Barriers and Facilitators to Incorporating Community-Led, Health Equity Approaches in Public Health Emergency (PHE) Planning and Response and what the Federal Government can do to Address Them
Open Access DepositedBackground: In the United States, vulnerable and at-risk populations are routinely disproportionately impacted by public health emergencies (PHEs), including infectious disease outbreaks. Although there are several underlying reasons for the disparities experienced by these communities, a lack of prioritization and engagement of these vulnerable populations by public health officials is a significant contributor (Holden, 2022; Abrams, 2020; Hardeman, 2021; Gilmore, 2020; Vaughn, 2009). Lack of engagement with these communities leads to public health control measures that are poorly understood or supported by communities. This significantly influences the public health official’s ability to control the emergency. Communities are experts in identifying and implementing solutions that address their specific needs. Therefore, community-led solutions are essential to successful PHE control strategies that are acceptable to the most vulnerable populations and reduce health disparities. Although there are examples of community engagement and prioritization of vulnerable populations in prior PHEs, the level of engagement is inconsistent, and communities across America are not routinely engaged. Federal agencies provide funding, technical expertise, and lifesaving resources needed in a PHE. These resources and the agreements associated with them are opportunities the federal government has the potential to leverage to encourage widespread implementation of community-led, equity-focused solutions. Objectives:The overarching goal of this study is to identify specific actions the federal government can take to address barriers at the federal, state, and local levels to implement community-led approaches that promote health equity in PHE planning and response. The three aims of this study are as follows: 1.) Identify community-led health equity initiatives that have been leveraged during PHE preparedness and responses to infectious diseases 2.) Identify facilitators and barriers to incorporating community-led, health equity initiatives in PHE preparedness and response activities 3.) Identify specific actions the federal government can take to facilitate incorporating community-led, health equity approaches more broadly in PHE preparedness and response activities at the federal, state, and local levels. Including recommendations that facilitate incorporating these approaches at the state and local level is essential since PHE planning and response happens through state and local public health agencies, even though federal agencies provide significant funding and resources. Design: This study used a qualitative design, relying on in-depth interviews to identify facilitators and barriers to implementing community-centered approaches to address health equity and explore recommendations made by federal, state, and local public health leaders, external experts, and community representatives on how to prioritize these approaches to prepare for and respond to future emergencies. Methods:Semi-structured interviews were the primary qualitative data collection approach used in this study. A semi-structured interview guide was developed that focused interviews on the topics relevant to the research questions while allowing space for exploring information revealed during the interviews. Semi-structured individual interviews were conducted via Zoom and lasted approximately 60 minutes. Thirty individuals were interviewed in this study, with a minimum of five federal, five state, and five local government public health participants and five community representatives. Interviews were transcribed verbatim, an initial codebook was developed, and transcripts were analyzed using the codebook and Dedoose software. Thematic analysis was used to identify salient themes, and exemplary quotes were selected. Findings were compared to existing literature, and recommendations were developed based on the interview and literature information. Results:This dissertation explored diverse perspectives on the role of community-led solutions that prioritize vulnerable populations in PHE planning and response to infectious disease outbreaks. This research identified examples of successful community-led approaches, barriers and facilitators to implementing these approaches during PHEs, and specific actions that could be taken to encourage the widespread incorporation of these approaches. This study documented how community-led health equity initiatives were implemented during previous PHE preparedness and response, including H1N1, Ebola, COVID-19, and mpox. This included initiatives in which community members played an active role in developing national and state guidance, developing community needs assessments, educating community members, and making medical countermeasures (MCMs) available to the community. Study participants identified several facilitators for implementing community-led health equity initiatives during a PHE response, including supportive leadership, trust, existing relationships, funding, operating structure, and data. However, they also identified several barriers to incorporating these initiatives during a PHE, including a lack of leadership support for prioritizing health equity and the community's role in addressing health disparities. Lack of understanding, accountability, communication, and established relationships were also identified as barriers to implementing these approaches. Study participants recommended several actions that could be implemented to facilitate the incorporation of community-led initiatives more broadly in PHE preparedness and response activities. For example, they suggested that the nation’s public health approach shift to focus on more health equity and community-led solutions. Furthermore, study participants acknowledged the need to strengthen communication and coordination across stakeholders, ensure actionable data is available for future PHEs, and invest in community-based organizations (CBOs) and community-led activities. Conclusion:Community-led health equity initiatives were implemented in some, but not all, situations during previous PHE preparedness and response activities. Community-led health equity initiatives increased access to resources for at-risk, underserved populations needed in a PHE response. They also helped establish and strengthen relationships with key opinion leaders in the community, increased the trust of public health entities in communities, and better addressed barriers to at-risk communities to seek care. Several facilitators and barriers identified in this study impacted the ability of federal, state, territorial, local, and tribal (STLT) public health organizations to implement community-led initiatives during PHEs. Actions at the federal level can facilitate the incorporation of community-led initiatives. Furthermore, by identifying these actions, it may be possible to identify opportunities to improve the implementation of these initiatives in preparing for or responding to future PHEs.
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