Introduction

The novel coronavirus, COVID-19, has created a global health crisis leaving healthcare providers and public health professionals under-prepared and communities under-resourced. After the first confirmed case of COVID-19 was reported in the state of Michigan, on March 10, 2020, cases have increased rapidly [1, 2]. In particular, Wayne County has reported the highest number of confirmed cases within Michigan since the start of the pandemic and continues to increase into the fourth wave [3]. The city of Dearborn has been home to the highest concentration of Arabs outside of the Middle East for decades and has created a thriving cultural community [4]. The MENA American community is considered to be both an understudied and underreported population that lacks state level epidemiological data due to its lack of recognition as a formal federal racial category [5]. With the scarce literature on this community’s health status, health needs, and health behaviors significant disparities persist, and health outcomes continue to deteriorate [6]. The combination of long withstanding health inequities and the current pandemic has left communities of color’s health outcomes and health seeking behaviors dramatically altered [7, 8]. The importance of sharing accurate information related to COVID-19 with communities can limit the spread of COVID-19, enhance public awareness, and improve the efficacy of future interventions within this community [9].

There is limited information available about community knowledge and attitudes toward COVID-19 and how health needs and health-seeking behaviors have changed. The MENA American community represent a niche population for assessing these variables due to their lack of existing organizational data, scarce medical literature assessing health-seeking behaviors, and diverse sociocultural background. This study is the first of its kind in assessing the impact of COVID-19 on health knowledge, needs, attitudes, and health-seeking behaviors within the MENA American community using a Community Based Participatory Research approach (CBPR).

Theoretical Framework

To optimize the relevance and translatability of our findings, the study was approached using a Community Based Participatory Research design (CBPR). To expand the scientific knowledge and literature on this community, the study actively worked with community members to collaboratively agree on decisions throughout every step of the research process [10]. The co-investigator and research assistants all identified as MENA Americans, spoke Arabic and are residents of the city of Dearborn. Our research team is comprised of community members of our target population that are able to understand the intricacies of MENA Americans. Since the study’s inception, our team was able to collaborate with predominantly MENA American non-profit organizations, local schools, medical clinics, and businesses to study our own community.

In addition to CBPR, the study also applied cultural congruence to ensure that our study materials were culturally relevant and congruent with the community surveyed. It has been shown that cultural congruence of a research team allows for greater communication, predictability and trust among respondents [11, 12]. This study did not test these constructs; however, cultural congruence conceptually allowed the research team to ask questions that may have been sensitive or personal in nature in relation to the impacts of COVID-19 has had physically, emotionally, and economically on respondents. The study team’s cultural congruence encouraged participants to take part in the survey once research aims and community partners were presented.

Methods

After the study was determined to be exempt by the Institutional Review Board (IRBMED) at the University of Michigan Medical School, an anonymous, digital bilingual (English and Arabic) survey was created using a generalized survey service known as Qualtrics. The survey included 41 questions on demographics, COVID-19, and health-seeking behaviors. The demographics of respondents was determined through 15 questions asking about age, gender, race/ethnicity, Arab country of origin, county location, immigration status, education and income levels. Afterwards, (n = 9) questions were adapted from Geldsetzer to rapidly assess community perceptions of infectious disease outbreaks [13]. To assess knowledge and attitudes a multi-scale item question was adapted from Zhong et al. to evaluate mask-wearing habits [14]. Through Goodman-Casanova et al. (n = 4) questions were used from to assess comorbidities and care engagement to determine changes in healthcare services due to the shift to telehealth [15]. To understand the psychological needs and impact of COVID-19 on this community, (n = 4) questions were adapted from Wang et al.’s study to assess factors associated with the immediate psychological response [16]. The remaining questions (n = 8) were created based on published health belief studies assessing the Arab American community [12].

The survey was distributed to individuals between the ages of 18–65 years, with a focus on MENA American identifying individuals within Wayne County, Michigan. Participants were recruited online through groups affiliated with University of Michigan, Wayne State University, and University of Michigan Dearborn. Research assistants also recruited participants using influential social media pages based on popularity and following from MENA American identifying individuals.

Data Analysis

Statistical analysis was conducted using descriptive statistics, ANOVA, Two Samples Independent T-Tests and Chi Squared.

Results

Data was collected from June 14 to July 24, 2020, with a total number of surveys collected as 298. Table 1 characterizes the demographics of the respondents. The average age of respondents was 25.81 ± 8 years old. An overwhelming majority of participants, 75% (N = 224/298) identified as female. Most, 80% (N = 247/298) participants identified as Middle Eastern/North African and a significant portion, 56% (N = 149/265) identified as Lebanese. Additionally, 84% (N = 249/295) identified as Muslim and about 49% (N = 143/292) reported being moderately religious. The vast majority of participants, 82% (N = 231/281) resided in Wayne County, MI. Most respondents, 74% (N = 221/298) identified as being born in the US, however, about 20% (59/298) identified as being foreign-born. Additionally, 50% (N = 142/280) participants identified as being completing at least an Associate’s Degree. Overall, 56% (N = 156/277) of participants reported their household income as greater than $50,000 annually. In terms of employment, 36% (N = 101/279) reported being employed while about 10% (29/279) of respondents reported COVID related changes to their employment hours.

Table 1 Participant demographics

Table 2 characterizes the participants’ attitudes towards COVID-19 and social distancing practices. Overall, 76% (N = 181/238) of participants felt that their community had taken some precautions and was adhering to most self-quarantine rules, as opposed to the 16% (39/238) that expressed their community has taken all precautions and adhered to all guidelines. Additionally, this survey was distributed 1 week after the month of Ramadan that is observed by many Muslims within the MENA community. Overall, 60% (N = 145/239) of participants reported that they did not have any difficulty adhering to COVID-19 precautions and self-quarantine rules during Ramadan, while only 36% (87/238) of participants reported not having difficulties in maintaining COVID-19 precautions and self-quarantine rules after Ramadan. When prompting participants to select the places in which they wear masks, participants primarily selected grocery stores 38%, work 24%, and parks 12%. Overall, a majority of participants, 83% (N = 178/214) reported that at the time of the State of Michigan Stay-at Home order in June-July that they would remain practicing social distancing.

Table 2 Attitudes and social distancing

Table 3 characterizes participants’ COVID-19 related knowledge and perceptions. Participants estimated that on average the Coronavirus could be transmitted around 5.5 ± 3.5 feet away. When prompted to select what primary sources of COVID-19 information respondents primarily rely on to remain updated about the pandemic the social media accounts of healthcare professionals 23.93% (134/560) and the Center for Disease Control 23.04% (129/560) were the most frequently selected and were a close tie. Additionally, around 8% (44/560) of respondents opted to not be updated about the pandemic. About 27% (N = 69/255) of participants estimated that by the end of 2020 there would be around 251,000 to 500,000 COVID-19 related deaths. When prompted, 35% (N = 89/254) of participants estimated the portion of the US population to be infected with COVID-19 at the time of the survey as 20–49%. Additionally, when asked to estimate the same for MENA Americans, there was an exact tie with 23.58% (N = 54/254) estimating under 10% and the other 23.58% of respondents estimating around 20–49% of the MENA American population.

Table 3 COVID-19 knowledge & perceptions

Table 4 characterizes participants’ current health status and changes in health behaviors. Most participants, 58% (N = 138/238), reported that they did not to receive COVID-19 testing, 19% (N = 45/238) of participants reported that they received testing and tested negative, while 8% (N = 20/238) reported that they had not been able to receive testing. Overall, 67% (N = 160/239) of participants reported that they knew someone who tested positive for COVID-19 and on average participants knew about 5 (5.26 ± 4.68) individuals who tested positive for COVID-19. In terms of primary healthcare provider appointments, 41% (N = 89/214) participants reported that they themselves canceled their appointment out of fear or their physician canceled the appointment out of precaution. Additionally, 34% (74/214) of participants had their appointments with physician specialists were canceled or postponed for similar reasons. Among respondents or members in their household, the primary medications that are currently being taken are for blood pressure (17.16%), diabetes (13.94%), and general pain medication (11.53%). Finally, about 27% of participants felt that social isolation was negatively affecting their mental health.

Table 4 Health status and health behaviors

Discussion

This study, which used a community-based participatory research (CBPR) approach, is a crucial first step in understanding MENA Americans’ health needs, attitudes, and perceptions of COVID-19 during the COVID-19 pandemic. While the sampling design of the study relied on convenience sampling, the respondents, however, capture a niche MENA community in southeast Michigan. As presented in Table 1, this convenience sample was composed of a majority of young female adults that identified as MENA individuals which may have had an unintended influence in the survey results. Although this cohort does not represent all MENA Americans in the US, it does allow for a better understanding of COVID-19 within the MENA community in Wayne County, Michigan. The study collected data one-week post-Ramadan, in which Muslims fast from sun-up to sun-down daily for 30 days. Participants reported a slight increase (Table 2) in difficulty adhering to self-quarantine rules and safety precautions after Ramadan.

In regard to COVID-19 beliefs and perceptions, Table 3 highlighted that respondents understood the general transmission of COVID-19, mask wearing, and COVID symptoms. Interestingly, participants selected both the social media accounts of healthcare professionals and the Center for Disease Control as the primary sources of COVID-19 related news and information. With the increase of false information during the pandemic, it is important that communities of color, including the MENA community, are represented in healthcare as representation and inclusion in medicine can allow for culturally relevant communication. It is also necessary to better understand this vulnerable community’s health needs and address any misconceptions. Although our survey was not validated, participants were provided a range of questions about COVID-19 beliefs and social distancing practices and can help better understand trends among MENA Americans. As this community is largely understudied, understanding their health behaviors and COVID-19 perceptions can assist in addressing misconceptions and false information regarding COVID-19. Additionally, Table 4 reflects participants’ changes to their physical and mental health status and care. Overall, a majority of individuals knew someone who tested positive, while a vast majority of participants did not feel the need to be tested. This stark comparison could be a concern in limiting the spread of COVID-19.

Although the study achieved many of its objectives, there are a few limitations that should be considered. The MENA American community is widely under researched; thus, our study adapted an exploratory research design. Survey responses capture a niche community in Dearborn, Michigan, however it is important to note that this study is limited due to convenience sampling. Moreover, the majority of participant respondents identified as female, resulting in our data not being fully representative of the MENA community. This should be taken into consideration as the full depth of understanding about COVID-19 among young men may be less clear and remains an issue that needs to be addressed. Also, because participants were recruited via social media, this data may not be representative of those without a computer or internet access.

Further research is needed to better understand the unique effect of the COVID-19 pandemic on MENA individuals within Wayne County and throughout the US. With an increase in the cancellation of routine healthcare appointments and lack of COVID-19 testing within this community it is important healthcare providers and professionals work to mitigate these factors and address the MENA American community’s needs.

Future Directions

Future studies will assess the preventative health behaviors of this community, current health status, and perceptions towards the COVID-19 vaccine.