We obtained 20,901 Interaction Forms (routinely collected August 2021–May 2022), surveyed 301 residents (March–April 2022), and interviewed 32 stakeholders (April–May 2022).
The majority of surveyed participants were female (n = 212; 70.4%). Many (n = 249; 82.7%) mostly spoke languages other than English at home, most often Somali (37.9%; n = 114). Eleven participants (3.7%) were Aboriginal and/or Torres Strait Islanders. The median age was 45 years (range 16–101 years; Table 2).
Table 2. Demographic characteristics of survey participants
|
|
Participants [N=301]
|
n
|
%
|
Gender
Female
Male
Other/Prefer not to say
|
212
89
0
|
70.4
29.6
0.0
|
Age, years
Median 45 years; range 16-101 years; interquartile range (IQR) 32-60 years
|
Language mostly spoken at home
Somali
English
Arabic
Vietnamese
Tigrinya
Other (N = 23 languages)
Blank
|
114
52
38
26
15
54
2
|
37.9
17.3
12.6
8.6
5.0
17.9
0.7
|
No. people living in household
Median 3 people; range 1-11 people; IQR 2-5 people
|
Aboriginal Australian/Torres Strait Islander ethnicity
|
11
|
3.7
|
Residential estate
Carlton
Collingwood
Flemington
North Melbourne
|
74
77
76
74
|
24.6
25.6
25.2
24.6
|
Interviewed stakeholders comprised 14 residents (2–5 from each estate); eight Concierges (1–3 from each estate), five other cohealth staff; three DFFH staff and two Foundation House staff. Interviews with residents tended to be briefer than with other participants (mean duration 17 minutes versus 41 minutes). Thirteen of 14 interviewed residents mostly spoke a language other than English at home: seven spoke Somali, three Arabic, and one each of Cantonese, Hindi and Tigrigna. As 37 residents were invited, the resident interview response rate was 38%, with 23 not responding (none explicitly declined). No participants chose to review their interview transcripts. Two face-to-face interviews were conducted in Somali by Research Assistants who resided in included estates (RH; female, Bachelor of Applied Science, no prior qualitative research experience. SA; female, no tertiary qualifications or prior qualitative research experience). They had received two training sessions with JO (Research Fellow). Due to their limited availability, JO (female, PhD in public health, qualitative research experience) conducted all other interviews in English; six were face-to-face; 11 residents were interviewed by phone and 10 cohealth staff / other stakeholder interviews were via Zoom.
Key themes are presented according to the dimensions of the RE-AIM framework and related study outcome (Table 3).
Table 3
Dimensions of the RE-AIM framework and relationship to thematic findings and study outcomes*
RE-AIM framework dimension and key considerations
|
Application to the thematic analysis
|
Key theme
|
Reach
into the target population.
Who benefited from the intervention?
|
Did the program reach the
residents?
Did it reach those most in need?
|
Everyone knows they’re there
By stationing Concierges in residential building foyers, residents frequently encountered Concierges and had ready access to the information Concierges offered.
|
Effectiveness
How favourably did the intervention perform in practice?
|
Did the program achieve its goals?^
|
Concierges were great at the start of the pandemic, they don’t do so much now
While the program was valued during the initial rapidly changing public health response, many felt it had failed to evolve in the ‘COVID-normal’ phase. While some residents described having meaningful conversations with Concierges, many interactions described were superficial.
Some felt the true impact of Concierges’ work was underrecognized.
|
Adoption
considering target settings, institutions and staff
|
To what extent did residents engage with Concierges?
|
Inconsistent program adoption within communities
Perceptions around whether Concierges helped the community differed considerably. Some residents described feeling little connection with Concierges, while others valued Concierges and considered them part of their community.
|
Implementation
considering the consistency and cost of delivering the intervention
|
How consistently was the program delivered by Concierges?
|
Unclear expectations led to variable service
A lack of clarity around what the Concierge role required was a barrier to effective service.
The need to employ people who actually engaged with, and represented, the people they served came up frequently.
|
Maintenance
of intervention effects over time
Did the intervention produce desirable outcomes?
How can this be sustained?
|
To what extent did the program become part of routine practice and maintain effectiveness?
|
There’s so much more we could do
Many people mentioned an ongoing need for a bicultural information hub in the estates. There was a perception that not continuing the Concierge program was a missed opportunity to deliver health promotion and link residents with services.
|
*Table adapted from Foreman et al., 2017.(29) |
^Program goals: To share information about COVID-19, public health restrictions, health services, and have Concierges act as community supports.(5, 6) |
Reach: Everyone knows they’re there
Three-quarters of surveyed residents (225/301, 75%) reported ever having received information about testing from a Concierge, 92.0% of whom (207/225) reported they thought this information was accurate. Most surveyed residents (88%; 266/301) reported they had been tested for COVID-19 at least once, and 30% (91/301) reported being tested more than five times. A similar proportion (73%; 219/301) reported ever having received information about COVID-19 vaccines from a Concierge, 93% (203/219) of whom thought this information was accurate. Two-thirds, (191/301, 63%) reported speaking to a Concierge in their building in the prior six months; 14% (42/301) spoke to a Concierge more than five times in that period.
When interviewed, residents immediately recalled seeing Concierges and understood their role was to provide COVID-19 information and facemasks. Some remarked on seeing Concierges often and when asked, most said they would feel comfortable talking with a Concierge.
“I’ve seen [Concierges] a lot. I would just go up to them, especially because they are under my building, like “hey is it okay if I have masks?” Resident #7, Carlton
Interaction Form data showed Concierges provided COVID-19 related support in all 20,901 recorded interactions. In addition, ‘other’ support was provided in 78.3% (N = 16,365) of interactions, most commonly ‘Other health-related information’ (Table 4). On average, 5.5 supports were provided per interaction (range: 1–8 supports/interaction). Language support was provided in 8.7% (N = 2,359) of interactions.
Table 4. Supports recorded in Interaction Forms from Carlton, Collingwood, Flemington and North Melbourne estates, 1 August 2021 to 12 May 2022*
Type of support
|
No. of supports
|
% of supports [N=115,753]
|
% of interactions [N=20,901]
|
COVID-19-related supports
COVID-19 related information
Booking a COVID-19 test
Support to get tested
Booking a COVID-19 vaccine appointment
Support to get vaccinated
Face mask distribution
Hand sanitiser distribution
Well-being / Social check-in
COVID-19-related support total
|
11,726
1,068
10,191
606
8,872
19,999
17,281
13,879
83,448
|
10.1
0.9
8.9
0.5
7.7
17.3
14.9
12.0
72.1
|
56.1
5.1
47.9
2.9
42.4
95.7
82.7
66.4
100.0
|
Other supports
Other health related information
Mental health information
Housing support
Financial support information
Education support information
Other support total
|
13,785
5,220
4,856
4,003
3,797
32,305
|
11.9
4.5
4.2
3.5
3.3
27.9
|
66.0
25.0
23.2
19.2
18.2
78.3
|
* Data collected routinely by Concierges during the program
Nearly all (96.0%; n = 289/301) surveyed residents reported having received at least one COVID-19 vaccine, with 94.0% (n = 283) reported they had completed the recommended two-dose primary vaccine course. Nearly half (n = 39, 46.2%) reported they had received a booster (third) dose, lower than the proportion of eligible Victorians who had received a booster (65.9% as of 17 March 2022; all participants were eligible).(30) Trust in COVID-19 vaccines was fairly high; 75.7% (n = 228) stated they moderately/very much trusted COVID-19 vaccines (Fig. 1).
Effectiveness: Concierges were great at the start of the pandemic, they don’t do so much now
The median score from the Interaction Form data regarding satisfaction with the Concierge Service was 10 out of 10 (range: 1–10; IQR: 10–10). Residents shared experiences of Concierges supporting them whilst in home isolation, bringing supplies and keeping them updated on COVID-19-related news. Interviewed residents often identified Concierges as an important source of up-to-date information when public health advice and restrictions were rapidly changing. A few residents described Concierges teaching them ways to protect themselves from COVID-19 and being reminded to remain vigilant upon seeing them. One resident shared discussing COVID-19 vaccination with a Concierge.
‘Because of the information they give me, that lead me to take the vaccination. To protect myself and my children. … I’m immunocompromised.’ Resident #10, Collingwood
Generally, however, residents expressed there was no ongoing need for Concierges to be stationed in foyers sharing COVID-19 information once the public health response moved away from tight suppression approaches.
When the pandemic start, that’s when I feel like they [Concierges] were more useful… now, they just sit there. Resident #1, North Melbourne
Some Concierges disagreed, saying that residents came to them for reassurance as COVID-19 case numbers increased. While Concierges described working hard to support residents, some said they felt restricted behind their desks and wanted to engage more with the community.
Superficial interactions with Concierges while obtaining face masks and hand sanitizer were commonly described by residents, especially as pandemic restrictions eased. Residents often described Concierges as a source of simple, practical COVID-19 advice, such as where to get a COVID-19 vaccine. Residents largely perceived Concierges as having limited education and training, and therefore not being able to answer technical questions which they would save for a medical provider. Most residents said they would be unwilling to discuss non-COVID-19 health matters with Concierges.
“I didn’t ask them [Concierges] much questions, I just wanted to know where I could get the vaccination and they told me... I feel like they are not like educated… the doctor would know more.” Resident #1, North Melbourne
The median Concierge Health Care Competence Score was 2 out of 3 (IQR:1–3), equivalent to surveyed residents reporting the service was provided competently most of the time. The multivariate ordinal regression model indicated that residents who had > 5 COVID-19 tests had higher odds of giving a higher Competence Score compared to residents who had ≤ 5 COVID-19 tests (aOR: 2.47; 95% CI: 1.35–4.51; p-value: 0.003).
The median Respectful Communication Score was 3 out of 3 (IQR:1–3), equivalent to residents reporting Concierges communicated respectfully all the time (Fig. 1). No predictors of a higher Respectful Communication Score were identified.
A subtheme concerned under-recognition of the full impact of Concierges’ work. cohealth staff discussed Concierges organising community services and events, including clothing libraries, walking groups and festivals. Some suggested the residents simply saw these as being cohealth-run and were unaware of the Concierges’ contributions.
cohealth staff discussed Concierges insights as critical to informing their health service; particularly mass COVID-19 vaccination and testing services.
“[Concierges] ….were saying, “can you change your operating hours to 12 to 6:30, so you can capture everyone coming home?” “Can we make sure we have got these languages on this day?” cohealth staff #1
Several cohealth staff felt that the program was constrained by its COVID-19 funding remit, and the impact of Concierges work was not captured by HRAR indicators or recognised by funders.
“…we [cohealth] will continue to step into some other issues that are onsite like mental health. …[the program] it’s been labelled COVID response. …it's more than that.” cohealth staff #5
Adoption: Inconsistent program adoption within communities
No interviewed residents said that a Concierge would be their first source of COVID-19 advice; most would initially look at Health Department webpages. Despite this, some, including those who had very limited interactions with Concierges, said they felt the program helped residents and it was a shame it would not continue. cohealth staff and Concierges emphasised the close, trusted relationships which they perceived Concierges had built with residents, and spoke of how this trust carried through to other cohealth services. Conversely several residents and Concierges discussed residents being too busy to speak with Concierges, and some residents described feeling people in their high-rises had very little connection to Concierges.
‘They [Concierges] are just sitting at the bottom at the door and people are going and coming… after some time, people just started ignoring them. …They didn’t even connect with the community around here.’ Resident #2, North Melbourne
Some residents strongly criticized Concierges for their perceived lack of engagement. They said the estate resident-leaders had to step in to support vulnerable neighbours through the pandemic and promote COVID-19 vaccine uptake themselves as no-one else was.
“The Concierge is... there with the paper [COVID-19 vaccine pamphlet], but the African communities [residents], they are not believing the paper. Some people can’t read … But as a community leader, … we mention how easy and important [COVID-19 vaccination] is… The community leaders, they are working hard to get the community to do it [undergo CONVID-19 vaccination], but I don’t know about the Concierge.” Resident #11, Flemington
Meanwhile, Concierges and other cohealth staff described Concierges providing highly varied, impactful support to residents, not limited to COVID-19/related issues.
“[Concierges] They’re friendly people. And they’re working very hard. They will give you information. They are so nice…. They understand what the community needs. They are part of the community too.” Resident #3, Collingwood
Surveyed residents scored their trust in the Victorian public health authorities’ ability to respond to a localised infectious disease outbreak highly. The median confidence score was 3 (‘very confident’); range 0–3; IQR: 2–3. No difference in the median score was observed according to whether or not estates experienced Operation Benessere (p = 0.52). Participants who mostly spoke languages other than English at home scored higher (aOR: 2.74 [95% CI: 1.49–5.07]; p-value: 0.001), as did participants who reported having ≥ 2 COVID-19 vaccine doses compared to participants who had < 2 COVID-19 vaccine doses (aOR: 5.27 [95%CI: 1.89–14.7]; p-value: 0.0002; Fig. 1).
Implementation: Unclear expectations led to variable service
Poorly defined hiring criteria were sometimes said to have resulted in inappropriate people becoming Concierges. The merits of employing residents were often discussed. A need for this to occur in a meaningful way, employing people who actually engaged with, and represented, the community they served came up frequently. Concierges sometimes discussed a lack of clarity around their management and reporting pathways, inadequate supervision and unclear expectations around what they were required to do. This confusion was said to have caused some Concierges to disengage, feel bored and behave unprofessionally.
“…we had management around sometimes, but generally we were just left to our own devices. That was pretty ugly. And it meant also that the Concierges who were always naughty got even naughtier.” Health Concierge #7
Some Concierges felt the training they had received was too little, too late. This view was also articulated by Foundation House employee.
‘I think by 2021, [ Concierges ] were more confident in the role but… there didn’t really seem to be much change in the support available for them, especially around risky situations [aggression from residents]. …but people still kept loving the job.’ Other stakeholder #5
Maintenance: There’s so much more we could do
cohealth staff and Concierges commonly voiced a perception that not expanding the program was a missed opportunity. Interviewed people, including residents, discussed a need for a community health hub, or similar service, where bicultural workers could provide residents with referrals to varied service providers, conduct health promotion and act as an information point. Residents spoke of their estates having building maintenance issues, residents needing language support, experiencing food insecurity, and requiring greater access to medical, oral and mental health services. Some discussed how Concierges helped to address these issues.
…he [a Concierge] thought it would be really important to create a space, initially where men could talk about mental health, so he created a wellness walk, which we do on most Tuesday and Thursday mornings and now it’s sort of open to everybody.
cohealth staff #3
Concierges spoke of the sense of purpose their work brought them and how much they enjoyed helping residents. This came despite more difficult aspects of the role, particularly having to work in uncomfortable temperatures and sometimes facing aggression. Several single mothers described how working flexible hours on-site allowed them to have employment despite their caring responsibilities. Concierges expressed grief, anger and worry that their roles were to soon end abruptly. They described feeling unappreciated and used by government, and also by cohealth. They discussed their perceptions that their work benefitted end-users and there was a need for it to continue. Concierges shared sacrifices they had made for their work, the emotional toll of working at the estate they lived in, and their dedication to helping others.
[Said through tears] ‘Upset, worried. Very upset with how it is and we help the community a lot. Why is the job gone? And we were working very hard for this government.’ Health Concierge #6