Achieving Sustainable Health Equity Locally After the COVID-19 Emergency Response.

In May 2023, the United States ended the federal COVID-19 pandemic public health emergency declaration.1 The pandemic exposed preexisting gaps in health outcomes among and between different groups, most notably Black, Indigenous, and People of Color (BIPOC) and Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ+) communities.2 Local Health Departments (LHDs) utilized funding from the National Initiative to Address COVID-19 Health Disparities Among Populations at High-Risk and Underserved, Including Racial and Ethnic Minority Populations and Rural Communities grant (hereafter referred to as OT21-2103) sponsored through the Centers for Disease Control and Prevention to support marginalized communities that directly act on root causes of health inequities. Three OT21-2103 LHD recipients have since amplified health and racial equity sustainability through their work. Douglas County Health Department (DCHD) (Omaha, Nebraska), the Boston Public Health Commission (BPHC) (Boston, Massachusetts), and Mecklenburg County Public Health (MCPH) (Charlotte, North Carolina) have created avenues to advance and sustain health and racial equity among marginalized communities. Douglas County has built a new division in its department to respond to racism as a public health crisis; Boston is preparing to unveil an LGBTQ+ health equity assessment; and Mecklenburg County has found success in establishing a Hispanic/Latino Community Liaison position. Recommendations from these examples are offered later in the article to aid LHDs in current and future health and racial equity work. DCHD, Nebraska Douglas County, Nebraska, located in Eastern Nebraska and encompassing the City of Omaha, is the largest city in the state. The population is majority White (79.7% White, 19.3% BIPOC) (US Census Bureau, 2022) and has a history of redlining; these repercussions are still evident in 2023. Racial and ethnic segregation remains a feature across some Omaha Metro neighborhoods that exhibit greater poverty, less economic development, and fewer schools compared with more affluent and predominant White neighborhoods (Graham and Masters, 2020). Utilizing OT21-2103 funding, DCHD created an office of health equity (OHE) comprising a health equity educator, a health equity epidemiologist, a health equity advisor, and a health planner. Accreditation, Performance Management and Quality Improvement, and Workforce Development were moved under the OHE to ensure that concepts of equity are built into the foundational work of the department, and not simply a “box to check.” The OHE has already been invaluable to ongoing work, including reaching targeted populations during outbreaks like COVID-19. One major contributing factor to the OHE's work so far was a leadership commitment to encourage all programs to seek the guidance and recommendations of the OHE. This has led to collaborations across divisions in hiring; development of health education materials; workforce development training focused on equity and inclusion; and gathering and analyzing data in a disaggregated way that further highlights disparities and gaps in health by race/ethnicity, age, and gender (DCHD BOH, 2020). DCHD's leadership commitment illustrates how operationalizing approaches to improving health equity can be much more than checking the proverbial diversity, equity, and inclusion (DEI) box. MCPH Department, North Carolina Mecklenburg County's Hispanic/Latino/x population has increased 24.6% from 2010 to 2020.3 Because of this increase, the MCPH Department established a Hispanic/Latino Community Liaison position using OT21-2103 funding to focus on systems level change related to equity for the Hispanic/Latino/x community, particularly as it relates to COVID-19 and social determinants of health (SDOH). This liaison was able to build partnerships and serve as a conduit between MCPH and individuals/organizations in the county. The overall goal of the liaison was to effectively reach the Latinx community and ensure the resources and services from MCPH met the needs of the community.4 The liaison's work were steps to help close the health equity gap among Latino/Hispanic communities in Mecklenburg County. The institution of the liaison inspired several initiatives, including the development of an organization-wide translation request process, a focused and culturally appropriate media campaign, and a comprehensive strategic plan. An organization-wide translation project began with a quality improvement analysis and resulted in a new process that became part of the department's Administrative Policy for all staff members. A focused media campaign was also created to address issues related to COVID-19 health disparities (eg, vaccine/booster education and information) and other SDOH within the population of focus. Finally, a strategic plan was commissioned to address how the ongoing work to better serve the Hispanic/Latino/x community could be built upon and sustained for the future. Community involvement was key in the planning, development, and execution of the initiatives. All MCPH staff members have equal knowledge and access to the process through the updated MCPH Limited English Proficiency (LEP) Administrative Policy. Feedback from clients, community leaders via MCPH WhatsApp group, and staff helped drive focus areas needed to effectively serve the Hispanic/Latino/x community and guide the direction of a focused media campaign. The feedback helped MCPH provide marketing knowledge and media connections/resources to reach the county's Hispanic/Latino market with culturally relevant health information. The development of the strategic plan focused on areas of need during the COVID-19 pandemic. BPHC, Massachusetts The BPHC and a partnering local consulting group, Ocha Transformations (OCHA), are utilizing OT21-2103 funds to conduct an LGBTQ+ Health Equity Assessment for Boston residents following the COVID-19 emergency. This initiative aims to identify health inequities created or exacerbated by the pandemic and actionable resolutions within the LGBTQ+ community, particularly among minoritized and racialized LGBTQ+ groups. A Community Working Group (CWG) consisting of LGBTQ+ community leaders and organizational partners was established to inform all aspects of the planning and implementation of the project. Eight community conversations were conducted with intersectional identity groups within the LGBTQ+ community in which participants identified challenges, highlighted community strengths, and shared their vision for a healthy LGBTQ+ community in Boston to ensure actionable recommendations. Adjustments to planned community conversations based on CWG feedback were incorporated, including adding minoritized religious group conversations and modifying recruitment approaches to prioritize participant safety and comfort. Six virtual focus groups were conducted with organizational partners working closely with LGBTQ+ communities on health-related issues. These data collection methods acknowledge intersectionality of race,5,6 ethnicity,7,8 religion,9 and ability10 within the LGBTQ+ experience and the overlapping forms of discrimination and marginalization that contribute to their unique health experiences and challenges.11 A consensus-building workshop will be held with members of the CWG and project participants to collectively analyze data and findings into actionable recommendations for an LGBTQ+ Health Equity Report. This report will be disseminated directly to community members, local leaders, and community-based organizations to support sustainable implementation of recommendations. This report will serve as the catalyst for future collaboration between BPHC and LGBTQ+ communities, particularly across the CWG members. In addition, the findings will be integrated into future strategic planning initiatives at BPHC and community health planning through the Boston CHNA/CHIP Collaborative to ensure the integration of findings into future citywide assessments and action plans. Recommendations As OT21-2103 funding concludes, LHDs still face several challenges to sustaining health equity post–COVID-19 emergency response. Some of those issues include how to incorporate health equity principles across the health department, confirm health resources and services are available and meet the needs of communities, and identify solutions to address minoritized and racialized LGBTQ+ health inequities. Understanding promising practices among recipients of OT21-2103 is essential to develop multifaceted and equitable resolutions that will improve LHDs and the health of their jurisdictions. The cases shared provided some recommendations imperative to progress: Leadership must intentionally and urgently act to ensure health equity is integrated in their health systems. Leadership teams should assess the composition and work of their LHD to acknowledge the necessary work that remains to achieve health equity. NACCHO's Roots of Health Inequity course is a valuable tool health leadership can use to better understand the redirection and restructuring needed to introduce more inclusive practices into the department's culture and work. Community ownership should drive practices to establish health equity systematically. Deliberate power-sharing between LHDs and their communities can initiate a path to sustainable relationships that improve health outcomes. NACCHO's Mobilizing for Action through Planning and Partnerships (MAPP) 2.0 Assessments and Human Impact Partners (HIP) power-building trainings are resources to assist LHDs working with communities to design, implement, and evaluate community and health equity–centered solutions. Intersectionality should be an approach in all LHDs' plans to effectively combat health inequities. According to a recent study published in BMJ, the intersectionality approach is still rare in research and health practice (Mothupi, 2023). Therefore, LHDs must continue to collaborate with and elevate the voices of marginalized people, such as BIPOC, LGBTQ+, people living with disabilities, and so forth, to develop strategies that dismantle unconscious bias and mitigate health inequities. Health systems are exiting the state of COVID-19 emergency response and entering an unprecedented time ripe for meaningful change. By enacting these recommendations, LHDs can get closer to a sustainable and equitable health system that provides secure and safe environments for all communities.