How Fear Induced Messaging Worsened the Response to COVID Capstone Project

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How Did Mayor Bill de Blasio’s COVID Lockdowns Affect Access to Healthcare for the Minority Population in Tremont?Chapter 1IntroductionThe panic regarding the 2020 COVID-19 pandemic led to new administrative challenges regarding protecting and serving communities at the same time. Many cities across America reacted to COVID by trying to curb the virus\'s spread through the implementation of lockdowns. Local governments implemented drastic measures that changed daily life overnight and exposed the vulnerabilities of already underserved and marginalized communities.In New York City, the epicenter of the pandemic in the United States, Mayor Bill de Blasio\'s office issued a series of lockdown policies starting in March 2020 (NYC, 2020) These policies included the closure of non-essential businesses, the implementation of remote learning, the restriction of public gatherings, and the enforcement of social distancing in essential services (NYC, 2020). The media by and large reported on these measures as necessary to contain the public health crisis; however, for the public affected by these measures, there were far-reaching consequences—particularly for the population of Tremont in the Bronx.Tremont is a predominantly minority community in the Bronx. It has long been characterized by socio-economic disparities, such as high poverty rates and inadequate access to healthcare (NYC, 2020). There are 28,095 residents in Tremont, with a median age of 32. 46.46% are males and 53.54% are females. US-born citizens make up 54.9% of the residents in Tremont, and non-US-born citizens account for 25.36%. 19.74% of the population consists of non-citizens. The neighborhood\'s residents are mostly African American (11%), Asian (23%), and Hispanic (57%), all groups that have historically dealt with systemic barriers to economic mobility and healthcare equity (Census Reporter, 2024; Gilbert et al., 2022). The COVID-19 pandemic lockdown response essentially aggravated already existing challenges for this population by further limiting access to critical services. The purpose of this dissertation is to explore the specific impact of the lockdown policies implemented between March 2020 and September 2020 on the socio-economic conditions of low-income residents in the Tremont neighborhood. In particular, the research will focus on how these policies affected access to healthcare for the minority population in this community.Contextualizing the Tremont Neighborhood in the BronxIt is important to understand the pre-pandemic socio-economic condition of Tremont. Like many other neighborhoods in the South Bronx, Tremont is home to a low-income, minority population that has experienced continual challenges related to poverty, healthcare access, and environmental racism (Brennan, 2021; Estevez, 2020). Indeed, the Bronx has one of the highest poverty rates in New York City, with many residents relying on public assistance and living in overcrowded housing (Clark & Shabsigh, 2022). These socio-economic conditions have long contributed to health disparities in the borough, as minority communities experiencing higher rates of chronic diseases compared to other parts of the city (Shiman, 2021).The social determinants of health also include environmental factors which have certainly impacted the health of Tremont residents. The South Bronx, including Tremont, has been disproportionately affected by environmental hazards, such as poor air quality and high levels of pollution. Estevez (2020) notes that the South Bronx has historically been subject to political practices that have allowed hazardous industrial activities in the area, which have in turn contributed to high rates of respiratory illnesses among residents. These pre-existing conditions made the Tremont community particularly vulnerable.Additionally, Tremont residents have faced systemic barriers to accessing quality healthcare (Shiman et al., 2021). The Bronx is home to several public hospitals and community health clinics, but many of these facilities are underfunded and understaffed due to structural racism within the healthcare system, which has contributed to disparities in healthcare access, with minority communities in neighborhoods like…

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…HowDidMayorBilldeBlasio’sCOVIDLockdownsAffectAccesstoHealthcarefortheMinorityPopulationinTremont?Chapter1IntroductionThepanicregardingthe2020COVID-19pandemicledtonewadministrativechallengesregardingprotectingandservingcommunitiesatthesametime.ManycitiesacrossAmericareactedtoCOVIDbytryingtocurbthevirus\'sspreadthroughtheimplementationoflockdowns.Localgovernmentsimplementeddrasticmeasuresthatchangeddailylifeovernightandexposedthevulnerabilitiesofalreadyunderservedandmarginalizedcommunities.InNewYorkCity,theepicenterofthepandemicintheUnitedStates,MayorBilldeBlasio\'sofficeissuedaseriesoflockdownpoliciesstartinginMarch2020(NYC,2020)Thesepoliciesincludedtheclosureofnon-essentialbusinesses,theimplementationofremotelearning,therestrictionofpublicgatherings,andtheenforcementofsocialdistancinginessentialservices(NYC,2020).Themediabyandlargereportedonthesemeasuresasnecessarytocontainthepublichealthcrisis;however,forthepublicaffectedbythesemeasures,therewerefar-reachingconsequences—particularlyforthepopulationofTremontintheBronx.TremontisapredominantlyminoritycommunityintheBronx.Ithaslongbeencharacterizedbysocio-economicdisparities,suchashighpovertyratesandinadequateaccesstohealthcare(NYC,2020).Thereare 28,095residents inTremont,withamedianageof32.46.46%aremalesand53.54%arefemales.US-borncitizensmakeup54.9%oftheresidentsinTremont,andnon-US-borncitizensaccountfor25.36%.19.74%ofthepopulationconsistsofnon-citizens.Theneighborhood\'sresidentsaremostlyAfricanAmerican(11%),Asian(23%),andHispanic(57%),allgroupsthathavehistoricallydealtwithsystemicbarrierstoeconomicmobilityandhealthcareequity(CensusReporter,2024;Gilbertetal.,2022).TheCOVID-19pandemiclockdownresponseessentiallyaggravatedalreadyexistingchallengesforthispopulationbyfurtherlimitingaccesstocriticalservices.ThepurposeofthisdissertationistoexplorethespecificimpactofthelockdownpoliciesimplementedbetweenMarch2020andSeptember2020onthesocio-economicconditionsoflow-incomeresidentsintheTremontneighborhood.Inparticular,theresearchwillfocusonhowthesepoliciesaffectedaccesstohealthcarefortheminoritypopulationinthiscommunity.ContextualizingtheTremontNeighborhoodintheBronxItisimportanttounderstandthepre-pandemicsocio-economicconditionofTremont.LikemanyotherneighborhoodsintheSouthBronx,Tremontishometoalow-income,minoritypopulationthathasexperiencedcontinualchallengesrelatedtopoverty,healthcareaccess,andenvironmentalracism(Brennan,2021;Estevez,2020).Indeed,theBronxhasoneofthehighestpovertyratesinNewYorkCity,withmanyresidentsrelyingonpublicassistanceandlivinginovercrowdedhousing(Clark&Shabsigh,2022).Thesesocio-economicconditionshavelongcontributedtohealthdisparitiesintheborough,asminoritycommunitiesexperiencinghigherratesofchronicdiseasescomparedtootherpartsofthecity(Shiman,2021).ThesocialdeterminantsofhealthalsoincludeenvironmentalfactorswhichhavecertainlyimpactedthehealthofTremontresidents.TheSouthBronx,includingTremont,hasbeendisproportionatelyaffectedbyenvironmentalhazards,suchaspoorairqualityandhighlevelsofpollution.Estevez(2020)notesthattheSouthBronxhashistoricallybeensubjecttopoliticalpracticesthathaveallowedhazardousindustrialactivitiesinthearea,whichhaveinturncontributedtohighratesofrespiratoryillnessesamongresidents.Thesepre-existingconditionsmadetheTremontcommunityparticularlyvulnerable.Additionally,Tremontresidentshavefacedsystemicbarrierstoaccessingqualityhealthcare(Shimanetal.,2021).TheBronxishometoseveralpublichospitalsandcommunityhealthclinics,butmanyofthesefacilitiesareunderfundedandunderstaffedduetostructuralracismwithinthehealthcaresystem,whichhascontributedtodisparitiesinhealthcareaccess,withminoritycommunitiesinneighborhoodslikeTremontreceivinglower-qualitycarecomparedtowealthier,predominantlywhiteareas(Shimanetal.,2021).ResearchSignificanceInTremont,manyresidentsworkinlow-wage,essentialjobs,oftenwithouttheluxuryofworkingfromhome,whichincreasedtheirvulnerabilityduringthepandemiclockdowns.Theareahaslongfacedsystemicinequitiesinhousing,healthcare,andemploymentopportunities,makingitoneofthemostvulnerablecommunitiesinthecity.Residentswerealreadyathigherriskforpoorhealthoutcomesduetounderlyingconditionssuchasasthma,diabetes,andhypertension(Clark&Shabsigh,2022;Estevez,2020).TheimportanceofresearchingtheimpactofMayorBilldeBlasio\'sCOVID-19lockdownpoliciesonTremontliesinunderstandinghowthesepublichealthmeasuresworsenedexistingsocialandeconomicdisparities.Theargumentatthetimewasthatlockdownswouldhelptoslowthespreadofthevirus(Hammond,2021).However,littleattentionwasgiventothepotentialproblemofinequalitiesinhealthcareaccessworseningforlow-income,minoritycommunitieslikeTremont.Tremontresidentsalreadyfacedbarrierstoaccessinghealthcare,andin2020,duetoclinicclosures,overwhelmedhospitalsystems,andthelackoftechnologyfortelehealthservices,thehealthsituationofthecommunityworsened.Economically,theshutdownofserviceindustryjobshitthecommunityhard,leadingtounemployment,foodinsecurity,anddifficultiesinobtainingunemploymentbenefits,allofwhichaffectedthesocialdeterminantsofhealthforpoorcommunitieslikeTremont(Shimanetal.,2021).Researchingtheseissuesisimportantbecauseitallowsforgaininginsightsintotheunintendedconsequencesofpandemicpoliciesonmarginalizedpopulations.ThereisaneedtoknowandunderstandthespecificchallengesfacedbycommunitieslikeTremont,sothatpolicymakersinthefuturecandevelopandadoptmoreequitableapproachestopublichealthcrisesinthefuture,andsothatlow-incomeandminoritypopulationsarenotdisproportionatelyaffectedbysimilarmeasures?.COVID-19LockdownPoliciesinNewYorkCityInresponsetotheCOVIDcrisis,MayordeBlasio’sofficeusheredinapolicyoflockdownthatlastedformonths.Essentialbusinesseslikegrocerystoresandhealthcareproviderswereallowedtoremainopenbutwererequiredtoimplementstrictsocialdistancingandhygieneprotocolstoprotectbothemployeesandcustomers(NYC,2020).ManyTremontresidentswereemployedinthesesectorsandwereunabletoworkremotely.Helmreich(2023)notesthattheeconomicimpactofthelockdownwasparticularlysevereintheBronx,wherealargeproportionofresidentsrelyonhourlywagesanddonothavethefinancialsafetynetsthatwealthierindividualsmightpossess.Moreover,theclosureofschoolsandtheshifttoremotelearningposedadditionalchallengesforlow-incomefamiliesinTremontduetothepre-existingdigitaldivide.Thelong-termeffectsofthiseducationaldisruptionarestillbeingstudied,butearlyresearchsuggeststhatstudentsfromlow-incomehouseholdsexperiencedsignificantlearninglossduringthepandemic(Friedmanetal.,2023).PerhapsoneofthemostcriticalareasaffectedbytheCOVID-19lockdownpolicieswashealthcareaccess.ForresidentsofTremont,whoalreadyfacedsignificantbarrierstohealthcare,thelockdownpoliciesfurtherlimitedtheirabilitytoaccessmedicalservices(Roldósetal.,2024).Theclosureofnon-essentialmedicalfacilities,suchasprimarycareclinicsanddentaloffices,meantthatmanypeoplewereunabletoreceiveroutinecare—nottomentionthefactthatthepoliciesofthemayor’sofficesupportedasocialstigmaalreadyintroducedbynon-stopmediahypeofthedangersofgoingoutinpublic.Peoplewerescaredandhesitanttoseekmedicalcareduetoconcernsaboutexposuretothevirus.Asaresult,conditionsthatmighthavebeenmanageableundernormalcircumstancesworsenedduringthelockdownperiod.HuangandLi(2022)pointoutforinstancethatspatialhealthdisparitieswereworsenedduringthepandemic,withlow-incomeandminoritycommunitiesexperiencinghigherratesofsevereillnessanddeathduetodelayedcareandreducedaccesstohealthcareresources.Thepandemicalsorevealedlong-standingissuesrelatedtohealthequityinNewYorkCity.COVID-19mortalityratesweredisproportionatelyhighinneighborhoodswithlargeminoritypopulations,suchastheSouthBronx(Friedman&Lee,2023).Factorssuchasovercrowdedhousing,aneedtorelyonpublictransportation,andlimitedaccesstohealthcarecontributedtothehigherratesofinfectionanddeathinthesecommunities(Friedmanetal.,2023).Thelockdownpoliciesshowedlittleconsiderationfortheunderlyingstructuralissuesandmayhaveworsenedexistingdisparities.Isthishowpolicyservesacommunity?ProblemStatementThecoreproblemthisresearchseekstoaddressistounderstandhowtheCOVID-19lockdownpoliciesimplementedbytheNewYorkCitygovernmentimpactedhealthcareaccessandsocio-economicconditionsinTremont.Thepolicieswereintendedtomitigatethepublichealthcrisis,buttheymayhaveactuallyworsenedthesituationforlow-income,minoritypopulations.Understandingthespecificsocio-economicandhealthcarechallengesfacedbythesecommunitiesiscrucialfordevelopingmoreequitablepublichealthpoliciesinthefuture.TheBronxhasconsistentlyexhibitedhighpovertyratesandunemployment,particularlyinlow-incomeneighborhoodssuchasTremont.Priortothepandemic,theBronxhadapovertyrateofnearly27%,thehighestofallNewYorkCityboroughs(Clark&Shabsigh,2022).Thisisanimportantpointbecauseofthesocialdeterminantsofhealth,whichaffecthealthoutcomesinbigwaysforcommunitieslikeTremont.Whenhealthcareaccessisrestricted,andthesocialdeterminantsofhealthareworsenedduetorestrictivepolicieslikelockdowns,itcancreateaperfectstormthatwreakshavoconcommunityhealth.AccordingtoShimanetal.(2021),structuralracismandinadequatehealthcareinfrastructurehavelongaffectedminoritycommunitiesintheBronx,andhavealreadycontributedtopoorhealthofthepopulation.TheCOVID-19pandemicfurtherstrainedthesealreadylimitedhealthcareresources.TremontandotherpartsoftheSouthBronxhavealsosufferedfrompoorairqualityandotherenvironmentalhazards,whichhavecontributedtohigherratesofasthmaandotherrespiratorydiseases(Estevez,2020).ThispointjustgoestoshowthatresidentsinTremontwerealreadyinapoorhealthposturebeforethelockdowns.Helmreich(2023)showsthatthelockdownmeasuressignificantlyincreasedunemploymentratesintheBronx,wheremanyresidentsworkedinsectorshardesthitbythepandemic,suchasretailandhospitality.Withouteconomicsupportandstability,socialdeterminantsofhealthcanquicklydisappearleavingresidentswithouthealthsupport.ResearchObjectivesThemainobjectiveofthisdissertationistoexaminethesocio-economicandhealthcareimpactsoftheCOVID-19lockdownpoliciesontheTremontneighborhoodintheBronx.Specifically,theresearchaimstoanswerthefollowingquestions:HowdidthelockdownpoliciesaffectaccesstohealthcarefortheminoritypopulationinTremont?Whatwerethebroaderconsequencesofthesepolicies,particularlyintermsofpublichealth?Throughanexplorationofthesequestions,thisdissertationlookstocontributetoadeeperunderstandingofhowemergencypublichealthmeasurescanimpactvulnerablecommunitiesandtoprovideinsightsintohowfuturepoliciescanbedesignedtoconsidersucheffects.Indoingso,thisresearchwilldrawonarangeofprimaryandsecondarysources,includingpublichealthdata,governmentreports,andacademicstudies.ItwillalsoconsidertheperspectivesofcommunitymembersandhealthcareprovidersinTremont,whocanoffervaluableinsightsintothelivedexperiencesofresidentsduringthepandemic.Ultimately,thegoalofthisdissertationistoshedlightonthespecificchallengesfacedbylow-income,minoritycommunitiesduringtheCOVID-19pandemicandtoproviderecommendationsforaddressingthesechallengesinfuturepublichealthemergencies.Toachieveitsobjective,thisstudyusesaqualitativeresearchmethodology,whichissuitedbecausethisresearchrequiresin-depthexplorationofthelivedexperiencesofresidentsandstakeholdersduringthepandemic(Crabtree&Miller,2023).Afocusonsubjectiveexperiencesandcommunity-specificissuescanbeappliedbywayofthequalitativemethodology,whichsupportsdeepunderstandingofhowthelockdownpoliciesinfluencedhealthcareaccessandsocio-economicconditionsinthislow-income,minorityneighborhood(Crabtree&Miller,2023).Datawillbecollectedprimarilythroughsemi-structuredinterviewswithresidentsofTremont,healthcareprofessionals,localbusinessowners,andeducators.Theseinterviewswillexploretheirperceptionsofthelockdownpolicies,focusingontheireffectsonaccesstohealthcare.Thesemi-structurednatureoftheinterviewsallowsforflexibility,enablingparticipantstosharepersonalexperienceswhileensuringthatkeyresearchquestionsareaddressed(Crabtree&Miller,2023).Additionally,focusgroupswillbeconductedwithcommunity-basedorganizationstogathercollectiveinsightsintohowthepandemicaffectedthebroaderneighborhood.Documentanalysiswillalsobeemployed,reviewinglocalgovernmentreports,publichealthdata,andnewsarticlesthatdocumenttheimplementationofCOVID-19policiesinNewYorkCity.Thiswillprovidecontextualbackgroundandhelptriangulatethefindingsfrominterviews.Thematicanalysiswillbeusedtoidentifypatternsandthemesemergingfromthequalitativedata.Thisapproachallowstheresearchertocategorizeandinterpretthedatabasedonrecurringconcepts,suchasbarrierstohealthcareoreconomichardships.Theuseofqualitativemethodswillofferrich,detailedinsightsintothesocialandhealthcareinequalitiesexacerbatedbytheCOVID-19lockdown,contributingtoadeeperunderstandingofitsimpactonvulnerablecommunities.Chapter2:ImpactofCOVID-19LockdownPoliciesonHealthcareAccessinTremontIntroductiontoTremontTremontisanoverwhelminglylow-income,minorityneighborhoodlocatedintheSouthBronx,NewYorkCity.LikemanyneighborhoodsintheBronx,Tremonthasapoortrackrecordwhenitcomestothesocialdeterminantsofhealth,duetohighpovertyrates,environmentalhazards,andinadequateaccesstohealthcareservices.ThecommunityisprimarilycomposedofAfricanAmericanandHispanicpopulations,manyofwhomhavehistoricallyfacedsystemicbarrierstohealthcare.TheseexistingdisparitiesmadeTremontparticularlyvulnerableduringtheCOVID-19pandemic,asresidentswerealreadyathigherriskforpoorhealthoutcomesbecauseofunderlyingpre-existinghealthconditionslikeasthma,diabetes,andhypertension(Clark&Shabsigh,2022;Estevez,2020).ThisresearchfocusesspecificallyonthehealthcareimplicationsoftheCOVID-19lockdownpoliciesimplementedbyMayorBilldeBlasio’sofficebetweenMarch2020andSeptember2020.Throughtheclosingofnon-essentialbusinessesandmandatingsocialdistancingandremotelearning,themayor’spolicieshadfar-reachingeffectsonaccesstohealthcareforminoritypopulationsintheneighborhoodofTremont.Tremontcouldstandinasrepresentative,infact,oflow-income,marginalizedminorityneighborhoods.Thus,understandinghowthemayor’spoliciesaffectedhealthcareaccessinTremontishelpfulfromapublicadministrationstandpointbecauseitcanshedlightonthestructuralvulnerabilitiesofmarginalizedcommunitiesduringpublichealthcrisesandtheextenttowhichpublicadministrators’policiesandactionsworsenorhelpalleviatethosevulnerabilities.Furthermore,itcanprovideimportantinsightsintohowfutureemergencymeasurescanbedesignedtoprotectandsupportlow-income,minoritypopulationsmoreeffectively.COVID-19LockdownPoliciesandTheirRelevancetoHealthcareinNYCandTremontIn2020,inthetwozipcodeareasinwhichTremontislocated,COVID-19caseswerebetween39,000and44,000per100,000people(NYCCOVID-19Data,2024).TotaldeathcountofthetwozipcodesforCOVID-relateddeathswas688(NYCCOVID-19Data,2024).TheBronxoverallwasthehardesthitareaofNYCwith3,556hospitalizationsper100,000(NYCCOVID-19Data,2024).Likewise,theBlackandLatinocommunitieswerethemostaffected,whichiswhatmakesupthemajorityoftheTremontpopulation(NYCCOVID-19Data,2024).Per100,000BlacksandLatinosinallofNYC,3,000ofeachwerehospitalizedduetoCOVID(NYCCOVID-19Data,2024).Furthermore,peopleinveryhighpovertywerehospitalizedthemost,with3,539hospitalizationsoftheveryhighpovertydemographicper100,000residentsoccurringcitywide(NYCCOVID-19Data,2024).OnMarch15,2020,theOfficeoftheMayorissuedapressreleasethatcoveredavarietyofactionsthattheresidentsofthecitywereexpectedtofollowregardingCOVID.Actionpertainingtohealthcareincludedthefollowingundertheheadline“NewGuidanceforHealthProviders”:“Tominimizepossibleexposurestohealthcareworkers,vulnerablepatientsandreducethedemandforpersonalprotectiveequipment,theDepartmentofHealthandMentalHygienewilladvisepatientswithmildtomoderateillnessestostayhome.”(NYC,2020b).Thisdirective,whileseemingperhapsmildinintention,carriedagreatdealofgravityinlightoftheensuingpressreleasesandnoticesthatfollowedoverthecourseof2020—allofwhichcarriedanintensifyingtoneofworry,concern,causeforalarm,andoverallfearforthespreadofCOVID.Essentially,itlaidthegroundworkforresidentstobeginpullingbackfromalifeofnormalcy;thesuggestionappearedtobethat—unlessonehasahealthemergency—donottrytoaccesshealthcare.Intentionalornot,thatmessageisconveyedinthesub-textofthispressreleaseofMarch15,andreinforcedbythenumerousnoticesthatfollowed.PerhapsthemostimportantpressreleasefromtheMayor’sOfficecameonMarch22nd,2020,whenalarmbellsbegantoberungbycityofficialsinearnest.Mayor’sOfficePressRelease:NewGuidanceforNewYorkers“EffectiveSunday,March22nd,at8:00PM,allnon-essentialbusinessesinNewYorkCitywillbeclosed. Onlybusinesseswithessentialfunctionswillbepermittedtooperate,suchasgrocerystores,pharmacies,internetproviders,fooddelivery,banks,financialinstitutionsandmasstransit.Businessesthatprovideessentialservicesmustimplementrulesthathelpfacilitatesocialdistancing.TheNYPDwillbeoutinneighborhoodsacrosstheCitytoensurecompliancewiththepolicies.“TheCitywillalsoenforcethefollowingrulesfornon-vulnerableindividualswithfinesandmandatoryclosures:·Nonon-essentialgatherings;anyconcentrationofpeopleoutsidetheirhomemustbelimitedtoworkersprovidingessentialservices·Practicesocialdistancinginpublic(6feetormore)·Individualsshouldlimitoutdoorrecreationalactivitiestonon-contact.·Limituseofpublictransportationtoonlywhenabsolutelynecessary.·Sickindividualsshouldnotleavehomeexcepttoreceivemedicalcare.“TheCitywillalsoenforce“Matilda’sLaw,”whichsetsthefollowingrestrictionsforvulnerableNewYorkerswhoareovertheageof70and/orimmune-compromised:o  Remainindoorso  Limitoutdooractivitytosolitaryexerciseo  Pre-screenallvisitorsandaidesbytakingtemperatureo  Wearamaskwhenincompanyofotherso  Donotvisithouseholdswithmultiplepeopleo  Everyoneinpresenceofvulnerablepeopleshouldwearamasko  Staysixfeetfromotherpeopleo  Donottakepublictransportationunlessabsolutelynecessary”(DeBlasio,2020).Themessagewasclear:peopleshouldnotbeoutandabout,shouldnotbegoingabouttheirlivesnormallyastheywouldotherwise;andbyextensiontheyshouldnottrytoaccesshealthcareastheynormallywould.MayordeBlasio’sguidancewasfollowedthreeweekslaterbythefollowinghealthalert:“April11,2020DearColleagues:IthasbeenmorethanfiveweekssinceNewYorkCityreporteditsfirstpersondiagnosedwithCOVID-19.WecontinuetoseeanincreasingnumberofpersonsdiagnosedwithCOVID-19,includingthosewhorequirehospitalization.AsofApril11,2020,therewere96,522COVID-19casesreportedinNewYorkCity,with27%hospitalized,and5,463confirmeddeaths.Tocontinuetoflattenthecurveofthispandemicandtoprotecthealthcaredeliverysystems,itiscriticaltocontinuetoenforceandadheretoexistingmitigationmeasures,includingallsocial(physical)distancinginterventions”(2020HealthAlert#10,2020).Again,themessagetoresidentswasclearandominous:sociallydistance,anddonotgooutorbenearothers.FearcontinuedtobeamplifiedandNewYorkerscontinuedtobewarnedthattheymustadheretoMayordeBlasio’slockdownprotocolsto“flattenthecurve.”Insuchaheightenedstateofalarm,allnormalcycouldbeexpectedtobeabandoned—includingthereceptionofregularhealthcareservices.Thesemaywellindeedhaveremainedavailable,technically,buttheMayor’sOfficewasclearlywarningresidentsthattheyshouldhide.Thefollowingmonth(May4,2020)HealthAlert#13wentoutalertingresidentsofanotherinfectiousdiseasespreading:“apediatricmulti-systeminflammatorysyndrome”whichratchetedupfearsstillfurther,asthoughNewYorkersneededmorefuelfortheirworry(2020HealthAlert#13,2020).ByOctober2020,thestrategymeanttoslowthespreadandflattenthecurvewasnotonlystillbeingimplementeditwasalsobecomingmoredraconian,asthecityissuedyetanotherNOTICEtoNewYorkers:October9,2020NOTICE:NewYorkCity’sLocalizedCOVID-19RestrictionsToalllicenseesandregistrants:“TheCityofNewYorkhastakenactioninresponsetotheincreasedspreadofCOVID-19casesinparticularneighborhoodsbyimplementingrestrictionsinthreezonesidentifiedbytheState—designatedred,orange,andyellow.Visitnyc.gov/COVIDZonetoidentifytheareasineachzoneandfamiliarizeyourselfwiththerestrictionsrelatingto:•Publicandnon-publicschools•Businesses•Foodserviceestablishmentsincludingindoorandoutdoordining•Housesofworship•Non-essentialgatheringsRestaurantslocatedintheredzonesareprohibitedfromindoorandoutdoordiningandmayonlyoffercarryoutanddeliveryoptions.Restaurantslocatedintheorangezonescanofferoutdoordiningandtakeoutanddeliveryserviceonly.Thereisafour-personmaximumpertable;noindoordiningisallowed.OnlyessentialbusinessesasdesignatedbyNewYorkStateEmpireStateDevelopmentCorporationcanremainopenintheredzones.Allnonessentialbusinesseslocatedintheredzonesmustclose.Licenseesandregistrantsshouldcommunicatewiththeircustomerstoensurewasteiscollectedpromptlyandsafely.BusinessIntegrityCommissionenforcementagentswillbepatrollingtheaffectedareas”(NYC,2020c).ByDecember2020,thecityessentiallyannouncedthattherewouldbenoreturntothepre-COVIDnormal—lifewasnowchangedforeverfromhereonout:“TheCOVID-19pandemichaschangedhowweliveandworkinNewYorkCityinmanyways…”thepressreleasebegan(NYC,2020d).Itpertainedprimarilytoroadsafety—buttheominoustonetoldfarmorethanthetextonthestatementdid.MayordeBlasio’sCOVIDresponsehadalteredthewaythepeopleofNewYorklivedtheirlives—and,tosomeextent,howtheycaredforthem.Finally,onMay1,2021,alittleoveroneyearaftertheinitialpressreleasegivenbytheMayor,anoticeentitled“ManagingtheReturntotheOfficeintheAgeofCOVID-19”wasissued.NotonlywasallpretensetoslowingthespreadgoneforgoodbuttheOfficewasnowusingthetragic-sounding“AgeofCOVID-19”todefinethetimesinwhichpeoplenowfoundthemselvesliving.AmongtherequirementsofpeoplereturningtoworkoneyearaftertheattemptbytheMayortobeginflatteningthecurvewithlockdownswerethefollowing:·PublicareasarebeingcleanedinaccordancewithDOHMH’sguidance·6ft.markershavebeenimplementedandposteforenforcingtheCity’shealthassessmentrequirementsforemployers,visitors,andclients.·Occupancylimitationsforsharedspaces(e.g.,conferencerooms,huddlespaces,pantries,breakrooms,copyrooms)havebeenposted.·Signagehasbeenpostedthroughoutallworkspacesremindingindividualstoadheretoproperhygiene,physicaldistancingrules,facecoveringrequirements,andcleaninganddisinfectingprotocols.·Workspacesthatdonotallowforphysicaldistancinghavebeenblockedoff(NYC,2021).Incaseanyonehadfailedtorealize,MayordeBlasio’sOfficehad,toputitcolloquially,doubled,tripled,andquadrupleddownonhisinitialCOVIDresponsestrategy.WhateversenseNewYorkershadofbeingpartofacommunityinwhichtheycouldlive,breathe,andmingleasonepeoplewithoutfearorworrywaseffectivelyallbutgone.Surely,thisapproachtoapublichealthcrisishadaneffectontheextenttowhichthepeopleofTremontenjoyedaccesstoregularhealthcare.OtherConsiderationsNewYorkCity’slockdownsin2020delayedserioushealthcareproceduresformanyintheBronx.Cancerandmentalhealthtreatmentswerepostponedduring2020atalarminglyhighrates(Dorviletal.,2023).Indeed,Dorviletal.(2023)foundthat“morethanhalfofparticipants(54%)reporteddisruptiontoeitherroutinephysicalhealthcareormentalhealthservices.ConcernaboutgettingCOVID-19(61%),stay-at-homepolicies(40%),beliefthatcarecouldsafelybepostponed(35%),andappointmentchallenges(34%)wereamongreasonsfordelayingroutinehealthcare.ConcernaboutgettingCOVID-19(38%)andreducedhoursofservice(36%)wereprimaryreasonsfordelayingmentalhealthcare.Reportedreasonsforthesustaineddelayofcarepast18?monthsinvolvedCOVIDconcerns,appointment,andinsurancechallenges”(p.1).Ultimately,Hammond(2021)boileditdowntoafewpoints:·“Thestate’searlyresponsewasunderminedbyflawedguidancefromthefederalgovernment,inadequateplanningandstockpiling,limitedconsultationwithexperts,exaggeratedprojectionsandpoorcooperationbetweenfederal,stateandlocalofficials,amongotherissues.·“Todate,noneoftheLegislature’spandemic-relatedhearingshasfocusedonthecriticalmisstepsofthestate’searlyresponse.·“Better-controlledoutbreaksincountriessuchasSouthKoreademonstratethevalueofpublichealthpreparednessandcouldserveasamodelforNewYork”(p.1).Clearly,theCOVID-19lockdownshadbigconsequencesforlow-incomecommunities.TheeffectswereparticularlysevereintermsofaccesstohealthcareforthepeopleofTremont,however.Tremontexperiencednewbarrierstohealthcareduringthelockdown.Theclosureofclinicsandrestrictedpublictransportationoptionsmadeitdifficultforresidentstoaccessessentialmedicalservices,asDorviletal.(2023)pointedout,iftheyevenwantedtotryinthefaceoftheMayor’sOffice’swarnings.Theshifttotelemedicinealsolikelyaffecteddisparities,asmanylow-incomehouseholdslackedaccesstostableinternetorthenecessarytechnologytoparticipateinvirtualhealthcarevisits(OfficeoftheStateComptroller,2021).ThisdigitaldividewasamajorissueforthecommunityofTremont,whereresidentsalreadyfacedsystemicbarrierstohealthcarebeforethepandemic.InTremont,aselsewhereintheUS,therewasreducedaccesstopreventivecare,chronicdiseasemanagement,andevennecessarymentalhealthservices(Irimataetal.,2023).Thelockdownordersessentiallyexposedhealthcareinequitiesforthosedealingwithdiabetesandotherchronicconditionsthatrequireconsistent,regularmanagement.Theclosureofnon-essentialbusinessesandhealthcarefacilitieslimitedresidents’accesstoroutinemedicalservices,preventivecare,andmanagementofchronicconditions.ThiswasparticularlyproblematicforTremont’sminoritypopulation,manyofwhomrelyonlocalcommunityhealthcentersandpublichospitalsforaffordablehealthcare.Thesefacilities,alreadyunderfundedandstrainedbeforethepandemic,werefurtheroverwhelmedbythesurgeofCOVID-19cases,makingitdifficultforresidentstoreceivetimelyandadequatemedicalcare(Shimanetal.,2021).HealthcareAccessChallengesDuringtheLockdownOneofthemostsignificantconsequencesofthelockdownpolicieswasthedisruptionofhealthcareservicesinTremont,asintheotherlow-incomecommunitiesoftheBronx(OfficeoftheComptroller).Thecitywideshutdownofnon-essentialservicesincludedmanyhealthcareproviders,suchasprimarycareclinicsandspecialists,whichplayedanimportantpartinmanagingchronicconditionsforresidentsoflow-incomeneighborhoodslikeTremont.Chronicconditions,includingasthma,diabetes,andcardiovasculardisease,areprevalentintheBronxanddisproportionatelyaffectminoritypopulations(Clark&Shabsigh,2022).Withlimitedaccesstohealthcareprovidersduringthelockdown,manyresidentswereunabletoreceiveessentialcare,leadingtoadeteriorationintheirhealth.TheOfficeoftheComptroller(2023)concluded:“AccordingtothemostrecentNewYorkCityCommunityHealthProfiles,eachofthe10neighborhoodsintheboroughhadratesofdiabetes,obesityandhypertensionthatweresimilarorhigherthanthecitywideaverage,withnoneexperiencingratesbelowtheaverage.TheNewYorkCityDepartmentofHealthandMentalHygienehasnotedtheprevalenceofthesepoorerhealthoutcomesinlow-income,minoritycommunitieswhereeconomicstressanddiscriminationcanlimitaccesstoqualityhealthcare.“AnalysisofthecorrespondencebetweenCOVID-19healthoutcomesintheBronxandmedianhouseholdincomeandshareofminorityresidentsfoundanassociationwithmoreseverehealthimpacts.Ingeneral,throughoutthepandemic,thesixneighborhoodswiththelowesthouseholdincomesintheBronx,amongthelowestcitywide,havebeenamongthosewiththehighesthospitalizationratesfromCOVID-19.MostZIPcodesassociatedwiththeseneighborhoodsfellwithinthetopthirdofhospitalizationratescitywide.ThefourBronxneighborhoodsthathadmoremoderatemedianhouseholdincomesalsohadlowerhospitalizationrates.“NeighborhoodsintheCitythathadahighershareofminorityresidentsgenerallyexperiencedhighercumulativecaseratesanddeathrates.EighteenoftheCity’s55Census-definedneighborhoodshadaminoritypopulationinthetopthirdin2019,greaterthan83percent. Ofthese18Cityneighborhoods,eightwereintheBronx.The20ZIPcodescoveringtheseeightBronxneighborhoodsallhadcumulativedeathrateswithinthetophalfofallCityZIPcodes,and11wereinthetopthird.Theresultsareverysimilarforcaserates.“Whilesimilarneighborhoodsarealsolocatedinotherboroughs(andwereaffectedsimilarlytothoseintheBronx),thoseboroughsalsoincludemoremiddle-andhigh-incomeareas,whichwereaffectedlessseverelyandgenerallysufferedfromlowerratesofhospitalizationsanddeaths.”Additionally,thehealthcaresystemintheBronxwasoverwhelmedbythepandemic,withhospitalsinundatedbyCOVID-19patients(OfficeoftheComptroller,2023).Thisstrainonthesystemresultedindelaysintreatmentfornon-COVIDconditions,furtherexacerbatinghealthcaredisparitiesinTremont.Residentsfacedlongerwaittimesformedicalappointments,reducedaccesstotestingandtreatmentforchronicconditions,andlimitedavailabilityofhealthcareprofessionalsduetothereallocationofresourcestowardCOVID-19care(Friedman&Lee,2023).ThelackofaccessiblehealthcareduringthiscriticalperiodmayhavecontributedtoworsenedhealthoutcomesinTremont,asresidentswereunabletomanagetheirexistinghealthissueseffectively.DisproportionateImpactonMinorityPopulationsinTremontTheCOVID-19pandemicdisproportionatelyaffectedminoritypopulationsacrossNewYorkCity,withAfricanAmericanandHispaniccommunitiesexperiencinghigherratesofinfection,hospitalization,anddeath(OfficeoftheComptroller,2023).InTremont,wherethemajorityofresidentsbelongtotheseminoritygroups,thelockdownpoliciescompoundedexistinghealthcaredisparities.Structuralfactorsincludedovercrowdedhousing,relianceonpublictransportation,loweraccesstohealthcare,andlowerratesofhealthinsurancecoverage,allofwhichincreasedresidents’vulnerabilityandlimitedtheirabilitytoaccesshealthcareservicessafelyduringthelockdown(Friedmanetal.,2023).Moreover,manyTremontresidentsfacedlanguagebarriers,lackofinternetaccess,andlimitedhealthliteracy,whichfurtherhinderedtheirabilitytonavigatethehealthcaresystemduringthepandemic(OfficeoftheComptroller,2023).Thetransitiontotelemedicineservices,whichbecamemoreprevalentduringthelockdown,posedadditionalchallengesforlow-incomeresidentswholackedreliableinternetaccessorthedigitalliteracyneededtoparticipateinvirtualhealthcareappointments(Roldós,Jones,&Rajaballey,2024).Asaresult,manyresidentswereunabletoreceivetimelymedicaladviceorfollow-upcare,furtherexacerbatinghealthdisparitiesinthecommunity.TheRoleofPublicHospitalsandCommunityHealthCentersPublichospitalsandcommunityhealthcentersareessentialinprovidinghealthcaretolow-incomeresidentsinneighborhoodslikeTremont.However,theseinstitutionswereseverelyimpactedbythepandemic,astherewereresourceshortages,staffburnout,andanoverwhelminginfluxofCOVID-19patients.AccordingtoHuangandLi(2022),hospitalsintheBronx,includingthoseservingTremont,wereamongthehardesthitduringtheearlymonthsofthepandemic,withmanyreachingcapacityandstrugglingtoprovideadequatecare.Communityhealthcenters,whichprovideessentialservicessuchasprimarycare,dentalcare,andmentalhealthsupport,wereforcedtoreduceservicesorclosetemporarilyduetothelockdownpolicies.ThisleftmanyTremontresidentswithoutaccesstobasichealthcareservices,whicharecriticalformanagingchronicconditionsandmaintainingoverallhealth.Thereducedavailabilityoftheseservicesduringthelockdownmayhavecontributedtothedeteriorationofhealthoutcomesintheneighborhood,particularlyforvulnerablepopulationswhorelyonaffordable,accessiblehealthcare(Shimanetal.,2021).TheConsequencesofDelayedandReducedHealthcareAccessThedelayedandreducedaccesstohealthcareduringthelockdownhadsignificantconsequencesforthehealthandwell-beingofTremontresidents.Forindividualswithchronicconditions,suchasdiabetesorhypertension,regularmedicalvisitsareessentialformonitoringandmanagingtheirhealth.Theinabilitytoaccesstheseservicesduringthelockdownlikelyledtotheworseningoftheseconditions,increasingtheriskofcomplicationsandhospitalizations(Clark&Shabsigh,2022).Furthermore,thedelayinseekingcareduetofearofcontractingCOVID-19inhealthcaresettingscontributedtopoorerhealthoutcomes.Manyresidentswerehesitanttovisithospitalsorclinicsduringthepandemic,evenforurgenthealthissues,duetoconcernsaboutexposuretothevirus.Thisfear,combinedwiththeoverwhelmedhealthcaresystem,resultedinmanyindividualsdelayingorforgoingnecessarymedicalcare,leadingtopreventablehealthcomplications(Huang&Li,2022).AddressingtheHealthcareDisparitiesExacerbatedbytheLockdownTheCOVID-19pandemicunderscoredthedeep-rootedhealthcaredisparitiesthatexistinlow-income,minorityneighborhoodslikeTremont.Thelockdownpolicies,whilenecessarytocontrolthespreadofthevirus,furtherlimitedaccesstohealthcareforvulnerablepopulationsandexacerbatedexistinginequalities.Movingforward,itisessentialforpolicymakerstoconsidertheuniqueneedsofmarginalizedcommunitieswhendesigningpublichealthinterventions.Ensuringequitableaccesstohealthcare,particularlyduringpublichealthemergencies,iscriticaltopreventingfurtherharmtothesecommunities.Policyrecommendationsforfuturepublichealthcrisesshouldincludeincreasedfundingforpublichospitalsandcommunityhealthcenters,expandedaccesstotelemedicineserviceswithsupportfordigitalliteracyandinternetaccess,andtargetedoutreacheffortstoensurethatminoritypopulationsreceivetimelyandaccuratehealthinformation.Byaddressingthesesystemicissues,policymakerscanhelpreducehealthcaredisparitiesandimprovehealthoutcomesforlow-income,minoritycommunitieslikeTremontduringfuturecrises(Shimanetal.,2021;Friedman&Lee,2023).ConclusionTheCOVID-19pandemicandthesubsequentlockdownpoliciesenactedbyMayorBilldeBlasio’sofficebetweenMarch2020andSeptember2020hadseriouseffectsonlow-incomecommunitiesacrossNewYorkCity,particularlyinneighborhoodslikeTremontintheBronx.Asthisresearchhasshown,Tremontishometoapredominantlyminorityandlow-incomearea,andwasalreadygrapplingwithsignificantsocio-economicchallenges,includinginadequateaccesstohealthcare,highratesofchronicillnesses,andenvironmentalinjustices,allofwhichcontributetothesocialdeterminantsofhealthanddisease.Thesepre-existingvulnerabilitieswereespeciallyworsenedbythepublichealthmeasuresofthemayor’soffice.ThelockdownpoliciesresultedinthetemporaryclosureorlimitationofmanyhealthcarefacilitiesthatresidentsofTremontreliedonforessentialservices.Communityclinicsandpublichospitals,whichprovidecaretouninsuredandunderinsuredresidents,werealsooverwhelmedbythesurgeofCOVID-19patients.Thisledtodelaysincarefornon-COVID-relatedhealthissuesandareductioninroutinemedicalservices,suchaschronicdiseasemanagementandpreventivehealthcare,worseninghealthoutcomesformanyinthecommunity.Furthermore,thehealthcaredisparitiesthatwerealreadypresentinTremontbecamemorepronouncedasaccesstocarediminishedduringthelockdown.Factorssuchasovercrowdedlivingconditions,relianceonpublictransportation,andlimitedaccesstodigitalresourcesfortelemedicinefurtherexacerbatedthesechallenges,placingTremont’sresidentsatahigherriskofsevereillnessanddeathfrombothCOVID-19anduntreatedpre-existingconditions.Chapter3:MethodologyThischapterdiscussestheresearchmethodsusedtoexplorehowMayordeBlasio’sCOVID-19lockdownpoliciesaffectedaccesstohealthcarefortheminoritypopulationinTremont.Asthisstudy’sintentionistoexploreandbetterunderstandthelivedexperiencesofamarginalizedcommunity,aqualitativeresearchmethodologyisutilized.Thisapproachallowsforadetailedinvestigationintotheperceptionsandhealthcare-relatedexperiencesandrealitiesfacedbyresidentsduringthepandemic.ResearchDesignThestudyusesacasestudyapproachtofocusonTremont,alow-income,predominantlyminorityneighborhoodintheBronx.Thequalitativemethodologyischosenbecauseitprovidesanin-depthexaminationofpersonalexperiences,asdescribedbyCrabtreeandMiller(2023).Thisapproachenablestheresearchertoexploretheconsequencesoflockdownpoliciesonhealthcareaccess,employment,andeducationbygatheringprimarydatafromtheaffectedcommunity.Thetwoprimarymethodsofdatacollectionusedweresemi-structuredinterviews,conductedwithresidentsofTremontandlocalhealthcareprofessionals;anddocumentanalysis,reviewinglocalgovernmentnoticesandpressreleases,publichealthdata,andmediaarticlesdocumentingtheimplementationofCOVID-19policies.SamplingApurposivesnowballsamplingmethodwasusedtoensurethatparticipantsreflectdiverseperspectiveswithintheTremontcommunity.TheinterviewsampleincludedresidentsofTremont,i.e.,low-incomeindividualsandfamiliesaffectedbythecity’spolicies.Italsoincludedhealthcareprofessionals,i.e.,workersfromclinicsandhospitalsservingTremont.ResidentsofTremontEffortsweremadetoincludeindividualsfromvariousagegroups,genders,andethnicbackgroundstocapturetruedemographicrepresentationofresidentswithinthefullrangeofhealthcareaccessexperiences.Thisgroupofparticipantsoverallencompassedindividualswithchronichealthconditions,whohadamoreurgentneedforhealthcare,aswellasgenerallyhealthyresidentswhostillencounteredbarrierstohealthcareaccess.Prioritywasgiventolow-incomeresidents,aseconomiclimitationsoftencompoundedbarrierstoaccessinghealthcareduringthepandemic.Residentswithdirectexperiencesofeitherdelayedordeniedcareduetofacilityclosures,transportationrestrictions,orlackoftelehealthresourceswerespecificallytargeted.HealthcareProfessionalsServingTremont:Thissubgroupconsistedofdoctors,nurses,andadministrativestafffromhealthcarefacilitiesinornearTremont.Theseprofessionalswereselectedfortheirfirsthandinsightsintothesystemicstrainplacedonlocalhealthcareresourcesandthechallengesofadaptingtotelemedicine,facilityrestrictions,andotherpandemic-relatedadjustments.Includingvarioushealthcarerolesallowedthestudytocaptureamulti-layeredperspectiveonhowdifferentfunctionswithinhealthcarefacilitiesrespondedtotheincreaseddemandandlimitationsimposedbylockdownpolicies.Forexample,physicianscoulddescribetreatmentdelays,whileadministrativestaffcouldspeaktochallengesinschedulingandcommunicatingwithpatients.Thissamplingapproachwasstructuredtoachievedatasaturation,sothatrecurringthemesandissuescouldbecapturedacrossdifferentparticipantgroups.WithafocusonresidentswithvariedexperiencesandroleswithinthehealthcareandresidentsectorsofTremont,thesamplewasdeemedlikelysufficienttoaddressthestudy’sresearchquestionscomprehensively,togaininsightsintothelivedexperiencesofhealthcareaccessandthecommunityimpactoflockdownpolicies.DataCollectionSemi-structuredInterviewsTheinterviewsaresemi-structured,allowingflexibilitytocapturedetailedpersonalnarrativeswhileensuringkeyresearchquestionsareaddressed.Eachinterviewlastedapproximately45minutestoonehour.Theinterviewswereconductedinperson,withaudiorecordingsofeach.Theaudiorecordingsweretranscribedverbatimforanalysis.DocumentAnalysisToprovideabroadercontext,thestudyincorporatesananalysisofsecondarydatasources,including:·PublichealthrecordsfromtheNewYorkCityDepartmentofHealth.·ReportsissuedbytheMayor’sofficeonlockdownregulations.·Localnewsandmediaarticlesdocumentingtheimplementationofthelockdowninthecity.Thesedocumentswereanalyzedtotriangulateinterviewfindingsandprovideinsightsintobroaderpolicyimpacts.DataAnalysisThedatawereanalyzedusingthematicanalysis,whichinvolvesidentifyingrecurringpatternsandthemesfromtheinterviewtranscriptsanddocuments.Thematicanalysisiswell-suitedforthisstudyasitallowsforthecategorizationofcommonissuessuchasbarrierstohealthcareaccess,economichardship,andsocialinequalitiesexacerbatedbythelockdown.Importantstepsintheanalysisprocessincludedfamiliarization,coding,andthemedevelopment.Familiarizationinvolvedreadingthroughtranscriptsanddocumentstogainacompleteunderstandingofthedata.Codinginvolvedlabelingsegmentsoftextwithcodesthatrepresentkeyideasorconcepts(e.g.,\"healthcarebarriers,\"\"economicimpact\").ThemedevelopmentinvolvedgroupingrelatedcodesintothemesthatreflecttheprimaryissuesaffectingTremontresidents.EthicalConsiderationsThisresearchadherestostrictethicalguidelinestoensuretheconfidentialityandwell-beingofparticipants.Participantsprovidedinformedconsent,andalldatawereanonymizedtoprotecttheiridentities.Theinterviewswereconductedwithsensitivitytoparticipants\'experiencesduringthepandemic,andtheywereofferedemotionalsupportresourcesifneeded.Semi-StructuredInterviewQuestions:HealthcareAccessThesemi-structuredinterviewprocesswassupportedthebythefollowinginterviewquestions:ForResidents1.AccesstoHealthcareServices·HowdidtheCOVID-19lockdownaffectyourabilitytoaccesshealthcareservices(e.g.,doctor’sappointments,medications)?·Werethereanyspecifichealthservicesthatbecameharderorimpossibletoaccessduringthelockdown?·Howdidtheclosureofnon-essentialhealthcarefacilitiesimpactyourabilitytomanagechronichealthconditions,ifapplicable?2.TelemedicineandDigitalAccess·Wereyouabletousetelemedicineduringthelockdown?Ifso,howwasyourexperiencewithaccessingvirtualhealthcareservices?·Didyouencounteranyissuesrelatedtotechnologyorinternetaccesswhentryingtousetelemedicine?·Howdoyoufeelabouttheshiftfromin-persontovirtualhealthcareduringthelockdown?Wasitsufficientforyourneeds?3.DelayedorForgoneCare·DidyoudelayoravoidseekingmedicalcareduringthelockdownduetoCOVID-19concerns?Ifyes,why?·Howdidanydelaysincareaffectyourhealthorthehealthoffamilymembers?·Werethereanyspecifictreatmentsorproceduresyouhadtopostpone?Howdidthepostponementsimpactyourcondition?4.HealthOutcomesandConcerns·Inwhatwaysdidthelockdownpoliciesinfluenceyouroverallhealthandwell-being?·Werethereanyhealthissuesthatworsenedduetothereducedaccesstohealthcareduringthelockdown?·Whatwereyourbiggestconcernsregardinghealthcareaccessduringthepandemic?5.PerceptionofHealthcareSystemResponse·Howwouldyoudescribetheresponseoflocalhealthcarefacilitiesduringthelockdown?Didyoufeelsupportedorabandonedbythehealthcaresystem?·Inyouropinion,howcouldthehealthcaresystemhaverespondedbettertomeettheneedsofpeopleinyourcommunityduringthelockdown?6.BarrierstoAccess·Whatweretheprimarybarriersyoufacedinaccessinghealthcareduringthelockdown(e.g.,transportation,fearofexposure,facilityclosures)?·Didyouencounteranyfinancialbarrierstoreceivinghealthcareduringthisperiod?7.GeneralReflection·Lookingback,whatwouldyousaywerethebiggestchallengesrelatedtohealthcareaccessduringthelockdown?·Ifanotherpublichealthcrisisweretohappen,whatimprovementsinhealthcareaccesswouldyouliketoseeforyourcommunity?ForHealthcareProfessionals1.Whatweresomeofthebiggestchallengesyourfacilityfacedinprovidinghealthcaretonon-COVIDpatientsduringthelockdown,especiallythosewithchronicconditions?2.Howdidthelockdownimpactyourabilitytocommunicatewithandsupportpatientswhohadlimitedaccesstotechnologyorinternetfortelemedicineservices?Thesequestionsweredesignedtoelicitdetailedandpersonalaccountsoftheexperiencespeoplefacedregardinghealthcareaccessduringthelockdown,sothatkeythemessuchasbarriers,delays,andtelemedicineusewerecovered.PilotingoftheResearchQuestionsBeforeconductingthefullseriesofinterviewsforthestudy,apilottestoftheinterviewquestionswasconductedwithtwointerviewees.Thispreliminarystepaimedtoevaluatetheclarity,relevance,andeffectivenessofthequestionsincapturingthedesireddataonhealthcareaccessduringtheCOVID-19lockdown.Thetwoparticipantsselectedforthepilotwere:1.ParticipantA:Alocalresidentwithachronichealthcondition(asthma)thatrequiredregularmedicalcare.2.ParticipantB:AhealthcareprofessionalworkinginacommunityclinicinTremontduringthepandemic.Thepilotingprocessprovidedvaluableinsightsintothesuitabilityoftheinterviewquestionsandallowedforadjustmentstobemadebeforethefulldatacollection.ClarityofQuestionsBothparticipantsfoundthequestionsgenerallyclearandeasytounderstand.However,ParticipantAexpressedsomeconfusionaboutthephrasingofthequestionregardingtelemedicineaccess,particularlywhenaskedabout“digitalbarriers.”Theyrequestedmorespecificpromptsrelatedtointernetaccessordeviceusage,whichledtotherewordingofthisquestiontoincludeexamplessuchas\"Didyouhavetroublewithinternetaccessorusingtelemedicineapps?\"RelevancetoResearchObjectivesThequestionseffectivelyeliciteddetailedresponsesfrombothinterviewees.ParticipantAsharedpersonalexperiencesaboutpostponingmedicalappointmentsandtheemotionalstresscausedbylackofhealthcareaccess.Thishelpedconfirmthatthequestionswerewell-alignedwiththeresearchobjectiveofunderstandingthelivedexperiencesofresidentsduringthelockdown.ParticipantBofferedinsightsfromahealthcareprovider’sperspective,particularlyonthestrainfacedbyclinicsandthechallengesoftransitioningtotelemedicine.Thequestionsabouthealthcaresystemresponsesanddelayedcareprovidedrichdataonthehealthcaresystem\'slimitationsandthebarriersthatpatientsfaced.However,ParticipantBsuggestedincludingafollow-upquestionabouttheavailabilityofresourcesorsupportduringthetelemedicineshift,whichwaslateraddedtotheinterviewguide.AbilitytoProduceIn-depthResponsesBothparticipantsprovidedextensiveresponsestomostquestions,indicatingthatthesemi-structuredformatencouragedthemtosharetheirexperienceswithoutfeelingrestrictedbyoverlyrigidquestioning.ParticipantAgavedetailedaccountsoftheirinabilitytoaccessasthmamedication,andhowtheyattemptedtoself-managethecondition.ParticipantBexplainedtheoverwhelmingdemandforhealthcareservicesduringthelockdown,coupledwithlimitedresources,illustratingthechallengeshealthcareprovidersfaced.However,thepilottestrevealedthatsomequestions,particularlythoseondelayedorforgonecare,couldbenefitfromadditionalprobing.Forinstance,whenParticipantAmentioneddelaysincare,afollow-upquestiononthespecifichealthimpactsofthosedelayselicitedmorenuancedresponses.Thisinsightledtotheadditionofpromptslike“Howdidthesedelaysimpactyourhealthorwell-being?”EmotionalSensitivityandEthicalConsiderationsThepilotinterviewsdemonstratedtheimportanceofemotionalsensitivity,especiallyforresidentswhofacedsignificanthealthchallenges.ParticipantAbecameemotionalwhendiscussingthestressofmanagingachronicconditionduringthelockdown,whichhighlightedtheneedforempatheticinterviewingtechniques.Thispromptedtheinclusionofmoresupportivelanguageinthefinalinterviews,suchasofferingparticipantsachancetotakeabreakorskipquestionsiftheyfeltuncomfortable.AdjustmentsMadeBasedonPilotFeedbackTermswereclarifiedandquestionsrewordedabouttelemedicineanddigitalbarriersforbetterclarity.Also,morepromptswereadded,includingmorefollow-upquestionstoelicitdetailedaccounts,especiallyrelatedtotheconsequencesofdelayedcare.Somemoreempathywasalsogiventophrasingbyadjustingthelanguagetobemoresensitive,sothatparticipantsfeltcomfortablesharingemotionallychargedexperiences.Overall,thepilotinterviewsconfirmedthattheresearchquestionswereeffectiveingeneratingthedesireddataonhealthcareaccess,whilealsoprovidinganopportunitytorefinetheinterviewguideforthefullstudy.Theseadjustmentshelpedensurethattheinterviewswouldnotonlyproducerich,detaileddatabutalsoallowparticipantstoexpresstheirexperiencesinasafeandsupportiveenvironment.Chapter4:FindingsThefindingsofthisstudyareorganizedaroundthemajorthemesidentifiedthroughthematicanalysisofinterviewdataandrelevantdocuments.ThesethemesarederivedfromtheresponsesofTremontresidentsandhealthcareprofessionals.TheyrevealthechallengesresidentsfacedinaccessinghealthcareduringtheCOVID-19lockdown.Theyalsoshowthecompoundedeffectsofsocio-economicfactors,technologyaccessdisparities,theresponseoflocalhealthcare,andthemessagingoftheOfficeoftheMayor.Firstpresentedareanswerstothequestions,andsecondarethethemesastheyappear.ForResidents1.AccesstoHealthcareServices·HowdidtheCOVID-19lockdownaffectyourabilitytoaccesshealthcareservices(e.g.,doctor’sappointments,medications)?·\"Theyshuteverythingdown.Myregularspotwasclosed.Icouldn’tgetmedslikeIusedto.I’dcall,theysay,‘Sorry,wefullup’ortheydon’tanswer.Ijustdealwithitonmyown.\"·\"Forgetaboutit.Itriedgettinganappointment,buttheykeeppushback.Imisswholemonthbloodpressurepills‘causenobodyishelp.\"·\"Itwasnearlyimpossibletoseemydoctorduringthelockdown.MyregularclinicwaseitherclosedorhadsuchlongwaitingtimesthatIgaveup.Iwentwithoutmymedicationforawhilebecausegettingarefillfeltlikesuchachallenge.\"·\"Totalmess.Mydoctor’sofficeclosed,andwhenIcalledtheyjustsaid‘tryagainnextweek’orsomenonsenselikethat.Iwasleftjusttrynaholdittogetheronmyown.\"·\"Itwasrealhard…Mymomgotcheck-ups,butallthatgotputonhold.Iwasworriedeveryday‘causewecouldn’tseethedoctorlikeusual.\"·\"Appointmentswerecanceled.Itwasjusthard.Saidtheycouldonlyoffervirtualconsultations,likewhatthe----isthat?\"·Werethereanyspecifichealthservicesthatbecameharderorimpossibletoaccessduringthelockdown?·\"Yeah,Iwassupposedtogetmykneecheckedout,buteveryplacetoldme,‘Nah,weonlytakin’emergenciesrightnow.’BytimeIgotappointment,itwaswayworse.Couldn’tbarelywalkbythen.\"·\"Ineededadentistbad‘causemytoothwaskillin’me,buttheywasn’ttakin’nobodyunlessitwasanemergency.Hadtolivewiththatpainformonths.\"·\"Ineededphysicaltherapy.Nope,nothin’open,toobad.Whentheyfinallyopen,there’sawaitlistamilelong.\"·\"Can’tevengetnodentist!Ihadatoothinfection,man!Nope!Theyain’tevengonnaopenup.\"·\"Forreal,Ineededsomedentalwork,buttheywouldn’tevenletmeinthedoor.\"·\"Icouldn’tgettomyregularasthmaappointments.Iwasjustouthere.IhadtojusthopeIdidn’tgetworse.\"·Howdidtheclosureofnon-essentialhealthcarefacilitiesimpactyourabilitytomanagechronichealthconditions,ifapplicable?·\"Ihavediabetes,soIneedregularcheck-upstomanagemybloodsugarlevels.Whentheclinicclosed,Icouldn’tgetthesupportormonitoringIneeded,whichledtoafewemergencyvisits.\"·\"ThelockdownmeantIcouldn’tgoinformyasthmachecks,whichusuallyhelpmemanagemysymptoms.Withoutthosevisits,IendedupintheERmorethanoncebecauseIcouldn’tkeepitundercontrol.\"·\"Igotasthma,Igotdiabetes,Igotitall.Igothighbloodpressure.Iusuallyseemydoctoreveryfewweekstokeepmeincheck.ButIcouldn’tgetnohelp,couldn’tgetnoinhalerontime.Nothin’.Iwasstrugglin’bad,andtherewasnoonearoundtohelp.\"·\"Mysistergotasthma,andshecouldn’tseeherspecialist.Shestartedwheezingrealbad,andwehadnowheretogo.It’sliketheyjustforgotabouteverybodywhowasn’tdealingwithCOVID.\"·\"Thediabetesgotrough.Mynumberswasallovertheplace‘causeIcouldn’tseemydoc.Theykepttellin’metocallback,butnoonewouldpickup,andIdidn’tknowwhattodo.\"2.TelemedicineandDigitalAccess·Wereyouabletousetelemedicineduringthelockdown?Ifso,howwasyourexperiencewithaccessingvirtualhealthcareservices?·\"Nah,Iain’tgotnolaptoporfancyphone.Theytalkin’‘boutvideocalls,butIcouldbarelygetaphonecalltogothroughwithoutdroppin’.Ain’tnowaythatwasworkin’forme.\"·\"Itrieditonce,butthedoctorcouldn’thearmehalfthetime.Plus,Igotaprepaidphone,andtheminutesrunoutquickwithvideo.Justwasn’tmadeforfolkslikeus,youknow?\"·\"Telemedicinewasalltheyoffered,butIdon’thavegoodinternet.Itriedtouseitacoupleoftimes,butitwasdifficult.IwashangingupoutoffrustrationbecauseIcouldn’thearwhatthedoctorwassaying.\"·\"Yes,Iusedtelemedicine,butitwasn’tveryeffectiveforwhatIneeded.Thedoctorcouldn’texaminemephysically,sotheyjustprescribedmedicationbasedonwhatIdescribed.Itfeltveryimpersonal.\"·\"Yeah,Itried,butitwasweird.Icouldn’tgetagoodsignalhalfthetime,andIjustkeptsayin’,‘Hello?Youhearme?’Itwasn’tworkin’right.Feltliketheywasjustrushin’meoffthephone,youknow?\"·Didyouencounteranyissuesrelatedtotechnologyorinternetaccesswhentryingtousetelemedicine?·\"Absolutely.Idon’thaveasmartphoneoralaptop,andtheinternetconnectioninmyareaisn’treliable.Iendedupmissingafewappointmentsjustbecausethecallkeptdropping.\"·\"Idon’tgotWi-Fi,soIwasjusttrynadoitoffmydata.Butthevideokeptfreezingup,andthenI’dgetkickedoff.Ihadtogiveup‘causeitwasjusttoostressfultrynamakeitwork.\"·\"Ihadtoborrowmycousin’sphonejusttomakeitwork,andeventhen,itwasrough.Idon’tgotnocomputer,andmyoldphonekeptfreezin’up.Ifeltliketheywasspeakin’anotherlanguage.\"·\"Iwasusingmyphone,anditwasfrustratingbecauseIcouldn’tgetclearinstructionsonmycondition,andIfeltlostmostofthetime.\"·Howdoyoufeelabouttheshiftfromin-persontovirtualhealthcareduringthelockdown?Wasitsufficientforyourneeds?·\"Notatall.Ipreferface-to-faceconsultationsbecausemydoctorcanactuallyseewhat’swrong.Virtualcaredoesn’tgivethesamelevelofattention,anditfeltliketheywerejusttryingtorushthroughthecall.\"·\"Telemedicinemightbeokayforsomethings,butitdidn’tworkforme.Myneedsweren’tmetbecauseit’shardtoexplaincertainsymptomsoverthephonewithoutthedoctorseeingme.\"·\"Itain’thelp.Theyactin’likeit’sallthesame,butit’snot.Sometimesyouneedsomeonetolookatyou,notjusttalkonsomescreen.\"3.DelayedorForgoneCare·DidyoudelayoravoidseekingmedicalcareduringthelockdownduetoCOVID-19concerns?Ifyes,why?·\"Ohyeah,Istayedhome.Everyonewassayin’howdangerousitwasoutthere,soIjusttriedtohandleitmyself.Hadalottafearaboutcatchin’somethin’ifIwenttotheclinic.\"·\"Ididn’teventhinkaboutgoin’nowhere‘causetheymadeitsoundlikeifyoustepoutside,yougon’getsick.Didn’twannaendupinthehospital,soIkeptputtin’itoff.\"·\"IwasworriedaboutcatchingCOVIDattheclinic.Idecidedtowaitoutmysymptoms,butthatprobablymadethingsworse.\"·\"Absolutely.Withallthefear,Ijustdidn’twanttogonearanyhealthcare.EvenwhenIfeltreallysick,Istayedhome,thoughtIcouldmanageonmyown.\"·Howdidanydelaysincareaffectyourhealthorthehealthoffamilymembers?·\"BythetimeIwenttogethelp,myconditionwaswayworse.Couldn’thardlybreathesomedays.IendedupintheER‘causeIcouldn’tmanageitnomore.AndfeltliketheyjustaboutkilledmeintherewithalltheircrazyCOVIDprotocols—feellikeI’mluckytobealive!DefinitelyfeellikeIwouldhavebeenbetterjuststayinghome,man.\"·\"Mydiabeteswentouttacontrol.IknewIneededhelp,butIkeptwaitin’andwaitin’.NowIgotmoreissuesthanIdidbeforeallthisstarted.Endeduppassin’outoneday,andtheyhadtocallanambulance.Scaredmyfamily.\"·\"Thedelaystookatoll.MybloodpressurespikedbecauseIwasn’tmonitored,allcouldhavebeenavoidedwithregularcheck-ups.\"·\"Idelayedgoingtothedoctor,andmyconditionworsened.WhatwouldhavebeenasimpletreatmentturnedintoamoreseriousissuebecauseIwasn’tabletogethelprightaway.\"·Werethereanyspecifictreatmentsorproceduresyouhadtopostpone?Howdidthepostponementsimpactyourcondition?·\"Iwassupposedtogetsomekindascandoneonmyback.Hadtocancelit,though,‘causetheyweren’tseein’nobody.NowIgotmorepainthanbefore,andit’sliketheyjustdon’tcare.\"·\"Iwasscheduledforaminorsurgerythatgotpostponedindefinitely.Withoutit,mysymptomsworsened,andIexperiencedalotofpainthatcouldhavebeenavoided.\"·\"Hadanappointmenttofixabadtooth,buttheycanceledit.WhenIfinallygotseen,theyhadtopullitout.Allthatpain,justtolosethetooth.\"·\"Iwassupposedtogetsometestsdoneformyheart,buttheyshutitdown.Idon’tevenknowwhat’sgoin’onwithme‘causeIain’tbeenabletoseenobody.\"·\"Ihadtodelayadentalprocedureforacavity.EndedupIneededarootcanalinsteadofafilling,whatshouldhavebeenafilling,Imean.\"4.HealthOutcomesandConcerns·Inwhatwaysdidthelockdownpoliciesinfluenceyouroverallhealthandwell-being?·\"Thelockdownaddedsomuchstresstomylife.Financialstruggles.Notbeingabletoseemydoctor.Depressiongotworse.\"·\"Stress,straightup.Iwasstressedoutallthetime,worriedaboutgettin’sick,andmyhealthgotworse.Bein’stuckinside,notseein’mydoctor,itallstacksup.Ifeltdrainedeveryday.\"·\"Iwasscared,honestly.Healthwasalreadyshaky,andwithnodoctoraround,Iwasjustprayin’Ididn’tgetworse.Myanxietywentthroughtheroof.\"·\"Itmadememoreanxiousandisolated.Myphysicalhealthwentdownhilltoo,especiallybecauseIcouldn’tmanagemychronicconditionsaswellwithoutregularhealthcareaccess.\"·Werethereanyhealthissuesthatworsenedduetothereducedaccesstohealthcareduringthelockdown?·\"Yeah,myasthmawaswayworse.Icouldn’tgetmyrefillsontime,soIwasusin’whatIhadsparingly.Hadalotmoreattacks,anditscaredmetogototheER.\"·\"Mysugarlevelswentupbad.Ididn’thavetheusualcheck-ups,couldn’tgooutandgetexercise,justeatin’bad,couldn’tkeepthingsundercontrol.Mydoctorcouldn’tseeme,soIjustgotbad.\"·\"Mydiabetesgotoutofcontrol,andIhadothercomplicationsbecauseIcouldn’tgetadjustments.\"·\"Myasthmawasworse.Wasastruggletobreatheattimes.Icouldn’tgethelpeasily.\"·Whatwereyourbiggestconcernsregardinghealthcareaccessduringthepandemic?·\"Iwasmostworriedaboutmyconditionworseningtoapointwhereitwouldbehardtorecover,simplybecauseIcouldn’tgetthecareIneededintime.\"·\"IworriedthatIwouldendupwithseriouscomplicationsfrommyuntreatedissues.NotknowingwhenIcouldgethelpagainmademeveryanxious.\"·\"Thebiggestthingwasnotknowin’whatwasgonnahappennext.Ineededhelp,buteverydoorwasshut.FeltlikeIwasonmyown,likenobodycared.\"5.PerceptionofHealthcareSystemResponse·Howwouldyoudescribetheresponseoflocalhealthcarefacilitiesduringthelockdown?Didyoufeelsupportedorabandonedbythehealthcaresystem?·\"Ifeltlikewewasforgotten.Liketheyonlycared‘boutCOVIDpatientsandlefttherestofustodealonourown.Theysayin’tostayhome,butwhatifstayin’homeismakin’usworse?\"·\"Ifeltabandoned.ThesystemwassofocusedonCOVID-19thatitfeltliketheyforgotaboutpeoplewithotherhealthissues.Therewasnoguidanceonwhattodoforpeoplelikeus.\"·\"Itseemedlikethesystemdidn’tcareaboutus.Wewereonourown.Ineededhelp,buteverythingwaseitherclosedoroverwhelmed.Itwasadifficulttime.\"·Inyouropinion,howcouldthehealthcaresystemhaverespondedbettertomeettheneedsofpeopleinyourcommunityduringthelockdown?·\"Theycouldasetupsomething,soweain’tmixedwiththeCOVID.Separatespots,Idon’tknow.Itwouldamadeadifference.\"·\"Theyshouldathought‘boutpeoplewithnointernet,notech.Iftheyreallycared,they’dmakesureeveryonehadaccess,notjusttheoneswhocangoonline.\"·\"Thereshouldhavebeenmoreresourcesfornon-COVIDconditions,evenifthatmeantsettingupforchronicpatients.\"·\"Thesystemcouldhavedonemoretosupportpeoplewhoneededregularcare.Keepingthingsopenwouldhavemadeabigdifference.\"6.BarrierstoAccess·Whatweretheprimarybarriersyoufacedinaccessinghealthcareduringthelockdown(e.g.,transportation,fearofexposure,facilityclosures)?·\"Thebiggestthingwasfear.EverytimeIthoughtaboutgoin’out,I’drememberhowtheysaidstayhomeoryou’llgetsick.Thatstuckwithme,soIdidn’twannagonowhere.\"·\"Themainbarrierwasthatmyusualclinicwasclosed.Icouldn’tgettherewithoutreliabletransportation,andIdidn’tfeelsafetakingpublictransitduringCOVID.\"·\"Fearofexposurewasabigoneforme.Ididn’twanttoriskgoingintoaclinicwhereCOVIDmightbespreading,soIstayedaway.\"·Didyouencounteranyfinancialbarrierstoreceivinghealthcareduringthisperiod?·\"Yes,thelockdownaffectedmyjob,soIwasworriedaboutthecosts.IdelayedsomecarebecauseIwasn’tsureifIcouldafforditwithmyreducedincome.\"·\"Absolutely.IlosthoursatworkandwasafraidIcouldn’tpayformedications,soIskippedsomeofmyregularmedicationstosavemoney.\"·\"Moneywastight,yeah.Ilosthoursatwork,andpayin’formedsgothard.Istartedrationin’mypills‘causeIdidn’tknowwhenIcouldaffordmore.\"·\"Forsure.Losthours,couldn’taffordmymeds.Hadtoskipdoses‘causeIcouldn’tpay,andIknewitwasn’tgoodforme,butIain’tgotnochoice.\"7.GeneralReflection·Lookingback,whatwouldyousaywerethebiggestchallengesrelatedtohealthcareaccessduringthelockdown?·\"Notbein’abletogoseemydoctor,thatwasnumberone.Feltlikeallthehealthcaredoorswasclosedtous,likewedidn’tcount.\"·\"Thehardestpartwasgettin’help.EverytimeIcalled,theywasclosedorbookedup.Iwasjustonmyownformonths.\"·\"Thebiggestchallengewasthelackofin-personhealthcare.Virtualappointmentsdidn’tfeellikeenough,especiallyforpeoplewithchronicissues.\"·\"Accesswasthebiggestissue.Everythingwaseitherclosedorrestricted.Wefeltleftoutandhelpless,especiallysincethesystemseemedsofocusedonCOVIDcases.\"·Ifanotherpublichealthcrisisweretohappen,whatimprovementsinhealthcareaccesswouldyouliketoseeforyourcommunity?·\"Thereshouldbedesignatedclinicsfornon-COVIDpatientssowecanstillgetthecareweneed.\"·\"Bettertelemedicineoptions,moresupportforlow-incomepatients,andaplantokeepchroniccareclinicsopenwouldbeessential.Weneedahealthcaresystemthatconsidersallhealthissues,notjustthecrisisathand.\"ForHealthcareProfessionals1.\"Whatweresomeofthebiggestchallengesyourfacilityfacedinprovidinghealthcaretonon-COVIDpatientsduringthelockdown,especiallythosewithchronicconditions?\"·\"Thehardestpartwashavingtoturnawaypatientswhoneededregularcare.OurfocuswasshiftedalmostentirelytoCOVIDpatients,somanagingchroniccaseswaspushedtothebackburner.Wedidn’thavethestafforresourcestohandlebothCOVIDandourregularpatientload,sopeoplewithchronicconditionswerelefttowait,sometimesformonths.\"·\"BalancingCOVIDcarewitheverythingelsewasnearlyimpossible.Alotofournon-COVIDpatientsreliedonfrequentvisitsforthingslikediabetesandhypertension.Asthma,thingslikethat.ButPPEandstaffshortage—itgotsothatwecouldonlyseeemergencies.Wewantedtohelp,butsomanyrestrictions,therewasn’tmuchwecoulddo.Itwasheartbreakingbecauseweknewthesituationforalotofpeoplewasprobablydeclining.\"·\"Wewereshortonalmosteverything—staff,equipment,time.Chronicpatientsneedroutinemanagement,buteverytimewetriedtoarrangeappointments,wehadtoconsidertheriskofexposure.Foralotofthem,thevisitstheyneededtostaystablejustdidn’thappen,anditwasfrustratingforus,too.\"2.\"Howdidthelockdownimpactyourabilitytocommunicatewithandsupportpatientswhohadlimitedaccesstotechnologyorinternetfortelemedicineservices?\"·\"Itwasarealstruggle.Weofferedtelemedicine,butmanyofourpatientsdidn’thaveWi-Fiorasmartphone,sowewerelefttryingtomanagetheircarethroughphonecalls,whichjustisn’tthesame.Forsomeconditions,youreallyneedtoseethepatienttoassessthemproperly,andwithoutvideo,wecouldonlyguessatwhatwasgoingon.\"·\"Alotofourpatientsweren’tsetupfortelemedicine.Wetriedcallingpatients,butwithoutvideo,wecouldn’tgetaclearpictureoftheircondition.Itwasaconstantworry,especiallyfortheelderlypatientswhocouldn’tjustswitchtotelemedicine.Weendeduplosingtouchwithsomeofthem,andthatwashardbecauseweknewtheyneededhelp.\"·\"Thetechnologygapwasabigproblem.Evenwhenpatientshadthedevices,somedidn’tknowhowtousethemformedicalappointments.Wetriedtoguidethemthroughit,butitoftenturnedintoalong,frustratingprocess,bothforusandforthem.Ithinkalotofthemjustgaveupontheideaofgettingcarebecauseofhowdifficultitwas.\"ThemesBarrierstoHealthcareAccessDuringtheLockdownAdominantthemeacrosstheinterviewsconductedwithTremontresidentsandhealthcareworkerswasthepresenceofbarrierstohealthcareaccessduringthelockdown.Participantsdescribedasetofobstacles,includinglimitedfacilityavailability,relianceonvirtualcare,andfearsrelatedtoCOVID-19exposure.Thesebarrierswereespeciallyfeltbyresidentswithchronichealthconditionswhorequiredconsistentmedicalsupportbutfaceddelaysordisruptionsintheirregularcare.Oneresident,whosuffersfromasthma,illustratedthesebarriersbyexplaining:“Wheneverythingshutdown,myappointmentswerecanceled.Iwasleftwithoutanoptiontogetmyinhaler.TheclinicsIreliedonwereclosedoroverloaded.Everythingwaschaos.Iliterallycouldnotevengooutsidewithoutfearsomebodywasgoingtoturnmein.ItmademeanxiousbecauseIcouldn’tcontrolmyhealththewayIusuallycould.”Healthcareproviderssimilarlynotedthatpatientfearsandrestrictedfacilityavailabilitydisruptedroutineandpreventivecare.AnursefromaTremontcommunityclinicshared:“Wewereforcedtoreschedulealotofpatients.Manypeoplecalledinscared,askingifthey’dbesafecomingtotheclinic,butwedidn’thaveenoughpersonalprotectiveequipmentatfirst,andpatientswerehesitant.”Likewise,ahealthcareadministratornoted:“Wehadtomaketoughchoices,limitingourservicestoemergenciesonly.WetriedtoprioritizecriticalcareforCOVIDpatients,butitcameattheexpenseofregular,preventivecare.”Theseresponsesreflecthowbarriersemergedatmultiplelevels.Facilityclosuresandoverwhelmedresourcescombinedwithpatientanxiety,effectivelylimitingresidents\'accesstonecessaryhealthcare.TheDigitalDivideandTelemedicineChallengesAnotherprominentthemethatemergedisthedigitaldivideinaccesstotelemedicineservices.Whiletelemedicinewaswidelypromotedasanalternativetoin-personcare,manyTremontresidentsfacedtechnologicalanddigitalliteracybarriersthatmadevirtualhealthcarechallengingorevenunattainable.Forresidentswholackedreliableinternetordigitaldevices,accessingtelemedicineserviceswaseitherimpossibleorfraughtwithdifficulty.Oneresidentrecalledherexperiencewithtelemedicine:“TheykeptsayingIcouldtalktoadoctoronline,butIdon’thavenocomputer,andmyphonewastoooldtohandleit.Ifeltleftout‘causepeoplekepttellingmetherewas‘helpavailable,’butitwasn’treallyforpeoplelikemewhocouldn’tgetonline.”Healthcareprofessionalsalsoexpressedfrustrationwiththeconstraintsoftelemedicine.Aphysiciannotedthelimitationsofvirtualconsultations:“Wetriedtoadaptbyofferingphoneconsultations,butdiagnosingandtreatingwithoutseeingthepatientinpersonisverydifficult,especiallyforchronicconditions.Formanyofmypatients,itwasatemporarysolutionthatdidn’treallyaddresstheirneeds.”Aspartofthelockdownadaptation,telemedicinewasintroducedtomaintainhealthcareaccess;however,socio-economicdisparitieslimiteditseffectiveness.Manyresidentslackedinternetaccess,digitaldevices,ordigitalliteracytoengagewithtelemedicineplatforms,leavingthisoptioninaccessibleforasignificantportionofthecommunity.Forlow-incomeresidents,theeconomicburdenofsecuringreliableinternetorpurchasingcompatibledeviceswasofteninsurmountable,andtelemedicineinadvertentlybecameanavenueofexclusionratherthaninclusion.Oneresidentexplained:“Everyonekepttalkingaboutgoingonline,butIdidn’thavethemoneyforagoodphoneorWi-Fi.Itfeltlikethey[thehealthcareproviders]assumedweallhadthesameresources,butthatain’tourreality.”HealthcareprovidersalsoacknowledgedthelimitationsoftelemedicineforcommunitieslikeTremont.Adoctorremarked:“InaneighborhoodlikeTremont,thedigitaldivideisreal.Telemedicinecouldonlygosofar,anditquicklybecameclearthatitwasn’tmeetingourpatients’needs.Manyofthemsimplydidn’thavetheinfrastructureforit,andthosewhodidfounditinadequateforrealmedicalconsultation.”Theseresponsesindicateamajordisconnectintheadaptationstrategiesusedbythehealthcaresystem.Telemedicinewasmeanttobeanaid,butitinadvertentlyhighlightedthesocio-economicdisparitiesinTremont,wherelimitedaccesstotechnologyintersectedwithexistinghealthcarebarrierstofurtherrestrictresidents\'healthcareaccess.Someresidentswereunabletoaccesscareinthisformat,andeventhosewhocouldoftenfeltthattelemedicinelackedthedepthandqualityoftraditionalin-personvisits.ImpactonChronicConditionManagementAnotherthemeseenamongresidentswithpre-existinghealthconditionswasthestruggletomanagechronicillnessesduringthelockdown.Manyreportedthattheunavailabilityofregularmedicalappointmentsandtheinabilitytoaccesspreventivecareledtoworseningconditions.Oneresidentwithdiabetesrecounted:“Ineededregularcheck-upstokeepmybloodsugarundercontrol,butwiththelockdown,Imissedappointments.Iwasjusttooafraid.Weweretoldstayinsidestayinside,ohmyGod,itwas,like,neverending,stayinside!Ijustfeltlikewe,likeeverything,myhealth,italljustwentdownhill.Ihadtogoonnewmedications‘causeofallthis.”Aresidentsufferingfromhypertensiondescribedtheirexperienceasfollows:“IwastoldtogototheERonlyifitwasanabsoluteemergency.But,whenyougotaconditionlikemine,everydayisanemergencyifyourhealthain’tmanagedright.Thestressalonewas,like,uptohere,youknow,madeitworse,knowingIhadnowheretogoformycheck-ups.”Healthcareprofessionalsconfirmedthatdelaysincareoftenresultedinpatientspresentingwithmoreseveresymptomsthanusual.Adoctorfromalocalhospitalexplained:“Wesawalotofcaseswherepatients’conditionsdeterioratedbecausetheycouldn’tgetthecaretheyshouldhaveornormallywouldhavereceived.Peoplewhowouldcomeinforroutinevisitswerecomingafterlongabsencesandwithemergencies.”Thisthemesuggeststhatwithoutregularcare,manyresidentsexperiencedadeclineinhealththatcouldhavebeenavoidedundernormalcircumstances.PsychologicalandEmotionalImpactofHealthcareDisruptionsThedisruptionstohealthcareaccessalsoappeartohavehadapsychologicalimpactonresidents,withsomeexpressingincreasedstressandfrustrationduetotheinaccessibilityofhealthcareservices.ThefearofcontractingCOVID-19compoundedthesefeelings.Residentsfeltcaughtbetweenriskingexposureandforegoingnecessarymedicalcare.Aresidentwhocaresforanelderlyparentwithhypertensionexplained:“Iwasterrifiedtotakemymothertotheclinic,butatthesametime,Iknewsheneededhermedication.Itwasaconstantworry—doIriskherhealthbytakingherout,ordoIriskherhealthbykeepingherathome?”Onehealthcareprofessionalsimilarlynotedthepsychologicalstrainamongpatients.Anurserecountedhowstressed-outpatientsseemed.“Peoplewouldcallinandcry,askingwhattheycoulddo,andwehadnoanswers.Itwasheartbreaking,especiallyforthosewhoalreadyhadmentalhealthconcernsthatworsenedduetotheaddedpressure.”ThesefindingssuggestthatboththelimitedaccesstohealthcareservicesduringthelockdownandthetoneandcontentofthemessagingformtheOfficeoftheMayorcontributedtoasenseofbeinglostorleftbehindfeltbyresidentsandafeelingofhavinghandstiedbysomehealthcareworkers.Thesecanbeseenasnotjustphysicalbarriersbutalsoasmentalandemotionalbarriers.Likewise,ascityofficialsandmediamessagesemphasizedtherisksofvirusexposure,oneresidentshared:“Everywhereweturned,weweretoldtostayhomeandavoidcontactwithothers.Mademethinkrealhardaboutgoingatall.”Thehealthcareworkersinterviewedsimilarlynotedthatthecommunity’sapprehensionreducedthenumberofpeopleseekinghelp.Anursecommented:“Wehadpeoplecancelappointmentsrepeatedly,evenwhentheywerecriticallyneeded.Itwashardforustoreassurethembecause,intruth,wecouldn’treallyguaranteeaCOVID-freeenvironment.”Overall,residentsdescribedheightenedanxiety,stress,andfeelingsofisolation,madeworsebytheuncertaintysurroundingthelockdownandthefearofcontractingCOVID-19.Theclosureofin-personhealthcarefacilitiesandlackofaccessiblementalhealthsupportintensifiedthesefeelings.Aresidentshared:“Everydayfeltlikejusttryin’tosurvive.Betweenmyhealthandmyfamily,Iwasonedge,yeah,forsure.Therewasnowheretogo.Feltlikewewasjuststraight-upabandoned.”Healthcareprofessionalsalsoobservedincreasedstressamongpatients,manyofwhomweremanagingmentalhealthconditionsexacerbatedbyisolationandfear.Ahealthcareworkerstated:“Patientswouldcallusjusttotalkbecausetheywerelonelyorscared.Therewasnoformalmentalhealthsupportforthem,sowetriedtobethereinanywaywecould,butitwasn’tenough.”ThecompoundedstressfromboththephysicallimitationsinhealthcareaccessandtheemotionaltollofisolationhighlightedtheprofoundmentalhealthimpactofthelockdownonTremontresidents.Thisfindingemphasizestheneedforintegratedmentalhealthresourcesinfutureemergencyresponses,especiallyinvulnerablecommunities.SummaryandConclusionThisstudyidentifiedseveralcriticalthemeshighlightingthehealthcareaccesschallengesfacedbyTremont’sminorityresidentsduringtheCOVID-19lockdown.Aprimarythemewaslimitedaccesstoessentialhealthcareservicesasclinicsclosedorlimitedappointments,impactingresidents’abilitytomanagechronicconditions.Manyreporteddifficultyaccessingregularmedicationsandnecessarytreatments,leadingtoworseninghealthandemergencyinterventions.Anothersignificantthemewasthedigitaldivideandbarrierstotelemedicine,whereresidentslackinginternetaccessordigitaldevicescouldnotutilizevirtualhealthcare.Eventhoseabletousetelemedicinefounditinadequatefordiagnosingandtreatingchronicconditions,revealinganinequityinhowhealthcareadaptationsduringthelockdownoverlookedlow-incomecommunities.Delayedorforgonecarewasacommonconsequence,withmanyresidentspostponingoravoidingmedicalvisitsduetofearofexposure,compoundedbyinconsistentaccesstoservices.Thisdelayledtodeteriorationinconditionslikeasthma,diabetes,andhypertension,reflectingthehealthrisksposedbyreducedhealthcareaccess.Manyresidents,especiallythosemanagingchronicconditionslikediabetes,asthma,andhypertension,struggledtogetmedicationsandregulartreatments,leadingtohealthdeteriorationand,inseverecases,emergencyinterventions.ThestrainonhealthcareresourcesandfocusonCOVID-19patientsleftmanyfeelingneglected.Theemotionalandpsychologicaltollonresidentswasalsosignificant,asfearofCOVID-19andisolationfromhealthcaresupportledtoheightenedanxietyandstress.Manyexpressedfeelingabandonedbythehealthcaresystem,citingalackofsupportoraccessibleresourcesfornon-COVIDhealthissues.Overall,thefindingsshowacompoundedimpactofhealthcareandsocio-economicdisparitiesonTremont’sresidentsduringapublichealthcrisis.Addressingsuchinequitiesinfuturehealthcareresponseswillrequiretargetedstrategies,includingbetteraccesstophysicalcareforchronicpatients,digitalresourcesforlow-incomecommunities,andsupportsystemsthatprioritizevulnerablepopulationstopreventfurtherhealthdisparities.

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