Proposal (Government essay)

RESEARCH ARTICLE

Using a rapid assessment methodology to

identify and address immediate needs among

low-income households with children during

COVID-19

Shreela V. Sharma1☯, Amier HaidarID 1☯*, Jacqueline Noyola2☯, Jacqueline Tien2☯,

Melinda Rushing1☯, Brittni M. Naylor1☯, Ru-Jye Chuang1☯, Christine Markham3☯

1 Department of Epidemiology, Human Genetics and Environmental Sciences, Michael & Susan Dell Center

for Healthy Living, The University of Texas Health Science Center at Houston (UTHealth) School of Public

Health, Houston, TX, United States of America, 2 Brighter Bites, Houston, TX, United States of America,

3 Department of Health Promotion and Behavioral Sciences, The University of Texas Health Science Center

at Houston (UTHealth) School of Public Health, Houston, TX, United States of America

☯ These authors contributed equally to this work. * [email protected]

Abstract

Objective

Brighter Bites is a school-based health promotion program that delivers fresh produce and

nutrition education to low-income children and families. Due to COVID-19-related school

closures, states were under “shelter in place” orders, and Brighter Bites administered a

rapid assessment survey to identify social needs among their families. The purpose of this

study is to demonstrate the methodology used to identify those with greatest social needs

during this time (“high risk”), and to describe the response of Brighter Bites to these “high

risk” families.

Methods

The rapid assessment survey was collected in April 2020 across Houston, Dallas, Washing-

ton DC, and Southwest Florida. The survey consisted of items on disruption of employment

status, financial hardship, food insecurity, perceived health status and sociodemographics.

The open-ended question “Please share your greatest concern at this time, or any other

thoughts you would like to share with us.” was asked at the end of each survey to triage

“high risk” families. Responses were then used to articulate a response to meet the needs of

these high risk families.

Results

A total of 1048 families completed the COVID-19 rapid response survey, of which 71 fami-

lies were triaged and classified as “high risk” (6.8% of survey respondents). During this time,

100% of the “high risk” participants reported being food insecure, 85% were concerned

about their financial stability, 82% concerned about the availability of food, and 65%

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OPEN ACCESS

Citation: Sharma SV, Haidar A, Noyola J, Tien J,

Rushing M, Naylor BM, et al. (2020) Using a rapid

assessment methodology to identify and address

immediate needs among low-income households

with children during COVID-19. PLoS ONE 15(10):

e0240009. https://doi.org/10.1371/journal.

pone.0240009

Editor: Michael L. Goodman, University of Texas

Medical Branch at Galveston, UNITED STATES

Received: June 24, 2020

Accepted: September 17, 2020

Published: October 1, 2020

Copyright: © 2020 Sharma et al. This is an open access article distributed under the terms of the

Creative Commons Attribution License, which

permits unrestricted use, distribution, and

reproduction in any medium, provided the original

author and source are credited.

Data Availability Statement: All relevant data are

within the manuscript and its Supporting

Information files.

Funding: SS received funding for the study

provided by Brighter Bites through Feeding Texas

and the Texas Health and Human Services

Commission. The funders had no role in study

design, data collection and analysis, decision to

publish, or preparation of the manuscript.

concerned about the affordability of food. A qualitative analysis of the high-risk group

revealed four major themes: fear of contracting COVID19, disruption of employment status,

financial hardship, and exacerbated food insecurity. In response, Brighter Bites pivoted, cre-

ated, and deployed a framework to immediately address a variety of social needs among

those in the “high risk” category. Administering a rapid response survey to identify the imme-

diate needs of their families can help social service providers tailor their services to meet the

needs of the most vulnerable.

Introduction

On March 11, 2020, the World Health Organization declared the SARS COV-2 (COVID-19) a

pandemic [1]. On March 13, 2020 the United States (U.S.) declared a national emergency con-

cerning the COVID-19 outbreak, leading to numerous social distancing measures including,

school closures, cancellation of public gatherings, and remote working [2]. Starting the week

of March 16th 2020, through the week of March 23rd 2020, states began ordering schools to

close for the academic year and issuing statewide stay-at-home orders, with many companies

implementing work from home policies [3]. These social distancing measures had the detri-

mental consequences of disrupting food systems, businesses, and economies throughout the

U.S. [4–6].

Rapid epidemiological assessment (REA) refers to post-disaster assessment methods that

attempt to accurately assess a population by using the fewest resources in the shortest time [7].

These measures have included surveys, door-to-door assessments, surveillance methods, and

screening and individual risk assessment using qualitative and quantitative methods [8]. Typi-

cally, during an outbreak investigation, these methods may be used to assess symptoms of dis-

ease to contain and prevent further outbreaks [7]. However, the application of a rapid

assessment could extend to identifying social determinants of health needs during a disaster

such as food insecurity, financial instability, unemployment, housing insecurity, and access to

healthcare among vulnerable populations. This is particularly important to COVID-19, given

that reducing risk of COVID-19 complications is related to maintaining optimal immune

function and health, all of which are linked to these social determinants of health [4–6].

Brighter Bites is a non-profit, school-based health promotion program implemented across

six cities (Houston, Dallas, Austin, New York City, Washington, D.C., and Southwest Florida

areas) in the U.S., with the goal of delivering fresh produce and nutrition education to low-

income children and families in underserved communities to mitigate food insecurity and

improve dietary habits. Brighter Bites currently has an ongoing partnership with University of

Texas Health Science Center at Houston (UTHealth) School of Public Health for research and

evaluation. During the month of April 2020, amid the COVID-19 pandemic, while states were

under “shelter-in-place” orders, Brighter Bites conducted a rapid assessment survey of families

across four of the six cities (Houston, Dallas, Washington DC, and Florida). The survey

screened families for food security, housing security, financial stability, employment status,

transportation needs, access to childcare, and access to healthcare, to better understand the

immediate needs of families, identify those with the greatest need, and provide them with criti-

cal resources during this time of crisis.

The purpose of this study is to demonstrate the methodology used to conduct the rapid

assessment of needs using qualitative and quantitative measures among low-income house-

holds with children during the COVID-19 pandemic to identify those in greatest need, to pres-

ent our findings, and describe the strategies taken to meet the participants’ needs.

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Competing interests: I have read the journal’s

policy and the authors of this manuscript have the

following competing interests: Dr. Sharma is on the

Board of Directors of Brighter Bites nonprofit

organization, the goal of which is to improve

access to fresh fruits and vegetables and nutrition

education among underserved communities. This

is an unpaid, advisory board position. The other

authors have no conflicts of interest relevant to this

article to disclose. This does not alter our

adherence to PLOS ONE policies on sharing data

and materials.

Methods

Study sample

The rapid assessment survey was collected in April 2020 across Houston, Dallas, Washington

DC, and Southwest Florida. The self-report survey was administered electronically using For-

msite (Vroman Systems Inc., Illinois, USA) in English and Spanish to 16,500 BB families who

were enrolled in the program in the 2019–2020 school year and had provided their contact

information to the program. The participants in our study were predominately Hispanic

(87%), while 7% were African American, and 5% were White/other. This is significantly higher

than the sampled cities where the Hispanic population makes up at most 45% of the popula-

tion in Houston, 42% in Dallas, 27% in Florida, and 11% in Washington D.C.

Completion of the survey was voluntary and informed consent was obtained from all par-

ticipants prior to the start of the study. Data is collected by Brighter Bites non-profit organiza-

tion, and then is de-identified and shared with the University of Texas Health Science Center

(UTHealth) for analysis as part of a data sharing agreement and approved by the UTHealth

Committee for Protection of Human Subjects. Data obtained in the first wave of survey

responses, while cities were under “shelter-in-place” orders, were used for this paper.

Data collection

The self-reported rapid assessment survey consisted of a 30-item questionnaire on COVID-19

related concerns, social determinants of health, and sociodemographics. The 5–10 minute in

length survey was administered in English and Spanish.

Sociodemographic variables included child gender, respondents’ relationship to child, race/

ethnicity of both parent and child, parent education level, parent employment status, and gov-

ernment assistance program enrollment. Program options included the Special Supplemental

Nutrition Program for Women, Infants, and Children (WIC), Supplemental Nutrition Assis-

tance Program (SNAP), Double Dollars, Medicaid, Medicare, National School Lunch and/or

Breakfast Programs, and Children’s Health Insurance Program.

Household food security status was self-reported by the participants using the two-item

Hunger Vital Sign™ screening questionnaire developed and validated by Hager et al. [9]. If the participant responded “often true” or “sometimes true” to either of the two questions, then the

household was considered food insecure. If a participant answered “never true” to both ques-

tions, then the household was considered food secure.

Participants were asked about their concerns regarding various social determinants of

health including financial stability, employment status, access to food, affordability of food,

availability and affordability of housing, access to reliable transportation, access to childcare,

access to clinic/doctor, or other concerns, which was open-ended for participants to fill in. Par-

ticipants could check all that applied. Participants were asked to rate their health status.

Responses included poor, fair, good, very good, and excellent.

STATA 15.0 (StataCorp College Station, TX) was used to perform all data analysis. Means,

standard deviations, and frequency distributions were computed. Significance was set at

p<0.05.

Qualitative analysis

The open-ended question “Please share your greatest concern at this time, or any other

thoughts you would like to share with us.” was asked at the end of each survey. The responses

to this question were collated and analyzed for themes. Two trained UTHealth project staff

conducted a thematic analysis to analyze the responses using an inductive approach, where

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codes and themes are derived based on the content from the survey data [10, 11]. The coding

of the data was done initially through Microsoft Word using an open coding method by each

coder. To ensure reliability of codes, coders collectively re-coded the data in Microsoft Excel.

A codebook of codes and definitions was created, and codes were used to search for patterns

and to identify possible themes.

Triaging for “high risk” families: “high risk” families were defined as the following: 1) If indi-

cated in the open-ended question “Please share your greatest concern at this time, or any other

thoughts you would like to share with us “the following response”: a) running out of food, b)

diagnosed with COVID-19 and/or living with someone who has been diagnosed with COVID-

19 and experiencing challenges, c) is ill and needs assistance, d) is about to lose their place of liv-

ing, e) is about to lose their utilities, or f) no one at home is making an income; or 2) If indicated

on the survey as “poor” on the question when they were asked to rate their current health status.

If they met any of these categories, they were classified as “high risk”. Subsequently, these data

were used to articulate a response to meet the needs of these high risk families.

Results

The sociodemographic characteristics of the high-risk families are presented in Table 1. A total

of 1048 families completed the COVID-19 rapid response survey, of which 28 families were tri-

aged and classified as high risk (2.8% of survey respondents). Overall, the mean age of high-

Table 1. Sociodemographics, social needs, and health status of high-risk families (n = 71), Brighter Bites COVID-

19 response survey.

N %

Cities

• Houston 54 76.06

• Dallas 6 8.45

• Washington DC 7 9.86

• SW Florida 4 5.63

Does your family use the following?

• WIC 21 30.00

• SNAP 19 27.14

• Double Dollars 0 0.00

• Medicaid/Texas Health Steps 35 50.00

• Medicare 5 7.14

• Free/Reduced meals 57 80.28

• CHIP 9 12.86

Parent Race

• Black or African American 5 7.25

• Mexican-American, Latino or Hispanic 60 86.96

• White 0 0.00

• Other 4 5.80

Child Race

• Black or African American 5 7.14

• Mexican-American, Latino or Hispanic 59 84.29

• White 2 2.86

• Other 4 5.71

Home language

• Most or only English 7 9.86

(Continued)

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risk participants was 37 years, with 97% being female, 87% Hispanic, and 7% African Ameri-

can. A majority were Spanish speaking only (60%), 27% Spanish or English, and 10% only

English. Interestingly, while 80% of children reportedly participated in the free/reduced meal

program at the school, only, 30% reported receiving WIC, and 27% reported receiving SNAP

assistance. Half of respondents were receiving Medicaid, 7% receiving Medicare, and 13% on

CHIP. On average, there were five family members in the home.

During this time frame, 100% of the high risk participants reported being food insecure,

85% were concerned about their financial stability, 82% concerned about the availability of

food, and 65% concerned about the affordability of food. They were also concerned about the

availability/affordability of housing (50%), while 45% were concerned their employment status

would change in the near future. Other concerns were access to reliable transportation (11%),

access to childcare (13%), and access to a clinic/doctor (35%). Almost half the participants

(49%) reported being of fair or poor health status during this time.

Table 1. (Continued)

N %

• Both English and Spanish equally 19 26.76

• Most or only Spanish 42 59.15

• Other language 3 4.23

Parent Gender

• Male 2 2.82

• Female 69 97.18

Number of people live in your home mean SD

• Children 2.95 1.44

• Elders .14 .43

• Adults 2.28 .79

• Total 4.79 2.29

Parent age (years) 36.6 7.24

Health Status and Social needs

N %

Food insecurity due to coronavirus

• Food secure 0 0.00

• Food insecure 71 100.00

Due to the coronavirus, are you concerned about any of the following in

regards to you and your family? (check all that apply)

• Financial stability 60 84.51

• My employment status will change in the near future 32 45.07

• Availability of food 58 81.69

• Affordability of food 46 64.79

• Availability and/or affordability of housing 36 50.70

• Access to reliable transportation 8 11.27

• Access to child care 9 12.68

• Access to your clinic/doctor 25 35.21

How would you rate your current health status?

• Poor 12 16.90

• Fair 23 32.39

• Good 20 28.17

• Very good 8 11.27

• Excellent 8 11.27

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While overall results of the qualitative thematic analysis for the n = 1048 participants are

presented elsewhere (Sharma et al., under review), a qualitative analysis of participant

responses in the high-risk group revealed four major themes presented in Table 2: fear of con-

tracting COVID-19, disruption of employment status, financial hardship, and exacerbated

food insecurity. Fear of contracting COVID-19 was an immediate threat for the families as is

witnessed in one of the comments “My daughter was diagnosed with coronavirus and I am very scared for all the members of my family”. Moreover, loss of employment was of major concern leaving parents with little or no resources to meet their family’s needs. One parent said, “I don’t have enough work, I’m a single mother, I have two children and I no longer have enough for food for my children and I’m behind with the rent.”

Table 2. Themes from qualitative triage assessment of the high-risk families (n = 71), Brighter Bites COVID-19 response survey.

Themes Example Comments Response (what did Brighter Bites do)

Fear of contracting

COVID-19

“My daughter was diagnosed with coronavirus and I am very scared

for all the members of my family.”

{{e.g. BB produce vouchers provided, grocery drop off}}

• Provided language-appropriate information and resources on safety

measures–hand washing/sanitizer, wearing masks (talked about various

items that could be a mask if they did not have access to any) social

distancing and staying home.

• Encouraged to seek testing if there was a concern of potential

COVID-19 infection.

• Provided information on community resources for clinics, doctors

and testing sites by way of family resource links

“We are worried that my husband does not have a job and we do not

know how we will be able to buy food, pay the mortgage, electricity,

water, the internet, what will happen to our future, we are very afraid,

regarding the virus, of taking our children to the doctor, to the

dentist, etc.”

“I don’t want to go to the store and I no longer have food, afraid of

going out.”

Disruption of

employment status

“I was left without work, and I don’t have for supplies, or bills, or

food.”

• Provided information on community resources for employment and

unemployment benefit services.

• Provided electronic $50 gift card to a local retail store. If they did not

have access to an email, the $50 gift card was printed and hand-

delivered to them.

“I’m very worried because I haven’t had work for three weeks and I

don’t have money to pay rent, electricity, or water. My work has been

reduced by 90%, I’m an assistant housecleaner.”

“I don’t have enough work, I’m a single mother, I have two children

and I no longer have enough for food for my children and I’m behind

with the rent.”

“There’s no work, and you still have to pay rent, and there’s not

enough money for food.”

Financial Hardship “My biggest worry is not being able to pay next month’s rent and not

knowing where to go.”

• Provided information on community resources for assistance

programs, housing, transportation, child care and other services such as

free or reduced internet access by way of family resource links

• Cross-checked that they were receiving the produce vouchers to local

grocery retail store and updated contact information accordingly.

• Sent electronic $50 gift card to local retail store. Multiple electronic

$50 gift cards were sent to families that communicated continued

hardship. If they did not have access to an email, the $50 gift card was

printed and hand-delivered to them.

“Not having food for my children and frustration because I don’t

know what I’m going to do to pay rent. Thanks to you I have had

some food. Thank you very much. May God give you more to

continue helping. God bless you.”

“My main worry is that I do not have for the rent and food and we are

two families who live here and neither of us are working and both

families have children.”

“I have a water bill of $ 2141.79 and it will be cut off the 13th of this

month. I’m in panic of being left without water.”

“I am worried about not being able to pay my rent next month

(May_2020) because we are out of work.”

Exacerbated Food

Insecurity

“I don’t have enough food for my children.” • Provided dates and times for community food distributions and

Brighter Bites food distributions.

• Sent electronic $50 gift card to local retail store

• If they did not have access to an email, the $50 gift card was printed

and hand-delivered to them.

• If they could not go shopping due to barriers such as lack of

transportation, groceries were bought and delivered to them. (Family

was asked to share food preferences)

• Families received a $25 produce voucher to the local grocery retail

store.

“I am worried about how to feed the children because there is no

work right now, I am worried about paying my debts”

“My biggest worry at the moment is food for my family.”

“I feel worried because I’m not giving enough vegetables and fruit to

my children since my husband only works 3 days, and I’m not

working because my baby was just born, so there are 4 children and 2

adults and I’m short of food and diapers for my baby, but what I need

is food for the family. Thank you.”

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Loss of employment further led to financial instability leaving parents unable to pay their

bills or buy food. One parent commented, “My biggest worry is not being able to pay next month's rent and not knowing where to go.” This financial uncertainty also left parents con- cerned about their food security, and about how they were going to access healthy foods with

the limited produce available and the increasing prices in the grocery stores. One parent

described their concerns by saying, “I feel worried because I'm not giving enough vegetables and fruit to my children since my husband only works 3 days, and I'm not working because my baby was just born, so there are 4 children and 2 adults and I'm short of food and diapers for my baby, but what I need is food for the family.”

Brighter Bites response to high risk families: In response to these aforementioned needs,

Brighter Bites pivoted and created an infrastructure and a standardized framework to meet the

needs of these high-risk families (see Fig 1). A core, centralized group of Brighter Bites staff

was assigned specifically to address these families’ immediate concerns. Following the triage,

trained Brighter Bites staff made follow up phone calls to each high-risk family and obtain

more details regarding their concerns and assistance needed. A tracking database was created,

in which all phone calls and family concerns were tracked for each family. This information

was then relayed back to the Brighter Bites leadership where a tailored response was generated

for each family. Brighter Bites partnered with public health and medical schools’ faculty and

students to develop educational materials and informational resources to provide to the fami-

lies (Haidar et al., under review). Responses ranged from a) providing immediate financial

relief in the form of gift cards to local retail stores, b) grocery drop off to families unable to

leave home, and c) providing area-specific resources via text, email and phone regarding food

distributions, financial assistance, safety from eviction due to inability to pay rent, COVID-19

testing sites near their homes, participation in government assistance programs etc. All

responses were documented in the tracking database for each family. A 100% of the high-risk

families were reached through this process.

Discussion

The COVID-19 pandemic has had a major impact on the U.S. economy leading to a worldwide

economic crisis [6]. The most vulnerable populations in our communities have been dispro-

portionality affected by the direct and indirect health, social, and financial hardships of

COVID-19 [12, 13]. Low-income, vulnerable populations contribute the most to healthcare

costs, are more likely to suffer from health disparities, have increased risk factors, and have

fewer resources for promoting health and treating illness [14]. It is therefore imperative that

pertinent health, financial, and critical needs resources are provided in a timely matter to fami-

lies and communities in need. This study provided insight into how organizations could

potentially identify and respond to the needs of communities in times of crisis and demon-

strates how to effectively reach families that are struggling and need support.

Social factors play a critical role in determining health outcomes [15, 16]. Addressing the

social determinants of health of underserved communities through rapid response is impor-

tant to reduce health disparities and improve health outcomes associated with COVID-19 and

other comorbidities [12]. Minority populations, specifically African-American and Hispanic

have been disproportionately affected by COVID-19, with increased risk of complications and

mortality [17–19]. These same populations also suffer the most from chronic diseases such as

obesity, diabetes, respiratory disorders, and other pre-disposing conditions, accounting for the

majority of healthcare costs [20]. Often times, these diseases are also rooted in unequitable

social and structural needs surrounding employment, transportation, housing, poverty, food,

education, and health literacy [21, 22]. Conducting a COVID-19 rapid response survey was a

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Fig 1. Flowchart of triage and response to need for high risk families, n = 71.

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purposeful decision on part of Brighter Bites to identify those with highest need during this

time of crisis and develop a framework to immediately address a variety of social needs among

those in the “high risk” category. Due to the rapid transmission of coronavirus, many cities

including the four in our study were rapidly brought to a halt with many states issuing state-

wide stay-at-home-orders, closing schools, restaurants, and businesses [3]. For low-income

families this resulted in loss of wages and increased financial instability adding further strain

to previous economic hardships. Administering a rapid response survey during such times is

important to help identify the immediate needs of these families can help social service provid-

ers re-direct their services to meet the needs of this vulnerable population.

In response to the COVID-19 pandemic, Brighter Bites pivoted rapidly to invest its network

into addressing urgent needs of their participating families. Brighter Bites used the expertise of

public health faculty and students of their partner institutions to create and rapidly provide

resources for their families. For example, if a parent indicated that they were fearful of con-

tracting COVID-19, the team discussed safety measures such as handwashing, social distanc-

ing, and various items that could serve as a mask. If a parent was concerned about paying for

rent or food, then Bright Bites team provided information on community resources for food,

bill relief, and ensured they were receiving vouchers, and gift cards to local grocery stores.

Details regarding these strategies and their dissemination is provided elsewhere (Haidar et al.,

under review). By having a triaging and tracking system, along with a centralized response

team and strategic partners, in place, Brighter Bites was able to have a targeted response to

meet the needs of 100% of families with the highest needs during this time. Social service orga-

nizations can use similar strategies to identify and address the needs of their populations rap-

idly during times of disaster.

This study has some limitations and strengths. The study sample is a sub-sample of families

who participated in Brighter Bites in the 2019–2020 school year. The sample size varied across

each city as family enrollment in the Brighter Bites program is not proportional to size of the

city, and likely those families who needed the most help responded to the survey. Finally, sur-

vey was conducted to families electronically which introduces a selection bias as a limitation

due to the fact that only families that had access electronically could participate. However, in

this phase of the pandemic, given closures of schools and businesses, this was the most effective

way to reach people. Finally, the qualitative themes observed in our study cannot be sorely

attributed to the pandemic, and could be a result of other multitude of factors which remain to

be seen. The purpose of this study was to identify the families with the highest need for social

services during a time when all cities surveyed were in “shelter-in-place” and deploy an imme-

diate response, which was successfully achieved. Finally, the timeline from the pandemic

occurring to our response to these families is one of the major strengths of this paper.

Conclusion

Our study provides the methodology and framework to screen at-risk low-income families for

social needs during the time of the COVID-19 pandemic, and to provide a timely response to

these critical needs. In the future, this framework could be used for other pandemics and times

when an immediate response to screen at-risk families will be needed.

Supporting information

S1 Data.

(XLSX)

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S1 File.

(PDF)

S2 File.

(PDF)

Acknowledgments

The authors would also like to acknowledge the families who participated in this study.

Author Contributions

Conceptualization: Shreela V. Sharma, Christine Markham.

Data curation: Shreela V. Sharma, Jacqueline Noyola, Jacqueline Tien, Melinda Rushing, Brit-

tni M. Naylor, Ru-Jye Chuang.

Formal analysis: Jacqueline Noyola, Jacqueline Tien.

Funding acquisition: Shreela V. Sharma.

Investigation: Shreela V. Sharma, Amier Haidar, Christine Markham.

Methodology: Shreela V. Sharma.

Project administration: Shreela V. Sharma, Jacqueline Tien, Melinda Rushing, Brittni M.

Naylor, Ru-Jye Chuang, Christine Markham.

Resources: Jacqueline Noyola.

Supervision: Shreela V. Sharma.

Writing – original draft: Shreela V. Sharma, Amier Haidar.

Writing – review & editing: Shreela V. Sharma, Amier Haidar, Jacqueline Noyola, Jacqueline

Tien, Melinda Rushing, Brittni M. Naylor, Ru-Jye Chuang, Christine Markham.

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