35 - Stories of Community Implementation: Exploring Barriers and Facilitators of Implementing an At-Home SARS-CoV-2 Antigen Self-Testing Intervention.

Abstract Information:

Background: Community collaboration improves program engagement and sustainability. In collaboration with community-based organizations, we implemented COVID-19 at-home testing programs in underserved communities, seeking to improve testing rates and understand barriers. We aimed to capture the voices of community stakeholders engaged in the implementation of these programs. by exploring their implementation experiences.

Methods: Guided by the Outcomes for Implementation Research framework, we conducted semi-structured interviews and focus groups with participants involved in program dissemination and implementation. Qualitative data were analyzed by three members of the team using a primarily deductive rapid content analysis approach. Our analysis focused on dimensions and constructs: 1) that could be productively explored through qualitative inquiry, and 2) had the most immediate implications for practitioners and decision-makers seeking to replicate the program model, including factors that motivated community members to participate (communication/engagement, adoption), what it took for them to implement the program (appropriateness/feasibility), and what they felt worked well and what didn’t about the community-engaged program (acceptability, barriers/facilitators, recommendations).

Results: Community partner narratives (5 advisory board members, 15 distribution partners) noted that community collaboration drove program adoption among grassroot stakeholders; community engagement practices were a critical facilitator of acceptability and success. Establishing and sustaining trusted relationships was important in engaging community partners with aligned values and existing capacity. Respondents characterized the programs as generally feasible and appropriate, and community partners felt capable of delivering the program successfully. However, they described an increased burden on their workforce and desired more support from the program team. Better aligning service availability with periods of community needs and receptivity was a key recommendation for improvement and sustainability.

Discussion: Our findings provide insight into how community-engaged dissemination approaches can catalyze grassroots mobilization in public health disasters. To facilitate program adoption, the programs used communication and engagement strategies that centered and leveraged existing community relationships. As we continue to inform and advance community-engaged disaster response practice, a parallel reimagining of public health funding mechanisms and timelines could provide a foundation for trust, collaboration, and community resiliency that endures beyond a given crisis.

Relevance Statement: Mounting evidence supports that partnering with communities to implement public health programs is important for impact and sustainability. Among historically underserved or marginalized communities, meaningful engagement in public health programs is especially critical. Shared decision-making around program design, implementation, and research results in more tailored, acceptable, and ultimately impactful interventions within communities that have been historically left out of, or actively harmed by, public health efforts. Community-engaged interventions that center on unique community strengths and preferences are essential to reduce disparities in COVID-19 impacts. Looking beyond the present crisis, the risk of large-scale emergencies, including pandemics and natural disasters, is slated to rise over the coming decades, with impacts likely to accrue disproportionately among historically marginalized groups. Explicating both promising intervention models and the community engagement strategies that gave rise to them is a vital and timely need. Our study fills a gap in the literature by describing lessons learned through partnering with communities to develop and evaluate two COVID-19 self-testing interventions. These qualitative findings provide crucial insight that researchers and practitioners can use to inform community-engaged responses in future public health emergencies. The Say Yes COVID Test (SYCT) and the related You and Me COVID Free (YMCF) initiatives were disseminated and implemented as part of the Rapid Acceleration of Diagnostics in Underserved Populations (RADx-UP) program. The core components of SYCT and YMCF were the distribution of free rapid at-home testing kits to those disproportionately impacted by COVID-19 seeking to improve testing rates and understand barriers to testing. Both programs relied on community partnerships to create a meaningful program implementation. The programs were grounded in community engagement principles; both programs leveraged established networks and partnerships to operationalize a community-specific implementation plan, harness community expertise and assets, and maximize the program’s acceptability, uptake, efficiency, and impact. Our study examines the experiences of individuals engaged in organizing and executing SYCT and YMCF in their communities to generate practice-relevant information on the strengths and weaknesses of the community-engaged implementation strategy. The Outcomes for Implementation Research, a heuristic taxonomy developed through a rigorous review of implementation science literature, guided the development of data collection and analysis tools and processes. This taxonomy was selected because it draws on proven and foundational evaluation [e.g., Glosgow’s RE-AIM framework] and implementation science models [e.g., Rogers’ Diffusion of Innovations theory], grounded in an understanding of how components are being applied in practice. Our study provides rich qualitative insight into the ways in which the COVID-19 at-home testing programs’ community engagement strategies supported program adoption, acceptability, and feasibility. Situating these findings within a body of qualitative work around this issue that engages different perspectives and contexts will provide richer and more valid insight. Optimizing community-engaged disaster response practice will require a broader reimagining of public health systems, especially in how we fund our work. Although daunting, this effort would provide a critical foundation for trust, collaboration, and community resiliency that endures beyond a given health threat or response.