“Programs are needed that use relationships with trusted sources of information to build mutual
respect, inform and educate, and provide opportunities for individuals, organizations and populations
to actively engage with COVID-19 testing education,” says Shawna Hudson, PhD, professor and chief, Research Division, Department of Family Medicine and Community Health, and
director, Center Advancing Research and Evaluation for Patient-Centered Care (CARE-PC), Robert Wood
Johnson Medical School. Dr. Hudson is principal investigator for the NJ HEROES TOO (New Jersey Healthcare Essential WoRker Outreach and Education Study – Testing Overlooked Occupations) study.
NJ HEROES TOO, an 18-month project supported in part by the New Jersey
Alliance for Clinical and Translational Science (NJ ACTS), was funded under the National Institutes of
Health’s (NIH) Rapid Acceleration of Diagnostics (RADx) initiative, RADx Underserved Populations
(RADx-UP). Rutgers is one of 32 institutions that received an NIH award through the RADx-UP program to
support projects designed to rapidly implement COVID-19 testing strategies in populations
disproportionately affected by the pandemic.
The timing is critical. Although a concerted
effort to address health disparities nationally began in earnest more than two decades ago, early and
emerging COVID studies demonstrate there is still a long way to go. In fact, the Centers for Disease
Control and Prevention has stated that the pandemic “has highlighted that health equity is still not a
A 2021 report by the APM Research Lab, a member of the American Public Media
Group family, showed Black and Hispanic/Latino Americans were 2.7 times more like to have died of
COVID than white Americans in 2020. In New Jersey, the highest COVID mortality rates were found among
Black and Latinx residents—346 per 100,000 and 352 per 100,000, respectively.
echo findings of Rutgers studies in the early phases of the pandemic, which showed higher rates of
positivity in Black, Latinx, and lower-income workers. Compared to non-Hispanic white participants,
the odds of a positive test were twofold higher among Black and Latinx populations, according to the
RWJ Screening Study, which looked at hospital and medical staff in New Brunswick. In addition, the
study showed infection rates were especially high among lower-income medical roles (e.g., technicians
and phlebotomists), as well as hospital support roles (dining/food service, maintenance/housekeeping,
and security/support)—positions that are more likely to be held by poor women and disproportionately
by people of color.
As a result, NJ HEROES TOO focuses specifically on Black and Latinx
individuals who are working in lower-income healthcare professions. These populations are extremely
important, because they are microcosms of their communities, says Dr. Hudson.
Developing an Effective Strategy
The researchers hypothesized that Black and Latinx healthcare workers reaching out to their family
and friends about COVID testing could be as effective as traditional community outreach efforts, and
knew that Rutgers already had a pool of potential “ambassadors” at its disposal through the RWJ
Screening Study and Rutgers Corona Cohort.
The concept for the program is straightforward:
Talk to Black and Latinx healthcare workers and their communities to find out their thoughts and
concerns about COVID testing and vaccines, develop informational materials to address those concerns
and encourage testing, and implement an at-home testing program using the Rutgers-developed saliva
test. Then, researchers would compare this method against traditional community education techniques
to evaluate the cost and effectiveness of an ambassador strategy.
The scope of the project is massive—covering four of the most densely populated counties in the most
densely populated state in the country—with the involvement of more than two dozen Rutgers
researchers, and 22 community-based organizations and health care employers. The counties selected
(Essex, Middlesex, Passaic, and Union) all have shown a high burden of COVID among their Black and
Latinx populations. As many as 2,000 individuals will ultimately be tested as part of the NJ HEROES
TOO initiative, half through the ambassador strategy and the remaining thousand through standard
community education efforts.
In the initial phase of the project, researchers interviewed
approximately 110 individuals across the four counties being studied, soliciting opinions on COVID
testing and their experiences with COVID, as well as their thoughts about the vaccine and vaccine
acceptance. That feedback was used to craft the toolkit used for the testing intervention, which
started in May 2021, Dr. Hudson says.
The interviews yielded interesting, and in some cases
surprising, feedback from participants that served not only to shape the materials but also prompted
the team to adjust some of the assumptions it initially made during the planning of the project, Dr.
Hudson notes. For example, the team initially believed that their healthcare worker ambassadors would
have access to COVID testing through their workplaces, but learned that was not necessarily the case.
As a result, NJ HEROES TOO expanded COVID testing availability to include the healthcare workers in
addition to their family and friends, Dr. Hudson says. Concerns about individuals’ reluctance to
participate in mail-in and supervised testing also proved to be unfounded, as respondents in the focus
groups said the ease of mail-in testing was particularly helpful for those with transportation or
child care issues, and supervised testing would help them feel more comfortable in “collecting the
sample in the way that it needs to be collected,” she adds. With regard to vaccine hesitancy, much of
what was learned helped in targeting messages to the correct sensitivity points for people. While
historical issues—such as the Tuskeegee study on untreated syphilis and the use of Henrietta Lacks’
cells in research without her knowledge—were still important, much of what the researchers heard were
informed questions that individuals felt were not being answered—or that they did not have people they
felt comfortable speaking with to address their issues, Dr. Hudson explains.
challenge regarding the messaging related to COVID testing was making a compelling argument for why it
is still important, she says.
“We’ve had really strong messages about the importance of
getting the vaccine, but not the same kind of emphasis on testing as another part of the toolkit.
We’ve gotten messaging on hand washing, on social distancing, on wearing face masks, but not the same
emphasis on testing. I think that’s that one of the major challenges for us in this project,
particularly in the context of limited vaccine uptake in some of our communities and limited access to
vaccine for children,” she says.
That message is needed for healthcare workers in addition
to other community members, Dr. Hudson notes.
“One of the reasons that testing works is
that you know how has it and who they are exposing. Healthcare workers were saying, ‘Well, we’re the
only ones exposed; our family members aren’t.’ It really underscored the need to get the message out
about the importance of testing, particularly at a time when people are looking at vaccines as a
complete return to normalcy, but there are unvaccinated people who still remain unprotected,” she
says. “You can still get COVID. It’s really important to know what your status is, because while there
are some people who are vaccinated, there are still many others who aren’t. Before, people were a
little bit more circumspect in their behavior. Now with face-mask mandates easing it is important,
particularly for those unvaccinated, to test—in some ways even more than we did before—and people are
not seeing or understanding why that is important.”
In addition to developing
project-related materials, the team also developed “enduring materials” to help provide a seamless
transition from the testing phase of the NJ HEROES TOO project, with information on other sites for
testing in the county, networking information, support resources, and so on, she says.
Contributing to the National Discussion
As a Rutgers alumna who earned her undergraduate, master’s, and doctoral degrees at the university,
Dr. Hudson finds it particularly gratifying to play a role with her alma mater and fellow Rutgers
alumni in a project with the potential for such far-reaching impacts on the community.
of the project directors—Manny Jimenez, Diane Hill, and I—are Rutgers alumni and have been part of
these communities for some time,” she says. “We’re not swooping in from an ivory tower, divorced from
what’s happening here. We live here. These are the issues I’m talking about with the women I get my
hair done with. These are the things we’re seeing and experiencing, from the ground up.
would really love for this study to be known. It is one of the biggest forays of Rutgers community
responses to address health disparities in our local communities,” Dr. Hudson adds. “There have been
lots of efforts, but nothing that’s ever been on this scale, where we’ve been able to work with so
many community and healthcare organizations to bring all of these forces to bear on a critical
Dr. Hudson hopes NJ HEROES TOO will be fundamental in addressing the current needs
“We still have disparities in terms of treatment, access, who is getting
care, and outcomes,” she says. “We would love for this study to add to the national discussion about
effective strategies to actually engage our communities and address those issues at a national
level—to be an ‘incubation site’ for great ways to work with the community on these issues, and show
how we, as New Jerseyans, can actually add to the larger discussion nationally.”
that discussion should involve primary care, she asserts, noting that the lack of engagement with
primary care regarding COVID has been a major issue.
“People in our study talked about the
importance of their primary care doctors as the place they trust for their healthcare. But in terms of
COVID response, the major initiatives around testing and vaccine were concentrated in pop-up megasites
and pharmacies for roll-out, but not primary care,” she says. “When you think of our populations and
where they’re going for their care and who they’re actually talking to, I think that primary care
being left out of that conversation was a major misstep nationally. It will be interesting to see in
the coming months, when these sites shift their focus, how the continued disparities will be
Because the project involves not only four different counties, but also a lifespan approach, the team
needed to think broadly in terms of the coalitions with whom they were working, Dr. Hudson says. That
meant collaborating with organizations ranging in size, scope, and focus, she says. For example, the
project is working with faith-based organizations, senior centers, maternal and child health
corsortia, and organizations that work with issues of social determinants of health, as well as those
focused on Black and Latinx communities, such as the Urban League, New Brunswick Area Branch of the
NAACP, Puerto Rican Action Board, and ASPIRA, she says. This expansive approach was needed, she
explains, because individuals seek information from different types of sources depending on their life
In addition to Dr. Hudson, the project directors include three Robert Wood Johnson
Medical School faculty members: Manny Jimenez, MD ‘06, MS, FAAP, assistant professor of pediatrics and
family medicine and community health, and director of developmental and behavioral pediatrics
education at the medical school’s Boggs Center on Developmental Disabilities; Martin J. Blaser, MD,
professor of medicine and biochemistry and molecular biology, Robert Wood Johnson Medical School, and
director, Rutgers Center for Advanced Biotechnology and Medicine (CABM); and Reynold A. Panettieri
Jr., MD, professor of medicine, Robert Wood Johnson Medical School, and vice chancellor, Clinical and
Translational Research, Rutgers Biomedical and Health Sciences. Director of the Rutgers Institute for
Translational Medicine and Science, Dr. Panettieri also serves as chair of the NJ ACTS Executive
NJ HEROES TOO project directors also include Diane Hill, PhD, assistant
chancellor for University-Community Partnerships at Rutgers University–Newark; and Emily S. Barrett,
PhD, associate professor of biostatistics and epidemiology, Rutgers School of Public Health/Rutgers
Environmental and Occupational Health Sciences Institute (EOHSI).
Ultimately, the research
team plans to take lessons learned about implementation and opportunities for sustaining these
initiatives and developing a process that can be adapted by other sites, as well as easily expanded
beyond the healthcare realm to other front-line and essential workers, Dr. Hudson says.