Capstone Project Change Proposal Presentation for Faculty Review and Feedback

PREVENTING CHRONIC DISEASE
P U B L I C H E A L T H R E S E A R C H , P R A C T I C E , A N D P O L I C Y
V o l u m e 1 7 , E 8 3 A U G U S T 2 0 2 0

COMMENTARY

Community Engagement of African
Americans in the Era of COVID-19:

Considerations, Challenges, Implications, and
Recommendations for Public Health

Tabia Henry Akintobi, PhD, MPH1; Theresa Jacobs, MD2,3; Darrell Sabbs3,4; Kisha Holden, PhD, MSCR5;
Ronald Braithwaite, PhD1; L. Neicey Johnson, JD, RN, BSN3,6; Daniel Dawes, JD5; LaShawn Hoffman7,8

Accessible Version: www.cdc.gov/pcd/issues/2020/20_0255.htm

Suggested citation for this article: Henry Akintobi T, Jacobs T,
S a b b s D , H o l d e n K , B r a i t h w a i t e R , J o h n s o n L N , e t a l .
Community Engagement of African Americans in the Era of
COVID-19: Considerations, Challenges, Implications, and
Recommendations for Public Health. Prev Chronic Dis 2020;
17:200255. DOI: https://doi.org/10.5888/pcd17.200255.

PEER REVIEWED

Summary

What is already known on this topic?

African Americans are more likely to contract coronavirus disease 2019
(COVID-19), be hospitalized for it, and die of the disease when compared
with other racial/ethnic groups. Psychosocial, sociocultural, and environ-
mental vulnerabilities, compounded by preexisting health conditions, ex-
acerbate this health disparity.

What is added by this report?

This report adds to an understanding of the interconnected historical,
policy, clinical, and community factors associated with pandemic risk,
which underpin community-based participatory research approaches to ad-
vance the art and science of community engagement among African Amer-
icans in the COVID-19 era.

What are the implications for public health practice?

When considered together, the factors detailed in this commentary create
opportunities for new approaches to intentionally engage socially vulner-
able African Americans. The proposed response strategies will proactively
prepare public health leaders for the next pandemic and advance com-
munity leadership toward health equity.

Abstract
African Americans, compared with all other racial/ethnic groups,
are more likely to contract coronavirus disease 2019 (COVID-19),
be hospitalized for it, and die of the disease. Psychosocial, so-

ciocultural, and environmental vulnerabilities, compounded by
preexisting health conditions, exacerbate this health disparity. In-
terconnected historical, policy, clinical, and community factors ex-
plain and underpin community-based participatory research ap-
proaches to advance the art and science of community engage-
ment among African Americans in the COVID-19 era. In this
commentary, we detail the pandemic response strategies of the
Morehouse School of Medicine Prevention Research Center. We
discuss the implications of these complex factors and propose re-
commendations for addressing them that, adopted together, will
result in community and data-informed mitigation strategies.
These approaches will proactively prepare for the next pandemic
and advance community leadership toward health equity.

Introduction
Racial/ethnic minority populations have historically borne a dis-
proportionate burden of illness, hospitalization, and death during
public health emergencies, including the 2009 H1N1 influenza
pandemic and the Zika virus epidemic (1–4). This disproportion-
ate burden is due to a higher level of social vulnerability — “indi-
vidual and community characteristics that affect capacities to anti-
cipate, confront, repair, and recover from the effects of a disaster”
— among racial/ethnic minority populations than among non-
Hispanic White populations (5). These characteristics include, but
are not limited to, low socioeconomic status and power, predispos-
ing racial/ethnic minority populations in general and African
Americans in particular to less-than-optimal living conditions.
Some racial/ethnic minority populations are more likely than non-
Hispanic White populations to live in densely populated areas,
overcrowded housing, and/or multigenerational homes; lack ad-
equate plumbing and access to clean water; and/or have jobs that
do not offer paid leave or the opportunity to work from home
(6,7). These factors contribute to a person’s ability to comply with

The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health
and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions.

This publication is in the public domain and is therefore without copyright. All text from this work may be reprinted freely. Use of these materials should be properly cited.

www.cdc.gov/pcd/issues/2020/20_0255.htm • Centers for Disease Control and Prevention 1

the mitigation mandates of the coronavirus disease 2019 (COVID-
19) pandemic established to reduce risk for infection, such as
physical distancing and sheltering in place (8).

The COVID-19 pandemic presents new challenges for public
health evaluators, policy makers, and practitioners, yet it mirrors
historical trends in health disparities and poor health outcomes
among African Americans. African Americans are more likely to
contract, be hospitalized, and die of COVID-19–related complica-
tions (9–12). Social vulnerability is often compounded by preex-
isting health conditions, exacerbated during times of crisis
(13–17).

Public health leaders are now at a critical juncture to advance
health equity among vulnerable African Americans. To advance
this health equity, we must first have a comprehensive understand-
ing of the factors that create health disparities and the factors that
can contribute to an effective, multilevel response. With this un-
derstanding, we can then deploy effective mitigation strategies
based on a community-based participatory research framework
that fosters and sustains community leadership in the assessment
and implementation of culturally appropriate and evidence-based
interventions that enhance translation of research findings for
community and policy change (18,19). The objective of this com-
mentary is to 1) detail the interconnected historical, policy, clinic-
al, community, and research challenges and considerations central
to comprehensively advancing the art and science of community
engagement among African Americans in the COVID-19 era; 2)
describe The Morehouse School of Medicine Prevention Research
Center (MSM PRC) pandemic response strategies, driven by
community-based participatory research (CBPR); and 3) discuss
community-centered implications and next steps for public health
action.

Challenges and Considerations
Historical context

Racial/ethnic health disparities have always existed in the United
States. Differential health outcomes between African Americans
and non-Hispanic White Americans have been part of the Americ-
an landscape for more than 400 years (20). Many measures of
health status have been used to assess differences among racial/
ethnic groups; more recently, health researchers have advanced
concepts and constructs of health equity and social determinants of
health (21). Reaching back to the mid-20th century, the US gov-
ernment documented that African Americans were far more likely
than non-Hispanic White Americans to have a wide range of po-
tentially fatal illnesses, including noncommunicable diseases such
as type 2 diabetes, asthma, end-stage renal disease, and cardiovas-
cular disease (21). In 1985, the US Department of Health and Hu-

man Services published the landmark Report of the Secretary’s
Task Force on Black and Minority Health, better known as the
Heckler report (21). The report documented an annual excess
60,000 deaths among African American and other racial/ethnic
minority populations. These underlying determinants can only res-
ult in disproportionately adverse health outcomes for racial/ethnic
minority populations during the COVID-19 pandemic.

The COVID-19 pandemic is intensified by the long-standing in-
come inequality between non-Hispanic White people and racial/
ethnic minority populations. Economists use the Gini coefficient
to measure income inequality. Values for this measure range from
0 to 1, with higher values representing greater income inequality.
From 1990 to 2018, the Gini coefficient in the United States rose
from 0.43 to 0.49 — an increase in income inequality. When in-
come disparities exist along with other disparities (eg, health in-
surance, employment, education, social justice, access to quality
health care), public health pandemics marginalize racial/ethnic
minority groups, and this marginalization requires a strong and
strategic response (22).

Policy landscape

Racial/ethnic minority populations are disproportionately affected
by COVID-19 (23), as they are by many diseases. In the United
States, African Americans, Hispanics/Latinos, Native Americans,
Native Hawaiians, and Pacific Islanders are more likely than other
racial/ethnic groups to die of COVID-19 (24). The pandemic has
not affected all populations equally for several reasons, including
social, behavioral, and environmental determinants of health. In
addition, economic and social policies have not benefitted all pop-
ulations equally. Obesity, asthma, depression, diabetes, heart dis-
ease, cancer, HIV/AIDS, and many other disorders that put vulner-
able populations at greater risk of dying of COVID-19 can often
be linked to a policy determinant (25). Air pollution; climate
change; toxic waste sites; unclean water; lack of fresh fruits and
vegetables; unsafe, unsecure, and unstable housing; poor-quality
education; inaccessible transportation; lack of parks and other re-
creational areas; and other factors play a large role in overall
health and well-being (26). These factors increase a person’s stress
and limit opportunities for optimal health (27). Too often, public
health researchers and practitioners stop at the social determinants
of inequities. These social determinants do, indeed, play an out-
sized role in these human-made inequities, but underlying each
one is a policy determinant that should be addressed to improve
health equity.

Consider, for example, the problem of asthma among many racial/
ethnic minority populations. One community, in East Harlem, one
of Manhattan’s poorest neighborhoods, found that a bus depot
caused the high rates of asthma among children who lived near it

PREVENTING CHRONIC DISEASE VOLUME 17, E83
PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY AUGUST 2020

The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services,
the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions.

2 Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2020/20_0255.htm

(28). Six of 7 bus depots in Manhattan are located in East Harlem,
and East Harlem has the highest rate of asthma hospitalizations in
the country (29–31). In another community, the exhaust and dust
from the vehicles traveling a major highway that cut through the
middle of the community was found to contribute to the high rates
of asthma among residents who lived near it (32). In both of these
examples, an underlying policy determined the placement of the
bus depots and the highway, which led to the eventual health in-
equities.

Examples of how legislative and policy change can immediately
affect the social determinants of health are demonstrated in gov-
ernment and public responses during the first 3 months of the
COVID-19 pandemic in the United States. Federal, state, and loc-
al policies were implemented to stimulate local economies and in-
fuse communities with free food and direct revenue, including in-
creases in SNAP (Supplemental Nutrition Assistance Program) be-
nefits and expanded unemployment benefits. These initiatives
have helped communities and individuals during the crisis. Des-
pite these programs, however, some marginalized African Americ-
an communities have not benefitted. As the nation adjusts to the
“new normal,” it is imperative that the social, economic, and
health gaps in these communities also conform to a “new normal”
that is driven by new or expanded and sustained policies.

Clinical mechanisms, chronic conditions, and
increased risk of COVID-19

African Americans are twice as likely as non-Hispanic White
Americans to die of heart disease and 50% more likely to have hy-
pertension and/or diabetes (33,34). This elevated risk increases the
likelihood of other complications and death from COVID-19
(35,36). Let us consider, for example, people living with diabetes.
Their immune system is depressed overall, because their blood
glucose is not well controlled (hyperglycemia) (37). It is hypothes-
ized that hyperglycemia causes an increase in the number of a par-
ticular receptor in the lungs, pancreas, liver, and kidneys; this in-
crease impairs the function of white blood cells, which are de-
signed to fight off infections (37). This impairment predisposes
the person living with diabetes to an increased risk of bacterial and
viral infections. When severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2) enters the lungs by way of this par-
ticular receptor, it overwhelms the alveoli (air sacs) in the lungs
and disables the exchange of oxygen and carbon dioxide (38). As
a result, some people with diabetes may need supplemental oxy-
gen, intubation, and/or admission to an intensive care unit (37).
Hyperglycemia in combination with a disease such as COVID-19
makes recovery difficult (37). People with diabetes who are in
good mental health, know the names and dosages of their medica-
tions, and know their blood pressure, blood glucose, and other
laboratory values, such as hemoglobin A1c, tend to have better

control of their disease and have lower levels of illness and death
(16,37). Emphasizing the importance of good blood glucose con-
trol to prevent diabetes complications and associated COVID-19
risk is more important now than ever (36–38). Mental health plays
a major role in a person’s ability to maintain good physical health
and optimally manage their chronic conditions, and mental ill-
nesses may affect the ability to participate in health-promoting be-
haviors (39).

Mental and behavioral health

The constellation of stressors triggered by the COVID-19 pandem-
ic undermines the nation’s mental health (40–42). Various disrup-
tions in daily life, coupled with the threat of contracting the deadly
virus, is leading some people to experience anxiety and depres-
sion, sometimes to the extreme. Reports of family violence and
use of suicide prevention hotlines have increased (43,44). Physic-
al distancing, shelter-in-place orders, business and school closures,
and widespread unemployment have radically changed ways of
life and contributed to a sense of hopelessness, isolation, loneli-
ness, helplessness, and loss (45,46). Pandemic-related factors, in-
cluding quarantine, have led to posttraumatic stress disorder, con-
fusion, and anger (47). One study indicated that a constant con-
sumption of media reports had detrimental psychological effects
on some people (48). If interrelated mental, behavioral, and emo-
tional issues are not adequately addressed, disorders among racial/
ethnic minority populations and other vulnerable populations (eg,
the medically underserved, homeless, and disabled; inmates in the
criminal justice system) will surge and exacerbate disparities (49).

Interrelated COVID-19–related stressors include childcare and
safety, elder care, food insecurity, and interpersonal relationships
(50). These stressors may trigger aspects of unresolved trauma.
Poor coping mechanisms (eg, use of illicit drugs, excessive alco-
hol consumption, overeating, inadequate sleep) may develop or
worsen. In addition to facing chronic stressors, communities of ra-
cial/ethnic minority populations often deal with the stigma associ-
ated with seeking mental and behavioral health care. A Surgeon
General’s report, Mental Health: Culture, Race, and Ethnicity,
concluded that racial/ethnic minority populations, compared with
the non-Hispanic White population, have less access to mental
health care, are less likely to receive treatment, and when treated,
often receive poorer quality of care (51). As a result, racial/ethnic
minority populations often have a greater burden of behavioral
disorder–related disability (51). Addressing the multifaceted men-
tal and behavioral health needs of racial/ethnic minority popula-
tions in the United States is a complex issue that warrants atten-
tion from clinicians, researchers, scientists, public health profes-
sionals, and policy makers. It is imperative to recognize the signi-

PREVENTING CHRONIC DISEASE VOLUME 17, E83
PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY AUGUST 2020

The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services,
the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions.

www.cdc.gov/pcd/issues/2020/20_0255.htm • Centers for Disease Control and Prevention 3

ficant role of community leaders in exploring solutions to COVID-
19–related mental and behavioral health problems among racial/
ethnic minority communities. Their lived experiences are central
to the co-creation of pandemic response strategies for these popu-
lations.

Perspectives of community leaders

The realities of research, evaluation, and clinically focused com-
munity engagement after the COVID-19 pandemic may change
for the foreseeable future. Efforts to initiate and sustain culturally
competent engagement of racial/ethnic minority groups previ-
ously relied on face-to-face interactions in homes, churches, and
other community settings. Social or physical distancing has nearly
stopped communities and their collaborators from real-time gath-
ering. These changes challenge the human need for connection and
in-person exchange. Although the adjustment has been difficult,
the pandemic has resulted in new modes of engagement. Webinar
and digital technology are now accessible for most people at low
or no cost. Many community residents have newfound capacities
to use technology for social and professional interactions as part of
daily life.

Current health communication and messaging require community-
informed improvements. The use of terms like sheltering in place,
social distancing, and flattening the curve do not naturally reson-
ate with many people. For some, these terms foster anxiety and
distrust of systems perceived to separate communities rather than
promote COVID-19 mitigation strategies. Community leaders, as
well as business and faith leaders, have found themselves in a
space of terminology and descriptions that are understood mostly
by public health practitioners. Therefore, health literacy and the
interpretation of current health conditions are vital.

The pandemic has intensified the economic strains among low-
income and moderate-income people and families (52). Low-wage
workers, many on the frontlines of the pandemic since it began,
have had little to no increase in income (53). African American
families who struggled to make ends meet before COVID-19 are
now facing dire economic circumstances in making the best de-
cisions for their families. Stressors include, but are not limited to,
deciding how to pay rent or a mortgage, paying for food, assisting
children with virtual learning, and protecting themselves with min-
imal or no health care benefits. The mental and behavioral health
implications of these problems, along with the economic and prac-
tical challenges, have made a fragile ecosystem even more un-
stable. Low-wage workers in hospitality, food service, and retail
industries cannot work from home. Workers who depend on
employer-provided health insurance now have the additional bur-
den of how to maintain health insurance coverage (54). Ulti-

mately, lack of adequate access to health care, along with the com-
plex realities of the COVID-19 pandemic, will increase health dis-
parities for socially vulnerable African American employees and
their families.

Local examples of COVID-19 response strategies
driven by community-based participatory research

The MSM PRC relies on a deeply rooted, community partnership
model that responds to the health priorities of vulnerable African
American residents before, during, and after public health emer-
gencies such as the COVID-19 pandemic. For more than 20 years,
the MSM PRC has applied dynamic CBPR approaches that focus
on prevention, establish partnerships between communities and re-
search entities, and are culturally tailored (6,55–57).

The MSM PRC capitalizes on community wisdom through a com-
munity coalition board (CCB) that has governed the center since
its inception. The CCB is composed of 3 types of members: neigh-
borhood residents (always in the majority), academic institutions,
and social service providers (58). Neighborhood residents hold the
preponderance of power, and all leadership seats and are at the
forefront of all implemented approaches. Neighborhood resident
members are intentionally recruited from census tracts with a high
incidence and prevalence of chronic and infectious diseases. The
communities served by the MSM PRC are majority (87%) Afric-
an American, have an average household income of $23,616, and
rank lowest among other local communities in other socioeconom-
ic conditions and community neighborhood health factors (55).

The MSM PRC has strategically partnered with the CCB and the
community to facilitate health research and related interventions
based on a comprehensive understanding of historical, political,
clinical, and community considerations. The community gov-
ernance model was developed to address CBPR challenges that
exist when academics are not guided by neighborhood leaders in
understanding a community’s ecology, when community mem-
bers do not lead discussions about their health priorities, and when
academics and neighborhood leaders do not work together as a
single body with established rules to guide roles and operations
(59,60).

The MSM PRC conducts a recurring (every 4 years) community
health needs and assets assessment (CHNA2) process through the
CCB, empowering community members to take on roles as cit-
izen scientists who develop locally relevant research questions and
identify priority health strategies (60). The recently completed
CHNA2 (February 2018) was co-led by neighborhood residents to
advance a community health agenda. Survey development, data
analyses, and response strategies are reviewed, monitored, and
evaluated by the CCB and its Data Monitoring and Evaluation

PREVENTING CHRONIC DISEASE VOLUME 17, E83
PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY AUGUST 2020

The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services,
the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions.

4 Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2020/20_0255.htm

Committee (55). This 7-member committee, established in 2011,
is designed to extend the CBPR engagement of CCB members in
the work of the MSM PRC. It exists through academic–com-
munity co-leadership (a CCB neighborhood resident member and
the MSM PRC assistant director of evaluation) of a group of CCB
members tasked with leading assessments. For CHNA2, members
met bimonthly (every other month, when the CCB did not meet) to
discuss and inform evaluation and data collection activities and
prepare for reporting of evaluation findings and interim results to
the broader CCB to determine corresponding respond strategies.
CHNA2 primary data included surveys administered to 607 com-
munity residents. The most frequently cited community health
concerns were diabetes, nutrition, high blood pressure, over-
weight/obesity, and mental health. County-level, top-ranking
causes of illness and death, including cardiovascular disease, dia-
betes, and mental health disorders, align with these community
perspectives (61).

CHNA2 is relevant, despite being administered before the out-
break of COVID-19. The chronic conditions and health problems
identified are those exacerbated by COVID-19 (diabetes, cardi-
ovascular disease, and mental health), thereby making their focus
even more relevant to the community.

The mental and behavioral health components of CHNA2 were
amplified to address the stress and anxiety caused by the pandem-
ic. First, during National Mental Health Awareness Month (May
2020), the MSM PRC convened a virtual forum, Our Mental and
Behavioral Health Matters. It was strategically designed to ad-
dress the culturally bound mental health stigma in racial/ethnic
minority communities that is due, in part, to the schism between
religion and therapy. The forum also addressed challenges related
to social isolation. Concerns centered on how to navigate a virtual
mental health checkup and support for parents seeking to help
their children process the realities of the pandemic and minimize
childhood trauma. Featuring psychologists, researchers, and
community- and faith-based pioneers, the forum engaged more
than 230 local and national participants. Second, a CCB member
representing Fulton County’s Department of Behavioral Health
and Developmental Disabilities helped the MSM PRC to develop
and disseminate an infographic on mental and behavioral health
services for insured and uninsured residents. Third, the MSM PRC
will offer annual Mental Health First Aid (62) trainings to com-
munity residents and professionals over the next 4 years.

The MSM PRC leads the Georgia Clinical and Translational Sci-
ence Alliance’s Community Engagement Program, which is de-
signed to advance community-engaged clinical and translational
research (63,64). The Program is led by a community steering
board adapted from the CCB model and includes co-leaders (fac-
ulty and staff, including a community health worker) from Emory

University, the Georgia Institute of Technology, and the Uni-
versity of Georgia. The program conducted a webinar, Community
Engagement in the Era of COVID — Opportunities, Challenges
and Lessons Being Learned, in May 2020. The webinar addressed
the challenges and opportunities associated with initiating or sus-
taining community-engaged research during physical-distancing
and shelter-in-place mandates. Clinicians, scientists, and com-
munity leaders from Atlanta, Athens, and Albany, Georgia, dis-
cussed uniquely nuanced issues for urban and rural community en-
gagement and the basic need for social connectedness through vir-
tual navigation of community engagement strategies (eg, via
Zoom) and newly expanded access to telehealth medical visits
(65). The webinar emphasized the importance of being a credible
source of COVID-19 information and linkage across social and
economic services, given heightened community anxiety and
preexisting mistrust of medical research.

The MSM PRC is a central collaborator in a national initiative led
by the National Center for Primary Care at Morehouse School of
Medicine and the Satcher Health Leadership Institute, also at
Morehouse School of Medicine. The National COVID-19 Resili-
ency Network is designed to mitigate COVID-19 in racial/ethnic
minority, rural, and socially vulnerable communities. The initiat-
ive will work with community organizations to deliver education
and information on resources to help fight the pandemic. The in-
formation network will strengthen efforts to link communities to
COVID-19 testing, health care services, and social services
through the institution’s leadership in policy, community engage-
ment, and primary care. The MSM PRC’s CCB model will be
scaled to collaborate with community organizations in highly af-
fected geographic areas to assess and inventory community assets
for COVID-19 testing, vaccination, and other health care and so-
cial services through a national community coalition board. The
MSM PRC CHNA2 model will also be scaled to inform mitiga-
tion approaches implemented by community-based organizations
through establishment of a centralized inventory of culturally ap-
propriate COVID-19 response strategies, by geography and popu-
lation vulnerability. Approaches will engage community health
workers, who are mission-critical stakeholders, nationally galvan-
ized, and locally deployed.

These MSM PRC activities are founded on long-standing,
community-partnered, and informed relationships in response to
preexisting health priorities that are simply heightened by the
COVID-19 pandemic. Ideally, this CBPR framework is estab-
lished before a public health crisis. This framework and the prac-
tice of identifying community needs and mobilizing strengths are
now poised, adapted, and scaled up in response to the COVID-19
pandemic. The continued evolution of the pandemic means that

PREVENTING CHRONIC DISEASE VOLUME 17, E83
PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY AUGUST 2020

The opinions expressed by authors contributing to this journal do not necessarily reflect …

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