Commentary: An Equitable Approach to Serving Structurally Marginalized Communities : Family & Community Health

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Commentary: An Equitable Approach to Serving Structurally Marginalized Communities

Reid, Kaydian S. DrPH; Odusanya, Anne O. DrPH; Lawrence, Wayne R. DrPH; Hastings, Julia F. PhD

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doi: 10.1097/FCH.0000000000000345
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Abstract

IN 2020, the stay-at-home public health mandates tied to the COVID-19 pandemic response allowed time for many in the United States (US) to grapple with health inequities. Although health was at the forefront of our minds, the numerous news reports about the state-sanctioned unjust killing of Black people fostered conversations on systemic racism and how health and social service organizations can promote health equity. Consequently, many health and social service organizations released statements on their support in combating structural racism and being antiracist. Although it is noteworthy to release statements acknowledging systemic racism, the community they serve (ie, Black, Indigenous, and People of Color [BIPOC]) lacks sustainable resources and capacities. Therefore, we aim to describe actionable recommendations health and social service organizations can take to serve marginalized communities equitably with a focus on (1) utilizing community-based participatory research (CBPR) to resolve health inequities; (2) addressing health equity in research funding and allocation of resources to underserved and underfunded community programs; and (3) collecting and reporting data on minoritized populations.

CBPR APPROACH TO REDUCE INEQUITIES

Power needs to be shared between health and social service organizations and BIPOC community-led organizations to support the self-determination and resilience of marginalized communities with the goal of disrupting racial and ethnic inequities. BIPOC community-led organizations are often well respected and positioned in their communities.1 In contrast, BIPOC communities are more likely to have lower levels of trust with the health and social service organizations, often due to their or similar organizations' historical and/or ongoing harms inflicted on the BIPOC community.2 To move toward equity, health and social service organizations must have BIPOC community leaders at the decision-making table by providing grant funding that requires little to no match funds associated with purposeful technical assistance provided by health and social services organizations. Purposeful technical assistance can contribute to the capacity building of community-led organizations for health and social services to form and maintain trusting relationships with communities. Purposeful technical assistance comprises professional development centered on (1) grant writing skills and resources, (2) program planning and implementation, (3) monitoring and evaluation, and (4) capacity building with other organizations with similar missions. Moreover, public health organizations should provide time and resources to expand the capacity of community-led organizations to be competitive for grants, as this funding mechanism is often critical for sustaining and growing an organization.

To improve health outcomes and reduce health inequities, health and social service organizations can utilize a CBPR approach to develop culturally responsive, appropriate, and informed solutions to resolve public health issues within the communities they serve.3 CBPR maintains that community members are not only involved in every aspect of the research process (eg, development, implementation, evaluation, data interpretation, and dissemination) but are equal partners in the decision-making process because they are the experts of their own lived experiences.3 This partnership results in shared ownership of products (eg, reports, data, presentations). CBPR emphasizes cultural humility to address the power dynamics necessary to create and sustain mutually beneficial and respectful partnerships with communities.3 To make a measurable positive change, health and social service organizations need to back their community efforts with financial support and abandon the “helicopter approach” of gathering data and leaving communities without further contact.

EQUITABLE STRATEGIES FOR SUCCESSFUL FUNDING AND ALLOCATION

Community-led organizations can benefit most and promote sustainable policies, systems, and environmental changes for equity-oriented health research. However, they are often not competitive for various reasons (ie, lack of research capacity, human capital, and grant writing resources). It is unclear how funders design their funding to incentivize equity-oriented health research.4 Often, health equity requests for proposals administered by health and social service organizations focus on addressing health conditions that disproportionately affect a specific population. Unfortunately, these requests for proposals do not provide guidelines for collaboration with community-led organizations, thereby not ensuring inclusive and equitable initiatives/programs.5 For example, the United State's Office of Minority Health's funding announcement page for equity-oriented health encourages applicants to collaborate with similar minority-serving community-led organizations for quality assurance. These collaborations are often not fruitful for the community-led organization as they are frequently not involved or given enough power on decisions that will impact the communities they serve. In addition to vagueness in the equity-oriented health partnership, equitable health resource allocation decisions do not detail how equity is evaluated in applications.6

For the aforementioned reasons, we call for a concerted effort to implement strategies to

  1. strengthen equitable partnership development between community-led organizations and health and social service organizations to assess health equity research, interventions, and evaluation of capacity needs;
  2. recognize existing community assets through BIPOC community-led needs assessments to identify communities that need more resources to be competitive when applying for grants;
  3. provide ongoing “free” technical assistance for quality assurance (ie, monitoring and evaluating action-oriented equity research and interventions), so that community-led organizations can document the program's effectiveness for future funding to scale up their programs; and
  4. supply sustainable resources and skills building (ie, grant writing) for community-led organizations' key stakeholders.

These strategies are well positioned for equity-oriented community-led research, interventions, and evaluations while emphasizing sustainability in the planning phase. Ideally, a mutually beneficial relationship between the community, funders, and academic institutions should equally share the benefits and burdens. However, historically, BIPOC communities often lack power and decision making. Given the current increased focus on translational research and emphasizing health equity, responsibility for beneficial outcomes must be agreed upon as well as mutually shared. Therefore, when community residents are given the power to control funds, make decisions, and lead activities, programs are sustainable and research is more translatable. Funding does not last a lifetime; however, sustainable strategies and programs at the grassroots level will.

DATA COLLECTION AND REPORTING

During the beginning months of the COVID-19 pandemic, most state health departments were missing COVID-19 data by race and ethnicity, despite being common for health departments to collect these data on mortality and nearly all diseases routinely.7 This was detrimental as Black and Hispanic/Latino individuals had disproportionately higher COVID-19 incidence and mortality but were not adequately accounted for, hindering the ability to develop early and tailored interventions that may have prevented deaths and disabilities. Health and social service organizations need to collect data and report on racial and gender minoritized populations, and other marginalized groups to promote health equity. Finally, to ensure an accurate translation of data to intervention development, health and social service organizations must examine race from a sociopolitical framework and not biological. They must justify their conceptualization of racially minoritized groups and their racial/ethnic categorization.

CONCLUSION

The opportunity is upon us to resolve health inequities and disparities in disease burden. Unfortunately, the US' habits of committing to an issue and not following through in a meaningful and sustainable way continue to hinder equity-oriented practices, policies, systems, and social-environmental changes. If health and social service organizations want to eliminate health inequities, they must evaluate how they serve marginalized populations and promote changes, especially at the community and public policy levels. The three approaches: (1) use of CBPR to address and reduce health inequities; (2) intentionality in research funding and allocation of resources; and (3) routine collection and reporting of data on minoritized populations are vital practices that can improve health outcomes among marginalized people. Moreover, as the current US political climate aims to promote health equity, health and social service organizations are well supported to implement an equity agenda to improve the quality of life of marginalized populations.

REFERENCES

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2. Centers for Disease Control and Prevention. Health equity considerations and racial and ethnic minority groups. https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/race-ethnicity.html. Published 2021. Accessed May 1, 2021.
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4. Pratt B, Hyder AA. Designing research funding schemes to promote global health equity: an exploration of current practice in health systems research. Dev World Bioeth. 2018;18(2):76–90. doi:10.1111/dewb.12136.
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6. Braveman P. What are health disparities and health equity? We need to be clear. Public Health Rep. 2014;129(suppl 2):5–8. doi:10.1177/00333549141291S203.
7. Krieger N, Testa C, Hanage WP, Chen JT. US racial and ethnic data for COVID-19 cases: still missing in action. Lancet. 2020;396(10261):e81. doi:10.1016/S0140-6736(20)32220-0.
Keywords:

Black; Indigenous; and People of Color; community-based participatory research; health equity

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