The Importance of Community-Based and Community-Partnered COVID-19 Testing for Reducing Disparities Among African American Populations

Background: Health inequalities in African American communities have been further exacerbated by COVID-19. Public health departments and other safety-net providers across the United States have partnered with community-based organizations to address barriers to COVID-19 testing in disproportionately impacted communities. This narrative review summarizes lessons learned from published examples of these community-based COVID-19 testing efforts. Methods: We searched online databases for peer-reviewed articles on community-based COVID-19 testing interventions in the United States aimed at increasing COVID-19 testing among African American populations. We abstracted information about each example and synthesized the primary lessons learned and key aspects that contributed to their success. Results: Seven examples of community-based COVID-19 testing aimed at increasing testing among African Americans and other underserved populations were identified and described, across various U.S. locations and involving multiple types of partners (1) St. Paul, MN (faith, health centers, Mayo Clinic); (2) Chicago, IL (university hospital and health centers); (3) NC (health centers, Community Advisory Board); (4) Baltimore, MD (hospitals, community clinic, mobile clinic); (5) Marion County, FL (health department and community partners); (6) New Orleans, LA (health department and health system); and (7) New York City, NY health and hospital system, mobile clinic). Discussion: Several key aspects of the COVID-19 testing models included the following: (1) close proximity of the testing site to affected communities and availability of walk-up and drive-through testing options; (2) partnerships between safety-net providers and broad community networks, which facilitated outreach and trust; (3) increased resources for safety-net providers; and (4) the use of data to identify areas of need and track impact. The merging of resources and relationships among well-equipped, safety-net providers and other health care institutions and culture-rich, community-centered organizations, to jointly address structural and systemic inequities, is key to cultivating health equity in the distribution of COVID-19 testing and other essential public health services.


Introduction
The United States has had the most cases and deaths from COVID-19 in the world, 103,804,263 and 1,123,836, respectively, as of March 10, 2023. 1 Although COVID-19 has affected all racial groups across diverse locations and stages of the pandemic, the virus has disproportionately affected racialized and minoritized populations, with African American communities experiencing the greatest impact. 2 For example, even early in the pandemic ( June 2020), data showed that in Maryland, African Americans made up 31% of the population but accounted for 52% of the deaths from COVID-19; in Michigan, African Americans were 14% of the population but 40% of the COVID-19 deaths; in Louisiana, African Americans accounted for 70.5% of deaths while comprising 32% of the population. 3hese inequalities, although disturbing, are tragically not surprising, as health disparities in African American communities existed long before the COVID-19 pandemic.African American populations experience disproportionate rates of chronic illness, which exacerbated their susceptibility to COVID-19.Health conditions that increase COVID-19 risk, such as hypertension, peripheral arterial disease, and type II diabetes, have been found to be twice as high in African American populations compared with white populations, even when controlling for risk behaviors (e.g., tobacco use, alcohol consumption). 2In addition, African American communities face ongoing environmental and employment risks that place them at greater risk to contracting COVID-19.
To really understand the causes of these health inequalities, one must consider the structural racism that African American communities experience.As noted by Egede and Walker, structural racism, or ''the ways in which societies foster discrimination through mutually reinforcing inequitable systems,'' 4 affects health through multiple paths, including social deprivation, increased environmental exposures, inadequate access to quality health care, and injury and trauma from state-sanctioned violence. 5An example of structural inequities are the persistent disparities in health insurance coverage by race/ethnicity.The federal government has acknowledged that a major barrier to health care access is inadequate health insurance coverage. 6][9] Medical mistrust among African American populations originates from years of mistreatment and racist interactions within the health care system and continues today evidenced by lack of acknowledgment of medical concerns or poor communication during medical visits. 8Although often framed in the literature as an issue to be addressed within the African American community, the solution to medical mistrust lies in addressing the systemic inequities experienced by this group of people. 10n terms of the social deprivation path to COVID-19 inequalities, African Americans are overrepresented among service industry workers, who, during COVID-19, were deemed essential workers and thus experienced disproportionately higher levels of COVID-19 exposure because of high levels of public interaction, their inability to work from home, and greater likelihood of using public transportation.Furthermore, workers in the service industry face more barriers to COVID-19 testing and care, given that they often do not have paid sick time and experience gaps in health insurance, reflecting inadequate access to health care.
Adequate access to and utilization of COVID-19 testing, especially for highly impacted groups such as African American populations, are essential for pandemic control, as they facilitate early detection, selfisolation, and prevention of onward transmission. 11articularly during the early stages of the pandemic, COVID-19 testing was woefully inadequate, particularly for communities of color, due to barriers limiting access to testing sites and services.For example, North St. Louis, a predominately black community that was one of the areas with the highest infection rates in Missouri, did not have a single testing site several weeks into the pandemic; perhaps not surprising, then, that data from March to September 2020 found that black populations had consistently lower COVID-19 testing rates per diagnosed cases compared with white populations in two Missouri regions. 11n New York City, African American and Hispanic communities experienced higher rates of disease and deaths compared with whites, but even after dramatically increasing the testing sites in black and Latino areas, in May 2020, more testing sites (39%) were located in predominately white zip codes compared with black (17%) and Latino (17%) areas. 12Participants involved in focus groups conducted in urban and rural Alabama expressed concerns regarding the lack of access to reliable transportation, perceived cost of the test, and medical mistrust as deterrents to obtaining a test outside of their community. 13ow 3 years since the advent of the pandemic and even with widespread availability of COVID-19 vaccinations, COVID-19 testing remains an important tool in controlling the pandemic.Identifying best practices on how to provide community-based, accessible COVID-19 testing in ways that are acceptable to the most vulnerable populations is critical.Communitybased testing models have been successful in addressing barriers to testing for other types of health issues that disproportionately affect African American communities, such as HIV and other sexually transmitted infections. 14,15For example, studies have found that community-partnered HIV testing interventions with African American faith communities in Kansas City and Los Angeles-offering church-based HIV testing and a supportive environment for testing-can improve testing dramatically. 16,17hus, we examined the current literature for examples of community-based COVID-19 testing initiatives to identify lessons learned that might inform broader scale implementation of community-based testing strategies.

FAITH!-OCHC
This partnership involved Fostering African American Improvement in Total Health (FAITH), a communitybased participatory research program on health and wellness within African American communities, Open Cities Health Center (OCHC), a federally qualified health center (FQHC) serving socioeconomically disadvantaged populations, and the Mayo Clinic in Minnesota. 18OCHC provides care for more than 10,000 patients annually.Their patient population is racially and ethnically diverse, predominantly low-income, and underinsured or uninsured (81%).A large proportion are African American (47%), of low English proficiency (17%), and immigrants or refugees.A majority are essential workers in public and service sector occupations (long-term care facility workers, grocery store clerks, delivery drivers) and reside in overcrowded neighborhoods with multigenerational households. 18he FAITH!-OCHC partnership was established due to concerns about disproportionately high rates of COVID-19 cases among African Americans in Minnesota and lack of accessible testing.The project aimed to provide easily accessible COVID-19 testing to medically underserved populations and to mitigate community spread.The team disseminated information about the community-based testing site through OCHC's website as well as culturally sensitive texts and mailings to health center patients.A dedicated triage line was established for patients experiencing COVID-19 symptoms and the community-based testing site was near a public transportation route. 18Patients received their results within 24-48 h, which was supplemented with appropriate guidance if they were positive, to isolate to minimize further transmission.Beginning in May of 2020, they established a drive-through COVID-19 testing lane at the OCHC medical facility, which provided culturally sensitive primary care to residents of seven counties in the Minneapolis-St Paul metropolitan area.
At the conclusion of the 10-week project period, a total of 2006 tests had been completed, or *200 per week.Early on during the project, the positivity rate peaked at 46%, but by week 10, it had declined to 8%.

UIH/MSHC
This project was a collaboration between the UIH in Chicago and MSHC, a network of FQHCs run by UIH.MSHC has been providing care to neighborhoods in Chicago for more than 50 years and has 14 practice sites, including 6 community health clinics, 7 schoolbased health centers, and 1 clinic in Rockford. 19he aim of the UIH/MSHC COVID-19 testing project was to increase testing capacity in the most affected racial/ethnic minority communities, which were identified as the West and South sides of Chicago, which are primarily black communities. 19In March of 2020, UIH and MSHC set up an outpatient testing response, inclusive of drive-through as well as walk-up testing capability.The team used the Plan-Do-Study-Act model, which allowed for quickly planning, implementing, evaluating work done, and making changes real time.
Guided by this model, subsequent site modifications and the establishment of new sites occurred.For example, two additional drive-through sites, in the Near West side and Southwest side, opened by April 2020, and six walk-up testing sites were incorporated to provide access to those without cars. 19The walk-up sites were based in FQHCs in highly segregated racial/ethnic minority communities, A total of 63.5% of those tested at the walk-up sites were black, compared with 43.9% of individuals tested by the city of Chicago. 19ver 5 months, this collaboration completed 7523 tests, 5289 at drive-through sites and 2234 at walk-up sites.Overall, walk-up sites had a 19% COVID positivity rate in comparison with the 18% positivity rate at drive-through sites.The positivity among age groups was consistent with Chicago rates, see the decreasing rates with age. 19rth Carolina Health System Initiative This initiative included six health centers, Novant Health, Atrium Health, Neighborhealth, Cone Health, UNC Rex Wake County, and UNC School of Medicine.The initiative deployed mobile testing across 13 counties in North Carolina.Each mobile site was chosen through input from community partners and/or state and GIS data.For example, UNC Rex health developed a Community Advisory Board composed of organizations that served black and Latino individuals, to help identify testing sites in Southeast Raleigh.Neighborhealth partnered with community-based organiza-tions and used state data to identify high poverty areas. 20After identifying sites, each health system leveraged community partnerships to host testing in trusted community spaces such as churches, community centers, food processing plants, homeless service agencies, shopping centers, and farms.
With the help of community stakeholders, UNC health systems developed messaging to inform communities about the testing sites.Information about the sites was disseminated through social media, community networks (word of mouth), support from recording artists, a Spanish language helpline, and online tools.In addition, Atrium Health developed a taskforce to develop culturally appropriate communication to engage minority communities; this task force was independent of the Community Advisory Board established by UNC Rex Health.
All COVID-19 testing sites included in the North Carolina Initiative offered wraparound services such as interpreters to facilitate whole-person care and screenings for social drivers of health such as food security, housing, and behavioral health.Care coordination to community services and the establishment of medical homes were provided by several of the sites at either their institution or a partner clinic.All programs worked closely with local health departments to ensure that those who tested positive were contacted for case investigation and contact tracing.
A total of 64,442 individuals (79% nonwhite) were tested across all sites, with an 18% positivity rate.Because this rate was higher than the rates for the state of North Carolina, it illustrated the success of the project being able to reach the residents at highest risk. 20

Baltimore Mobile Health Clinic Pilot
This pilot project took place on the west side of Baltimore, Maryland, and was led by Life Bridge Health, a major health provider that manages hospitals throughout Greater Baltimore.This organization sought to pilot a Community Mobile Health Clinic program to provide health services, including COVID-19 testing, to hard-to-reach populations, which included black residents. 21They used a vulnerability index developed by the Maryland Department of Public Health and Socially Determined, Inc., to identify highest risk community members by location, who were then contacted for mobile clinic appointments.The mobile clinic included two vans with drivers, a registered nurse, and a community health worker supported by clinicians at Life Bridge's ''virtual hospital,'' a provider-staffed triage and care support arm of the health system. 21he pilot program confirmed 343 primarily Medicare patients to participate in the mobile clinic.Three hundred sixteen patients were assessed and 288 consented to COVID-19 polymerase chain reaction (PCR) tests during the 6-week period ( June to July 2020); 8% of patients canceled their appointment.Of the patients served at the mobile clinic, 84% identified as black. 21n addition, the program measured patient satisfaction as well as the proportion of patients with chronic health conditions to understand the usefulness of this model postpandemic.Ninety-three percent of patients reported being very satisfied or satisfied with services at the mobile clinic.Many patients reported being diagnosed with various chronic health conditions such as hypertension, diabetes, and asthma, among others.

Marion County Health Department COVID-19 testing intervention
This intervention began in April 2020, led by the Marion County Health Department (FL).COVID-19 surveillance data were utilized to identify community testing sites in high-need areas, defined as areas disproportionately affected by the COVID-19 infection. 22he health department matched case reports from public and private laboratories to electronic health records to create a community dashboard.The sites established were in Indianapolis, Indiana, some temporary and others more long-term, according to COVID-19 infection data.Once a neighborhood was established as a hotspot, the health department partnered with community-based organizations, churches, and community clinics to identify testing sites within that area. 22The health department continued these partnerships throughout the duration of the intervention.
Testing sites included in-person registration, to ensure that people who lacked access to the internet were able to access services.The testing sites were walk-up and drivethrough and near public transportation.In addition, testing services were available on the weekend to account for varying work schedules.In response to this intervention, the case and testing disparity gap between the most vulnerable populations, black, Latino, and Burmese, decreased in comparison with white populations in Indianapolis. 22Although the community-based testing intervention will not be sustained postpandemic, the health department will continue using surveillance data to identify and address health disparities experienced by vulnerable communities in Marion County. 22

NOHD and LCMC Walk-Up Testing Project
This project took place between May and June 2020.The NOHD partnered with LCMC, a local health care network, to improve COVID-19 testing services for low-income and minority communities by hosting walk-up sites throughout the city of New Orleans.Mobile testing sites were selected through the identification of communities that were at highest risk of contracting COVID-19 and were advertised through the media and at the neighborhood level.Spanish and Vietnamese language interpreters were available at most sites. 23Mobile sites operated on a rotational basis, remaining in neighborhoods for 2 to 3 days before moving on to the next neighborhood.NOHD and LCMC also used geocoding (patients' home address, race, age, and gender) to understand the distance that patients traveled to obtain a COVID-19 test and the nearest testing site they could potentially have gotten tested. 23ver 2 months, 9721 tests were performed.The transition from drive-through testing to walk-up sites increased the percentage of Orleans Parish residents who got tested from 46% to 78%.The mean percentage of the population in each census tract getting tested doubled from 1% to 2%.Overall, only 20% visited the closest testing site to their address.Patients on average traveled an additional 3.1 miles to get tested. 23African American and Asian patients were more likely to travel the least distance to get tested compared with white patients.Hispanic residents were more likely to travel further distances to obtain a test, partially due to living in the suburbs of New Orleans.

NYC Test and Trace Mobile Testing Project
This project took place between December 1, 2020, and April 1, 2021, with the aim to reduce COVID-19 testing inequities.Test and Trace was established by NYC Health and Hospitals guided by the following three pillars: COVID-19 testing, contact tracing, and ''take care'' (isolation and after care support). 24The Test and Trace team sought to address testing inequities among black/African American and Hispanic communities.They developed mobile testing sites in collaboration with community partners, which included houses of worship, small retailers, government and contracted service providers, and traditional community-based organizations. 24Partners were identified through an online survey, the Test and Trace advisory board, partners in the NYC Care program, and traditional governmental referral mechanisms.Test and Trace managed the operations of the mobile sites while community partners led outreach, testing site placement, and direct selection of testing locations.
The project consisted of clinician-administered and patient-administered sites.The clinician-administered sites had the following three phases: (1) outdoor testing ( June to November 2020), 14 clinical teams offered free PCR testing, M-F, at locations under pop-up tents; (2) vehicle testing (November 2020 to April 2021), 8 teams and an enclosed testing vehicle; and (3) expanded vehicle testing (December 2020).Test and Trace engaged an additional vendor to provide both vehicle and mobile testing services and was scaled to 40 mobile units by mid-March 2021.Patient-administered testing took place in community-based spaces such as churches and senior centers.This consisted of staff trained in self-swab testing guiding patients in collecting their sample using home test kits, packaging the sample, and sending the samples to the laboratory.Patients were contacted by the laboratory through the email that they provided during registration. 24esting locations were selected according to elevated positivity rates, community partner recommendations, and existing city resources such as parks and public housing campuses. 24ver 5 months, the Test and Trace mobile testing project served 150,351 unique patients and processed 274,083 tests in total, of which 6% returned a positive result.The model accomplished its goal of improving testing access to communities.For example, selfidentified black/African American residents comprise 24% of NYC's population but 31% of completed clinician-administered tests.Similar statistics for selfidentified Hispanic residents were evident in the data (29% of the total NYC population, but 48% of the completed clinician-administered tests). 24

Discussion
Across the United States, public health departments and other health providers have implemented diverse approaches to increase accessibility to COVID-19 testing.In this study, we have identified and explored seven examples of community-based COVID-19 testing from the literature that specifically aimed to increase the reach of COVID-19 testing among African American or black populations.Review of these models has yielded several key issues or aspects that potentially contributed to their success: (1) close proximity of the testing site to the affected communities and the availability of both walk-up and drive-through testing op-tions; (2) partnerships between safety-net providers and broad community networks, which can facilitate outreach and trust to increase access to and use of COVID-19 testing; (3) increased resources for safetynet providers; and (4) the importance of data to identify areas of need and track impact.We expand on these lessons below to inform community-based COVID-19 testing strategies going forward.

Testing accessibility
Regarding testing locations, the interventions were placed in communities that were impacted disproportionately by COVID-19, and particularly in community settings that are frequently accessed (e.g., churches, shopping areas) and, in the case of mobile vans, in the residential areas most affected.This strategy helped address transportation issues, which are a barrier to accessing health services for underserved populations, especially African American communities. 13In addition, walk-up testing was offered to increase accessibility for those who may not have private vehicles.Walk-up testing and on-site registration can also greatly facilitate access for persons who may not be able to preregister for testing services due to limited access to data-driven devices such as computers or smartphones, broadband internet, as well as limited skills to effectively manage COVID-19 online registration platforms. 20

Community-based partnerships
In terms of partnership and facilitating trust, the UIH, FAITH!, NYC Test and Trace project, and New Orleans Department of Health projects implemented testing through trusted community entities, MSHC, OCHC, and LCMC, respectively.These safety-net providers have long tenures serving their racially and ethnically diverse, predominantly low-income, and underinsured or uninsured communities.They have extensive networks of care within underserved communities through established community clinics and school-based health centers.
Nevertheless, opening testing sites in underresourced communities in and of itself may not be enough to increase testing participation.All seven COVID-19 testing efforts described the above-involved partnerships between safety-net providers and/or public health departments and broad community networks such as faith-based organizations.[27] Adequate resources Although financing of community-based COVID-19 testing was not addressed explicitly in these published examples, federal policies and funding undoubtedly have played an important role.Increased financial support for testing and programmatic funding, for example, through the Department of Health and Human Services-Center for Medicare and Medicaid, one of the primary sources of funding for community health centers, is necessary to enhance the capacity of the safety-net providers and hospitals that play a valuable role in reducing health inequities.As cited by Yearby et al., such organizations are under-resourced and financially constrained and score lower on patient satisfaction surveys, underperform on evidence-based metrics, and report higher rates of adverse safety events and complications, which perpetuate health inequities and inequalities in African American communities. 69][30] The result of the lack of sustainable funding is currently illustrated nationally, due to the dwindling of federal COVID-19 relief funds used to reimburse community health centers and hospitals for interventions that minimized the spread of COVID-19.In addition, funding through research mechanisms such as the National Institutes of Health (NIH), National Health Foundations, or academic funding is critical to better understand disparities and promising models for addressing them.

Data accessibility
Finally, accessibility of COVID-19 data was an essential step in the development of all the COVID-19 testing interventions to effectively identify areas of greatest need for COVID-19 testing and impact.The Marion County Health Department and the NYC Test and Trace used local positivity rates in conjunction with other resources such as community partner recommendations, to decide where to place testing sites; Marion County also used race-specific testing rates over time to evaluate their strategies. 24A lack of information about COVID-19 disparities at different points during the pandemic and regarding testing hampered strate-gies to ensure equitable access to COVID-19 testing.For example, during August 2021, all 50 states reported COVID-19 infection and death rates by race/ethnicity, whereas only 8 states reported COVID-19 testing rates by race/ethnicity, which directly impacts the ability to allocate COVID-19 testing resources where needed. 31he COVID-19 Health Equity Dashboard, a tool developed by Emory University, shows the number of cases and deaths for each U.S. county by age, race, ethnicity, employment status, poverty, and length of commute to the nearest hospital. 32This kind of stratified information helps to identify areas with the greatest COVID-19 burden and enables resources to be directed toward these communities. 5Having similar information for COVID-19 testing would help direct strategies and resources to subgroups within communities who are most affected and vulnerable.
The interventions described in the examples illustrated success as they were able to address COVID-19 testing access barriers, including hesitancy and proximity to the community, but there were important omissions in their descriptions that may impede replication.The articles provided limited detail about the follow-up process, including information about the staff who provided the test results, how a positive result was managed, and the communication between testing staff and the patient's primary care provider (if applicable).Examples with more detailed information could enable elected officials and public health administrators to advocate for financial resources and/or the development of policy and replicate successful models with adequate capacity.
Nevertheless, the examples reviewed provide important lessons about successfully expanding access to COVID-19 testing for African Americans and other high-risk and underserved populations, which can be useful for ongoing efforts to provide testing and vaccinations for COVID-19 and other critical health issues.In the midst of a public health emergency, real-time data on testing and outcomes are essential for identifying and prioritizing communities most in need, tracking changes over time (particularly in response to interventions), and identifying new strategies to increase access to and uptake of testing.Having ongoing community-level data that are broken down by racial/ ethnic groups can also serve as a measure of accountability for health care systems' commitments to achieve health equity. 11Proximity of testing and availability of both walk-up and drive-through options are also key to consider.
Finally, the merging of resources and relationships among well-equipped safety-net providers and other health care institutions and culture-rich, communitycentered organizations, to jointly address structural and systemic inequities in underserved populations, such as African American communities, is key to cultivating health equity in the distribution of COVID-19 testing and other public health services. 18Strong partnerships with trusted community organizations are essential in building systems that result in health equity for all communities. 24