Factors Associated with COVID-19 Testing in Structurally Vulnerable Populations: An Exploratory Study in Southern Maine

Introduction: The COVID-19 pandemic disproportionately affected structurally vulnerable populations in the United States. COVID-19 testing was instrumental in controlling viral spread and linking people to treatment; however, testing rates were lower among racial and ethnic minority groups. Our objective was to identify factors associated with desired COVID-19 testing behavior among vulnerable populations. Methods: We conducted an exploratory cohort study of at-home COVID-19 testing between March 2022 and November 2023 in Portland, Maine. Partnering with trusted community organizations, we engaged participants from immigrant, housing-unstable, substance-using, and low-income/uninsured communities. Participants received 5 at-home COVID-19 tests every 8 weeks for 48 weeks. Participants completed a baseline survey and follow-up surveys every 4 weeks on COVID-19 exposures and symptoms, as well as use of COVID-19 tests, with additional questions every 8 weeks on behavioral factors (ie, risk perceptions, attitudes, norms) around COVID-19 testing. The primary outcome was “desired testing behavior score,” or the proportion of instances a participant tested when they should have based on guidance from the Centers for Disease Control and Prevention. Results: We enrolled 93 participants, of whom 39 (42%) were immigrants, 30 (32%) were unhoused or had a history of chronic homelessness, 28 (30%) reported substance use, and 60 (65%) were low income and/or uninsured. Overall, participants tested 66% of the recommended times. In bivariate regression, 4 factors (age, confidence in ability to use a COVID-19 test, perceived usefulness of testing, and commitment to testing) were significantly associated with desired testing behavior. However, these associations were not statistically significant in multivariable linear regression. Discussion and Conclusions: Participants from vulnerable communities engaged with COVID-19 testing when provided with at-home tests, but more research is needed to understand what factors drive testing behavior.