ARTICLE HISTORY Received 13 May 2020 Accepted 22 July 2020

African Americans and COVID-19: Beliefs, behaviors and vulnerability to
infection
Elyria Kempa, Gregory N. Pricea, Nicole R. Fullera and Edna Faye Kempb

aCollege of Administration, University of New Orleans, New Orleans, LA, USA; bKemp Dentistry, Indianapolis, IN, USA

ABSTRACT
In the United States, during the early outbreak of the coronavirus (COVID-19) pandemic, African
Americans experienced disproportionately high rates of infection and mortality relative to their
share of the United States population. New Orleans, Louisiana was one of the places most
heavily affected by the coronavirus during its early outbreak. The study that follows explores
the attitudes of African Americans in New Orleans toward the virus, social and normative
conditions which affected individual behaviors, as well as access to healthcare services and
COVID-19 testing. In part one of the study, qualitative responses were collected from a
sample of African Americans in the New Orleans area to garner perspective about their
attitudes and behaviors related to the coronavirus outbreak. Part two of the study builds on
findings from Study 1 with parameter estimates from a Logit regression to examine how
social, economic and physical conditions determine vulnerability to COVID-19 infection
among African Americans. Implications for how healthcare organizations can address the
needs of vulnerable populations during a health-related crisis are discussed.

ARTICLE HISTORY
Received 13 May 2020
Accepted 22 July 2020

KEYWORDS
Health equity; Social
determinants of health;
African Americans; COVID-19;
Theory of planned behavior

In 2020, the World Health Organization declared the
novel coronavirus, or COVID-19, a global health emer-
gency as it spread ferociously across the globe [1]. The
first confirmed case of the virus appeared in January
2020 in the United States [2]. Within months, the
virus sickened many and resulted in thousands of
deaths.

As more data emerges regarding the impact of
COVID-19 in the United States, it has become evident
that the virus has affected racial and ethnic minorities
at an alarmingly high rate. Specifically, African Amer-
icans have experienced disproportionately higher rates
of infection and mortality than their representative
share of the United States population [3,4]. In early
May 2020, African Americans accounted for approxi-
mately 34% of total COVID-19 deaths in states where
they represent only about 13% of the state’s population
[3]. Some states reported even more egregious dispar-
ities. For example, in Louisiana blacks accounted for
70% of the deaths from COVID-19, but only 33% of
the population. Similarly, in Alabama, blacks
accounted for 44% of COVID-19 deaths, yet only
make up 26% of the state’s population [5].

Some officials have linked the disproportionate
numbers regarding the effect of the virus on African
Americans to individual behavior (i.e. including practi-
cing unhealthy behaviors and suffering from comor-
bidities which make the coronavirus more deadly)
[6]. However, the situation is likely more nuanced.
African Americans are more likely to work in service

sector jobs and were deemed ‘essential workers’ during
the coronavirus outbreak [7]. In larger urban areas,
they are also are more likely to use public transit – all
which place them in closer contact to others and
make them more susceptible to the virus [6].

This research examines the attitudes, behaviors as
well as social and physical conditions of African Amer-
icans in New Orleans, Louisiana, and their perceived
vulnerability to COVID-19 infection. New Orleans
was one of the places most heavily affected by the cor-
onavirus during its early outbreak. In March 2020, New
Orleans experienced one of the fastest growth rates in
new cases of COVID-19 in the world [7]. By early
May, the city reported over 450 deaths from the
virus, with African Americans making up over 75%
of the deaths [8]. The study that follows explores the
attitudes of African Americans in New Orleans toward
the virus, social and normative conditions which
affected individual behaviors, as well as access to
healthcare services and COVID-19 testing. The study
applies two distinct methodological techniques to pro-
vide insight. In part one of the study, qualitative
responses were collected from a sample of African
Americans in the New Orleans area to garner perspec-
tive about their attitudes and behaviors related to the
coronavirus outbreak. Part two of the study builds on
findings from Study 1 by examining how social, econ-
omic and physical conditions determine vulnerability
to virus infection and COVID-19 testing participation.
Implications for how healthcare organizations can

© 2020 Informa UK Limited, trading as Taylor & Francis Group

CONTACT Elyria Kemp [email protected] College of Administration, University of New Orleans, 2000 Lakeshore Drive, New Orleans, LA
70148, USA

INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT
2020, VOL. 13, NO. 4, 303–311
https://doi.org/10.1080/20479700.2020.1801161

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address the needs of vulnerable populations during a
health-related crisis are discussed.

Conceptual background

Individual behavior – attitudes, beliefs and
norms

During the early months of the coronavirus outbreak, a
significant part of containing the spread of the virus in
the United States involved following the guidelines
proposed by the Centers for Disease Control and Pre-
vention (CDC) and the White House Coronavirus
Taskforce. During March 2020, these guidelines
included avoiding social gatherings of 10 or more
people; social distancing by remaining at least 6 feet
from others in public spaces; using drive-thru, pick-
up or delivery options at restaurants and grocery stores;
avoiding discretionary travel, not visiting nursing
homes or long-term care facilities unless providing
critical assistance; and finally, practicing good hygiene,
such washing hands, avoiding touching the face, sneez-
ing or coughing on a tissue or into the elbow, and dis-
infecting surfaces (note: wearing face masks were not
recommended until April 2020) [2,9]. Government
and private entities disseminated messaging in various
media encouraging the practice of these behaviors to
help mitigate the spread of the virus.

According to the psychology literature, one’s atti-
tudes and beliefs are linked to whether one will practice
a certain behavior. For example, in the theory of
planned behavior (TPB) there are three determinants
of behavioral intention – attitude toward the behavior,
subjective norms, and perceived behavioral control
[10]. Attitudes toward the behavior address the extent
to which a person has a favorable or unfavorable
appraisal of the behavior in question. Subjective
norms are social variables that reflect the perceived
social pressure to perform or not to perform the behav-
ior. Finally, perceived behavioral control addresses the
perceived ease or difficulty in performing the behavior
and captures past experiences as well as anticipated
obstacles. The more favorable the attitude and subjec-
tive norms regarding the behavior, and the greater the
perceived behavioral control, the stronger an individ-
ual’s intention to perform the behavior in question
[10,11].

To a considerable degree, individual behavior in
adhering to the guidelines and directives of govern-
ment officials and health experts would impact the pro-
liferation of the coronavirus and the likelihood of being
infected with the virus. Thus, intentions to practice rec-
ommended behaviors to contain the virus might be
determined by considering the attitudes of individuals
about the severity of the virus and the need to control
the spread as well as social and normative pressures to
perform or not perform the recommended behaviors.

In addition, examining the perceived difficulty individ-
uals had in not practicing recommended behaviors (e.g.
having to leave home for work or to care for a loved
one) might also play a factor.

Access to health services

In addition to considering individual behavior, both
access to healthcare and the quality of health services
can influence health. Lack of access to quality health
services can affect an individual’s health status. For
example, due to limited availability to healthcare, an
individual may be less likely to participate in preventive
care as well as delay medical treatment [12].

Public health practitioners and policy makers are
beginning to consider the broader determinants of
health as part of a more inclusive approach to improv-
ing health [13]. For example, social determinants of
health are social factors and physical conditions in
the environment which impact health status and sub-
jective wellbeing. Social determinants of health are
also affected by the availability of resources to meet
daily needs, such as educational and job opportunities,
living wages, healthy foods, discrimination, social sup-
port, exposure to mass media and emerging technol-
ogies, socioeconomic conditions and transportation
options [14–16]. Addressing social determinants of
health is essential to eradicating systematic disparities
in health and achieving health equity. Health equity
is when everyone has the opportunity to realize their
full health potential, barring the inability to do so
because of social position or other socially determined
circumstances [17].

With respect to COVID-19, individual behavior,
which included adhering to the guidelines delineated
by the CDC and the White House Coronavirus Task-
force, played a central role in reducing infection
rates. As literature from the behavioral sciences
suggests, such behavior may be predicated on an indi-
vidual’s attitudes toward the behavior, social pressures,
and elements within the individual’s control to perform
the behavior [10]. In addition, social, economic and
physical conditions as they relate to access to quality
healthcare can play a role in virus detection, treatment
as well as mortality rates from the virus. The study
which follows first examines the attitudes and beha-
viors of African Americans in New Orleans as they
relate to COVID-19. It then explores how social, econ-
omic and physical conditions are related to access to
healthcare services and COVID-19 testing.

Study part I: Beliefs and behaviors

Methodology

The research participants in this study were African
Americans who reside in New Orleans. African

304 E. KEMP ET AL.

Americans comprise about 59% of the population in
New Orleans [18]. We enlisted Qualtrics, a professional
research firm for our data collection efforts. Enforced
quota constraints were applied in our sampling with
the goal of attaining a research panel demographically
representative of African Americans in the city of New
Orleans. Following appropriate ethical research
approval (from the Institutional Review Board),
responses were collected online from a panel consisting
of 104 participants from 11–22 April 2020. Sixty-seven
percent of participants were female and thirty-three
percent were male. The mean age was 40 and 35% of
participants self-reported as ‘essential workers’ during
the coronavirus outbreak (see Table 1). Participants
were asked questions concerning their attitude toward
the virus, normative and economic conditions which
may have affected their ability to comply with direc-
tives of government officials, as well as their percep-
tions regarding healthcare access.

Our data analysis enlisted a form of content
analysis where themes were identified using a cod-
ing process. The goal of this approach was to recog-
nize themes based on the experiences and
observations of participants [19]. We independently
performed a comprehensive assessment of the data
and developed themes. Next, using an iterative,
back-and-forth reading process [19,20] we achieved
general consensus on themes which repeatedly
appeared across participants’ responses. The follow-
ing are emergent themes which were consistent with
the responses from the participants. Participants
were assigned aliases.

Results: Thematic findings

Attitudes toward the virus and susceptibility
Attitudes are an organization of beliefs, feelings, and
behavioral tendencies towards significant objects,
groups, events or symbols [21]. Knowing a person’s
attitude helps predict their behavior. Many of the
respondents in our research acknowledged the serious-
ness of the coronavirus. As a result, they expressed that
they were making efforts to safeguard themselves from
possible infection. This sentiment was echoed in the
comments of many participants.

“COVID is a serious virus. I’m hoping that I don’t
catch it … but I am taking all the precautions to
protect myself.” Mary, 61, Educator

“Since I am at high risk, I really practice social distancing
and avoid all risky situations. As a private nurs,e I
only have one patient for the patient’s safety as well
as mine. My siblings also take care with associations
and practice hand safety.” Jackie, 66, Nurse

Unfortunately, some participants had lost loved
ones to COVID-19. They also expressed how the health
crisis was taking a toll on them emotionally.

“I have had at least two emotional breakdowns. It
takes a lot to remove the focus off the crisis and refo-
cus on other things.” Marguerite, 60, PBX Operator

However, younger respondents were more optimistic
about their vitality, and felt less susceptible to the virus.

“My family and I are very healthy. We have a very
[strong] immune system. So we aren’t very likely
to catch COVID-19.” Lakeisha, 21, Cashier

Attitude toward government leaders and health
experts
People expect their leaders to be consistent and model
what they advise for their constituents [22]. During the
coronavirus outbreak, trust was an important factor as
people looked to their leaders for knowledge and infor-
mation. Trust embodies a dynamic, relational link
between people and is meaningful in situations in
which one party is at risk or vulnerable [23]. Many
respondents had mixed feelings about leadership, indi-
cating some confidence in state and local political
officials, while expressing distrust in federal leadership.

“I don’t trust anyone implicitly, especially politicians! I
trust the mayor to give as much info as she can give
without causing a panic. I see how she is trying to
do as much as she can. I trust the governor as
much as I can. I see where he is trying … .As far
as federal leaders, I don’t trust them at all. Most
of what they say and do is self-serving …” Evelyn,
70, Retired Administrative Assistant

Table 1. Summary of respondents’ demographics.
Count Proportion Average

Observations 102
Male 33 32%
Age 40
18–39 53 52%
40–59 25 25%
≥60 23 23%

Single 64 63%
Education
Some high school 6 6%
High school diploma 21 21%
Some college 24 24%
College degree 27 26%
Post-grad degree 24 24%

Income $36k–$50k
≤ $25k 41 40%
$26k- $50k 24 24%
$51k- $75k 17 17%
$76k – $150k 14 14%
≥ $151k 5 5%

Essential worker 36 35%
Unemployed 21 21%
Top Industries
Arts & Entertainment 12 12%
Education 10 10%
Restaurants 8 8%
Healthcare 8 8%
Social Services 3 3%

INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 305

“It’s hard to trust … I admire the job that our Mayor is
doing … Not hearing too much from the Gover-
nor. The president is trying, but he lies so much
…” John, 48, Longshoremen

Participants appeared to have more trust in health
experts and expressed sympathy and gratitude towards
front-line healthcare workers.

“I do trust the health officials. They are working under
harsh situations with limited supplies to help and
heal others. They are putting their own life and
their families in danger of the virus. They want
this to end much more than we do. I trust they
are trying to find a cure to protect us in the future.”
Sheila, 52, Educator

However, participants did exhibit some frustration
with the information they were receiving from health
officials. They acknowledged that there had been a
fair amount of equivocation regarding best practices
to combat the virus. In some ways, a modicum of dis-
trust existed with the way some things had been
handled during the nascent stages of the virus out-
break. Nonetheless, many conceded to the reality that
circumstances were novel, and that health experts
were learning new things daily.

“I know they are learning more about it every day given
that this disease hasn’t been seen before, but they
need to get their facts straight. They’re constantly
giving out information that contradicts infor-
mation they gave out previously. We’ve seen time
and time again with any infectious disease that
masks have been used to contain the spread, but
because they can’t afford to have enough mass pro-
duced for every single person they are telling us
that we don’t need them. They’ve let weeks and
weeks go by without it being required.” Carrie,
25, Self-Employed

“Most of the information [from healthcare experts] I
trust, but who knows what to believe.” Tammy, 21

Because attitudes provide meaning and knowledge,
understanding attitudes can predict behavior. Many
of the participants in this research recognized the ser-
iousness of the coronavirus. However, there were
some participants, primarily younger adults (ages 35
and under), who were not convinced about the ferocity
of the virus. Furthermore, leadership during crisis
moments plays an important role. During uncertain
times, informed and trustworthy leadership is para-
mount. Participants had a measure of distrust and
cynicism toward federal political leaders. However,
many trusted the leadership at the local and state
level. They also looked to health experts for advice
while acknowledging that the situation was fluid.

Social norms and social distancing
Subjective or social norms are variables which refer to
the belief that an important person or group of people
will approve and support a certain behavior [10,24].
Subjective norms can be measured and accessed from
the perspective of expectations set by referent groups
such as family, relatives, and friends, in terms of
whether an individual should or should not engage in
a behavior. Subjective norms may also include descrip-
tive norms, which refer to actual activities and beha-
viors others are undertaking [24]. In the case of
descriptive norms, individuals may not only be con-
cerned with what others think, but also with how
others behave.

Norms within New Orleans emphasize culture, tra-
dition and celebration. The city is known for the axiom
‘laissez les bons temps rouler,’ meaning ‘let the good
times roll.’ People in New Orleans are very ‘social.’ In
fact, the popular press has ranked New Orleans as
one of the friendliest cities in the United States
[25,26]. Given these social norms, maintaining physical
distance was challenging for some.

“I know for a fact that some are not social distancing. I
have spoken to friends who have been attending par-
ties, baby showers, crawfish boils, card games–all
with multiple people. They totally believe that the
virus is like the flu and they will recover if they get
it. It’s like they don’t know or care about the way
this virus affects us all.” Nancy, 47, Bank teller

“When I was in the store yesterday, people were walking
around like nothing is going on. A few of us had on
masks and long sleeves and so forth. But a large
group of people were out with no protection, with
kids running around and no protection, and not
adhering to any social distancing guidelines …”
Evelyn, 70, Retired Administrative Assistant

“People can say that they’re doing it, but actually aren’t
… like my neighbors playing basketball in the
street–between 8–12 guys … unbelievable…”
Diane, 62, Enforcement

One young adult participant was very candid about
his lack of effort to social distance.

“Not really [not social distancing],but it’s other people
opinion,” Carl, 21

Although several of the participants noticed that
other people were not social distancing, the majority
indicated that physical distancing had become the
‘new norm’ among family and friends.

“I call, email and text my friends and colleagues. My
children and grandchildren call me and text me.
They have not come over since March 13, 2020.”
Geraldine, 63, Educator

306 E. KEMP ET AL.

“The only thing I do is to go for a walk/jog, and I have
been to my students’ homes to leave a message on
their front porches and deliver Easter treats.”
Sheila, 52, Educator

Control limits and disparities
Perceived behavioral control addresses the perceived
ease or difficulty in performing a behavior and captures
anticipated obstacles. For some of the participants in
this research, self-isolation was infeasible. Specifically,
Americans were advised to work from home during
the early stages of the coronavirus outbreak; however,
according to the Economic Policy Institute, only 19.7
of African American have jobs which allow them to
work from home [27]. In our study, 35% s of partici-
pants self-reported as ‘essential workers.’ Subsequently,
some were working away from home during the
outbreak:

“My job is considered essential, but … precautions are
being taken.” John, 48, Longshoremen

Moreover, and unfortunately, income and race play
a role in determining who uses New Orleans’s public
transit systems to travel to work. In New Orleans,
91% of White/Caucasian households have at least one
car, compared with just 74% of African American
households [28]. Reliance on public transit further
decreases the likelihood of social distancing.

During the outbreak, older adults were advised to
self-isolate [29]. This included grandparents isolating
themselves from grandchildren. In New Orleans,
12.2%of African Americans 60 years and older live in
multigenerational households, compared to 3.8% of
white elders [30]. Such living conditions, where grand-
parents live with their grandchildren, might make them
more susceptible to COVID-19. One of our partici-
pants addressed this reality.

“Since I am elderly and in only fair health, I believe that
I could get the virus. I worry about my kids and
grandkids since I do have contact (at home) with
them.” Linda, Retired, 62

Health services. Given African Americans’ dispropor-
tionate COVID-19 infection and mortality rates, par-
ticipants in this research were asked about their
personal access to health care as well as their percep-
tion of the quality of healthcare they receive. In 2016,
Louisiana accepted Medicaid expansion (created in
the Patient Responsibility and Affordable Care Act
passed by the U.S. Congress in 2010). Louisiana’s Med-
icaid expansion program provided health insurance for
non-elderly adults with income less than 138% of the
Federal Poverty Level. As a result of the expansion pro-
gram, the uninsured rate in Louisiana fell by half –

from 22.7% to 11.4% – from 2015 to 2017 [31,32].
While Medicaid expansion was instrumental in extend-
ing access to healthcare, participants still questioned
the quality of care and health equity for African
Americans.

– “I am aware that some do not [receive the same level
of care as others]. I have private insurance. I
worked in health care. I see the bias shown to
the poor, homeless, mentally challenged, those
with addictions, overweight …” Harriet, 48,
Retired Healthcare Worker

– You get turned away when you can’t pay or you’re
sent to lower quality hospitals. Iris,34, Bartender

Some specifically felt that health inequities exist.

“I’m Black and people seem to not take my words as
seriously as others–even when I’m suffering.” Samuel,
29, Hospitality

“I do believe that black women have to be aggressive
about their healthcare. I have had to make sure I
bring questions with me to all my doctor visits.
Some important information is sometimes left out of
the visit. Seemingly, if I don’t ask, the doctor won’t
tell me all of the information I need.” Kay, 55,
Administrator

In summary, behavior may be predicated on an indi-
vidual’s attitude toward a behavior, social pressures,
and elements within the individual’s control to perform
the behavior [10]. The first part of this study examined
the attitudes and behaviors of African Americans in
New Orleans during the early outbreak of the corona-
virus. Many of the participants recognized the serious-
ness of the coronavirus. However, there were some
participants, primarily younger adults (ages 35 and
under), who were not compelled by the seriousness
of the virus. Furthermore, during the early stages of
the coronavirus outbreak, trust from leadership was
an important factor as people looked to their leaders
to shape attitudes about the virus. Responses from par-
ticipants reveal a measure of distrust and cynicism
toward federal political leaders. However, many trusted
local leadership as well as the health experts.

The opinions and actions of others, or subjective
norms, also affect the behavior of individuals [10]. Par-
ticipants recounted instances where they noticed others
who were not physically distancing. Nonetheless, the
majority of the participants in this research indicated
that they were taking measures to physically distance.
The ‘norm’ had been set among family and friends to
engage in this behavior.

There were some participants in this research who
discussed how their circumstances did not permit
them to completely self-isolate. For example, some
respondents indicated that living in mutigenerational
housing or having to continue to go to their ‘essential’

INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 307

jobs exposed them to more people. Finally, the high
rate of African American mortality from COVID-19
was concerning for participants. At a macro level, par-
ticipants offered considerable discussion regarding the
state of healthcare for African Americans and ques-
tioned whether true health equity exists in commu-
nities. In the second part of our study, we examine
specific factors influencing access to healthcare and
health equity for African Americans in New Orleans
as it relates to COVID-19 testing.

Part II: COVID-19 testing in New Orleans

Methodology

In response to evidence that COVID-19 infections and
deaths have impacted African Americans disproportio-
nately [4,33,34], our survey data captured information
on individual characteristics that may be possible dri-
vers of racial disparities in COVID-19 infections. We
measured these individual characteristics to first deter-
mine, via a rigorous least absolute shrinkage and selec-
tion operator, or LASSO [35], the best predictors of
taking a COVID-19 test among survey respondents.
LASSO is a machine-learning algorithm to identify
regressors, via induction, that best explain/predict an
outcome – regressand – of interest [36].

Results

Table 2 reports the results of the predictive covariate
selection from the rigorous LASSO among all the
quantitative covariates in the respondent survey. We
used the RLASSO procedure in Stata 15 [37]. In gen-
eral, RLASSO selects regressors that minimize the
mean squared prediction error, subject to a penalty

on the absolute size of coefficient estimates. The pre-
dicted outcome of interest is a binary variable indicat-
ing whether a survey respondent was tested for
COVID-19. Among the quantitative covariates, the
RLASSO selected the respondent’s age, whether he/
she is an essential worker, and the respondent’s self-
reported health status as predictors.

Given the selected predictors, Table 3 reports par-
ameter estimates across five Logit specifications to
determine how these predictors matter for the prob-
ability of an individual having had a COVID-19 test.
We report Pseudo-R2 and the xs statistic for the joint
significance of all the parameters as goodness-of-fit
measures. To inform practical versus statistical signifi-
cance, we report parameters as an odds ratio, which
indicates the quantitative impact a regressor has on
the outcome of interest. An odds ratio less(greater)
than unity indicates that having a particular

Table 2. Rigorous Lasso variable selection.
Covariate Definition Selected

Age Age of respondent in years Yes
College Binary variable equal to No

unity if respondent has
a baccalaureate degree

Essential Worker Binary variable equal to Yes
if respondent is an essential worker

Health Respondent’s position in Yes
health quintile distributiona

Household Size Number of people in No
in respondent’s household

Male Binary variable equal to No
if respondent is a Male

Married Binary variable equal to No
if respondent is Married

Median Income Median Income in No
Respondent’s zip codeb

Notes: aDerived from respondent’s self-reported 1–10 health-rating, with
10 being the highest-rated measure of health. For each respondent,
the measure was converted to a position in a distribution of quintiles.

bSource: https://www.incomebyzipcode.com/louisiana/70119.

Table 3. Logit odds ratio parameter estimates: COVID-19 …