. 2024 Jan 3;24:12. doi: 10.1186/s12913-023-10341-w

Table 2.

Themes for Top Reasons for COVID-19 Testing Program Failure from Patient and Provider Interviews during Early Implementation and Mid-Implementation Phases

Patients	Providers
Phase 1/Early Implementation Themes (n) - Subthemes	Phase 2/Mid-Implementation Themes (n) - Subthemes	Phase 1/Early Implementation Themes (n) - Subthemes	Phase 2/Mid-Implementation Themes (n) - Subthemes
Advertising/Sharing information (n = 3) - Not doing enough publicity/promotion - Brochures/information sheets having too many words, too much to read "I think, not doing enough publicity, that wouldn’t help them either. I feel that people need to be informed about the tables or tents being there, that everyone is informed, because many people don’t know about it.”	Access to testing (n = 4) - Hours are limited (n = 2) - Not being available when need to get a test - Not having enough or weekend days "the number one is the hour of operation. I believe during the week it's from 8:00 to 3:00. Yeah. So I feel those hours are difficult for people to come out and get tested because of their work."	Handling test results/Return of results (n = 4) - Hard time reaching patients (n = 3) - Extra work for staff if need to deliver results at in-person appointments "the third and final thought was just imagining that follow-up for positive results may be unreliable. Phone numbers are not always as reliable for our population. And what do we do with a positive result and an inability to get a hold of [them?]"	Access to testing (n = 7) - Testing locations not convenient or safe from cars driving by (n = 3) - Not having extended or weekend hours (n = 2) - Interfering with patient access to care due to parking and logistics - Lack of technology literacy/access “I think just access to testing. And what I mean, access to testing, it's just the time that you're available to test and not being limited to just daytime hours, but opening it up to extended hours or PM hours in addition to weekend access as well….this is a working-class community. A lot of people are commuting to work or in work or commuting back home during those times. So it could be a little difficult for somebody that needs to seek care after work or before work, and not having that available could be a deterrent.”
Safety – Patients (n = 2) – not following COVID-19 safety protocols – testing location near the main clinic entrance might make others fearful of being exposed "even seeing the cases of the deceased or deaths, they don’t follow the care protocols. So since people don't believe, and don't follow the protocols of care, I think that can lead to the failure of the samples or tests that you might do."	Handling test results/ Return of results (n = 3) - Not knowing how to complete form if don’t have US address - Not knowing how to complete form if don’t have email - Mistrust of emailed test results due to formatting "I notice that some of the formatting is different on the emails that you guys send out to give the results. Right? I mean pretty much, it's the same. But when you guys either format the date of birth or put the name, it's a little bit different. So I feel if you guys had a more– if only you guys agreed on one basic template and used that template that just throw in everybody's name and date of birth, that'd be easier, because I can see how elaborate some of the these confirming those results would be like, "Why are those results different?" They're all the same, but why is their name or date of birth formatted in different areas so it looks like they're manipulated? When in fact they're not."	Patient beliefs and views regarding the SARS-CoV-2 virus "And others that have already been infected by COVID and believe that they have natural immunity; thus, no need to be vaccinated or tested."	Safety (n = 3) - Patients (n = 2) - being around potentially infected people - not maintaining social distancing during testing process - Staff (n = 1) - not enough protective equipment "see if there's patients who are symptomatic versus patients that are not symptomatic or people that are doing this for travel, there's less risk of them having it. So that could be a potential like, yes, they can do the survey, but for the other ones, I would say maybe after they've received a negative result, we could re-initiate the survey just to make sure because I think at one point we noticed there is a lot of people just in the area where the survey was…And there's also another red flag regarding too many people and the fact that they just got tested that they're not sure if they have COVID or not."
Patient beliefs and views regarding the SARS-CoV-2 virus (n = 2) "I think, more importantly, it’s the people who are apathetic, who don’t believe in this virus, who don’t trust it, who believe that there are, for example, political reasons to distract people. I think that’s the most important thing, there are many people who do not believe it, who believe that it’s something temporary"	Advertising/Sharing information - Not doing enough publicity "one of them is I didn't know about the program until here, so I don't know if this is something that is being promoted somewhere else. "	Difficult consent process "So the first thing I noticed is that the consent process could be difficult, right in the beginning, getting consent to enter the study."	Handling test results/Return of results (n = 2) - Return of results not timely - Not communicating positive results to provider "Turnaround time on test collection data. If it's taking more than 24 h to get a test result back, it could cause somebody not want to refer or to return if symptomatic, for a particular reason, just because they need results in a sooner manner"
Free testing sends message that it is not good quality "And, with having free testing, like Latinos always believe that something is bad, like it won’t be good quality, when it’s something for free. That would be the reason, that they don’t trust, that’s contradictory, because first it’s too expensive, and you don’t have the money to pay for it, but then they offer it to you for free and you distrust it. In Mexico we say, “I don't want to be the guinea pig,” that’s, I don't want to be the test animal, for example. When it's free, people think of it that way."	Clinic location in parking lot might seem untrustworthy (for those with Latino backgrounds) "I think having a testing site out in the parking lot can seem a little bit untrustworthy. I mean, yeah, it's next to a clinic. It's next to a licensed building with just doctors and everything, but having it out in the parking lot can seem a little untrustworthy for other people coming from a Latino background"	Cost of appointment for patient to discuss positive results "And essentially, it's going to be difficult for a newly registered patient who has no funding to complete that part of the system. Because when we do a telephone visit, our receptionists call up and say, we're doing this telephone visit, there's a fee. Do you have medical insurance? If you don't, then there's a fee. So at that point, even though every step before that would be free, the clinic's not going to do telephone visits for free, so."	Advertising/Sharing information (n = 2) - Not doing enough publicity “If we're not promoting enough awareness to the testing access or to the testing activities, that could be a barrier as to why it would not be successful….promotion of the services, what's being done in the community to really get the word out that this is available.”
Misinformation from unreliable sources "..think this is one of the main problems, that really, the news, the way the information reaches us or the information is downloaded [inaudible], many times it’s not that reliable. Unfortunately, social media right now– people let themselves be guided too much by social media, instead of taking into consideration if it’s true, or that it’s a way of spreading information, rather than being something true on social media, on Instagram, not from Twitter, not from Facebook. "	Staff member needed to supervise on site logistics and supplies "that there be a person supervising that, who’s on top of that, “Let’s see, what’s lacking? Know what? We’re lacking–,” whether that be tarps or more medical equipment, more chairs, more security. That somebody’s on top of that."	Culture, fears, beliefs of patients “Culture is a big one. Here being predominantly a Mexican community, the culture here is, in a sense, very traditional. And I want to say that there's skepticism within the culture. And it is a barrier that I think the health care in general has to work to continue getting people over the barrier of them saying, "Well, in my culture, we wouldn't necessarily take our kids to get tested for this or that. We're going to stay home and do home remedies."	Patients feeling ill and not wanting to participate "if someone's ill or under the weather, that may be a factor, too, in terms of them wanting to participate. They're there for care or they want to get that care and then be on their way"
Patients might think testing is not free as early tests were expensive "despite the fact that here, you’re trying to make them free, the tests, for example, the first tests were very expensive, access to the COVID test was too expensive, so people didn’t do it. But I believe that we have, unfortunately, no way to make them aware that it does exist, and that it’s necessary to carry out these tests."		Interfering with patient access to care and satisfaction due to increased documentation/paperwork "the intake and everything could potentially interfere with general patient flow for their visit, delaying them getting registered for their visit. There can be quite a lot of paperwork that they have to do just around a physical. Often their insurance may not be active, it has to be– so it's already a slow process from the time they hit the door to the time they see the physician. And if we're throwing more questionnaires and obstacles in that way, it may delay their experience at the clinic to a point where it– past the tipping point of them being satisfied with their experience…"	Survey length too long and reading level too high "in terms of survey, just the length of the survey, 50 questions seems like a lot to have to go through because you do have to spend some time to really read and understand the questions. And I don't know at what literacy level the questions are being promoted at"
Process not being agile and efficient "there are a lot of people who are very impatient, so it could be, like, if the process were agile, so that it could get done. That’s the most important, because I’ve had to go to certain places, and there are many procedures, and it’s very time consuming, so make it agile, I think that’s the important thing for the patients."		Lack of trust in system and science by patients "Also a lack of trust in the system by some. … Well, not only from what I see, of course, on the news, but the patients that we do speak to, those who are being hesitant, there is a lot of conversation about how trustworthy science is and, specifically, this vaccine. Everyone is talking about how it was developed so quickly, all of the different conspiracies. And so patients come in with their stories. And they field a certain believe that creates a barrier, and it does not allow them to trust, in this case, the health care ystem. So they brushed it off. And that's why I feel that there is a level of lack of trust in the system, the government. In the science."	Testing options offered - not having options such as rapid antigen tests "the testing options that are available at the test site, so maybe rapid antigen testing, and give options in terms of what the patient may want– or what the patient has available."
Religious beliefs of patients "Yes. Religion, religious beliefs, I think of that. I mean, there are an infinity of cults that don’t allow getting vaccines, even as a baby, so right now, I think that one, also."		Ordering of tests process is not that easy "Who is actually going to order the tests? Someone has to be on staff here to be able to order a test and have set access to order tests through our system. It wasn't clear to me whether the test was being ordered through Cocreate or was it being ordered through our system. In our system we're going to have that next gen access and figure out how to do that. It's not that easy. "
	Registering patients on system can be time consuming "The idea of newly registering a patient in five minutes is very optimistic. I can tell you that happens all the time with us. That would be very optimistic. And often they don't really get assigned even their newly registered right to a primary care physician. So we'd have to make sure that that happens."
	Testing options offered - parents might be reluctant collecting sample for their children "So the first one was just self-collection and whether parents would be comfortable doing that for their young children, especially an infant or a toddler. I'm assuming it's an anterior nares swab that you're having them do, and that's not that invasive, but they still would potentially be reluctant to do that"
	Vaccination leading to no need for testing "the research may fail because of the vaccine because people are getting vaccinated. We're really pushing the vaccine and we are now pushing for 12 and over. So the study may fail because of just the vaccine"

Patients

Providers

Phase 1/Early Implementation

Themes (n)

- Subthemes

Phase 2/Mid-Implementation

Themes (n)

- Subthemes

Phase 1/Early Implementation

Themes (n)

- Subthemes

Phase 2/Mid-Implementation

Themes (n)

- Subthemes

Advertising/Sharing information (n = 3)

- Not doing enough publicity/promotion

- Brochures/information sheets having too many words, too much to read

"I think, not doing enough publicity, that wouldn’t help them either. I feel that people need to be informed about the tables or tents being there, that everyone is informed, because many people don’t know about it.”

Access to testing (n = 4)

- Hours are limited (n = 2)

- Not being available when need to get a test

- Not having enough or weekend days

"the number one is the hour of operation. I believe during the week it's from 8:00 to 3:00. Yeah. So I feel those hours are difficult for people to come out and get tested because of their work."

Handling test results/Return of results (n = 4)

- Hard time reaching patients (n = 3)

- Extra work for staff if need to deliver results at in-person appointments

"the third and final thought was just imagining that follow-up for positive results may be unreliable. Phone numbers are not always as reliable for our population. And what do we do with a positive result and an inability to get a hold of [them?]"

Access to testing (n = 7)

- Testing locations not convenient or safe from cars driving by (n = 3)

- Not having extended or weekend hours (n = 2)

- Interfering with patient access to care due to parking and logistics

- Lack of technology literacy/access

“I think just access to testing. And what I mean, access to testing, it's just the time that you're available to test and not being limited to just daytime hours, but opening it up to extended hours or PM hours in addition to weekend access as well….this is a working-class community. A lot of people are commuting to work or in work or commuting back home during those times. So it could be a little difficult for somebody that needs to seek care after work or before work, and not having that available could be a deterrent.”

Safety

– Patients (n = 2)

– not following COVID-19 safety protocols

– testing location near the main clinic entrance might make others fearful of being exposed

"even seeing the cases of the deceased or deaths, they don’t follow the care protocols. So since people don't believe, and don't follow the protocols of care, I think that can lead to the failure of the samples or tests that you might do."

Handling test results/ Return of results (n = 3)

- Not knowing how to complete form if don’t have US address

- Not knowing how to complete form if don’t have email

- Mistrust of emailed test results due to formatting

"I notice that some of the formatting is different on the emails that you guys send out to give the results. Right? I mean pretty much, it's the same. But when you guys either format the date of birth or put the name, it's a little bit different. So I feel if you guys had a more– if only you guys agreed on one basic template and used that template that just throw in everybody's name and date of birth, that'd be easier, because I can see how elaborate some of the these confirming those results would be like, "Why are those results different?" They're all the same, but why is their name or date of birth formatted in different areas so it looks like they're manipulated? When in fact they're not."

Patient beliefs and views regarding the SARS-CoV-2 virus

"And others that have already been infected by COVID and believe that they have natural immunity; thus, no need to be vaccinated or tested."

Safety (n = 3)

- Patients (n = 2)

- being around potentially infected people

- not maintaining social distancing during testing process

- Staff (n = 1)

- not enough protective equipment

"see if there's patients who are symptomatic versus patients that are not symptomatic or people that are doing this for travel, there's less risk of them having it. So that could be a potential like, yes, they can do the survey, but for the other ones, I would say maybe after they've received a negative result, we could re-initiate the survey just to make sure because I think at one point we noticed there is a lot of people just in the area where the survey was…And there's also another red flag regarding too many people and the fact that they just got tested that they're not sure if they have COVID or not."

Patient beliefs and views regarding the SARS-CoV-2 virus (n = 2)

"I think, more importantly, it’s the people who are apathetic, who don’t believe in this virus, who don’t trust it, who believe that there are, for example, political reasons to distract people. I think that’s the most important thing, there are many people who do not believe it, who believe that it’s something temporary"

Advertising/Sharing information

- Not doing enough publicity

"one of them is I didn't know about the program until here, so I don't know if this is something that is being promoted somewhere else. "

Difficult consent process

"So the first thing I noticed is that the consent process could be difficult, right in the beginning, getting consent to enter the study."

Handling test results/Return of results (n = 2)

- Return of results not timely

- Not communicating positive results to provider

"Turnaround time on test collection data. If it's taking more than 24 h to get a test result back, it could cause somebody not want to refer or to return if symptomatic, for a particular reason, just because they need results in a sooner manner"

Free testing sends message that it is not good quality

"And, with having free testing, like Latinos always believe that something is bad, like it won’t be good quality, when it’s something for free. That would be the reason, that they don’t trust, that’s contradictory, because first it’s too expensive, and you don’t have the money to pay for it, but then they offer it to you for free and you distrust it. In Mexico we say, “I don't want to be the guinea pig,” that’s, I don't want to be the test animal, for example. When it's free, people think of it that way."

Clinic location in parking lot might seem untrustworthy (for those with Latino backgrounds)

"I think having a testing site out in the parking lot can seem a little bit untrustworthy. I mean, yeah, it's next to a clinic. It's next to a licensed building with just doctors and everything, but having it out in the parking lot can seem a little untrustworthy for other people coming from a Latino background"

Cost of appointment for patient to discuss positive results

"And essentially, it's going to be difficult for a newly registered patient who has no funding to complete that part of the system. Because when we do a telephone visit, our receptionists call up and say, we're doing this telephone visit, there's a fee. Do you have medical insurance? If you don't, then there's a fee. So at that point, even though every step before that would be free, the clinic's not going to do telephone visits for free, so."

Advertising/Sharing information (n = 2)

- Not doing enough publicity

“If we're not promoting enough awareness to the testing access or to the testing activities, that could be a barrier as to why it would not be successful….promotion of the services, what's being done in the community to really get the word out that this is available.”

Misinformation from unreliable sources

"..think this is one of the main problems, that really, the news, the way the information reaches us or the information is downloaded [inaudible], many times it’s not that reliable. Unfortunately, social media right now– people let themselves be guided too much by social media, instead of taking into consideration if it’s true, or that it’s a way of spreading information, rather than being something true on social media, on Instagram, not from Twitter, not from Facebook. "

Staff member needed to supervise on site logistics and supplies

"that there be a person supervising that, who’s on top of that, “Let’s see, what’s lacking? Know what? We’re lacking–,” whether that be tarps or more medical equipment, more chairs, more security. That somebody’s on top of that."

Culture, fears, beliefs of patients

“Culture is a big one. Here being predominantly a Mexican community, the culture here is, in a sense, very traditional. And I want to say that there's skepticism within the culture. And it is a barrier that I think the health care in general has to work to continue getting people over the barrier of them saying, "Well, in my culture, we wouldn't necessarily take our kids to get tested for this or that. We're going to stay home and do home remedies."

Patients feeling ill and not wanting to participate

"if someone's ill or under the weather, that may be a factor, too, in terms of them wanting to participate. They're there for care or they want to get that care and then be on their way"

Patients might think testing is not free as early tests were expensive

"despite the fact that here, you’re trying to make them free, the tests, for example, the first tests were very expensive, access to the COVID test was too expensive, so people didn’t do it. But I believe that we have, unfortunately, no way to make them aware that it does exist, and that it’s necessary to carry out these tests."

Interfering with patient access to care and satisfaction due to increased documentation/paperwork

"the intake and everything could potentially interfere with general patient flow for their visit, delaying them getting registered for their visit. There can be quite a lot of paperwork that they have to do just around a physical. Often their insurance may not be active, it has to be– so it's already a slow process from the time they hit the door to the time they see the physician. And if we're throwing more questionnaires and obstacles in that way, it may delay their experience at the clinic to a point where it– past the tipping point of them being satisfied with their experience…"

Survey length too long and reading level too high

"in terms of survey, just the length of the survey, 50 questions seems like a lot to have to go through because you do have to spend some time to really read and understand the questions. And I don't know at what literacy level the questions are being promoted at"

Process not being agile and efficient

"there are a lot of people who are very impatient, so it could be, like, if the process were agile, so that it could get done. That’s the most important, because I’ve had to go to certain places, and there are many procedures, and it’s very time consuming, so make it agile, I think that’s the important thing for the patients."

Lack of trust in system and science by patients

"Also a lack of trust in the system by some. … Well, not only from what I see, of course, on the news, but the patients that we do speak to, those who are being hesitant, there is a lot of conversation about how trustworthy science is and, specifically, this vaccine. Everyone is talking about how it was developed so quickly, all of the different conspiracies. And so patients come in with their stories. And they field a certain believe that creates a barrier, and it does not allow them to trust, in this case, the health care ystem. So they brushed it off. And that's why I feel that there is a level of lack of trust in the system, the government. In the science."

Testing options offered

- not having options such as rapid antigen tests

"the testing options that are available at the test site, so maybe rapid antigen testing, and give options in terms of what the patient may want– or what the patient has available."

Religious beliefs of patients

"Yes. Religion, religious beliefs, I think of that. I mean, there are an infinity of cults that don’t allow getting vaccines, even as a baby, so right now, I think that one, also."

Ordering of tests process is not that easy

"Who is actually going to order the tests? Someone has to be on staff here to be able to order a test and have set access to order tests through our system. It wasn't clear to me whether the test was being ordered through Cocreate or was it being ordered through our system. In our system we're going to have that next gen access and figure out how to do that. It's not that easy. "

Registering patients on system can be time consuming

"The idea of newly registering a patient in five minutes is very optimistic. I can tell you that happens all the time with us. That would be very optimistic. And often they don't really get assigned even their newly registered right to a primary care physician. So we'd have to make sure that that happens."

Testing options offered

- parents might be reluctant collecting sample for their children

"So the first one was just self-collection and whether parents would be comfortable doing that for their young children, especially an infant or a toddler. I'm assuming it's an anterior nares swab that you're having them do, and that's not that invasive, but they still would potentially be reluctant to do that"

Vaccination leading to no need for testing

"the research may fail because of the vaccine because people are getting vaccinated. We're really pushing the vaccine and we are now pushing for 12 and over. So the study may fail because of just the vaccine"

Bold text indicates a theme repeated across time and/or patients and providers

N indicates the number of times mentioned