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Commentary: Rebuilding With Impacted Communities at the Center The Case for a Civic Engagement Approach to COVID-19 Response and Recovery

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Commentary: Rebuilding With Impacted
Communities at the Center
The Case for a Civic Engagement Approach to COVID-19
Response and Recovery
Gloria Itzel Montiel, PhD; Patricia J. Cantero, PhD; Israel Montiel, BA; Kyle Moon; Saira Nawaz, PhD
ACROSS the United States, the Latinx com-
munity is among the most impacted by
COVID-19. From February to June 2020, the Cen-
ters for Disease Control and Prevention (CDC)
reported Hispanic/Latinx persons as the largest
group by population size living in hot spot
counties.1Additional CDC data from May to Au-
gust 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 individu-
als represent 32.2% of tests, yet 42.5% of positive
tests, the highest proportion of conrmed rates
among any other racial/ethnic group.2Thus far,
disparity data have been explained through the
greater medical and social vulnerabilities of his-
torically marginalized populations, including the
increased risk of preexisting conditions and the in-
creased likelihood of working essential jobs that
place them at risk.3Research has pointed to the
role of Social Determinants of Health (SDoH) in
creating COVID-19 disparities.4However, SDoH
analyses are almost exclusively framed around ac-
cess 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 commu-
nities of color. Civic engagement is paramount to
Author Affiliations: Latino Health Access, Santa Ana, California
(Drs Montiel and Cantero and Mr Montiel); AltaMed Institute for
Health Equity, LosAngeles, California ( DrMontiel); U niversityof Cal-
ifornia, Los Angeles (Mr Montiel); and Center for Health Outcomes
and Policy Evaluation Studies, College of Public Health, the Ohio
State University, Columbus (Mr Moon and Dr Nawaz).
The authors acknowledge the entire Latino Health Access team,
especially the promotores who have tirelessly worked to respond
to the COVID-19 pandemic in Orange County with swiftness, cre-
ativity, and equity.
Conflicts of Interest: None.
Correspondence: Gloria Itzel Montiel, PhD, Latino Health Ac-
cess, 450 W 4th St, Santa Ana, CA 92701 (gmontiel@latinohealth
Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/FCH.0000000000000294
inclusive decision-making and even more critical in
response to the COVID-19 pandemic.
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 so-
cial capital and that voting, specically, has been
associated with better self-reported health.5For ex-
ample, 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 car-
diovascular disease prevention.6In 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.7These efforts resulted in the
placement of participants in various community
leadership roles (eg, school PTO, County Com-
munity Health Center Board of Directors) and
in the procurement of grant funding for county-
based health programs developed in partnership
with trained participants.7These examples illustrate
a broad denition 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 pro-
gramming. The Latinx community has historically
had lower voter turnout than other racial/ethnic
groups8and is also the racial/ethnic group with low-
est naturalization rates, which presents structural
challenges to voter eligibility.9Yet, there is evidence
that Latinx communities are civically engaged in
other ways that include volunteering and/or mem-
bership in faith-based or charitable organizations.10
As a matter of equity, COVID-19 response and re-
covery 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 experi-
ences into local decision-making and broader public
Copyright © 2021 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Family and Community Health April–June 2021 Volume 44 Number 2 81
82 Family and Community Health April–June 2021 Volume 44 Number 2
policy, given the decennial census that will deter-
mine federal funding in communities for the next
10 years. In the years following the pandemic,
accurate counts are paramount for Latinx com-
munities that have experienced disproportionate
economic impact of job loss or medical leaves of
absence due to COVID-19 exposure in essential in-
dustries. At the local level, civic engagement can also
be a critical strategy in developing and deploying
equity-centered rapid response efforts, disseminat-
ing 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, ad-
vocating and ensuring implementation of local rent
moratoriums, among other strategies that will mit-
igate 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 nonprot
community-based organization in Orange County,
California, was founded using a promotor-driven
model. Established in 1993, the organizationʼs
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 under-
lying systemic inequities.11 Traditional mechanisms
for civic participation (eg, voter engagement, speak-
ing 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 neighbor-
hoods, and failing to address linguistic, cultural,
and socioeconomic barriers to engagement. In
contrast, LHA promotores create culturally appro-
priate 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 coun-
ties in the State of California. The rst step in
implementation was to prepare an informal inter-
view guide where promotores provided feedback on
an introductory message and connected to assess
the effects of the pandemic among their partici-
pants. 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’ inter-
est in civic engagement in preparation for the 2020
general election and Census participation.
Twenty-four promotores from LHA reached out
to 481 Latinx voters (identied through the Political
Data Inc [PDI] database, as part of its nonparti-
san voter engagement program) and 1892 current
program participants who were mostly nonvoters
(95%). LHA’s current program participants are pre-
dominantly female (72%), Spanish speakers (90%),
and reported earning less than $30 000 per year
(85%). In addition, in 2019, 95% of program par-
ticipants reported being born outside the United
States, and 46% of adult participants reported be-
ing uninsured. Although LHA does not request
immigration status to provide services, based on
eligibility for insurance and other benets, it can
be surmised that almost half of its participants are
undocumented and many more live in mixed-status
households. On the contrary, individuals identied
through PDI are US citizens and registered to vote.
Although both groups reported high levels of
COVID-19 vulnerabilities, nonvoters had signi-
cantly 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 iso-
lation (59% vs 14%, P<.001). Despite increased
vulnerabilities, LHAʼs current participants reported
comparable levels of civic participation as voters, in-
cluding 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%,
These preliminary data show that nonvoters ex-
perience greater COVID-19 vulnerabilities related
to SDoH and present a unique opportunity to de-
sign strategies to engage them in urgent response
and future recovery efforts. LHA provides exam-
ples of how to do this in the times of COVID-19.
For example, LHA promotores organized primarily
Copyright © 2021 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
G. I. Montiel et al. Rebuilding With Impacted Communities at the Center 83
nonvoters through a Consejeria de Vivienda (Hous-
ing Counselor) program funded by the Kresge
Foundation, aimed at informing community mem-
bers 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 appropri-
ate creative COVID-19 campaigns using principles
of popular education. Moving forward, civic en-
gagement of marginalized communities will ensure
that they are equitably represented in decision mak-
ing 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 mecha-
nisms to build resilience for future health crises.
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Copyright © 2021 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
... The Emotional Wellness program was enhanced to expand delivery of mental health services while addressing social needs of food and housing insecurity. Through these services, LHA ensured its mental health response was rooted in addressing the social inequities that created the conditions by which COVID-19 devastated working-class racial and ethnic minority communities and exacerbated mental health stressors (12). The Emotional Wellness program adopted a population health approach to address behavioral health needs along a continuum, regardless of whether participants had a mental or emotional health condition, providing a range of services (6). ...
... Before the pandemic, LHA provided programming in diabetes self-management, obesity prevention, and chronic pain management (16), all of which were promotor-led with group and individual meetings. Like mental health needs, disease management needs did not disappear during the pandemic, but because of the economic impact of COVID-19 on Latino communities, it became pressing to provide the referrals and additional services linked to the entrenched social determinants of health that resulted in greater social needs for vulnerable populations (12,17). Therefore, an equitable response to mental health during the pandemic had to, at a minimum, also account for the social needs and heightened stress that affected these communities. ...
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Introduction: The disproportionate impact of the COVID-19 pandemic on Latino communities has resulted in greater reports of depression, anxiety, and stress. We present a community-led intervention in Latino communities that integrated social services in mental health service delivery for an equity-based response. Methods: We used tracking sheets to identify 1,436 unique participants (aged 5-86) enrolled in Latino Health Access's Emotional Wellness program, of whom 346 enrolled in the pre-COVID-19 period (March 2019-February 2020) and 1,090 in the COVID-19 period (March-June 2020). Demographic characteristics and types of services were aggregated to assess monthly trends using Pearson χ2 tests. Regression models were developed to compare factors associated with referrals in the pre-COVID-19 and COVID-19 periods. Results: During the pandemic, service volume (P < .001) and participant volume (P < .001) increased significantly compared with the prepandemic period. Participant characteristics were similar during both periods, the only differences being age distribution, expanded geographic range, and increased male participation during the pandemic. Nonreferred services, such as peer support, increased during the pandemic period. Type of referrals significantly changed from primarily mental health services and disease management in the prepandemic period to affordable housing support, food assistance, and supplemental income. Conclusion: An effective mental health program in response to the pandemic must incorporate direct mental health services and address social needs that exacerbate mental health risk for Latino communities. This study presents a model of how to integrate both factors by leveraging promotor-led programs.
... However, even when testing was provided at no cost in areas with large numbers of Latinos, they still faced barriers to accessing services (King County Hospitals for a Healthier Community, 2021). These findings highlight the importance of engaging community members to disseminate health information and deliver messages through trusted sources, such as promotoras (Montiel et al., 2021;Ornelas & Ogedegbe, 2021). Local public health officials must also provide accurate information in Spanish through social media, internet, and television programming to combat the continued spread of misinformation (Barua et al., 2020). ...
Introduction We sought to describe how Latina immigrants living in King County coped with the pandemic, including their attitudes and behaviors related to COVID-19, and the impact of the pandemic on their mental health and wellbeing. Method We conducted surveys by phone with adult Spanish-speaking Latina immigrants ( n = 137) in the summer of 2020. Results Very few women had been infected with COVID-19, and 23% reported having been tested. Most frequent reasons for not being tested were not knowing where to go (14%), concerns over the cost (15%), and not wanting to know if they were infected (12%). Most participants had concerns about paying for housing (76%) and food (73%). Depression and anxiety symptoms were in the moderate range. Almost all participants were practicing recommended preventive behaviors. Conclusion Although few participants had COVID-19 infection, the pandemic had significant impacts on their mental health and ability to meet basic needs.
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What is already known about this topic? Persons aged ≥65 years and members of minority racial and ethnic groups are disproportionately represented among COVID-19-associated deaths. What is added by this report? Analysis of 114,411 COVID-19-associated deaths reported to National Vital Statistics System during May-August 2020, found that 51.3% of decedents were non-Hispanic White, 24.2% were Hispanic or Latino (Hispanic), and 18.7% were non-Hispanic Black. The percentage of Hispanic decedents increased from 16.3% in May to 26.4% in August. What are the implications for public health practice? These results can inform public health messaging and mitigation efforts focused on prevention and early detection of infection among disproportionately affected groups so as to minimize subsequent mortality. © 2020 Department of Health and Human Services. All rights reserved.
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What is already known about this topic? Long-standing health and social inequities have resulted in increased risk for infection, severe illness, and death from COVID-19 among communities of color. What is added by this report? Among 79 counties identified as hotspots during June 5-18, 2020 that also had sufficient data on race, a disproportionate number of COVID-19 cases among underrepresented racial/ethnic groups occurred in almost all areas during February-June 2020. What are the implications for public health practice? Identifying health disparities in COVID-19 hotspot counties can inform testing and prevention efforts. Addressing the pandemic's disproportionate incidence among communities of color can improve community-wide health outcomes related to COVID-19. © 2020 Department of Health and Human Services. All rights reserved.
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We used data from the Medical Expenditure Panel Survey to explore potential explanations for racial-ethnic disparities in coronavirus disease 2019 (COVID-19) hospitalizations and mortality. Black adults in every age group were more likely than whites to have health risks associated with severe COVID-19 illness. However, whites were older on average than blacks. Thus, when all factors were considered, whites tended to be at higher overall risk compared to blacks, with Asians and Hispanics having much lower overall levels of risk compared to either whites or blacks. We explored additional explanations for COVID-19 disparities, namely differences in job characteristics and how they interact with household composition. Blacks at high risk of severe illness were 1.6 times as likely as whites to live in households containing health-sector workers. Among Hispanic adults at high risk of severe illness, 64.5 percent lived in households with at least one worker who was unable to work at home, versus 56.5 percent among blacks and only 46.6 percent among whites. [Editor's Note: This Fast Track Ahead Of Print article is the accepted version of the peer-reviewed manuscript. The final edited version will appear in an upcoming issue of Health Affairs.].
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There is growing attention to disparities in the incidence, prevalence, and mortality associated with COVID-19 (Coronavirus disease 2019) in racial/ethnic communities. The conditions leading to these disparities may be a function of social determinants of health and stigma linked to the disease. It is important to examine how these factors may be implicated in COVID-19 onset, treatment, and outcomes. A brief overview of these issues allows for a cursory examination of the role of social determinants of health and stigma in COVID-19. Consideration is given to how understanding COVID-19 in the context of social determinants and stigma may be included in interventions to mitigate its transmission within vulnerable populations.
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Background Despite increased risk for cardiovascular disease (CVD) and related conditions, evaluations of health interventions indicate that Black/African American women are less likely to benefit than their white counterparts and are not as likely to engage in behaviors that reduce CVD risk. The purpose of this study was to test the feasibility and effectiveness of civic engagement as an intervention strategy to address heart health in Black/African American women. Methods Using a quasi-experimental pre-post study design, civic engagement was tested by convening a convenience sample of self-identified Black/African American women, ages 30–70 years, English-speaking, and BMI ≥25.0 (n = 28) into “Change Clubs” in four churches. Feasibility was examined through adherence, satisfaction, retention, and ability of Change Clubs to meet at least 50% of self-identified action steps for community change. Effectiveness data included: dietary intake, measures of physical activity, cardiorespiratory fitness, blood pressure, and anthropometrics. Psychosocial factors hypothesized to serve as the mechanisms by which civic engagement enacts behavior change were also assessed. ResultsAt baseline, the study sample (n = 28) had a mean age of 50.5 y; 53.6% had an associate degree or higher; 60.7% had an income of $35,000 or higher; and 57.4% were employed full time. At the conclusion of the study, all participants were satisfied with the progress of their Change Club and with the overall experience and Change Clubs met their self-identified action steps for community change. The intervention had a significant effect on finish time on the cardiorespiratory fitness test (p < 0.001) and systolic blood pressure (p < 0.001). Conclusions Study results suggest feasibility and evidence of preliminary effectiveness of using a civic engagement approach to address behavior change in a way that is appealing and acceptable to Black/African American women. Trial registrationNCT02173366
The U.S. South has experienced rapid Latinx growth; yet, little is known about how Latinx residents are civically integrating into new communities. This article explores whether, where, and why Latinx in Charlotte-Mecklenburg, North Carolina, are civically engaged. Participants in a Latino Civic Engagement Project conducted 382 surveys with fellow Latinx residents in a county with Latinx growth rates over 1,800% from 1990 to 2014. Among respondents, 58.5% had volunteered in the past year and 47.0% were members of a faith-based or charitable organization. Household income, educational attainment, and English proficiency were most strongly correlated with civic engagement ( r = .456, r = .453, and r = .464, respectively). The main reason for engagement was the betterment of the Latinx community. Main barriers were lack of information (37.1%), limited time (17.2%), disinterest (7.8%), and documentation status (4.3%). Findings can shape conversations about Latinx engagement in ways that include, but go beyond, voting and political representation.
This article describes the Latino Health Ambassadors Network (Voceros de Salud ) project created to support and mobilize Latino community leaders to address health inequalities in a rural Oregon county. Voceros de Salud is discussed as a model that other rural communities may implement towards strengthening Latino civic engagement for health.
Does the academic literature on U.S. immigration adequately capture the experiences of immigrants outside their traditional areas of concentration? This article reviews the three major fields of research in immigrant incorporation—economic, sociocultural, and political. It emphasizes the two most prominent conceptual frameworks in each: the human capital frame and the more recent sociological frame, which highlights “modes of incorporation” and “contexts of reception.” Although research in immigrants' political incorporation is less developed than its economic and sociological counterparts, I pay close attention to the ways in which structural and contextual factors shape participation. Immigrants' geographic dispersal complements this trend toward contextualism by providing greater variation in their places of destination; that variation can help advance the comparative research agenda. a
Civic participation | Healthy People 2020
  • Healthypeople
  • Gov Civic participation | Healthy People 2020. Accessed August 31, 2020.
Reported voting and registration by race, Hispanic origin, sex and age groups
  • Us Census
  • Bureau
US Census Bureau. Reported voting and registration by race, Hispanic origin, sex and age groups: November 1964 to 2018. tables/time-series/demo/voting-and-registration/votinghistorical-time-series.html. Accessed August 31, 2020.