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Healthcare during COVID-19 in Canada: Need for Strengthening Providers’ Capacity for Best Practices in African, Caribbean and Black Community Service Provision

Josephine Etowa, Getachew Abrha, Egbe Etowa, Bishwajit Ghose*

Department of Health Sciences, School of Nursing, University of Ottawa, Ottawa, Ontario, Canada

Abstract: The COVID-19 pandemic has been a threat of unprecedented scale for societies, business, and healthcare systems across the world. In Canada and the United States, the immigrants including the African, Caribbean and Black (ACB) community and those of Hispanic origin are facing the brunt of the pandemic and account for a disproportionately higher percentage of hospital admission and mortality from the virus. Needless to mention, these ACB community are also the most disadvantaged socioeconomic demographic strata in North America who share a not only a heightened risk of infection, but also the adverse health, social, and financial consequences that arise from the lockdown and similar adjustment policies. In Canada, the ACB community share a long-standing history of social marginalization and have shown to represent the population with highest prevalence of HIV and other infectious diseases, to which COVID-19 seems to be no exception. The situation is extraordinarily challenging and requires bold and comprehensive policy measure to remedy the short-term outcomes and building resilience for the caregiving of ACB population in the long-term. This can be achieved by conducting expert assessments regarding the current knowledge gaps and formulating evidence-based strategies and best-practice policies. The current paper presents the views of experts on social indicators, health disparity and infectious diseases in an effort to shed light on the current knowledge gaps in the COVID-care for the ACB population, and thereby propose some policies to address these gaps.

Keywords: African, Caribbean and Black community, COVID-19, health disparity, healthcare systems

Received January 13, 2021; Revised January 29, 2021; Accepted February 05, 2021

Citation: Josephine Etowa, Getachew Abrha, Egbe Etowa, Bishwajit Ghose, Healthcare during COVID-19 in Canada: Need for Strengthening Providers’ Capacity for Best Practices in African, Caribbean and Black Community Service Provision. American Journal of Public Health Research, 9 (2). 52-56. January 2021. doi:10.12691/ajphr-9-2-2

1. Background

African, Caribbean and Black (ACB) communities represent some of the most vulnerable populations in Canada in terms of their susceptibility to health risks, receipt of adequate care and chance of recovery. [5,6,7,8,9] For instance, ACB communities account for a quarter of the people living with HIV (PLHIV) in Canada although they constitute merely 5% of the population. [7] No race-based data is currently being collected on COVID-19 in Canada but the Black population is overrepresented among hospitalized patients in the US and mortality rates among Black persons (92.3 deaths per 100,000 population) are substantially higher than those among white (45.2) or Asian (34.5) persons in NYC. Similar statistics have emerged in other US cities and states. [1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19]

Social determinants, including structural inequalities and discrimination, are known to account for the disproportionate health risks and differential health outcomes experienced in ACB populations. [8,9,10,11,12] In the case of COVID-19, excess cases and deaths have been attributed to disproportionately high rates of co-morbid conditions (e.g., diabetes, hypertension) in these communities, as well as structural factors related to income, employment, food insecurity, and the built environment which necessitate, for example, risky working conditions outside the home and using public transportation. [13,14,15,16,17,18,19] Moreover, the same population is overrepresented in jails and prisons where social distancing is impossible. [15] In Canada, data is limited but we know from national surveys that Black Canadians exceed 50% on economic vulnerability arising from the COVID-19 crisis; 61% have seen a decrease in their income, 50% have difficulty meeting their financial obligations and 47% have are unable to pay their mortgage or rent on time. [20] The increased burden of COVID-19 morbidity and mortality among ACB populations translates into greater challenges for healthcare systems and for governments through loss of social capital, productive labour force, and erosion of cultural equity. [21,22,23]

Evidence from previous public health disasters to show that one size does not fit all in terms of the inadequacy of traditional risk communication systems for vulnerable populations such as ACB community. [24,25] Ability to understand and respond appropriately to risk information is influenced by underlying socio-ecological factors such as poverty, low health literacy, socio-cultural issues and lack of political voice. [26,27] Critical health literacy is becoming a cornerstone in these days of COVID-19 where there is information excess and high expectations to integrate this sea of information into personal behavioural actions to promote health. [28] It is also well-documented that ACB communities experience multiple and intersecting barriers to accessing appropriate and responsive health services. These include, institutional discrimination; poor representation in healthcare leadership, researchers and decision-makers; lack of awareness of available services; lack of culturally appropriate services in relevant languages, and lack of culturally competent health professionals. [29,30]

In response, numerous scholars have identified the need to build capacity, and reduce stigma and paternalism among health providers working with ACB communities. [29,30,31] Health protection relies not only on a well-functioning health system with universal coverage, but also on social inclusion, justice, and solidarity. In the absence of these factors, inequalities are magnified and scapegoating persists, with discrimination remaining long after. [14] There is also widespread acknowledgement that ACB communities and scholars need to be involved in all aspects of prevention, treatment and outreach. [15,26,32,33] As the COVID-19 pandemic continues unabated, disproportionately affecting the lives and livelihoods of ACB communities, there is an urgent need for research and action to mitigate their health risks and strengthen the capacity of healthcare systems. [34]

The ongoing COVID-19 pandemic has emerged as an unprecedented challenge for public and private life, and for healthcare systems across the world. African, Caribbean and Black communities (ACB) represent some of the most vulnerable populations in terms of their susceptibility to health hazards, receiving adequate care and chance of recovery. [5,6,7,8,9] Increased burden of COVID-19 morbidity and mortality among marginalized populations translates to greater challenges for healthcare systems and for governments through loss of social capital, productive labour force, and erosion of cultural equity. [21,22,23] As the pandemic continues unabated and disproportionately affecting the lives and livelihoods of ACB communities, there is an urgent need for action to mitigate their health risks and strengthen the capacity of healthcare systems. [29] Actions towards addressing health inequalities will not only help tackle the pandemic, but also develop better resilience and healthcare capacity building during the post-pandemic era.

Currently, there is a critical need to improve the health system’s response during and after the COVID-19 pandemic by developing evidence-based models to inform policy and collaborative best practices to mitigate its spread and related health consequences in vulnerable communities. The Coordinated Global Research Roadmap35 also recognizes the severe strain placed by COVID-19 on clinical services, including the provision of chronic care services, and the need to focus attention on the current and impending health needs of vulnerable populations. The wide-spread impact of COVID-19 demands that previously considered local concerns are now global concerns. In Canada, provincial collaborations should attempt to bring different research perspectives to the issue of COVID-19 and health service provision from the perspective of ACB people. The underlying objective will be to promote and strengthen knowledge exchange and links to providers, knowledge users and researchers with the potential for scale-up, facilitate exposure to new ideas and approaches and provide opportunities for redesigning and identifying promising models for post-pandemic care informed by critical and diverse perspectives. While there are no quick fixes, sustained gains in providers’ COVID-19-related health equity capacity will be crucial for addressing critical post-pandemic health priorities.

2. Current Knowledge Gaps

Information on how factors such as socioeconomic vulnerability, comorbidity, critical health literacy, and discrimination affect healthcare access and outcomes in ACB communities; 2) Information on the types of knowledge and training needed by frontline health workers (and administrators) in the context of service provision to ACB communities; and 3) Information to inform the development of strategies to ensure health equity and mitigate the impact of COVID-19 in ACB communities. Actions need to be taken across a broad range of levels and sectors to facilitate addressing health inequalities. This will not only help tackle the pandemic, but also develop better resilience and healthcare capacity building during the post-pandemic era. We propose the following socioecological model to achieve this:

3. What Interventions should be Taken

1) Engage ACB communities and health provider stakeholders in research and decision-making processes.

2) Examine the contextual vulnerability and challenges experienced by ACB communities.

3) Identify the adequacy and non-intended consequences of current health care practices on ACB communities.

4) Increase individual, community and organizational capacity and leadership and generate strategies to address COVID-19 related-health outcomes.

5) Share new knowledge and support its translation into policy and practice models to mitigate the impact of COVID-19 on ACB communities.

Figure 1. Socioecological Model (SEM) showing the different levels of action to improve COVID-19 related care for racialized communities.

Potential impacts of these interventions: Both short-term and long-term outcomes and impacts should be targeted. The intended short-term outcome will be to increased knowledge, confidence, and skills among health providers working with ACB clients to address the risk of COVID and/or other co-morbid conditions. Long-term outcomes will include a demonstrated improvement in integrating contextual and health-related information in practice, positive effect of training on agencies, and improved collaboration with ACB health and community-based agencies. The expected impacts will include experiences of several target groups at multiple levels of action: strengthening multisectoral collaborative partnerships in COVID-19 responses to ACB communities; Identifying best evidence-based models and interventions to strengthen health systems’ capacity to care for vulnerable populations such as the ACB community; Improving critical health literacy among ACB people and their response to COVID-19; and, Generating new knowledge to reduce COVID-19-related health inequities in ACB communities.

The wide-spread impact of COVID-19 demands that previously considered local concerns are now global concerns. Provincial collaborations, such as this one, bring different research perspectives to the issue of COVID-19 and health service provision from the perspective of ACB people in Canada. New research should aim to promote and strengthen knowledge exchange and links to providers, knowledge users and researchers in Canada with the potential for scale-up, facilitate exposure to new ideas and approaches and provide opportunities for redesigning and identifying promising models for post-pandemic care informed by critical and diverse perspectives. While there are no quick fixes, sustained gains in providers’ COVID-19-related health equity capacity such as the one that would be provided by health researchers will help harness knowledge providers who can address critical post-pandemic health priorities.

4. Policy Recommendation

Based in the aforementioned discussion, special policy attention is warranted in the following areas: 1) Engaging ACB communities and health provider stakeholders in research and decision-making processes 2) Examining the contextual vulnerability and challenges experienced by ACB communities 3) Identifying the adequacy and non-intended consequences of current health care practices on ACB communities 4). Increasing individual, community and organizational capacity and leadership and generate strategies to address COVID-19 related-health outcomes, and 5). Sharing new knowledge and support its translation into policy and practice models to mitigate the impact of COVID-19 on ACB communities.

Table 1. Step-by-step guidelines for problem identification, goal-setting and targeted outcomes

5. Conclusion

This paper represents the results of expert views and reviews regarding the disproportionately higher rate of COVID-19 morbidity and mortality in comparison to their population percentage in Canada and the United States. It is well-documented that ACB communities experience systematic biases within the healthcare system. As described in WHO Global Research Roadmap, there is a strong need to prioritize vulnerable population subgroups suffering from stigmatization and/or with other co-morbid conditions. Strengthening multisectoral collaborative partnerships in COVID-19 responses of ACB communities; identifying best evidence-based models and interventions to strengthen health system’s capacity to care for vulnerable populations such as the ACB community. Our assessment of the situation and policy recommendations are limited by the existing evidence gaps and availability of quality data regarding the ongoing pandemic, which may become resolvable with the gradual increase in research publications and as more government, civil society and NGOs reports become available. To our knowledge, this is the first paper to assess current knowledge gaps and gather evidence from the policy related literature and present them in a easily communicable manner. More research and knowledge exchange activities are necessary for improving critical health literacy among ACB people and their responses to COVID-19; and generating new knowledge to reduce COVID-19-related health inequities in ACB communities to address the pandemic in Canada and beyond. This paper is call for action to address current knowledge and policy gaps and to take immediate measures to reinforcing the preventive steps for the COVID-19 crisis in the short term, as well as to remedy the situation with the broader aim of promoting health among ACB in the long-term.

Funding

This research was funded by Canadian Institute of Health Research.

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