Introduction: Acute stroke and acute myocardial infarction (AMI) treatments are time sensitive.
Early data revealed a decrease in presentation and an increase in pre-hospital delay for acute stroke and AMI during the coronavirus disease 2019 (COVID-19) pandemic. Thus, we set out to understand community members' perception of seeking acute stroke and AMI care during the COVID-19 pandemic to inform strategies to increase cardiovascular disease preparedness during the pandemic.
Methods: Given the urgency of the clinical and public health situation, through a communitybased participatory research partnership, we utilized a rapid assessment approach. We developed an interview guide and data collection form guided by the Theory of Planned Behavior (TPB). Semi-structured interviews were recorded and conducted via phone and data was collected on structured collection forms and real time transcription. Direct content analysis was conducted guided by the TPB model and responses for AMI and stroke were compared.
We performed 15 semi-structured interviews. Eighty percent of participants were Black Americans; median age was 50; 73% were women. Participants reported concerns about coronavirus transmission in the ambulance and at the hospital, hospital capacity and ability to triage, and quality of care. Change in employment and childcare also impacted participants reported control over seeking emergent cardiovascular care. Based on these findings, our community and academic team co-created materials to address the community-identified barriers, which has reached over 8,600 users and engaged almost 600 users.
We found that community members' attitudes and perceived behavioral control to seek emergent cardiovascular care were impacted by the COVID-19 pandemic. Communityinformed, health behavior theory-based public health messaging that address these constructs may decrease prehospital delay.
Acute stroke and acute myocardial infarction (AMI) treatments are available and reduce disability and mortality; however, their effectiveness is highly time-sensitive. 1, 2 In the setting of the coronavirus disease 2019 (COVID-19) pandemic, early data revealed a decrease in presentation and an increase in pre-hospital delay among patients experiencing an acute stroke or AMI. 3, 4 The state of Michigan has been severely impacted by COVID-19, with over 152,000 confirmed cases and 7,000 deaths as of October 22, 2020. 5 We anticipate the number of cases and deaths to increase prior to and after publication of this manuscript. compared to their white counterparts, Black Americans experience greater stroke and AMI prehospital delay, and lower treatment rates. [7] [8] [9] [10] Thus, in the context of an ongoing communityengaged, health behavior theory-based, peer educator-led, community-wide stroke preparedness intervention, Stroke Ready, we sought to understand the community perception of seeking acute stroke and AMI care during the COVID-19 pandemic. Due to the urgent clinical and public health implications, we opted to use a rapid assessment approach in order to inform ongoing and future public health campaigns both locally and nationally.
We utilized a community-based participatory approach, where academic and community partners collaborate in project conceptualization, study design, participant recruitment, review of analyses, material development and results dissemination. 11 Given the urgency of the clinical and public health situation, we also incorporated a rapid assessment approach-a real-time, participatory, iterative, mixed-methods approach to collecting and analyzing data and designing culturally appropriate interventions for health and social problems. 12 The accumulating national and international quantitative data 4 confirmed our local community partners' impression of a decline in stroke presentations. Thus, we used a health behavior theory framework, the Theory of Planned Behavior, to understand the determinants of seeking emergency cardiovascular care during the COVID-19 pandemic which, in turn, informed public health material development. We performed semi-structured interviews from April 9 to May 7, 2020, during which the state of Michigan was under a 70-day -stay-at-home‖ order in response to the COVID-19 pandemic.
This study was approved by the University of Michigan IRB.
We recruited participants from the Flint community, a city with a population of 100,000; 40% of whom live in poverty; and 57% are Black American. Recruitment was done through word-of-mouth via phone and community partner social media, followed by participant snowball sampling.
We developed an interview guide based on the Theory of Planned Behavior to assess stroke and AMI perceptions during COVID-19 and to understand the determinants of behavioral intent to call 911 (Appendix A). 13 We queried participants on: 1) overall perception and knowledge of the coronavirus in order to contextualize our findings; 2) attitude toward stroke and AMI preparedness, subjective norms, and perceived behavioral control of stroke and AMI preparedness; and 3) information they thought would be helpful to address community specific barriers to seeking emergency care for stroke and AMI.
To honor social distancing guidelines, we conducted all interviews virtually via HIPAAapproved teleconferencing. All interviews were conducted by a primary interviewer. Data collection was conducted by two real-time data collectors on structured data collection forms and real time transcription (Appendix B). Interviews were recorded with the plan to review the recordings if needed to supplement or confirm the real time data collection. Two reviewers performed data reduction followed by directed content analysis using the Theory of Planned behavior as a template. 14 Any discrepancy was discussed at academic-community partner team meetings. Responses for AMI and stroke were qualitatively compared. We then worked with our community partners to develop health behavior theory-based and behavior change strategyinformed 15 materials that addressed the community specific barriers to accessing emergency cardiovascular care.
We reached thematic saturation after performing 15 semi-structured interviews with Flint community members. Eighty percent of participants were Black American; median age was 50;
73% were women and 47% reported some college or above. The interviews were a mean duration of 40 minutes. The majority of participants described a general understanding of COVID-19 transmission. Participants expressed concerns on risks for infection and death, both for them and those they knew, the lack of vaccine, and the general uncertainty around COVID-19.
Guided by the Theory of Planned Behavior, we identified themes within each of the theoretical constructs (Table 1) .
The majority of participants stated they would call 911 for both stroke and heart attack symptoms, with severe or worsening symptoms being a motivating factor for response in both scenarios. However, participants reported greater hesitation to perform these immediate actions than prior to the pandemic. No differences in the intention to call 911 for acute stroke versus AMI symptoms were noted, yet differences in perceived risks and outcomes were different for most participants. Many felt there was a greater risk of dying with an AMI than with a stroke.
Participants attitude toward calling 911 for a cardiovascular emergency was impacted by the COVID-19 pandemic. Participants reported concerns about the risk of contracting COVID-19 in the ambulance. Additional identified barriers to calling for an ambulance included cost as well as the perception of being able to get to the hospital quicker by driving oneself rather than taking an ambulance.
Participants also reported concerns regarding the hospital's ability to prevent the spread of COVID-19. Many were unsure of their risk of infection if they were to go to the hospital with a stroke or heart attack. In addition, participants were also concerned about hospital capacity and triage capability noting longer wait times and receiving lower quality of care due to competing priorities of caring for COVID-19 patients.
Before and during the COVID-19 pandemic, participants' behavioral intent was influenced by the belief that their family would want them to call 911 or go to the hospital if they were having symptoms of a stroke or heart attack. However, there would have been less hesitation pre-
Participants who reported they would call 911 for themselves would also call 911 if they witnessed stroke symptoms. However, even those who would not call 911 immediately for themselves reported that they would eventually call 911 or tell someone to call 911 for someone experiencing stroke symptoms. Participants also noted that due to present day conditions, they may try to keep their distance and make sure they are covered appropriately in order to prevent themselves from contracting COVID-19, whereas previously there would be no hesitation in approaching someone experiencing stroke symptoms.
Participant perceptions of their ability to seek emergent care during the COVID-19 pandemic was informed by individual and system level factors. These responses centered around their perceived power over factors impacting emergency response such as fear of getting or dying from COVID-19 and not being able to have visitors at the hospital. Several participants also mentioned that they were not confident in their ability to recognize symptoms and discussed the potential for incorrect symptom casual attribution, such as having symptoms of indigestion and mistakenly identifying it as a heart attack.
All participants whose employment status was negatively impacted by COVID-19 (n=4, 27%) were concerned about their finances and reported this as a factor impacting their decision to go to the hospital. Additionally, two of the participants reported they had children and mentioned childcare was also a factor impacting their decision to go to the hospital to seek emergency care, since it would require them to find someone to care for their children.
Participants' clinical-based recommendations included "calling 911 is the #1 thing to start with" and emphasis on risk of not seeking immediate medical care, "long-term effects of having a stroke or heart attack if you don't get treated." In addition, participants recommended promotion of the hospitals' sanitary conditions to decrease fear of ambulance and hospital-based COVID-19 transmission. Many participants also noted the importance of consistent messaging to combat misleading information of COVID-19 transmission; "leaders are not giving the right information; you wonder what the right information is." Suggested mediums for messaging included social media for the working-aged, TV commercials and computerized -robocalls‖ for older adults, and flyers, billboards and word-of-mouth for the general public.
Based on these findings, our community and academic team co-created materials that addressed the community-identified barriers. Our Stroke Ready COVID-19 response materials primarily focused on attitude toward seeking emergent care during the COVID-19 outbreak through behavior change techniques of knowledge, self-belief, and goals and planning. 15 Materials posted on our social media sites included fact sheets, photo infographics, informational videos and links to additional resources, which highlights: 1) stroke is always an emergency, even during the COVID-19 pandemic ( Figure 1) ; 2) -even if‖ messaging that address the community's specific concerns (Figure 2 ).
We also created an original COVID-19 stroke preparedness song, with the following lyrics: Michigan.gov on ways to remain healthy and safe to our Stroke Ready social media platforms.
Additionally, we shared information on resources our community partners identified, such as food delivery for homebound older adults and water distribution sites that were continuing operations. From May to July, while we continued to share COVID-19 related information and resources, we also incorporated our Stroke Ready COVID-19 response materials. Our messaging remained consistent-that stroke is an emergency and not to delay seeking care even during the pandemic. On May 20, we launched our COVID-19 stroke preparedness song and music video, which had reached 1,200 users by November 1, 2020.
In this rapid assessment of community determinants of intent to access emergent care for stroke and AMI in the setting of the COVID-19 pandemic, we found that participants intend to seek emergent care, particularly for severe symptoms. However, compared to prior to the pandemic, many participants reported greater hesitation in calling 911. This greater hesitation was driven predominately by participants' attitudes and perceived behavioral control over seeking emergent cardiovascular care. There was less of an impact due to subjective norms, although participants noted they would take greater precautions when assessing someone who may have had a stroke.
We found an unfavorable attitude towards seeking emergent cardiovascular care via the ambulance and at the hospital. Participants reported concerns about coronavirus transmission at the hospital for both stroke and AMI, hospital capacity and ability to triage, and quality of care.
Participants were concerned that the care of patients with COVID-19 would supersede that of stroke and AMI.
The social and economic impacts of the COVID-19 pandemic were noted to impact perceptions of behavioral control. Participants noted concerns about hospital policies such as, ‗no visitors' as impacting their control over the situation. For participants with young children, the ability to secure childcare, especially now that schools and daycare are not in session, would be a factor in their decision to seek emergent care. Additionally, working-age participants who experienced furloughs or reduced work hours expressed financial concerns, such as the cost of ambulances. Addressing these barriers will likely require policy level initiatives at the hospital, local, state and national level.
Utilizing both a community based participatory research and rapid assessment approach enabled us to identify relatively early in the COVID-19 pandemic that the public was not seeking emergency cardiovascular care, understand the community's determinants, and create timely community-informed, health behavior theory-based, behavior change strategy materials. The rapid assessment approach provided a framework to integrate national quantitative with local qualitative data and facilitated qualitative data analysis. In addition, working in partnership with the community brought to our attention the possibility of community delays. Our communityacademic partnership also facilitated participant recruitment during stay-at-home orders and the development and dissemination of community-relevant materials.
During the height of the COVID-19 outbreak in Michigan and under State imposed stay-at-home orders, in partnership with the Flint community, we co-created community informed Stroke Ready COVID-19 response materials. Implementation measures include reach for which over 8,600 people saw the materials and engagement for which almost 600 people shared or liked our Stroke Ready COVID-19 response materials. However, the ultimate question is whether the Stroke Ready COVID-19 response materials decreased pre-hospital delay and increased acute stroke treatments. At this point, we lack a definitive answer. This question will be informed by the final analysis of Stroke Ready where the acute stroke treatment rates of Flint will be compared with demographically matched Michigan communities which will occur in the Summer/Fall 2021.
The following limitations warrant attention. Despite cognizance of the challenges of recruiting men, men were still under-represented in our study. Additional strategies such as intensifying community partners' efforts to recruit men and earlier focus on encouraging participants to identify men who may participate may provide more equitable gender-based recruitment. Our findings are limited to one predominately Black American community and may not represent other communities. Finally, interviews were conducted over the phone due to COVID-19 precautions.
Our findings reveal that community members' attitude and perceived behavioral control to seek emergent cardiovascular care were impacted by the COVID-19 pandemic. Communityinformed, health behavior theory based public health messaging that address these barriers through behavior change techniques may decrease prehospital delay and minimize missed opportunity to deliver time-sensitive treatments. 