Novel Strategies to Increase COVID-19 Testing Among Underserved and Vulnerable Populations in West Virginia

Abstract

This project addressed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing barriers in rural West Virginia by providing testing enhancements that included (1) a flexible testing staff, (2) mobile testing, (3) essential supplies, and (4) specialized testing in communities of color. A total of 142 775 polymerase chain reaction tests were performed from December 2021 through February 2022; positivity rates were 21% and 17% in clinics and mobile testing venues, respectively. The project results showed that, within a statewide network of health care clinics, administrators quickly identified and distributed enhancements and thus reduced testing barriers. (Am J Public Health. 2022;112(S9):S892–S895. https://doi.org/10.2105/AJPH.2022.307004)

The novel coronavirus (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]) led to many difficulties and much distress for clinics, communities, and individuals in West Virginia (WV). The project described here identified sources of strain on these entities with respect to provision of SARS-CoV-2 testing and developed an intervention that directly addressed improving testing capacity in WV communities.

INTERVENTION AND IMPLEMENTATION

The SARS-CoV-2 pandemic has swept the globe, posing many significant diagnostic testing challenges, particularly for medically underserved and rural populations such as those residing in WV. WV’s population is the third oldest in the nation and ranks at or near the bottom in most US chronic disease categories, including those related to increased COVID-19 mortality.^1,2 The WV Rapid Acceleration of Diagnostics-Underserved Populations (RADx-UP) project was implemented to rapidly increase testing for SARS-CoV-2 in underserved WV communities in which multiple groups are at risk for severe COVID-19 disease and death.

In 2020, focus groups held among rural WV health care providers identified barriers to testing in clinical and community settings. Rural clinics reported limited amounts of testing swabs, viral transport media, and personal protective equipment. Sites noted strain on staff time and budget available to obtain supplies. Rural clinic staff members expressed strain as they worked to manage normal care duties combined with increased testing. Limited space in rural clinics reduced the capacity to provide safe testing environments during high-volume testing. Once patients were tested, clinics voiced concerns over perceived long wait times for laboratory analyses and difficulties in transportation to testing sites among rural and underserved populations.

On the basis of these findings, the WV RADx-UP project enacted targeted interventions starting in December 2020 to increase SARS-CoV-2 testing in WV communities by partnering with the WV Practice-Based Research Network (WVPBRN), the WV National Guard, and the WV Department of Health and Human Resources. The following interventions were implemented:

• •Hiring and training of 11 regionally located personnel (“flex agents”), made available to expand testing capacity across the state.
• •Procurement and distribution of testing swabs, viral transport media, and personal protective equipment throughout the state to protect testing staff and alleviate supply chain concerns.
• •Provision of outside shelter facilities (e.g., tents) for drive-through testing to protect staff and maintain services during high-volume test times.
• •Provision of convenient testing in remote rural areas by staffing and deploying mobile vans throughout the state.
• •Hiring and training of culturally competent personnel who provided on-site testing in African American communities.

PLACE, TIME, AND PERSONS

The WVPBRN is a 129-site clinical research network composed predominantly of primary care clinics in rural WV. Although a step-wedge, cluster randomized study was initially planned, the 51 participating clinics were in urgent need of the planned interventions, and we concluded that it would be unethical to withhold interventions from any clinic. Therefore, all interventions were implemented in December 2020.

Mobile van units were deployed to provide testing in counties with anticipated near-term (approximately seven days) increases in SARS-CoV-2 incidence and with limited or no testing venues. Near-term (one-week) increases in SARS-CoV-2 cases were predicted with a machine learning approach involving a long short-term memory network and epidemiological statistics such as the instantaneous reproductive number, county population information, and time series trends, including information on major holidays as well as statewide COVID-19 trends across counties.³ Testing events were advertised with flyers and on local health department dissemination platforms, including Web sites. One mobile unit with culturally competent staff was deployed to WV African American communities.

PURPOSE

As noted, the purpose of the RADx-UP project was to rapidly increase SARS-CoV-2 testing in underserved WV communities where multiple groups are at risk for severe COVID-19 disease and death.^1,2

EVALUATION AND ADVERSE EFFECTS

Flex agents were placed in 20 of the 51 clinic sites, and 12 770 personal protective equipment items, four building or tent structures, and an unspecified amount of testing equipment (e.g., swabs) were provided. In the first two intervention months, 23 685 SARS-CoV-2 polymerase chain reaction tests were conducted, an increase of 8454 tests from the two months before the intervention. From December 2020 through February 28, 2022, 130 206 SARS-CoV-2 polymerase chain reaction tests were procured by participating WVPBRN clinics; in 21% of these tests, the results were positive (Figure 1). Sixteen WVPBRN sites (36%) enacted RADx-UP practice changes to enhance SARS-CoV-2 testing, including implementing outdoor testing structures, designating specific testing times, and incorporating flex agents who completed required paperwork, prepared testing kits, and supported drive-through testing, thereby minimizing clinic staff time.

FIGURE 1—

West Virginia Practice-Based Research Network Clinic Sites, Mobile Unit Tests by Month, and Percentages of Tests With Positive Results, 2020–2022

Note. PBRN = Practice-Based Research Network

Additionally, 10 803 SARS-CoV-2 polymerase chain reaction tests (17% positive) were performed at more than 540 mobile test events in 33 counties. The communities of color van performed 1766 tests (3% positive) in eight counties, collaborating with 12 partner organizations including churches, barber shops, and private businesses (Figure 1).

Individuals aged 18 years or older who were able to read and understand English and had a SARS-CoV-2 test at a WV RADx-UP site were asked to complete a Web-based testing satisfaction survey and questions pertaining to general health status. A $30 gift card was provided electronically for a completed survey. Survey information was submitted by 633 participants (60% women, average age of 36 years, 89% White, 6% Black; Table A, available as a supplement to the online version of this article at http://www.ajph.org). Twenty individuals (3%) reported their health as poor, 15% had no health insurance, and 57% had received at least one dose of a SARS-CoV-2 vaccine. Participants’ satisfaction was high; 87% were satisfied or very satisfied with their testing experience.

Fifty-two of WV’s 55 counties received RADx-UP services. Locations of testing sites were prioritized on the basis of a predictive near-term model of increasing COVID-19 incidence and limited availability of other testing options. Both clinic- and mobile van-based testing demonstrated high positivity rates (21% and 17%, respectively), which may have resulted in part from the prioritization strategy.

Engaging with clinical partners during project development and addressing needs they identified resulted in a quick and effective response at a very stressful time for both caregivers and state health officials. We used practice facilitation methods in each clinical site to identify project interventions needed to increase testing rates. Flexibility and adaptability were essential to effectively address changing demands. For example, when vaccine rollout redirected staff away from testing, flex agents mitigated the barrier of limited testing staff within clinical sites. In the case of community testing, health departments identified areas that were found to have low testing rates. Use of mobile testing units in these locations increased testing rates and prompted health departments to continually schedule visits from the mobile units to maintain these higher rates.

SUSTAINABILITY

This project employed SARS-CoV-2 testing strategies to meet the testing demand in various locations until technologies and supplies were available to all communities in WV. By early 2022, COVID-19 testing, including home testing, had become readily accessible in WV, decreasing the need to support testing in some locations. More than one third of participating clinics enacted practice changes to enhance testing efficiency, contributing to the sustainability of SARS-CoV-2 testing availability in WV. Testing availability in underrepresented minority communities is essential, and testing must continue to be provided by trusted organizations.

PUBLIC HEALTH SIGNIFICANCE

Identifying barriers to testing, effectively responding to those barriers, and building relationships with multiple partners have effectively driven COVID-19 testing in WV and resulted in practice changes that will sustain testing capacity. Mobile van testing was essential in providing testing to the locations with the greatest need (i.e., few testing options and predicted increases in SARS-CoV-2 incidence). Emergent disease response in rural areas must focus specifically on community needs and must be nimble to effectively address changes in those needs. Lessons learned during the RADx-UP project can inform responses in rural areas to the next epidemic.