Existing disparities in access to health care and other predictors of health status have led to two key effects among Latinx communities during the pandemic: increased risk of COVID-19 disease burden and increased risk of negative economic and social effects. Nationally, Latinx community members are at 1.9 times higher risk of contracting, 2.8 times higher risk of being hospitalized for, and 2.3 times higher risk of dying from COVID-19 than non-Hispanic, White populations. Similar to other historically marginalized populations, Latinx community members have experienced housing, job, and food insecurity. Key reasons underlying the disproportionate impact of COVID-19 include the long-standing effects of social and structural determinants of health, poverty, discrimination, and structural racism. For example, many Latinx community members lack paid sick leave or health insurance, lack a secure job, and live with daily uncertainty and fear related to immigration status.
During an early peak of the pandemic in June 2020, Latinx community members in Durham, North Carolina, represented 75 percent of COVID-19 cases. This figure is five times greater than the share of the population in Durham that identifies as Hispanic, Latino, or Latinx. Throughout the summer months, the intensive care unit at Duke University was filled with Spanish-speaking patients who were sick with COVID-19. According to many Latinx, long-time Durham residents, their hospitalization for COVID-19 was their first interaction with the health system. This reality reflects decades of disconnection and systemic exclusion from the existing health infrastructure and networks, which continues to this day.
The Latinx Advocacy Team and Interdisciplinary Network for COVID-19 (LATIN-19) is a coalition of partners established in March 2020 to connect Latinx communities in North Carolina to COVID-19 resources. Collaborations among LATIN-19, health systems, public health departments, state health officials, and local community partners have reduced barriers to COVID-19 testing and vaccination sites, misinformation in communities, and disparities in COVID-19 vaccination rates. Duke Health COVID-19 vaccination events conducted in partnership with LATIN-19 reached substantially more people who identify as Hispanic/Latino/Latinx compared to Duke Health events without LATIN-19’s collaboration (exhibits 1 and 2).
Exhibit 1: Percent of vaccination recipients of Hispanic/Latino/Latinx ethnicity at Duke Health vaccination events, February–July 2021
Source: Authors’ analysis of Duke Health clinical data.
Exhibit 2: Proportion of COVID-19 vaccination doses by race and ethnicity administered at LATIN-19 and Duke University Health System COVID-19 vaccination events, February–July 2021
Source: Authors’ analysis of Duke Health clinical data. Notes: All events were sponsored by Duke Health. Duke Health LATIN-19 events were designed and executed in partnership with LATIN-19 including at the Latino Credit Unions in Durham and Raleigh, Village Lanes, La Semilla at Ashbury UMC, and Immaculate Conception. Duke Health non-LATIN-19 events were not conducted in partnership with LATIN-19. The Wheels Fun Park vaccination site includes events conducted in partnership with LATIN-19 and events not conducted in partnership with LATIN-19. We were unable to isolate which days were coordinated with LATIN-19 and which days were only coordinated by Duke Health. In total, from February to July 2021, 2,800 COVID-19 vaccines were distributed at Duke Health COVID-19 vaccination events implemented in partnership with LATIN-19; 189,237 vaccinations were distributed at other Duke Health sites; and 24,084 vaccinations were distributed at the Wheels Fun Park vaccination site.
LATIN-19 has helped bridge the health equity gap among Latinx communities by linking community engagement and empowerment to policy changes and by addressing the immediate social needs that community members have experienced during the pandemic. The policy changes have included improved data collection on race and ethnicity, changes to requirements of government issued ID, and additional funding for community health workers. Other factors have included the provision of wrap-around services, culturally responsive food distribution, and personal protective equipment distribution at community-based events. The experience of health systems providing COVID-19 testing and vaccinations in partnership with community organizations elucidated equity gaps in care delivery. We describe three key strategies for creating policies that embed health equity principles in their design and implementation to move us closer to an equitable health care system.
Elevate Community Voices To Account For Community Priorities
The first strategy is to elevate the voices of community members who are the intended recipients or beneficiaries of a policy change. This strategy aims to re-center the policy decision-making process to include the voices and perspectives of individuals and communities who have often experienced patterns of systemic exclusion from health services and policy-making processes. LATIN-19 is one of the only spaces where community members can meet face to face with senior leadership of the Duke University Health System, North Carolina Department of Health and Human Services leadership, medical directors of community clinics, and leadership in the North Carolina state government. As a result, LATIN-19 has emerged as a space to strategize and communicate directly among community and institutional leaders, and to inform and modify initiatives and solutions.
Centering community voices is a dynamic process that requires consistent and frequent community engagement throughout the design, implementation, and reassessment of any health policy or initiative. Community dialogue has focused on requirements to present identification and messaging to capture cultural nuances. Community members raised concerns around the language used by the Health Resources and Services Administration’s COVID-19 Uninsured Program, for which providers are asked to request identification but patients are not required to present the identification. Conversations through LATIN-19 focused on clarifying messaging around this federal requirement. These discussions quickly informed the state’s guidance that testing vendors, and later vaccine providers, should not require a person to present a government-issued identification card to get tested. In addition, consistent engagement has facilitated a continuous feedback loop to further refine policies and guidance as challenges have emerged in implementation. For example, community members raised the concern that, while identification cards were not necessarily being requested by vendors, appointment confirmation emails and signage throughout Durham still included reminders to bring identification.
Strengthen Meaningful Community Partnerships Early To Tailor Solutions
The second strategy is to strengthen meaningful partnerships and collaborations with community partners to meet the immediate needs of a community. For example, the immediate needs of the Latinx community in North Carolina include housing and food insecurity. Mirroring national trends, the Latinx population in North Carolina is over-represented in front-line, low-wage positions in industries such as meat packing, farm working, and the health care and service sectors, which has resulted in higher risk of housing and food insecurity.
In some cases, policy makers may need to establish and build these connections. Partnering with existing organizations facilitates building trust, encourages a health system that is community-driven, and moves us closer to a community health approach.
Community partnerships have facilitated the following actions overtime: outreach, information sharing, and increased access to solutions that extend beyond health care to improve overall health and well-being. LATIN-19 has partnered with trusted community organizations to couple COVID-19 resources, such as testing and vaccinations, with food distribution. As exhibits 1 and 2 illustrate, community members were more likely to attend testing or vaccination events when it was hosted at a familiar site, such as the Cooperativa Latina Credit Union or a church, or to attend events hosted with Latinx organizations that distributed food throughout the year. Furthermore, community members attended events when recruited by trusted community leaders, such as community health workers, or promotoras de salud, members of the LATIN-19 network, or other representatives of the community. These trusted community leaders often supported vaccination events, easing people’s concerns, answering questions, and guiding people through the process.
Create Care Delivery Models That Reach People Where They Are
The third strategy is to create care delivery models that reach people where they are and intentionally reduce the isolation, fear, and prohibitive cost of accessing services. A key reason for the dramatic COVID-19 disparities among Latinx communities in North Carolina is the systemic exclusion from health services and health networks that Latinx populations experience. This systemic exclusion can occur even when health systems are in close proximity to where people live and work, but remain inaccessible to community members. For example, testing resources initially flowed through existing clinic locations despite increased disease burden and risk of exposure among minoritized communities in Durham who historically did not have access to those clinics. As a result, many people remained disconnected from testing sites even when testing was free to anyone regardless of insurance. Acknowledging these limitations and gaps of the current health delivery system to meet the Latinx communities’ needs requires redesigning how care is delivered and lowering systemic barriers to access.
Community-based approaches can bridge the gap between the community and the health care system, but these approaches will require policy and payment changes to address the underlying health system gaps that create an inequitable system. LATIN-19’s testing and vaccination events have been frequent and in trusted locations that are close to where people live and work. They have included providers and volunteers who are Latinx themselves or are bilingual and can communicate with individuals in their preferred language. The North Carolina Department of Health and Human Services also partnered with organizations working directly with migrant farmworkers and employees of meat processing plants to increase testing. The state contracted community organizations and bilingual community health workers to support the implementation of culturally appropriate strategies to increase access to testing and outreach efforts with community members.
Looking Ahead: Policy Reforms To Support Community-Level Health System Transformation
Lessons learned from our experience demonstrate that health equity gaps can be addressed through a multipronged approach that links community engagement and community empowerment to health policy. Key policy steps to address structural health equity gaps—by removing systemic barriers to access, creating incentives to sustain community partnerships, and creating incentives to enable community-based care delivery models—are:
Remove Systemic Barriers To Access
- Expand health coverage in Latinx communities as lack of health insurance is one of many factors underlying the systemic exclusion of Latinx communities from receiving timely health care.
- Build community health approaches that account for cross-sector needs and include interventions in housing, education, and food justice to improve overall health outcomes.
- Strengthen efforts to improve the collection of and reporting of race and ethnicity data to direct additional resources for tailored interventions.
- Center historically marginalized voices when considering new guidance and policies.
- Mitigate systemic barriers including requirements for proof of identification, presence of law enforcement, and inability to miss work
Create Incentives To Sustain Community Partnerships
- Identify resources to cover unpaid work of community organizations and community health workers who build confidence and increase access among communities.
- Provide regular, free trainings to community organizations and community health workers on relevant public health issues and how they can work with the state.
Create Incentives To Enable Community-Based Care Delivery Models
- Develop and implement alternative payment models for primary care that reward equitable health outcomes.
- Build on the infrastructure developed for mobile- and community-based testing or vaccination that have reduced disparities in access to these COVID-19 services.
- Encourage racial/ethnic concordance among providers and populations—until this occurs, embed community health workers in health care settings to support community members who often experience discrimination when interacting with health providers.
- Provide incentives to providers who demonstrate equitable outcomes through community-based models.
As we look ahead, linking community empowerment and community engagement to policy reforms can support efforts to reduce health disparities. Creating an equitable health care system will require health policy reforms to account for root causes of health inequities, including discrimination and structural racism, that many Latinx community members experience in their everyday health interactions. Solutions that bring needed services to communities where they are, intentionally align to community-identified needs, and reduce isolation and fear of accessing services are key steps toward bridging the health equity gap.
Viviana Martinez-Bianchi is co-founder of LATIN-19. All other authors are members of the LATIN-19 research group.