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. 2023 Jan 19;18(1):e0280460. doi: 10.1371/journal.pone.0280460

Attitudes, perceptions, and preferences towards SARS CoV-2 testing and vaccination among African American and Hispanic public housing residents, New York City: 2020–2021

Chigozirim Izeogu 1,*,#, Emily Gill 2,#, Kaitlyn Van Allen 2,‡, Natasha Williams 2,‡, Lorna E Thorpe 2,‡, Donna Shelley 3,‡
Editor: Sze Yan Liu4
PMCID: PMC9851504  PMID: 36656814

Abstract

Background

African American and Hispanic populations have been affected disproportionately by COVID-19. Reasons are multifactorial and include social and structural determinants of health. During the onset and height of the pandemic, evidence suggested decreased access to SARS CoV-2 testing. In 2020, the National Institutes of Health launched the Rapid Acceleration of Diagnostics (RADx)- Underserved Populations initiative to improve SARS CoV-2 testing in underserved communities. In this study, we explored attitudes, experiences, and barriers to SARS CoV-2 testing and vaccination among New York City public housing residents.

Methods

Between December 2020 and March 2021, we conducted 9 virtual focus groups among 36 low-income minority residents living in New York City public housing.

Results

Among residents reporting a prior SARS CoV-2 test, main reasons for testing were to prepare for a medical procedure or because of a high-risk exposure. Barriers to testing included fear of discomfort from the nasal swab, fear of exposure to COVID-19 while traveling to get tested, concerns about the consequences of testing positive and the belief that testing was not necessary. Residents reported a mistrust of information sources and the health care system in general; they depended more on “word of mouth” for information. The major barrier to vaccination was lack of trust in vaccine safety. Residents endorsed more convenient testing, onsite testing at residential buildings, and home self-test kits. Residents also emphasized the need for language-concordant information sharing and for information to come from “people who look like [them] and come from the same background as [them]”.

Conclusions

Barriers to SARS CoV-2 testing and vaccination centered on themes of a lack of accurate information, fear, mistrust, safety, and convenience. Resident-endorsed strategies to increase testing include making testing easier to access either through home or onsite testing locations. Education and information sharing by trusted members of the community are important tools to combat misinformation and build trust.

Introduction

The COVID-19 pandemic has had disparate effects on African American and Hispanic populations compared to non-Hispanic Whites. The reasons are multifactorial, involving social and structural determinants of health including differential access to health insurance, high quality medical care, economic opportunities and quality housing [1–3]. During the early stages and height of the pandemic, low-income, predominantly minority populations had less access to SARS CoV-2 testing compared to more affluent, predominantly White populations [4–6]. Testing infrastructure has since improved, however disparities related to SARS CoV-2 testing persist [4, 6, 7]. Testing is a central strategy for curbing the pandemic. Testing provides an opportunity for early diagnosis, monitoring, treatment, and prevention of disease spread. Testing, particularly at the start of the pandemic, was critical for informing policy decisions, including resource allocation and when and where to enact public restrictions such as mask wearing mandates and school and business closings. Even as infection rates have declined, ensuring equitable access to testing remains a high public health priority.

In New York City, patterns of disproportionate COVID-19-related morbidity and mortality mirror those documented nationally. Neighborhoods with higher rates of poverty and densities of Black and Hispanic populations have experienced significantly higher rates of hospitalizations and deaths due to COVID-19 [8]. This is particularly true among those living in public housing. The New York City Public Housing Authority (NYCHA) is the largest public housing authority in the U.S. with more than 400,000 residents. Developments are spread throughout the city but concentrate in lower-income neighborhoods. Median family income is $20,000, and approximately 90% of NYCHA residents are Black or Hispanic. Prior studies have documented that NYCHA residents have a higher burden of conditions associated with poor COVID-19 outcomes relative to those who are White or are living in higher income households [9, 10]. The literature on COVID-19 testing indicates that these disparities are related to a combination of potentially modifiable individual (e.g., health literacy, health status, trust in healthcare system) and structural barriers (e.g., language barriers, wait times at test sites, test properties, cost of isolation) [11–13]. Additionally, prior research examining the attitudes about COVID-19 testing among Black adults found that there was a lack of enthusiasm for testing if individuals were asymptomatic. However, if there was perceived disease susceptibility, such as an exposure or exhibiting pathognomonic symptoms, SARS CoV-2 testing was found to be acceptable [14].

In response to nationwide COVID testing disparities, the National Institutes of Health launched the Rapid Acceleration of Diagnostics (RADx)- Underserved Populations initiative to improve SARS CoV-2 testing in underserved communities. In September 2020, New York University (NYU) Schools of Medicine and Global Public Health received RADx-UP funding to launch the New York City Housing Authority (NYCHA) Resident COVID Response (RCR) project with the primary goal of improving SARS CoV-2 testing among NYC public housing residents. The purpose of this paper is to present findings from a series of focus groups that were conducted to gain a deeper understanding of the barriers to testing among NYCHA residents prior to launching a randomized controlled trial that would compare interventions to increase testing rates in this population. During the course of the study, the FDA gave emergency use authorization to two mRNA COVID-19 vaccines, and in response to significant interest among participants a parallel set of questions exploring similar themes related to SARS CoV-2 vaccination were explored.

Methods

Study setting

We identified three neighborhoods in NYC (Harlem, Lower East Side, and East New York) with high densities of public housing residents, a population selected due to their disproportionately high rates of SARS-CoV-2 infection per data released by the New York City Health Department. Prior to implementing the trial, in collaboration with community-based organizations (CBOs) serving these neighborhoods, we conducted a formative assessment to gather additional data on factors that may influence testing uptake and guide adaptations to the proposed interventions operating in each of the distinct neighborhoods. The CBOs, all with a history of impacting the health and wellbeing of NYCHA residents, included Harlem Congregations for Community Improvement, Inc. (HCCI), Henry Street Settlement (HSS), and Church Avenue Merchant Block Association (CAMBA). Together with these CBO partners, we formed the NYCHA Resident COVID Response (NYCHA RCR) Community Steering Committee (CSC), consisting of municipal agencies such as the NYC Health Department and NYC Test and Trace, along with NYCHA leadership and residents. The purpose of the CSC was to foster meaningful collaboration and to address long-standing concerns around mistrust and inequities of resources and power that have informed the dynamic between underserved populations and research or medical entities [15]. Though the CSC was formed for the purpose of the study, members have found it to be a valuable source of bidirectional learning and resource sharing, and agreed to continue meeting beyond the study’s conclusion [16]. The study was conducted December 2020 through March 2021, approximately one year after the beginning of the COVID-19 pandemic and after the FDA gave emergency use authorization to two mRNA COVID-19 vaccines.

Participant recruitment, eligibility and enrollment

We conducted nine virtual focus groups from December 2020 through March 2021 with adult NYCHA residents living in select public housing developments in Brooklyn and Manhattan. Eight focus groups were conducted in English, and one was conducted in Spanish. Participants were considered eligible if they were 18 years and older and lived in NYCHA. The NYCHA RCR CSC provided feedback on the focus group guide before it was finalized. Residents were recruited from six NYCHA housing developments through flyers distributed in buildings and on-site at CBO locations. CBOs also promoted the study at public and virtual events. Residents were encouraged to contact the study research assistant to obtain additional information. Once contacted, the research team screened individuals for eligibility and provided a date and time for the virtual meeting. Because of the low-risk nature of the study, in addition to the fact that we were unable to convene in-person, we were approved to collect verbal consent from participants. Participants were read the consent form over the phone, and their approval was documented in a secure electronic database. Thirty-six residents participated in the focus groups using Zoom. To maintain anonymity and confidentiality, upon logging on each participant was renamed with an alias. Focus groups were recorded and then transcribed verbatim for analysis. Focus groups lasted approximately one hour, and participants were reimbursed with a $30 Amazon electronic gift card via email. The study protocol was approved by the Institutional Review Board of NYU Grossman School of Medicine. (i20-01636).

Focus group guide

The guide was informed by the integrated behavior model, which posits that attitudes, perceived norms and personal agency (i.e., self-efficacy and perceived control) are associated with intention to modify behavior [15]. The model further suggests that the salience of the behavior and environmental constraints can further modify behavior. Interview questions assessed knowledge about and attitudes towards testing and vaccination, including confidence in accuracy of the tests, perceived community norms related to testing and vaccination, risk perception, and environmental constraints related to testing and vaccination. We also explored how residents accessed information about COVID-19 [17, 18]. The study was conducted December 2020 through March 2021, approximately one year after the beginning of the COVID-19 pandemic and after the FDA gave emergency use authorization to two mRNA COVID-19 vaccines. Therefore, we included a parallel set of questions exploring similar themes related to vaccination.

Data analysis

Focus group findings were analyzed using rapid qualitative methods [19]. This approach is useful when conducting formative research in which there is a time limited engagement and the goal is to conduct a deductive analysis. We assigned a code for each of the focus group guide questions (i.e., themes) to create a template to guide the systematic extraction and analysis. Four members of the research team engaged in an iterative process of transcript review and coding that did allow for additional codes to emerge. Coders used the template to document main concepts and illustrative quotes. the analysis began with the team reviewing two transcripts and meeting to review side-by-side comparisons and to address discrepancies. This process was repeated using two more transcripts and the revised template. Once the template was finalized, two members of the team completed the analysis and created a final matrix of findings that were then synthesized across themes.

Results

We present main themes and subthemes that emerged from the analysis. Themes are grouped into reasons for and against getting tested, testing preferences and strategies to increase testing, as well as attitudes towards vaccination against SARS CoV-2. Mistrust emerged as an overarching theme across the majority of the focus group discussions.

Why residents were not getting tested

Fear of testing

Residents expressed fears about storage of and access to test results, with some reluctant to provide personal information. One resident (FG2) noted, “some may not want to give their personal information or to feel that they are being traced, so they hold back altogether on being tested.” Some also feared the test itself, with some citing concerns that the test itself might transmit SARS CoV-2. One resident (FG1) stated, “Black folk and poor folk and folk of color, we’re not very trusting of our government…I had a woman say to me…“How do I know they’re not givin’ it to me when they swab my throat or my nose?” Others reported that the nasopharyngeal swab test was painful, or that they witnessed others experiencing discomfort. Residents were also concerned about the potential consequences of a positive test. This included being forced to isolate themselves from their families without their consent. As one resident (FG4) said “not everybody understands quarantine,” explaining that some people have the conception that it’s “you being locked up in a room, and the key is thrown away with nobody else around you.”

Misinformation

Residents received information about COVID-19 from a wide range of sources, including the news, local politicians, and word of mouth. Word of mouth emerged as a primary source of misinformation. Participants reported that many residents did not believe that SARS CoV-2 was real but rather a government tactic to scare racial/ethnic minority groups. As one resident (FG3) said, “many people feel that Trump is just doing this because he wants to keep us down. He doesn’t want us to work anymore, he’s trying to scare us.” Some residents (FG5, FG1) heard from neighbors that the novel coronavirus was “fake,” and not as serious as it has been depicted in the media: “a lot of people, they just don’t know what’s going on…They don’t believe in COVID, or that it’s real.” Several residents observed that young people “seem to be unaware of the severity of COVID. It’s almost like the younger you are, you think you’re [impervious]. You’re Superman, so COVID won’t affect you” (FG9). This was described in the context of concerns about adolescents not wearing masks in the elevators.

Challenges getting tested

For those who were tested or tried to get tested, one of the main challenges was having to wait in long lines and the perceived associated risk of exposure to infection while waiting. As one resident (FG3) said, “the lines are long, and we can catch COVID [while waiting in line].” Similarly, residents who reported having to travel on public transportation to get to a testing location were concerned about getting infected with SARS CoV-2. “We worry to go on the bus because if we go on the bus, we are worried to catch COVID and then worried to take the train because we could catch COVID” (FG3). Another potential barrier was the possibility of paying for a test. A few participants described receiving a bill despite having Medicaid, which covers testing. One resident (FG1) recalled, “Some people went…and they got a big bill from being tested for the coronavirus…a lot of people don’t want to go to these sites because [they] are getting billed for the corona test.”

Why residents were getting tested

More than half of participants had been tested at least once. Reasons for getting a SARS CoV-2 test included: preparing for a medical procedure, exposure to someone with the virus and having a high-risk job. As one resident (FG3) noted, “I’m always in the community. I volunteer in the community.”

Preferences for testing

Most residents preferred getting tested in a clinical setting. However, they also endorsed onsite testing options (i.e., in their housing development), with the caveat that those conducting the testing had some clinical training. One resident (FG5) proposed the community centers that are on-site at all housing developments, saying “as far as NYCHA is concerned, I think they should have [testing] in the nearest hospital by their facility or even within their community center. Every development has a community center…Everybody knows where the community center is, and it’s easy to access.” Most residents were open to self-administration, with guidance. Residents preferred testing methods that caused less discomfort and were interested in home test kits. One resident (FG4) described the ideal test as one that was similar to an at-home pregnancy test, “if it’s a testing kit as a woman would use to find out if she’s going to have a baby, I’m all for it.” Some residents did express concerns about their ability to conduct a self-test correctly. For example, one resident (FG9) said, “I feel doing it yourself, I would be wary about whether or not it was done correctly. That’s why I would feel I would rather have someone who is educated in doing do it, rather than me at home trying to do it myself.”

Strategies for increasing testing

Resident recommendations for increasing the uptake of testing in the community are summarized in Table 1. Residents suggested disseminating information in multiple languages, saying (FG3) “keep constant communication, especially to those who English is a second language. Messages should be in their home language.” They also described setting up information tables in the housing developments, sending information to residents’ homes, and communicating through flyers, social media posts and emails. As one resident (FG3) suggested, “use social media for young people and door to door for older people.” Residents also responded positively to the idea of a community health worker (CHW) model in which CHWs were available to provide this information and other resources. Residents were particularly intrigued by the idea of a saliva test, saying, “it’s convenient and less painful” (FG6).

Table 1. Resident suggestions for increasing acceptability and uptake of SARS CoV-2 testing.

Provide accurate easy to read information (e.g., develop a COVID handbook)
Host events/testing in housing developments or community centers
Create multilingual materials
Continue conducting outreach
Knock on doors with COVID tests on hand
Post to social media/email information
Create age-appropriate materials
Make self-tests available
Keep Testing Convenient
Open in a new tab

All of the residents emphasized that messages must come from a trusted source, and preferably someone from within their community. One resident (FG4) noted, “The source of information should be… someone who looks like us, who talks like us.” They liked the idea of one-on-one interactions with a knowledgeable person from the community: “that’s a great thing, [it] just has to be community structured. Meaning it has to be discrete, very one-on-one” (FG4).

Attitudes towards vaccines

Focus groups were conducted shortly after the first vaccine in the U.S. received its emergency use authorization and availability was more limited. At that time, most residents adopted a wait and see approach and were not planning to get vaccinated. Residents raised concerns about safety related to the perceived speed with which the vaccination was brought to market, saying “it hasn’t been fully tried. It hasn’t been fully tested. This is a cross your fingers and wish us luck type of thing” (FG5). As one resident (FG3) explained, “I want to hear experiences from the people and not just one person. I’m going to watch the news, of course, and I want to hear people like the nurses that got it and politicians.” Residents also expressed the need for information about the safety and effectiveness among different populations including racial/ethnic minorities, older adults, and those with chronic health conditions. They (FG2, FG6) were not convinced that these groups were appropriately represented in the clinical trials, saying “when they first started the trial runs on the vaccine… they were not getting that many people of color to be participants in the research” and “I feel like they’ve only tested those vaccines on fairly healthy people. I don’t know how it would affect me with my whole transplant issue, with all the medications that I’m taking.” These beliefs persisted even in the final focus group, which occurred after vaccines became more widely available. The few residents willing to get the vaccine acknowledged that they did not know the long-term effects and indicated that they would still have to protect themselves with a mask and maintain social distance. One resident (FG3) who wanted to get vaccinated was rethinking this decision based on others’ opinions, “[I] think I’m going to take it. I really don’t have doubts, but people put doubts in my head sometimes.”

In the English language focus groups that included primarily African American participants, many residents described a general lack of trust in the government: “do not trust them. Do not trust the government” (FG4). This lack of trust extended to the scientific community. The Tuskegee experiment was specifically mentioned as an example of a history of unethical treatment of Black Americans. As one resident (FG4) stated, the “That Tuskegee experiment has damaged the government badly.” Another noted that the “history of things regarding shots and vaccines is where the stress value lies.”

In contrast, those in the Spanish language group reported no vaccine hesitancy except for some concerns about having a preexisting condition that might result in a side effect from the injection. For these participants (FG8), the range of trusted sources of information on the vaccine was quite broad, and included “the people that make the vaccine, the company, the doctors, the scientists,” healthcare staff, and “university students doing the research.”

Discussion

Among a minority, low-income population of residents living in multiunit public housing developments, about half of the participants had never obtained a SARS CoV-2 test. Similarly, in focus groups conducted after the vaccine was available most participants had no plans to get vaccinated. Reasons for testing were largely driven by the need to prepare for a medical procedure, work-related requirements, or a known exposure to someone who tested positive.

We identified a range of barriers to SARS CoV-2 testing that could be addressed with increased engagement and communication from trusted sources to reduce confusion and concerns about the purpose and safety of testing and to reduce challenges related to accessing testing. General mistrust in the information they were receiving was particularly strong among African American participants. Our findings were consistent with a recent study examining SARS CoV-2 testing perceptions in under-resourced African American neighborhoods in urban and rural Alabama [20]. In that study, Bateman and colleagues reported that poor access, cost, and fear of contracting SARS CoV-2 through the act of testing itself were predisposing barriers to testing [20]. Our findings were also highly comparable with a literature review of COVID testing hesitancy, in which barriers were organized according to the “three delays” model: planning (individual factors such as knowledge about testing), process (characteristics of the test itself, such as accessibility of testing sites) and outcomes (consequences of the COVID-19 testing results, such as consequences on employment) [11].

Mistrust emerged as a major underlying theme throughout the focus groups and ranged from mistrust of government leaders, the news media and general mistrust of research and the health care system. Conspiracy theories and misconceptions about the origin and nature of various diseases have been described among minority populations prior to the COVID-19 pandemic [21, 22]. For example, among a nationally representative e-mail survey of 868 African Americans aged 18–50 years (February–April 2016) substantial percentages agreed that HIV is man-made (31%) and that the government is withholding a cure for HIV (40%) [23]. These types of theories and myths can affect adherence to treatment as well as disease screening and surveillance programs [24–26].

The historic context of medical mistrust among the African American community came up in the form of reference to the Tuskegee Syphilis Study, a U.S. Public Health Service run research study in which Black men were enrolled without their consent and intentionally left without treatment when one was available [27]. Similar to Bateman and colleagues’ study in which participants brought up the Tuskegee Syphilis Study in three of their focus groups, several Black participants referenced the study in a few of our focus groups [20]. It is notable, that the African American NYCHA residents still share in the collective trauma from the memory of the unethical treatment of Blacks in this study and link it to their decision-making regarding testing and vaccination during the COVID-19 pandemic. Moreover, as Willis et. al., mention in their study, distrust of the medical establishment by Black Americans goes well beyond just the one incident, and that "racism within the medical establishment is ongoing, and Black/African Americans do not need an extensive knowledge of the history of medical racism to inform their view of vaccines when many only need to consider recent experiences” [28].

Spanish-speaking participants appeared less concerned about vaccine safety and were less likely to question the effectiveness of the vaccine. In general, they were more willing to get vaccinated compared with the majority of African American English-speaking participants. These findings are consistent with published survey results from a national survey conducted Sept. 1–15, 2020, in which 18% of Black Americans and 40% of Hispanics reported trusting the efficacy of the COVID-19 vaccine; fewer than half of Black Americans intended to get vaccinated against COVID-19 [29]. In this study, the Spanish-speaking participants’ greater willingness to be tested may have been due to timing. This focus group was hosted later in the timeline of vaccine distribution and therefore residents would have been exposed to more information that may have impacted their beliefs. Another possibility for differing attitudes between Black and Hispanic participants may be a shorter history of experiencing injustices in the US health care system due to length of time in the country.

Residents suggested several strategies to increase testing that directly address the barriers they described. This included more tailored and targeted communication that is delivered by trusted sources. Clear, accurate and consistent messaging will continue to be important as the pandemic and associated changes in guidelines for testing and vaccination change. Similarly, the overwhelming amount of information available about the vaccine and news about variants has created even more confusion in the community about whether or not the current vaccines work. Again, ongoing communication, using platforms that offer language concordant information and reach a range of age groups and communities, is needed to reinforce the benefits of COVID-19 testing and the need for vaccination. Residents requested that vaccine efficacy and safety data be reported by subgroups (e.g., older adults, racial/ethnic minorities). They also endorsed patient navigator and community health worker models that provide opportunities to work with trained individuals who know the community and are viewed as a trusted source of information about COVID-19.

Our study had several limitations. First, we did not collect demographic data other than race/ethnicity. This was in response to our CBO partner’s concerns that residents would view this as too intrusive and, therefore, they would be less likely to engage in the study. Second, we did try to conduct an equal number of English and Spanish language focus groups, however this population was reluctant to enroll, therefore we only conducted one in Spanish. Finally, there is a chance that our study was subject to voluntary response bias, as our participants were self-selected volunteers. This could have particular relevance to the topic of mistrust of the medical establishment; our recruitment materials clearly indicated the focus groups were hosted by New York University.

This study is one of the first few studies exploring the attitudes and beliefs about COVID-19 testing and vaccines among Black and Hispanic public housing residents, a population that has disproportionately experienced negative outcomes of the COVID-19 pandemic. Similar to others, we found that barriers to SARS CoV-2 testing and vaccination centered on themes of a lack of accurate information, fear, mistrust, safety, and convenience. Resident-endorsed strategies to increase testing included making testing easier to access either through home or onsite testing locations. In addition to increasing access, providing culturally appropriate education and information sharing by trusted members of the community were identified as vital tools to combat misinformation and build trust. Closing the racial/ethnic and economic gaps in testing and vaccination will require continued engagement with communities to provide data and other information that can change attitudes and beliefs that are aligned with vaccination. With the increasing availability of at-home test kits, future research should investigate accessibility, usage, and how attitudes and beliefs continue to evolve about this issue along with other COVID preventive measures.

Supporting information

S1 File

(DOCX)

Click here for additional data file. (33.8KB, docx)

Acknowledgments

We would like to thank our colleagues at the New York City Housing Authority and partnering community-based organizations (Harlem Congregations for Community Improvement, Inc., Henry Street Settlement, and Church Avenue Merchant Block Association) for their assistance in conducting this research.

Data Availability

All relevant data are within the paper and its Supporting information files.

Funding Statement

NW, DS, and LT received financial support for the research, authorship, and/or publication of this article from the National Institutes of Health (Grant No: 3R01CA220591-03S1 (https://www.nih.gov/). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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Decision Letter 0

Sze Yan Liu

18 Apr 2022

PONE-D-21-34989Attitudes, perceptions, and preferences towards SARS Cov-2 testing and vaccination among African American and Hispanic public housing residents, New York City: 2020-2021PLOS ONE

Dear Dr. Shelley,

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Additional Editor Comments:

The reviewers and I agree on the importance of this topic. However, the reviewers bring up multiple good points about the need for more detail and greater clarity in your study that we would like to see addressed.

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Reviewers' comments:

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Comments to the Author

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: N/A

Reviewer #2: N/A

Reviewer #3: N/A

**********

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Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: No

**********

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for the opportunity to review an interesting paper with significant issues identified for increasing uptake of testing and vaccination of African American and Hispanic people.

I do think that the manuscript would benefit from some changes and further considerations, which I outline for each section.

Introduction

The Introduction described the study well and what was done, as well as some brief consideration of the issues faced regarding testing with African American and Hispanic people. What is needed is some more consideration of the literature regarding the topics of testing and vaccinations - the Introduction is currently very focused on the project, rather than what literature informed the project. Some discussion of what we know from literature about the determinants/predictors of willing to be tested (and vaccinated) is needed. There may not be work with these specific populations, but there should be some work that has been done more generally.

The Introduction should also end with a purpose statement. Rather than focusing on what was done (the focus groups), the purpose of the study - e.g. to examine African American and Hispanic people's perceptions of COVID testing and vaccinations, and barriers/enablers to both - would situate the paper more as a research-oriented paper.

I did question whether the information on the project should move to the Method. I am happy for it to stay in the Introduction, but more research literature or theory is needed in the Introduction.

Method

The Method was described well. More information is needed regarding how participants were recruited - for example, how were they recruited (e.g. social media) and how did they get in touch with the researchers.

Some example interview questions should be included in the Method.

The analysis was said to use rapid qualitative methods. Some more information on the use of this approach and a justification is needed. I wondered why an approach such as thematic analysis was not utilised. It is also stated that a deductive approach was used - however, without theory or models and previous literature presented in the Introduction, it is difficult to know how this was done. The integrated behaviour model is mentioned in passing in the Method, but if this was the underlying approach, this needs to be discussed in the Introduction.

Results

The results provide interesting data. I did think some more nuance in discussion of results was needed - at times, statements are made that make it sound like every participant was in agreement. Consider some more discussion of to what extent certain attitudes were prevalent.

Some themes received very little attention - the theme 'Why residents are getting tested' was very short. At other times, statements are made very briefly - e.g concerns about getting a positive tests are given one sentence only.

Focus group numbers and participant numbers should be included so the reader can see the diversity in use of participant responses.

It is mentioned towards the end of the Results that there was a difference between African American and Hispanic responses. This perhaps should be mentioned earlier, if there was such a marked difference.

I did wonder if both attitudes to testing and attitudes to vaccines could be discussed together in each theme - e.g. the misinformation theme could include reflections regarding both - but I will leave this up to the authors to decide if they want to do this.

Again, I would have liked to see, given the deductive approach, how it reflected parts of the models used. The models do not need to be explicitly mentioned in the Results, but there should be some connection between their description in the Introduction and then the themes in the Results.

Discussion

Discussion was well done. I would like to see more reference to COVID literature - again, this may not necessarily be from studies with African Americans and Hispanic people (if there are only a few), but issues such as attitudes to vaccines, questioning existence of the virus etc., have been investigated and the current results should be examined in light of these findings.

Data availability

I wasn't sure if the transcripts need to be potentially available to other researchers (e.g. on request). I will let the Editor decide that as I am very familiar with the data policies of the journal.

Thank you and I hope the review is helpful to the authors.

Reviewer #2: Authors present themes in the perceptions of African-American and Hispanic-American individuals living in New York public housing units on COVID-19 testing and vaccination access and uptake. This article will be helpful in informing future COVID-19 testing and vaccination initiatives aiming to meet the needs of low-income and racial minority populations in this region. Minor revisions are suggested.

1. Introduction 69-70 highlights broad applications of the findings of this study. Were they also directly used to improve testing services by RADx, NYU, or other institutions or initiatives noted in the introduction?

2. Introduction. Provide context on where the nation was in terms of testing and vaccination availability at the time that this intervention was carried out. Were opinions shared on a real or hypothetical vaccine candidate? A bit on this is discussed in results but it should be discussed here.

3. Introduction 59-67. This description of the focus group discussion design is likely more appropriate for the methods section. It would be helpful to include an explanation (including references) in the introduction on the importance of working with CBOs such as those in the design of such an intervention.

4. Introduction 63 "Collectively, they designed and conducted..." recommend rewording to clarify if "they" includes the authors/NYU because as it stands this seems to suggest this is referring to the CBOs.

5. Methods 87-90. Please provide examples of focus group questions.

6. Methods. 92-94. Clarify what the authors "protocol-driven, deductive" approach was. What protocol or theory was informing the analysis? The referenced article does not add clarity to the statement. Were the domain names identified based on a particular guiding framework? Based on consultation with the CSC?

7. Results. Demographics. Was any participant demographic information beyond race collected that might help contextualize the study findings? Age, for example? In results 194-203 you seem to suggest most of the 8 focus groups were with African-Americans and 1 was with Hispanic Americans. It would be helpful to clarify the amount of participants identifying as African-American and/or Hispanic American included in the sample.

8. Results. 149. Suggest "development" -> "housing development"

9. Results. Table 1. Would be helpful to include how often these suggestions came up to illustrate how well they are endorsed by the sample. Did only one person in one focus group suggest this? Did it come up in each of the 9 focus groups?

10. Discussion. 210-214. You describe differences with respect to some of these conclusions among Af-AM and His-Am participants in the results section- it will be important to preserve these distinctions in this section so as to not conflate the perceptions and experiences of these two groups inappropriately.

11. Discussion 249-262. Some of this is new data that should be in the results, likely in the section titled "Strategies for increasing testing," not introduced for the first time in the discussion. Eg. "with the vaccine now widely available, residents who are vaccinated were confused about the indications for future testing."

Reviewer #3: The authors describe a qualitative focus group study to understand attitudes towards SARS-CoV-2 testing and vaccination to inform an intervention to increase testing among public housing residents. The topic is important and interesting, but the manuscript is lacking in its framing in the introduction, the description of methods, and valuable interpretation/contextualization in the discussion. It also has significant readability issues. Specific comments for each section follow:

Introduction:

- The authors should describe and cite existing literature on perceptions towards testing and vaccination among marginalized groups

- The last sentence of the introduction is the first time that vaccination is mentioned - why did the study also include perceptions towards vaccination? The authors need to provide framing and justification for this

Methods:

- The authors might consider briefly explaining the integrated behavioral model

- Many more details are needed on the specific interview questions and topics covered in the focus groups

- More information on the CBO-academic partnerships would be of interest and relevance to other researchers

Results:

- The authors should consider first describing the demographic composition of their focus group participants

- A lot of the wording in this section is awkward/clunky, i.e. "reasons for getting or not getting tested"

- "testing data storage and access" reads in a confusing way, the authors might instead consider "storage of and access to test results"

- A lot of the sentences do not use parallel structure, which impedes readability, i.e. "Residents suggested disseminating information through flyers, social media posts and emails, and that the information be translated into multiple languages." and "They also described setting up information tables in the developments, sending information to residents’ homes, and some suggested knocking on doors."

- The authors should avoid interpreting in Results rather than Discussion, ie "This comment demonstrates the potential negative impact of misinformation often spread by word of mouth."

- It is unclear how the authors classified and distinguished fears of testing from misinformation from mistrust, since there seemed to be a lot of overlap across the three

- Why were the responses from the predominantly Black group compared with the one Spanish speaking group, rather than with participants of other races in any group?

Discussion:

- "general lack of knowledge about testing recommendations, a similar lack of knowledge about risk factors for infection," - this was not presented at all in the Results

- The authors should discuss similar interventions that have been effective

- It would be helpful for the authors to suggest more concrete solutions to mitigating mistrust and increasing access (ie transportation, ensuring that tests are free, etc.)

- The authors need a limitations paragraph, especially detailing the potential biases (ie voluntary response, potential underrepresentation/lack of representation of certain perspectives or subgroups), shortcomings of methods, limited generalizability to other populations, etc.

**********

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Reviewer #1: No

Reviewer #2: Yes: Debbie Dada

Reviewer #3: No

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PLoS One. 2023 Jan 19;18(1):e0280460. doi: 10.1371/journal.pone.0280460.r002

Author response to Decision Letter 0

20 Oct 2022

October 15, 2022

Dear Dr. Liu,

Thank you for reviewing our manuscript and for the opportunity to revise it to meet PLoS One’s publication standard. Please find listed below the comments submitted by the reviewers and our response to each comment in bolded italicized font. Please let us know if we can clarify anything further.

Reviewer #1: Thank you for the opportunity to review an interesting paper with significant issues identified for increasing uptake of testing and vaccination of African American and Hispanic people. I do think that the manuscript would benefit from some changes and further considerations, which I outline for each section.

Introduction

The Introduction described the study well and what was done, as well as some brief consideration of the issues faced regarding testing with African American and Hispanic people. What is needed is some more consideration of the literature regarding the topics of testing and vaccinations - the Introduction is currently very focused on the project, rather than what literature informed the project. Some discussion of what we know from literature about the determinants/predictors of willing to be tested (and vaccinated) is needed. There may not be work with these specific populations, but there should be some work that has been done more generally.

RESPONSE. We updated the introduction to address the reviewer’s comments which included reviewing additional literature and moving sections that described the methods to that section. We agree with this reviewer’s comment that much of what was previously included in the Introduction is more fitting for the Methods section.

REVIEWER. The Introduction should also end with a purpose statement. Rather than focusing on what was done (the focus groups), the purpose of the study - e.g., to examine African American and Hispanic people's perceptions of COVID testing and vaccinations, and barriers/enablers to both - would situate the paper more as a research-oriented paper.

REPONSE. We thank the reviewer for this comment and have added a purpose statement at the end of the Introduction section.

REVIEWER. The Method was described well. More information is needed regarding how participants were recruited - for example, how were they recruited and how did they get in touch with the researchers.

RESPONSE. We have added more information including eligibility criteria and more detail on recruitment strategies.

REVIEWER. Some example interview questions should be included in the Method.

RESPONSE. The interview questions will be provided in the supplemental appendix.

REVIEWER. The analysis was said to use rapid qualitative methods. Some more information on the use of this approach and a justification is needed. I wondered why an approach such as thematic analysis was not utilized. It is also stated that a deductive approach was used - however, without theory or models and previous literature presented in the Introduction, it is difficult to know how this was done. The integrated behavior model is mentioned in passing in the Method, but if this was the underlying approach, this needs to be discussed in the Introduction.

RESPONSE. We have expanded the description of the theoretical framework that informed the focus group guide. Rapid qualitative methods and analysis is a well described approach that emerged from the need, in situations such as in the case of formative work, where the timeline is short and the data is needed to inform modifications to be used in a larger randomized controlled trial. We used the integrated behavioral theory framework to inform the questions that were asked. Then using those questions, we created a template for the deductive analysis. We used a team based, highly iterative process that did allow for additional codes to emerge. This process doesn’t preclude more inductive assessments in the future

REVIEWER. Results. The results provide interesting data. I did think some more nuance in discussion of results was needed - at times, statements are made that make it sound like every participant agreed. Consider some more discussion of to what extent certain attitudes were prevalent. Some themes received very little attention - the theme 'Why residents are getting tested' was very short. At other times, statements are made very briefly - e.g. concerns about getting positive tests are given one sentence only.

RESPONSE. In many of the focus groups, there was agreement among the participants as it pertains to specific topics/themes, particularly among the African American participants. Where there were differences, we did highlight those themes, specifically in the last two paragraphs of the results section. For example, the results indicate that the Spanish language focus group participants did not report vaccine hesitancy and had much higher trust in mainstream information sources.

REVIEWER. Focus group numbers and participant numbers should be included so the reader can see the diversity in use of participant responses.

RESPONSE. Focus group numbers have been added to participant responses. As part of the transcription process, any distinct or identifying information between participants is removed to ensure the data is completely de-identified. As such, we cannot provide individual participant numbers.

REVIEWER. It is mentioned towards the end of the Results that there was a difference between African American and Hispanic responses. This perhaps should be mentioned earlier, if there was such a marked difference.

RESPONSE. We tried to recruit equal numbers of Hispanic and African American participants; however, Hispanic individuals were reluctant to enroll. This may have been due to the sociopolitical context of the time in terms of concerns about immigration status. As a result, we only had one Hispanic focus group. Due to the limited amount of data from this population, we highlight some of the clear difference, however, we cannot make any additional conclusions about substantive differences between the two groups.

REVIEWER. I did wonder if both attitudes to testing and attitudes to vaccines could be discussed together in each theme - e.g. the misinformation theme could include reflections regarding both - but I will leave this up to the authors to decide if they want to do this.

RESPONSE. RADx-UP was and is an initiative to increase SARS-Cov-2 testing. However, once we launched the study, the vaccine was made available so we included information about the vaccinations because participants were interested in discussing it. We agree that it wasn’t explored as robustly as the testing questioning, however, vaccination uptake/hesitation was included in this manuscript because it became a major point of discussion during the focus group sessions given the timing of the study which coincided with the emergency use approval of the first vaccinations against Sars-Cov-2 in the U.S.

REVIEWER. Again, I would have liked to see, given the deductive approach, how it reflected parts of the models used. The models do not need to be explicitly mentioned in the Results, but there should be some connection between their description in the Introduction and then the themes in the Results.

RESPONSE. As per the response above, we have expanded on this section.

REVIEWER. Discussion was well done. I would like to see more reference to COVID literature - again, this may not necessarily be from studies with African Americans and Hispanic people (if there are only a few), but issues such as attitudes to vaccines, questioning existence of the virus etc., have been investigated and the current results should be examined in light of these findings.

RESPONSE. This is addressed in the updated introduction.

REVIEWER. Data availability. I wasn't sure if the transcripts need to be potentially available to other researchers (e.g. on request). I will let the Editor decide that as I am very familiar with the data policies of the journal.

RESPONSE. The data is available for review upon request.

Reviewer #2: Minor revisions are suggested.

Introduction 69-70 highlights broad applications of the findings of this study. Were they also directly used to improve testing services by RADx, NYU, or other institutions or initiatives noted in the introduction?

RESPONSE. Yes, the study was completed to inform the development of an intervention to increase uptake of Sars-CoV-2 testing among African American and Hispanic residents in public housing.

REVIEWER. Introduction. Provide context on where the nation was in terms of testing and vaccination availability at the time that this intervention was carried out. Were opinions shared on a real or hypothetical vaccine candidate? A bit on this is discussed in results but it should be discussed here.

RESPONSE. We have provided this information in the Methods section under the “Context” sub-heading. The focus groups began roughly a year after the start of the pandemic, by which point COVID tests were widely available and routine testing encouraged. The bulk of the discussions around vaccine happened after vaccines had been rolled out and approved for emergency usage by the FDA.

REVIEWER

Introduction 59-67. This description of the focus group discussion design is likely more appropriate for the methods section. It would be helpful to include an explanation (including references) in the introduction on the importance of working with CBOs such as those in the design of such an intervention.

RESPONSE. We thank the reviewer for this comment and we have moved this portion to the Methods section.

REVIEWER

Introduction 63 "Collectively, they designed and conducted..." recommend rewording to clarify if "they" includes the authors/NYU because as it stands this seems to suggest this is referring to the CBOs.

RESPONSE. This is addressed in the updated Introduction.

REVIEWER. Methods 87-90. Please provide examples of focus group questions.

RESPONSE. Focus group interview guide questions available in supplemental appendix

REVIEWER. Methods. 92-94. Clarify what the authors "protocol-driven, deductive" approach was. What protocol or theory was informing the analysis? The referenced article does not add clarity to the statement. Were the domain names identified based on a particular guiding framework? Based on consultation with the CSC?

RESPONSE. See the previous response to this question. Given the nature of the COVID-19 pandemic and the need to generate actionable next steps to inform the final design of the intervention, the analysis was conducted using a rapid qualitative analysis process. The questions were drawn from integrated behavior model with guidance from the CSC, and the main code names were derived from the questions.

REVIEWER. Results. Demographics. Was any participant demographic information beyond race collected that might help contextualize the study findings? Age, for example? In results 194-203 you seem to suggest most of the 8 focus groups were with African-Americans and 1 was with Hispanic Americans. It would be helpful to clarify the number of participants identifying as African-American and/or Hispanic American included in the sample.

RESULTS. No other demographic information beyond race/ethnicity were collected under suggestion by a CBO partner because of concern that too many personal questions may be considered as too intrusive by the study population. This is a limitation of the study. As for the breakdown of the demographics, of our 36 participants 4 identify as Hispanic/Latino; 30 Black or African American, and 2 Asian.

REVIEWER. Results. Suggest "development" -> "housing development"

RESPONSE. This is addressed in the updated manuscript.

REVIEWER. Discussion. 210-214. You describe differences with respect to some of these conclusions among Af-AM and His-Am participants in the results section- it will be important to preserve these distinctions in this section so as to not conflate the perceptions and experiences of these two groups inappropriately.

RESPONSE. We have highlighted the thematic distinction with supporting quotes between these two groups in the final two paragraphs of the results section.

REVIEWER. Discussion 249-262. Some of this is new data that should be in the results, likely in the section titled "Strategies for increasing testing," not introduced for the first time in the discussion. Eg. "with the vaccine now widely available, residents who are vaccinated were confused about the indications for future testing."

RESPONSE. We have edited this in the discussion section.

Reviewer #3: The topic is important and interesting, but the manuscript is lacking in its framing in the introduction, the description of methods, and valuable interpretation/contextualization in the discussion. It also has significant readability issues. Specific comments for each section follow: Introduction:- The authors should describe and cite existing literature on perceptions towards testing and vaccination among marginalized groups

RESPONSE. We have added additional references to the literature.

REVIEWER- The last sentence of the introduction is the first time that vaccination is mentioned - why did the study also include perceptions towards vaccination? The authors need to provide framing and justification for this

RESPONSE. The study was designed specifically to address testing and not vaccination uptake or hesitancy. We have added in the introduction that the vaccine became available in the middle of our formative research and therefore we decided we needed to add those questions to our focus group guide.

REVIEWER. Methods: The authors might consider briefly explaining the integrated behavioral model. Many more details are needed on the specific interview questions and topics covered in the focus groups.

RESPONSE. This is addressed in the updated Methods. Topics covered are in the focus group interview guide which is available as a supplement. We do outline the key topics in the methods section.

REVIEWER. More information on the CBO-academic partnerships would be of interest and relevance to other researchers

RESPONSE. We have expounded on this partnership in the Methods section under the Study Setting subheading.

REVIEWER Results:- The authors should consider first describing the demographic composition of their focus group participants

RESPONSE. As previously discussed, no other demographic information beyond race/ethnicity were collected under suggestion by a CBO partner because of concern that too many personal questions may be considered intrusive by the study population. This is a limitation of the study.

REVIEWER.

- A lot of the wording in this section is awkward/clunky, i.e. "reasons for getting or not getting tested"

- "testing data storage and access" reads in a confusing way, the authors might instead consider "storage of and access to test results" A lot of the sentences do not use parallel structure, which impedes readability, i.e. "Residents suggested disseminating information through flyers, social media posts and emails, and that the information be translated into multiple languages." and "They also described setting up information tables in the developments, sending information to residents’ homes, and some suggested knocking on doors."

RESPONSE. We thank the reviewer for this comment and have revised to improve clarity.

REVIEWER The authors should avoid interpreting in Results rather than Discussion, ie "This comment demonstrates the potential negative impact of misinformation often spread by word of mouth."

RESPONSE. We have removed this commentary from the Results section.

REVIEWER- It is unclear how the authors classified and distinguished fears of testing from misinformation from mistrust, since there seemed to be a lot of overlap across the three

RESPONSE. These themes are not mutually exclusive, and often times in analysis a quote could be considered part of multiple domains. As reflected in our paper, fear of testing can encompass both practical issues (fear of a positive result, fear of pain as a result of the nasal swab), and outcomes that may be a result of mistrust or even misinformation. Misinformation as a separate domain can refer to untrue beliefs that residents hold about COVID-19 and testing, that don’t necessarily precipitate fear, i.e., that COVID-19 is “fake.”

REVIEWER - Why were the responses from the predominantly Black group compared with the one Spanish speaking group, rather than with participants of other races in any group?

RESPONSE. Across all English-speaking focus groups, each group was predominantly or entirely comprised of non-Hispanic Black participants, so comparison of responses across other races is not feasible given the limited data.

REVIEWER Discussion:

- "general lack of knowledge about testing recommendations, a similar lack of knowledge about risk factors for infection," - this was not presented at all in the Results

- The authors should discuss similar interventions that have been effective

RESPONSE: We have revised this sentence.

REVIEWER - It would be helpful for the authors to suggest more concrete solutions to mitigating mistrust and increasing access (ie transportation, ensuring that tests are free, etc.)

RESPONSE: Our solutions were those pulled directly from FG participants, which are reported in the Results section.

REVIEWER - The authors need a limitations paragraph, especially detailing the potential biases (ie voluntary response, potential underrepresentation/lack of representation of certain perspectives or subgroups), shortcomings of methods, limited generalizability to other populations, etc.

RESPONSE. This has been added to the discussion section.

Sincerely,

Chigozirim Izeogu, MD MPH

Attachment

Submitted filename: RADx FG PLoS One_Response to Reviewers_final.docx

Click here for additional data file. (27.6KB, docx)

Decision Letter 1

Sze Yan Liu

11 Nov 2022

PONE-D-21-34989R1Attitudes, perceptions, and preferences towards SARS Cov-2 testing and vaccination among African American and Hispanic public housing residents, New York City: 2020-2021PLOS ONE

Dear Dr. Gill,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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We look forward to receiving your revised manuscript.

Kind regards,

Sze Yan Liu, PhD

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments :

As the reviewers note, this manuscript has been greatly improved. There are some minor revisions regarding additional information to include, primarily in the Introduction section, that would further strengthen this paper.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #3: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #3: N/A

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for making changes based on Reviewer recommendations. I believe the manuscript has been improved by your changes. I do have some additional relatively minor changes.

Introduction

Besides mentioning that there are 'social and structural determinants of health' impacting COVID-19 experiences between populations, is there any literature that you can mention in the Introduction on the beliefs or experiences related to testing and vaccination willingness/hesitancy? This may not be in African American and Hispanic groups, but I do believe the Introduction should acknowledge some of the research in this space, which if there is very little in these groups, leads to the gap this study is aiming to address.

Line 56 - this should be 'populations'.

Method

Line 102 - how were these neighborhoods and areas identified as having large infection rates?

Could you provide information on how the CSC fit in with the study – was it formed to conduct the study or was the study an offshoot of this wider approach?

Line 126 - correct extra I in COVIID.

Discussion

Line 296 - remove the 1 from this sentence - seems to be a typo.

The Discussion ends with a Limitations section. It would be a shame to end with this when the study has collected important data. I would recommend a short Conclusion summarising what was found and future research or public health initiatives that are suggested.

Reviewer #3: I appreciate the attention of the authors to addressing all my comments, and I feel that the manuscript has significantly improved. Just one minor thing remaining:

The authors state that they added in the Introduction that the vaccine became available in the middle of their research and therefore they added those questions to the focus group guide. However, I only see that mentioned in the Methods. It is important to add this to the Introduction.

Otherwise I am happy with the revisions made and recommend the manuscript for publication. No need to come back to me as long as the above addition to the Intro is made.

**********

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Reviewer #1: No

Reviewer #3: No

**********

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PLoS One. 2023 Jan 19;18(1):e0280460. doi: 10.1371/journal.pone.0280460.r004

Author response to Decision Letter 1

26 Dec 2022

Dear Dr. Liu,

Thank you for reviewing our manuscript and for the opportunity to revise it to meet PLoS One’s publication standard. Please find listed below the comments submitted by the reviewers and our response to each comment in bolded italicized font. Please let us know if we can clarify anything further.

Reviewer #1: Thank you for making changes based on Reviewer recommendations. I believe the manuscript has been improved by your changes. I do have some additional relatively minor changes.

REVIEWER. Introduction. Besides mentioning that there are 'social and structural determinants of health' impacting COVID-19 experiences between populations, is there any literature that you can mention in the Introduction on the beliefs or experiences related to testing and vaccination willingness/hesitancy? This may not be in African American and Hispanic groups, but I do believe the Introduction should acknowledge some of the research in this space, which if there is very little in these groups, leads to the gap this study is aiming to address.

RESPONSE. We have added additional literature on SARS-CoV-2 testing hesitancy among Black adults in the United States to the Introduction, specifically lines 76-80.

REVIEWER. Introduction. Line 56 - this should be 'populations'.

RESPONSE. We thank the reviewer for bringing this error to our attention and have edited our manuscript accordingly.

REVIEWER. Methods. Line 102 - how were these neighborhoods and areas identified as having large infection rates?

RESPONSE. We have added a clarifying sentence to the Methods section to delineate how neighborhoods were selected for our study (lines 111-114).

REVIEWER. Methods. Could you provide information on how the CSC fit in with the study – was it formed to conduct the study or was the study an offshoot of this wider approach?

RESPONSE. We have added additional details regarding the formation of the community steering committee, as well as a new citation directing readers to a recently published paper on the formation and function of the CSC (lines 133-135).

REVIEWER. Methods. Line 126 - correct extra I in COVIID.

RESPONSE. We thank the reviewer for bringing this error to our attention and have edited our manuscript accordingly.

REVIEWER. Discussion. Line 296 - remove the 1 from this sentence - seems to be a typo.

RESPONSE. We thank the reviewer for bringing this error to our attention and have edited our manuscript accordingly.

REVIEWER. Discussion. The Discussion ends with a Limitations section. It would be a shame to end with this when the study has collected important data. I would recommend a short Conclusion summarising what was found and future research or public health initiatives that are suggested.

RESPONSE. We have added an additional paragraph to the end of our Discussion section (lines 405-418).

Reviewer #3: I appreciate the attention of the authors to addressing all my comments, and I feel that the manuscript has significantly improved. Just one minor thing remaining:

REVIEWER. Introduction. The authors state that they added in the Introduction that the vaccine became available in the middle of their research and therefore they added those questions to the focus group guide. However, I only see that mentioned in the Methods. It is important to add this to the Introduction. Otherwise I am happy with the revisions made and recommend the manuscript for publication. No need to come back to me as long as the above addition to the Intro is made.

RESPONSE. We have added this to our revised manuscript (lines 105-108).

Attachment

Submitted filename: RADx FG PLoS One_SecondRevision_Response to Reviewers.docx

Click here for additional data file. (17.7KB, docx)

Decision Letter 2

Sze Yan Liu

3 Jan 2023

Attitudes, perceptions, and preferences towards SARS Cov-2 testing and vaccination among African American and Hispanic public housing residents, New York City: 2020-2021

PONE-D-21-34989R2

Dear Dr. Gill,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Sze Yan Liu, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: (No Response)

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

**********

Acceptance letter

Sze Yan Liu

9 Jan 2023

PONE-D-21-34989R2

Attitudes, perceptions, and preferences towards SARS CoV-2 testing and vaccination among African American and Hispanic public housing residents, New York City: 2020-2021

Dear Dr. Gill:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Sze Yan Liu

Academic Editor

PLOS ONE

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