Examining the Impact of COVID-19 on Upper Manhattan Community-Based Organizations: A Qualitative Analysis of Employee Focus Groups.

Community-based organizations (CBOs) play a key role in assisting local communities, especially those in under-resourced areas, through their deep knowledge of the community's needs and available resources. We examined perceptions of COVID-19's impact on health-related services in CBOs located in Upper Manhattan, New York City (serving East Harlem, Central Harlem, Morningside Heights and Hamilton Heights, and Washington Heights and Inwood). Three focus groups were conducted on Zoom in November 2020; focus groups were composed of participants employed at CBOs in this catchment area. Deidentified interview transcripts were evaluated using an iterative process of thematic content analysis. We identified five major themes related to the impact of COVID-19 on community needs: 1) increased mistrust and decreased service utilization, 2) breakdowns in communication, 3) shift in need, 4) increased risk factors for negative health outcomes among staff and community, and 5) decreased funding and an uncertain future. Because of the pandemic, CBOs have pivoted to cater to the immediate and changing needs of the community and, in doing so, revised their menu of services as well as their service delivery model. In trying to maintain connectivity with and the trust of community members, participants had to construct novel strategies and develop new outreach strategies; participants also recognized the role strain of trying to balance community needs with home responsibilities. Given these findings, concern arises around the long-term health and well-being of community members and participants. The government must provide the necessary resources to ensure the viability of CBOs and create a stronger infrastructure for future emergencies.

Introduction

Community-based organizations (CBOs) provide a range of essential services and are especially important in less resourced urban areas. Because of their knowledge of the community’s health needs and available resources, CBOs play a pivotal role in assisting local communities (Rivera et al., 2019). CBOs can bridge communities and local health officials by sharing community needs and offering potential strategies to help address the needs (Centers for Disease Control and Prevention, 2022a). With respect to public health and health care, CBOs may play an advocacy role for vulnerable population subgroups and work with the health system to develop needed programs and services (Wilson et al., 2012). Such services are critical for long-term primary prevention efforts such as increasing physical activity and promoting a healthy diet, smoking cessation, immunizations, and optimal mental health (Centers for Disease Control and Prevention, 2022a, b; Perry et al., 2010; National Institute of Health, 2019; National Institutes of Health, 2006). These services are integral to preventing cancers as well as a myriad of other chronic conditions.

In New York City, the COVID-19 pandemic has had a profound impact on the most vulnerable communities that face worse health outcomes on the basis of the social determinants of health (Hashim et al., 2016). Numerous investigators have demonstrated a relationship between neighborhood characteristics and COVID-19 testing, number of cases, and death rates, with an association between areas having a higher proportion of Blacks and Hispanics and COVID-19 case rates (Kim et al., 2021). Members of these communities may be more likely to have experienced food and housing insecurity, job loss, and loss of health insurance (Hashim et al., 2016). Similarly, these groups may not be able to have the same resources needed to maintain physical activity. The lack of physical activity and increased stress may adversely impact mental health, leading to higher rates of obesity, diabetes, heart disease, and cancer; they can also be associated with an increase in other behavioral risk factors such as smoking and alcohol use (Chandrasekaran & Ganesan, 2020). Furthermore, other services, such as routine screening for cancer, have been utilized less during the pandemic (Mitchell, 2020). For example, the first three months of the COVID-19 pandemic led to missing approximately 80,000 cases of cancer in the United States alone (Kelkar & Cogle, 2020). At a time when demands for services offered by CBOs would be expected to dramatically increase, i.e. a public health emergency, the degree to which CBOs are able to tackle community needs is uncertain.

A needs assessment of New York City CBOs conducted prior to the pandemic indicated that only a small percentage of organizations reported having funds allocated for emergency response (Rivera et al., 2019). Yet, having earmarked funds available would be critical, given the impact on capacity, funding, communication strategies, and availability of volunteers. Not only did funds vary among organizations, but the speed of distribution of Congress’s COVID-19 Paycheck Protection Program (PPP) loans varied, too. Residents of predominantly white neighborhoods received PPP loans faster than those in predominantly Black and Latino or Hispanic neighborhoods (Liu & Parilla, 2020).

The following study examined perceptions of the impact of COVID-19 on CBOs and the perceived challenges due to COVID-19 on these organizations. These perceptions are based on experiences just prior to the beginning of the second wave of the pandemic, a time when the COVID-19 vaccine was not yet available (Bowen et al., 2022). Specifically, we targeted providers who focused on an array of areas aimed at enhancing different aspects of health. These focus groups were intended to serve as the basis for constructing a community needs assessment that would target prevention related to chronic diseases such as cancer.

Methods

Study Design and Setting

We assessed the perspectives of participants on their experiences working at CBOs and agencies in Upper Manhattan during the COVID-19 pandemic. This target area of Upper Manhattan was determined using data from the New York City Community Health Profile and included East Harlem, Central Harlem, Morningside Heights and Hamilton Heights, and Washington Heights and Inwood (Hinterland et al., 2018a, b, c, d; Liu & Parilla, 2020). This qualitative assessment employed virtual focus groups using the Zoom platform. While employing an online or virtual methodology has been shown to be an effective way to conduct focus groups (Rupert et al., 2017), this method was chosen based on the need for social distancing and the closure of the City College of New York campus due to the pandemic (Reisner et al., 2017).

Participant Recruitment and Data Collection

Eligible focus group participants were identified based upon the participants who worked in the target geographic area and with the local population for more than one year. The team constructed a list of CBOs and agencies that offered services covering aspects of health promotion and disease prevention. Individuals were invited to participate in focus groups through an initial email contact and two follow-up emails. All groups were held on different afternoons in November 2020. While we initially planned on holding two focus groups, we added an extra group so that all interested participants were able to find a date that worked for their schedule. Late afternoon (4 pm or 4:30 pm) was preferred by participants, given that many participants were working off-site and some were supervising children who were attending school remotely. Focus groups were approximately 90 min in length and led by a trained qualitative expert (KAL) using a semi-structured moderator’s guide to explore the following topics: 1) Organization characteristics, including population served and cancer-related activities, 2) Impact of COVID-19 on cancer-related activities and service delivery, 3) Changes in communication with staff and community members, 4) Changes in information sources and partnerships, 5) Impact of COVID-19 on staff health and well-being, 6) Impact of COVID-19 on organizational funding, 7) Other challenges in providing community services. Consistent with focus group methodology, the moderator also asked follow-up questions (‘probes’) to allow participants to elaborate on relevant experiences and respond to one another. This guide was developed collaboratively by members of the study team based on the emerging literature related to the public health impacts of COVID-19, including the potential impacts on cancer-related risk factors, screening, and rates (Chandrasekaran & Ganesan, 2020; Kelkar & Cogle, 2020; Mitchell, 2020).

These groups were audio- and video-recorded and transcribed verbatim for analysis. All transcripts were de-identified so that speakers were listed by a study ID number (e.g. Speaker 1, Speaker 2…) rather than their real name. All participants provided verbal informed consent at the beginning of the session. Participants were compensated with $50 Amazon gift cards that were sent via email. The study was approved as exempt from the City College of New York IRB (Protocol Number 2020–0526).

Data Analysis

Deidentified interview transcripts were evaluated using an iterative process of thematic content analysis. One member of the research team (KAL) with training and experience in qualitative analysis guided four additional investigators (JMW, CH, RH, NN) through the process of independently coding each of the three transcripts according to a set of a priori codes derived from the focus group topics. The team met regularly to refine code names and definitions and incorporated inductively-derived codes based on novel concepts that emerged from the data. Once all data were coded, the team grouped coded statements into conceptual categories; statements within each category were then collaboratively reviewed to identify and reach a consensus on primary themes. Qualitative software NVivo v. 12.0 (QSR International, 2019) facilitated the analyses.

Results

Participant Demographics

The first focus group consisted of four participants, the second focus group consisted of three participants, and the third focus group consisted of five participants. An equal percentage of participants belonged to the following three age groups: 18–34, 35 to 55, and above 55 years. Two-thirds of participants identified as female while all participants reported their highest level of educational attainment to be a college degree or postgraduate studies. Most participants reported working at their organization or agency for more than ten years.

Participants worked at diverse organizations serving the needs of the Upper Manhattan community. Specifically, 33% worked in an educational capacity (peer training), 25% worked as healthcare providers (pediatrician, nurse practitioner), 17% worked in advocacy (health advocate, student health advocate), and 25% worked in service delivery (social worker, financial advisor, director). Full demographics of participants are listed in Table 1.

Table 1

Demographics of Employees at Community-Based Organizations

Participant Demographics	Total
Gender
Male	4
Female	8
Age
18–34	4
35–55	4
55 +	4
Level of educational attainment
Less than high school	0
High school or equivalent	0
Some college	0
College degree	2
Post-graduate education	10
Length of employment at current agency
Less than 1 year	1
1–5 years	3
5–10 years	3
More than 10 years	5
Type of Employment Agency
Education	4
Health Center	3
Advocacy Organization	2
Service Delivery	3

Description of Community-based Organizations

Organizations provided various services related to health and well-being, including screening, prevention, education, and psychosocial support. Participants were employed in a number of different settings, including being self-employed, working in small- and medium-sized nonprofits, and working in ambulatory practices and hospital-based settings.

Major Themes

We grouped our codes into the following eight major categories: changes in information-seeking and assessing community needs; changes in programming, including cancer-specific program changes; COVID-19 negative impacts on organization; funding; impact of COVID-19 on communication; impact on community; personal impacts; plans for the future. From a review of these categories, we identified five major themes related to the impacts of COVID-19 on community needs: 1) increased mistrust and decreased service utilization, 2) breakdowns in communication, 3) shift in community need, decrease in cancer screening and prevention, 4) increased risk factors for negative health outcomes among staff and community, and 5) decreased funding and an uncertain future. Each theme will be discussed in detail below. Table 2 summarizes major categories and associated key quotes.

Table 2

Description of Themes that Emerged during Focus Groups

Theme	Categories	Sample quotes
Increased mistrust and decreased service utilization	Changes in information-seeking and assessing community needs	• […] so, I think I’ve spent more time with community boards 9, 10, and 11. Um, on the district needs assessment and sharing the surveys that we’ve been doing around the city, around the impact of COVID. And being able to share and sort of focus that data and specifically to Harlem and, um, looking also at food insecurities as it relates to people with chronic illnesses with a focus on cancer in particular. So, I think in that way, um, hearing and being apart in a very different sort of way has been very helpful and insightful in attending Town Hall meetings • A lot of ours has been through a networking process before, and a lot of that has broken down. During this time because people aren't accessing another ser, another source, a lot of ours has been through faith groups. So a lot of the faith groups have lost some of their connection with their members and aren't gathering people together on a regular basis. So that creates a breakdown back, otherwise, as far as getting a feel for, what the feel in the community is and what the needs in the community are. So we've had to do some shifting that way
Breakdowns in communication	Communication challenges	• I—we’ve definitely had those challenges as on the community-based organization and that, uh, when the pandemic first happened, that there were so many, uh- the big crisis at the moment was trying to communicate with our members that we didn’t have the space to communicate with our academic partners, um, so that took a little bit of time to workout, um, but our workload is definitely way more than it was pre-pandemic, so carving out the time, especially if it’s not written out in a grant or if it’s not like financially funded, finding the time to communicate has been a big challenge, and even thinking forward to planning for the future, um, that’s sort of taken some extra time and I think at this point now we have more space to communicate and continue building on those partnerships, but the breakdown in communication with our members really hindered the discussions that we were having in the translation around cancer care and prevention for us • However, communication with management really broke down, especially at the very beginning there was no communication. We didn’t know where we were going, from one day to the next, or what tasks were to be doing since our clinics were closed. Um, so that was a really big challenging situation
Shift in need, but cancer risk factors increasing	Negative impact on organization due to COVID-19	• I think we found that y’know, it’s hard for people to think about cancer screenings when they’re trying to stay healthy, um, yea, and, y’know not get infected with COVID. […] There weren’t a lot of opportunities in Harlem for people to get tested for COVID for a while, y’know, and gradually, they did start to have some pop up centers, um, but y’know, I think that had an impact on them as well. Often times, y’know, um, people in our area- we’re in like the East Harlem area, often times people get scared- a couple people mentioned trust issues with community members and sometimes they just wait until they’re really sick to come in, y’know? At our site, we have like um- 50% no show rate, and then a 40% walk in rate. So, um, y’know, so, um referring people or encouraging people to get their cancer screening is not an easy feat, right- you really have to establish very important, like, trust with the patient, um before they will trust you enough to go for their screenings, y’know? • I think in our population, everything was just kind of put on the back burner. They- y’know they’re young, mostly adolescent, (Inaudible) they were totally not thinking about getting their HPV vaccine during the pandemic. Their, like, more focused on their birth control and even that was a challenge to get them and so, I think that parents also kind of like didn’t take their kids in for their annual screenings. A lot of the clinics were not even bringing kids in for their, um, annual check ups, for their well (inaudible) child care visits. People were scared- rightfully so
Negative health outcomes among staff and community	Personal impact and impact on community	• I found it to be challenging, um, for like mental health services and keeping that going, um, everything went remote, but it was still kind of a challenge just to, y’know, keep on track of the when the appointments were and dental- just like preventative care- it was completely shut down through, like, the end of June, I believe. The ADA shut down all dentists. And so just basic preventive care was really, really hard to schedule your appointment. I was able to get my physical early July, but before that they were like: “We’re not gonna see you before this time. You- you’re and essential worker? Do you really have to come in?” I’m like: “Yes! I need my cleaning!”
Decrease in funding and an uncertain future	Funding and plans for the future	• I actually have no idea where our program is going. (inaudible) and we’re not having the visit numbers that we’re used to having and so, I mean, just hoping and praying that the program is able to sustain itself in the long run and able to survive through this time • Don’t know where the future is headed, as a grant-funded entity, who survives on tax-levy dollars, it's going to be interesting to see how that happens, so crossing our fingers that we’re able to continue the work

Theme 1: Increased Mistrust and Decreased Service Utilization

The first theme that emerged related to barriers participants faced in accessing services due to medical mistrust, COVID-related fears, and widespread misinformation. Participants reported consistently engaging with community members to combat misinformation during virtual events. For example, one participant noted, “…spending a lot of time actually telling people where to go for the right information on their end. Um there’s a lot of misinformation out there and so we end up dealing with a lot of, you know, weird questions about COVID and other things. You spend a lot of time trying to re-educate people and get rid of the misinformation.”

Additionally, several participants noted that while the overall demand for services has increased due to COVID-19 related stressors, the utilization of the available services has decreased due to fear, mistrust, and a lack of access to services due to pandemic-related shutdowns and the shift to virtual programming. Participants further described how COVID-19 had widened pre-existing economic inequalities in the city, including, “being able to pay their rent, not being able to do recertification, say if they’re on assistance or public benefits. Getting missed, mixed messages from public benefits. Like they’re going to get turned off, and you know, getting turned off in the middle of a pandemic or thinking that you can’t pay your rent in the middle of a pandemic.”

Multiple participants agreed on the importance that service delivery plays in building trust in the community. However, pandemic-related shutdowns and the shift to virtual programming limited the target population’s access to critical services, facilitating a sense of fear and mistrust. One speaker stated that the shift to virtual support groups led to hesitancy from community members, as, “…you know people were like nah you know [we’ll] wait til you find a new location because we enjoy the in-person experience.” Other speakers discussed the difficulty of accessing communities with limited access to stable internet connections during this time.

Theme 2: Breakdowns in Communication

A second theme identified was a breakdown of communication at both the organizational and community levels. Participants agreed that they were forced to adjust to a ‘new normal.’ Organizations not only had to adjust to the challenge of accessing and properly using technology but also had to improvise in the ways they sought and provided information to their members. As stated by one participant, “I always say it is a concern for me, you know, many people do have technology, but there’s so many people that don’t, right. And so you run the risk again of losing people, falling between the cracks and not being educated and informed about these cancers and what screenings are available […] this pandemic is definitely exacerbating the barriers that have been in existence […].”

Organizations also had to find innovative ways to ensure that virtual sessions are kept confidential, given that members might not have access to a private space. For example, one participant stated, “It has been a struggle in terms of [privacy]. Being able to have counseling sessions with them in a completely private space, something that I've done and [is] just like ideas we've come up with is having code words. […] So instead of saying, like ‘boys,’ we can say something like ‘math test.’ And so that's one way we've been able to kind of get[ting] around that.” Similarly, one participant added, “We've…had some people who have cars…so they've gone out into their cars and they've sat in their car for the hour, which is not an ideal setting to try to be conducting a counseling session…."

Theme 3: Shift in Community Need, Decrease in Cancer Screening and Prevention

The third theme that emerged was a decreased focus on cancer risk factors since the start of the pandemic. The emphasis on COVID-19 prevention decreased the attention on cancer prevention and screening. Participants shared the sentiment that COVID-19 has decreased the number of health screenings and vaccines (HPV) administered. One participant noted, “That’s so important, to have a trusted person in the community to help you to talk to people and to get them to feel like it's safe to have your screenings. And so we couldn’t do that this year. And even during the fall and the winter, we usually go- a church invites us, for example. To come out, we would do screening tests with us. Now we can’t do that anymore.” Some cancer-specific programs were forced to adjust their health screening events, including health fairs and screening tests, due to COVID-19 restrictions. Such events served as an opportunity to build trust between the community and CBOs.

Theme 4: Negative Health Outcomes Among Staff and Community

During the COVID-19 pandemic, participants noted that communities have experienced food insecurity, heightened mental health concerns, and decreased health screenings. One participant described COVID-19’s impact on the community, “...because you know mental health has definitely been exacerbated in this time. And and you know the the domestic violence is definitely, you know, on on the rise and these and and we never really talked about mental health in this country before and so we’re not prepared for the demands that are needed to address mental health and so many other issues and so this this this pandemic has definitely put a lot of things under the spotlight.” Participants providing mental health services to high school students indicated a high demand for their services.

Many participants shared that COVID-19 had a negative impact on their own mental health and well-being. Participants noted that their work and personal schedules overlapped, thereby, blurring their work-life balance. Participants emphasized feeling overworked and experienced role strain. The participants noted making a purposeful effort to set boundaries between work and personal time, and to make an effort to step away to take care of themselves. Some participants expressed difficulty accessing child care and refilling prescriptions due to COVID-19’s impact on services. Other participants shared their difficulty in getting a doctor's appointment due to the practice’s abridged office hours. As noted by one participant, “My doctor’s office hours changed, uh, y’know, both for my gynecologist and my regular doctor, they’re 9-5 now. Um, and so I had to take a day off of work in order to go to one of them, I prioritized the gynecologist first because I needed a refill for my birth control. But for the 3 months before I was able to get in, I was just asking friends, my sister if they could spare a pack here, spare a pack there. It was, like, pathetic.” Finally, the pandemic has resulted in an increased workload for both the organizational and community levels.

Theme 5: Decrease in Funding and an Uncertain Future

The final theme identified a decrease in funding for organizations and uncertainty in planning for the organization's future. The COVID-19 pandemic negatively impacted the funding and operation of organizations and many participants noted a loss in revenue at their organization. One participant asked “how do we try to operate because there’s still a need but the revenue is down and […] how do you support your constituents and still keep the lights on.” Organizations also struggled to continue providing services amid losses in revenue, leading some organizations to furlough staff in order to save on operating costs. Some organizations could rely on private funding to continue operating and providing services, but others found themselves facing “budget cuts coming up because of COVID and so we did end up having to cut some programming for the students.”

Participants highlighted looming budget cuts, staff furloughs, extended working hours, isolation, programming cuts, and felt uncertain about the future of their organization’s programming. One participant said, “we really are going to be forced to figure out how do we do business differently because […] the need is clearly there because cancer has not gone away […]the organization is trying to figure out how it’s going to pivot and be the most effective in the times that we’re in and it’s just trying to remain as flexible, adaptable, as we can because things are so unsure and uncertain as each day passes.”

Discussion

This study highlights a number of themes that emerged from CBOs and agencies focused on health and well-being in Upper Manhattan (New York City) during the COVID-19 pandemic. Because of the pandemic, CBOs have pivoted to cater to the immediate and changing needs of the community and, in doing so, revised their menu of services offered as well as their service delivery model. Specifically, the guidance to remain home meant that participants needed to maintain connectivity with community members through alternative ways and that organizations and agencies needed to maintain the trust of the community. In making modifications, however, specific services, particularly those offered in a school setting, could not be offered, and privacy issues became more prominent. Furthermore, participants expressed the problem of role strain with regard to balancing work and home responsibilities.

Over the past year, the impact of the pandemic on health and well-being has begun to be assessed in a more comprehensive manner. For example, cancer screening has been shown to be an effective and integral preventive measure towards reducing cancer incidence and mortality. However, a large decrease in screenings has become evident since the COVID-19 outbreak, thereby, leaving a vast number of patients without access to recommended healthcare services (Cancino et al., 2020). In May 2020, Epic Health Network observed between an 86% and 94% drop in cancer screenings (“Delayed cancer screenings,” 2020) while a WHO, UNICEF & Gavi poll of 61 countries revealed that 85% of the respondents noted that vaccination levels were lower in January 2020–February 2020 as compared to May 2020 (Gavi, 2020; UNICEF, 2020 ). A considerable drop in vaccinations has also been noted, which raises concern due to the possibility of outbreaks of vaccine-preventable illnesses, like measles and whooping cough (Sun, 2021). As schools reopen and restrictions on social distancing are easing, persons who missed vaccinations may be at greater risk for vaccine-preventable illnesses. Similarly, the Centers for Medicaid and Medicare noted that utilization of primary care, preventive services, and mental health services declined among children during the pandemic (“CMS data shows vulnerable Americans forgoing mental health care during COVID-19 pandemic,” 2021). Ultimately, concern arises that children and adults will remain behind on their preventive care as restrictions begin to recede. A Kaiser Family Foundation health tracking poll from July 2020 revealed that adults are reporting specific negative impacts on their mental health and well-being that include difficulty sleeping or eating, increases in alcohol consumption or substance use, and worsening chronic conditions as a result of COVID-19. This is especially prevalent in communities of color, as they have been disproportionately affected by the pandemic and typically have difficulty accessing mental health services (Panchal et al., 2021). During this period, compared to white adults, Black and Hispanic adults have been more likely to report symptoms of anxiety and/or of depressive disorders (Panchal et al., 2021).

The transition from in-person to remote programming has had adverse impacts on particular communities, especially those who experience pre-existing inequalities. These inequalities were further exacerbated by the digital divide. Millions of Americans lack high-speed internet access, and practitioners and policy makers have advocated that broadband access should be included as a social determinant of health (Benda et al., 2020). Our participants worked in a catchment area serving neighborhoods in New York City that, based upon having higher proportions of racial/ethnic minorities, higher rates of poverty, and lower educational attainment, would be more likely to have higher rates of poor access to broadband internet. These sociodemographic factors also have been associated with excess COVID-related hospitalizations and mortality (Eruchalu et al., 2021). In addition to being disproportionately impacted by COVID-19, Black and Hispanic communities have a high population attributable risk for comorbidities such as hypertension and diabetes. The increase in physical distancing has worsened the pre-existing disease burden, thus, leading to progressively worse outcomes as a result of inadequate outpatient follow-up (Odlum et al., 2014). This is especially prevalent for these populations due to reports of low healthcare literacy, low prevalence of internet access (15% among Blacks and 22% among Hispanics) and limited access to resources such as telehealth (Jain et al., 2021). The digital divide in these communities must be further examined, given the sparse literature on the consumer health information needs of these populations despite the clear need for health information access (Odlum et al., 2014).

In terms of trust, participants highlighted the importance of maintaining trust with the community through maintaining connections and providing timely and evidence-based information. This is especially important as professional trust is regarded as a crucial determinant for adherence to the recommendations of healthcare providers. Health agencies have been shown to enhance public trust and positively influence people’s willingness to adopt recommended behaviors. Rates of vaccination, for example, are positively associated with a higher level of professional trust (Saechang et al., 2021). Studies have highlighted that different subgroups of persons have a greater trust in certain types of information. For example, non-white and younger respondents have been found to be more likely to trust private sources of information and social media as compared to whites and older persons who were more likely to trust government sources of information (Fridman et al., 2020).

Participants also understood the importance of privacy, especially for teenagers. This expression of the need to provide privacy to teenagers, who were largely unable to attend in-person school in New York City during this time period, has been noted by others, too (Hall & McGraw, 2014). Understanding the emotional needs of this often overlooked subgroup, especially with regard to mental health, will be critical over the upcoming months with the reopening of the New York City public schools (Jalali et al., 2021). Telehealth has flourished during the pandemic and would have otherwise have taken years to evolve. Despite the obvious benefits of telehealth’s widespread use, the associated risks and challenges must be addressed, such as threats to cybersecurity/privacy and maintenance of technology infrastructure (Jalali et al., 2021).

Finally, participants vocalized that the closure of their organizations had led to difficulties navigating the separation of work and home as well as the ability to care for their own health needs. COVID-19 has not only impacted the Upper Manhattan community, but participants of the CBOs have been affected, too. During the pandemic, many participants shifted to an at-home-setting, given that places of work had closed. Additionally, the closure of schools forced many working parents to supervise their children, thus, stunting productivity (Toniolo-Barrios & Pitt, 2021). These changes have led to many participants experiencing lower work productivity, lessened motivation, increased stress, and poorer mental health (Toniolo-Barrios & Pitt, 2021).

The comments noted by female focus group participants about the effect of the pandemic on work-life balance and the need to access childcare and caring for their own health is consistent with the literature on the caring economy or the invisible and unpaid work traditionally done by women (Power, 2020). Simultaneously, an increased demand for childcare during quarantine led to the revival of traditional gender roles, which could potentially counteract efforts to close the wage gap (Arntz et al., 2020). Given the school closures in the New York City area, the unpaid care burden has increased even more. Ultimately, this might adversely impact health through increased psychological distress (Xue & McMunn, 2021).

The decreased funding noted by the participants in this study also is not unique. Surveys from the National Council on Aging during the pandemic indicate that COVID-19 had impacted the resources of CBOs, with slightly less than half of these organizations reporting having lost funding and reducing staff in October 2020 (The National Council on Aging, 2021). The pandemic decreased the resources of many CBOs, including the number of volunteers, and, ultimately, these CBOs had to construct new partnerships such as with their local departments of health (The National Council on Aging, 2021). Similarly, the Nonprofit Finance Fund (NFF), in collaboration with the Commonwealth Fund, conducted a survey of nonprofit leaders of CBOs from different sectors and found that the majority of organizations were concerned about long-term financial survival (Tsega et al., 2020).

Looking forward (post-pandemic), specific areas would benefit from additional emphasis. First, providers should not only reinforce the importance of COVID-19 vaccinations but also promote the receipt of vaccinations for other vaccine-preventable conditions such as HPV. Second, based on previous investigations on the long-term impact of disasters on mental health, providers should highlight the sustained effect of the pandemic on mental health (Panchal et al., 2021). Additional mental health resources should be available for persons who have developed or experienced an exacerbation of mental illness from this pandemic. Third, new infrastructure should be constructed to assist communities disproportionately impacted by the pandemic. Such an infrastructure should cover increasing mental health care resources and providing broadband to at-risk communities. Reliable broadband also would facilitate access to telehealth that, ideally, could be obtained in a private setting. Recently, the Centers for Disease Control and Prevention (CDC) announced a plan to invest $2.25 billion in order to address health disparities related to COVID-19 and advance health equity among high-risk and underserved populations. Finally, CBOs can examine different ways to build trust among the communities they serve (Centers for Disease Control and Prevention, 2021). A report from the Connecticut Health Foundation examined ways to create successful clinical-community partnerships and highlighted the importance of all partners investing their time in setting the stage for a long-term collaborative relationship marked by trust and transparency (Zahn et al., 2019). As restrictions on in-person gatherings currently are being lifted, perhaps CBOs can implement pre-pandemic strategies (health fairs, community meetings, etc.) as well as continue to have a more pronounced online presence.

Limitations

This study was limited by a relatively small sample size and may not be representative of the spectrum of participants working in these target areas. In addition, only individuals with availability and access to join a 90-minute Zoom call were able to participate. While we attempted to overcome this limitation by scheduling multiple groups, we may have been unable to connect with the individuals with the highest burden of care and greatest levels of burnout. However, despite the low sample size, we were able to sample a diverse group of participants working in various roles (e.g. education, advocacy, and service delivery) across multiple health-related organizations. Finally, our focus groups were conducted at a single point in time (November 2020) as opposed to multiple points during the pandemic. By this point, New York City no longer was the epicenter of the pandemic, but, while the curve was flatter, cases were beginning to rise and vaccinations were not yet being administered.

Conclusions

In conclusion, our study examined the insights of participants employed at CBOs in Upper Manhattan that were involved in programming related to public health and healthcare during the pandemic. Our participants expressed a variety of experiences related to the five themes delineated. While these examples were primarily based on the short-term impact of COVID-19, concern arises with respect to the longer-term effects on the health and well-being of community members and participants. In particular, while a vaccine was available to adults shortly after these focus groups, and New York City had shifted from being the epicenter of the pandemic, the effects of the pandemic continued, making it all the more important for CBOs to find innovative ways to support the vulnerable communities they serve. Similarly, the future capacity of these organizations and agencies to serve their constituents may be in jeopardy if the government does not ensure the financial viability to cover some of the fiscal losses incurred and create a stronger infrastructure for future emergencies.