Operationalizing A For Us–By Us Partnership with Orthodox Jewish Communities of New York City

The New York City Department of Health and Mental Hygiene (DOHMH) is one of the nation's oldest public health agencies in the United States of America.  With over 7,000 employees, the Department is also one of the largest public health agencies in the world. Daily, DOHMH staff and partners protect and promote the health of over 8.4 million New Yorkers across five boroughs. New York City is home to more than 3 million foreign-born residents from more than 200 different countries, making it the most diverse city in the world. New York City is home to the world's largest Orthodox Jewish (OJ) Hassidic and Haredi community outside of Israel, at over 1.6 million. The neighborhoods of Borough Park (Boro Park) and Crown Heights, Brooklyn, have the largest resident population of Hassidic and Haredi Jewish communities estimated at 200,000.

There are enduring gaps in health outcomes in NYC which vary by age, race/ethnicity and place of residence. Established in 2016, the Center for Health Equity and Community Wellness (CHECW), aims to eliminate racial and other inequities resulting in premature mortality. CHECW addresses inequities through community-led, whole-health approaches to address physical, behavioral, social, and community needs. Through CHECW, the DOHMH is tackling health inequities with innovative policies and programs.

Orthodox Hasidic and Haredi Jewish communities are profoundly religious and insular and are often not reached by traditional public health programs. As a result, the Orthodox Jewish (OJ) neighborhoods of Brooklyn have been the epicenter of many vaccine-preventable disease outbreaks. These neighborhoods were hard hit by the COVID-19 pandemic with higher case, hospitalization and death rates than borough-level or city averages. The use of preventive health services, including vaccination, has been historically low. A year after COVID-19 vaccines became available, vaccination coverage in the seven zip codes in Brooklyn with majority OJ residents remained below 40%. In addition to low COVID vaccination rates, vaccination levels for other preventable diseases continued to decline. DOHMH has experienced challenges connecting with the OJ community due to limited engagement opportunities . Early in the COVID pandemic response, there were less than five Yiddish speakers recruited to contact tracing programs. Further, information disseminated by DOHMH did not meet the diverse language needs of the community. It was evident that the traditional model of partnership of DOHMH staff-led outreach efforts was ineffective. The challenge of how to provide culturally and linguistically appropriate messaging that accounts for the unique needs of the Orthodox Jewish Community persisted as vaccination coverage and use of other preventive health services remained low.

The DOHMH established a Brooklyn Orthodox Jewish Partnership (BOJP) to develop community-driven solutions tailored to the Hassidic and Haredi communities in Brooklyn to build trust in the public health infrastructure. Our objective was to pivot from rigid risk communication program models to a true engagement model that fully assigned decision-making and control to community partners, such that the community can fully leverage its own wisdom and experiences to design and implement public health programs. The success of this "for us by us” partnership model with active decentering of the public health department is presented.

Below were the steps taken to implement this partnership model

·        A request for applications was issued for community partners with staff and presence in the Hassidic and Haredi communities willing to lead engagement to increase uptake of public health services in Brooklyn zip codes. Three organizations with majority OJ staff responded to the request, including the Jewish Orthodox Women's Medical Association (JOWMA).

·        A Collective Action Framework was developed outlining clear responsibilities. DOHMH was responsible for providing funding, material, and data resources to guide and evaluate the partnerships while Partners were responsible for the development and implementation of all activities.

·        Partners conducted a needs assessment to document longstanding health priorities in their assigned neighborhoods. The needs assessment was used to guide the development of a responsive program that provides the OJ community with services to meet their stated needs.

·        Partners hired culturally competent staff to conduct community outreach, education, provide referrals to health and other social services, and design health events with community leaders.

·        Partners created all messaging and communication products. As internet usage is limited, magazines, flyers etc were developed to promote health events and provide health information. All literature was developed in relevant languages with no DOHMH branding.

·        One partner received funding to staff a hotline to answer community members' questions about health issues, including COVID.   

·        Partners formed community advisory groups to inform for their work, including a doctor's advisory group.

·        DOHMH provided weekly data on COVID case, hospitalization and mortality rates and vaccination coverage data for each zipcode. DOHMH staff also provided trainings on COVID vaccine 101 and how to access city services and resources.

There are several positive outcomes attributed to this community-led partnership model when compared to traditional models of partnership.

1.      Rapid expansion of the public health workforce with culturally competent community health workers that were recruited, supervised, and trained by community-based organizations

2.      Increased uptake of testing, vaccination, social services, and primary health care in historically underserved OJ community

a.      Vaccination increased from an average of 40% to 60% in the 7 zipcodes

b.      Testing rates increased and consistently exceeded borough and city averages

c.      Number of people who called the hotline for health-related information at any time 1,332 and average calls per month 266

d.      In-person outreach to 4,977 community members by 104 Community health workers

e.      26 in-person community conversations.

f.       1,664 pieces of educational literature distributed

g.      Vaccine information was provided to 7,671 people.

3.      Reduction in COVID cases, hospitalization, and death rates in the OJ communities from higher than to the city average  

4.      Trust and partnership with the OJ community and willingness to collaborate with health department staff on several issues.

Using the model to both fund and support communities to identify and enact solutions to complex public health issues is of critical importance. The work of the NYCDOHMH Public Health Corp can be found here: https://www.nyc.gov/site/doh/health/neighborhood-health/public-health-corps.page

New York City is home to the world's largest Orthodox Jewish (OJ) community outside of Israel with over 1.6 million residents identifying as members of Hassidic or Haredi Orthodox Jewish sects. The neighborhoods of Borough Park and Crown Heights, Brooklyn, (also known as Boro Park) respectively contain the largest subsection of the Hassidic and Haredi Jewish population, with estimates of over 200,000 residents. Building partnership and faith in public health institutions and messaging in New York City's estimated Hassidic and Haredi Orthodox Jewish communities has been an ongoing effort by NYCDOHMH for many years prior to the COVID-19 pandemic. New York City's OJ communities are often not reached by traditional public health programs. As a result, these neighborhoods of Brooklyn have been the epicenter of many vaccine-preventable disease outbreaks, such as the Measles Outbreak in Brooklyn (>600 cases) in 2018-19; Whooping cough (pertussis) in Brooklyn (>200 cases), 2014-16; Chickenpox in Brooklyn (>200 cases), 2016.  These neighborhoods were also hit hard by COVID-19 pandemic with higher case, hospitalization and death rates than borough-level or city averages. The use of preventive health services including vaccination has been historically low in the Hassidic and Haredi Orthodox Jewish Communities. A year after COVID-19 vaccines became available, average vaccination coverage in the seven zipcodes in Brooklyn with majority OJ residents remained below 40% compared to a city average of over 70%. In addition to low COVID vaccination rates, vaccination levels for other preventable diseases such as polio and measles, mumps, and rubella (MMR) continued to decline well under established thresholds. 

 Data suggests that the high population density of the Orthodox Jewish neighborhoods coupled with communal lifestyle attributed to the significant impact of COVID-19 on New York's Hassidic and Haredi communities. These communities obtain health information from many sources: from physicians, in-person conversations, social media, and text messaging/direct messaging. To further contextualize the lack of existing Health Agency support to this community, Boro Park and Williamsburg, two of the largest enclaves of Hassidic and Haredi Jewish Communities fall outside of the DOHMH's major community health initiative, the Neighborhood Health Action Centers, situated in Brownsville and Bedford-Stuyvesant, respectively. It was evident that the traditional model of partnership of DOHMH staff-led outreach and programming efforts were ineffective for this community. The challenge of how to provide culturally and linguistically appropriate messaging that accounts for the cultural, social, and religious beliefs of the Orthodox Jewish Community persisted as vaccination coverage and use of other preventive health services remained low.

The DOHMH set a goal to establish a Brooklyn Orthodox Jewish Partnership (BOJP) to develop community-driven solutions tailored to the Hassidic and Haredi communities in Brooklyn to build trust in the public health infrastructure using health equity as a central focus. Given the historical ineffectiveness of traditional health department programs, our objective was to pivot from a more traditional, rigid, command and control model of risk communication and hierarchical programming to a model that fully assigned decision-making and control to the community partners such that the community can fully leverage its own wisdom and experiences to design and implement public health programs.

Brooklyn Partnership is a creative utilization of various theories and practices in community engagement, such as the Collective Impact Model, Trauma-Informed Care, and the Ladder of Community Participation that could be replicated with other communities with similar characteristics. Existing models of leadership center Agency and Agency representatives as the expert voices in program design and implementation. Instead of arriving at power-sharing objectives, BOJP started by centering power within the community, and decentralizing the primacy of the Agency and its staff in a typical Agency knows best” fashion. Instead, the BJOP recognizes and understands that the community carries the collective wisdom and power to enact solutions to meet the community's complex problems. The Brooklyn Partnership model is entirely evidence-based utilizing frameworks from SAMHSA's Trauma-Informed Care, HP2030 social determinants of health, The World Health Organization's community engagement framework, and other peer-reviewed practice and guidance.

The ultimate goal of PHC is to promote an equitable recovery from COVID-19 and to reduce underlying health disparities that have contributed to poorer health outcomes. In alignment with this goal, and as the pandemic response continues to evolve, the DOHMH Brooklyn Orthodox Jewish Partnership (BOJP) project objectives have remained flexible and fluid to ensure that the goals of the Orthodox engagement initiative are responsive to community-directed needs. To support achieving these goals, DOHMH assigned staff to manage the relationship with CBOs. The Partner Engagement Coordinators” ensure smooth and seamless communication between the agency and CBO. Additionally, partners were regularly provided with COVID-19 vaccine and case rate data, along with masks, and personal protective equipment (PPE) to support the distribution of human and material resources to areas with high need. 

PHC is an ongoing DOHMH initiative launched in September 2021 and the BOJP was convened in February 2022. As part of PHC, there are various grants and contracts from diverse funding sources such as City, State, and Federal governments and with various overlapping timelines. Funding for partners to support community engagement with the Orthodox Jewish community began in earnest in December 2021 and will continue through 2024.

The BOJP community engagement grew from an awareness of the underlying health inequities present in parts of Brooklyn, New York during the COVID response. The role of the Health Department under the Collective Impact model framework is as a convener and the backbone” coordinating structure. The community partners, in turn, offer their expertise and understanding of key community issues and are the main implementing partner of all community-based work, shifting the power from the Agency to the community directly. The CBOs selected for funding demonstrated the ability to meaningfully reach target populations, and in the case of the Orthodox Jewish engagement, many of the organizations are led directly by community members. These CBOs had deep ties to local faith leaders and other key stakeholder groups to ensure that engagement continues to be impactful and resonant.

The objectives of the PHC are:

1.      Reduce gaps in COVID-19 testing and vaccination rates by race/ethnicity, place of residence and age.

2.      Expand access to care, services, resources and investment in communities most impacted by COVID-19.

3.      Improve long-term community recovery from COVID-19 and health equity.

4.      Build vaccine confidence.

To this extent, the work of PHC and the BOJP is ongoing. However, through partnerships with CBOs, clear and measurable objectives have been attained. Since, the start of the funded relationship there have been over 15,000 referrals to other health and social services have been made in Hassidic and Haredi-majority communities. Additionally, over 30 meetings with funded partners have been held to increase bidirectional communication.

            All PHC programs undergo, at minimum, formal baseline and end-of-project evaluations. Surveys are sent to partner organizations to assess baseline organizational capacity to conduct community engagement programs in addition to collecting demographic information about the organization such as size and operating budget. To monitor progress on vaccine uptake and COVID-19 case rates, PHC uses public data sources available from NYC Health: Data. To review other routine immunization data, DOHMH is able to access the City Immunization Registry (CIR).

            There are many excellent and published models for community engagement and collaboration in public health: including the collective impact model (CI), community coalition action theory (CCAT), and WHO's community engagement framework. The BOJP builds upon and expands these models for a true community-led approach to creating hyperlocal change in difficult-to-reach populations. There is a need for wider, adaptable partnership models that utilize true shared decision-making and action for addressing complex, ongoing health inequities. Additionally, such structures should allow funding and resources to be allocated to respond to emerging community concerns and community-driven solutions.

To support sustainability and ongoing collaboration, DOHMH regularly meets with Brooklyn-based community partners through the PHC partner's forum, a monthly equity collaborative. BOJP stakeholders meet monthly to review program progress and discuss equity considerations.

The project objective to demonstrate the feasibility of a model to develop community-driven solutions tailored to the Hassidic and Haredi communities in Brooklyn to build trust in the public health infrastructure was met. The specific factors leading to success and lessons learned include:

1.      Availability of flexible funding to support this model of partnership.

2.      A trust-focused result framework that allowed for horizontal rather than narrow vertical programs.

3.      A willingness of health department leadership to completely center the community and forego co-branding and other requirements to promote visibility of the health department.

4.      The agency commitment to shifting resources and power to the communities that bear the greatest burden of marginalization, racism, and health inequities.