have led to posttraumatic stress disorder, con- fusion, and anger (47). One study indicated that a constant con- sumption of media reports had detrimental psychological effects on some people (48). If interrelated mental, behavioral, and emo- tional issues are not adequately addressed, disorders among racial/ ethnic minority populations and other vulnerable populations (eg, the medically underserved, homeless, and disabled; inmates in the criminal justice system) will surge and exacerbate disparities (49).

Interrelated COVID-19–related stressors include childcare and safety, elder care, food insecurity, and interpersonal relationships (50). These stressors may trigger aspects of unresolved trauma. Poor coping mechanisms (eg, use of illicit drugs, excessive alco- hol consumption, overeating, inadequate sleep) may develop or worsen. In addition to facing chronic stressors, communities of ra- cial/ethnic minority populations often deal with the stigma associ- ated with seeking mental and behavioral health care. A Surgeon General’s report, Mental Health: Culture, Race, and Ethnicity, concluded that racial/ethnic minority populations, compared with the non-Hispanic White population, have less access to mental health care, are less likely to receive treatment, and when treated, often receive poorer quality of care (51). As a result, racial/ethnic minority populations often have a greater burden of behavioral disorder–related disability (51). Addressing the multifaceted men- tal and behavioral health needs of racial/ethnic minority popula- tions in the United States is a complex issue that warrants atten- tion from clinicians, researchers, scientists, public health profes- sionals, and policy makers. It is imperative to recognize the signi-

PREVENTING CHRONIC DISEASE VOLUME 17, E83 PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY AUGUST 2020

The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions.

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ficant role of community leaders in exploring solutions to COVID- 19–related mental and behavioral health problems among racial/ ethnic minority communities. Their lived experiences are central to the co-creation of pandemic response strategies for these popu- lations.

Perspectives of community leaders

The realities of research, evaluation, and clinically focused com- munity engagement after the COVID-19 pandemic may change for the foreseeable future. Efforts to initiate and sustain culturally competent engagement of racial/ethnic minority groups previ- ously relied on face-to-face interactions in homes, churches, and other community settings. Social or physical distancing has nearly stopped communities and their collaborators from real-time gath- ering. These changes challenge the human need for connection and in-person exchange. Although the adjustment has been difficult, the pandemic has resulted in new modes of engagement. Webinar and digital technology are now accessible for most people at low or no cost. Many community residents have newfound capacities to use technology for social and professional interactions as part of daily life.

Current health communication and messaging require community- informed improvements. The use of terms like sheltering in place, social distancing, and flattening the curve do not naturally reson- ate with many people. For some, these terms foster anxiety and distrust of systems perceived to separate communities rather than promote COVID-19 mitigation strategies. Community leaders, as well as business and faith leaders, have found themselves in a space of terminology and descriptions that are understood mostly by public health practitioners. Therefore, health literacy and the interpretation of current health conditions are vital.

The pandemic has intensified the economic strains among low- income and moderate-income people and families (52). Low-wage workers, many on the frontlines of the pandemic since it began, have had little to no increase in income (53). African American families who struggled to make ends meet before COVID-19 are now facing dire economic circumstances in making the best de- cisions for their families. Stressors include, but are not limited to, deciding how to pay rent or a mortgage, paying for food, assisting children with virtual learning, and protecting themselves with min- imal or no health care benefits. The mental and behavioral health implications of these problems, along with the economic and prac- tical challenges, have made a fragile ecosystem even more un- stable. Low-wage workers in hospitality, food service, and retail industries cannot work from home. Workers who depend on employer-provided health insurance now have the additional bur- den of how to maintain health insurance coverage (54). Ulti-

mately, lack of adequate access to health care, along with the com- plex realities of the COVID-19 pandemic, will increase health dis- parities for socially vulnerable African American employees and their families.

Local examples of COVID-19 response strategies driven by community-based participatory research

The MSM PRC relies on a deeply rooted, community partnership model that responds to the health priorities of vulnerable African American residents before, during, and after public health emer- gencies such as the COVID-19 pandemic. For more than 20 years, the MSM PRC has applied dynamic CBPR approaches that focus on prevention, establish partnerships between communities and re- search entities, and are culturally tailored (6,55–57)Community Engagement of African Americans in the Era of COVID-19.

The MSM PRC capitalizes on community wisdom through a com- munity coalition board (CCB) that has governed the center since its inception. The CCB is composed of 3 types of members: neigh- borhood residents (always in the majority), academic institutions, and social service providers (58). Neighborhood residents hold the preponderance of power, and all leadership seats and are at the forefront of all implemented approaches. Neighborhood resident members are intentionally recruited from census tracts with a high incidence and prevalence of chronic and infectious diseases. The communities served by the MSM PRC are majority (87%) Afric- an American, have an average household income of $23,616, and rank lowest among other local communities in other socioeconom- ic conditions and community neighborhood health factors (55).

The MSM PRC has strategically partnered with the CCB and the community to facilitate health research and related interventions based on a comprehensive understanding of historical, political, clinical, and community considerations. The community gov- ernance model was developed to address CBPR challenges that exist when academics are not guided by neighborhood leaders in understanding a community’s ecology, when community mem- bers do not lead discussions about their health priorities, and when academics and neighborhood leaders do not work together as a single body with established rules to guide roles and operations (59,60).

The MSM PRC conducts a recurring (every 4 years) community health needs and assets assessment (CHNA2) process through the CCB, empowering community members to take on roles as cit- izen scientists who develop locally relevant research questions and identify priority health strategies (60). The recently completed CHNA2 (February 2018) was co-led by neighborhood residents to advance a community health agenda. Survey development, data analyses, and response strategies are reviewed, monitored, and evaluated by the CCB and its Data Monitoring and Evaluation

PREVENTING CHRONIC DISEASE VOLUME 17, E83 PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY AUGUST 2020

The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Community Engagement of African Americans in the Era of COVID-19

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