To mitigate the effects of COVID-19, diagnostic testing is an essential tool to rapidly identify cases, isolate and treat infected individuals when indicated, and quarantine those who may have been exposed (1, 2). For diagnostic testing to be effective, tests must be widely available, easy to access, and trusted (3). Moreover, testing and access to other public health resources should be prioritized for communities facing increased vulnerability to the effects of the pandemic.

Within the United States, Black and Latinx populations have been disproportionately impacted by COVID-19 infections, illness, and death—in part, due to fewer resources to help prevent the spread of the virus (4–7). Additional upstream drivers of these disparities include lower household incomes, higher propensity for working in essential services, as well as residing in high-poverty neighborhoods and overcrowded housing (8–11).

As part of the National Institutes of Health’s Rapid Acceleration of Diagnostics – Underserved Populations (RADx-UP) initiative, NYU’s Grossman School of Medicine and Global School of Public Health, in partnership with community-based organizations (CBOs), received funding to study strategies to improve COVID-19 testing among residents of public housing. New York City Public Housing Authority (NYCHA) is the largest public housing authority in the nation. Home to approximately 400,000 people, or roughly 5% of the city’s population, residents of NYCHA have an average household income of just under $25,000 and approximately 90% identify as Black or Latinx (12–14). With respect to transmission risk, residents are disproportionately employed in essential service sectors that were associated with higher COVID incidence and mortality rates, including healthcare, retail and food services, transportation, warehousing, and manufacturing (15–17). In addition, NYCHA developments have a population density that far surpasses that of the city as a whole (18–20).

Nested within NYCHA communities are two subgroups with distinct risk profiles: young adults and older adults. Young adults, though at a lower risk for COVID-19 morbidity and mortality, consistently experience the highest rates of transmission, and are disproportionately responsible for COVID resurgences and hotspots, making them a key group to target for preventative efforts (7, 21). Older adults, in contrast, are far more susceptible to the effects of COVID-19. The risks are compounded for older residents of NYCHA, who have poorer self-reported health as well as higher rates of chronic conditions and limitations on activities of daily living when compared to older residents living in New York City (NYC) (22). Moreover, the proportion of older adults who live alone is far higher in NYCHA, making this a particularly hard-to-reach group for health promotion and disease prevention services (22).

This paper presents findings from focus groups conducted in 2022, after the introduction of at-home testing. We focused on young adults (ages 16 to 29 years) and older adults (ages 60 years and older) because previous research has not focused on comparing these two groups’ knowledge and attitudes about COVID-19 testing options, potential barriers and facilitators to getting tested, reasons for testing oneself, and sources of information about testing. Though both groups are disproportionately impacted by COVID-19, they are distinct populations with distinct experiences, beliefs and needs. By highlighting where the two populations overlap versus where they may require separate, targeted interventions, these findings can be used to guide policies and programs that optimize reach across risk groups.

To our knowledge, this is the first study to identify barriers specific to at-home testing for older adults, and to draw comparisons between the attitudes of older adults and younger adults toward COVID-19 testing. We found that mainstream media, doctors and government agencies remain the most trusted sources of information among younger and older residents alike. Residents offered viable strategies to improve testing, including suggestions to leverage the infrastructure of public housing for testing services, and for public housing authorities to continue distributing tests to all residents.

Among the young adults and older adults who participated in age-specific focus groups, multiple themes emerged that spanned both groups. Both groups reported several trusted sources of information, including major media outlets, doctors, and public health officials or government employees. While this is consistent with previous literature (28–32), it is notable these remained the named trusted sources well into the pandemic, despite widespread concerns about erosion of trust in public health authorities and the medical establishment, and of the proliferation of fake news (28, 30, 33–35). One of the main differences between the groups was that young adults were more likely to access information from social media, despite being aware that these sources may contain misinformation, a concern noted in prior COVID-19 studies (25, 30, 32). Conversely, older adults preferred people with whom they can actually discuss their health, as opposed to the Internet (36). This included healthcare providers, friends and family, and community or faith-based organizations.

Both groups cited a COVID-19 exposure or exhibiting symptoms as the main reason for getting tested. Separately, older adults emphasized awareness of their own vulnerability to the virus in high-risk settings (e.g., social events) as a reason for testing. This is consistent with other studies examining the relationship between older age and COVID-related behaviors (37, 38). Feeling more susceptible, older adults are more likely to test, get vaccinated, and more likely to perceive preventative behaviors—such as social distancing and avoiding crowds—as effective (37, 39, 40). In contrast, young adults in the study were motivated to test to protect older or more vulnerable people in their social circle. Younger adults, though they see themselves as less susceptible, recognized the increased risk to older groups, and often cited “protecting others” as a primary motivation for testing and vaccination (31, 41).

Participants identified a number of barriers to testing, including some of which have been identified in prior studies, such as long lines, difficulty navigating questions about insurance coverage and how to access tests, and cost (28, 30, 42–44). While at-home COVID testing was seen as a more convenient and accessible alternative to in-person testing by younger participants, older adults expressed concern about making an error during self-testing. As other population groups have identified, both young adult and older adult participants emphasized the benefits of easier access via a central well known location, in-home visits, free or low-cost tests, and increased outreach (28, 42, 45, 46). Notably, all groups recommended the housing authority as a venue for testing service provision.

Participants in this study provided recommendations that could be utilized and expanded on, many of which were specific to NYCHA. For example, participants proposed that building management could distribute PPE or test kits, and a number of participants reported a higher level of cleanliness in communal areas of their buildings (e.g., lobbies; stairwells), which supported their ability to reduce transmission of COVID-19 through safe hygiene practices. Though underexplored in research literature, there are examples of the critical role of public housing programs in addressing the spread and effects of COVID-19. One paper examining the impact of the U. S. Housing and Urban Development sponsored service coordinators found that throughout the pandemic these coordinators were crucial in several areas, including resident needs assessment, benefits and program applications, dissemination of public health recommendations, addressing loneliness/isolation, and coordination between organizations (47). In the face the of rapidly changing nature of the pandemic, as well as lapses in typical benefits and services, these coordinators were able to leverage their knowledge of residents’ needs, property resources and staff, and public and community service programs to great effect (47).

In NYC specifically, NYCHA was a key partner to government agencies and CBOs. Test & Trace – the city’s interagency initiative to provide testing, contact tracing, and aftercare support – implemented a mobile testing program to address testing inequities in neighborhoods disproportionately affected by COVID-19. Between June 2020 and December 2021, Test & Trace was the largest provider of COVID testing services in NYC, operating 586 testing sites throughout the city (48). Many of these testing sites were set up on or near NYCHA property, including on-site senior and community centers (48, 49). Moreover, 90% of NYCHA service coordinators surveyed indicated that their properties had offered on-site vaccination at least once (47). Our participants repeatedly referenced these on-site centers, stating that they were crucial in making testing and vaccination accessible, and should continue to serve as a site for COVID-19 related resources and services. One analysis of housing and COVID-19 found that living in NYCHA may have a protective effect (9). One possible explanation could be that as a public entity, NYCHA—and therefore the residents—can more easily be connected to public services and initiatives (49, 50). This was demonstrated in another study, whereby public housing residence was associated with lower rates of uninsurance and unmet medical need. The authors posited that housing stability and reduced housing costs may give residents the opportunity and resources needed to access care (51). Presumably, this holistic approach could also contribute to COVID-19 awareness.

Our study has some limitations, including the small sample size of 32 focus group participants. Focus groups were only conducted in English due to time and staffing constraints, which limited our reach to other populations, particularly Spanish-only speaking older adults who may have been linguistically isolated (51). Additionally, using a virtual platform for the focus groups may have been a barrier to participation for some older adults, possibly hindering their enrollment. The confluence of these two factors may explain why our older adult group was both smaller and more homogenous than that of young adults. However, our sample can still be considered representative with regards to other characteristics: all participants were residents of public housing, and there was a high degree of similarity for certain socioeconomic factors (income, percent employment, educational attainment) that remained consistent across race/ethnicity (12, 52). Moreover, though women were overrepresented in our participant pool, this is also reflective of NYCHA’s overall population, including older residents (12). The timing of the study may also present a limitation – focus groups were conducted from June through November of 2022, when the level of public concern for COVID-19 was declining (52). Some of our focus group questions asked participants to recall how they felt during the early stages of the pandemic, which may have introduced some recall bias (53).

Despite these limitations, our findings are still a major contribution to the literature due to our populations of interest. A focus on residents of public housing is important given the particular vulnerabilities of this group, as well as the potential for public housing infrastructure to provide resources to improve COVID-19-related information sharing and testing. Equally important is our focus on two high-risk, understudied age profiles. To adequately target these distinct populations, a comparative understanding of their needs, beliefs and behaviors will be required, and our findings can be used to inform interventions in the event of future COVID surges or similar epidemics. Though it has been several years since the acute phase of the COVID-19 pandemic, there remains a potential for COVID-19 resurgences due to new variants, waning immunity, low vaccination rates, and the relaxation of social distancing and other protective behaviors. As such, mitigation strategies specific to COVID-19 may still be needed in the future (54–56). Moreover, our results are also broadly applicable to other infectious diseases, in particular respiratory viruses such as influenza, RSV, streptococcus, and other coronaviruses, which, like COVID-19, are seasonally epidemic, disproportionately affect the same populations, and have multiple means of diagnostic testing (clinical and at-home) that can be leveraged to reduce spread and burden of disease (57–60).