Capstone Project Topic Selection and Approval

African Americans and COVID-19: Beliefs, behaviors and vulnerability to infection Elyria Kempa, Gregory N. Pricea, Nicole R. Fullera and Edna Faye Kempb

aCollege of Business Administration, University of New Orleans, New Orleans, LA, USA; bKemp Dentistry, Indianapolis, IN, USA

ABSTRACT In the United States, during the early outbreak of the coronavirus (COVID-19) pandemic, African Americans experienced disproportionately high rates of infection and mortality relative to their share of the United States population. New Orleans, Louisiana was one of the places most heavily affected by the coronavirus during its early outbreak. The study that follows explores the attitudes of African Americans in New Orleans toward the virus, social and normative conditions which affected individual behaviors, as well as access to healthcare services and COVID-19 testing. In part one of the study, qualitative responses were collected from a sample of African Americans in the New Orleans area to garner perspective about their attitudes and behaviors related to the coronavirus outbreak. Part two of the study builds on findings from Study 1 with parameter estimates from a Logit regression to examine how social, economic and physical conditions determine vulnerability to COVID-19 infection among African Americans. Implications for how healthcare organizations can address the needs of vulnerable populations during a health-related crisis are discussed.

ARTICLE HISTORY Received 13 May 2020 Accepted 22 July 2020

KEYWORDS Health equity; Social determinants of health; African Americans; COVID-19; Theory of planned behavior

In 2020, the World Health Organization declared the novel coronavirus, or COVID-19, a global health emer- gency as it spread ferociously across the globe [1]. The first confirmed case of the virus appeared in January 2020 in the United States [2]. Within months, the virus sickened many and resulted in thousands of deaths.

As more data emerges regarding the impact of COVID-19 in the United States, it has become evident that the virus has affected racial and ethnic minorities at an alarmingly high rate. Specifically, African Amer- icans have experienced disproportionately higher rates of infection and mortality than their representative share of the United States population [3,4]. In early May 2020, African Americans accounted for approxi- mately 34% of total COVID-19 deaths in states where they represent only about 13% of the state’s population [3]. Some states reported even more egregious dispar- ities. For example, in Louisiana blacks accounted for 70% of the deaths from COVID-19, but only 33% of the population. Similarly, in Alabama, blacks accounted for 44% of COVID-19 deaths, yet only make up 26% of the state’s population [5].

Some officials have linked the disproportionate numbers regarding the effect of the virus on African Americans to individual behavior (i.e. including practi- cing unhealthy behaviors and suffering from comor- bidities which make the coronavirus more deadly) [6]. However, the situation is likely more nuanced. African Americans are more likely to work in service

sector jobs and were deemed ‘essential workers’ during the coronavirus outbreak [7]. In larger urban areas, they are also are more likely to use public transit – all which place them in closer contact to others and make them more susceptible to the virus [6].

This research examines the attitudes, behaviors as well as social and physical conditions of African Amer- icans in New Orleans, Louisiana, and their perceived vulnerability to COVID-19 infection. New Orleans was one of the places most heavily affected by the cor- onavirus during its early outbreak. In March 2020, New Orleans experienced one of the fastest growth rates in new cases of COVID-19 in the world [7]. By early May, the city reported over 450 deaths from the virus, with African Americans making up over 75% of the deaths [8]. The study that follows explores the attitudes of African Americans in New Orleans toward the virus, social and normative conditions which affected individual behaviors, as well as access to healthcare services and COVID-19 testing. The study applies two distinct methodological techniques to pro- vide insight. In part one of the study, qualitative responses were collected from a sample of African Americans in the New Orleans area to garner perspec- tive about their attitudes and behaviors related to the coronavirus outbreak. Part two of the study builds on findings from Study 1 by examining how social, econ- omic and physical conditions determine vulnerability to virus infection and COVID-19 testing participation. Implications for how healthcare organizations can

© 2020 Informa UK Limited, trading as Taylor & Francis Group

CONTACT Elyria Kemp [email protected] College of Business Administration, University of New Orleans, 2000 Lakeshore Drive, New Orleans, LA 70148, USA

INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 2020, VOL. 13, NO. 4, 303–311 https://doi.org/10.1080/20479700.2020.1801161

address the needs of vulnerable populations during a health-related crisis are discussed.

Conceptual background

Individual behavior – attitudes, beliefs and norms

During the early months of the coronavirus outbreak, a significant part of containing the spread of the virus in the United States involved following the guidelines proposed by the Centers for Disease Control and Pre- vention (CDC) and the White House Coronavirus Taskforce. During March 2020, these guidelines included avoiding social gatherings of 10 or more people; social distancing by remaining at least 6 feet from others in public spaces; using drive-thru, pick- up or delivery options at restaurants and grocery stores; avoiding discretionary travel, not visiting nursing homes or long-term care facilities unless providing critical assistance; and finally, practicing good hygiene, such washing hands, avoiding touching the face, sneez- ing or coughing on a tissue or into the elbow, and dis- infecting surfaces (note: wearing face masks were not recommended until April 2020) [2,9]. Government and private entities disseminated messaging in various media encouraging the practice of these behaviors to help mitigate the spread of the virus.

According to the psychology literature, one’s atti- tudes and beliefs are linked to whether one will practice a certain behavior. For example, in the theory of planned behavior (TPB) there are three determinants of behavioral intention – attitude toward the behavior, subjective norms, and perceived behavioral control [10]. Attitudes toward the behavior address the extent to which a person has a favorable or unfavorable appraisal of the behavior in question. Subjective norms are social variables that reflect the perceived social pressure to perform or not to perform the behav- ior. Finally, perceived behavioral control addresses the perceived ease or difficulty in performing the behavior and captures past experiences as well as anticipated obstacles. The more favorable the attitude and subjec- tive norms regarding the behavior, and the greater the perceived behavioral control, the stronger an individ- ual’s intention to perform the behavior in question [10,11].

To a considerable degree, individual behavior in adhering to the guidelines and directives of govern- ment officials and health experts would impact the pro- liferation of the coronavirus and the likelihood of being infected with the virus. Thus, intentions to practice rec- ommended behaviors to contain the virus might be determined by considering the attitudes of individuals about the severity of the virus and the need to control the spread as well as social and normative pressures to perform or not perform the recommended behaviors.

In addition, examining the perceived difficulty individ- uals had in not practicing recommended behaviors (e.g. having to leave home for work or to care for a loved one) might also play a factor.

Access to health services

In addition to considering individual behavior, both access to healthcare and the quality of health services can influence health. Lack of access to quality health services can affect an individual’s health status. For example, due to limited availability to healthcare, an individual may be less likely to participate in preventive care as well as delay medical treatment [12].

Public health practitioners and policy makers are beginning to consider the broader determinants of health as part of a more inclusive approach to improv- ing health [13]. For example, social determinants of health are social factors and physical conditions in the environment which impact health status and sub- jective wellbeing. Social determinants of health are also affected by the availability of resources to meet daily needs, such as educational and job opportunities, living wages, healthy foods, discrimination, social sup- port, exposure to mass media and emerging technol- ogies, socioeconomic conditions and transportation options [14–16]. Addressing social determinants of health is essential to eradicating systematic disparities in health and achieving health equity. Health equity is when everyone has the opportunity to realize their full health potential, barring the inability to do so because of social position or other socially determined circumstances [17].

With respect to COVID-19, individual behavior, which included adhering to the guidelines delineated by the CDC and the White House Coronavirus Task- force, played a central role in reducing infection rates. As literature from the behavioral sciences suggests, such behavior may be predicated on an indi- vidual’s attitudes toward the behavior, social pressures, and elements within the individual’s control to perform the behavior [10]. In addition, social, economic and physical conditions as they relate to access to quality healthcare can play a role in virus detection, treatment as well as mortality rates from the virus. The study which follows first examines the attitudes and beha- viors of African Americans in New Orleans as they relate to COVID-19. It then explores how social, econ- omic and physical conditions are related to access to healthcare services and COVID-19 testing.

Study part I: Beliefs and behaviors

Methodology

The research participants in this study were African Americans who reside in New Orleans. African

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Americans comprise about 59% of the population in New Orleans [18]. We enlisted Qualtrics, a professional research firm for our data collection efforts. Enforced quota constraints were applied in our sampling with the goal of attaining a research panel demographically representative of African Americans in the city of New Orleans. Following appropriate ethical research approval (from the Institutional Review Board), responses were collected online from a panel consisting of 104 participants from 11–22 April 2020. Sixty-seven percent of participants were female and thirty-three percent were male. The mean age was 40 and 35% of participants self-reported as ‘essential workers’ during the coronavirus outbreak (see Table 1). Participants were asked questions concerning their attitude toward the virus, normative and economic conditions which may have affected their ability to comply with direc- tives of government officials, as well as their percep- tions regarding healthcare access.

Our data analysis enlisted a form of content analysis where themes were identified using a cod- ing process. The goal of this approach was to recog- nize themes based on the experiences and observations of participants [19]. We independently performed a comprehensive assessment of the data and developed themes. Next, using an iterative, back-and-forth reading process [19,20] we achieved general consensus on themes which repeatedly appeared across participants’ responses. The follow- ing are emergent themes which were consistent with the responses from the participants. Participants were assigned aliases.

Results: Thematic findings

Attitudes toward the virus and susceptibility Attitudes are an organization of beliefs, feelings, and behavioral tendencies towards significant objects, groups, events or symbols [21]. Knowing a person’s attitude helps predict their behavior. Many of the respondents in our research acknowledged the serious- ness of the coronavirus. As a result, they expressed that they were making efforts to safeguard themselves from possible infection. This sentiment was echoed in the comments of many participants.

“COVID is a serious virus. I’m hoping that I don’t catch it … but I am taking all the precautions to protect myself.” Mary, 61, Educator

“Since I am at high risk, I really practice social distancing and avoid all risky situations. As a private nurs,e I only have one patient for the patient’s safety as well as mine. My siblings also take care with associations and practice hand safety.” Jackie, 66, Nurse

Unfortunately, some participants had lost loved ones to COVID-19. They also expressed how the health crisis was taking a toll on them emotionally.

“I have had at least two emotional breakdowns. It takes a lot to remove the focus off the crisis and refo- cus on other things.” Marguerite, 60, PBX Operator

However, younger respondents were more optimistic about their vitality, and felt less susceptible to the virus.

“My family and I are very healthy. We have a very [strong] immune system. So we aren’t very likely to catch COVID-19.” Lakeisha, 21, Cashier

Attitude toward government leaders and health experts People expect their leaders to be consistent and model what they advise for their constituents [22]. During the coronavirus outbreak, trust was an important factor as people looked to their leaders for knowledge and infor- mation. Trust embodies a dynamic, relational link between people and is meaningful in situations in which one party is at risk or vulnerable [23]. Many respondents had mixed feelings about leadership, indi- cating some confidence in state and local political officials, while expressing distrust in federal leadership.

“I don’t trust anyone implicitly, especially politicians! I trust the mayor to give as much info as she can give without causing a panic. I see how she is trying to do as much as she can. I trust the governor as much as I can. I see where he is trying … .As far as federal leaders, I don’t trust them at all. Most of what they say and do is self-serving …” Evelyn, 70, Retired Administrative Assistant

Table 1. Summary of respondents’ demographics. Count Proportion Average

Observations 102 Male 33 32% Age 40 18–39 53 52% 40–59 25 25% ≥60 23 23%

Single 64 63% Education Some high school 6 6% High school diploma 21 21% Some college 24 24% College degree 27 26% Post-grad degree 24 24%

Income $36k–$50k ≤ $25k 41 40% $26k- $50k 24 24% $51k- $75k 17 17% $76k - $150k 14 14% ≥ $151k 5 5%

Essential worker 36 35% Unemployed 21 21% Top Industries Arts & Entertainment 12 12% Education 10 10% Restaurants 8 8% Healthcare 8 8% Social Services 3 3%

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“It’s hard to trust … I admire the job that our Mayor is doing … Not hearing too much from the Gover- nor. The president is trying, but he lies so much …” John, 48, Longshoremen

Participants appeared to have more trust in health experts and expressed sympathy and gratitude towards front-line healthcare workers.

“I do trust the health officials. They are working under harsh situations with limited supplies to help and heal others. They are putting their own life and their families in danger of the virus. They want this to end much more than we do. I trust they are trying to find a cure to protect us in the future.” Sheila, 52, Educator

However, participants did exhibit some frustration with the information they were receiving from health officials. They acknowledged that there had been a fair amount of equivocation regarding best practices to combat the virus. In some ways, a modicum of dis- trust existed with the way some things had been handled during the nascent stages of the virus out- break. Nonetheless, many conceded to the reality that circumstances were novel, and that health experts were learning new things daily.

“I know they are learning more about it every day given that this disease hasn’t been seen before, but they need to get their facts straight. They’re constantly giving out information that contradicts infor- mation they gave out previously. We’ve seen time and time again with any infectious disease that masks have been used to contain the spread, but because they can’t afford to have enough mass pro- duced for every single person they are telling us that we don’t need them. They’ve let weeks and weeks go by without it being required.” Carrie, 25, Self-Employed

“Most of the information [from healthcare experts] I trust, but who knows what to believe.” Tammy, 21

Because attitudes provide meaning and knowledge, understanding attitudes can predict behavior. Many of the participants in this research recognized the ser- iousness of the coronavirus. However, there were some participants, primarily younger adults (ages 35 and under), who were not convinced about the ferocity of the virus. Furthermore, leadership during crisis moments plays an important role. During uncertain times, informed and trustworthy leadership is para- mount. Participants had a measure of distrust and cynicism toward federal political leaders. However, many trusted the leadership at the local and state level. They also looked to health experts for advice while acknowledging that the situation was fluid.

Social norms and social distancing Subjective or social norms are variables which refer to the belief that an important person or group of people will approve and support a certain behavior [10,24]. Subjective norms can be measured and accessed from the perspective of expectations set by referent groups such as family, relatives, and friends, in terms of whether an individual should or should not engage in a behavior. Subjective norms may also include descrip- tive norms, which refer to actual activities and beha- viors others are undertaking [24]. In the case of descriptive norms, individuals may not only be con- cerned with what others think, but also with how others behave.

Norms within New Orleans emphasize culture, tra- dition and celebration. The city is known for the axiom ‘laissez les bons temps rouler,’ meaning ‘let the good times roll.’ People in New Orleans are very ‘social.’ In fact, the popular press has ranked New Orleans as one of the friendliest cities in the United States [25,26]. Given these social norms, maintaining physical distance was challenging for some.

“I know for a fact that some are not social distancing. I have spoken to friends who have been attending par- ties, baby showers, crawfish boils, card games–all with multiple people. They totally believe that the virus is like the flu and they will recover if they get it. It’s like they don’t know or care about the way this virus affects us all.” Nancy, 47, Bank teller

“When I was in the store yesterday, people were walking around like nothing is going on. A few of us had on masks and long sleeves and so forth. But a large group of people were out with no protection, with kids running around and no protection, and not adhering to any social distancing guidelines …” Evelyn, 70, Retired Administrative Assistant

“People can say that they’re doing it, but actually aren’t … like my neighbors playing basketball in the street–between 8–12 guys … unbelievable...” Diane, 62, Law Enforcement

One young adult participant was very candid about his lack of effort to social distance.

“Not really [not social distancing],but it’s other people opinion,” Carl, 21

Although several of the participants noticed that other people were not social distancing, the majority indicated that physical distancing had become the ‘new norm’ among family and friends.

“I call, email and text my friends and colleagues. My children and grandchildren call me and text me. They have not come over since March 13, 2020.” Geraldine, 63, Educator

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“The only thing I do is to go for a walk/jog, and I have been to my students’ homes to leave a message on their front porches and deliver Easter treats.” Sheila, 52, Educator

Control limits and disparities Perceived behavioral control addresses the perceived ease or difficulty in performing a behavior and captures anticipated obstacles. For some of the participants in this research, self-isolation was infeasible. Specifically, Americans were advised to work from home during the early stages of the coronavirus outbreak; however, according to the Economic Policy Institute, only 19.7 of African American have jobs which allow them to work from home [27]. In our study, 35% s of partici- pants self-reported as ‘essential workers.’ Subsequently, some were working away from home during the outbreak:

“My job is considered essential, but … precautions are being taken.” John, 48, Longshoremen

Moreover, and unfortunately, income and race play a role in determining who uses New Orleans’s public transit systems to travel to work. In New Orleans, 91% of White/Caucasian households have at least one car, compared with just 74% of African American households [28]. Reliance on public transit further decreases the likelihood of social distancing.

During the outbreak, older adults were advised to self-isolate [29]. This included grandparents isolating themselves from grandchildren. In New Orleans, 12.2%of African Americans 60 years and older live in multigenerational households, compared to 3.8% of white elders [30]. Such living conditions, where grand- parents live with their grandchildren, might make them more susceptible to COVID-19. One of our partici- pants addressed this reality.

“Since I am elderly and in only fair health, I believe that I could get the virus. I worry about my kids and grandkids since I do have contact (at home) with them.” Linda, Retired, 62

Health services. Given African Americans’ dispropor- tionate COVID-19 infection and mortality rates, par- ticipants in this research were asked about their personal access to health care as well as their percep- tion of the quality of healthcare they receive. In 2016, Louisiana accepted Medicaid expansion (created in the Patient Responsibility and Affordable Care Act passed by the U.S. Congress in 2010). Louisiana’s Med- icaid expansion program provided health insurance for non-elderly adults with income less than 138% of the Federal Poverty Level. As a result of the expansion pro- gram, the uninsured rate in Louisiana fell by half –

from 22.7% to 11.4% – from 2015 to 2017 [31,32]. While Medicaid expansion was instrumental in extend- ing access to healthcare, participants still questioned the quality of care and health equity for African Americans.

- “I am aware that some do not [receive the same level of care as others]. I have private insurance. I worked in health care. I see the bias shown to the poor, homeless, mentally challenged, those with addictions, overweight …” Harriet, 48, Retired Healthcare Worker

- You get turned away when you can’t pay or you’re sent to lower quality hospitals. Iris,34, Bartender

Some specifically felt that health inequities exist.

“I’m Black and people seem to not take my words as seriously as others–even when I’m suffering.” Samuel, 29, Hospitality

“I do believe that black women have to be aggressive about their healthcare. I have had to make sure I bring questions with me to all my doctor visits. Some important information is sometimes left out of the visit. Seemingly, if I don’t ask, the doctor won’t tell me all of the information I need.” Kay, 55, Administrator

In summary, behavior may be predicated on an indi- vidual’s attitude toward a behavior, social pressures, and elements within the individual’s control to perform the behavior [10]. The first part of this study examined the attitudes and behaviors of African Americans in New Orleans during the early outbreak of the corona- virus. Many of the participants recognized the serious- ness of the coronavirus. However, there were some participants, primarily younger adults (ages 35 and under), who were not compelled by the seriousness of the virus. Furthermore, during the early stages of the coronavirus outbreak, trust from leadership was an important factor as people looked to their leaders to shape attitudes about the virus. Responses from par- ticipants reveal a measure of distrust and cynicism toward federal political leaders. However, many trusted local leadership as well as the health experts.

The opinions and actions of others, or subjective norms, also affect the behavior of individuals [10]. Par- ticipants recounted instances where they noticed others who were not physically distancing. Nonetheless, the majority of the participants in this research indicated that they were taking measures to physically distance. The ‘norm’ had been set among family and friends to engage in this behavior.

There were some participants in this research who discussed how their circumstances did not permit them to completely self-isolate. For example, some respondents indicated that living in mutigenerational housing or having to continue to go to their ‘essential’

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jobs exposed them to more people. Finally, the high rate of African American mortality from COVID-19 was concerning for participants. At a macro level, par- ticipants offered considerable discussion regarding the state of healthcare for African Americans and ques- tioned whether true health equity exists in commu- nities. In the second part of our study, we examine specific factors influencing access to healthcare and health equity for African Americans in New Orleans as it relates to COVID-19 testing.

Part II: COVID-19 testing in New Orleans

Methodology

In response to evidence that COVID-19 infections and deaths have impacted African Americans disproportio- nately [4,33,34], our survey data captured information on individual characteristics that may be possible dri- vers of racial disparities in COVID-19 infections. We measured these individual characteristics to first deter- mine, via a rigorous least absolute shrinkage and selec- tion operator, or LASSO [35], the best predictors of taking a COVID-19 test among survey respondents. LASSO is a machine-learning algorithm to identify regressors, via induction, that best explain/predict an outcome – regressand – of interest [36].

Results

Table 2 reports the results of the predictive covariate selection from the rigorous LASSO among all the quantitative covariates in the respondent survey. We used the RLASSO procedure in Stata 15 [37]. In gen- eral, RLASSO selects regressors that minimize the mean squared prediction error, subject to a penalty

on the absolute size of coefficient estimates. The pre- dicted outcome of interest is a binary variable indicat- ing whether a survey respondent was tested for COVID-19. Among the quantitative covariates, the RLASSO selected the respondent’s age, whether he/ she is an essential worker, and the respondent’s self- reported health status as predictors.

Given the selected predictors, Table 3 reports par- ameter estimates across five Logit specifications to determine how these predictors matter for the prob- ability of an individual having had a COVID-19 test. We report Pseudo-R2 and the xs statistic for the joint significance of all the parameters as goodness-of-fit measures. To inform practical versus statistical signifi- cance, we report parameters as an odds ratio, which indicates the quantitative impact a regressor has on the outcome of interest. An odds ratio less(greater) than unity indicates that having a particular

Table 2. Rigorous Lasso variable selection. Covariate Definition Selected

Age Age of respondent in years Yes College Binary variable equal to No

unity if respondent has a baccalaureate degree

Essential Worker Binary variable equal to Yes if respondent is an essential worker

Health Respondent’s position in Yes health quintile distributiona

Household Size Number of people in No in respondent’s household

Male Binary variable equal to No if respondent is a Male

Married Binary variable equal to No if respondent is Married

Median Income Median Income in No Respondent’s zip codeb

Notes: aDerived from respondent’s self-reported 1–10 health-rating, with 10 being the highest-rated measure of health. For each respondent, the measure was converted to a position in a distribution of quintiles.

bSource: https://www.incomebyzipcode.com/louisiana/70119.

Table 3. Logit odds ratio parameter estimates: COVID-19 testing in Orleans Parish. Specification (1) (2) (3) (4) (5)

Regressand: Respondent has been tested for COVID-19

Regressors: Constant .467 .552 .466 .467 .466

(.706) (.775) (.613) (.577) (.317) Age .971 .969 .971 .971 .971

(.240) (.186) (.322) (.106) (.314) College 4.21 3.82 4.21 4.21 4.21

(.032)b (.042)b (.037)b (.042)b (.116) Essential Worker .309 .277 .309 .309 .309

(.065)c (.040)b (.032)b (.008)a (.001)a

Health 1.64 1.74 1.64 1.64 1.64 (.124) (.101)c (.048)b (.053)c (.011)a

Standard Error Robust Zip Code Industry Household Marital Clustering Employed Income status

Number of Observations 102 99 102 102 102 Pseudo-R2 14.49a 16.14a 11.13b 19.48a 21.65a

Ho: ∑

b i = 0 .199 .214 .199 .199 .199 (x 2 k−1) Akaike Information Criterion 75.28 73.39 75.28 75.28 71.27

Notes: Approximate P-value in parentheses. aSignificant at the .01 level. bSignificant at the .05 level. cSignificant at the .10 level.

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characteristic measured by a regressor increases (decreases) the probability of testing for COVID-19. We also report the value of the Akaike Information Criterion (AIC) [38] which measures the information discrepancy between the estimated model and the true population model. A smaller AIC suggests less dis- crepancy between the estimated model and the true population model.

The first column in Table 3 reports parameter estimates with robust standard errors. The last 4 cluster the standard errors on a respondent’s zip code, indus- try of employment, household income, and marital status, which may be a source assignment into the treatment of having been tested for COVID-19. This mitigates bias in the parameter estimates [39]. Across the parameter estimates, being an essential worker and position in the health quintile are always statisti- cally significant. More specifically, essential workers are approximately 61% less likely to have been tested for COVID-19, and individuals in the top quintile of self-reported good health are approximately 64% more likely to have been tested for COVID-19.

In general, the parameter estimates in Table 3 suggest that the disproportionate COVID-19 burden borne by African Americans is possibly driven by race-based testing disparities. The sign and magnitude of the estimated odds ratio suggest that, at least in New Orleans, Louisiana, African Americans employed as essential workers, and those who are in poor health, are less likely to be tested for COVID-19. As such, the most vulnerable African American citizens are at risk of being infected with COVID-19 and not being treated. This increases the risk of COVID-19 related deaths among African Americans, and contributes to race-based disparities in COVID-19 deaths.

Discussion

During the early stages of the coronavirus outbreak, African Americans were dying from the disease at alarming rates [3,4]. This research examined the atti- tudes and beliefs of African Americans in the city of New Orleans concerning COVID-19. It also investi- gated how social, economic and physical conditions determine vulnerability to infection as well as COVID-19 testing participation among African Amer- icans. Findings in our study indicate that Americans did recognize COVID-19 as a threat and many were making efforts to socially distance. However, there may have been factors beyond their control that pre- cluded some from completely self-isolating. This included the inability to work from home as well as liv- ing in multigenerational housing. Further, results also revealed that some of the most vulnerable (i.e. least healthy and essential workers) in the study were at risk of being infected with COVID-19 and not being treated. This increases the risk of COVID-19 related

deaths among African Americans, and contributes to race-based disparities in COVID-19 deaths.

Implications for healthcare organizations Findings from this research underscore the need for health care organizations to work to ensure that societal decisions about the distribution of health resources safeguard the interests of patients and pro- mote access to health services. Especially during a health-related crisis, individuals look to healthcare pro- viders for information. Health care providers can employ a collaborative, patient-centered approach that promotes trust [40]. Health care providers should consider how an individual’s circumstances (e.g. access to transportation, healthy foods) impact the effective- ness of health promotion efforts. For example, many healthcare providers ramped up telehealth efforts during the coronavirus pandemic. Telehealth, when appropriate, can help close the disparity gap in tra- ditionally underserved and vulnerable patient popu- lations. It can facilitate health service delivery by overcoming transportation obstacles and economic status. In addition, mobile health clinics [41] might be an effective way to provide health services (i.e. COVID-19 testing) to vulnerable populations.

Further, during a health crisis such as the COVID- 19 pandemic, healthcare organizations and policy makers should direct targeted messages at vulnerable populations through appropriate media [42,43]. There were some young adults in our study who did not fully accept that COVID-19 was a serious threat. Special social marketing efforts to reach this group might be warranted. In addition, communication efforts should also be tailored to a group’s risk level. Sometimes persons most affected by a disease outbreak or health threat perceive the risk differently from health experts.

In addition to addressing the physical needs of vul- nerable populations during a health crisis, mental health must also be a priority. Many of the participants in this study were very anxious about the virus out- break and a few had lost loved one. During crisis moments, people may be experiencing grief, stress, depression and worry. For some, these feelings may become overwhelming. Making resources available to these populations should be paramount.

Limitations and future research Although this research provides insight on how health- care organizations can address the needs of vulnerable populations during a health-related crisis, future research opportunities abound. One of the limitations of this research is that it only explored the beliefs, beha- viors and circumstances of one ethnic minority group in the United States. Other ethnic minority groups who may be at risk during a health-related crisis might be examined. For example, Latinos also

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experienced high coronavirus infection rates in urban areas in the United States [44]. In addition, other vul- nerable groups, including the elderly, the disabled, pregnant women and the impoverished should be con- sidered in future research.

Further, this research suggests that essential workers might be those less likely to receive appropriate medi- cal care and attention during a health-related crisis. Future research might embark on a more comprehen- sive investigation regarding essential workers. More information on how this work segment is defined, and how their needs can be addressed during a health-related crisis would provide insight and direc- tion for needed public policy to ensure the safety of these individuals.

Finally, when examining the health status of various populations, health organizations, institutions, and education programs are encouraged to also address underlying elements related to social determinants of health. This involves understanding the dynamic inter- action between behavioral, clinical, policy, and environmental determinants of health.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Notes on contributors

Elyria Kemp, PhD is Associate Professor of Marketing in the College of Business Administration at the University of New Orleans. She holds the Edward G. Schlieder Chair in Higher Education and Health Initiatives and the Bank One Endowed Professorship in Minority & Emerging Business

Gregory N. Price, PhD is Professor of Economics in the Col- lege of Business Administration and the Urban Entrepre- neurship & Policy Institute at the University of New Orleans

Nicole R. Fuller, PhD is Assistant Professor of Management in the College of Business Administration at University of New Orleans

Edna Faye Kemp, DDS is a practicing dentist at Kemp Den- tistry and in the public healthcare sector in Indianapolis, Indiana

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[3] John Hopkins University and Medicine. Racial data transparency [Internet]. 2020 [cited 2020 May 1]. Available from: https://coronavirus.jhu.edu/data/ racial-data-transparency.

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