Caregivers of Black and Latino/a/x Students and School Personnel Perspectives on School‐Based SARS‐CoV‐2 Testing: Implications for Testing and Test‐to‐Stay Programs in K‐12 Schools

ABSTRACT

BACKGROUND

“Test‐to‐stay” (TTS) is an effective approach for keeping students in school post‐exposure to severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). To prepare for school‐based SARS‐CoV‐2 testing, we implemented formative research to gather perspectives on school‐based testing among school personnel, as well as caregivers of Black and Latino/a/x students given systemic racism, existing school inequalities, and the disproportionate effect of COVID‐19 on Black and Latino/a/x populations.

METHODS

We conducted in‐depth interviews with caregivers of K‐12 grade Black and Latino/a/x students and focus group discussions with K‐12 school personnel. We described the forthcoming school‐based SARS‐CoV‐2 testing program and explored potential benefits and concerns, including concerns about testing‐related stigma and discrimination, particularly toward Black and Latino/a/x students, and implementation recommendations.

RESULTS

Perceived testing benefits included school community reassurance and preventing school outbreaks. Concerns included potential student anxiety, classroom disruption, inaccurate results, and limited information for caregivers. Some participants mentioned that testing‐related stigma and discrimination could happen based on the testing selection process or results but not due to race or ethnicity. Participants provided numerous testing recommendations, including suggestions to prevent negative outcomes.

CONCLUSIONS

Participants believed that stigma and discrimination from SARS‐CoV‐2 testing is possible, although differential treatment based on race or ethnicity was not anticipated. Participants' narratives provide support for school‐based testing and the testing component of TTS.

Research has demonstrated that school‐based transmission of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) is low in schools implementing coronavirus disease 2019 (COVID‐19) mitigation practices. ¹ , ² , ³ Nevertheless, children are exposed to SARS‐CoV‐2 outside of school, as well as in schools that lack masking policies. ⁴ Previous recommendations by the Centers for Disease Control and Prevention (CDC) suggested that unvaccinated school‐aged children exposed to COVID‐19 while unmasked should quarantine for up to 14 days, ⁵ leading to substantial in‐school learning gaps. Recent studies have demonstrated that a “test‐to‐stay” (TTS) approach, where students participate in serial SARS‐CoV‐2 testing during a specified time period after exposure, effectively limits transmission and keeps students in school. ⁶ , ⁷ , ⁸ In December 2021, the CDC revised their guidelines to include TTS. ⁹ Although approaches to TTS vary, school‐based SARS‐CoV‐2 testing is an essential component of most TTS programs.

Prior to the identification and promotion of TTS by the CDC and others, ¹⁰ we had initiated the research described here as part of the National Institutes of Health Rapid Acceleration of Diagnostics Underserved Populations (RADx‐UP) initiative on the social, ethical, and behavioral considerations of school‐based SARS‐CoV‐2 testing among underserved and vulnerable populations. Recognizing the importance of incorporating the voices of individuals who are the focus of public health interventions, we conducted rapid formative research to gather the perspectives of key stakeholders on school‐based SARS‐CoV‐2 testing to inform school‐based testing programs for the fall 2021 school semester. We were also interested in identifying the potential for any negative effect of school‐based SARS‐CoV‐2 testing among students who identify as Black and Latino/a/x and their families, due to long‐standing systemic racism in the United States; ¹¹ the disproportionate effect of COVID‐19 on Black and Latino/a/x populations; ¹² , ¹³ , ¹⁴ and existing inequalities in schools toward Black students, Latino/a/x students, and other students of color. ¹⁵ , ¹⁶ , ¹⁷ , ¹⁸ As researchers, we acknowledge that race is a social construct, ¹⁹ and the historical experiences of inequalities and racism based on the concept of race shaped the overall purpose of our study. We also designed our study so that the findings could be actionable and rapidly disseminated to stakeholders who could implement the participants' recommendations in forthcoming school‐based SARS‐CoV‐2 testing programs. Our objective was to foster the positive aspects and mitigate negative effects from SARS‐CoV‐2 testing in schools among Black and Latino/a/x students by: (1) gathering the perspectives of caregivers of students who identify as Black and Latino/a/x, as well as school personnel, on the potential benefits and concerns about testing students for SARS‐CoV‐2 in school, including testing‐related stigma and discrimination, and on recommendations for implementation; and (2) sharing this information with key community, health, and education stakeholders to inform the implementation of SARS‐CoV‐2 in‐school testing in the fall of 2021 (ie, 2021‐2022 school year).

In this manuscript, we describe the findings of this research and share the perspectives of school personnel, as well as caregivers of students who identify as Black and Latino/a/x, on SARS‐CoV‐2 testing in schools in general and then describe the implications for TTS.

METHODS

We conducted a small, rapid, formative qualitative descriptive study ²⁰ , ²¹ using telephone one‐on‐one in‐depth interviews (IDIs) and virtual focus group discussions (FGDs) in a single county in North Carolina. Within this county, the public school student population was 41.6% African American; 32.8% Hispanic/Latino; 19.0% White; and 6.6% American Indian, Asian, Hawaiian‐Pacific, or multi‐racial in 2021. ²² The charter school student population was 52% African American; 18% White; 17% Hispanic/Latino; 8% multiracial; and 5% Asian in 2018. ²³

For the IDIs with caregivers of students, we purposefully selected ²⁴ adult caregivers (eg, parent, grandparent, or legal guardian) who provided the day‐to‐day care of a K‐12 Black and/or Latino/a/x student who attends public or charter school. Two local community‐based networks recruited caregivers: (1) the African American COVID Taskforce Plus (AACT+); ²⁵ and (2) the Latinx Advocacy Team and Interdisciplinary Network for COVID‐19 (LATIN‐19). ²⁶ For the FGDs with school personnel, we purposefully selected ²¹ individuals who were employed as K‐12 school personnel in public charter schools. School administrators, principals, assistant principals, school nurses, counselors, teachers, and support staff were eligible to participate. School‐based partners of the ABC Science Collaborative's ²⁷ RADx‐Up study recruited school personnel. The ABC Science Collaborative helps schools and community leaders make informed decisions about school‐based SARS‐CoV‐2 policies and conducts SARS‐CoV‐2‐related research to determine how best to keep children and adults safe from SARS‐CoV‐2 while at school.

Our overall inquiry was framed by: (1) the CDC's Guiding Principles of the COVID‐19 Response Health Equity Strategy, ²⁸ including their recommendations to “use data driven approaches,” “foster meaningful engagement with community institutions,” and “reduce stigma”; and (2) the Equity‐Focused Implementation Research for Health Programs (EquIR), ²⁹ where we focus on activities within the program planning phase (eg, identifying current health inequalities and equity‐sensitive recommendations). The Theory of Care‐Seeking Behavior ³⁰ and the Health Equity Implementation Framework ³¹ , ³² guided the topics we explored in the IDIs and FGDs, respectively, and are described in more detail below.

Racial and ethnic concordant interviewers conducted the interviews with caregivers. A bilingual, Latina interviewer conducted the IDIs with caregivers of Latino/a/x students in English or Spanish, per the caregiver's preference. One of 2 Black female interviewers conducted the IDIs in English with caregivers of Black students. The IDIs were audio‐recorded with permission and explored the following constructs of the Theory of Care‐Seeking Behavior: (1) affect: a caregivers' feelings about having their child tested for SARS‐CoV‐2 at school, with an emphasis on exploring concerns about confidentiality, privacy issues, existing school‐based stigma and discrimination, and anticipated stigma or discrimination associated with testing toward any student, as well as the potential for differential treatment toward Black and Latino/a/x students; (2) utility: caregivers' beliefs about the expected outcome and the value placed on testing at schools; and (3) external facilitating conditions: including suggestions for facilitating testing in schools.

The audio‐recorded FGDs explored the following constructs of the Health Equity Implementation Framework: (1) recipient factors: perceptions of the effect of school‐based SARS‐CoV‐2 testing on students and their families (ie, perceived benefits and potential concerns), including the possibility of any disproportionate negative effect of testing on students; and (2) inner‐level (school) factors: perceptions of the effect of testing on school personnel and school functioning, as well as recommendations for implementing testing in schools.

Prior to the IDI and FGD questions on SARS‐CoV‐2 testing, we explained to participants that schools will offer SARS‐CoV‐2 testing when students return to school in the fall (ie, 2021‐2022 school year). We indicated that schools may implement different testing programs. For example, some schools may choose to implement surveillance testing, where consenting students and staff are randomly selected to participate in testing. Other schools may choose to implement exposure testing, where students and staff who have been in close contact with a person diagnosed with COVID‐19 will receive a recommendation for testing. We explained that testing may be done at school by the local health department, by partners at a local university (ie, the ABC Science Collaborative), or home tests may be provided, and tests will use a non‐invasive nasal swab.

After we completed data collection, we used a rapid analysis approach ³³ to analyze the data, summarizing information from the structured debriefing forms that interviewers completed after each IDI and FGD. We then: (1) sent summaries of key findings ³⁴ from the rapid analysis to participants, with their permission, before publicly disseminating the findings; and (2) presented the rapid analysis findings ³⁴ to community groups and North Carolina government officials associated with school‐based testing, so the findings could inform school‐based testing in the fall 2021 semester.

To formally analyze the data, we created verbatim transcripts following a transcription protocol, ³⁵ and used applied thematic analysis. ³⁶ The interviewers and FGD moderator were also trained qualitative analysts and part of the analysis team. We analyzed the IDIs and FGDs separately using the same approaches. First, using NVivo 12, ³⁷ analysts applied structural codes ³⁸ to segment participant narratives into broad conceptual categories. The structural codebook was informed by the rapid analysis findings, as well as the constructs of The Theory of Care‐Seeking Behavior ³⁰ and The Health Equity Implementation Framework. ³¹ , ³² Analysts conducted inter‐coder reliability (ICR) assessments, and afterward, adjusted the structural codebook and re‐coded transcripts, as appropriate. Next, analysts identified and applied content codes ³⁸ to sections of participant narratives captured in each structural code, conducted additional ICR assessments, and adjusted content codebooks and re‐coded transcripts as needed. After all participant narratives were coded, analysts created data reduction tables to help identify salient perspectives, wrote memos to summarize participants' narratives, and included all findings in analytical reports with illustrative participant quotes.

For this paper, we combined findings from the formal analysis on similar concepts (ie, benefits, concerns, and implementation recommendations) from the theoretical and framework constructs described above.

RESULTS

Study Participants

We conducted 12 IDIs with caregivers and 2 FGDs with 7 school personnel from June 2021 through August 2021. Caregivers were 31‐71 years of age. All caregivers self‐identified as cisgender female; a range of highest level of education was reported, from sixth to eighth grade (n = 1, 8%) to a master's degree (n = 3, 25%). Five caregivers of Black students identified as non‐Hispanic Black or African American and 1 identified as Black Latina. All caregivers of Latino/a/x students identified as Hispanic or Latina (Table 1). The caregivers' children attended traditional public or public charter schools, with ages ranging from 7 to 17, although almost all were 12‐17 years of age. Five caregivers had previously tested positive for COVID‐19, 8 reported a family member with a previous positive COVID‐19 diagnosis, and 8 knew someone who had died from COVID‐19 complications. Among school personnel, 4 participated in the first FGD and 3 in the second FGD. All were teachers or teaching assistants employed at 1of 2 public charter schools and taught a range of grades. Six identified as cisgender female, 2 identified as Black, and 1 identified as Hispanic/Latina (Table 2). School personnel had experience with school‐based SARS‐CoV‐2 testing since their schools had implemented a brief testing program during the spring 2021 semester (ie, 2020‐2021 school year).

Table 1.

Caregiver Demographic Characteristics

Characteristic	n (%*), n = 12
Age
30‐39	3 (25.0)
40‐49	5 (41.7)
50‐59	3 (25.0)
70‐79	1 (8.3)
Gender: cisgender female	12 (100.0)
Race
Black or African American	6 (50.0)
Other †	5 (41.7)
Prefer not to respond	1 (8.3)
Hispanic or Latino/a/x ethnicity	7 (58.3)
Highest level of education
6th‐8th grade	1 (8.3)
9th‐12th grade	4 (33.3)
High school graduate	2 (16.7)
Some college (did not complete degree)	1 (8.3)
Technical, vocational, or associate's degree	1 (8.3)
Master's degree	3 (25.0)

^*Some totals do not equal 100% due to rounding.

^† Participants responded “Mexico,” “Mexican,” or “Indigenous to Mexico.”

Table 2.

School Personnel Demographic Characteristics

Characteristic	n (%), n = 7
Age
30‐39	1 (14.3)
40‐49	6 (85.7)
Gender
Cisgender female	6 (85.7)
Cisgender male	1 (14.3)
Race
Black or African American	2 (28.6)
White	5 (71.4)
Hispanic/Latino/a/x ethnicity	1 (14.3)
Highest level of education
Bachelor's degree	2 (28.6)
Master's degree	5 (71.4)
Role
Teacher	5 (71.4)
Teaching assistant	2 (28.6)
Grade level taught
Kindergarten‐grade 3	2 (28.6)
Grades 4‐8	3 (42.8)
Grades 9‐12	2 (28.6)

Perceived Benefits of School‐Based SARS‐CoV‐2 Testing

Caregivers

Most caregivers believed it was beneficial to test children for SARS‐CoV‐2 in schools and perceived 4 main benefits. First, caregivers elaborated on the reassurances that testing would provide. Caregivers explained that students may be comforted in knowing that they are taking precautions to stay safe. They explained that caregivers like themselves would perceive that the school is taking steps to create a safe environment for their children, particularly given that children interact with people outside of their households when in school. Caregivers also expressed that school‐based testing would provide reassurance by contributing to keeping others outside the school environment safe, particularly family members living with students and people with whom the family frequently interacts. Some caregivers found it reassuring that their children would be tested at school because they or other family members had medical conditions which put them at greater risk for acquiring SARS‐CoV‐2.

Second, several caregivers suggested that testing students for SARS‐CoV‐2 in schools would bring awareness of COVID‐19 and resources to communities. Caregivers explained that their communities lack accurate information about COVID‐19 and that some people in their communities do not believe COVID‐19 exists. Caregivers also believed that SARS‐CoV‐2 testing in schools would lead to the identification of communities that need additional resources to combat COVID‐19, based on number of cases identified.

Third, some caregivers suggested that school‐based testing is a convenient testing option for families. School‐based testing saves time because caregivers do not need to seek out community testing sites, it prevents students from missing school to be tested elsewhere, and it provides an opportunity for students to be tested who do not have regular access to health care (Table 3, Section 1). Fourth, a few caregivers expressed that school‐based testing could reduce community spread by detecting cases earlier compared to no school‐based testing.

Table 3.

Caregiver Quotations on SARS‐CoV‐2 Testing in Schools

Sub‐Topic	Participant Quotation
Section 1: Benefits of SARS‐CoV‐2 testing in schools
Reassurance
For students	[Testing provides] reassurance that he's okay… he'll know if he got it or not. It won't be on his mind. [He'll think] “I got tested this week. It came out negative. Okay, I'm good. I've been doing good. I've been keeping my mask on. I've been doing social distancing. I've been washing my hands.” It's a solid reminder that you got to be careful.—Caregiver of a Black student
For caregivers	[Testing] is a way to reassure me they haven't been exposed to the virus, and that they're not going to spread it to other children in case they do have it.—Caregiver of a Latino/a/x student
For family members	It would be [beneficial to have testing in schools] because they [ie, participants' children] have grandparents that are elderly. So, it would be beneficial for us to know so we know not to go around them.—Caregiver of a Black student If they are testing at school and detect infected children—for example, if [child's name] has been exposed and tests positive—we can take measures at home, and isolate them, so that they do not infect other children or other family members.—Caregiver of a Latino/a/x student
Community awareness and resource provision	I think that there would be many benefits for the community. Some people say, “Oh, not my daughter,” or they think that COVID isn't true. But I think that [testing] would be of great help because…when you know that someone already has it [ie, tests positive], you can tell them and prevent many infections.—Caregiver of a Latino/a/x student Getting the peace of mind. Getting resources to that community. If a certain area is getting tested and there's a lot of positives, then you can send in reinforcements to help so it will stop the spread. Because sometimes people are catching COVID because they don't have the resources to protect themselves.—Caregiver of a Black student
Convenience	[I]f they do [testing] at school, you don't have to worry about where to take them to get tested, especially for working parents who don't have a lot of time to get off work and take them. It is better if they are done at school.—Caregiver of a Black student I guess some kids don't have a primary doctor…They should have it at school for some of the people that can't make it to a doctor's office.—Caregiver of a Black student
Reduce community spread	Yes, I see some benefits for the community because then people are able to kind of put a stop to it. If they find out they have it, they can kind of go into quarantine, and more people won't be affected…—Caregiver of a Black student To have better control of the disease…to know who is infected and to take precautionary measures…People who don't have access to testing and don't know they are sick. I think that's one way the disease can spread further.—Caregiver of a Latino/a/x student
Section 2: Concerns with SARS‐CoV‐2 testing in schools
Inaccurate results/type of test	I just want to know is it just like doing a DNA test? Are they going to do it? …How sure am I you're not going to get it mixed up with someone else's? I think that's my only concern about that. It could be anonymous, but I don't want you to say “Johnny” [pseudonym] got it and it wasn't “Johnny”, it was his friend “Chris.” How would they make sure that it's anonymous but you have the accurate test for the person?—Caregiver of a Black student Are they going do the rapid testing at schools? … But what's the accuracy of the testing for the students doing the rapid test or doing a regular test? Because tests, some can be positive, some can be negative or false negative and I know [my child] had a friend that got very sick with all the symptoms and her test was negative.—Caregiver of a Latino/a/x student
Logistics	I would want to know who is doing the testing… how long is it going to take for this testing? Is this just the school nurse? Is it some random person that they just said “Hey, we do free testing”? It's a lot of questions.—Caregiver of a Black student
Stigma and discrimination
Toward students testing positive	If they test positive and the student has to be sent home, when they come back, you have the stigma that a lot of students or friends…were concerned about pointing fingers. “She's sick.” or “She might still be sick,” even though she came back. Things like that. It's not a matter of race anymore. This is a matter of—I guess a lot of people that have been through it—survival.—Caregiver of a Latino/a/x student [I]f somebody has COVID and they come to school, “Oh, they had COVID.” Yes, I guess there is a bigger stigma to it…for the middle school and high school [students], they make fun. It will be some bullying or some kicking. So, for children who have to be tested at school… keep it as discreet as much as possible.—Caregiver of a Black student
Toward Black and Latino/a/x students	[Students] shouldn't be discriminated against because I think [testing] is a good thing, and it should be the same for everybody. Probably if a child tests positive, they might not want to go around them; it's logical that maybe that child would have to be isolated, but I don't think it would have anything to do with racism…I think it would be anyone who has the disease. I think they don't feel racism from their teachers, but sometimes kids tend to make fun, instead of saying, "Too bad this person has the virus."—Caregiver of a Latino/a/x student No. I don't think so [differential treatment toward Black and/or Latino/a/x students from testing]. Here you don't see a lot of racism, yes there is, but not much. Racism is not on a high scale here. Here almost everything is equal, in this county, almost everything is the same for everyone.—Caregiver of a Latino/a/x student No [differential treatment toward Black and/or Latino/a/x students in general]…because he's primarily been in schools that are majority Black or Brown. And that is by design. I want him to feel safe and be able to maximize his learning experience.—Caregiver of a Black student
No concerns	No. Not really. No concerns. I'm sure that they'll do, organized in the best way, the ways that work best for them. So, no real concerns—Caregiver of a Black student
Section 3: Recommendations for SARS‐CoV‐2 testing implementation
Selection process	Be fair about it. Test everybody. If you want to test the first 100 people that come today, we're making sure that when you get ready to do another day, you are not testing the same children. Because we all know the first ones there are the ones who need breakfast, and most of the time it's going to be our Black babies.—Caregiver of a Black student I think they should just ensure that the same children are not being tested repeatedly. They need to come up with some kind of system. If you guys are going to do—and they may not even want to do it by the class, they might want to start doing it by the last name. We'll do A through B today, C through D.—Caregiver of a Black student
Communication	To gain the trust as a parent, they would have to have that communication open…What they're going to do? How they're going to follow procedures? Who can you contact? How are they going to contact parents if the student tests positive? And, what are their guidelines? Posting all that on their website at school, it's going to bring a little bit of ease. And, for parents to be able to trust that they know that something is going be put in place. There's steps to follow, there's guidelines to follow. Who's going to do what, who you can call. The school being available for …any question that we might need [answered].—Caregiver of a Latino/a/x student Yes, giving information to parents…for example, I imagine that a month later saying, “Okay, in this month, there have been no cases.” Like, updating us and saying, “Okay, this number of tests were done this week on these many students.” And then, saying, “There haven't been any positive cases” or “There's been one, but these precautions were taken, and we prevented it from spreading.” Something like that.—Caregiver of a Latino/a/x student
Services during quarantine	Making sure [students] have the supplies so they can continue to go to school at home remotely. So they won't miss out. Give them a care package. “Okay, you tested positive. Here's your care package. We'll see you when you get back.”—Caregiver of a Black student Looking for all of those resources, “Okay, you got COVID, this is what you have to do.” Provide all the resources they can for that family, from food to hospital or clinic phone numbers that can see them in case the disease would get complicated. Also, in this case, the child, how to help him while he's at home and what he can do regarding school.—Caregiver of a Latino/a/x student

COVID‐19, Coronavirus 2019; SARS‐CoV‐2, Severe Acute Respiratory Syndrome Coronavirus 2.

A few caregivers did not identify any direct benefits of school‐based SARS‐CoV‐2 testing because they said their children were vaccinated or because they could be or were tested elsewhere. Ultimately, all but 1 caregiver either wanted or found it acceptable for their children to be tested for SARS‐CoV‐2 at school; the remaining caregiver wanted to be present when her child was tested as she is normally present during other medical testing.

School personnel

School personnel described 4 main benefits of school‐based SARS‐CoV‐2 testing. First, school personnel believed that testing could prevent a COVID‐19 outbreak at their school. They explained that awareness of a positive diagnosis in a classroom would allow them to keep classrooms separate during activities when classrooms typically congregate during the day, ideally containing cases to a single classroom. Additionally, identifying asymptomatic cases would help the school identify “invisible outbreaks” and prevent students from being exposed to the virus at school.

Second, testing students at school would give students and their families peace of mind and reassurance that the school was doing everything it can to keep the school community safe. School personnel elaborated that school‐based testing would be reassuring for students and their families because awareness of a positive result could allow steps to be taken to reduce transmission to family members and those vulnerable to the virus. They also recognized that many parents are nervous about sending their children to in‐person school, and school‐based testing could help to ease parents' anxiety. Moreover, they described that in‐school testing would provide school personnel with peace of mind because of the potential for reducing their exposure at work, particularly as students come to school with symptoms that could be either a normal cold or COVID‐19.

Third, school‐based testing could foster a sense of community, pride, and empowerment among students because they are doing their part to end the pandemic, recognizing that everyone needs to work together to keep others in their community safe.

Fourth, school personnel emphasized that testing for SARS‐CoV‐2 in schools was convenient and eliminated the need for caregivers to figure out the complicated logistical aspects of having their child tested. For students without regular access to medical care and for students from Spanish‐speaking families, having testing readily available at school could help to relieve the burden on families by providing access to testing or by eliminating the need for families to find a Spanish‐speaking testing site (Table 4, Section 1).

Table 4.

School Personnel Quotations on SARS‐CoV‐2 Testing in Schools

Sub‐Topic	Participant Quotation
Section 1: Benefits of SARS‐CoV‐2 testing in schools
Prevent outbreaks	[I]f one classroom is exposed, you can…stop it from progressing to other classrooms. We share recess spaces with other classrooms at times. That's a way of making sure we don't send two classrooms in at one time to the field, for example, and then passing it on. The obvious benefit being hopefully catching some of the asymptomatic cases that are coming through our community…so, hopefully being able to catch bigger problems before they evolve and affect more people.
Peace of mind and reassurance	…in the same way I'm not super eager to be swabbed myself, I doubt my kids are going be super eager either…But, we will endure this in exchange for some peace of mind, some confidence that the school [is] spending all this time really trying to monitor and make sure that this is a safe environment for everybody. I think for some kids, it would be reassuring. I know last year we had several kids that every time they would sneeze, they just automatically assumed…I can see [testing] providing some kids that are super anxious or hyper‐focused on certain things that you just have a cold. You don't have COVID. That sense of relief for the students possibly. [Testing shows that] we're doing everything we can. We can confidently tell the families, “Hey, I know you live with grandma. We're doing everything we can to make sure the student who comes back to you is not being exposed to COVID.” We can say as of right now, they were not in the perimeter that makes them high risk for exposure to COVID. And just being able to have those conversations within the parameters of privacy and just say, “Please know we have your back.”
Sense of community, pride, and empowerment	I feel like some kids would have a sense of empowerment. Like they're helping in this situation that we're all in. Yes, you are only 9 or 10 years old, but you can play your part by getting tested, helping prevent the spread if you are positive. My hope is that [testing] lends to a community, kind of greater good feeling that we're trying to protect one another. And that we're trying to keep each other healthy and our community safe. That's my hope, anyway…I hope that's the feeling that is perpetuating.
Convenience	I know in the spring we had a lot of Spanish‐speakers in our classroom, and we had a couple of instances where kids came sick and got sent home. Then [caregivers were like] “Where do I take them?” Trying to serve as a translator, I do a lot of trying to find somewhere that [is a] Spanish‐speaking testing site for those parents. [School‐based testing] would eliminate that whole hassle. I would say for my students at my school, we're a Title I school, so the students may not go frequently just to have simple things done at the doctor's or physician's office. But having [testing] taken care of at the school, I think that kind of takes some pressure off the demographic of our school, off the parents to know that, “Okay, at least we know that this is what's occurring.”
Section 2: Concerns with SARS‐CoV‐2 testing in schools
Student anxiety	I can see kids being concerned that Mom or Dad is not there to hold their hand. Some kids get anxious if they have a test. I can see some kids just perhaps not coming to school if they knew it was their day to be tested…But again, I think as a school if we can educate the kids and let them know what this will look like, that would go a long ways hopefully. I think that the students could be worried that they may actually have it or they may be the one that carried it home and caused grandma or uncle to be in the hospital.
Stigma and discrimination	But I just worry [about] a teacher who's possibly against this testing just making it harder on the students…Being more angry about it. Like [to the student], “Oh, my goodness. You have to go get tested, you're going to miss this activity.” Just making it harder than it has to be instead of understanding that you may not want to be tested, but this is important for our school community. I think right now it's that unfortunate political divide that keeps happening. People make a lot of assumptions based on the fact you're willing to volunteer and be tested for COVID. I think that happens with the kids…[referencing their Spring 2021 testing program]. I think that sometimes there was a political component to kids who were like, “I'm going to go get tested for COVID. My parents volunteered me.” And, then the kids who were like, “Ew, why would your parents do that? COVID's fake.” So, just parroting what they hear from their parents…it's a little tricky when you hear the kids parrot what they hear at home. It creates these divides that were not necessarily there before that…But right now, COVID is just that hot topic that they're able to say either, “I'm willing to be tested for COVID. I believe this is a real thing.” Or, “This is fake news. Just ignore it. It's going to go away.” …I do think it was a slight con for a few kids who were like, “Oh my gosh, I can't believe my parents signed me up for this. Now all my classmates know.” My school is like 99% Brown. So, at my school we're all in this fight together. So, we haven't experienced that [differential treatment toward students due to race and ethnicity].
Privacy	I could see some considering it an invasion of their privacy. Just that it's not going be over the intercom, “[Name] has COVID. He tested positive today.” …I could see a parent being concerned. “Is my child going be targeted?” In whatever sense that could be.
Classroom disruption	During a FGD conversation among school personnel: Participant #1: I just think about the potential disruption. The logistical implementation. When is it happening? How often is it happening? I don't like it when they take [school] pictures during class time because I need their booties in chairs doing stuff, listening every minute. Participant #2: Lost instruction time, I would say. Participant #3: Particularly for the anxious kids, that a 5‐minute stepping out becomes an ordeal. Participant #2: And, even the kids waiting to go, I would be the one, “Oh gosh, maybe I'm next. I'm not listening to what my math teacher – I've got to go in five.”
School personnel involvement	My question would just be…would we be the ones in charge of relaying the message to parents? I could see some parents getting upset with us saying your child has to stay home for X number of days. My question would be, what would our role be in this? …I could see that taking up a big portion of the day possibly. Just with emails of maybe not agreeing with the test or just not knowing.
Section 3: Recommendations for SARS‐CoV‐2 testing in school
Framing	I actually had some kids who had to quarantine [in Spring 2021] and it was just no big deal to them. I think it's all in how we frame it. If you frame it as a stigma, then it's going appear that way. But in my class, we have safety precautions. As a [name of subject] teacher, I've always had safety precautions. It's just another day. They just log onto Zoom. Then once their quarantine was over, they just came back and there really was no issue that I saw.… like the way that our managing director and our principal and the teachers too. The way that we frame it, if we make it seem like a stigma, like ooh, it's your turn to get tested, then that's going be a problem. But can you just run over and do your test and come right back, that kind of thing, then kids don't really think anything of it. I think that's where it really starts from the top. You approach this with your students, especially at my school, we supposedly strive for empathy. Testing for COVID, at the end of the day, is an empathetic move. We're trying to keep our community safe. I think if you approach it from that aspect, that changes the face of the game. I think that's something that really needs to happen, is it has to start from the top. Our administration and all administrations need to look at it. We're trying to move forward. We want to keep each other safe. We want to keep each other healthy. I think if you approach as an empathetic move for your school and use that empathy as your kind of avenue, that changes how your students look at the process and why you're doing it.
Privacy	I can say from the group that I hosted [in Spring 2021 testing], that was a big spark for them [ie, having a private space] because they were like, “Why am I coming out with two fourth graders, two fifth graders, two sixth graders?” It became a discussion point very quickly. I'm sure it went back to the classrooms like, “You're never going to believe who I just went to get COVID testing with.” So, even if they were proud of it, they were very willing to spill the beans on what was happening. If they just went out with one other person from their grade level, that's not unusual. But to go up with 10 other people, they're like, “Oh my gosh, you are not going to believe who I just went up to the elementary school with. Here let me write it down for you.”
Translation	We don't translate anything into Spanish…Huge problem. So, those parents probably didn't even know we had this pilot program [in Spring 2021]. I can think of two parents right now that their children were in [grade level] last year that don't speak English. Luckily, we have a [staff member] that is a native Spanish speaker on staff. But what if we didn't?
Caregiver and school personnel support	I just think that having the support of the parents, and the parents fully understanding what is happening and why it's happening, and then having admin also being supportive and being part of the process. I think those are the main things that make this program successful, the parent support and the administrators' support as far as willingly being a part of the testing process.

COVID‐19, Coronavirus 2019; SARS‐CoV‐2, Severe Acute Respiratory Syndrome Coronavirus 2.

Potential Concerns with School‐Based SARS‐CoV‐2 Testing

Caregivers

Many caregivers did not express any concerns with implementing SARS‐CoV‐2 testing in schools, and several indicated that they trusted their school to organize testing. The 2 concerns that were expressed focused on the possibility of receiving inaccurate test results and wanting to be well‐informed about testing logistics, including who is conducting the testing, the type of test used, how students would be selected, and how often testing would be done.

Half of the caregivers did not anticipate any stigma or discrimination to result from school‐based SARS‐CoV‐2 testing and hoped this would not occur. Conversely, about half felt that stigma or discrimination might be directed toward students testing positive, although this outcome would not be based on race or ethnicity. A few caregivers said the method of selecting students for testing could result in stigma and discrimination, although they did not anticipate this outcome. A few caregivers elaborated that stigma and discrimination was not expected because their school had a high number of Black and/or Latino/a/x students or because they have not previously witnessed racism at their school (Table 3, Section 2).

School personnel

School personnel's concerns focused on 5 main areas. First, school personnel thought testing might cause students, particularly younger students, anxiety because they might be unaware of how the testing process works and a caregiver would not be present to comfort them. Additionally, a positive result might worry students because they would then be aware that they could pass the virus to others in their household, leading school personnel to suggest that some students may prefer not to be tested, since “ignorance is bliss.”

Second, school personnel recognized the potential for stigma or discrimination toward students participating in the testing program by teachers and fellow students, given the divided political climate in the United States. For example, school personnel expressed worry that teachers who are opposed to testing might negatively frame the testing process, stigmatizing students who are tested by emphasizing missed classroom time. They also explained that they witnessed extreme political divisions regarding COVID‐19 among caregivers, which led to the politicization of their spring 2021 testing program. Social media contributed to this divide, and school personnel expressed concern that parents who are vocally opposed to testing might make other parents uncomfortable and, therefore, less likely to provide consent for testing. They further described that they witnessed negative comments by some students toward their peers who were participating in the spring 2021 testing program, believing that in many cases, students were echoing their caregivers' attitudes toward testing. School personnel also expressed concern that comments by other students, particularly among students in the upper grades, might make some students reluctant to continue participating in the testing program. Additionally, past non‐COVID‐19‐related examples of differential treatment by teachers and students toward Black and/or Latino/a/x students were mentioned. Some school personnel had also witnessed differential treatment toward Black and/or Latino/a/x students related to COVID‐19 exposure and diagnosis. Nonetheless, narratives about stigma or discrimination related to SARS‐CoV‐2 testing at school focused on the potential for differential treatment due to being tested and students' test results, as opposed to differential treatment due to race and ethnicity.

Third, student privacy was described as a potential concern, with school personnel commenting that some families might consider testing to be an invasion of their privacy or worry that their child's personal information, such as their COVID‐19 diagnosis or participation in the testing program, would be released publicly.

Fourth, school personnel voiced concerns about the potential impact of testing on instruction time, explaining that long testing times would reduce time for classroom learning and might be disruptive; some students might find it difficult to focus on a lesson when testing is pending, and after testing, some students might not transition easily back into the classroom once their focus has been interrupted.

Finally, some school personnel noted it would be burdensome to be personally involved with administering the SARS‐CoV‐2 test or communicating test results to caregivers (Table 4, Section 2).

Recommendations for Implementing School‐Based SARS‐CoV‐2 Testing

Table 5 lists numerous caregiver and school personnel recommendations for implementing school‐based SARS‐CoV‐2 testing. Participants stressed that schools should establish clear SARS‐CoV‐2 protocols based on CDC guidelines. They also emphasized that the framing of the testing program and the method for selecting students would be critical for reducing the potential for any stigma or discrimination toward students. For example, testing and quarantine could be likened to other safety precautions routinely used in school; whole classrooms could be selected for testing, or students could be tested in alphabetical order, so that students do not feel or are perceived to be individually targeted; and communication about testing could focus on the common good and how anyone can get COVID‐19. Other recommendations focused on caregiver communication, privacy, translating all communications into the appropriate languages, garnering caregiver and school personnel support, and providing necessary services (see Tables 3 and 4, Section 3 for participant quotes).

Table 5.

Caregiver and School Personnel Recommendations for School‐Based SARS‐CoV‐2 Testing

Schools should establish clear SARS‐CoV‐2 protocols (eg, masking, distancing, communication of test results, quarantine policies) based on CDC guidelines and follow them consistently

The framing and presentation of the SARS‐CoV‐2 testing program to the school community (eg, students, caregivers, school personnel), as well as the method of selecting students for testing, will be critically important, both for acceptance of the testing program and to reduce the possibility of it resulting in stigma or discrimination toward students

Providing clear communication about the specifics of the testing program, contact information for support and questions, and regular updates about case numbers will build caregiver trust toward schools

Informational materials about school‐based SARS‐CoV‐2 testing should be provided in English and other languages, particularly Spanish, and translators should be available to ensure understanding, particularly for caregivers who cannot read

Caregiver and school personnel involvement in planning school‐based SARS‐CoV‐2 testing, as well as their support, is essential, allowing for testing procedures to incorporate solutions that address caregiver concerns and minimize teacher burden and classroom disruption

Testing should be conducted before or after school, or at designated times per grade, and teachers and students should be alerted in advance to minimize classroom disruptions

Student privacy can be maintained by treating testing like other activities for which students are pulled out of class, only testing students with others from their grade, and utilizing a private space

Health care professionals, rather than school personnel, should conduct the testing and make contact with affected families, and caregivers should be informed before students, preferably through a phone call so that questions can be answered immediately

To protect student privacy, only essential details, such as grade level, should be communicated to the school community when a student tests positive; the school community should also be informed that only close contacts of students who test positive will be contacted during contact tracing

Schools should develop plans for keeping students who are diagnosed with SARS‐CoV‐2 engaged with the school community and for providing families with essential services during the quarantine period, such as means to continue learning (eg, provide laptop and other school materials and incorporate virtual learning), support for students' overall well‐being (eg, provide counseling with a social worker, meals, care package), and informational resources (eg, guidance for managing COVID‐19 and contacting the health department)

COVID‐19, Coronavirus Disease 2019; SARS‐CoV‐2, Severe Acute Respiratory Syndrome Coronavirus 2.

DISCUSSION

We conducted a small qualitative study to rapidly gather and analyze key stakeholder perceptions on SARS‐CoV‐2 testing in schools in a single county in North Carolina. We learned that caregivers and school personnel support school‐based SARS‐CoV‐2 testing and believe it would provide many benefits to students, their families, and their communities. Concerns exist, although most could likely be addressed through establishing policies and practices that include the perspectives of these key stakeholders, followed by clear communication of the schools' plans to the school community. Some caregivers and school personnel described that testing‐based stigma and discrimination toward students could occur, although they did not perceive that differential treatment would happen based on race and ethnicity. Participants stressed how framing the testing program is critical and gave numerous suggestions to limit negative outcomes. Some schools in which participants were affiliated had a higher percentage of Black and/or Latino/a/x students compared to students of other races and ethnicities, which may have influenced this finding. Caregivers and school personnel also gave numerous, actionable recommendations for implementing school‐based SARS‐CoV‐2 testing.

Next Steps

We are conducting a qualitative evaluation of SARS‐CoV‐2 testing during the 2021‐2022 school year with Black and Latino/a/x students, caregivers of Black and Latino/a/x students, and school personnel to gather their perspectives on the social, ethical, and behavioral outcomes of implementing school‐based SARS‐CoV‐2 testing. Our inquiry also includes perceptions of and experiences with other COVID‐19 mitigation practices, including masking, vaccines, and quarantine/TTS procedures. Importantly, this upcoming evaluation includes student voices, providing an opportunity for those who are most affected by school‐based COVID‐19 mitigation to share how these mitigation efforts have affected them.

IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY

Caregivers and school personnel were largely supportive of school‐based SARS‐CoV‐2 testing, which is an essential component of most TTS programs. Promoting participants' perceptions of the benefits of SARS‐CoV‐2 testing in schools, addressing participants concerns, and incorporating their suggestions into school‐based policies may improve the social, ethical, and behavioral outcomes of school‐based SARS‐CoV‐2 testing.

Limitations

Our research had some limitations. Qualitative research often includes small sample sizes; however, our sample was particularly small because we needed to rapidly collect and analyze data within a few months in order to disseminate findings in time to inform fall semester 2021 testing. Also, our research was limited to 1 county in North Carolina, and all school personnel were from public charter schools. Nonetheless, caregivers and school personnel provided practical insights and considerations for the implementation of school‐based SARS‐CoV‐2 testing that may be beneficial to schools within and outside of our research area.

Conclusions

Our findings have implications for TTS programs. Caregiver and school personnel narratives provide support for school‐based SARS‐CoV‐2 testing, suggesting that the testing component of TTS is appropriate. Participants believed that stigma and discrimination from SARS‐CoV‐2 testing is possible, but differential treatment toward students based on race or ethnicity was not anticipated. Schools can consider and incorporate the implementation recommendations described here when they create policies and plans for implementing TTS, as they could potentially reduce any negative social, ethical, and behavioral outcomes from SARS‐CoV‐2 school‐based testing.

Human Subjects Approval Statement

The Duke University Health System Institution Review Board determined the research to be exempt from further IRB review (Pro00108025). All participants received an informational sheet describing the study prior to participation.

Conflict of interest

None of the authors have conflicts to disclose.

Corneli A, McKenna K, Dombeck C, Molokwu N, Taylor J, Vergara L, Benjamin DK Jr., Zimmerman KO,the ABC Science Collaborative . Caregivers of Black and Latino/a/x students and school personnel perspectives on school‐based SARS‐CoV‐2 Testing: Implications for testing and test‐to‐stay programs in K‐12 schools. J Sch Health. 2022; DOI: 10.1111/josh.13263