Good afternoon, everybody. Thank you for joining us today. My name is Dalia Nassim, and I'm an associate professor at the University of Texas Health Science Center at Tyler. Our session is titled, A Mixed Methods Assessment of SARS-CoV Testing of Workers, Facilitators, Barriers, and Implications of Social Marketing. So as the nation's businesses confront the pandemic's economic setbacks, safety of workers and returning to work safely amidst the pandemic has been on the forefront. Many businesses have been faced with the need to determine how to use and assess COVID-19 testing for their employees. So the goal of this study was to determine the type and frequency of COVID-19 testing activities offered by small, medium, and large U.S. employers to their respective workforce. Secondary goals included identification of facilitators and barriers to testing and health and safety concerns of these employers. So the EDGE study, as we called it, Employer Testing of COVID-19 History, EDGE, was done through the NIOSH Intergovernmental Personnel Act Agreements. The study team consisted of faculty from the University of Texas at Tyler Health Science Center, University of Miami School of Medicine, University of South Florida, and University of Utah School of Medicine, in addition to NIOSH faculty. These are all our study team who participated in this study. So the study was conducted in two phases. Phase one consisted of focus groups and interviews with various employers about their experience and perspectives with offering COVID-19 testing to their workforce voluntarily. Data collected from this was used to inform a survey instrument used in phase two of the study. This survey instrument was administered anonymously to a large sample of NORA business sectors. Data was analyzed using the SAS version 9.4. So to give an overview of the next hour, this session will consist of three presentations. Presentation one by Dr. Alberto Caban-Martinez discusses the findings of the phase one studies. Dr. Martinez is an Assistant Provost for Research Integrity. He is the MD MPH Program Deputy Director, University of Miami, in the Mueller School of Medicine. Presentation two by Dr. Claudia Parventa discusses a social marketing analysis of the H phase one data and creating a value proposition for COVID-19 testing of the workforce. Dr. Parventa is the professor and she is the Director of Florida Prevention Research Center in the College of Public Health, University of South Florida. Presentation three by Dr. Matthew Cease discusses the preliminary results of the H phase two study. Dr. Cease is the Associate Professor and Deputy Director for the Occupational Injury and Prevention Program and the Targeted Research Training Program Director in the Rocky Mountain Center for Occupational and Environmental Health, University of Utah School of Medicine. So without further ado, I invite Dr. Caban-Martinez. Thank you very much, Dr. Nessim. Good afternoon, everyone. So my name's Alberto and I get to kick off this conversation by telling you a little bit about the phase one study. It was interesting because I was talking to our coworkers before the start of our session that in the previous session, they were asking these very questions about what some of the organizations were going through during the early phases of the pandemic and their strategies for mitigation. And so hopefully some of these results that we'll present to you this afternoon show you that information. So as Dr. Nessim alluded to, I'm going to tell you a little bit about phase one. Why did this happen? So early on during the pandemic, NIOSH organized a lot of IPAs, interagency professional agreements to get a lot of subject matter experts in occupational health to work on different topics that were going on during the COVID-19 pandemic. And our team, which is meeting for the first time today, by the way, we've been on Zoom weekly for two years and are actually meeting in person, thank God, were tasked with trying to understand what was going on with businesses across the United States, across different sectors of the economy. So very tall order. And during that time period, if we can, what feels like a long, long time ago, a lot of U.S. companies were asking, you know, what is the best way to evaluate employees' illness, return to work, and what strategies are there for testing? They were receiving a lot of different information in the media from government agencies at the state level, the local level, and the federal level, and very confused about how they evaluate that information in order to maintain their livelihood. So we started off with a mixed method study to be able to answer a little bit about what was going on during that time, and the objective was to really characterize facilitators and barriers to SARS-CoV-2 testing among U.S. companies. And so on your right-hand side, you can see the distribution of the companies that we set forth to begin. Keep in mind that our ultimate goal was to design a survey instrument to test these facilitators and barriers in a large sample of U.S. organizations or companies. Before we can get to that step, we needed to understand their pain points. What were those facilitators and barriers? So we began with a qualitative study, which is etch phase one. So between January 19, 2021, and April 3 of 2021, we conducted this qualitative phase. Our goal was to identify at least two representatives from each NORA, National Occupational Research Agenda sector, and ask them, what are those facilitators and barriers to testing and evaluation? The respondents tended to be either the owners of the company or somebody in high-level leadership, so someone in human resources, the managers of the organization. And the national scope is everything from a small business up to a large organization. So you can see, based on the table on the right-hand side, that we were almost getting two representatives from each organization using our NIOSH networks, which I'll talk about in a second, but manufacturing was over-represented by five respondents. And so the methodology here is that we wanted to do qualitative data, so an interview methodology. So we begin with the mixed methods approach by understanding, going in-depth, what the concerns are, facilitators and barriers, that will later inform the design of this larger study that my colleague will present to you shortly. So before we set up these interviews with the participants, we asked them to complete an interview on RedCap. So we called it the pre-interview survey that asked some basic questions about the respondent's demographics, as well as a little bit about their company and their organization. The interviews were structured through Zoom or Microsoft Teams, and audio recorded with the camera turned off for privacy, to be able to collect the audio and then later transcribe it. So thanks to my colleague, Dr. Parvanta, and Neseli, her graduate student, we were able to conduct thematic coding of all those audio transcripts that were collected using MaxQ2A 2020, and we used what's called a modified grounded theory approach to be able to make sense of the data and the codes that were put together in there. So what was in the survey? So as I mentioned, we asked them about their sector and the services that are provided by their organization, what the respondent's role in the organization was, the location of the workforce in terms of geography or in the Northwest, South state, the size of the company, how many employees that they have, what routine, work routine or environments they were performing in, and did they have some sort of worksite wellness program, which was very interesting, because many people confuse worksite wellness programs with having an EPA or a health insurance program. So what did we learn from these interviews with this small subset of representative NORA sector groups? The first is that there was challenges with access and knowledge of COVID-19 tests. The second are strategies for symptomatic and asymptomatic testing. The third is type and availability of PPE that they're supposed to use in order to mitigate these exposures. What are the best return to work policies? They needed guidance and communication on actual COVID-19 testing. And when contact tracing actually became a thing, and I tried to explain to them contact tracing is older than dust, but yes, now they're in COVID, we do contact tracing. You know, how does that work, especially when you have people that become vaccinated or at a certain risk for COVID? So I'm going to spend a couple of minutes walking you through a little bit in depth about those themes that emerged. So the first one is on access and knowledge of COVID-19 tests. Three sub-themes emerged from this data. The first is that there's limited access to testing supplies and training. So early on during the pandemic, these organizations were struck with how do they find specific supplies and training? You can see somebody from the marketing manufacturing NORA sector said from the get-go, there was a shortage in testing supplies. Another sub-theme was lack of knowledge concerning COVID-19 testing, like how to use it, when to use it. And about half of the organizations have improved their access to and knowledge of COVID-19 during that process. You see somebody from the public safety sector said having access to a laboratory nearby really made testing even easier. The second theme that emerged and informed our survey instrument were strategies for symptoms strategies for symptomatic and asymptomatic testing. So three sub-themes emerged here. Companies testing employees on a case-by-case basis, self-reported symptoms, and upon high-risk workplace exposure events. You can see somebody from the healthcare sector who had been testing said, we only tested based on exposure and based on symptoms. Another important sub-theme that emerged here was companies with an onsite testing relief on the local department of health and partnerships with providers and local clinics for testing. So the importance of partnering with their local health department in order to make do with testing opportunities there. And you can see the respondents from the public safety manufacturing center that leveraged that. The other sub-theme that emerged here was just that there was a lack of interest from the actual employees on wanting to get tested, right? You see somebody here from the coal mining industry saying that they are coal miners. Some of them would refuse to get tested unless you force them to simply because they don't think there's really a big problem with COVID or they didn't believe in it. So the third major theme that emerged was the type and availability of PPE to mitigate coronavirus exposures. So two sub-themes emerged here from these interviews. The first was the perception or risk of exposure. So you can see somebody from the manufacturing sector said, given the way our workplace is set up, it's very conducive to COVID. Basically people come in, they go to their stations, they do their jobs, and they interact with each other throughout the course of the day. The second sub-theme was that the PPE was thought to prevent transmission of COVID in the workplace. You can see that somebody here from the healthcare sector said, I think that's the unique in our area of work. We pretty much always have to rely on PPE for most infections. So in interviewing these companies, the major theme of design of return to work policies emerged very early on during the pandemic. The major sub-theme here was challenges and practices for the return to work policies. In the manufacturing sector, somebody said, so as far as the return to work process, they were offered the opportunity to go get testing. And if they accepted, then we sent them. And that was an antibody test. We did that for about three months, but that was the only time that we did that. And so that's what they were using for return to work. The fifth theme was guidance on communication of COVID-19, how they were getting information about the COVID response. And what you can see here is that there was significant differences on how they were receiving the guidance and the type of communication that was shared with them. For example, in the public safety sector, they said the lack of communication when a person should be tested, how often they should be tested, after exposure, or should it be a routine? So hopefully you can start seeing from these communications, there's a lot of confusion early on during the pandemic for these different groups and organizations. The last major theme that emerged from this discussion was the use of contact tracing and vaccination to limit COVID-19 risk. Two sub-themes emerged here, one on contact tracing and one on vaccination. So you can see here that in terms of contact tracing, somebody from the education sector said they did contact tracing related to that work-related exposure, but it was a very limited scope because the buildings were already shut down when it happened. So they really had nobody to trace there for. And the second sub-theme was when vaccinations were on the horizon and coming out, trying to get employees to think about vaccination as an option. And you can see somebody from the healthcare sector said, we're trying as leaders in our departments to talk about getting folks vaccinated. So overall, what we learned in phase one was a series of facilitators and barriers that we could use to design a larger survey and ask the general workforce population. The summary of what we learned is that there were challenges in the options for COVID-19 testing and deciphering what to use. The information and the reliability and guidance of COVID-19 testing really differed across different sectors of the economy. There was a need or a gap in understanding return to work strategies across some of these different sectors and a high level of uncertainty in contact tracing to limit risk. I think this public safety respondent that was interviewed summed it best when he said, with this COVID virus, it's just that so many people don't believe. The disbelief has created a lot of discord with us in trying to vaccinate the whole country. I think one of the biggest barriers is the divided country and people who don't believe in what's going on. So I want to welcome next my colleague, Dr. Claudia Parvante, who will show you how we created a value proposition for COVID-19 testing in the workforce. She'll be joining us virtually. Thank you very much, Alberto. And unfortunately, I'm not lucky enough to be there with you in person. I would so love to be meeting everyone, but I think that moment will come soon, I hope. So I'm going to have to say next slide, that kind of a thing. So please, next slide. As my colleague just shared, the qualitative study uncovered barriers and facilitators to testing. And I suggested that we reanalyze the statements using a social marketing framework to give us different insights. These could potentially guide future communications about testing for the workforce. And this snapshot could serve as a case study to show how social marketing can be applied to an occupational safety and health situation. So what do I mean by social marketing? Can I have the next slide, please? A compact definition of marketing is solving a problem with a product for a price. Social marketing is a broad set of strategies and tools that bring products to the marketplace. It's not only advertising and sales. Social marketing has adapted many of these strategies and tools to generate change in individual and public health, safety, and environmental stewardship. So we're not talking about social media, let's just get that off the table. Social marketing has been used in chronic and infectious disease prevention and health promotion. For example, this slide shows one of the CDC synergy training resources that the Office of Communication at CDC created for social marketing. And you can still get this through CDC's health communication website. For some reason, occupational safety and health and environmental medicine have not really tapped into the strength of social marketing that much, but hopefully we can change that. Next slide, please. So an essential element of marketing is involving the intended customers in the design of a product or service and in creating its promotional strategy. We did the same in social marketing, sometimes going so far as to train community members to conduct and interpret the research themselves. Next slide, please. Now I'm going to go fast. Here's a very fast introduction to social marketing to get us all on the same page. Social marketing uses the same mix as the commercial activity, and we refer to that as the four P's, product, price, place, and promotion. This slide shows the primary differences between how the P's look in commercial versus social marketing. Beginning with the product, in commercial marketing, the product tends to be a tangible item or service. It provides the benefits that a consumer needs or wants, like clean teeth or to be attractive to others. In social marketing, the product sometimes is tangible or could be a service, but more often it's a behavior change. And sometimes there's a total lack of awareness of the need for the behavior. So flossing your teeth is an example of a behavior and involves a product, but it's the repetitive nature of the behavior that creates the benefit. So next slide, please. In getting to know occupational health, I came across numerous sources with titles like why won't workers wear their PPE? So there are products, but the behavior of using them is essential. In occupational safety and health, this tends to be regulated. As I will discuss, even when behavior is mandated, a level of voluntary commitment is necessary to get full compliance. And social marketing research is designed to uncover factors to prompt such voluntary behavior change. Next slide, please. This also clearly distinguishes social from commercial marketing, as in the commercial world, there is a profit that comes back to every entity in the distribution chain which makes up the cost of a product. In social marketing, we consider the psychological costs, time, and energy demands that performing the new behavior makes of intended adopters. For example, when someone is asked to be a designated driver, they give up some pleasure and possibly going against social norms. And in the PPE example that I just gave, the perceived comfort or restriction of movement would have to be considered cost of performing the behavior. Next slide, please. The differences between commercial and social marketing are less sharp when we get to place and promotion. The goal is to make both the product or information about a behavior as accessible as possible. As for promotion, which is what most people think of when you say marketing, we say our goal is to make whatever behavior we endorse fun, easy, and popular. I'll let you laugh about that a little. And it involves the communication channels and media most used by our target audience. Next slide, please. This slide gives you a good visual, I want you to keep this in your mind, to remember a value proposition. What benefit do you seek and what are you willing to give up for it? As Lisa Simpson says, she isn't just babysitting. She sells peace of mind for $1 an hour, $2 after 9 p.m. The value proposition that we hope employers and employees accept is that the protective behavior testing provides is worth its cost. With that very compressed introduction to social marketing, let's see how we are able to apply it to the EDGE employer data. Next slide, please. We ran some additional queries in MaxQDA and gave our research team homework to reorganize coded data by marketing mixed factors, the four Ps. We also asked them to suggest potential value propositions for specific occupational groups with which they are most familiar. So what do we find in this analysis? Next. We begin with the product. As I said to begin, marketing is about solving a problem with a product for a price. We in public health saw testing as solving the problems of knowing whether an employee was healthy enough to work and knowing whether an employee was infectious or could make others at the work site sick. In fact, nobody in our interviews articulated that testing was how they solved these problems. Next slide, please. In fact, what we call product substitutions came first. We all recognized that the problems faced by employees at the outset were overwhelming. Material, for example, N95 masks, were in short supply. Testing was limited. Public health guidance provided temperature and symptom checking, quarantine post-exposure, and this all depended on the honesty system. These were embraced by employers in our study, and using marketing terms, they were cheap, easy, and accessible. And I want to put a pin in the honesty system because it's a source of some stress, as I will elaborate. Next one, please. Keeping with the product, we asked what employers would want in a test. So certain and quick results is not a surprise. The benefits of that would be faster return to work, fewer employees out, and therefore, a more stable productivity and less loss. These benefits would be the nucleus of a value proposition for testing. Next slide, please. So there are further issues with this product, and I'm going to give you several. And now we are speaking about both tests as items and testing as a process. The primary problem was it lacked a clear identity. And a product without a name, like Crest, or a clear function, like toothpaste, is really hard to sell. Now, some have questioned why we speak about testing as if it were monolithic. And I know Alberto talked about asymptomatic and symptomatic testing, but this is kind of the point. Outside of healthcare, respondents described tests by attributes, such as analytical target, RNA antigen, technique, like PCR, or benefit, rapid. But often, these were confused, or we could see when we interviewed them that they were being misapplied. We have all been learning the nuances of what it means to be infected with COVID-19, sick with its symptoms, versus infectious and able to infect studies, infect others. But when our study was being done, this perspective was not broadly shared. What an antigen test or an antibody test revealed wasn't really well understood. And therefore, employers began to doubt the results and felt they needed the function without them. Next one, please. The cost of testing was perceived to be high. Our employees didn't dwell much on the actual medical or lab fees, but the associated costs included the new technologies and their lack of knowledge, new partnership arrangements that they had to form, additional efforts from workers who were now sick, of course, the loss of productivity, and they were very sensitive to employees who were not eligible for federal emergency paid sick leave, and they were losing wages. In addition, a really important cost, and this is one that remains with us in terms of vaccination, is the psychological burden of invading employee privacy or band-aiding a medical procedure. So just keep that in mind. Those are very costly things in their minds. Next one, please. There were also several problems related to place, including rules for reporting positive cases, contact tracing, and return to work guidance varied by locality, and could be very confusing for multi-state or county companies. The testing locations were not convenient if they were not done on site. An interesting aspect of place, which is really time, is that if you had shift employees, when were you going to get them all and when were you going to test them? The use of commercial labs and pharmacies grew over time, but this grew over time, but this required time away from work in order to avail themselves of them. And we have some questions about the use of home tests, because again, this one would rely on trust, and that is an important issue for them. Next one, please. So the value proposition of using testing to screen employees for safe return to work was perceived to have too many costs and insufficient benefits, and it was not a unique solution to a problem. The substitutions, even though we might not think they're substitutions, they perceived them to be substitutions, and they were perceived to be cheaper and easier. Next slide, please. So how can we do better next time? Well, for one thing, if we can come up with very clear test names that relate to what the purpose is, we'll be way ahead. And then we need to provide simple guidelines for what to do with an employee based on the results. Of course, the test needs to be easy to administer, interpret, and be painless. As far as the price, we were looking at under $15 and preferably $1 per use. And we have to sort of think about how do we reframe an employer's role in personal or public health. As far as the place, it needs to be delivered to work sites or people need to do it at home. So with the home-based delivery of test kits across the U.S., we probably caught up to what employers wish they had from the outset. But to make this feasible, we have to keep that trust cost in mind. Finding a solution to that, either some way to record and transmit results or bringing the kit to the work site might be necessary to get over that perceived very high cost of testing. Next one, please. So for promotion, we found that we might be able to potentially segment an audience in terms of their perception of exposure and transmission. Now, this is not the same thing as what you might come up with as their actual risk of transmission and exposure, but it's their perceived risk. And so we have them divided into groups such as health care, those who have a high degree of public interaction, those who have very little public interaction but work closely together in set spaces, and those who really have very little public or work site interaction. And these four segments, which are a lot fewer than all of the neurosectors or all the occupations, we might be able to tailor messages about the benefits of testing versus its cost based on those four segments, because they will perceive the benefits differently, and they will perceive the cost and the risks differently. What we really need to do, though, is to do this social marketing feasibility assessment now, before we get into our next pandemic. Can I have the next slide, please? And this is my last slide. So we do know that if you have, the only tool you have is the hammer, every problem looks like a nail. And something that we've learned in health communication is that very few public health interventions can be achieved through education alone. They have to be very easy, low cost, and have obvious benefits. On the other hand, only those things that are clearly difficult, they're costly, and have few obvious benefits require regulation or mandates. There's a broad field in the middle where social marketing or involving the attended users in the product's design and promotional strategy could be tried to persuade voluntary adoption. So this is something I'd like us to really try to consider as we all move forward. And I hope that this case study gives us some room for thought about how we might be using social marketing more in the field of occupational safety, health and medicine, and environmental medicine. So now I'm going to turn it over to Matt Teese, who will move us on to the quantitative study. I get to talk about phase two. So phase one, we did these interviews, we collect all this information, we designed a comprehensive, well, what we thought at least was a comprehensive questionnaire, that we were then able to roll out across the country to collect a lot of information here. So with the goal of really trying to be able to get a barometer of where companies were at the time, as well as what they had had to battle through at the beginning, right. So distributed widely across the United States, from June 1, through September 15 of 2021. So well into the pandemic, things had had stabilized, for lack of a better term, it was anonymous, and it was electronic. So we, we really rolled it out any way we could, we contacted all the education and research centers, the ag centers, total worker health centers, asked them to communicate it as widely as possible, worked with businesses, worked with trade organizations, as well as contacted organizations and companies that we had worked with directly, to really try and get a large cross section of participants here. Again, with the goal of really being able to say, based on these interviews that we had, what are the challenges that companies were facing in terms of testing and as well as other things with COVID, to try and prevent stuff from happening in the future, whether that's another pandemic, or whether that's an outbreak, right, of COVID. So in total, we had 27 questions within these six domains, or five domains. A lot of these questions had sort of sub parts to them. And I'll go through the ones that that we're going to be talking about today. So we tried to keep it relatively tight. So it wasn't a big burden for people to complete. And really tried to collect information about a lot of these factors in a lot of these domains that we had identified in our interviews. So in particular, today, I'm going to be talking about difficulties that their companies had with COVID testing, as well as talking about the actions that that the company would take, or they think they would take at least if a vaccine resistant variant outbreak, or just another big outbreak, right. So a lot of these questions, we also asked at your current time. So the time that they were completing the questionnaire, as well as historically at the beginning of the of the pandemic in 2020, March, April and May of 2020. So here's an example of questions. Did any of the following events take place in your organization? So our unit of measurement here is an organization. We're not asking about individual workers within that organization or that company. It's as your organization, what happened, right? Did they have to lay people off or furlough people? Did they lose revenue or customers? Did they have to close either temporarily or permanently, some locations? And then did they also go out and try and obtain some funding? Was that something that they needed to do? The two big questions that I'm going to be talking about today in terms of the analyses are this one, asking about the difficulty in terms of testing employees. Specifically, you know, did your company have challenges with availability of testing or cost? Tell us about, you know, what was your level of confidence with those results? Were you, did you feel like you could make decisions, actionable decisions based on results from your testing? Were there challenges with time delays, logistics, and then also working with employees? How many of the companies had employees, had difficulty because employees didn't want to go get tested for one reason or another? And then getting to what Dr. Caban-Martinez brought up, this lack of knowledge, right? You have all of this information. What are you going to do? Do you know what you should be doing? Are you still following CDC guidance as it was changing, if you remember early on in the pandemic? We also asked a question about, and this is the exact wording, if there was a vaccine resistant outbreak, COVID-19 variant outbreak in the near future, how much do you agree with these statements? So it was a strongly disagree all the way up to strongly agree. What would those companies do? You know, would they have disinfection protocols, distancing protocols, and all of these things? I can let you guys read it. What we were trying to get to is what had, what would companies do and how is that related to either the industry or the size of the company, as well as potentially what was their prior experience with COVID-19 and these challenges, right? So in terms of analyses, what we did, we were trying to address these two hypotheses. First, is there a relationship between company size and difficulties with testing? And then is there a relationship between company size and the actions they would take if there was a future outbreak? Our hypothesis is that different company sizes would have different challenges. And we wanted to be able to look at that. So we're calculated odds ratios and 95% confidence intervals saying, okay, essentially small companies compared with large companies, are they equally as likely to have these types of difficulties or were small companies more likely to have difficulties? And if so, what was the magnitude there and vice versa? So let's talk a little bit about descriptive statistics. We had 348 companies who completed at least 70% of the questionnaire. We used a 70% cutoff because in looking at the data, it was a good natural break point. Because it was anonymous and it was administered online, we actually had quite a few companies participate, but they would only get through the demographics and maybe the first couple and then run out of time for one reason or another, not be able to complete it. So again, it's a convenient sample across the entire United States and is a cross-sectional study. So there's some hazards or some shortcomings with having a convenient sample in a cross-sectional study, which we'll get to. But in terms of distribution across industries, we had pretty good distribution. I think this models pretty well what company distribution is in the United States. And then this bar chart here is how companies responded to having to lay off or furlough workers with about just under a third of companies saying that they had to lay people off or furlough them and were unable to have them just work from home. So I'm an epidemiologist. I like talking about the results and numbers here. So if I gloss over anything, we are going to have some time for questions here at the end. But if it's one of those burning questions, feel free to just raise your hand or chime in online and say, hey, Matt, what about this, that, or the other? So what we did is take companies and split them into two groups, one to 99 employees and then 100 or more employees, and looked at those relationships between the company size and then these challenges that they had. And we found that larger companies, and these odds ratios here are for early on in the pandemic. So in March, April, and May of 2020, were there differences in company size, were there differences in these challenges based on company size? So large companies were three and a half times more likely to have employees refuse to get tested or have hesitancy to get tested, where it actually was, they would rate it as a difficult thing for their company. It impeded, by their perception, was a difficulty there. On the other hand, small companies had more difficulty with getting delays as well as just logistics of routine testing. If they had incorporated any type of routine testing, they were almost two and a half times more, small companies were two and a half times more likely to have challenges with those logistics, as well as three times more likely to have challenges with getting with the delays and the results. We then asked the question, you know, at the current time, the time they were filling out the questionnaire in between June and September of 2021, how are these differences, right? Were there still problems that the same problems that you had at the beginning, and these differences had lessened, right? So small companies and large companies were acting very similarly and having the same types of challenges in 2021 as compared with in 2020. We also asked, okay, predicting in the future based on the experiences you had, what would your company do or what is it likely your company would do? So small companies were significantly less likely to do all of these abatement or any of these actions if there was a variant resistant outbreak. So they were 3.1 times less likely to do any disinfection protocols, 12 times less likely to do any physical distancing, three and a half times less likely to do symptom screening, and 3.2 times less likely to make workers work remotely. So smaller companies were much less likely to do any of these things as compared to larger companies. But they were essentially on par with doing quarantining or isolation and on par with doing any type of antigen testing. So again, based on what companies were experiencing in the past, we think may have had some relationship on what they would expect to do going on in the future, whether it's, and I think this could probably be extrapolated not just to COVID, but if there was another communicable disease outbreak. So like any study, there's some strengths and weaknesses. In terms of strengths, we had a large national sample. There were many industries, company sizes, and experiences. So we felt like we got a really good sort of distribution in terms of everything that was going on and all of the different experiences that companies had with communication, with testing for COVID. Weaknesses, because it was a self-selection convenient sample, there may be a self-selection bias here, meaning that companies that were very busy, workers, you know, the health and safety worker or something in that company may have still been quite busy and may not have had time to fill that out. So there may be some self-selection bias there. There's also a potential for response bias. There are several companies, particularly, you know, in the service industry, food service industry, that just went out of business during COVID. And so because this was conducted, this survey was done in 2021, companies that had gone out of business early on or before that point due to COVID would not be represented in this sample. And then lastly, recall bias. We're asking people to remember back to, at least for me, what was a pretty tumultuous time. And so there may be some selective memory there for some different things based on the experiences that they had, whether that was a conscious thing or not. So there are some weaknesses here, but we still think this is a pretty good study. So again, I'd like to say thank you very much to the research team and everything that we've all accomplished. And like Alberto said, it's fun to be here in person and, you know, to meet each other in person. So we have a great research team here, and I think it's time we have some time for questions. Yes, Carrie. Hi, cool. Thanks. Cool presentations. All you guys had really great presentations on the virtual person. I had a question about the survey. So it seems like the questions that you asked were kind of directed at leadership type people, like what would my company do? So did you target, like, CEOs or did they describe in their job title, like, what they were? And then how did that impact what their responses were and how you analyzed that? That's a wonderful question, and I did gloss over that part. So thank you. Yeah, so this was targeted to either the CEO or someone in management, whoever was responsible for their employee worker health. We asked them to do that. We also asked them to put in what their job title was. We had quite a few who were CEOs, who were the president, who were the chief medical officer. Yeah, HR VP of Health and Wellness. So we did try and get directed to those people who were the people who would be either understanding this and or making those decisions. So we think that that is pretty reliable. There were a couple of people who were, you know, identified as interns and we actually excluded them from these analyses. Very interesting results. I wonder and doubt, but I wonder nonetheless, whether your study would allow you to draw any conclusions about the role of occupational medicine or nursing personnel. So in other words, could you make a distinction in your respondents between respondents who had access to occupational health advice from nurse or physician or PA versus those who did not? So let me try and sort of just reframe your question, make sure I understand. Is there a difference in how people responded based on if they had occupational health and safety education background resources versus if they were just a manager, president, HR person who was given this title but didn't have any specific training? Is that sort of where you're going? That's kind of where I'm going and I'm guessing that you didn't, you weren't able to tease that out. I'm guessing. But maybe you can help us not guess at it. So I think it's a great question. I think that we probably could tease that out. Obviously there'd be some gray areas there, but we did have quite a few people who identified as an EHS professional, as a nurse, as a MD. So I think that we probably could do some subset analyses and see what's going on there. It's always nice to find ways that our profession moves the needle. And to be able to demonstrate that with numbers to say, look, this is why it's important that we're doing what we do. I'm attending today, I'm just saying this to give you guys some thoughts for the future. I'm attending today because I am thinking about how I can talk to paper mills that I take care of into allowing us to distribute home tests to our workers for certain purposes and how I could integrate that with the concept that didn't exist when you guys did your study of test to treat. I find that I've been talking to people since the beginning of the pandemic about, or since vaccines were available, I've been talking to them about vaccination and we have respectful conversations but I still get a lot of disagreement and we have a high proportion of people who are hesitant, not accepting of vaccines. But those people still seem to be, in my experience, extremely interested in Paxlovid because they don't lose anything by having to give up on a previously taken position and they can still get, in many respects, a comparable benefit. And so that really, to me, adds a level of value to testing that didn't exist before. Absolutely. I think that's a great point. Would either of you, or Claudia, or Kevin Moore, actually? Oh, Kevin's here too. Okay, wow. Perfect. Just like we're in Zoom. Exactly. So just two responses I wanted to mention, if that's okay. So in addition to identifying who the respondent was on the survey, another opportunity, and I can't remember the questions off the top of my mind, but if we have any of the characteristics about what other things the company had, like worksite wellness programs and stuff, might help us to get some triangulation on the respondents and do that type of analysis where you compare whether they did have some sort of occupational support versus not. So that could be a really good question. Yeah. And also, I mean, since it's a retrospective design, you could actually just ask them. Right. Oh, well, so we actually don't have... Because we promised them there was an anonymous survey, we don't have a way of contacting them back. Oh, okay. Yeah. That was done on purpose because we wanted to make sure that they felt confident and honest in saying whatever was really going on in their place of work. Great. Thank you. And then to address your second question. I work a lot with first responders, and they are very stubborn about wanting to get vaccinated. Testing was interesting because the municipality would ask them to do the testing, but there was such a fatalistic mentality about, I'm going to get it either way because of the job that we do. And I found that sometimes using the family angle was a little bit good at being persuasive about the testing and the vaccination. So if you're not doing it for yourself, at least try to protect your spouse and kids from not getting vaccinated, where you might see some value add in the reason to do the weekly testing or get vaccinated. Because unfortunately, I'm in Florida, in South Florida, and they're very stubborn there about wanting to get vaccinated. And we try to get creative about how we have conversations around it and using peers to navigate that. Have you been talking to your people about vaccination? The question was if we've been talking to the first responders at Paxil, but yes. And they have a similar mentality about, I'd rather get treated if I get it, but not it. But I think it's about how we create a culture and climate and the discussion within each fire station, not the department at the organizational level, but the culture that happens within their unit and the shifts that they're in about it. And then bring somebody that was in the ICU, a firefighter that was hospitalized, and talk to them about the importance of this and to protect your spouse and your kids from getting this so you don't bring it at home, even if you're comfortable with getting it. And it sort of helps, but it's not a panacea to increasing acceptance. I don't know if my colleagues, Dr. Parvanta, Dr. Moore, anything you want to add? I think that what you were talking about, Alberto, has to do with tailoring the message for different groups. And I think that that's something we have to look into. But it also sounds like you're reaching over to vaccination. And there's certainly a lot of work that we need to do in order to find out what is behind resistance and finding those who are ready to adopt and having them convince the others. I agree as well that there's a little work we can do with some analysis of job positions within the organization if we want to dig in a little bit deeper on some of those. We had some challenges previously, but I think we've got those a little more under control now and could take a second look at that. Hi. Thank you so much for this wonderful work and for these wonderful presentations. I have two questions. My first question is, I was just curious about why some of the questions about practices had to do with PCR testing. But in the question about a future variant that is resistant to vaccines, you asked about antigen testing, so the difference between PCR versus antigen testing. And my second question is more general. This was a presentation about preliminary results from EHG-2, and I was wondering what directions you have in maybe further analyzing the data from that. Thank you. Sure. Great questions. I'll take the first stab, and then you guys can fill in the many holes I leave. So the question about PCR versus antigen testing, if you remember early on in the pandemic, we didn't even have antigen testing. And so we were asking specifically about PCR. Then there was an overlap period where we had both PCR and antigen testing. And then future going, ideally, we would be able to rely on antigen testing. So it had to do in large part with the evolution of the testing and test procedures that we had available to us during the pandemic. However, that does highlight a challenge that I think both came up in the interviews, as well as a concern that we had in phase two, which is this lack of understanding about, okay, what is a PCR test versus what is a rapid test, PCR test, or is it not? And then that faith and trust in those results to be able to make decisions, I think, was something that, at least in the interviews that I did, was a sort of consistent theme. Yeah, absolutely. I even remember in one of my interviews with public safety, they were thankful that the health department had something that they could do, because they would just then put all the employees, go to the health department, the health department will know how to test. And so the data set that we have now with all that survey data is, there's so much data in there, because it looked at things, asked perspectives before and after the pandemic and experiences with contact tracing, vaccination, and all that. So our team is actually going through that process now. I think the hardest thing is going through the federal government's review and clearing process. So even though you have the data and you want to ask a different question of it, you still have to go through that process, which has been very interesting, as somebody who's not in the federal government. But we do have some additional research questions we want to ask of that data set, like what we described. Yeah, I think mostly, like the future analysis would be like, our dependent variables are mostly like the facilitators and barriers to testing, and it's relation to mostly like company demographics, like Matt already did, like the company size, lots of the relation with the company size. We can also do like the age of the company, the duration of the company, and stuff like that, like the independent company demographics. We're also looking at industry, what industry sector they're in, both as a confounding relationship between company size, as well as a potential predictor. I'm sure it's not any surprise to anyone that there was big variation across industries. Question on like, as the virus is flowing around, if you had to wait for case burden to be high enough in certain regions, or if the duration of when the questionnaire could be open and closed to get the right responses at the right time to meet where it was maybe in Utah versus in Florida, it's going to be different. That is a great question. Like looking at just time trends over the period with which the surveys were responded. I'll take a first stab at that, maybe you guys can fix my hole. So I was thinking, you know, we do have a healthy sample size there that we could do some of those analyses by maybe region of the United States and see if there are differences when there's peaks of COVID-19 response. But I don't know if we'll have enough, you know, depending on how we slice and dice the region. Because I think we asked them what state they're in. And in our process, we made all the questions voluntary. So somebody can show, you know, can select whether or not they want to select them. And so not all of them have like the state variable available. But that is something that we can definitely look at. We have, we haven't. We do, I do have some concerns about the accuracy of the state variable actually, right? Because we have an exorbitant number of people from Alabama, which just happens to be the first state on our alphabetical list, like disproportionately high. So there may be some issues there, which again, is good that it was a anonymous confidential response. So, yeah, we did look at, you know, there was CDC changed their recommendations at during that time point. It was near the July 27th or something, I'm trying to remember. So we did look to see, was there a difference in terms of responses? People who participated and responded before that change in recommendation versus after. There's nothing statistically significant, even though it was pretty, pretty well balanced. But I think it's an interesting question of being able to look at, were there variations in terms of case counts or other things going on at a state level, at a region level, at an industry level that may be able to tease out some of these differences too and help us better, better work with our workers. I'd also like to echo my appreciation for the work that you've done, the presentations today. I met Proctor and Gamble and was the medical lead for testing in the United States and supervised globally. So this is a dear subject to me. I have never heard of social marketing. I was very intrigued by this concept and especially as we move to endemic and I think personal accountability and an approach of test to treat versus test to screen is where we're going to go. And I'm wondering if you can elaborate on how social marketing can be used to influence this. We have the right person in the room. Dr. Parvanta, please answer that one. Did you hear the question? Is this the one that's in the chat or is it something else that's now? Could you repeat it? Yeah, maybe it was a little. Roberto, could you repeat the question? Yeah. Can you hear me? Yeah. Okay. I'm going to have her repeat the question one more time. Sorry. Okay. Sorry. Can you hear me now? Yes. Can you elaborate on how you believe we can use social marketing in the future for management of COVID? As I believe moving forward in an endemic phase, we're going to transition to personal accountability for management of the disease in addition to a position as a country that will test to treat versus test to screen. Okay. That sounded like a sort of complex question. Are you asking me about how we can use social marketing to manage the communications around COVID? Or are you asking how we would use it to do something else in terms of how we're positioning testing? Well, it's a little bit of both, so it's a large question. But in general, this idea of social marketing is new to me, but one that sounds very interesting in how we can modify behaviors because a lot of public health is changing behavior. And I think managing COVID ultimately long-term is going to be a lot about managing personal behavior versus implementing restrictions, right? So we have to be personal accountable. And I'm wondering if you see a way that we can use social marketing to do this. Yeah. That's what I'm suggesting. Thank you for that question. What I'm suggesting is that even just speaking to these employers, we didn't design it to be a social marketing study, but the way they were describing the barriers and the facilitators, it became very clear to me that the product for them wasn't really suited to what they were looking for. And in other words, they didn't see testing as an answer to the problems that they were having. And in fact, it caused them greater problems. So if we would want them to embrace testing, or let's say we want them to embrace using vaccination, we have to bring these people on board or into a formative research process to learn what it is that they see as the benefits to doing this behavior. We can't make that assumption for them as public health or occupational health or any other kind of professional. We have to go to them, present them with what we think is there, and then try to derive from them what they see as the benefits. And very often, as Alberto alluded to with the firefighters, we need to engage them as the spokespersons for the community that they are part of. So it's not like a fix it overnight sort of a thing, but I think we've learned enough and we're learning more, and we're still in the process of trying to collect some more information about this, of how can we use occupational sectors or regions of the country or various other things in order to tailor more of the communication that we're doing. And of course, then we will also divide the audience by whether you're a healthcare provider, you know, or you're in another sector of the world. Also, if I can ask, Claudia, is there a way to use social marketing tools or methods to persuade or encourage the worker to adopt personal testing for COVID-19 versus creating sort of organizational policies or frameworks to force them to get tested? Could the social marketing tools and methods be garnered more for making them feel more personally accountable or encouraged to go test? Well, I think that's what we're trying to get to, but they aren't necessarily divorced from each other. There would need to be, for any behavior change, I've always said there's like, there's what I want you as the individual to do, but we need to create the enabling environment for it. Now, whether the enabling environment is one that's coercive or it's one that's just facilitating, we don't know. The main thing is we have to raise the value. We have to increase the benefits that we, the people that were saying, I need you to be more personally responsible for this, what's in it for them? What do they get out of being more personally responsible? And so this all requires some layer of research to sort of figure that out, but it's been done for many, many, many other interventions, and I don't think that this is any different. Kevin's got a thought. Claudia, I just, the questioner brought up the whole test to treat, and I think that's a really good example of sort of changing the way that we think about this, because now the benefit is I can get rapid access treatment that's going to help to reduce the severity of my disease, and now the driving force for testing starts to get more personal. So I think that's a good example of a kind of a shift that we're looking at, and I think we have to change our marketing, right, to try to reflect that more effectively. And you know, I've heard a number of reports about challenges with people not realizing how much more access we're beginning to have to these treatment options, and that we need to change our marketing and our messaging that we have to make that clear to individuals, and hopefully what that will lead to is, you know, more positive behaviors. If someone is feeling ill, instead of just completely counting it out as saying, well, it's allergies or something like that until they really start to feel lousy, that there would be a benefit to pushing them to going and testing. And so I do think that's a great example of what you're talking about in your social marketing part of the talk today. Yeah, actually, if you were a smart commercial marketer, you realize you just changed the whole game. It's a game changer from a marketing perspective, because now before we had a product in search of a problem, but now we have the problem that it will solve. Now we know whether they give you this treatment or not. So I think we're approaching the end of our session, and we are no longer live stream. I want to thank you all for attending, and thank you for our wonderful presenters. And we can be available offline for any further questions. Thank you. Thank you.

SARS-CoV testing

COVID-19 testing

mixed methods assessment

small companies

medium companies

large companies

employer perspectives

survey analysis

difficulties with testing

future actions