Evidence-based Interventions - Individual, Community, and Structural Factors That Predict Lower Rates of COVID-19 Screening Testing in Underserved and Vulnerable Populations

Background: The purpose of this study was to identify individual, community, and structural factors associated with lower rates of COVID-19 testing in Northern New England (NNE), with a focus on underserved and vulnerable populations. Populations of interest included communities with high social vulnerability, community-dwelling older adults, individuals with comorbidities known to increase risk of severe COVID-19, and rural or remote communities.

Materials/Methods: The study combined comprehensive all-payer claims data across Vermont and Maine with state-level COVID-19 testing data and the CDC vulnerable community index to qualitatively estimate factors associated with higher or lower probability of being tested. Geographic information system methods were used to assess the geospatial distribution of disparities in testing, examining testing center density and distance. Structural differences between Vermont and Maine were exploited to identify system-level factors such as provider accessibility, testing availability, and payment rules. Key outcomes were COVID-19 testing, hospitalizations, and excess mortality among underserved populations. Quantitative analyses were augmented with focus groups that gathered input from vulnerable populations on barriers to testing. Two intervention strategies were tested once barriers were identified: (1) a Discrete Choice Experiment (DCE) conducted both in vulnerable NNE communities and in a nationally representative rural adult sample to identify optimal testing strategies using hypothetical scenarios, and (2) targeted communication interventions delivered through rural communication networks to test whether communication strategies increased testing uptake and reduced disparities.

Outcome/Impact: This mixed-methods study identified barriers to COVID-19 testing at the individual, community, and structural levels and evaluated approaches to reduce disparities in testing. By testing communication strategies and preference-based interventions, the study sought to inform evidence-based strategies to increase testing uptake, improve equity, and reduce excess hospitalizations and mortality among vulnerable populations in Northern New England.