The National Institute on Minority Health and Health Disparities has awarded NYU Silver Professor and Associate Dean for Research Marya Gwadz a two-year, $2.3 million grant to use the multiphase optimization strategy (MOST) framework to optimize an intervention to address the challenge of insufficient COVID-19 testing among Black and Latino/Hispanic (BLH) frontline essential workers (FEW). MOST is an engineering-inspired framework for developing social/behavioral interventions that balance effectiveness, affordability, scalability, and efficiency. The new study is part of the National Institutes of Health’s Rapid Acceleration of Diagnostics (RADx®) initiative to speed innovation in the development, commercialization, and implementation of technologies for COVID-19 testing.
The project (U01MD017418) is a multidisciplinary research collaboration between NYU Silver, NYU Grossman School of Medicine, and Northern Manhattan Improvement Corporation (NMIC), a large community-based organization founded in 1979 that operates under a settlement house model to address the needs of vulnerable and under-served communities. The team includes NMIC Executive Director Maria Lizardo, who will serve as the site Principal Investigator for the study at NMIC. NYU Silver Professor Victoria Stanhope and McSilver Associate Professor in Poverty Studies Robert L. Hawkins; NYU Grossman Associate Professor Charles M. Cleland and Clinical Assistant Professor Lalitha Parameswaran; and NMIC Deputy Executive Director and COO Greg Bangser are Co-Investigators on the study. The project was developed in collaboration with a Community Advisory Board (CAB) comprised of BLH community members, including BLH-FEW, who will continue to play an active role throughout the study.
“Testing for COVID-19 has an important role to play in controlling the epidemic. Among those at highest risk for exposure to COVID-19 is the large population of frontline essential workers in lower status occupations, in which Black and Latino people are overrepresented,” said Dr. Gwadz. “Those occupations, which include food preparation and serving, retail and sales, building and grounds cleaning and maintenance, personal care, and in-home health care services, require frequent close contact with others in indoor settings. But, essential workers in these professions rarely have easy access to COVID-19 testing, and testing and vaccination for COVID-19 are generally not required by their workplace settings, although local health departments generally recommend regular testing. We urgently need brief, efficient interventions to improve COVID-19 testing rates in this population.”
The rise of the highly contagious Omicron variant of COVID-19 has only underscored the importance of regular COVID-19 screening testing for frontline essential workers, even when asymptomatic. However, explained Dr. Gwadz, BLH-FEW experience serious multi-level impediments to COVID-19 testing. “At the individual/attitudinal level of influence, barriers to COVID-19 testing include insufficient knowledge of local testing guidelines, and health beliefs and emotions such as fear of the consequences of a positive test (e.g., needing to miss work and lost income), distrust of tests and the medical establishment, and counter-narratives about COVID-19, as well as cognitive biases that reduce intentions to test. At the social level of influence, social norms appear to impede needed testing, but at the same time, altruism and collective responsibility support testing. Structural-level barriers such as insufficient local testing sites, language barriers, and lack of paid sick leave impede access to testing.”
The new mixed-methods study will test four structurally and culturally salient candidate intervention components, each of which is designed to address a specific theoretical barrier to COVID-19 testing and is either brief or requires only minimal staff time to implement. The four components are all informed by critical race theory and self-determination theory, guided by the theory of triadic influence, and build on Dr. Gwadz’s team’s prior HIV social/behavioral research. They are: A) motivational interview counseling, B) a text message component grounded in behavioral economics, C) peer-to-peer education, and D) access to testing (via navigation to a test appointment vs. a self-test kit).
In the quantitative arm of the study, the four candidate components will be tested using a highly efficient factorial experimental design. The study will engage 448 BLH-FEW who have not been tested for COVID-19 in the past six months and who are not fully vaccinated for COVID-19. Participants will be randomly assigned to one of 16 intervention conditions, engage in the assigned components, and be assessed at 6- and 12-weeks post-baseline. All participants will also receive the standard of care, which is a health education information session on COVID-19 testing and referral to testing sites.
In the qualitative arm of the study, a subset of 50 participants will engage in in-depth, semi-structured interviews about their experiences with and perspectives on the intervention components and on COVID-19 testing and vaccination.
Based on pre-specified decision criteria, the study team will identify the most effective combination of candidate components for improving the primary outcome: COVID-19 testing with medical confirmation. This optimized intervention can then be disseminated for use in clinical and community-based settings and also tested in a randomized controlled trial. The study team, in collaboration with the CAB, will also identify and describe factors that may promote or impede implementation of the optimized intervention so it can be rapidly implemented by NMIC and other community-based settings at the conclusion of the study.
“From the earliest days of the COVID-19 pandemic, social inequities between groups of workers, along with disparities in incidence rates, have been striking,” said Dr. Gwadz. “I look forward to leveraging the MOST framework to create urgently needed interventions to increase COVID-19 testing among BLH-FEW, which is an essential component of the multipronged national strategy to control the pandemic and reduce its racial and ethnic disparities.”