A Systems Perspective of How Community-Engaged Public Health Addresses Social Determinants of Health: A Case Study of a Population-Based COVID-19 Testing Program.

CONTEXT: Despite the recognition that social determinants of health (SDOH) are key to improving the health of all communities, the causality and specific mechanisms through which SDOH impacts health behaviors and outcomes are often ambiguous. OBJECTIVE: The aim of this study was to use systems thinking to document pathways through which SDOH affected health-seeking behaviors and identify how community engagement strategies intervened to address SDOH barriers. DESIGN: We leveraged the case context of a large federal initiative (Rapid Acceleration of Diagnostics-Underserved Populations [RADx-UP]) designed to improve COVID-19 testing for underserved populations through community-engaged and participatory approaches. First, we used structured sessions with RADx-UP partners to create causal maps that documented relationships between factors relevant to SDOH, a health-seeking behavior (COVID-19 testing), and community engagement strategies. Second, we searched, reviewed, and tied evidence from RADx-UP peer-reviewed literature to contextualize the causal maps. RESULTS: We identified 17 unique pathways that linked SDOH to COVID-19 testing. The map also highlighted 3 mechanisms through which the community engagement addressed SDOH: (1) improving access to testing, (2) addressing health and digital literacy, and (3) conducting social needs screening and assistance. CONCLUSIONS: Our findings highlighted the complexity of public health issues such as COVID-19 and how community engagement is critical to addressing SDOH and health equity. Importantly, dedicating resources to community engagement created positive reinforcing dynamics to improve the health of communities; however, as COVID-19 became better managed, funding also diminished and decreased the capacity for community-engaged efforts. Research in public health needs to focus on understanding and reshaping systems that better support community-engaged efforts.