key: cord-0825477-uyfp30ha authors: Kas-Osoka, Chioma; Moss, Jamal; Alexander, Leah; Davis, Jamaine; Parham, Imari; Barre, Iman; Cunningham-Erves, Jennifer title: African American Views of COVID-19 Contact Tracing and Testing date: 2022-03-07 journal: Am J Infect Control DOI: 10.1016/j.ajic.2022.02.032 sha: be736038a38a1f9ddfe7a57427648344ea9ae1af doc_id: 825477 cord_uid: uyfp30ha Objectives: Increasing COVID-testing and contact tracing is necessary to control the COVID-19 pandemic, considering suboptimal vaccine rates. Methods: We conducted semi-structured interviews to explore views towards contact tracing and testing among African Americans. Results: Based on our findings, participants identified COVID-19 testing and contact tracing as beneficial, yet medical and governmental mistrust, stigma associated with SARS-CoV-2, lack of access, poor communication, and costs as major barriers. Conclusion: This study also highlights intervention targets to improve COVID-testing and contact tracing. remain suboptimal with 63.9% of the US population fully vaccinated. 1 While African Americans comprise 12.4% of the U.S. population, only 9.9% are fully vaccinated. 1 This warrants concern as COVID-19 disproportionately impacts African Americans. Structural racism drives health care inequities, 2 underscored during the COVID-19 pandemic. Communities of color, including African Americans lack access to testing and contact tracing and cite poor engagement with healthcare providers. 3 There is historical mistrust in medical systems, researchers, and the government, elevating negative perceptions towards these behaviors. 4 Furthermore, miscommunication during previous pandemics has been commonly cited and has exacerbated health inequities and governmental mistrust. 5, 6 Many health officials highlight these issues with a need for exploratory data on this topic. 7 Our study purpose is to explore African Americans views towards COVID-testing and contact tracing to inform messaging and intervention targets. We conducted a phenomenological, qualitative study between May and September 2020 among a purposive sample of African Americans. The interview protocol asked questions about views towards contact tracing and testing along with facilitators, barriers, and potential strategies to increase use. Participants provided consent then completed a brief survey and interview. Descriptive statistics summarized survey data and rapid qualitative data analysis was conducted by two team members. Specifically, they: 1) coded interview data until saturation met, and 2) conducted cross-case analysis of codes to form themes. Data triangulation, peer debriefing, and thick rich descriptions were used to establish trustworthiness. Meharry Institutional Review Board approved this study. Of the 62 participants, mean age was 40 years. Majority were female (69.4%), had never been tested (62.9%), and had an Associate degree or higher (64.5%) ( Table 1) . No interviewees had participated in contact tracing. A major factor negatively impacting participation was lack of knowledge. Several participants had a general understanding of contact tracing; however, a few had not heard of or had no definition of contact tracing. Most were unfamiliar with its' role in SAR-CoV-2 prevention. Additionally, some participants were unclear about the guidelines for notification (i.e., who and when to notify someone) during the contact tracing process. Participants described contact tracing as invading ones' privacy and infringing on personal rights. For testing, participants described lack of understanding related to the degree of pain, length of the process, and rationale for nasal swab for testing. Others did not understand testing guidelines. A few perceived tests sometimes yielded false positives, while those who had not been tested perceived the process as painful. While views of contact tracing and testing were influenced by the internet, family and/or peers, and news, many had experienced testing. Participants varied in level of physical and mental discomfort during testing. Experiencing pain and depth of nasal swab insertion were commonly noted. Anxiety and fear were mentioned by participants who were tested and those who observed others being tested. Some participants cited close friends and colleagues' experiences with contact tracing as well as the information they received from the media. Many were unclear of what happened during their experiences which left more questions while others understood it but did not trust it. All participants cited no personal experiences with contact tracing. Across all participants, regardless of category, testing was considered beneficial. While no participants had engaged in contact tracing, many viewed this behavior as beneficial. The main benefits cited for both behaviors were: 1) a peace of mind; 2) awareness of status and ability to take precautions if needed; and 3) identification of viral hot spots. Ultimately, knowing ones' status allowed them the opportunity to be informed and provide some if not full protection to their family and friends. It further allowed them to gain understanding of places that should be avoided due to the possibility of high transmission. For testing only, participants perceived that testing free of cost made people more inclined to do it. For some participants, personal, family, or peer testing experiences (e.g., long wait times, painful) made participants less likely to get tested. Furthermore, the perceptions towards these behaviors (e.g., false positives from testing or contact tracing invading privacy) prevented many from participated in these behaviors. A few lacked awareness of testing locations outside of traditional drug stores or hospitals especially being in a rural area while others expressed discomfort navigating testing centers outside of traditional hospital locations. They were unaware of sanitation procedures and feared contracting SARS-CoV-2. Additionally, tests were only provided to individuals, especially those in rural areas, experiencing symptoms. Furthermore, some were charged by their insurance provider, so fee for service was a barrier. Last, some participants, especially those who were the financial provider, were unable to quarantine for the designated timeframe if received a positive test. "Governmental conspiracy" was identified as a barrier for contact tracing (e.g., collecting personal information for tracking purposes) and testing (e.g., microchip insertion as tracker). For both testing and contact tracing, shame and embarrassment associated with notifying co-workers, family members, or friends of contracting SARS-CoV-2 limited participation. Participants' hesitancy was also due to general mistrust of the healthcare system and researchers due to medical experimentation and poor healthcare experiences for communities of color. This was further exacerbated by contaminated testing viewed in the media, a perception that the healthcare system was trying to increase fear of SARS-CoV-2 and gain more control over Americans. Participants provided constituent-involving, communication strategies on multi-levels to inform pandemic response plans in the areas of SARS-CoV-2 contact tracing and testing among African Americans. Preferred information sources were the national government and healthcare providers. In some instances, family members and/or friends were considered information sources if in fields of research and medicine. Another strategy was increased communication at testing sites and in places with high traffic. Accessible testing sites, increase in test availability, and minimization of testing restrictions (e.g., symptomatic only) was also mentioned. Figure 1 : Data Summary). Similar to past studies, 8 contact tracing and testing were viewed as necessary to prevent SARS-CoV-2 transmission, yet many lacked knowledge of these procedures. Participants articulated several barriers to engaging in these behaviors. Unsurprisingly, negative testing experiences influenced decision-making, 9 supporting that improved procedures might increase use. Mistrust in government, healthcare, and research is commonly cited as a barrier to engagement in healthcare recommendations. 10 Trauma informed care could be used to address these concerns which involves screening and recognizing trauma, being aware of trauma impact, offering patient-centered communication and care, recognizing emotional safety while avoiding triggers, and being helpful to patients on treatment options 11 . In addition, multi-level changes should be made to address racial discrimination to begin to restore the mistrust in our government, researchers, and healthcare system. 12, 13 While there is increase an COVID-testing rates, 1 it is still challenging to gain trust for participation in contact tracing and testing to promote SARS-CoV-2 prevention. 8, 10, 11 Similar to previous research, this study highlights economic barriers, such as the inability to take time away from work, as contributing to the reluctancy to engage in contact tracing and testing among African Americans. 7 Inequities in social determinants of health partially reflect lack of access to testing (i.e., location). 10 Stigma and embarrassment are not uncommon for several preventive behaviors in African Americans 10, 14 and can lead to disbelief or reluctance to use these tools. 11 Citing strategies to improve communication from multi-level stakeholders reflects low knowledge levels and poor communication from the national government, 6 which negatively influenced communication within other channels (e.g., providers, family and friends, peers). This is not uncommon in past pandemics. 6  Linguistic strategies. Involves ensuring the language is appropriate, ongoing, and appeals to the norms and values of the African Americans. Information should explain the process and guidelines for COVID-testing and contact tracing. An example strategy involves allowing community members to review messaging that promotes testing and contact tracing to ensure appropriateness and the context is acceptable.  Socio-cultural strategies. Involves discussing contact tracing and testing in cultural context of African Americans. There are four cultural characteristics of the African American community: religiosity, collectivism, racial pride and perception of time. 15 Therefore, strategies include: 1) creating faith-based programs to disseminate materials (e.g., via church bulletin, flyers, health ministry) and offer these preventive tools during outreach activities (religiosity); 2) offering messaging which promotes the need to engage in these behaviors to protect family and friendships since these relationships are highly valued (collectivism); 3) using African American media to highlight low participation rates in testing and contact tracing and its' correlation with high COVID-19 hospitalization and mortality while discussing how to reverse participation rates through strategies such as increased education (racial pride); and 4) messaging should highlight how engaging in these behaviors now can prevent spread of COVID-19 to loved ones and future sequelae such as COVID-19 long haul (perception of time).  Constituent-involving strategies. Involves allowing African Americans who have participated in contact tracing and testing to help inform, plan, and potentially conduct programs to increase engagement in these behaviors. Trusted messengers include community leaders, providers, researchers, along with family and friends. This study is not without limitations. This study cannot be generalized to other populations. Views and experiences of contact tracing was due to media, close friends, and colleagues, limiting participants perspectives towards contact tracing. This could potentially be due to: 1) our research being conducted during the early stages of the pandemic; or 2) the lack of trust or understanding in the process as commonly cited in the literature 4,6 and in our study. Furthermore, we did not aim to collect information about past experiences, whether positive or negative. So, this was an emerging finding that was explored. Future research should examine the lived experiences of those who have participated in contact tracing. A cross-sectional survey could also be used quantify reasons for participation and/or non-participation in COVID-testing and contact tracing. This information can be used to inform intervention targets to increase engagement in these preventive behaviors. We identified COVID-19 testing and contact tracing as being beneficial among African Americans, yet mistrust, SARS-CoV-2 stigma, location, and "perceived" costs as major barriers. This study also highlights intervention targets to improve COVID-testing and contact tracing among African Americans. Lack of Knowledge on Definition of Contact Tracing "What's the point? What are they being monitored for? I don't really know anything about it" (Young Adult) Invasion of Privacy "I'm worried about the whole privacy thing because if you're invading privacy, someone's privacy, at this level, who's to say that that you won't continue to do it even after the pandemic and after all of this is done and over with" (Underlying medical condition) Stigma "…it's almost like it's an STD like people don't want to Be known to have it and they're so embarrassed by and they feel the shame" (Essential Worker) Fear "It's just something about seeing folks in their hazard stuff, you know, and they PPE when they suited down like that. That's frightening. That evokes fear. And I know it has to be, you know, but it's just so scary" (Parent) Uneasiness "I was just like, told I had to like go to this place. "I'm just nervous to be honest with you, just to go to one of the testing sites right. That's the thing because the way to say the virus spread so fast is it's airborne. You know, it's kind of nerve just to go to one of those sites" (Essential Worker) "If I did feel like I need to get a covid test, I probably would go to the hospital and get it, not from one of the free testing sites because I don't feel like the free testing sites have the best precautions or better precautions than inside of a hospital" (Parent) Extensive Wait Times for Testing and Results "I just see long line, so I don't know if it's better to set up an appointment. Or just pull up in one of the lines and do the government testing" (Parents) Lack of Access-Limited Tests "I was really hesitant for the second test because when I was getting the second test, Governor Hogan had just like, I think he had just gotten those extra tests. So everything was still really limited and I was just like, I don't want to take a test away from someone who really needed it" (Young Adult) Lack of Access-Geographic (only symptomatic tested) "…I had no visible symptoms…So I wasn't able to get tested anyway. I tried. I called. I don't know, four or five times to just see because the one that I wanted knowing I didn't have any symptoms" (Underlying medical condition) Lack of Access-Financial (insurance charges) "Yeah some people have had to pay but I think around here it's like free if you ain't got no insurance" (Essential Worker) Governmental Conspiracy "…when you say contract tracing that's now so much like, mentally, that sounds so much like microchipping" (Parent) Family Role "Some people don't have the luxury of taking off from work and staying in quarantine for 14 days, they have to go. They may be the only person in their families. Bringing in income and some sort. So that's definitely something we live in" (Underlying medical condition) Stigma-Shame & Embarrassment "…I hear that that's the problem these days, especially for a younger folks, they don't want to say where they were or who they were with, but it, it, this should not be a badge of shame… this should not be something that Peace of Mind "Knowledge is power, knowing is better than not knowing and having that uncertainty that causes me to be very irritable" (Parent) Access Local and National Hot Spots "…showing where the hotspots are and I mean it's a good thing to have…I guess it's helpful to know a lot of hotspots, you know, maybe try to stay out of that area" (Essential Worker) Personal Contact with Virus "…it could be a prevention tactic. It also could be like a means to get people tested so that we can get some definitive answers on like if the person has it" (Young Adult) Take Precautionary Measures "…if I come in contact with the virus and I need to take necessary precaution so that I don't pass it to anyone else and then like those who I've been around in case I do have that they should get tested as well" (Young Adult) Free of Cost (Testing) "…there's a lot of free testing. That's available cost you nothing to go there, spend three or five minutes, find out it's yes okay go quarantine yourself if it's no great now you know" (Parents) Increase Access to Tests and Lower Wait Times at Sites "I think that we should have a quicker way to come up with the results or to take the limitations off of who gets a rapid test" (Essential Worker) Change Testing Method "I think they should be working on that as well as the vaccine working on a quick test, a quicker test. Something like a blood test to be done within a day at least, if not a few hours" (Underlying medical condition) Structural racism and health inequities in the USA: evidence and interventions. The Lancet The disproportional impact of COVID-19 on African Americans More than Tuskegee: understanding mistrust about research participation The impact of disparities in health on pandemic preparedness Lessons from the pandemic: the need for new tools for risk and outbreak communication Addressing inequities in COVID-19 morbidity and mortality: research and policy recommendations Facilitators and barriers to engagement with contact tracing during infectious disease outbreaks: a rapid review of the evidence Confronting COVID-19 in under-resourced, African American neighborhoods: a qualitative study examining community member and stakeholders' perceptions A model for trauma-informed primary care Understanding and addressing racial disparities in health care Diagnosing and treating systemic racism Attitudes about COVID-19 testing among Black Adults in the United States Achieving cultural appropriateness in health promotion programs: targeted and tailored approaches The authors would like to thank the members of the African American community for their valuable insights on their lived experiences during the COVID-19 pandemic.