NYC Housing Authority Resident COVID Response (RCR) Project

Focus Group Analysis and Summary ABSTRACT INTRODUCTION Figure 1. Referral Sources Disclosed 10 As part of the National Institutes of Health-funded In response to the pandemic the National Insti- 8 Rapid Acceleration of Diagnostics-Underserved tutes of Health launched the Rapid Acceleration Populations initiative, New York University’s Rob- of Diagnostics (RADx)- Underserved Populations 6 ert I. Grossman School of Medicine and School initiative. In September 2020 New York University 4 of Global Public Health are studying barriers to received funding from this program to launch the 2 COVID-19 NYC housing authority. Focus groups NYCHA Resident COVID Response (RCR) project. 0 were conducted from December 2020 - March The aims are to develop and implement a commu- HCC HSS CAMBA Flyer Word of mouth MAP Social media NYCHA Email 2021, in partnership with community-based or- nity -engaged intervention to increase COVID-19 ganizations, including Harlem Congregations for testing. To inform the design of the intervention, Focus Groups Figure 3. Main Themes Community Improvement, Inc and Henry Street New York University, in partnership with communi- Due to COVID-19 restrictions in New York City, 1. Reasons for not getting tested Settlement. This report summarizes the focus ty-based organizations, including Harlem Congre- focus groups were conducted using Zoom. Upon 2. Reasons for getting tested group findings and implications for increasing gations for Community Improvement, Inc. (HCCI), logging on, each participant was renamed with an 3. Preferences for testing testing among NYCHA residents. Findings are Henry Street Settlement (HSS), and Church alias, to maintain anonymity and confidentiality. 4. Strategies for increasing testing informed the design of a community-engaged Avenue Merchant Block Association (CAMBA) Focus groups were recorded and then transcribed 5. Attitudes towards vaccine intervention to enhance uptake of testing among conducted focus groups to gain a deeper under- verbatim for analysis. racial/ethnic minority populations. standing of the barriers to testing among NYCHA residents. This report summarizes findings from Figure 2. Participant Neighborhoods the focus groups and suggests strategies for en- FINDINGS SUMMARY hancing testing in this population. Participant Neighborhoods We present the main findings from the analysis. Focus groups (FG) with residents living in New York Issues related to trust, or lack of trust, emerged City public housing elicited a range of structural METHODS Bronx throughout the discussions. They are therefore barriers (e.g., long lines, homebound, challenges Harlem reported across the main themes. quarantining), and attitudes, beliefs and gaps in Recruitment - Referral Sources East New York knowledge that were associated with a reluctance Residents were recruited through flyers and infor- Lower East Side WHY RESIDENTS ARE NOT GETTING TESTED? to get tested. These beliefs were related to a lack of mation sharing through our partnering communi- trusted sources of information, the spread of mis- ty-based organizations, HCCI, HSS, and CAMBA. Fear of testing information, concerns about the safety of the test Figure 1 summarizes the main source of refer- The NYCHA Resident COVID Response (RCR) Fear of testing was primarily related to a lack of and fear of receiving a positive test result. Residents rals based on residents’ response. Recruitment Community Steering Committee (CSC) provided trust. Residents expressed fears about where the were also unaware of recommendations for routine targeted six NYCHA developments in Harlem, feedback on the focus group guide before it was testing data was being stored and who would have testing. FG data was collected over 4 months, with a the Lower East Side, and East New York. These finalized. Eight focus groups were hosted in English, access to these data. The also feared the test itself. clear shift in attitudes towards greater trust in test- developments included Polo Grounds Towers and and one focus group was hosted for Spanish- For example, there were concerns that the test itself ing over time. More residents reported being tested Ralph J. Rangel houses in Harlem, Jacob Riis and speaking residents. All participants were reimbursed might transmit COVID-19. They were also hearing that for SARS CoV-2 infection and there was less con- Vladeck houses in the Lower East Side, and Pink with a $30 Amazon electronic gift card via email. the nasal swab test was painful or witnessed others cern about the safety, but the need for more conve- and Cypress houses in East New York. However, to experiencing discomfort which was associated nient testing options persisted. Vaccine hesitancy increase the number of attendees we expanded Analysis with reluctance to get tested. Fear of a positive test was prevalent and persisted over time. Resident eligibility criteria beyond the original four NYCHA Focus group findings were analyzed using a qualita- results was also reported as a barrier to testing. This feedback suggested modifiable barriers to testing developments. Thirty-six residents participated tive rapid analysis approach. This involved applying included concerns about who would have access to and vaccination that are informing a community-en- in nine focus groups conducted from December a deductive approach in which data were systemat- these data and fears about being forced to isolate gaged intervention that is specifically addressing 2020 through March 2021. Figure 2 shows the ically coded using a template that outlined the main themselves from their families without their consent. residents’ concerns and their need for accurate distribution of participants by neighborhood. topics covered in the focus group guide. The analysis One resident noted, “some may not want to give their information about vaccine efficacy and safety, the also allowed other themes to emerge. The research personal information or to feel that they are being need for ongoing testing despite the availability of team used an iterative process of meeting weekly to traced, so they hold back altogether on being tested.” vaccines, referrals to more convenient testing loca- discuss discrepancies until the team reached con- tions, and support to improve access to vaccines. sensus. The final themes are outlined inFigure 3. “How do I know they’re not givin’ it to me “ when they swab my throat or my nose?” Misinformation WHY RESIDENTS ARE GETTING TESTED I would rather have someone who is educated in formation to residents’ homes, and some suggest- Residents received information about COVID-19 doing do it, rather than me at home trying to do it ed knocking on doors. Residents also responded from a wide range of sources including the news, More than half of the FG participants had been myself.” Another noted, “It would be easier, but then positively to the idea of a community health worker local politicians, and word of mouth. When the tested at least once (Figure 4). Reasons included: again, you don’t know if you’re doing it correctly.” (CHWs) model in which CHWs were available to latter was probed, word of mouth emerged as a prep for a medical procedure, exposed to some- provide this information and other resources. primary source of misinformation and misunder- one with the virus and having a high-risk job. As “If it’s a testing kit as a woman would standing of the risk of infection. For example, focus one resident noted, “I’m always in the community. “ use to find out if she’s going to have a Figure 5. Resident Suggestions for group participants reported that many residents I volunteer in the community.” baby, I’m all for it” Increasing Testing did not believe that COVID-19 was real, but rather • Provide accurate easy to read information a tactic to scare racial/ethnic minority groups. As Figure 4. Resident Testing Activity Testing at a central location. (e.g., develop a COVID handbook) one resident said, its,“just a government tactic to Some focus groups included members of the • Host events/testing in developments or scare people of color”. They were hearing from Residents Mayor’s Action Plan for Neighborhood Safety community centers neighbors that the novel coronavirus is “fake,” and Who Have (MAP), which has been very active in addressing • Create multilingual materials not as serious as it has been depicted in the media: Been Tested community needs related to COVID-19 (e.g., shar- • Continue conducting outreach “A lot of people, they just don’t know what’s going ing information, distributing food). MAP commit- • Knock on doors with COVID tests on hand on…They don’t believe in COVID, or that its real.” Did not share tee members and other residents endorsed onsite • Post to social media/email information This finding again illustrated how a lack of trust Did not test testing options that leveraged existing space • Create age appropriate materials in information sources and the government more Previously Tested including, community centers and mobile units. • Make self-tests available generally is driving reluctance to get tested. • Keep testing convenient “It’s very easy here, I don’t want to go any-

Challenges getting tested PREFERENCES FOR TESTING “ where else… we have it easy here with the Three main themes emerged related to challenges mobile unit here below.” As previously described, self-testing was consis- tently the preferred method for testing. Residents related to getting tested. Most residents described a greater level of comfort were particularly intrigued by the idea of a saliva • Long Lines: Residents expressed concerns with getting tested in a clinical setting (e.g., minute Testing by professionals test to identify COVID, “it’s convenient and less about waiting in long lines for hours at sites clinics, hospital, or primary care practice) because As noted above, residents clearly described their painful.” Residents were also responded positively where they could not reserve an appointment of greater confidence in the staff. However, many preference for receiving the test from a trusted to an option that we described in which residents ahead of time. Associated with the inconve- residents endorsed onsite testing if it was clear that professional. Residents preferred licensed or cer- could self-administer the nasal swab test at con- nience was the fear that waiting would increase the staff conducting the testing were trained. Span- tified medical professionals to complete any tests, venient locations. their risk of COVID-19. As one resident said, “The ish-speaking participants similarly supported more specifically mentioning licensed practical nurse lines are long, and we can catch COVID [while convenient testing opportunities including having a (LPN), registered nurse (RN), and medical assis- The source of information should be ... waiting in line].” It was notable that so many mobile van in their development. In terms of prefer- tants (MA). However, most also agreed that they “someone who looks like us, who residents were relying on “minute clinics” as a lo- ences for the type of test, residents clearly preferred would be comfortable if the individual demon- “ talks like us.” cation for testing and other urgent care options. a self-testing option or options that caused less strated an appropriate level of knowledge. • Travel to Healthcare Facility: For similar reasons, discomfort and were interested in home testing. residents were concerned about being on public STRATEGIES FOR INCREASING TESTING All of the residents emphasized that messages must come from a trusted source, and preferably some- transportation, within an enclosed space with Self-testing options one from within their community. They liked the idea others who may be infected with COVID-19. “We Preferences for self-testing and at home testing Many residents were eager to share recommen- of one-on-one interactions with a knowledgeable worry to go on the bus because if we go on the bus, were associated with an interest in having more dations for increasing the uptake of testing in person from the community: “that’s a great thing, we are worried to catch COVID and then worried to control over the process. One resident described their communities. Participants suggested a more [it] just has to be community structured. Meaning take the train because we could catch COVID.” the ideal test as one that was similar to an at-home proactive approach to engaging residents to share it has to be discrete, very one-on-one.” • Cost: This issue was only mentioned by a pregnancy test, “If it’s a testing kit as a woman knowledge about COVID-19 testing options and couple of participants but is important to would use to find out if she’s going to have a baby, other information about COVID-19 including the ATTITUDES TOWARDS VACCINES note. These residents reported receiving a bill I’m all for it.” Although there was general enthusi- vaccine to counter misinformation, as summa- despite having Medicaid. One resident recalled, asm for self-testing options, several residents also rized in Figure 5. Residents suggested that NYCHA Waiting to see what happens and need for more “Some people went…and they got a big bill from expressed concerns about their ability to conduct disseminate this information through flyers, social information. being tested for the coronavirus…a lot of people the test correctly. For example, one resident said, “I media posts and emails and that the information In the earlier focus groups, most residents were don’t want to go to these sites because [they] feel doing it yourself I would be wary about whether is translated into multiple languages. They also not planning to get vaccinated. Most wanted to are getting billed for the corona test.” or not it was done correctly. That’s why I would feel described tabling in the developments, sending in- wait to see what happened to other so that they the potential negative impact of misinformation that IMPLICATIONS inclination to “wait until others have gone first”. could be more confident that the vaccine is safe. is often spread by word of mouth. Other recommendations include creating easy As one resident explained, “I want to hear expe- We identified a range of modifiable barriers to access to vaccinations and providing support to riences from the people and not just one person. Lack of trust surrounding vaccination. testing that can be addressed with a number of older adults and those who are less “tech savvy” I’m going to watch the news, of course, and I Many residents described a lack of trust based on the strategies that residents suggested. These include to sign up for vaccines. Among Latinx families who want to hear people like the nurses that got it and history of unethical treatment of Black Americans by creating more accessible and convenient testing appear more open to vaccination, focusing on politicians.” Residents also expressed the need the medical community and lack of transparency. As locations and adding at home and self-testing access will continue to be important. for information about safety and effectiveness one resident stated, the “History of things regarding options. The findings also indicated that a cadre of among different populations including racial/eth- shots and vaccines is where the stress value lies.” residents and/or community health workers, who Our data collection timeline allowed us to obtain nic minorities, older adults, and those with chronic Others offered more general statements that re- are viewed as trusted sources of information, are feedback before and after the vaccine became health conditions. They were not convinced that flected this lack of trust saying that residents,“do needed to disseminate information about COVID-19 available. Attitudes towards testing changed over these groups were appropriately represented in not trust them. Do not trust the government.” that addresses the specific concerns raised in the time with most of the residents in the later groups the clinical trials. These beliefs persisted in the FGs. This model has the potential to increase resi- having been tested and fewer raising concerns final focus group, which occurred after vaccines In contrast to the English language focus groups dents’ access to accurate information and increase about testing safety. A lack of convenient testing became available. In that group two residents that included primarily African American parti- trust in both the testing process and vaccination. sites remained a barrier. However, just as residents were vaccinated but among others the reserva- ci-pants, those in the Spanish language group are becoming more inclined to get tested, residents tions described in the first few groups persisted. report-ed no vaccine hesitancy except for some Similarly, there is a need to disseminate accurate believe that once vaccinated they no longer need- concerns about having a preexisting condition that information through channels that are trusted ed to be tested. Again, accurate and consistent The few residents who were willing to get the might result in a side effect from the injection. This by the community to reduce vaccine hesitancy. messaging from trusted sources will continue to be vaccine acknowledged that they did not know the higher level of trust may have been due to timing. Educational information should include data that important as the pandemic and response evolves. long-term effects and indicated that they knew they This focus group was hosted later in the timeline of participants indicated would be most likely to would still have to protect themselves with a mask vaccine distribution and therefore residents would motivate them to get vaccinated. This included Ongoing engagement with community-based and maintain social distance. One resident who didRiis have been exposed to more information that may specific breakdowns of vaccine efficacy among organizations like HCCI and HSS is a core compo- want to get vaccinated was rethinking this decision have impacted their beliefs. Another possibility for subgroups (e.g., older adults, racial/ethnic mi- nent of these efforts given the central role they are based on others’ opinions, “[I] think I’m going to •takehttps://upload.wikimedia.org/wi differing attitudes may be a shorter history of ex- norities). In addition, data on safety among the playing in addressing COVID-19 related challenges it. I really don’t have doubts, but people put doubts kipedia/commons/c/cc/Riis_Houin periencing injustices in the US health care system millions already vaccinated would address the in the communities they serve. my head sometimes.” This comment demonstratesses_%282020%29.jpg system due to length of time in the country. Rangel

Polo Grounds Polo Grounds Rangel Riis Vladeck Vladeck Pink Pink Cypress Cypress • Source: https://www.flick • Source: r.com/photos/28 https://www.flickr.com https://www • Source: https://newyork 516908@N08/32 /photos/joelrnyc/2429 .vice.com/sv/ https://www.n 65386204/in/pho 9731390/in/pool- article/bnpk .cbslocal.com/2 nycha/ ydailynews.co tolist-cUJ2JS- p3/one-of- 010/11/02/the- cUJ3FC-cUJ9Du- new-yorks- m/news/crime most- /nycha- polo-grounds- cUHZgG-cUHY4d- dangerous- then-and-now/ cUHVW7-cUJ8qY- housing- residents-rise- cUJ7kj-cUJ6cE- projects- major-crime- cUHUUQ- now-has-its- 2016-article- cUJ4Ub-mErLHn- own- Rangel Vladeck youtube- 1.2934944 dTYDjF-5YxXy9 show Polo Riis Pink • https://upload. https://www.flickr.com/ph Grounds otos/joelrnyc/1839517579 wikimedia.org/ • https://ny.cu 0/in/pool-nycha/ • Source: Cypress wikipedia/com rbed.com/20 https://ww https://nymag. mons/1/16/Ra 19/8/12/208 w.bkreader. • Source: com/intelligen ngel_Houses_ 02171/nycha com/2017/ https://www.s cer/2017/06/c NYCHA_jeh.jpg -audit-fema- 05/11/nych tvinc.com/proj ould-the- sandy- Vladeck a-farms- ect/nycha- grenfell-tower- Polo Grounds/Rangel recovery- bring-fresh- cypress-hills- disaster- work-city- Pinkproduce- boiler-and- • Source: happen-in- council https://www.flickr.co residents/ Cypressdomestic-hot- new-york.html https://www. m/photos/jeklee/4654 water-heater- flickr.com/ph 33534/in/photolist- • https://ww otos/154999 Riis H8tb7-jpk5fQ-jpgM8t- •replacementsSource: Polo 14@N06/908 jpgLRB-7jxZdA- w.usdoh.org https://u 2129056/size https://www.fli 2kfFx1Y-bmMu6v- pload.wi s/l/ ckr.com/photos /property/n Grounds /nicolasoran/63 8eiMQn-ntL6pp- kimedia. • Source: 37517836/sizes YM7ujw-9o2UbD- y_Linden_lo org/wiki /l/ hcjG3t-KUcU9B- u2w5Th-5BZVPa- uis-heaton- pedia/co https://www.fli pdJ1My-efxcB1- mmons/ ckr.com/photo 8en5fW-e1waDU- pink-houses 1/12/Cy s/wallyg/21347 7jyjsG-8en5ho- press_Hil 8eiNGP-8L92tN- 0920 efxc3S-2cWycCJ- l_Houses efxbtw-efxbZo-efxbqq- _NYCHA efxbi7-2kftUbS- _jeh.JPG jqTtWM-5zWsK1- 5zSaUe-2dPzeqG- efxcu9-efrsrr-efxchN- efxbE7-efxcpA-efrrRp- efrs1M-efrqvP-efrs7Z- efxazJ-oWfLst-efxaYA- pdKXDi-efrrBz-efxbSm- efrrDK/ Report Authors and Suggested Citation: “Kaitlyn VanAllen MPH, Emily Gill MPH, Chigozirim Izeogu MD, Filippa Juul PhD, Albert Tovar, Natasha Williams PhD, Lorna E. Thorpe PhD, Donna R. Shelley MD, MPH. NYC Housing Authority Resident COVID Response (RCR) Project: Focus Group Analysis and Summary. April 2021.”

NYCHA IMAGE SOURCES:

Polo Grounds Vladeck • newyork.cbslocal.com/2010/11/02/the-polo- • www.flickr.com/photos/joel- grounds-then-and-now/ rnyc/24299731390/in/pool-nycha/ • www.nymag.com/intelligencer/2017/06/ • www.flickr.com/photos/joelrnyc/18395175790/ could-the-grenfell-tower-disaster-happen-in- in/pool-nycha/ new-york.html • www.flickr.com/photos/jeklee/465433534/in/ • www.www.flickr.com/photos/wallyg/213470920 photolist-H8tb7-FCEwB

Rangel Pink • www.flickr.com/photos/28516908@ • www.vice.com/sv/article/bnpkp3/one-of-new- N08/3265386204/ yorks-most-dangerous-housing-projects-now- • upload.wikimedia.org/wikipedia/com- has-its-own-youtube-show mons/1/16/Rangel_Houses_NYCHA_jeh.jpg • www.bkreader.com/2017/05/11/nycha-farms- • www.flickr.com/photos/15499914@ bring-fresh-produce-residents/ N06/9082129056/sizes/l/ • www.usdoh.org/property/ny_Linden_louis-hea- ton-pink-houses Riis • upload.wikimedia.org/wikipedia/commons/c/ Cypress cc/Riis_Houses_(2020).jpg • www.nydailynews.com/news/crime/nycha-resi- • ny.curbed.com/2019/8/12/20802171/nycha-au- dents-rise-major-crime-2016-article-1.2934944 dit-fema-sandy-recovery-work-city-council • www.stvinc.com/project/nycha-cypress-hills-boil- • www.flickr.com/photos/nicolaso- er-and-domestic-hot-water-heater-replacements ran/6337517836/sizes/l/ • upload.wikimedia.org/wikipedia/commons/1/12/ Cypress_Hill_Houses_NYCHA_jeh.JPG