When the coronavirus (COVID-19) pandemic began, the Center for Disease Control (CDC) guidelines prioritized healthcare workers (HCWs) for SARS-CoV-2 testing, including asymptomatic HCWs by June 2020. Reference Hughes, Groenewold and Lessem1 Yet HCW infections led to multiple healthcare facility outbreaks, resulting in high rates of morbidity and mortality. Reference Firew, Sano and Lee2 Despite priority for testing HCWs, specific barriers to SARS-CoV-2 testing include perceptions of access and employment factors. Using linked survey and employment data, we investigated perceived barriers to SARS-CoV-2 testing among HCWs who wanted testing in Boston, which was a pandemic epicenter in spring of 2020.
Methods
All employees were invited to complete a 19-item survey about the impact of COVID-19 on transportation, employment, finances and quality of life, and questions about interest in, receipt of, and perceived barriers to SARS-CoV-2 testing. In total, 10 answers were offered as potential barriers to SARS-CoV-2 testing, and a free text option. The survey was distributed from July 9 to August 14, 2020, via e-mail and in person.
Participants received a $10 gift card in return for their participation. All survey responses were linked to a human resources (HR) data file that included age, gender, race, ethnicity, residence (city, state), job title, salary, receipt of employer sponsored insurance, length of tenure, full-time equivalent (FTE) status, US citizenship status, and marital status. Annual salary for nonphysicians was calculated based on hourly wages for full time (40) hours. Physician salaries were provided as annual ranges instead of individual values owing to anonymity concerns.
Survey responses included number of household members and number of children in the household. Using both household number and annual salary, we calculated the percentage of the federal poverty level (% FPL) for each respondent, categorized as ≤200, 201–400, 401–600, or >600.
Job titles were collapsed into the following categories: administrative (employees with no patient contact including research staff, finance, administrative support, clinic managers, human resources staff, billing staff, information technology and others); executive staff; facilities (plumbers, heating ventilation and air conditioning repair, electricians and other building or maintenance staff); nursing and nursing supports (registered nurses, medical assistants, licensed practical nurses, nurse practitioners, certified nurse anesthetists and others who work as nurses or directly support nursing staff and responsibilities); patient care (jobs with direct patient facing responsibilities that are neither nursing nor physicians, eg, respiratory therapist, child life specialist, physical or occupational therapist, speech and language pathologist, social worker, and others); patient support (jobs that encounter patients regularly, but are not directly patient care, eg, environmental services, interpreters, patient transporters, operating room technologists, dietary and hospitality services, pharmacists, clinical coordinators, security guards); and physicians (including attending physicians, resident and fellow physicians, and physician assistants).
Our analytic sample included only the respondents who wanted SARS-CoV-2 testing. We performed univariate logistic regression with receipt of a SARS-CoV-2 test as the dependent variable and each response for why a respondent wanted SARS-CoV-2 testing as the independent variable. We reviewed the written-in responses from participants who selected “other” when asked “Why did you not receive a COVID-19 test?”
Results
From 6,736 eligible employees, we received 2,501 (37%) unique responses; 1,396 (56%) wanted SARS-CoV-2 testing and 873 (63%) of those who wanted SARS-CoV-2 testing received SARS-CoV-2 testing. Table 1 highlights differences between respondents who received testing, and those who did not, conditional on reporting that the respondent wanted to be tested for SARS-CoV-2.
Table 1. Characteristics of Participants Characteristic
Note.SD, standard deviation; PTO, paid time off.
a Includes respiratory therapists, physical therapists, occupational therapists, speech-language pathologists.
b Includes pharmacy staff, dietary staff, environmental services staff.
More HCWs who reported financial worries were not tested for SARS-CoV-2 (34% vs 27%; P = .005) (Table 1). HCWs who were tested for SARS-CoV-2 had higher odds of having a direct exposure (OR, 2.69; 95% CI, 2.13–3.42) or having symptoms (OR, 6.36; 95% CI, 4.80–8.77) than those who were not (Table 2).
Table 2. Associations of Reasons for Testing and Locations of Attempted Testing With Receipt of SARS-CoV-2 Test
Note. OR, odds ratio; CI, confidence interval.
The following barriers were most commonly reported by those who did not receive SARS-CoV-2 testing: did not meet testing criteria (67%), worried about using up sick time (18%), and worried about testing costs (16%) (Table 2). Also, 16% of respondents who did not receive SARS-CoV-2 testing selected “other” as a response and wrote in their responses. Most frequently, these write-in responses described confusion about testing criteria. Some HCWs reported mild symptoms but were turned away from the testing site.
Discussion
HCWs reported barriers to SARS-CoV-2 testing, which has significant implications for hospital infection control. First, both confusion about testing eligibility and concerns about the cost of the test suggests suboptimal communication about criteria for testing, which changed frequently. Email was the primary mode of communication during the pandemic, but many HCWs do not access their work email consistently. Communication strategies that include all employees may address disparities in access to timely and relevant information.
Second, changing workplace policies around sick leave is one potential employer action to encourage testing. Before the COVID-19 pandemic, HCWs regularly worked while sick due to staffing concerns and fear of letting colleagues down. Reference Szymczak, Smathers, Hoegg, Klieger, Coffin and Sammons3,Reference Tan, Robinson, Jayathissa and Weatherall4 Among our sample, 18% of respondents reported that they did not get a SARS-CoV-2 test due to concerns about using up their sick time, while 8% reported that they did not get a SARS-CoV-2 test due to concerns over lost wages if they tested positive and had to quarantine. In Massachusetts, being told to self-quarantine by a medical professional is a qualifying reason to apply for unemployment insurance, but this was not communicated to TuftsMC staff. Reference LaRochelle5,6
Designating certain staff as sick relief, rather than requiring others to work doubles or without cover, and clarifying what constitutes too sick to work are recommended workplace policies that encourage employees to stay home if they are sick. Reference Mitchell and Coatsworth7 Employees in this study who were required to get tested in order to return to work were more likely to do so, demonstrating that managerial support of testing and adequate coverage for employees was effective at ensuring employee SARS-CoV-2 testing.
This study had several limitations. First, this analytic sample examined only those who wanted a SARS-CoV-2 test. This introduces selection bias to our results, as it is likely that there are different barriers to SARS-CoV-2 testing among those who did not report wanting a test. Secondly, the survey responses were created as options within “select all that apply” questions, and therefore were not independent of each other. Third, contracted employees, such as traveling nurses, dialysis clinic staff, or members of the environmental services team, were not considered hospital employees and therefore excluded from data collection. Because these contracted employees frequently held positions with high risk of exposure but did not receive employer benefits, it is likely that they experienced significant barriers to SARS-CoV-2 testing.
Future research should examine occupational barriers to COVID-19 prevention strategies that include contracted workers. Our study found that despite walk-in on site employer-based SARS-CoV-2 testing during the first pandemic wave, communication limitations and occupational barriers reduced access for hospital employees. The digital divide contributes to disparities among hospital workers and their access to COVID-19–related communications.
Workplace policies to encourage sick leave are critical for uptake of appropriate diagnostic testing. 8 Our findings may extend to vaccination considerations, especially in health care settings with limited benefits such as home health and skilled nursing facilities. Reference Gharpure, Guo and Bishnoi9 As variants of SARS-CoV-2 continue to spread in 2021, we must translate the lessons learned from earlier in the pandemic.
Acknowledgments
No one other than the listed authors had a role in the preparation or gathering of the data.
Financial support
No financial support was provided relevant to this article.
Conflicts of interest
All authors report no conflicts of interest relevant to this article.
