Influence of context on engagement with COVID-19 testing: a scoping review of barriers and facilitators to testing for healthcare workers, care homes and schools in the UK

Abstract

Objective

The UK government’s response to the COVID-19 pandemic included a ‘test, trace and isolate’ strategy. Testing services for healthcare workers, care homes and schools accounted for the greatest spend and volume of tests. We reviewed relevant literature to identify common and unique barriers and facilitators to engaging with each of these testing services.

Design

Scoping review.

Search strategy

PubMed, Scopus and the WHO COVID-19 Research Database were searched for evidence published between 1 January 2020 and 7 November 2022. This was supplemented by evidence identified via free-text searches on Google Scholar and provided by the UK Health Security Agency (UKHSA).

Data extraction and synthesis

Data were extracted by a team of reviewers and synthesised thematically under the broad headings of perceptions, experiences, barriers and facilitators to engaging with the COVID-19 testing programme.

Results

This study included 40 sources, including 17 from projects that informed UKHSA’s decisions during the pandemic. Eight themes emerged and were used to categorise barriers and facilitators to engaging with the testing services for healthcare workers, care homes and schools: (1) perceived value, (2) trust in the tests and public bodies, (3) importance of infrastructure, (4) impact of media and social networks, (5) physical burden of the test, (6) perceived capability to undertake testing, (7) importance of relevant information and 8) consequences of testing.

Conclusions

Universal barriers and facilitators to engagement with the testing programme related to the core elements of each testing service, such as uncomfortable specimen collection and the influence of media and peers; these could be mitigated or leveraged to increase engagement across settings. However, the individuals involved, perceptions of value and available resources differed across services, leading to unique experiences between settings. Thus, consideration of context is crucial when designing and implementing a testing programme in response to a pandemic.

STRENGTHS AND LIMITATIONS OF THIS STUDY

• This review used a broad search strategy to identify a wide range of evidence published in real time during the pandemic or soon after to comprehensively scope the factors influencing people’s engagement with the COVID-19 testing programme in the UK.

• It also drew on data from unpublished UK Health Security Agency reports, research and documentation that were instrumental in shaping the UK’s evolving COVID-19 strategy and which are not otherwise widely publicly available.

• The review was also strengthened by substantial engagement with a diverse set of stakeholders: extracted findings were discussed iteratively with stakeholders from UKHSA, the Department of Health and Social Care and the Department for Education, enabling us to contextualise and interpret the findings more accurately.

• Limitations include the rapid turnaround time and the large volume of data, which required a large team of screeners and data extractors, which may have reduced the consistency of the application of inclusion criteria.

• No assessment was conducted of the quality of the papers included, which is consistent with scoping study methodology but may bias the results as all evidence was drawn on equally.

Introduction

In March 2020, the UK government launched a mass testing programme as part of its response to the COVID-19 pandemic.¹ Testing was a major component of the UK government’s ‘test, trace and isolate’ strategy.² This aimed to reduce transmission of COVID-19 through the rapid identification and isolation of cases and their close contacts in order to interrupt community transmission and thereby minimise COVID-19-related hospitalisations and deaths.³ It was implemented through testing of those with COVID-19 symptoms as well as mass testing of asymptomatic individuals to identify positive cases and their contacts.⁴ The testing programme cost £25.8 billion to distribute nearly 2 billion point-of-care lateral flow device (LFD) tests and conduct 158 million PCR tests. This programme detected up to 40% of the COVID-19 cases in England from October 2020 to March 2022.⁴ It was led by the National Health Service Test and Trace (NHSTT)—established as an executive agency of the Department of Health and Social Care (DHSC) in May 2020⁵—which became part of the United Kingdom Health Security Agency (UKHSA) when UKHSA—also established as an executive agency of DHSC—became operational in October 2021.⁴ (An overview of the key pandemic phases can be found in online supplemental additional file 1, and a timeline of COVID-19 policies and events can be found in online supplemental additional file 2.) UKHSA oversaw the implementation of the COVID-19 pandemic response and commissioned its subsequent evaluation.⁴

The importance of understanding engagement with the healthcare worker, care home and school testing services

The national COVID-19 testing programme included separate testing services within nine different ‘settings’—healthcare workers, adult social care, schools, elective care, events, targeted community testing, private sector, public sector and universities⁴—and a non-population-specific universal testing service.⁶ In England’s national testing programme, the adult social care, healthcare worker and schools services comprised the greatest cost of the population-specific services in the testing programme, responsible for 41.5% of tests conducted and 44% of the spend on the mass testing programme.⁴

Frontline staff were recognised as central to the success of the pandemic response, and the healthcare worker testing service aimed to reduce transmission in healthcare workers to protect staff and patients, as well as maintain functional healthcare services.⁷ The elderly (who make up the majority population in care homes) were a particularly high-risk group for COVID-19 morbidity and mortality,⁸ and therefore, a focus for the testing programme to reduce transmission and subsequent hospitalisations and deaths.⁹ The focus of the schools testing service was to minimise disruption to both children’s learning and parents’ work by reducing school closures.¹⁰ Additionally, schools were a site of interaction between members of many households and therefore seen as a point of control for community transmission.⁴

The importance of considering context in testing service implementation

The success of any intervention in achieving its aim is highly dependent on its implementation within a particular context.¹¹ Not only does uptake, and ultimately impact, depend on the characteristics of the intervention itself, but it is also determined by a number of different components: the inner setting (the internal environment, structural characteristics, culture or conditions within the organisation or context within which the intervention is implemented), the outer setting (the broader economic, political and social environment or conditions that influence the intervention setting), the individuals involved in implementing and receiving the intervention (such as their engagement, self-efficacy, knowledge and beliefs) and the process of implementation (including the planning, execution and evaluation of the intervention).¹²

Even within a particular overarching context such as the UK, there are nuances between different implementation settings. Context is multidimensional—including physical, spatial, organisational, cultural or social dimensions—and each dimension will impact how an intervention should be implemented to increase engagement.¹³ Therefore, a uniform service model is inappropriate across such differing settings with differing contexts.

To inform the design and implementation of future testing programmes, it is important to identify universal barriers and facilitators to testing and reporting across settings and understand the nuances of those settings that are likely to play an important role in testing programmes for future pandemics. Thus, with a view to gathering the real-time evidence that informed the pandemic response, we conducted a scoping review of evidence generated in ‘parallel to the crisis’¹⁴ to examine the perceptions, experiences, barriers and facilitators to testing within the three key settings of healthcare workers, care homes and schools.

Methods

Study design

The Ernst & Young–Oxford Health Analytics Consortium conducted an evaluation of UKHSA’s COVID-19 strategy in England.⁴ This evaluation included a rapid scoping review that summarised the large volume of rapidly generated heterogeneous evidence, identified gaps in knowledge and described the barriers and facilitators to engaging with the COVID-19 testing programme, including testing, reporting and self-isolation behaviour across services in the UK.¹⁵ The aim was to include emergent evidence from literature that was published during or soon after the pandemic and was available to inform policy. The study presented here focused on synthesising evidence from the three priority testing services (healthcare workers, care homes and schools), to identify common and unique barriers and facilitators across each service, which could influence strategy for future pandemic responses. We followed the 2005 Arksey and O’Malley framework,¹⁶ with the adaptations proposed by Levac et al in 2010,¹⁷ and the 2015 Joanna Briggs Institute guidance on conducting scoping reviews.¹⁸ Access to confidential internal documents was approved by the UKHSA. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews Checklist is presented in online supplemental additional file 7.

Settings

An overview of the three priority testing settings covered in this article—healthcare worker, care home and school services—is given in table 1. Care homes were one of several adult social care testing services, which also included supported-living services, adult day care centres, social workers and domiciliary workers. However, care homes made up the vast majority of the total volume of tests and spend within adult social care⁴ and were therefore the focus of the adult social care service.

Table 1. Aims and implementation of the three priority test settings and justification for their prioritisation.

	Healthcare worker testing service	Care home testing service	Schools testing service
Aims	Support the NHS in its infection control risk reduction strategy Reduce staff absenteeism due to COVID-19 Support clinical pathways Protect patients and staff7	Reduce transmission among staff and residents in care homes, thereby reducing hospitalisation and mortality rates9 Support the workforce and residents9 Enable settings to open up to visitors4	Increase pupil/parent/teacher confidence in attending school in-person10 Reduce disruption to parents and pupils through lost school and work days10 Reduce community transmission4 NB: there were differences in the stated aims for the schools testing service between NHSTT, the Department for Education, the government and UKHSA. Also, the priority of these aims changed over time. 4
Overview of implementation	Asymptomatic testing using LFD tests was rolled out to all patient-facing NHS staff in November 2020,7 expanding to all 1.3 million NHS staff working in NHS Trusts and Foundation Trusts in December 2020 and then expanding again to all 400 000 primary care staff64 in January 2021.65 Healthcare staff were required to report the results of every LFD test they conducted.4 RT-LAMP tests requiring saliva samples were piloted with some healthcare workers.7	In April 2020, DHSC announced plans to test all symptomatic social care workers and care home residents.9 66 Routine asymptomatic PCR testing was rolled out across care homes from July 2020; this was weekly for staff and monthly for residents.67 From December 2020, additional two times per week rapid LFD testing was introduced for care home staff,68 increasing to three times per week in December 2021.69 70 Testing was initially conducted on-site; however, home testing became available for care home staff from February 202144. Staff were required to report all test results to their care home or via the self-reporting portal.4 There were many policy changes for testing in care homes4; a timeline can be found in onlinesupplemental additional files 2 3.	Schools testing was initiated in January 202171 and ended in February 2022.72 Short-term, voluntary, on-site, asymptomatic testing was conducted in schools in January 2021, March 2021,71 September 202173 and January 202274 to test pupils as they returned to school from a national lockdown, summer holiday and Christmas holiday, respectively. Following on-site testing, home testing for pupils was advised for the remainder of each term, with pupils required to report their test results to their school.71 Variations in timings and guidance existed for SEND settings. From January 2021, school staff were offered the option of two days per week testing at home.71RT-LAMP tests requiring saliva samples were implemented in some schools settings for specific groups.4
Justification for inclusion in the review	The testing of healthcare workers accounted for 7.8% of the total spend of the testing programme in England and was associated with a reduction in nosocomial infections.4	The majority of the adult social care testing service occurred in care homes.4 Testing in care homes accounted for 17% of the total spend on the testing programme in England.4 This service was associated with reduced transmission in residents and staff and was therefore likely to have reduced COVID-19-related deaths among care home residents.4	The schools testing service accounted for 15.5% of the total spend of the testing programme in England and was shown to enhance asymptomatic case-finding.4

DHSC, Department of Health and Social Care; LFD, lateral flow device; NHS, National Health Service; NHSTT, National Health Service Test and Trace; UKHSA, United Kingdom Health Security Agency.

As a note, in this article the term ‘testing programme’ has been used to refer to the national COVID-19 testing programme, and ‘testing service’ to refer to the individual services within the national programme, for example, healthcare workers, adult social care and schools.

Search strategy and selection of the evidence

A wide search strategy was developed with input from a health sciences librarian, using key phrases from relevant articles¹⁶ and refined following a pilot search (online supplemental additional file 3). The search was conducted using PubMed, Scopus and the WHO COVID-19 Research Database. To identify any key studies that were missing, the initial screening was supplemented with free-text searches on Google Scholar; review of the bibliographies of included sources and stakeholder consultation,¹⁹ including UKHSA-provided documents (see online supplemental additional file 4 for the rationale for database selection). The search dates were selected to encompass studies with data generated and published in real time and soon after the pandemic, available to inform policy and the subsequent COVID-19 inquiry in the UK.

All sources were collated, uploaded into Rayyan²⁰ and duplicates removed. Following an initial screening pilot to refine the eligibility criteria, titles and abstracts were screened by two reviewers for assessment against the refined inclusion criteria. A sample of ≥20% was reviewed by a third reviewer to ensure consistency of inclusion.¹⁷ Table 2 outlines the eligibility criteria for inclusion. The inter-rater agreement for the final list was calculated using Gwet’s first-order agreement coefficient (AC1).²¹ Potentially relevant sources were retrieved in full and assessed against the inclusion criteria. Any disagreements were resolved through discussion, including with an additional reviewer if no consensus was reached. Once the publicly available data had been screened, sources from the supplementary search were screened by a larger team of 12 members. The overarching project used this evidence to produce a report on the barriers and facilitators of testing, reporting and isolation across different settings in the UK.⁴ The evidence on engagement with testing in the three priority service settings was drawn from this overarching project.

Table 2. Search parameters and inclusion/exclusion criteria categorised according to the ‘population, context, concept’ search framework⁷⁵.

	Inclusion	Exclusion
Search limits
Language	Published in English	Published in languages other than English
Dates	Published between 1 January 2020 and the search date (7 November 2022)	Published before 2020
Methods	Qualitative or mixed-methods studies	Purely quantitative studies
Eligibility
Literature	Journal articles, peer-reviewed material, articles under review, published books and book chapters, other academic research, research commissioned by governments, unpublished reports	Opinion or statement pieces, magazine articles, blog posts
Population	England, Northern Ireland, Scotland, Wales and the islands making up the British Isles	Countries outside the UK, including the Republic of Ireland
Context(service settings)	Healthcare worker testing servicesAdult social care testing servicesSchools testing services	Other services such as events, universities or universal testing services
Concept(key activities)	Description of the behaviour, barriers and/or facilitators of how people behaved with regards to the key activities: Antigen testing for COVID-19 (with a focus on lateral flow devices, but including RT-LAMP and PCR testing) Reporting test results Isolating (with a focus on isolating due to a positive COVID-19 test result, but including isolating after exposure to a positive contact)	Not describing testing, reporting or isolation in the three key settings

RT-LAMP, Reverse transcription loop-mediated isothermal amplification.

Data extraction, charting and synthesis

A team of 12 reviewers extracted the data, including study metadata (authors, title, year of publication/dissemination, publication stage, country, participant characteristics and methods), the setting (service setting and key activity) and information about the perceptions, experiences, barriers and facilitators to testing (online supplemental additional file 5). Data were extracted into a Microsoft Excel template, which was refined in the pilot of the initial included sources. In the pilot, two reviewers extracted data from the same two sources to check quality and support discussions to refine eligibility criteria. The articles were not assessed for quality, given the aim of the review was to scope rather than evaluate the evidence.¹⁶ Once all the data had been extracted, we synthesised the data thematically, identifying key topics within the broad headings of perceptions, experiences, barriers and facilitators to testing.

Stakeholder input

Due to the rapid turnaround time, patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research. However, stakeholders from UKHSA were consulted. These stakeholders included over 40 people, ranging from healthcare workers, to people who were directly involved in conducting research, and those in operational and policy roles. Stakeholders were consulted to identify additional sources of published and unpublished evidence not found in the original search.⁴ Emerging results and themes were presented to them to sense check our interpretation and put them in context of what was happening in the pandemic and the policy response at the time. Insights from these discussions are incorporated into our framing and discussion of the results.

Results

Overview of included evidence

After screening 4152 sources and including 173 in the overarching review, 40 sources of evidence were included in this synthesis (figure 1). Most (43%) were from the schools setting, with 40% from the care homes setting and 28% from the healthcare setting (it should be noted that some sources covered more than one setting). Across the UK, England contributed the most (83%, 33/40) sources compared with Scotland (0), Northern Ireland (0), Wales (1), the UK overall (4) and international studies including the UK (2). All sources of evidence described engagement with testing (40), with 45% (18/40) also including engagement with reporting and 23% (9/40) also describing isolation behaviour.

Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews flow diagram. UKHSA, United Kingdom Health Security Agency.

An overview of each of the included sources is presented in online supplemental additional file 6.

Themes

Eight themes were identified that described the perceptions of engaging with the COVID-19 testing programme in the healthcare worker, care home and schools testing services. These included (1) the perceived value of the testing programme, (2) trust in the tests and public bodies, (3) importance of infrastructure, (4) impact of the media and professional and social networks, (5) physical burden of the test, (6) perceived capability to undertake testing, (7) importance of relevant information and (8) the perceived consequences of testing.

These themes cut across the different service settings, but within each theme, both universal as well as unique experiences are highlighted. Additional information about these similarities and differences is presented in online supplemental additional file 8.

Perceived value of the testing programme

Across all settings, people felt motivated to protect their colleagues, communities, loved ones and the people in their care, and testing provided reassurance that they would not infect others.22,28 In the healthcare and schools settings, people also referred to a sense of pride in taking part in the testing programme.^{24 29}

Healthcare workers valued testing for reducing unnecessary absenteeism and helping reduce anxiety in the workplace.³⁰ They saw the value in keeping the healthcare workforce safe, in particular those from minority ethnic backgrounds due to the disproportionate mortality rates in these groups.³¹ This perception of value in relation to safety was higher among healthcare workers, who experienced a greater sense of personal risk from COVID-19 infection than other groups.³⁰ Healthcare workers reported feeling relieved following a negative test result as they were able to visit family, friends and vulnerable people.²⁴ Conversely, a positive test result reassured some healthcare workers that they would then have some immunity to COVID-19.³² In care homes, testing was valued as it enabled visits, which were deemed to be key to residents’ emotional, social and physical well-being.^{26 33} In schools, staff felt that testing reduced the risk of school closures.³⁴ Parents and school staff felt that the reassurance provided by regular testing could encourage pupils to attend school³⁴ and also provided reassurance for staff members vulnerable to severe COVID-19 infection.³⁵

However, some individuals did not find value in testing; for example, care home workers reported doubting the need for testing following vaccination.³⁶ There was also an indication of ‘testing fatigue’, with care home staff reporting that they felt tired of the frequency of testing.²⁶ Similarly, in schools, a minority of parents felt that a testing service of this scale was too expensive, too time-consuming and a waste of resources.^{37 38} A minority of parents and staff also expressed concern that positive cases identified through testing could result in school closures.³⁴

Trust in the tests and public bodies

Mistrust in the ability of LFD and PCR tests to accurately identify COVID-19 cases was reported across all three settings^{26 30 32 37 39 40} and was a stated reason for declining testing in healthcare workers,²² care home workers²⁶ and parents of schoolchildren.^{37 40} Reports of PCR and LFD tests taken at the same time but producing different results reduced trust in the accuracy of LFD tests,²⁶ and concern was raised by parents that self-administering tests would further decrease the tests’ accuracy.^{37 40} Healthcare workers, care home workers and parents of schoolchildren all reported concern about false-positive test results that could lead to unnecessary isolation.^{24 33 41}

Among school staff, parents and pupils, and among healthcare workers before point-of-care testing became routinely available, not understanding how LFD tests work created mistrust in these tests.^{25 38} Healthcare workers expressed the need for evidence of the clinical efficacy of tests,²⁵ but felt that the National Health Service (NHS) and government recommendations facilitated trust in the tests.²³

Within schools and healthcare settings, greater trust was expressed for local bodies, such as local NHS Foundation Trusts, than for central government and national bodies, such as NHSTT.²⁴ In the school context, while some parents, staff and pupils expressed trust that the government would process data appropriately,^{38 40} concerns were raised by some parents over the collection of data by the testing service.^{24 34} Trust in how personal data would be handled was undermined by a lack of engagement in testing services by parents, pupils and healthcare workers.²⁴

Importance of infrastructure

On-site testing

Setting up and conducting the testing services increased staff workload across all settings, although this was perceived to be particularly burdensome in care homes and schools.^{24 26 33 34 37 38 42} Healthcare workers described the additional workload as acceptable because it was perceived as being for a ‘good cause’.²⁴ Schools reported challenges with the time and effort required to set up the testing service.^{24 34 37 38} Shortly after the launch of the testing service, some schools reported they had insufficient testing kits to be able to comply with the recommended testing protocols,³⁷ with parents directed to order LFD testing kits from a pharmacy or online.⁴³ In addition, where testing was conducted on-site, gaining consent from parents and pupils was reported to be difficult, particularly when paper consent forms were used.¹⁰ In contrast, schools valued financial and logistical support to ease the staff workload when setting up asymptomatic testing sites in schools,^{24 34 37 38} including the deployment of council staff or mobile testing units to support the delivery of testing.⁴³

Limited space affected the ability of some care homes to accommodate visitor testing³⁶ and socially distance visitors appropriately prior to testing.²⁶ Space for testing and isolating was also a problem in smaller schools.²⁹

At-home testing

The ability to test at home was seen as more convenient than on-site testing for care home staff and healthcare workers.^{22 24 44 45} For healthcare workers, home testing facilitated participation in the testing service.22,24 Home testing also meant that care home staff did not need to attend care homes—unpaid—on their days off or before their shift in order to test^{33 42 45} and was generally seen as beneficial to both staff and the functioning of care homes.⁴⁴ However, concerns within some care homes over whether staff would test appropriately at home meant they continued with on-site testing.⁴⁴

Reporting

For both on-site and at-home testing, care homes and schools raised concerns over resources for reporting and registration of tests.^{26 29 37 42} In care homes, managers reported the need to keep additional local records of tests for Care Quality Commission audits or local authority inspections, which further increased their workload.⁴⁴ When self-reporting of tests was available, care home staff felt this process to be complex and time-consuming, with some staff stating that this made them less likely to test or report their results.^{36 46} Similarly, parents of schoolchildren found the need to report test results across multiple platforms confusing and burdensome, particularly within households with multiple children.^{37 41} To manage the workload in schools, some schools requested that only positive LFD tests were reported.³⁷

The impact of the media and professional and social networks

Across the settings, trust in the accuracy of tests and perceptions of testing were influenced by news and stories in the media and information and experiences shared by peer networks.^{25 26 30 36 44} For example, in schools, some parents and pupils reported concern about negative stories and conspiracy theories reported on the news or social media about tests and misuse of personal data.²⁹ In contrast to this, some pupils and parents reported feeling reassured by media coverage about testing and the reopening of schools involving media personalities.¹⁰

In care homes and schools, organisational encouragement to test was important.⁴⁷ Parents suggested that they needed to feel that testing was important to the school as this motivated them to continue encouraging their children to test; this perception was influenced by regular communication from the school about COVID-19.⁴⁸

In the healthcare and schools settings, people feared the stigma of testing positive for COVID-19.²⁴ In schools, concern around stigma was reported most frequently by individuals from ethnic minority backgrounds; families requested discretion and anonymity when receiving notification of a positive result.³⁴

The physical burden of the test

Across all settings, nose and throat swabbing was considered uncomfortable^{29 38 40 41} and often a key concern.⁴¹ Care home staff reported that residents found testing daunting, and the physical discomfort made swabbing residents difficult.^{46 49} This was particularly the case for individuals with dementia, and care home staff sometimes needed to reschedule testing around the needs of residents.⁴⁶ The impact of the discomfort was mixed, with some parents and carers stating that the negative experience of testing their child or care recipient meant they would be unlikely to engage in the testing service again,⁴¹ but for others it did not impact their intention to test again. Despite the discomfort involved in testing, repeated testing made it easier to perform for parents, pupils and school staff.³⁸

Perceived capability to undertake testing

There were differences in the perceived capability to conduct testing across settings. Healthcare workers reported feeling confident in their ability to conduct testing correctly, with continued and repeated testing and reporting building that confidence.²² Due to the perceived pressures and increased workload resulting from the pandemic, care home workers reported high levels of physical and emotional exhaustion, which compromised their ability to engage with the testing programme.^{26 33} In the schools testing service, few pupils reported a lack of confidence to conduct home testing. However, a lack of confidence was more prevalent among certain subgroups, including white pupils, pupils eligible for free school meals, pupils with special educational needs and pupils who reported being exempt from wearing a face covering.¹⁰ Parents also expressed concern about their ability to conduct the test properly¹⁰ and enforce testing at home, with teachers also reticent to take on an enforcement role.⁴⁸

Perceived capability to report test results

Challenges with reporting of test results were reported in care homes, but not in the schools or healthcare worker services. In care homes, the reporting of LFD results was noted to be challenging, with the ‘bulk upload’ process to simultaneously report multiple LFD tests being a particular challenge where there were lower information technology literacy levels among care home staff.⁵⁰ When self-reporting of LFD test results was introduced, some care home workers required individual training in the reporting process; however, care homes reported no issues with their staff’s ability to self-report.⁴⁴ The introduction of the COVID-19 LFD digital reader further supported reporting of LFD results. Of those care home workers involved in the pilot of the COVID-19 LFD digital reader, most reported a positive experience, and almost half of them reported that they would be more likely to report their results using the digital reader.²⁶

Importance of relevant information

Across the settings, when information was inadequate, it presented a barrier to implementing point-of-care testing.24,2630 36 41 44 Conversely, training videos were viewed positively among individuals in the care home and schools settings as they were considered easy to follow and engaging.⁴⁴ Individuals in these settings also valued in-person training.²⁹

Care homes and schools reported a lack of guidance for their specific needs. A small proportion of care homes flagged that the guidance was not always applicable to their setting,⁴⁴ with the guidance sometimes lacking key information specific to care homes, such as the testing protocols for agency workers and visiting professionals.³⁶ In schools, little testing guidance was provided for parents of children with special educational needs or other medical needs.⁴¹ Care homes and schools also reported challenges with remaining up to date with evolving guidance²⁶ and having to implement changes at short notice. Care home managers suggested that communications could more clearly highlight what had changed when guidance was reissued.²⁶

In the healthcare and schools settings, a lack of translation of materials from English to other languages hindered access to information, understanding of testing instructions and training in testing and reporting. Language barriers were therefore viewed as a barrier to testing^{24 41} and particularly to engaging people from ethnic minority groups.²⁴ In addition, there was confusion in care homes and schools when the training materials were inconsistent with the testing kits used.⁴⁴

Perceived consequences of testing

Universally across settings, the primary concern in relation to testing was the need to isolate and the negative consequences that would result.^{22 32 33 38 40} For healthcare workers and care home workers specifically, there was a worry that isolating would increase the workload for the rest of the workforce,³³ with healthcare workers describing feelings of guilt over the need to isolate.³² The negative consequences of isolation were a particular concern for healthcare workers who were worried about false-positive results, which for some led to them not testing.²⁴ For care home workers, the primary concern around isolation was the financial consequences of not being able to work, particularly for care assistants who were on a low wage.³³ In the schools setting, parents expressed concern about the disruption that was caused to their work when they had a child isolating, particularly when this happened several times.⁴⁰ Parents found the logistics of isolation challenging, with the isolation of children within a household often felt to be unfeasible.^{38 40} There was also concern about pupils missing classes and social engagement with classmates when isolating.³⁸

Discussion

This study identified eight factors that can act as either facilitators or barriers to people engaging with a pandemic testing programme: the perceived value of the testing programme; trust in the tests and public bodies; the importance of infrastructure; the impact of the media and professional and social networks; the physical burden of the test; the perceived capability to undertake testing; the importance of relevant information and the perceived consequences of testing. All of these factors influenced the uptake of the testing programme across the three priority services, although in varying ways.

Similarities across settings

The core function and components of the testing intervention remained constant across settings, which meant that many barriers and facilitators were experienced similarly in different services. First, across all settings, the tests were universally found to be uncomfortable,^{29 38 40 41} there were perceived increases in workload to set up and run services,^{24 26 33 34 37 38 42} and clear and adequate guidance was required to fully engage with the programme.24,2636 41 44

Second, across all settings, trust in the tests and those providing guidance was crucial to uptake, but there was also mistrust reported in both the test accuracy and those providing guidance.^{23 26 30 32 37 39 40} Trust was influenced in all settings by professional and social networks, as well as the media.^{25 26 30 36 44} The mistrust in central government^{24 34} may have been driven by a number of events that undermined the public’s trust in the UK government during the pandemic period, such as key figures of authority breaking lockdown rules.⁵¹ These breaches were widely publicised in the media, exerting influence across settings.

A final similarity across all settings was the consistency of people’s motivations for testing to protect others22,28 and the reassurance gained from testing.

Differences across settings

In contrast, a number of issues were specific to each setting. First, while the intervention itself was described as uncomfortable in all settings, different challenges manifested for each group in the various settings. For example, the discomfort of swabbing caused particular challenges for care home staff when collecting swab samples from patients with dementia.^{46 49}

Second, individuals involved in different settings of the testing programme had different capabilities and confidence to perform the testing. While healthcare workers found it quite easy to perform tests,²² many adult social care workers did not have the capacity to engage with testing due to burnout,^{26 33} and parents were not confident in swabbing their children.¹⁰ The confidence reported by healthcare workers may have been due to their familiarity with swabbing procedures as part of their existing roles, such as for point-of-care tests for other respiratory diseases like influenza,⁵² whereas staff in other services were unlikely to be as familiar with the procedure.

Third, the existing infrastructure of each setting influenced the logistics required and the capacity to implement services and therefore the practical challenges faced. The process of implementing the guidance played out differently across settings, with care homes and schools having particular challenges with the lack of specificity of guidance for their particular situations^{36 41 44} and the rapidity of the evolution of the guidance, having to implement these changes at short notice.²⁶ Healthcare workers did not seem to face the same challenge; however, the guidance changed less frequently within this setting.

Fourth, across settings, isolation was perceived by individuals to be the primary negative consequence of testing and reporting results.^{22 32 33 38 40 53} However, the reasons for this differed among service settings. For example, care home workers on lower wages were particularly concerned about the impact of isolation on their ability to work and earn money,³³ whereas for parents of school-aged children, the logistics of isolating children in the house was seen as unfeasible^{38 40} and threatened to disrupt their work, particularly when it occurred frequently.⁴⁰

A final difference across each setting was in the particular value found in the testing programme. For healthcare workers, testing was perceived to help avoid unnecessary absenteeism³⁰ and protect staff, particularly highly vulnerable healthcare workers.³¹ Schools also valued testing to protect staff members vulnerable to severe COVID-19 infection.⁴ Both schools and care homes valued testing for its ability to facilitate the lifting of social distancing and other restrictive measures: school staff valued testing to reduce the risk of school closures and encourage students to attend class,³⁴ and care home staff valued testing for facilitating visitor entry.^{26 33} This setting-specific value appeared to be related to the stated aims of the testing programme in that service setting, as shown in table 1, which varied according to the priority issues for that service during the pandemic. The differences in perceived value may play a role in differential uptake between settings and could be a target for communications to motivate people to engage with testing in future public health programmes.

Although barriers and facilitators have been discussed separately, they are interconnected and should not be considered in isolation. For instance, trust in institutions and confidence in test accuracy can shape perceptions of testing’s value. Social networks further influence these perceptions by reinforcing or challenging prevailing beliefs. Likewise, the accessibility and efficiency of testing infrastructure—such as test centres, home kits and digital reporting systems—impact both perceived capability and physical burden. Inefficient infrastructure can cause frustration, discouraging participation. A final example, clear, accessible and timely information is crucial as it can foster trust, enhance perceived capability and strengthen the perceived value of the testing programme.

Recommendations for future testing programmes

This review highlights a number of recommendations to increase engagement with testing and make future programmes more effective (box 1). These recommendations stem from the context-specific evidence coming out of the UK testing programme, which had a specific strategy and approach to implementation. However, lessons drawn from this setting may be useful in planning the implementation of other programmes, provided universal barriers and facilitators are considered alongside context-specific factors and the influence of the specific setting. Engaging key stakeholders, including people who will be implementing and using a testing programme, can help ensure that people’s perceptions, priorities, experiences and expertise are integrated into the programme design in a meaningful way, addressing likely barriers and leveraging opportunities to increase engagement.

Box 1. Broader recommendations for future testing programmes*.

Recommendations for future testing programmes

• Identify contextual factors that are likely to influence engagement with testing as these affect implementation and subsequent programme effectiveness.

• Consider potential levers to improving engagement such as

  • Media as a platform for socio-cultural and peer group influences, which are important drivers of trust.

  • Ease of access and use to facilitate uptake of testing at individual and facility levels.

  • Clear guidance for those implementing and using testing services.

• Ensure that the aims of the programme align with the priorities of people implementing the programme and the preferences and values of the people using the services.

• Consider the wider potential impacts of introducing the testing programme and how the programme interacts with existing programmes and other priorities.

• Reflect on and examine context, so that it can be taken into consideration in implementation, addressing the broader contextual vulnerabilities in an individual’s life that intersect with setting-specific challenges for a specific service.

• Adapt the package for different settings which will require devolved decision-making and a clear vision, so that different services can respond to their unique set of challenges to work towards a common goal.

It is important to identify those factors that will influence people to engage with testing across settings as leveraging these could have a broad impact. Given the consistency across settings with which media influenced trust in the accuracy of tests^{25 26 44} as well as other key behaviours such as vaccine uptake,⁵⁴ these socio-cultural and peer group influences could be leveraged as a tool to promote confidence in any future testing programme. The ease of use of public health interventions is also crucial in their uptake.⁵⁵ This is particularly true of home testing, where the ease of use of testing and reporting is even more vital to ensure that tests are conducted correctly and reported without supervision; furthermore, clear and relevant guidance should be widely available.¹²

It is important to consider the nuances of the intended aims, available resources, individual experiences and capabilities between each setting and the impact these have on how an intervention is implemented in a given setting. To increase uptake, the testing programme aims need to align with the priorities of those on the ground as well as those making decisions.¹² Health interventions must be aligned with the preferences and values of target populations to drive uptake and adherence, and the perceived value must outweigh the perceived costs of engagement.⁵⁶ The complexity of the perceived value and consequences, and the links between these with other protection measures such as isolation, mean that each programme should not be considered in a silo. For example, the rollout of the COVID-19 vaccine programme and the requirement to self-isolate if testing positive were both found to inadvertently reduce the uptake of testing.^{36 53} Interventions must be considered as a system,⁵⁷ with the potential effects of each intervention on the uptake of other programmes under the same strategy anticipated and mitigated.

Future testing programmes should recognise the complexity of the needs of individuals within a testing service, including how vulnerability is considered. Certain groups were demonstrated to have worse clinical outcomes from COVID-19^{8 31} and were more vulnerable to the financial impacts of COVID-19 self-isolation, such as ethnic minority groups58,61 and those on low incomes.³³ Therefore, while individuals using the service-specific testing programmes may have had similar experiences to their colleagues and peers when testing, they may also have faced different challenges common to the other social groups they were part of. Individuals may belong to different ‘groups’ at the same time and have had nuances in their experience of the programme, even within the same specific context; for example, an individual may be a healthcare worker with a specific set of experiences of the testing programme and also belong to a minority group whose members have a different set of experiences. Designing a testing programme for a specific service therefore needs to consider the complex intersections of both the vulnerabilities and capabilities of the individuals that will use it, as well as the nuances of the setting.

Context influences implementation and effectiveness.¹¹ This means that while the core function of a testing programme needs to reflect the ultimate aim of the programme and the core components must be consistent when the programme is scaled across different services, the exact form the programme takes should be adapted to the specific context.⁶² A customisable modular toolkit, including documents, educational materials, templates and strategies, may be appropriate to support implementation in different settings.⁶³ This requires devolving some decision-making power to the implementing team, with clear guidance on what can and cannot be adapted.⁶³

Strengths and limitations

This review used a broad search strategy to identify a wide range of published evidence and comprehensively scope the factors influencing people’s engagement with the COVID-19 testing programme in the UK. It also drew on data from UKHSA reports, research and documentation. These resources were instrumental in shaping the UK’s evolving COVID-19 strategy, and many are not otherwise in the public domain. In this review, we were able to incorporate a considerable body of unpublished material in the synthesis and bring these insights into the public domain. As this review focuses on work published in real time, this provides a foundation for future reviews that can focus on a more retrospective analysis of the pandemic. The review was also strengthened by substantial engagement with a diverse set of stakeholders: extracted findings were discussed iteratively with stakeholders from UKHSA, the DHSC and the Department for Education, enabling us to contextualise and interpret the findings more accurately.

Limitations include the rapid turnaround time and the large volume of data, which required a large team of screeners and data extractors. This may have reduced the consistency of the application of inclusion criteria. However, the screening was checked by a third screener, and the team tended to be over-inclusive rather than under-inclusive. Therefore, it is less likely that any information was missed and more likely that less relevant evidence was included that did not contribute meaningfully to the synthesis. No assessment was conducted of the quality of the papers included, which is consistent with scoping study methodology but may bias the results as all evidence was drawn on equally.

Conclusion

A testing programme is one of the key interventions to manage any pandemic. Policy and intervention strategies could be informed by lessons learnt from the COVID-19 testing programme in the UK. This review demonstrates that there were contextually universal barriers and facilitators to engagement with the COVID-19 testing programme, independent of the service setting. However, it is also crucial to consider the specific nuances of each service setting and use this understanding to inform the implementation of testing services and facilitate engagement.

Data availability statement

Data may be obtained from a third party and are not publicly available.