This research has documented the pandemic-related concerns of food service workers surrounding health and safety, stress and mental health, and the long-term effects of the COVID-19 pandemic. The research also provided an illustrative example of CBPR by demonstrating success in developing an academic-community partnership amid crisis. Food service workers described their experience living through the pandemic from its onset through the close of the study in February 2023, providing reasonably comprehensive coverage of the first 3 years of the pandemic from the perspective of New Orleans food service workers. Figure 1 summarizes the key findings and next steps for research, programs, and policy. Key findings were that food service workers (1) were provided workplace COVID-19 droplet-based protections that were insufficient against a highly-infectious airborne illness, (2) had to make difficult decisions about health and safety with limited definitive public health guidance and structural supports, (3) faced considerable stressors and mental health concerns, especially depression, anxiety, and substance use, with limited counseling support, (4) continue to experience long-term health, mental health, and financial impacts, and (5) want more support to prevent in-home COVID-19 transmission and gain more support around health, mental health, and financial well-being in the food service industry. Our multi-method, phased research process of moving from a survey to focus groups to a rapid qualitative assessment offered a combination of big-picture empirical evidence mixed with real-world examples and allowed us to increasingly shift from identifying problems toward targeting priorities for future solutions. Findings have implications for future research, programs, and policy aimed at mitigating the lingering impact of the COVID-19 pandemic, future pandemics and health crises, and other airborne respiratory illnesses among individuals at high risk of occupational exposure.
Summary of a CBPR Study Engaging the Food Service Worker Stakeholder Community and Scientists to Respond to Key COVID-19 Pandemic Concerns. The outside arrows show that community members and scientists were engaged in iterative feedback processes that encompassed all aspects of the project, from the proposal to methodology to findings to dissemination. The collaboratively designed funding proposal focused on three key issues (health and safety, stress and mental health, and long-term impact), which were studied using a combination of methods, a survey (S), three focus groups (FG), and a rapid qualitative assessment (RQA). Findings identified key concerns within each of the three topic areas. The project informed future research priorities, outreach activities, and plans for ongoing and future programs and policy initiatives
Although prior studies have documented some of the pandemic burdens faced by food service workers, this research highlighted the root of those burdens: food service workers were often offered low-level droplet mitigation rather than high-level airborne mitigation, creating high-exposure risk environments that led to a disproportionate burden from the pandemic. Adhering to common public health guidance, employers provided precautions mainly against basic droplet transmission (e.g., soap, hand sanitizer, gloves, low-quality masks), rather than airborne transmission (e.g., high-quality masks, ventilation, filtration via air cleaners, and air-quality monitoring). However, COVID-19 is now widely accepted to transit predominantly through the airborne route [36,37,38,39,40], with White House COVID-19 Response Coordinator, Ashish Jha, MD, referring to COVID-19 transmission as “purely airborne” in October 2022 [41]. Our research is the first of which we are aware to explain the pandemic-related burdens of food service work in terms of a lack of airborne COVID-19 mitigation.
This discrepancy between droplet precautions and airborne transmission helps explain prior findings that food services workers have experienced worse COVID-19 health outcomes than most other workers [1,2,3,4,5,6,7,8,9,10,11]. Like COVID-19, many illnesses transmit through the indoor air people breathe [40]. Recognizing the dangers of airborne illness transmission, the highest-ranking building engineering organization with 50,000 members in 130 countries, called the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE), published 2023 indoor air cleaning standards for the control of infectious aerosols [42]. The new standards indicate that restaurants and similar establishments should clean the air approximately 28–40 times per hour, depending on occupancy level (more precisely, 40 cubic feet per minute per person [cfm/person] or 20 L per second per person [l/s/person]) to reduce airborne illness transmission, approximately double the historic standard of 15 air changes per hour in U.S. operating rooms. To put in context, many restaurants, bars, and similar establishments clean the air 0.8 times per hour [43], 35–50 times lower than the current ASHRAE air cleaning standards. As the engineer Devabhaktuni Srikrishna frequently notes, even fish get 4–6 full water exchanges per hour in properly running fish tanks [44]. Essentially, food service venues are among the highest-risk settings and have the lowest mitigation. The ASHRAE standards are a firm indication of the occupational hazards of food service work. More research is needed to improve health and safety for food service workers, particularly during airborne illness crises.
Similarly, food service workers experienced a gap between what was offered and what was needed with regard to other COVID-19 health and safety concerns, stress and mental health, and the long-term impact of the COVID-19 pandemic. Regarding health and safety, employers encouraged food service workers to stay home when sick, but did not always provide free tests, guidance on testing, paid sick leave, or even health insurance. In general, food service workers faced challenging decisions surrounding vaccinations/boosters, masking, testing, isolation, quarantine, and how to reduce in-home transmission. Nonetheless, they often made wise, cautious decisions, with the vast majority having utilized vaccines, masks, testing, and routinized safety protocols. Additionally, participants indicated key concerns surrounding stress and mental health, especially related to anxiety, depression, and substance use and called for more mental health support in the community. Food service workers also indicated that they were experiencing long-term consequences of the COVID-19 pandemic in terms of mental health, Long COVID, and financial strain. Overall, food service workers were under-supported, often provided the ‘wrong’ tools or no tools at all, with broad impacts on health and mental health in the short- and long-term.
This research had strengths and limitations. The key strengths were stakeholder-engagement, community-centeredness, the use of multiple methods of assessment to triangulate priorities and capture variation over the course of the pandemic, and the innovation of responding to the pandemic in real-time, submitting a funding proposal in May 2021, when many thought the pandemic was “over,” instead of in a low point before viral evolution that produced the Delta variant, Omicron variant, and many Omicron subvariants. Limitations include the small sample sizes that are common when gathering detailed and sensitive information, the subjectivity of participants’ perspectives, and the dynamic nature of the pandemic, which means that findings at one point in time may be less relevant at a future timepoint.
Future research should focus on evaluating interventions to support the top concerns identified by stakeholders. In a world where most mitigation has been dropped, stakeholders universally cared about avoiding spreading COVID-19 within the home. At this point in time (September 2023), COVID-19 continues to transmit at a high rate, with over 800,000 American infected daily [19, 20]. In-home transmission has remained a concern throughout the pandemic [45,46,47]. Mitigation professionals identified actionable interventions to reduce in-home spread when someone has illness symptoms at home, including opening windows, using fans strategically, using DIY air cleaners called Corsi-Rosenthal Boxes, wearing high-quality masks, and testing to end isolation periods. Although these interventions have underlying efficacy data [30,31,32,33,34,35,36,37,38,39,40, 48,49,50], the question remains whether these specific interventions would work in the context of a comparative effectiveness trial to reduce in-home transmission under community-based circumstances with less scientific control. Such studies would be of high value for people working in settings with high transmission risk [9, 10], as well as for vulnerable populations like people with cancer or who are immunocompromised [34, 35]. Future studies should also examine interventions for reducing mental health concerns, like anxiety, depression, and substance use, as well as the financial strain exacerbated by the pandemic. This program of research would help reduce the pandemic impact experienced by people working in settings with high risk of exposure.
Although our report focuses on the development of a community-based partnership and the findings from such research, it should be noted that an important goal of CBPR is to establish long-term collaborations to drive the development of programs and policies to help the community. During the course of this partnership, we developed social media accounts, a website, and a listserv, held three public community meetings that were available live online, and wrote three brief handbooks with advice on conducting CBPR during public health crises [51,52,53]. These were collaborative efforts involving iterative input from scientists and the community. We have developed a strategic plan for the next three years. Moreover, we have already begun to develop programs and support improved policy initiatives for the food service worker community and others at high-exposure risk or with medical vulnerabilities [34, 35, 48, 54,55,56].
A few recent and ongoing examples may help illustrate how this type of project can have a broader impact on the community. Foremost, during the BA.1 Omicron surge, we led the first known research study [48] that involved distributing high-quality N95 masks to the community, launching our program before the New Orleans city and federal initiatives. We disseminated the work widely on social media, helping communities across the U.S., Canada, Europe, and Australia to develop “mask blocs” to provide free masks to those working in high-exposure settings or with medical vulnerabilities. A New Orleans mask bloc called Fight COVID NOLA – building upon but independent of our group – has now given away thousands of masks, often targeting support for the food service community. Second, we recently launched a COVID-19 dashboard [19] that uses national wastewater data to model current U.S. case rates, the percentage of the population who are actively infectious, the number of new daily Long COVID cases, and forecast future case rates. It has been viewed > 3 million times within the first 6 weeks of launch and will help people in high-risk settings to advocate for stronger mitigation. Third, in late June 2023, ASHRAE released the final draft of its standards for the control of infectious aerosols [42]. The standards use engineering terminology. We are translating that information into lay summaries and sharing through social media, recent [34, 35] and future publications, explainers, graphics, pro bono consulting with individuals and collective bargaining units, and more. As a part of our strategic plan, we will spend the next several years supporting improved air quality in restaurants, vaccine booster outreach, testing, and comprehensive interventions to reduce in-home transmission. These programs and policies will benefit the local food service worker community, food service workers in other communities, and society more broadly.
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