Abstract
Introduction:
Community-based organizations (CBOs) played a critical role in meeting the needs of immigrants during COVID-19. Immigrant women experienced a disproportionate burden of the social, economic, and health impacts of the pandemic as a result of intersecting vulnerabilities and constrained access to resources and services. Although extant literature has shed light on some of the key responses by CBOs during COVID-19, less is known about how CBOs incorporated gendered and antiracist approaches in their efforts to promote health equity.
Methods:
Our study draws on semistructured, in-depth interviews with 19 direct service providers from 15 CBOs that serve immigrant communities in New York City in early 2021.
Results:
Our findings show that through innovative, gender-responsive strategies, CBOs were able to provide women access to additional material resources, address digital disparities, and mitigate the negative consequences of social isolation and anti-immigrant hostility through interventions that fostered community and social connectedness.
Discussion:
Through flexible, adaptable, and gender-responsive approaches to programming, CBOs are well positioned to support immigrant women and their communities during times of crisis. CBOs are critical front-line responders due to their understanding of immigration women's intersectional needs and their ability to leverage existing relationships with women and their families.
Conclusion:
This study adds to the evidence that suggests investments in disaster preparedness should include long-term investments to strengthen CBOs. Moreover, this work highlights the ways that health and social service systems have modified their operations to focus on the promotion of health equity for immigrant women and their communities.
Introduction
During the COVID-19 pandemic, immigrant communities were one of the hardest-hit populations in the United States.1–5 Immigrants are racialized and subject to racism and xenophobia-driven disparities in health, and the pandemic compounded existing structural inequities for U.S. immigrant communities.6–8 Immigrant women, in particular, experienced a disproportionate burden of the social, economic, and health impacts of the pandemic as a result of intersecting race-, class-, and gender-based vulnerabilities.2,9 This includes gendered roles and expectations around caretaking, uneven household responsibilities, low wage and nontraditional labor, and a rise in gender-based violence (GBV).10–12
Immigrant women and their communities faced significant barriers in accessing resources, government benefits, and essential services throughout the COVID-19 pandemic.9,13 Health care and social service delivery was drastically curtailed by suspended services, shifts in hours of operation, and transitions from in-person to telephonic methods.1,14,15 For immigrant communities, these challenges were compounded by fear around immigration status, which deterred the utilization of public programs, as well as formal exclusion from public assistance.2,16–19 U.S. government relief measures, including expanded unemployment benefits and direct cash payments, excluded millions of immigrants who lacked documentation status and were therefore ineligible. 20 For immigrant women, gender-specific barriers to health and social services, including the shutdown of “nonessential” sexual and reproductive health care, created additional barriers to accessing critical resources.2,17,21
Community-based organizations (CBOs) fill a gap where governmental public health inadequately addresses the health needs of immigrants in the United States, particularly in the context of crisis. 22 CBOs include community residents in governance, leadership, program planning, service delivery, and evaluation. 23 Evidence from studies across the country illustrates the role CBOs played in addressing the unmet needs of marginalized communities during COVID-19.1,16,22,24–26 Community-based programming serves as a safety net for immigrant communities that are unable to access culturally responsive care through public systems or do not qualify for or are afraid to use public benefits and services.13,27
Within New York City (NYC), there were significant differences between neighborhoods in COVID-19 infection rates and prevalence. Among the most impacted were low-income, historically marginalized neighborhoods, usually home to high concentrations of immigrant families.28–30 During the pandemic, NYC Health + Hospitals, the city's largest health care provider to Medicaid and uninsured patients, identified food, housing, and income support as patients' most social pressing needs and built new programming to connect patients to resources. However, they faced challenges in addressing the needs of their large immigrant patient population, many of whom did not qualify for government benefits or were afraid to utilize health and social services. 15
Due to their established relationships and trust within immigrant communities, CBOs offer the most significant insights into health access and disparities at the neighborhood level.31,32 While CBOs were most responsive to increased demand for health and social services among immigrant women, they also faced significant challenges to service provision throughout the pandemic due to constraints on staff, resource scarcity, mental health distress, and staff burnout.16,22,33–35 CBOs were forced to adapt their programming and service delivery and implement new, innovative approaches to continue providing services and support to immigrant communities.
Although extant literature has shed light on some of the key responses to COVID-19 initiated by immigrant-serving CBOs in NYC,24,26 less is known about how CBOs incorporated gendered and antiracist approaches in their efforts to promote health equity during and after the height of the pandemic. Emerging antiracism efforts to address health inequities are strongest when they center the intersectional structures immigrant women are subjected to as a consequence of gender identity and systems of racialization.36,37 Additionally, gender response efforts in emergency and post-crisis contexts are critical for reducing the burdens of care, violence, and economic insecurity on women that are brought on or exacerbated by conditions of crisis. 38 Documenting and learning from the innovative strategies CBOs used is critical to advancing CBO objectives to improve health equity through evolving programming approaches, as well as informing preparation efforts for future large-scale emergencies.
Thus, this study draws on the first-hand accounts from direct service providers working at immigrant-serving CBOs in NYC to examine the strategies they employed to meet the multifaceted and emerging needs of immigrant women and their communities during the height of the COVID-19 crisis.
Methods
This qualitative study involved semistructured, in-depth interviews with 19 direct service providers from 15 CBOs that served immigrant communities in NYC in early 2021. The broader research study also involved 44 in-depth interviews with cisgender immigrant women. This analysis focuses only on the sample of direct service providers (N=19) to better understand how CBOs overcame barriers to promote health equity for immigrant women.
Recruitment for direct service providers began in March of 2021 and concluded in May of 2021. We sought out CBOs that serve predominantly immigrant communities—particularly with a focus on gender—and that represent a range of geographic locations in NYC and service sectors. We recruited direct service providers through correspondence by email or phone and through snowball sampling.
The 19 direct service providers who were interviewed represented executive staff (26%), clinicians (32%), and other service providers (e.g., social workers, advocates) (42%) at social service organizations (63%), family planning clinics (16%), and family practices or community health clinics (22%). Direct service providers from across all five boroughs (Bronx, Brooklyn, Manhattan, Staten Island and Queens) and Westchester County were interviewed; however, over half of the CBOs represented were in the borough of Manhattan (58%) (Table 1). The majority (66.7%) of the CBOs provided services specifically geared toward immigrant women and the others (33.3%) had a large immigrant client base.
Sample Characteristics for Direct Service Providers at Community-Based Organizations
The interview guide was developed by the study team based on the literature on structural racism, COVID-19, immigrant health, women's health, immigrants' sexual and reproductive health, and health and social service delivery. The interview guide included questions about challenges and strategies related specifically to immigration, racism, and gender, and it was revised and finalized after initial interviews. Interviews were conducted in either English or Spanish, through Zoom, video, or phone calls—all as per participant preference. Interviews lasted 45–60 min and were audio recorded. Each participant received an information sheet about the study and provided verbal consent for participation and audio recording before the interview. Participants were given a $50 Amazon gift card for their participation in the study.
The codebook was developed with a subset of transcripts using a line-by-line approach to identify prominent themes and patterns. Transcripts were deidentified, uploaded, and coded using Dedoose. Data were thematically analyzed using a constant comparative method. 39 Study team members identified and described themes and narratives that emerged about the strategies implemented by direct service providers to overcome barriers surrounding service provision for immigrant women during the early months of the COVID-19 pandemic. Institutional Review Board (IRB) approval was received for the study (AAT2404).
Results
Qualitative analyses revealed three key themes highlighting how CBOs adapted programming and service delivery to meet the needs of immigrant women throughout the COVID-19 pandemic, including (1) improving access to material resources, (2) addressing digital disparities, and (3) creating new approaches for community and social connectedness. The themes have been summarized below and direct quotes supporting each theme have been provided in Table 2.
Themes and Quotations from Semistructured Interviews with Direct Service Providers at Community-Based Organizations Across New York City, 2021
GBV, gender-based violence.
Addressing unmet needs for everyday survival through targeted outreach and material support
Direct service providers described how immigrant women struggled to meet needs for everyday survival during the pandemic, often because of intersecting vulnerabilities, including high rates of job loss, restricted access to government benefits, and gender inequality (e.g., exposure to GBV). Many direct service providers described the importance of assessing unmet needs through strategies that leveraged already-established relationships among their client base, and took into consideration new constraints generated by the pandemic on how, when, and where women were able to communicate sensitive information about their current circumstances.
One direct service provider at a center for women and youth in Queens, for instance, described how their community outreach workers went door to door inviting clients to speak with them on the stoop outside the house, where women could have some respite from the constant lack of privacy within the home. Others discussed making personal phone calls to women to assess their most pressing needs and then connect them with relevant resources and services.
One direct service provider who worked with GBV survivors in Manhattan described this type of personal outreach as a critical “lifeline” for women at a time when many agencies closed, and information about shelters and other resources for addressing violence became hard to attain. “We may be one of the few people that was like actually making human contact with them by phone…to give you hopefully accurate information.”
In addition to the need for information and service referrals, food insecurity and lack of basic material resources (e.g., clothing, household necessities) emerged as immediate threats to women and their families wellbeing. This was particularly prominent among undocumented immigrant women who were not eligible for federal financial support, including the stimulus checks that were distributed in 2021. Monetary and material deprivation was also exacerbated for those women who faced additional barriers to leaving the house to acquire essential goods, including single mothers with small children, and women who were unable to prepare meals within the home, such as those in GBV shelters or temporary housing that lacked full kitchens.
In response to these needs, direct service providers discussed different approaches to providing monetary support to their clients. One provider shared how they distributed several payments from a grant of four hundred thousand dollars to immigrant clients who were not eligible for the stimulus check. Another described adjusting the stipulations of the CBOs' client assistance program to increase participant eligibility and allow for multiple payments, rather than just a one-time stipend, recognizing that for many women during the pandemic, it might take months to regain financial stability. In other cases, CBOs focused on increasing access to material support, often through setting up new community food banks and food justice programs, even if that was not their organization's primary focus. Given the increasing constraints on women's mobility, several of these programs shifted from having clients pick up bags of food and supplies in person to transporting food and resources directly to women's homes.
One provider, for instance, from an antiviolence program in Manhattan, described hiring delivery workers to deliver things like feminine hygiene products, baby formula, and infant supplies to women; sometimes they would have items sent directly from Amazon to women's homes.
Narrowing digital divides to promote equitable access to and use of social services
Direct service providers shared that, because of public health measures to shelter-in-place during COVID-19, women assumed the brunt of the burden of meeting their family's needs through telecommunication, including the demands of their children's education and, in many cases, access to critical resources and services, such as health care, legal aid, and mental health support. However, women encountered several barriers when navigating phones and online platforms. Direct service providers described that many immigrant women did not have access to the necessary technology to stay connected and receive services, and that they also faced challenges in acquiring technical assistance (e.g., through their children's schools) due to both language barriers and a lack of digital proficiency.
To address these constraints, some organizations distributed cell phones and laptops to their clients. Additionally, direct service providers described that, in some instances, staff time was reallocated to offering training to clients in their first language to help them learn how to navigate new online processes, such as accessing telemedicine platforms or applications like Zoom. Furthermore, under such unprecedented conditions, direct service providers reported implementing any tool of communication at their disposal to deliver care and services, while doing their best to protect women's privacy. While as a last resort, a provider at a community health clinic in Manhattan, reported using applications on their mobile devices, such as FaceTime and WhatsApp, to stay connected.
Many of the services delivered by CBOs are sensitive in nature and typically conducted in person. As a result, direct service providers acknowledged challenges in creating safe spaces under the new virtual context but made their best efforts to make these digital spaces, safe spaces. One provider, for instance, described establishing a secret “safety word” with clients to help them signal the need for protection from violence in the home despite privacy constraints. Other providers discussed efforts to create welcoming and flexible virtual environments as a way to increase participation in their programs among mothers with young children. “We make it clear that we are welcoming of babies…They can nurse on camera or turn their camera, whatever they feel comfortable with.”
Fostering community to promote mental wellbeing and peer support among immigrant women
Direct service providers imparted that during the pandemic immigrant women faced challenges with social isolation and physical distancing, including increased mental health distress and, in some cases, exposure to GBV. This was often a result of the uneven burden of caretaking and household responsibilities within the home and other forms of structural gender-based inequities. In addition, as providers noted, when CBOs closed or reduced hours, many women lost an important space—and sometimes the only space they had—for connecting with other women from similar cultural and linguistic backgrounds and for building a sense of community.
Direct service providers recognized the importance of finding ways to build community and sources of mutual support for women beyond the immediate family. Many of the interventions they described were built on gender- and culture-specific approaches to nurturing interpersonal connections, informal dialog, and practices of self-care. One CBO, for example, which primarily serves South Asian communities, started a weekly “Chai on Zoom” event for women in the community to chat over biscuits and chai. This gave women the opportunity to catch up on community gossip and share information and resources. Another CBO, recognizing the tendency of their immigrant clients to prioritize their children's needs over their self-care, provided virtual mental health sessions to guide women through breath work and body exercises as a way of centering themselves and stepping away from their caregiving roles.
Psychosocial and spiritual support for immigrant women and their families who experienced illness and loss during the pandemic was also highlighted by CBOs as a critical intervention, especially given the high rates of mortality among immigrant communities and the lack of social support. Personal outreach by direct service providers, through both material and emotional means, helped reinforce and expand informal networks of care and mutual trust between CBO staff and their client communities with an emphasis on understanding women's immigrant-specific experiences and needs. This type of targeted outreach became a critical source of support for some of the hardest-to-reach families, especially given the sociopolitical context of escalating anti-immigrant hostility. One provider relayed, “We would just say, OK, seven o'clock, get on the phone and we would just pray together or and we would send cards and, you know, email e-cards and you know, just keep the person filled with good messages and stuff like that.”
Discussion
Serving immigrant communities in emergencies is often subsumed under a general crisis response through universal approaches that may fail to address the unique needs of historically marginalized communities. 22 This study illustrates how direct service providers working at CBOs modified their operations to center health equity, fill gaps in the governmental public health infrastructure, and meet the intersectional needs of immigrant women and their communities throughout the COVID-19 pandemic. Addressing the needs of immigrants is central to antiracism efforts, and these CBOs demonstrate approaches that recognize the structural intersectionality that shapes immigrant women's lives.40,41 During a period of exacerbated structural inequities, direct service providers facilitated access to material resources, addressed digital disparities and privacy issues, and mitigated some of the negative consequences of social isolation and anti-immigrant hostility by developing new approaches to foster community and social connectedness.
In this study, direct service providers described leveraging their relationships and well-established trust with immigrant communities to reconfigure and extend their existing services. CBOs were first responders and identified and addressed the immediate needs of immigrant women and their families related to health, labor, family, safety, and immigration status. 20 Organizations responded to housing crises, food insecurity, and financial uncertainty, in addition to their intended mission and scopes of work.
This observed elevated need aligns with work that found greater food insecurity during the pandemic among immigrant communities because of unemployment and loss of primary income sources. 3 CBOs shared that they expanded service provision to food pantries and delivery mechanisms to address food insecurity and constraints on movement. Financial insecurity was also prominent among CBO clients. Immigrant women are disproportionately represented in the informal work sector due to barriers (including citizenship and language requirements) posed by the formal work sector, which were exacerbated by COVID-19, leaving immigrant women and their families more financially vulnerable. 42
Furthermore, there is a reciprocal and reinforcing relationship between increased life stressors from social and economic disruptions during COVID-19 and GBV for immigrant women. 43 CBO efforts to provide material and financial resources were critical not just for COVID-19-related outcomes, but also to ensure immigrant women's safety from violence and to promote health equity.
CBOs were mindful of the intersectional challenges immigrant women were experiencing, particularly during this period of exacerbated structural inequities. Greater interpersonal discrimination and hate crimes coupled with lockdown and social distancing increased isolation among racially minoritized immigrant populations. 44 Immigrant-serving CBOs overcame some of these barriers by addressing the digital divide and thinking critically about access to and use of technology. For instance, CBOs used the internet to create safe spaces for immigrant women (e.g., encouraging breastfeeding while meeting virtually, on or off camera) and foster connection (e.g., Chai on Zoom). Many such strategies that emerged during the pandemic have remained intact as system-level changes to better center health equity for immigrant communities.
CBOs often play an essential role in fostering social belonging and connectedness within marginalized communities.25,45 By creating a safe space for people to come together through both informal and organized activities, CBOs can help community members form relationships built on trust and mutual support—with each other as well as CBO staff—and find an outlet for expressing their emotions and identities.24,46 During COVID-19, when CBOs were forced to close their facilities and implement social distancing measures, CBO staff had to find new ways to build community and foster social connectedness—interventions that became particularly salient considering the enduring conditions of social isolation, loneliness, and fear generated by the pandemic. Programs based on activities that brought women together, despite the circumstances, to exchange dialog and support beyond their immediate families helped to elevate women's voices and help them feel less alone.
This study includes a few limitations. This study is based on a nonrandom sample and findings are not generalizable to a broader population. There is also the possibility of respondent bias since participants were asked about the efficacy of their organizations where they remained employed. Also, the study was conducted in NYC so may not align with immigrant experiences in contexts with fewer immigrant-serving organizations or that instituted different pandemic response policies. However, NYC is home to one of the largest, most heterogeneous immigrant populations in the United States, and the perspective of immigrant-serving CBOs are a critical dimension of understanding immigrant health and social service experiences. As such, the findings in this study can illuminate patterns that are also likely to be experienced by immigrant communities across the United States.
Conclusion
CBOs were critical first responders and change agents for immigrant women in NYC, the epicenter of the COVID-19 pandemic. In alignment with historical precedent and existing evidence, CBOs emerged as the first to identify essential issues and create rapid solutions for immigrant women. 47 CBOs centered the intersectional needs of immigrant women by making sure their basic needs were met, ensuring their safety, and helping them find community with other women, despite limitations on in-person activities. These critical antiracist and gender-inclusive strategies have remained in place since the onset of the COVID-19 pandemic. CBOs, regardless of their original mission, now find themselves addressing a range of social and structural determinants of health to ensure the safety and wellbeing of immigrant women and their families.
This study adds to the evidence that suggests investments in disaster preparedness should include long-term investments to strengthen CBOs. 25 However, if health equity is to be achieved in the United States, the burden of gender-inclusive and antiracist work cannot rest upon CBOs alone—particularly during public health emergencies.
Existing shortcomings in governmental public health infrastructure and access must be remedied to appropriately address the social and health needs of immigrant women and their communities.
Footnotes
Acknowledgments
The authors are deeply appreciative to all direct service providers who shared their insights and perspectives about serving immigrant women and their communities during the pandemic.
Authors' Contributions
H.M.W.: Conceptualization (supporting); writing—original draft (lead); formal analysis (equal); and writing—review and editing (equal). T.F.A.: Formal analysis (equal); writing—original draft (supporting); and writing—review and editing (equal). A.-M.M.M.: Formal analysis (equal); writing—original draft (supporting); and writing—review and editing (equal). S.J.R.: Formal analysis (supporting); writing—original draft (supporting); and writing—review and editing (supporting). G.S.: Conceptualization (lead); methodology (lead); formal analysis (equal); writing—original draft (supporting); and writing—review and editing (equal).
Disclaimer
The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
This work was supported by a pilot grant from the Columbia Population Research Center. This pilot funding and administrative support were provided by The Eunice Kennedy Shriver National Institute of Child Health, and Human Development (NICHD)-funded Columbia Population Research Center (P2CHD058486). H.M.W. received funding support from the Eunice Kennedy Shriver National Institute of Child Health and Human Development Training Program (HD049339). G.S. is supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (K01HD103879), and the William T. Grant Foundation Scholars Program (200989).