Community testing - programme implementation: health board leads' experiences

Executive summary

Introduction

In January 2021, as part of its overall Testing Strategy, the Scottish Government implemented the Community Testing Programme. This aimed to detect cases both in areas with high or spiking Covid-19 rates, and in communities at higher risk of contracting the virus or with limited or no access to other asymptomatic testing routes.

This qualitative study analyses data from in-depth interviews conducted with Health Board leads on their experiences of the Programme, with a focus on good practice examples, challenges and strategies adopted by each local area to overcome barriers to Community Testing.

Background

The Community Testing Programme was launched with a pilot study between 26^th November and 9^th December 2020 in eight communities with stubbornly high prevalence. Following this successful first phase, the Programme officially commenced in a number of Health Boards on the 18^th January 2021 and combined fixed sites with pop-up and/or mobile solutions. The general public could drop-in or book a test in one of the available locations, where trained helpers performed or distributed tests and explained how to correctly administer them at home.

Given the differences in geography and demographics of each Health Board, these different testing solutions contributed to providing the most appropriate services to the populations targeted by Community Testing. They also represented an important presence in local areas, where they were responsible for advertising the Programme.

Research aims and objectives

This research provides insights into the set-up and management of the Community Testing Programme, with the aim of supporting national policy-making on testing and learning lessons from a rapid and significant programme of work to combat the spread of Covid-19. The objectives of this study are: reporting local leads' experiences of the implementation of the Programme; providing in-depth information on Health Board leads' views on the barriers to Community Testing encountered by their local populations; and exploring the strategies and approaches adopted by each local area to overcome these barriers.

Research questions

This study aimed to answer the following research questions:

• How has the Community Testing Programme been operating?
• How has community engagement been pursued and barriers to testing overcome?
• What lessons can be learned from the implementation of the Programme?

Research methods and sampling

The data presented here was collected between 1^st December 2021 and 25^th February 2022. A qualitative approach of semi-structured interviews was chosen to ensure that local leads' views of the implementation of the Community Testing Programme were captured.

Each interview lasted about 60 minutes and was audio recorded and transcribed. The transcripts have been analysed by theme for comparison purposes. Verbatim quotes are included in this report as examples of the research findings to present participants' voices.

Fourteen leads belonging to 12 Health Boards took part in the research. They had a varied professional background and worked in a number of different roles. Some had taken part in the Programme since its launch, while others joined at a later stage.

Information about each Health Board and individual participants has been anonymised in this report. The report has been shared with research participants before publication to ensure that they are content with the way their views and experiences are being represented and that they feel their anonymity has been protected.

Key findings

Findings from the interviews are analysed by theme with a focus on the following aspects:

Models of implementation

The implementation of the Community Testing Programme had to be achieved in a matter of just a few weeks and represented a demanding task for the Health Boards. Although the majority of the leads felt that the set-up of fixed sites went smoothly, difficulties in identifying the right locations were indicated as the main operational challenge of the initial phase. In some cases, these were due to a lack of venues meeting public health requirements; in others, to the impossibility of establishing which areas were in greatest need of targeted testing through existing data. Concerns about footfall in remote or rural settings with a very sparse population also led some Health Boards to question the need for fixed sites at all.

Mobile solutions represented an important development in the models of delivery and were perceived as a more flexible alternative, thanks to their potential to easily adapt to an ever-evolving situation and to address the logistical issues emerging in those areas where the setting-up of a fixed site was not possible. Yet, they presented the leads with further obstacles, such as the length and complexity of the process involved in their deployment or the pushback from a few community facilities that found the presence of MTUs disruptive.

When pop-up sites were being used to enhance the testing offer, some Health Boards struggled with additional challenges, such as timely delivery or purchase of vans, or poor signal inside the vehicles. Some interviewees also expressed concerns regarding the quality of the equipment and material used to build booths, while also praising local partners and the Army for offering more suitable or creative solutions allowing frequent handling and reducing the risk of damage due to wear.

With the increasing focus on the LFD Collect model at the beginning of 2021, the Programme benefited from the distribution of test kits in a number of additional locations and even door-to-door. This widespread availability of tests led some Health Board representatives to further question the need for the ATSs.

Finally, some leads felt strongly about the importance of dual testing, a model offering both LFD and PCR tests in the same location, which was adopted in a few local areas at a later stage.

During the Programme's evolution, a number of issues emerged. With services moving back to normal at the end of lockdown, keeping or replacing testing venues belonging to third parties became increasingly difficult. Furthermore, test supply or transport were complicated by uncertainties around uptake, bad weather conditions and international shortages of kits. Some leads also reported attempts to inappropriately use the Community Testing Programme on the part of those workplaces which considered the Government route for businesses too bureaucratic.

Recruitment of testing staff

The recruitment of testing staff didn't represent a challenge in the early phases of the Programme, thanks to the presence of the military, people sourced among those re-deployed from non-critical services, and the high number of employees who had been furloughed and were looking for a job. Indeed, it was even described by some leads as a positive unintended consequence of the Programme, which offered employment opportunities to the local population, while also adding skills and value to the NHS.

However, as society started opening up and people to go back to their previous jobs – and a number of job positions for vaccination venues were advertised – retaining testing staff became increasingly problematic. The issue related to the temporary nature of short-term contracts, the lack of competitiveness with salaries for other positions in the same NHS band and difficult working conditions (e.g. downtime, bad weather for those working in pop-up and mobile solutions, and abuse from some members of the public). In response to this, some Heath Boards proactively promoted staff wellbeing by adopting strategies meant to benefit or motivate them, and initiatives to recognise their contribution to the Programme.

Relationships with Partners

The financial resources for the implementation of the Community Testing Programme were provided by the Scottish Government to the Health Boards, who were then given the autonomy to manage and allocate funds to their Local Authorities. This flexibility resulted in three different approaches to setting up the Programme: in some cases, the Health Boards had full control of implementation; in others, the Local Authorities took the lead; whereas some areas preferred a partnership between the two.

In the majority of cases, the Health Boards and Local Authorities worked in partnership, with the former usually focusing on the delivery of test kits, processing of samples, provision of trained nurses and clinical governance; and the latter on the operational delivery, such as taking responsibility for the recruitment of testing staff and for the provision, set up and management of the sites.

Partnering with Local Authorities was seen as beneficial due to their deep knowledge of their area, which contributed not only to identifying the best locations in which to place the sites, but also to establishing or strengthening relationships with a network of other parties closely engaged with local communities.

With few exceptions, the Health Board leads described the collaboration with their Local Authorities in very positive terms. They considered it a result of previously strong relationships, but also suggested that increased trust and recognition of achievements contributed to improving cooperation further.

Collaboration with the Scottish Government, SAS (Scottish Ambulance Service), NSS (National Services Scotland) and the Army were mentioned by the interviewees as key relationships that developed thanks to the Community Testing Programme. Engagement with other partners, such as leisure providers and the voluntary sector, varied significantly by local area and seemed to depend on how well the NHS, or the Local Authorities as their intermediaries, were tied in with these groups before the implementation of the Programme.

Targeted communities and barriers to Community Testing

For the Community Testing leads, knowledge of the local populations and data gathering on case rates and wastewater were key for the identification of areas to target and the effective use of resources.

In many cases, rurality emerged as one of the demographics posing a major barrier to testing. The implementation of the Community Testing Programme was perceived as paramount in those remote settings that had issues with accessibility of tests (e.g. due to slow mail services and the exclusion from the Universal Offer home delivery service of some post codes) and a local perception of being at low risk of catching Covid-19 thanks to geographical isolation.

Socio-economic deprivation was also mentioned as a demographic determining both practical (e.g. travel to the testing venues and the associated costs) and psychological barriers (e.g. worries about receiving a positive test, having to self-isolate and losing earnings for taking time off work). Although support was provided, a few interviewees argued that this didn't always solve testing hesitancy due to the small number of grants which were actually awarded, the sometimes lengthy process involved in receiving funds and the variation in provision between Local Authorities.

The Health Board leads also factored in ethnicity as a demographic variable affecting testing uptake (for example, due to language barriers).

Other barriers identified pertained to accessibility: digital barriers (e.g. due to remoteness and connection issues, older age and lack of digital literacy); the lengthy process of registering a test; poor weather conditions for those accessing the Mobile Testing Units; and difficulties in locating the mobile solutions that were in place.

The majority of the leads also thought that testing uptake was impacted by poor health literacy and by the confusion caused in the public by the complexity of the testing landscape. There was a general perception that people struggled to understand why a test was needed in the absence of symptoms, differences between types of tests and what the Asymptomatic Testing Sites were, with some leads also reporting misconceptions and myths circulating about testing. Testing fatigue and concerns regarding Covid-19 tests in general, considered invasive and/or difficult to administer, were also seen as a likely further cause of disengagement from the Programme.

Finally, the leads reflected on the drop in demand and need for on-site assisted testing following the launch of the Universal Offer, and to the difficulty in establishing whether their Health Board had managed to identify all the populations that needed to be targeted.

Communication and outreach strategies

In order to promote awareness of the existence and objectives of the Community Testing Programme, encourage uptake and reduce barriers to testing, the Health Boards invested in a number of communication and outreach strategies.

Each area expanded the general guidelines received from the Scottish Government to include additions or modifications to the Programme discussed and agreed locally in order to target local areas' needs and improve accessibility.

Social media, and Council or other websites, were widely utilised for the flexibility they offered: they allowed the targeting of specific audiences, the addition of the most up-to-date information (e.g. on the locations of MTUs) and live support to users. Although with some caveats, social media also provided data on users' engagement and barriers to testing, which contributed to a picture of emerging issues and helped to develop targeted solutions. Traditional media were used in all the Health Boards too. These included local TV, radio and press, both for news releases and interviews with the leads.

Efforts to increase uptake also focused on accessibility (e.g. good public transport links and flexible opening times), visibility of testing sites and staff (not only in terms of location, but choice of colour for the site and the staff uniforms), clarity of signage and a presence in outbreak settings, in additional locations and at special events. Door-to-door distribution was also adopted in rural contexts to tackle structural factors such as sparse or dispersed populations, and limited facilities.

Positive interactions with the testing staff emerged from the interview as one of the strengths of the Programme. These were attributed to the emphasis on relationship building and communication, with testing teams not only distributing kits, but promoting knowledge of Covid-19 and testing, and addressing misconceptions and anxieties in the targeted populations. A couple of leads stated that this approach turned the Programme into a wellbeing resource at a time of social isolation and loneliness, with some repeat users attending the venues for social contact and a chat.

Collaboration with third sector organisations, Third Sector Interfaces (TSIs) and faith groups was described as crucial for the promotion of testing through trusted voices and the provision of additional data on specific groups and communities.

Finally, some interviewees found that their outreach work benefited from establishing links with vaccination venues and pop-up options. On the other hand, one lead suggested that those getting vaccinated were clearly engaging with Covid preventative measures and probably already accessing tests through other routes.

Reflections on the overall Testing Programme

The implementation of the Community Testing Programme stretched and evolved over the course of several months, as it adapted to changed circumstances and incorporated lessons learned from experience. During the interviews, the leads reflected on what this meant for their Health Boards.

Some interviewees mentioned initial resistance to the Programme, questioning its necessity, as well as the usefulness of LFD tests as a screening measure. Others focused on the operational side and discussed uncertainties around uptake.

The need for better data was reported by a few leads, who explained the difficulty in understanding case distribution or the actual impact of different models. It was suggested that more (possibly qualitative) analysis and evaluations were needed. Yet, some argued that, even if better data had been collected, these would still have referred to a very low number of tests and lacked significance. Furthermore, the interviewees stated that with the implementation of the LFD Collect model, the impossibility of establishing whether tests were collected but not used and/or recorded online made it trickier to assess any success.

A good number of interviewees believed that the Community Testing Programme maximised the opportunities for the public to find and pick up tests, with wide availability and ease of accessibility of tests seen as proof that the Programme achieved its main aim.

On the other hand, some Health Board leads stressed how these successes had to be measured against the costs of the Programme and questioned whether it was financially sustainable, especially longer term. As the testing landscape kept changing over the course of the pandemic, most of the leads struggled to imagine what the future of Community Testing would look like, while also suggesting that there may be scope for reviewing its original objectives.

Finally, the leads recalled how being part of the Programme meant working in a fast-paced and dynamic environment, characterised by frequent demands and unexpected challenges. As they faced an ongoing public health emergency and staff absence due to Covid sickness, long work hours and stress heavily impacted on their and their team's work-life balance. Nonetheless, they also expressed a sense of fulfilment for having worked towards achieving ambitious objectives and been part of an historic effort.