Prior epidemiologic research by our team documented stark racial and socioeconomic disparities in COVID-19 case prevalence, testing rates, and test positivity in Alabama. COVID-19 testing in vulnerable populations is paramount for current and future pandemic control and critical for reducing COVID-19 disparities. Reducing Ethical and Social Prejudicial Effects of COVID-19 Testing in Underserved Populations (RESPECT-UP) aims to understand and address the social, ethical, and behavioral factors surrounding COVID-19 testing in highly vulnerable urban and rural African American communities in Alabama, in the top quintile of the Social Vulnerability Index. The targeted geographic areas in Jefferson County (urban) and Dallas County (rural) have some of the lowest vaccination rates in the country, making their population a very high risk for future disease outbreaks. In Aim 1, we employ a sequential explanatory mixed methods design to assess social and structural barriers to COVID-19 testing while exploring stigma, discrimination, and behavioral factors that impact COVID- 19 testing intentions in the context of vaccine availability. In Aim 2, we develop actionable strategies to reduce inequities in COVID-19 testing and produce RESPECT-UP Toolkits tailored to various organizational and community contexts. In Aim 3, we deploy the toolkits and evaluate their effectiveness in urban and rural primary care settings; implementation in other settings will be evaluated in future efforts. Informed by a Social Determinants of Health framework and the Theory of Planned Behavior, this systematic approach to understanding the full continuum of structural, social, ethical, and behavioral determinants of COVID-19 testing generates important new scientific knowledge. Furthermore, working together with community stakeholders in a participatory way, the project produces concrete multi-level solutions – RESPECT-UP Toolkits – that can be used by organizations, communities, and policy makers to improve the equity, access, and uptake of current COVID-19 testing and be ready to deliver equitable, non-stigmatizing, and non-discriminatory testing in future outbreaks. The Toolkits can be adapted to a variety of populations and settings, which further increases their value, generalizability, sustainability, and potential impact. RESPECT-UP is supported by a community coalition of partners with a long-standing history of collaboration, and coordinates efforts with other COVID-19 research initiatives to maximize resources, community partnerships, and collected data.

PROJECT NARRATIVE The COVID-19 pandemic has created unique challenges for vulnerable populations in underserved communities and unique opportunities to understand how best to improve access to and rates of COVID-19 testing and follow-up care. The overall goal of Reducing Ethical and Social Prejudicial Effects of COVID-19 Testing in Underserved Populations (RESPECT-UP) is to understand and address the social, ethical, and behavioral implications of COVID-19 testing in vulnerable urban and rural racially diverse populations in Alabama.