Impact of COVID-19 on a Community Health Coalition and Its Residents in Allegheny County,Pennsylvania: Insights Into Adaptation From Focus Groups and Evaluation Reports

Focus Groups

This analysis centers focus groups held with adults in REACH priority neighborhoods between December 2020 and April 2021. The topic for three groups was coalition-centered and discussed residents’ needs, LWA²’s impact, and COVID’s effect; the other, perspectives on flu vaccines and the pandemic’s influence on COVID-19 vaccine views (see Table 1). Evaluation team members with external facilitator feedback developed discussion guides covering familiarity with the coalition, how the pandemic impacted residents, residents’ views on the vaccine, and priorities for nutrition, physical activity, and community–clinical linkages. The guide also contained community-specific questions regarding resources, such as the impact of closing a grocery store in one neighborhood. A focus group guide is available as supplemental material (see Supplemental Material).

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Table 1

Description of Focus Groups in Priority Neighborhoods Used in the COVID-19 Analysis

Focus group number and initial purpose	Month and location of recruitment for focus group	Percentage Black population per priority neighborhood a	Percentage of Black population below the federal poverty level a	Number of participants in attendance	Number of participants who reflected priority neighborhood
1-Coalition-centered	December 2020 Mon Valley	Mon Valley: 49%	Mon Valley: 37%	8	8
2-Coalition-centered	February 2021 Garfield, Larimer/Homewood/East Hills	Garfield: 69% Larimer/ Homewood/ East Hills: 85%	Garfield: 38% Larimer/ Homewood/ East Hills: 40%	8	8
3-Coalition-centered	February 2021 North Side	North Side: 33%	North Side: 41%	8	8
4-Flu vaccine-centered	April 2021 North Side, Garfield, Larimer/Homewood/East Hills, Wilkinsburg, Hill District, Mon Valley	North Side: 33% Garfield: 69% Larimer/Homewood/East Hills: 85% Wilkinsburg: 63% Hill District: 76% Mon Valley: 49%	North Side: 41% Garfield: 38% Larimer/Homewood/East Hills: 40% Wilkinsburg: 45% Hill District: 39% Mon Valley: 37%	6	5 b

a

From U.S. Census Bureau, 2016–2020 American Community Survey (ACS) census tract 5-year estimates, 2020 Census. ^b One participant lived in a majority Black neighborhood that is not part of the priority REACH neighborhoods.

Researchers recruited participants for the coalition-centered groups through social media flyers, community ambassador recommendations, and word of mouth. Each focus group was approximately 90 minutes long, comprised eight participants, and all participants were compensated for their time. Due to the pandemic, focus groups were conducted via videoconference on Zoom. Sessions were recorded, transcribed, and analyzed in NVivo 12. Two evaluation team members developed a codebook through an inductive and deductive process. The original codebook was developed through themes found in the focus group guide. Researchers added and edited codes in the codebook when new themes emerged. The team frequently met to discuss consensus among coders regarding new codes, definitions, methodology for application, and emerging themes. The agreement among coders was validated by assessing inter-rater reliability for all resident focus groups (Cohen’s kappa = 0.62). The evaluation team members also drafted memos for each focus group that analyzed emergent themes.

The 90-minute flu vaccine-centered focus group, held via Zoom, included six participants recruited through word of mouth and flyers shared via social media, emphasizing the recruitment of residents from priority neighborhoods. Three evaluation team members developed the codebook for the focus group in the same manner as the coalition-centered focus group guides. Two members coded the transcripts, and inter-rater reliability was assessed (Cohen’s kappa = 0.68). All three members drafted memos which providing additional thematic analyses. We asked participants their neighborhood of residence at the beginning of each session. Focus group participants were not required to keep their Zoom videos on but most chose to do so. All participants were compensated for their time via mailed gift cards. This study was not considered human subjects research by the University of Pittsburgh Human Research Protection Office (HRPO), and the evaluation team received documentation stating that no institutional review board (IRB) approval was required.

Coalition Partner Reports

As part of the larger comprehensive evaluation of the coalition’s work, evaluation team members collect data from coalition partners regarding the prior year’s progress. Data include performance measures for annual submission to the CDC and in-house data to track progress. In this context, coalition members from each organization, 10 in total, answered open-ended questions regarding successes and challenges they faced. In 2020 and 2021, we evaluated the impact of the COVID-19 pandemic on their work. Two evaluation team members assessed submitted responses for themes regarding barriers and progress made during the pandemic.

Impact on Access

In addition to feedback on the coalition and their communities, focus group participants discussed how COVID-19 impacted their access to nutrition and public transportation, their ability to engage in physical activity and receive clinical services, and other general changes to daily activities (see Table 2). Participants expressed that changing their usual methods of attaining their needs to either comply with new regulations or out of caution for their safety hindered their ability to tend to their health. Despite altered routines, they expressed how adapting led them to new resources, enabling them to address needs through different means.

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Table 2

Illustrative Quotes From Focus Groups and Partner Evaluation Reports

	Nutrition	Physical activity	Community–Clinical Linkages
Quote Source	Shift in methods to access nutrition	Less activity	Longer waiting times to access services
Focus Group Quotes	• “But the COVID, to me, we’ve already had a collective amount of neighborly helpers in our community naturally, but this has strengthened it more, and it brung [sic] people that normally would not come out and help. It gave them the courage to come out and help and team with one of us. Because we do that in the community. If we get produce into our house—some of us will get more produce. And it’ll be the target person that who have cars, who can deliver to those who need, or those who can come and get it from—you have that main house on your street or in that little block of area that you live in. So this community came together, just came together stronger than before.” • “. . . But yeah, as far as the COVID, I mean, it’s just hard to get out. So you don’t really want to go to the stores. You try to order in, try to get them to deliver meals and stuff like that. But it’s all so backed up. It’s hard to even get those resources.”	• “I have a nine-year-old son that probably put on 30 pounds since March. And I mean, do we eat healthy? Yes. We eat the healthiest? No. But I do think he eats pretty well. And with that being said, being stuck in the house with COVID has been very hard on him. But there’s not a lot to do. And it makes it very hard.” • “Well, it’s kind of hard to do physical activity now because . . . Most people are afraid to—sometimes it take groups or people are afraid sometimes to leave their house. I understand they say if you’re outside, but some people are afraid to leave their house and even go for walks and stuff.”	• “. . . access to mental health services has been impacted by COVID-19, long wait to get therapy. One place that she knows about has a six-month wait.” • “ . . . nowadays, you have to—they don’t want you in [services locations]. They don’t want a lot of people in. So you have to either sit outside or sit in your car. And that’s basically it. It’s just more time-consuming now.”
	Increase in food stamps	Move to virtual classes	Move to virtual programming
Partner Evaluation Reports	• “A major surge in demand for food stamp application assistance across the entire county began with the shutdown and has persisted, straining our internal capacity and making it impossible to target our services to specific geographies or demographic groups as planned.” • “The emergency improvements in food stamp benefits were a major improvement in food access for our at-risk neighbors, but the closing of physical state human services offices during the lockdown made it more challenging for people to know where to turn for help. Slow action by the federal government in approving various regulatory waivers on food assistance sought by the state government unnecessarily heightened barriers to meeting critical needs.”	• “Virtual programming is going to be the new norm. I am working on providing HIPAA secure platforms as well as call in classes for those that are not able to use virtual. This will be a must as we move forward.”	• “We have learned to be creative and innovative with our approach to community engagement during a pandemic to ensure the safety of our communities. With the shift from in-person engagement, we have been able to successfully launch virtual preventative health programs with promotion through partner organizations. Through this, we learned to be able to offer the program in a variety of ways (via Zoom or telephone) to ensure accessibility for various populations (i.e., low technology skills, limited to no access to technology resources)”

Nutrition

Regarding the impact on nutrition, participants discussed alternatives to getting their meals in grocery stores, such as picking up boxes and meals and relying on family and community members. One participant spoke about the hardship families with children were enduring when obtaining meals. When children were attending school virtually, the public schools offered meals to families to ensure nutritional needs of families were met (Stinelli, 2020). They reported a lack of variety in the food and confusion regarding when and how to receive it. Although some residents struggled maintaining healthy nutrition, participants discussed successful alternatives to grocery shopping, such as having family members assist them and relying on community members to share produce. One participant discussed how the community came together to ensure residents had food and described innovative methods for residents to aid each other (see Table 2).

Physical Activity

Participants reported that COVID-19 hindered their personal fitness goals due to lack of available in-person resources and not wanting to be close to other people. Although exercising alone was not viewed as ideal, participants stated that they would try exercising with others virtually. In addition to their own goals being deterred, one participant discussed the impact of lack of physical activity on her child. The combination of not eating healthy and the lack of movement caused substantial weight gain (see Table 2).

Traveling and Being in Public

Participants also discussed how traveling in public changed for them during the pandemic. While some reported that traveling was safe because fewer people were using public transportation and people were required to wear masks, others felt cautious about being near others in public. Participants noted an increase in the cost of using rideshare services, making them unaffordable to those experiencing financial difficulties during the pandemic. They also discussed stigma around contracting COVID-19 and mask wearing. Participants expressed wariness of being near someone diagnosed with COVID-19 and risking infection. When discussing masks in public, one participant stated that wearing one may be challenging because they may be mistaken for a gang member. They stated,

Yes. I just wanted to make the comment that I was accustomed—I grew up not wearing a mask or nothing but it came up to the fact that it was mandatory that you wore the mask and everything. And I said, and I told my wife, I said, “It’s like we’re all gang members. We getting ready to rob a bank or something.” I was afraid to go to the bank because you got mask on . . . . And it’s really affected me in a negative way . . .

Vaccine Feedback

Regarding the COVID-19 vaccine, most participants in the coalition-centered groups shared a willingness to be fully vaccinated or already being vaccinated. When discussing the impression of the vaccine within their communities, participants stated knowing people were cautious about receiving it due to the possibility of being injected with the coronavirus, believing the vaccine is unnecessary, or believing the vaccine would not help. The flu vaccine-centered focus group echoed COVID-19 vaccine skepticism. One participant expressed that offering monetary incentives made them question the motives behind the promotion of the vaccine and that focus should be placed on other chronic illnesses, such as diabetes or cancer, that have also been fatal in their community. They questioned the sincerity in vaccinating communities of color, believing that the primary motivation to vaccinate them is that their susceptibility to the virus puts the rest of the population at risk for onset of COVID-19 disease.

Regarding dissemination of vaccine information, participants preferred that information come from trusted messengers in the community. Specifically, they would prefer hearing about the vaccine and personal experiences with it from people in the Black community, doctors of the same ethnicity, and pastors. Confusion about how the vaccine works and the safety after the distribution of one COVID-19 vaccine was stopped then restarted caused hesitation. One participant noted that the scientific community seemed to be learning about the vaccine as they were trying to teach the public about it, which confused the accuracy of the information presented:

With COVID, I felt like they were teaching us while they were learning . . . It was just too much information that had to be retracted. And while that’s what happens in medicine, I don’t feel like we should have been front row center for it. I feel like the information was fed to us as they were getting it, and it was just very confusing.

Nutrition Challenges

Partner organizations experienced challenges of delays in food processing services, arranging for new service sites, limited in-person activities, increases in the need for food assistance, and strains on internal processes and staff. Other challenges included delivering food, conducting outreach, or screening for food insecurity. One partner who works with health care providers reported,

. . . A number of healthcare partners reported that they have not been screening for food insecurity or distributing food boxes due to COVID-19 and clinical workflow changes. Additionally, it was not realistic to try to engage new healthcare providers on screening for food insecurity since many were altering their patient visit models due to COVID-19 and the elements of creating a successful partnership were limited due to the public health crisis.

This time also highlighted existing inequities, and partners had to be flexible in meeting these needs. As one partner reported,

The pandemic has exposed the economic consequences of deep and structural racial inequity as never before and we continue to learn how to best respond. We have had to gain new flexibility in outreach strategy, social media, and communications technology in order to respond to the need for remote operations and other consequence of the emergency.

Although faced with their programming and operations challenges, the partners successfully developed innovative ways to reach community members and continue programming. Organizations reported developing new partnerships and new relationships with other partners to promote each other’s work and distribute food. One partner reported,

We now do home deliveries of food boxes, have a Community Partner Organization (CPO) Program where we provide emergency food boxes to organizations that don’t typically do direct food assistance (including healthcare facilities) so they can get those to community members that they see in need, and do Drive-Up Food Distributions.

In addition, those providing in-person services, such as breastfeeding classes, shifted to interactive, virtual activities in compliance with state and federal guidelines. One partner reported hosting virtual events and celebrations for the community. Finally, the shift to virtual programming also opened the possibility of attending conferences virtually for internal staff development.

Community–Clinical Linkages and Physical Activity Challenges

Challenges faced by community–clinical linkages and physical activity partners included canceling in-person outreach and events, fewer clients initially, shifting organizational priorities, and delays in grant opportunities. One organization reported calling for grant-funded opportunities a few days before businesses closed for in-person activities, which led to delays in the process and therefore delays in reaching their goals for the year. Another organization reported that in-person events such as fitness courses and health screenings could no longer meet. However, as the pandemic progressed, that same organization reported shifting to virtual programming for the third year of program implementation (August 2020–July 2021), in which community members were able to exercise at home. They reported success with virtual or hybrid fitness programming making it sustainable even after the pandemic.

Partner organizations canceled or reorganized in-person health screening and preventive health events. For example, one partner organization engaged in preventive health programming, developing virtual versions for health behaviors such as smoking cessation. They also stopped in-person health screenings and aided other partner organizations in pandemic relief by assisting with COVID testing, immunization clinics, and providing food resources. When restrictions eased for in-person events, they shifted their events to new venues including outdoor spaces in compliance with local public health regulations, and altered their focus by adding both flu and COVID-19 vaccinations to their events.

Limitations

Limitations include possible selection bias through the recruitment process and accessibility concerns. Recruitment relied on word-of-mouth processes, and participants opted into participating. Due to the restraint of the pandemic, participation required internet or phone access to attend the focus group, which may not have been possible for all members of the community. To preserve resident identities, we did not collect formal demographic data, although we asked about their neighborhoods of residence during the focus group. Given that our study advertisements were targeted to recruit from REACH priority neighborhoods and that most participants stated they were residents of these priority neighborhoods and appeared to reflect Black residents from the Zoom video view, we believe that focus groups were reflective of the priority population. Limitations of the partner summaries include the potential for social-desirability bias. Although their results can be confirmed through the quantitative data they also reported (e.g., writing in the open-ended section about canceling events and then confirming through quantitative data on the number of events they reported took place), social-desirability bias may still be present.