Development of an At-Home COVID-19 Test Results–Reporting System for a School District Primarily Serving Underrepresented Minority Groups, San Diego, CA, 2021–2022

Abstract

School-sponsored at-home COVID-19 testing benefits users, school administrators, and surveillance efforts, although reporting results remains challenging. Users require simple systems with tailored posttest guidance, and administrators need timely positive test information. We built a system to serve these needs and to collect data for our Rapid Acceleration of Diagnostics-Underserved Populations Return to School Program study in San Diego County, California, from October 2021 through January 2022. We describe this system and our participant outreach strategies and outline a replicable model for at-home results reporting. (Am J Public Health. 2022;112(S9):S883–S886. https://doi.org/10.2105/AJPH.2022.307073)

Communities Fighting COVID! Returning Our Kids Back to School Safely, funded by the National Institutes of Health (NIH) Rapid Acceleration of Diagnostics- Underserved Populations initiative (RADx-UP), is a collaboration between San Diego State University and the Sweetwater Union High School District to develop, test, and scale-up a program providing equitable access to simple, convenient, regular COVID-19 screening testing for middle school students, staff, and their families who are most affected by the COVID pandemic to reduce household, school, and community transmission.

INTERVENTION AND IMPLEMENTATION

We developed an at-home COVID-19 antigen test–reporting system for users to provide weekly screening results and receive tailored follow-up information. The system used an algorithm that followed evolving COVID-19 testing guidelines¹ for the K–12 setting from the local departments of health and education as well as Centers for Disease Control (CDC) antigen testing recommendations.² These include when follow-up testing is recommended, promptly notifying school administration of positive test results, reporting test results to the local health department, and collecting data for our NIH-funded RADx-UP Return to School Program study. This multisector Public Health 3.0 partnership³ was effective because of the attentiveness to stakeholder needs and the centering of community voices as relayed by frontline study staff.

As originally developed, the system involved the following:

• •was available in English and Spanish;
• •provided registration and results reporting through a Qualtrics (Seattle, WA) user interface;
• •used an application programming interface from Qualtrics to a customized application reporting system;
• •linked weekly results reporting to enrollment data through study IDs;
• •generated weekly e-mailed testing reminders with a unique link to access the results-reporting survey without requiring participant study IDs;
• •provided generic QR (quick response) codes on study materials, allowing participants to scan and access the results-reporting survey, although this required study IDs to be entered;
• •generated daily test results reports in an application reporting system using data received through the previously described application programming interface, which we securely submitted to the county health department;
• •facilitated daily test results reports sent through encrypted e-mail to school officials;
• •used an algorithm based on local health department K–12 guidelines and CDC antigen testing recommendations, provided participant vaccination history, and reported symptoms, previous positive COVID-19 test history, and current test result to determine suggested next steps (e.g., PCR [polymerase chain reaction] test required or second antigen test 24–36 hours later); and
• •enabled results letters sent via encrypted e-mail to the participant’s or parent’s or guardian’s e-mail address.

Subsequent modifications to the system included the following:

• •providing participants with personalized QR codes for study materials that linked to their individual results–reporting survey, as e-mail was not an effective reminder strategy in this population; and
• •offering participants the option to receive automated results letters e-mailed through Qualtrics rather than manually sent through encrypted e-mail by study staff to reduce time to receipt.

As shown in Figure 1, as enrollment increased, results reporting decreased in December 2021. Together with the district, our team implemented iterative modifications to improve weekly test results reporting. We began targeted telephone outreach to participants (or parents of student participants) who had not submitted test results. Lists of enrolled participants that had picked up tests but not yet submitted test results were generated and shared among study and school district outreach staff. Participants with more recent pickup dates were prioritized for calls to discuss any questions and to confirm that they understood how to report.

FIGURE 1—

Number and Percentage of Weekly At-Home COVID-19 Screening Test Results Reporting Among Middle School Student Participants Who Picked Up At-Home Testing Kits: South San Diego County, CA, October 30, 2021–January 22, 2022

Note. “Eligible to test” includes student participants who enrolled and picked up at-home COVID-19 test kits.

Telephone calls were placed from school telephones and study telephones. Study staff asked about any challenges, reviewed how to report results (including clarifying which study IDs were required), reminded the participants that negative results needed to be reported, and provided step-by-step real-time reporting assistance. Study staff recorded detailed notes in the shared file to track issues and facilitate teamwork.

We created and modified instructional materials, such as an infographic about the study and a “how-to” document for test reporting placed in test bags. We modified the individualized participant testing cards to include messages about weekly testing and a personal QR code to eliminate the need to enter study IDs (which often confused participants). Lastly, our team made the instructions in the reminder e-mail clearer based on participant feedback.

Another modification was more intensive outreach and instruction at the time of test pickup, which staff described as the most helpful. This capitalized on rare in-person interaction, allowing the provision of clear instructions, including walking participants through the QR code scanning and reviewing the results-reporting survey on the participants’ devices. Staff also began to show participants their own results-reporting data, helping them to understand that results were not being recorded. Lastly, our team made enhancements to the online reporting system described earlier (still images are shown in Figure A, available as a supplement to the online version of this article at https://ajph.org).

PLACE, TIME, AND PERSONS

Communities Fighting COVID! Returning Our Kids Back to School Safely is a research partnership between San Diego State University and Sweetwater Union High School District, a large, public independent school district serving the predominantly Hispanic/Latino community of south San Diego County, California. The county, which borders the Pacific Ocean and the US-Mexico border, is the fifth largest by population in the United States.

Students, staff, and household members from a single middle school participated in this initial phase of the study from October 2021 through January 2022. Effective interventions were later implemented at scale throughout the district.

PURPOSE

In partnership with school district staff, these enhancements were made to improve weekly screening results reporting by simplifying the process for participants and implementing modifications proposed by frontline staff. School officials used results for isolation guidance, exposure notification, and initiation of test-to-stay protocols.

EVALUATION AND ADVERSE EVENTS

Together, these interventions increased participant test reporting from a downward trend in late 2021 to a steady recovery through January 2022, despite a simultaneous increase in enrolled participants.

We noted benefits and challenges to each intervention. Staff informed us that after targeted telephone outreach, participants would often report results within 24 hours. Staff also found that text messages were sometimes preferred by both parties, as they facilitated communication at different times (because of work schedules). Staff reported that they appreciated the opportunity to review study protocols one-on-one with participants, that these calls felt more personalized and private, and that participants seemed more open to asking questions over the telephone when they had more time to focus. Challenges included disconnected or wrong numbers, although this provided the opportunity to correct telephone numbers in the study database.

The creation and modification of instructional materials resulted in clearer instructions and fewer questions from participants. Challenges remained in that students sometimes misplaced materials and parents often did not read materials, although staff were able to coach parents about where to find these materials and review them by telephone.

The intensive outreach at the time of test pickup was often difficult because of time constraints, long lines during COVID-19 surges, and students not relaying information to their parents (telephone calls did help in this regard).

SUSTAINABILITY

The results-reporting system is sustainable and replicable in congregant settings (e.g., schools and workplaces) where COVID-19 screening programs are desired. The system is acceptable to participants, school administrators, study personnel, and surveillance programs. The modifications we have detailed were based on feedback and recommendations from frontline staff who interacted with participants. Although these modifications require an investment in human resources, the subsequent increases in results reporting justify these costs. It is critical that community and frontline staff feedback be prioritized when modifying systems.

PUBLIC HEALTH SIGNIFICANCE

This Public Health 3.0 cross-sector partnership of university researchers, school officials, and a county health department demonstrates that innovative solutions to COVID-19 testing access and reporting in underserved communities are possible, particularly when the community voice is incorporated. These interventions are being scaled up to 11 district middle schools, with strong participant adherence to test results–reporting protocols.