ACROSS the United States, the Latinx community is among the most impacted by COVID-19. From February to June 2020, the Centers for Disease Control and Prevention (CDC) reported Hispanic/Latinx persons as the largest group by population size living in hot spot counties.1 Additional CDC data from May to August 2020 show that the percentage of Latinx decedents from COVID-19 increased by 10%, the largest increase among other racial/ethnic groups.2 Within community health centers, Latinx individuals represent 32.2% of tests, yet 42.5% of positive tests, the highest proportion of confirmed rates among any other racial/ethnic group.2 Thus far, disparity data have been explained through the greater medical and social vulnerabilities of historically marginalized populations, including the increased risk of preexisting conditions and the increased likelihood of working essential jobs that place them at risk.3 Research has pointed to the role of Social Determinants of Health (SDoH) in creating COVID-19 disparities.4 However, SDoH analyses are almost exclusively framed around access to health care, housing inequities, and income. In many ways, these issues can seem intractable without strong civic engagement and empowerment for marginalized communities. To date, there is no analysis on how civic engagement—as part of the Social and Community Context SDoH domain—affects COVID-19 vulnerabilities or how it affects the disease's social impact in working-class communities of color. Civic engagement is paramount to inclusive decision-making and even more critical in response to the COVID-19 pandemic.
CIVIC ENGAGEMENT AND HEALTH
A growing body of research has begun to test and link civic engagement to health interventions or health outcomes, especially among working class or communities of color. Healthy People 2020 proposed that civic engagement generates social capital and that voting, specifically, has been associated with better self-reported health.5 For example, a pilot study among Black/African American women suggests that a civic engagement approach effectively engages this population in addressing behavior change related to physical activity as cardiovascular disease prevention.6 In rural Oregon, the Voces de Salud program trained local Latinx residents to engage in community health planning, program development, public policy, research, and resource allocation.7 These efforts resulted in the placement of participants in various community leadership roles (eg, school PTO, County Community Health Center Board of Directors) and in the procurement of grant funding for county-based health programs developed in partnership with trained participants.7 These examples illustrate a broad definition of civic engagement that provides opportunities for the most marginalized members of a community—including those who may not be eligible to vote—to actively shape local health programming. The Latinx community has historically had lower voter turnout than other racial/ethnic groups8 and is also the racial/ethnic group with lowest naturalization rates, which presents structural challenges to voter eligibility.9 Yet, there is evidence that Latinx communities are civically engaged in other ways that include volunteering and/or membership in faith-based or charitable organizations.10
CIVIC ENGAGEMENT IN COVID-19 RESPONSE AND RECOVERY
As a matter of equity, COVID-19 response and recovery strategies need to prioritize the voices and experiences of Latinx communities, as one of the communities most impacted by the disease, both in epidemiological and social approaches. 2020 is a particularly important year to implement civic engagement strategies that elevate these experiences into local decision-making and broader public policy, given the decennial census that will determine federal funding in communities for the next 10 years. In the years following the pandemic, accurate counts are paramount for Latinx communities that have experienced disproportionate economic impact of job loss or medical leaves of absence due to COVID-19 exposure in essential industries. At the local level, civic engagement can also be a critical strategy in developing and deploying equity-centered rapid response efforts, disseminating information about and linking communities to a vaccine once it becomes available, advocating for and disseminating local health guidelines to protect workers from COVID-19 risk in the workplace, advocating and ensuring implementation of local rent moratoriums, among other strategies that will mitigate COVID-19 risk and harm in communities of color. In this context, it is important to learn from organizations that have taken a civic engagement approach to COVID-19 relief.
Latino Health Access (LHA), a nonprofit community-based organization in Orange County, California, was founded using a promotor-driven model. Established in 1993, the organization's mission is “to bring health, equity and sustainable change through education, services, consciousness-raising and civic participation.” Promotores or community health workers are paid employees of LHA, recruited from the communities in LHA's service area and trained in specialized topics (eg, chronic disease, mental health, youth engagement) using a SDoH framework. Promotores are both companions to the community and employees of the organization, which positions them in the dual role of service facilitators and organic community leaders. As such, they are able to accompany or “walk with the community” to make behavioral improvements toward better health outcomes while building community capacity to be civically engaged and mobilize change to address the underlying systemic inequities.11 Traditional mechanisms for civic participation (eg, voter engagement, speaking at city council meetings, providing input on local budget processes) have historically excluded LHA participants by not prioritizing outreach to their communities, disinvesting in their neighborhoods, and failing to address linguistic, cultural, and socioeconomic barriers to engagement. In contrast, LHA promotores create culturally appropriate mechanisms for its participants to engage in their primary language and invests time and resources to build their skills to create and lead their own local policy advocacy campaigns and to develop health and wellness programming that is responsive to community needs.
In March 2020, LHA implemented a countywide community-led COVID-19 Health Equity Response in Orange County, one of the most impacted counties in the State of California. The first step in implementation was to prepare an informal interview guide where promotores provided feedback on an introductory message and connected to assess the effects of the pandemic among their participants. The questionnaire gathered a status of the participants' basic needs amidst the pandemic and then delved further to offer resources. This was followed by another series of calls to community members within LHA's participant database to gain an understanding of emerging community needs. These outreach and assessment efforts coincided with LHA's efforts to assess its participants' interest in civic engagement in preparation for the 2020 general election and Census participation.
Twenty-four promotores from LHA reached out to 481 Latinx voters (identified through the Political Data Inc [PDI] database, as part of its nonpartisan voter engagement program) and 1892 current program participants who were mostly nonvoters (95%). LHA's current program participants are predominantly female (72%), Spanish speakers (90%), and reported earning less than $30000 per year (85%). In addition, in 2019, 95% of program participants reported being born outside the United States, and 46% of adult participants reported being uninsured. Although LHA does not request immigration status to provide services, based on eligibility for insurance and other benefits, it can be surmised that almost half of its participants are undocumented and many more live in mixed-status households. On the contrary, individuals identified through PDI are US citizens and registered to vote.
Although both groups reported high levels of COVID-19 vulnerabilities, nonvoters had significantly higher rates of food insecurity (20% vs 10%, P < .001), greater reductions in work hours (64% vs 38%, P < .001), more housing instability (68% vs 19%, P < .001), less knowledge of how to respond to a COVID-19 case in the household (20% vs 6%, P < .001), and less space for COVID-19–related isolation (59% vs 14%, P < .001). Despite increased vulnerabilities, LHA's current participants reported comparable levels of civic participation as voters, including participation in the census (96% vs 98%, P > .1), being informed of issues related to rent control (95% vs 87%, P < .001), and interests in signing a petition on rent control (50% vs 69%, P < .001).
These preliminary data show that nonvoters experience greater COVID-19 vulnerabilities related to SDoH and present a unique opportunity to design strategies to engage them in urgent response and future recovery efforts. LHA provides examples of how to do this in the times of COVID-19. For example, LHA promotores organized primarily nonvoters through a Consejeria de Vivienda (Housing Counselor) program funded by the Kresge Foundation, aimed at informing community members about their housing rights and advocating for local ordinances to expand them during the pandemic. The organization also partnered with community members to design and implement its comprehensive COVID-19 Health Equity Response, where community members led culturally appropriate creative COVID-19 campaigns using principles of popular education. Moving forward, civic engagement of marginalized communities will ensure that they are equitably represented in decision making as we address the underlying inequities that resulted in COVID-19 disparities.
The association of COVID-19 disparities across racial/ethnic groups and SDoH has been made in emerging research. What has not been proposed in existing literature is how to engage members of the most impacted racial/ethnic groups in codesigning strategies to respond to risk or harm mitigation, and virtually no data exist on the impact of civic engagement (or lack thereof) on COVID-19 vulnerabilities or its social impact. In Orange County, California, LHA provides a bright spot on how to begin collecting these data and leveraging it into organizing a targeted community-led response in the most impacted communities in the county. Without centering the voices and experiences of those most impacted by the pandemic, the health and social recovery from COVID-19 will leave these communities behind without appropriate mechanisms to build resilience for future health crises.
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8. US Census Bureau. Reported voting and registration by race, Hispanic origin, sex and age groups: November 1964 to 2018. census.gov
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