Health departments (HDs) provide a unique perspective to public health response activities. HDs serve on the front lines providing essential services and resources to the communities they serve, either directly or through collaboration with community partners. Say Yes! COVID Test (SYCT) is a program that was implemented by US federal health agencies along with academic and private sector partners, in collaboration with HDs. SYCT provided 5.8 million free rapid antigen COVID-19 self-tests to residents in selected jurisdictions experiencing a surge to help reduce COVID-19 community spread.1 The National Institutes of Health (NIH) in collaboration with the Centers for Disease Control and Prevention (CDC) launched 3 phases of the SYCT program between March and November 2021, when self-tests were not widely available on the US market.2,3 Criteria for selection of the jurisdictions included a surge in COVID-19 transmission, larger population size, low vaccination rates, ethnic or racial diversity, and high social vulnerability* (see Supplemental Digital Content Figure and Table, available at https://links.lww.com/JPHMP/B107 and https://links.lww.com/JPHMP/B108, respectively, for context of HD SYCT implementation).
HDs were then responsible for identifying communities of interest within their jurisdictions (eg, populations with higher SVI, lower vaccination rates),4 managing program scope, identifying and communicating with local partners for community distribution of self-tests, performing inventory of test distribution, reviewing of educational materials, preparing press releases, communicating with media, and conducting media campaigns.
Positive public opinion has been indicated regarding socially inclusive COVID-19 testing technologies and guidelines.5 Common barriers to testing include access, concerns about consequences of positive results, logistical issues such as transportation to testing sites, and uncertainty around eligibility for testing.5–8 High SVI has been associated with an increased risk for COVID-19, and differences in testing motivation have been found across race and ethnicity, education levels, and by socioeconomic status.9,10 National strategies implementing home-based, high-frequency self-testing have been predicted to improve COVID-19 pandemic control,11,12 and jurisdictional and community-supported testing programs for COVID-19 have been associated with increased testing in populations at a higher risk for the disease.13,14 The objective of this study was to gather qualitative in-depth information on the experiences of HDs with the SYCT program to better understand successes and barriers to implementing community-focused self-testing programs.
Using purposive sampling, invitations to participate as key informants (KIs) were extended to primary contacts representing the HDs in the 9 jurisdictions participating in the SYCT program between March 31 and November 30, 2021. Videoconference interviews were scheduled for 60 to 90 minutes with each participating HD. A structured interview guide following 4 high-level subject areas was developed by the study team and pilot-tested internally with a CDC audience, resulting in a final interview guide with minimal changes that was utilized for this study (see Supplemental Digital Content file, available at https://links.lww.com/JPHMP/B109). Consistency was maintained by employing the same facilitator to conduct all interviews, which were recorded and then transcribed by the study team.
All KIs provided verbal consent for the recording of the interviews with the assurance that their comments or quotes would not be linked to specific people or locations. This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.†
Interviews with HD KIs (one call per HD) were conducted using Microsoft Teams.
KIs were project and communication leads from HDs who agreed to participate in this capacity. An e-mail invitation was sent by the principal investigator of this study to all HDs that had participated in the SYCT program requesting a convenient time and date for an interview with 1 or more members of their team. KIs received no compensation for their interviews.
The transcription and coding of results were completed in Microsoft Excel following the aforementioned high-level grouping, with transcription aligned to each of the questions in the interview guide. Responses were placed in order of the questions in the guide, regardless of when in the discussion the KIs responded to the question. The interview was guided by the following topline summary topics:
- Community of Interest, that is, the population considered by the HD to be at a higher risk for COVID-19 and expected to benefit most from the program.
- Planning, Strategy, Operationalizing including coordination with sponsor, study team, and HDs' goals and objectives, time and effort, and staffing.
- Community Implementation Partnerships specifically community partners identified to help with implementation, existing versus new partners, their expected contribution, program structure, and how such partnerships operated.
- Lessons Learned including successes, failures, and sustainability.
Using grounded theory techniques, identification of themes and subthemes within and across the responses was completed independently by all team members.15,16 A schematic summary was created to facilitate organization of the results. Key quotes were extracted from the interview recordings to further clarify KIs' positions.
Characteristics of KIs
Sixteen KIs participated in the interviews and included SYCT program and communication leads representing HDs in 8 of the 9 jurisdictions participating in the SYCT program. Structured interviews were conducted independently with each HD from November 22 through December 16, 2021, with 1 to 3 KIs per interview. The structured interviews lasted 60 to 75 minutes.
Themes identified from KIs interviews
Four key themes were distilled from the KI responses and mapped to the sequential process of implementing the program: (1) Identifying Communities of Interest, (2) Mobilizing Community Partners, (3) Translating Learnings to Action, and (4) Closing Gaps and Improving Access. The Figure provides a schematic linking key themes. The first step in implementation was identifying populations and reaching selected communities. The next step was to expand communication via networking and media to mobilize community partners. Through iteration, lessons learned were translated into process improvements, which allowed closing of gaps (knowledge, process, logistical), and improved access to tests. Community-level engagement bolstered public health perceptions within the communities targeted by this program and allowed greater access to self-tests as the cycle continued.
Identifying communities of interest
All programs focused on specific zip codes in urban settings with high population density and acted through community partners to reach populations at a higher risk for COVID-19 (except for New Hampshire, which reached out to the entire state). One of the KIs shared that they were “reaching out to marginalized communities that had higher rates of COVID-19 infection and lower rates of vaccinations ... SYCT was an initiative that was presented to us that fit very nicely with what we were already trying to do.”
Specific channels, including schools, faith organizations, and shelters, were used to distribute self-tests to their populations. According to interviews, in county-level programs, outreach to selected communities worked well, with community partners receiving and distributing self-tests within their networks. Programs launched in large geographical areas (i.e., New Hampshire) experienced limitations for reaching some communities, as there was no funding for delivering kits to community partners. Some communities, such as persons experiencing homelessness, were identified as difficult to reach. This motivated some HDs to expand their network of community partners to reach the most local “grassroots” levels. KIs identified rural communities, school populations, and ethnic minority groups as communities that needed more lead time to prepare appropriately translated and targeted information. Some HDs had no experience in trying to reach communities through intermediary organizations and therefore needed more time to build their network of community partners. A KI stated:
Some of the groups [community partners] that we normally work with are not necessarily the folks who would most benefit in those zip codes. [We had] to reach down to another layer [of community partners] to try to target those who probably are a better resource to get to the community that we were trying to reach.
For these HDs, additional work needed to be done before they could begin the program in their selected communities.
Mobilizing community partners
HDs engaged with a wide range of community-based organizations serving specific groups, including religious organizations. They also partnered with private businesses such as tiendas, bodegas, or other ethnically oriented shops; employers; and with community institutions, such as schools, Federally Qualified Health Centers (FQHCs), libraries, YMCAs, firehalls, and other geographically appropriate services. In addition to physical distribution through known community locations, some community partners used events such as races, farmers markets, and Thanksgiving food pantry baskets to distribute test kits to the public. In some locations, public health nurses, social workers, and public officials went door to door providing information on COVID-19 as well as free test kits. Community partners also acted as a conduit for social media broadcasts and e-mailed information about the availability of tests to be ordered online or picked up directly at events or physical locations.
The community partners' most critical role was as a trusted intermediary with grassroots connections to the communities with greatest need. A KI shared:
We were able to learn and bridge and strengthen a relationship with our [redacted] community by working on this program, so we were able to develop a stronger relationship with that community partner and develop the relationship and understanding that we are here to help.
Through close collaboration with community partners, HDs were able to overcome multiple barriers, including language barriers and online ordering barriers by utilizing a hotline and door-to-door canvassing to aid in test kit ordering for those unable to access the program Web site.
The most effective community partners had a community engagement plan and already had followers via their social media accounts, mailing lists, and membership lists and were effectively linked to their grassroots communities. They were also a source of feedback, including anecdotes and ground-truthing, to the HDs. Creating trust through partners engaged with the community was explained by one KI:
These were folks that were in unvaccinated communities where we were really trying to help create that bond of trust in hopes that one day they will trust us to vaccinate.... We knew that they were a source for them for some need, whether it was food or social or mental support ... they were gatekeepers, if you will.
FQHCs were highly efficient distributors of test kits and functioned well as a cohesive network within their county, unlike other systems such as schools, where there was less facile communication between locations and limited ability to share and disseminate information to their staff, students, and families. One HD focused predominantly on distribution through large employers and churches and may not have been able to reach some populations at a higher risk for COVID-19 who are unemployed and not part of a congregation. Some locations, such as shelters, indicated that they had other sources for testing within their networks.
The variety of communication channels used was extensive and highly creative, employing social media influencers, social media pages, Web site links, press releases in both English and Spanish, local radio, national and local television, print, billboards, bus stops, and screens on gas pumps, among others. Some KIs participated in live TV interviews or live demonstrations and had high-level support from their government leaders. Links for online test ordering were included on community partner, HD, and other government Web sites. Members of the media showed interest in the program, and coverage was overwhelmingly positive and supportive. HDs routinely had a telephone helpline available that could assist with ordering kits and answering requests for information on quarantine and isolation. In some locations, word of mouth was all that was required to ensure community members were aware of and could take advantage of the free self-tests. In other locations, Facebook, WhatsApp groups, or influencers were used to conduct outreach to specific age groups and ethnicities.
Anecdotal responses from KIs indicate that interactive media such as influencers, live demonstrations on TV, and live media coverage of events garnered the greatest response. One of the KIs noted that their go-to methods of media were not enough and that they needed to expand their modes of communication:
I think we are changing from normal [media] ... newspaper, radio, and websites, we are just moving more towards social media and things like that. I think [social media] definitely helped us see avenues to try to better communicate with communities that may not have access to [traditional media sources] things.
Translating learnings to action
The methods of distribution offered both advantages and disadvantages. Direct-to-consumer (DTC) distribution was convenient for those able to access the Internet in English or Spanish and those who did not mind providing their name and address for shipment. This method was free of charge and did not require action by the HD. Some KIs indicated that they had received feedback on DTC distribution issues from program participants, relaying delays in delivery and that delivered kits lacked instructions about the program, requiring participants to return to the Web site to understand what was expected. The DTC Web sites restricted test allocation based solely on zip code. Telephone helplines established by HDs assisted people who could not access online ordering systems and otherwise would have been excluded.
Distribution to community members, whether through organizations or at events, had varying degrees of reach and in some cases had prohibitive cost. KIs mentioned that it was more efficient to distribute COVID-19 self-test kits than to manage testing clinics in terms of reach and durability of testing capacity. HDs without shipping support for bulk distribution relied on community partners to pick up their kits at a central location. Once kits were delivered to community partners, kits were provided to anyone who requested them without requiring any confirmation on whether they lived in a community at a higher risk for COVID-19. Registration and identification were not required to receive the tests, thereby allowing the recipient greater privacy and anonymity.
According to KIs, daily inventory of distribution was burdensome. HDs switched to weekly accounting or simply accounting for the number of overall kits distributed to community partners. Daily accounting for distribution through community partners was described as a barrier:
That [daily update] was ... painful. We're still struggling with that. They were excited to give [test kits] away, but I think in terms of, because they were not physically handing them out like our locations, it has been interesting trying to describe what the numbers are and how they got distributed. That is something that we are still trying to get right. That is ... one of the reasons why we did not have them distribute it from so many locations just because of the responsibility of trying to track that information was a lot.
KIs mentioned that HD staff were overwhelmed and did not have time to learn the program details, and the inventory reporting requirements were considered onerous for those that relied on community distribution, rather than DTC ordering from a Web site. Regarding staff burden, one HD shared:
We had our network of folks that were helping distribute, but even the groups that we had, you just need higher number of staff and resources, a bit more of a commitment to do it, because it is an extra thing that people have to do.
In some locations, competing initiatives such as vaccine/booster drives made staffing and management of community partners an overwhelming burden for HDs.
Closing gaps and improving access
Once SYCT program participants realized the test kits were free and available for use at their own convenience, in the privacy of their own home, and without mandatory reporting, response levels improved. A common response from KIs was that there was a learning curve. A KI said:
I don't think there was a great understanding at first ... that you can take [the test] at home, do it at home, in the privacy of home, 10 minutes [to obtain results] ... towards the tail end there was a lot more understanding in that.
Some KIs felt that the program expectation, of testing 2 to 3 times weekly, regardless of symptoms over a 4-week period was not realized. However, the KI believed that the tests were useful as a prevention strategy, particularly when people made plans to visit relatives who were at a high risk for COVID-19 or wanted to know their COVID-19 status prior to or returning from travel. One KI shared:
We know people held onto [test kits] to test only when they felt they've been exposed ... many, many people used it as a safeguard “I'm going on a trip, I'm going to somebody's house, I'm afraid, you know, I want to make sure I'm not infectious ... we do know that many people were hoarding these and testing when they had symptoms or thought they had been exposed.”
Regarding how the program could be improved, KIs recommended continued access to at-home testing. This could be sustainable with financial support for physical distribution, and continued engagement of community partners, HDs desired to see this program expanded to reach rural populations and communities that did not participate previously:
We wanted to cover the urban, rural, and sort of everybody in between. I think in a lot of ways, even though our distribution sites were in the city, this is a small city, and people from outside [redacted] within the county also got kits.
Staff from participating HDs felt the program had a positive influence on their communities and that their efforts were worthwhile contributions in support of community education, behavior, and attitudes toward the HD response to COVID-19. The HDs with existing relationships with community outreach organizations reaped the benefits of their early groundwork in relationship building, while those with less familiarity with community outreach organizations and their competencies had to quickly ramp up to find and vet organizations with deep community ties, which posed challenges to quickly implementing the program. Some HDs that did not partner with community organizations, or for whom those channels were too costly, slow, or time-consuming, still had good success at reaching people through DTC ordering on Web sites.
To effectively reach populations at a higher risk for COVID-19, and ultimately affect behavioral change, HDs could work through their grassroots community agencies and trusted intermediaries, including non-English media companies, religious organizations, and local retailers.17 Collaborating with these community partners to explore and understand the challenges and barriers to health within populations at a higher risk for COVID-19 will help HDs engage more effectively with their communities of interest and reach the least-served parts of the population. Mapping out the intersectionality of their population, and the overlapping points of contact with subpopulations, adds layers of exposure to messaging.18,19 A summary of lessons learned from SYCT is shown in the Table.
Learnings for Future Programs
HD benefit by continuously building relationships with community partners as part of their routine public health activities as there was not enough time to build new bridges during rapid implementation of programs during an emergency response.
Some community groups resisted this program until more clarity was obtained. Ensuring transparent, easily understood communication is essential to success.
More translation support is needed to reach populations at a higher risk for COVID-19 beyond Spanish; the languages and dialects of the communities of interest should be considered in development of program materials.
Some community groups could not participate in this program without any financial support for events and transportation to pick up test kits.
DTC distribution offered turnkey implementation for HDs, but there was uncertainty whether communities at a higher risk for COVID-19 were reached.
There is more perceived efficiency in distributing COVID-19 self-test kits than in managing testing clinics in terms of reach and durability of testing capacity, but testing results were not readily available to HDs.
Competing initiatives, such as vaccine and booster rollouts, can be too large a burden for the HD to manage simultaneously, so ensuring integration with other programs or providing paid surge staff support may be needed.
The desire for privacy and anonymity in testing and reporting results was a highly desired feature of this program.
Expanding the program across jurisdictions to reach more populations with a higher risk for COVID-19 would improve disease mitigation efforts.
The lessons learned from program planning and implementation offer tips for useful process improvement for future programs where community mobilization is needed to extend the reach and acceptance of public health programs.
Despite the acknowledged value in community engagement for emergency preparedness, mandates and capacity for community engagement have not increased significantly.20,21 By devoting resources to exploring and expanding the relationships between communities and their partners, HDs can close the gaps in communication and mobilize the most effective solutions to reach specific populations based on their unique characteristics including geography, language, age group, gender, cultural and religious identity, and possibly political ideology.18,22,23 Distribution through DTC online ordering systems may reach significant numbers in a given population but risks leaving out those without digital access because of age, socioeconomic disadvantage, language skills, lack of Internet access, or mailing locations. The populations with a higher risk for COVID-19 may, in fact, be the furthest from digital access.24 The desire for privacy and anonymity in testing made the self-tests particularly suitable. Awareness of this strong desire for privacy amongst some communities may be a consideration for future mass testing. Improvement in message testing is needed to avoid future circumstances where trust in the messaging of health agencies at local, state, federal, and global levels is unequally shared by populations. In addition, the most impactful messaging is sensitive to cultural and community barriers and is delivered through partnerships with trusted intermediaries who are well known in their respective communities.
The findings of this study are subject to several limitations. First, many of the insights provided by HDs were based on their perceptions rather than specific data on community distribution or specific program objectives. They were therefore providing opinions rather than facts about the uptake and acceptance of this program. This study did not examine reach, attitudes, or effectiveness of the testing program from the perspective of the community or community partners. Second, several months had passed between the completion of the first 5 SYCT programs and the KI interviews. There may therefore have been differing levels of recall bias across the phases of the program. Third, the qualitative nature of this work subjects the interpretation of the results to the perspectives and experience of the researchers. As employees and contractors to NIH and CDC, the ability of the authors to remain impartial is limited. Most of the study team members were not involved directly with the SYCT program, and every effort has been made to accurately reflect what was said by the KIs by recording and transcription. Finally, the awareness by KIs that CDC was conducting the interviews may have created sponsor bias in their responses.
The SYCT program included a small number of jurisdictions, which may not be representative of the experiences of all US HD jurisdictions. Perhaps, with larger numbers of SYCT programs, additional approaches and efficiencies would have been identified. KIs from 8 of the 9 programs were interviewed, and their experiences provide a comprehensive and candid perspective of the involvement of HDs in this self-testing program.
Implications for Policy & Practice
- Through efforts to increase community-level awareness, self-administered public health interventions using DTC distribution methods can have greater reach and acceptance within communities at a higher risk for COVID-19 and other emerging public health concerns.
- By investing time and effort in partnerships between HDs, trusted leaders, and organizations serving communities at higher risk, health promotion practitioners can more readily support public preparedness. The communities' confidence in the message may be impacted by the messenger.
- Engaging communities through tailored language, media type, and location increases the exposure of high-risk communities to messaging and helps them more rapidly accept messages and respond with behavior change or other mitigation efforts.
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