Public health agencies turn to locals to extend reach into immigrant communities

When covid-19 vaccines became available, Colorado public health officials initially relied on mass vaccination events publicized through Facebook, email, and texts, and required Coloradans to book appointments online. But when that go-big strategy drove large disparities in who was getting vaccinated, public health departments in the Denver area decided to go small instead.

They provided "microgrants," small sums for one-time projects, to community organizations serving immigrants and minorities, and allowed those groups to determine how best to use the money.

Some used apps and social media, including WhatsApp, Nextdoor, and Facebook Live. Others chose to pound the pavement and knock on doors. Vaccine promotion events occurred at Saturday soccer games and at the Mile High Flea Market. Over time, the disparities in vaccine rates in and around Denver narrowed, although it's difficult to know how much to attribute to the community ambassador program, as the initiative has come to be known.

The microgrant approach could well be the future of public health messaging for diverse populations and a way to combat the erosion of trust that came with the pandemic's politicization of public health. By setting public health goals but letting trusted sources within communities deliver them, health departments are rebuilding their capacity to disseminate science-based messages and engage communities at a granular level.

"I do think that community engagement is a road map for improving public health emergency work in these communities," said Dr. Ned Colange, associate dean for public health practice at the Colorado School of Public Health.

The success of the vaccine outreach program, a collaboration between Denver-area public health departments and the nonprofit Colorado Health Institute, has led to a second round of grants to address the stigma against mental illness. And with the impending end of the covid public health emergency, which prevented states from dropping people from Medicaid coverage, officials plan to use a similar approach to encourage people to update their information so the state can determine who is still eligible for benefits.

The ambassador program was launched in 2020 as health officials prepared for the covid vaccine rollout, with a pilot campaign to encourage flu shots. Once covid vaccines became available, heat maps showing vaccination rates down to census tracts identified neighborhoods with low uptake. The partners could then reach out to community organizations with boots on the ground in those areas to tailor their outreach.

Many of the groups invited to apply had minimal staffing — sometimes a single person — and often limited English-language skills. That would make writing grant proposals difficult. Instead, organizations applied through 30-minute interviews with program leaders.

Each of the funded organizations was required to participate in biweekly calls with the Colorado Health Institute, which handled the grants, and public health departments. Larger community groups served as mentors for smaller ones.

On those calls, health officials provided the latest updates on covid and vaccines, while the community organizations relayed what they were hearing on the street.

"I would hear about the covid vaccine concerns from our ambassadors before I would ever hear them in the media, really, because they had that immediate connection to the community," said Nicole Weber, senior program manager at the Colorado Health Institute.

The immunization program operates with a budget of $300,000 a year, funding 17 community organizations, while the mental health program has a $465,000 budget, funding 15 groups. They are among the more than 40 organizations that have been funded with grants of up to $30,000 since the ambassador programs launched in 2020.

"It's allowing a real lovely deepening of trust between the community-based organizations and public health," said Wendy Nading, a nurse manager with the Arapahoe County Public Health Department.

Colorado Changemakers Collective was one of those funded groups. It was launched in 2017 by a small group of residents in the Montbello neighborhood of Denver to link the primarily Hispanic population there with rent or utility assistance programs and health services. Using promotoras (Spanish for "promoters") — health workers who are members of the target population and share many of the same social, cultural, and economic characteristics — the collective has built deep roots in the community. It expanded its work to the entire Denver region, and soon to Grand Junction and Colorado Springs.

Because promotoras live in the communities they serve, they can quickly identify barriers and suggest strategies to overcome them. The collective, for example, persuaded health officials to shift the schedule for mobile vaccine clinics from daytime hours during the week to Friday from 5 p.m. until midnight. The shift allowed residents working hourly jobs with no time off to get their shots after work and have the weekend to recover from side effects.

The collective communicates through Facebook and other social media, including WhatsApp, a messaging app used globally and popular among immigrants. Through the app, the collective provides information on services and resources.

The collective is also participating in the mental illness stigma ambassador program, hosting community circles, both in person and online, in which promotoras lead discussions on topics such as getting enough sleep or communicating with your teen.

Funding from the program allows the collective to hire a licensed therapist to hold one-on-one sessions with residents who need help and to work with the promotoras on their own mental health issues that may develop in their stressful jobs.

Carlos Herrera, a project manager with the collective, said the model helps overcome immigrants' mistrust of government agencies by partnering with organizations that know the specific needs of those communities.

"When community members are approached by either city officials or somebody that seems too professional, they’ll just turn away," Herrera said. "They’ll practically give you the Heisman pose: 'No, get away from me.'"

It helps migrant workers to hear from a therapist about her own experiences traveling from one country to another, and her culture shock when she arrived in the U.S.

"People feel like, 'OK, this is someone that went through the exact same thing as I did,'" Herrera said. "They feel much more willing to share."

Last year, during one of the collective's mental health circles, a woman who had joined the call anonymously revealed she was a victim of domestic violence. A promotora followed up with her and connected her with a therapist. The woman, who might never have sought help through traditional public health channels, has moved out of her home and is no longer in danger, Herrera said.

Lori Freeman, CEO of the National Association of County and City Health Officials, said community organizations can act as a natural extension of the work of short-staffed health departments serving vulnerable communities that may distrust government.

"The pandemic further heightened the importance of work with community-based organizations when governmental entities and their associated messages became hyperpoliticized, and less about health messaging and more about impact of health measures to individual rights and freedoms," she said.

The covid vaccine program has now expanded to include all routine adult vaccinations and is funded through April. The program to address the stigma against mental illness is funded through the end of the year. The partners are now considering programs to promote routine vaccinations for children, as well.

The goal, Weber said, is to build capacity for community leaders to make and implement decisions.

"The people who know how to make sure that messages and interventions are culturally relevant to the populations we serve," Weber said, "are those who work all the time in the community."