While COVID-19 impacted every community throughout the County, data throughout the pandemic - and particularly during surges and resource scarcity - demonstrated devastating impacts among American Indians/Alaska Natives, Black/African Americans, Latino/a/x, Native Hawaiian/Pacific Islanders, Limited English Proficient communities, people with disabilities, immigrants (non-US born persons), and LGBTQ+ residents.
As early as April 2020, with 19,516 confirmed COVID-19 cases in LA County (excluding Long Beach and Pasadena), and racial and ethnic disparities in COVID-19 case rates and age adjusted death rates were already taking shape in surveillance data. Native Hawaiians and Pacific Islanders had the highest population rate of COVID-19 cases (840 per 100,000) and death rate (71 per 100,000), followed by Latinx (114 per 100,000 case rate, 9.8 per 100,000 death rate), African Americans (102 per 100,000 case rate, 13.2 per 100,000 death rate), Whites (78 per 100,000 case rate, 5.7 per 100,000 death rate), Asians (73 per 100,000 case rate, 7.9 death rate) and American Indian Alaska Natives (50 per 100,000 case rate, 2.9 per 100,000 death rate) (Department of Public Health).
By April 2021, the County's age-adjusted case rate was 11,886 per 100,000 residents, and the age-adjusted death rate was 217 per 100,000; however, Native Hawaiians and Pacific Islanders, Latinos/Latinx, American Indians/Alaska Natives, and Black/African Americans continued to experience higher case and death rates than the county average and/or their White counterparts. Native Hawaiians and Pacific Islanders (21,070 per 100,000 case rate, 374 per 100,000 death rate), Latinx (12,783 per 100,000 case rate, 355 per 100,000 death rate), American Indian/Alaska Native (8,866 per 100,000 case rate, 188 per 100,000 death rate), Black/African Americans (5,539 per 100,000 case rate, 202 per 100,000 death rate), Whites (4,592 per 100,000 case rate, 120 per 100,000 death rate) (Department of Public Health).
Race and ethnicity are not the only predictors of increased vulnerability to COVID-19 infection and death or overall health disparities. Of the 9,309.771 Los Angeles County residents over 5 years old, more than 55% speak a language other than English at home. Limited English Proficiency is considered a critical vulnerability for health and mental health, particularly for elderly immigrants. Additionally, individuals with disabilities comprise approximately 10.8% of the population (2021 ACS). Individuals with disabilities face increased health vulnerabilities, report their health to be poor to fair at four times the rate of people with no disabilities (Krahn, G. L., et al., 2015), and are disproportionately affected by the hardships of COVID-19 (Administration for Community Living, 2022). Immigrants comprise 33.3% of the LA County population, and their access to care and quality of care is affected by poverty level, immigration status, language proficiency, residential location, and stigma, marginalization, and racism. The LGBTQ+ population in LA County is estimated to be approximately 4.6% of the adult resident population (Gallup, 2015), or 361,658. LGBTQ+ individuals smoke more than heterosexual and cis gender peers (CDC, 27 June 2022) and experience higher rates of HIV and cancer (Olsen, K. , 2021), meaning potentially increased vulnerability to COVID-19. (2021 ACS)
This intervention prioritizes those most impacted and people living in vulnerable geographies by focusing on specific communities identified from the Healthy Places Index (HPI)+2.0. HPI combines 25 community characteristics, like access to healthcare, housing, education, and more, into a single indexed HPI score (total population 4,878,877). The healthier a community, the higher the HPI score. Equity Fund reached 3,072,711 people through outreach activities and 5770 individuals through system navigation. It is difficult to note what percent of the target population has been reached by outreach and education efforts due to how data was collected and the nature of large community events or virtual events, which obscures granular demographic or geographic details.
Prior to COVID-19, in Los Angeles County, historically marginalized populations and neighborhoods were already facing inequitable exposure to socioeconomic risks such as stable employment, housing, and access to other public benefits and social services. The pandemic exacerbated existing inequities and created dramatic and persistent disparities in the rates of infection, mortality, hospitalization, and vaccination/booster uptake. Moreover, due to the highly infectious nature of COVID-19, long-term persistence of infection in any group, no matter how small or isolated, puts the broader community and county at risk of further infection.
LA County is home to over 7 million BIPOC (Black, Indigenous, People of Color) individuals who have suffered the greatest health and social economic conditions (US Census, 2019; Portrait of Los Angeles County, 2017-2018; LA County Health Study/Community Health Profiles; Catalyst California, 2020), including:
- High rates of underlying health and chronic conditions,
- Most likely to have essential jobs that require interaction with people outside their household and many with limited or non-existent worker protections
- Many living in overcrowded multigenerational households and experiencing disproportionate rates of homelessness
- Barriers to healthcare access including lack of health insurance, immigration status, cost, linguistic and cultural barriers, in addition to distrust of governmental and health entities due to historical trauma
- Lower income levels and higher rates of joblessness
- Lower life expectancies
These systemic drivers laid the groundwork for inequitable trajectories during this pandemic, making these communities most vulnerable to adverse outcomes due to COVID-19 (higher rates of positive COVID-19 cases, hospitalizations, and deaths).
LA County Public Health has a well-established approach to utilizing best practices around community outreach and engagement, including direct community events and services at County facilities, community advisory boards, and subcontracting services with local community-based organizations. Many of these activities and the community networks tend to be narrowly focused on a particular health issue (ie. tobacco, nutrition, or maternal and infant health) and/or may center on a specific geographic area. These issue-specific initiatives can address focused health topics and resources to address them for those who are affected by them. Additionally, place-based community outreach can reach diverse local communities and address multiple health issues. This dual-pronged approach of issue-driven and place-based community outreach offers a balance of topical expertise and broad reach.
The Equity Fund model addresses health inequities by partnering with CBOs that provide services in priority areas, serving the target populations addressing drivers of disparity. Culturally competent messaging, different conceptualizations and perceptions about health, linguistic access to health information, access to health information through traditional and mainstream access points, understanding how to navigate county processes, cultural barriers to self-advocacy, socioeconomic factors such as poverty, and geographic factors such as distance all contribute to disparities in access to health care and supportive service resources. These CBOs understand how to advocate for and help individuals access local healthcare, social services, and government assistance from complex and often siloed systems.
COVID-19 has impacted multiple aspects of an individual's health and life across many social determinants of health. As such, it needs a multi-faceted approach, with resources drawn from various sources, and a broad-based partnership. The Equity Fund serves a critical role within that approach, building upon traditional models of outreach and navigation by creating integrated and responsive networks designed to adapt to emergent needs.
Equity Fund CBOs can provide culturally competent services to educate the public, provide navigation support and resources, and build community trust. Community members who are uninformed or misinformed about COVID-19 and its transmission risk contributing to community spread. Community members unable to adhere to quarantine and isolation guidelines risk exposing others to infection. As COVID-19 spread and variants created an air of unpredictability, having trusted partners in the community address questions was of utmost importance. Communities and subpopulations with more barriers to information and fewer resources experience even more vulnerability to adverse health outcomes, and therefore, building community trust is a critical priority for Equity Fund. The foundation of having no wrong door” allows partners to address the myriad challenges created by COVID-19 beyond the infection itself. Telling community members Equity Fund can help them with their needs has been critical to achieving the explicit objectives of the initiative and building community trust in an environment where trust in public health messaging was not assured.
Furthermore, using real-time data allows the CBOs to pivot to different communities strategically and address emergent service needs. As clusters of infection appeared, CBOs serving those areas deployed workers and tailored resources as necessary. As medical sheltering needs sharply increased during the Delta surge, navigators worked with the Public Health's quarantine and isolation intake line to ensure our most vulnerable clients could safely isolate.
Health equity is achieved when everyone has access to the goods, services, resources, and power they need for optimal health and well-being. The principles this definition is constructed on behind this are 1. Commitment to racial justice and social change; 2. Accountability to the community and each other; 3. Integrity and transparency in our internal and external processes; 4. Collaboration and shared learning.
Public Health strategies for realizing these principles include: 1. Increasing organizational competency and capacity to engage in sustained equity work; 2. Communicating in ways that amplify community voices and authentic narratives to drive action; 3. Supporting/building community capacity to engage in efforts that eliminate inequities; 4. Forging partnerships to enhance and promote efforts that result in equitable health outcomes; 5. Aligning current resources to work that eliminates inequities.
Equity Fund implements those strategies by investing resources in a vast CBO partnership network across LA County, supporting a workforce with the cultural and lived expertise to serve diverse communities across the County. This in turn guarantees that concerns communicated by residents are lifted up and utilized to inform Public Health's broader COVID-19 mitigation strategies (including strategies around vaccinations, testing, messaging, etc).
Equity Fund brings together two interconnected networks – outreach/education and system navigation – created a community-based continuum of care for COVID-19. The Outreach & Education program supports CBOs with existing footprints in their communities and leveraged cultural expertise and community trust to effectively convey essential COVID-19 information and messaging. System navigators facilitate culturally and linguistically appropriate connections to wrap-around services, effectively linking individuals and families to resources that address COVID-related needs - such as medical sheltering, COVID-19 testing and vaccinations services, and social supports (i.e, government assistance, housing, and food).
While an innovative approach to design and implementation, the Equity Fund strategies (outreach/education and system navigation) are built on well-established Evidence Based Practices. The instrumental and ethical importance of cultural competency in health education and outreach has drawn from several Evidence Based Practices including promatoras de salud, which has long demonstrated the effectiveness of trusted lay health educators to transmit and translate health information to both better understand public health issues, and support behavior change around health screening and healthy living (Balcazar, H.G. et al., 2009; Forster-Cox, S. C., et al. , 2007).
The system navigation program builds on the patient navigators” model, which helps patients navigate the myriad issues related to complex disease management, such as cancer (Freeman, H.P., 2004). Particularly within historically marginalized communities, the combination of lack of trust, high stress, logistical complexity, and potential cultural hostility of medical treatment plans, the need to navigate patients through a process and connect them with resources is highly beneficial. This enhances the experience, supports compliance with treatment, and ensures that required protocols are followed. Equity Fund system navigation was structured on this rationale to address challenges with confusing and ever-changing information during moments of COVID-19 illness and stress to improve access to resources, ensure compliance with health and safety protocols, and ultimately improve health outcomes.