Critical lessons from a pragmatic randomized trial of home-based COVID-19 testing in rural Native American and Latino communities.

PURPOSE: Native Americans and Latinos have higher COVID-19 infection and mortality rates and may have limited access to diagnostic testing. Home-based testing may improve access to care in rural and underserved populations. This study tests the effect of community health worker (CHW) support on accessibility, feasibility, and completion of COVID-19 home testing among Native American and Latino adults living on the Flathead Reservation in Montana and in Yakima Valley, Washington. METHODS: A two-arm, multisite, pragmatic randomized controlled trial was conducted using block randomization stratified by site and participant age. Active arm participants received CHW assistance with online COVID-19 test kit registration and virtual swabbing support. The passive arm participants received standard-of-care support from the kit vendor. Logistic regression modeled the association between study arm and test completion (primary outcome) and between study arm and test completion with return of valid test results (secondary outcome). Responses to posttest surveys and interviews were summarized using deductive thematic analysis. FINDINGS: Overall, 63% of participants (n = 268) completed COVID-19 tests, and 50% completed tests yielding a valid result. Active arm participants had higher odds of test completion (odds ratio: 1.66, 95% confidence interval [1.01, 2.75]). Differences were most pronounced among adults ≥60 years. Participants cited ease of use and not having to leave home as positive aspects, and transportation and mailing issues as negative aspects of home-based testing. CONCLUSIONS: CHW support led to higher COVID-19 test completion rates, particularly among older adults. Significant testing barriers included language, educational level, rurality, and test kit issues.

Distance Traveled for Abortion at a North Carolina Tertiary Care Center Following Restrictive Legislation.

Background: North Carolina enacted 5 statutes restricting abortion between 2011 and 2016. Our objective was to compare the proportion of women who traveled more than 25 miles to a Southern tertiary care center during 2 distinct time periods (2011 and 2017). Methods: We conducted a time-series retrospective cohort study of women who obtained an abortion at University of North Carolina hos-pitals in 2011 and 2017. We collected data regarding residence, demographics, gestational age, indication, parity, and referral source. Our primary outcome was distance traveled from a person's residence to the study center. Results: We enrolled 399 women, 139 in 2011 and 260 in 2017. In 2011, 72% (100 of 139) traveled more than 25 miles, compared with 75% (195 of 260) in 2017. Fewer women traveled greater than 100 miles from their residence to our clinic in 2011 (20%) compared to 2017 (26%). Fewer women from neighboring states were seen in 2011 than 2017 (p = .04). Women seeking abortion in 2011 were 4 times less likely to have been referred from a freestanding abortion clinic compared with women in 2017 (9% [13 of 139] versus 37% [96 of 260]). Limitations: The tertiary referral nature of our study limits generalizability. With 2 time-distinct cohorts, there may be factors that changed over the study period that remain unaccounted for. Conclusions: A similar proportion of women traveled more than 25 miles for abortion before and after the legislative changes. Our finding that more women traveled greater than 100 miles to obtain an abortion in 2017 compared to 2011 highlights a key burden to abortion ac-cess in North Carolina. The increased number of women seen from freestanding abortion centers and from neighboring states following the legislative changes highlights an important geographical burden potentially associated with strict abortion restrictions.

A pragmatic randomized trial of home-based testing for COVID-19 in rural Native American and Latino communities: Protocol for the "Protecting our Communities" study.

BACKGROUND: Home-based testing for COVID-19 has potential to reduce existing health care disparities among underserved populations in the United States. However, implementation of home-based tests in these communities may face significant barriers. This study evaluates the acceptability, feasibility, and success of home-based testing and the potential added benefit of active support from trusted community health workers for Native Americans and Hispanic/Latino adults living in rural Montana and Washington states. METHODS/DESIGN: The academic-community research team designed the trial to be responsive to community needs for understanding barriers and supports to home-based COVID-19 testing. The "Protecting Our Community" study is a two-arm pragmatic randomized controlled trial in which a total of 400 participants are randomized to active or passive arms. Participants of both study arms receive a commercially available home collection COVID-19 test kit, which is completed by mailing a self-collected nasal swab to a central laboratory. The primary study outcome is return of the kit to the central lab within 14 days. The cultural, social, behavioral, and economic barriers to home-based COVID-19 testing are also assessed by qualitative research methods. A survey and semi-structured interviews are conducted after the trial to evaluate perceptions and experience of home-based testing. DISCUSSION: Implementing home-based testing in underserved populations, including among Native American and Hispanic/Latino communities, may require additional support to be successful. The Protecting Our Community trial examines the effect of trusted community health workers on use of home-based testing, which may be adaptable for community-driven models of home-based testing in other underserved populations.

Comparing Website Identification for Crisis Pregnancy Centers and Abortion Clinics.

BACKGROUND: Crisis pregnancy centers (CPCs) seeking to dissuade women from abortion often appear in Internet searches for abortion clinics. We aimed to assess whether women can use screenshots from real websites to differentiate between CPCs and abortion clinics. METHODS: We conducted a cross-sectional, nationally representative online study of English- and Spanish-speaking women aged 18-49 years in the United States. We presented participants with screenshots from five CPCs and five abortion clinic websites and asked if they thought an abortion could be obtained at that center. We scored correct answers based on clinic type. Outcomes included ability to correctly identify CPCs and abortion clinics as well as risk factors for misidentification. The survey also included five questions about common abortion myths and a validated health literacy assessment. RESULTS: We contacted 2,223 women, of whom 1,057 (48%) completed the survey and 1,044 (47%) were included in the analysis. The median score for correctly identifying CPCs as facilities not performing abortion was 2 out of 5 (Q1: 0, Q3: 4). The median score for correctly identifying abortion clinics as facilities performing abortion was 5 out of 5 (Q1: 3, Q3: 5). Those less likely to endorse abortion myths had higher odds of correctly identifying CPCs (adjusted odds ratio, 2.43; 95% confidence interval, 1.78-3.32). A low health literacy score was associated with decreased odds of correct identification of CPCs (adjusted odds ratio, 0.39; 95% confidence interval, 0.25-0.59). CONCLUSIONS: Websites of CPCs were more difficult for women to correctly identify than those of abortion clinics. Women with limited knowledge about abortion and low health literacy may be particularly susceptible to misidentification of CPC websites.

Women's knowledge of their state's abortion regulations. A national survey.

OBJECTIVES: States vary significantly in their regulation of abortion. Misinformation about abortion is pervasive and propagated by state-mandated scripts that contain abortion myths. We sought to investigate women's knowledge of abortion laws in their state. Our secondary objective was to describe women's ability to discern myths about abortion from facts about abortion. STUDY DESIGN: This was a cross-sectional study of English- and Spanish-speaking women aged 18-49 in the United States. We enrolled members of the GfK KnowledgePanel, a probability-based, nationally-representative online sample. Our primary outcome was the proportion of correct answers to 12 questions about laws regulating abortion in a respondent's state. We asked five questions about common abortion myths. We used descriptive statistics to characterize performance on these measures and bivariate and multivariate modeling to identify risk factors for poor knowledge of state abortion laws. RESULTS: Of 2223 women contacted, 1057 (48%) completed the survey. The mean proportion of correct answers to 12 law questions was 18% (95% CI 17-20%). For three of five assessed myths, women endorsed myths about abortion over facts. Those who believe abortion should be illegal (aOR 2.18, CI 1.40-3.37), and those living in states with neutral or hostile state policies toward abortion (neutral aOR 1.99, CI 1.34-2.97; hostile aOR 1.6, CI 1.07-2.36) were at increased odds of poor law knowledge. CONCLUSIONS: Women had low levels of knowledge about state abortion laws and commonly endorse abortion myths. Women's knowledge of their state's abortion laws was associated with personal views about abortion and their state policy environment. IMPLICATIONS: Supporters of reproductive rights can use these results to show policy makers that their constituents are unlikely to know about laws being passed that may profoundly affect them. These findings underscore the potential benefit in correcting widely-held, medically-inaccurate beliefs about abortion so opinions about laws can be based on fact.