key: cord-0935733-80jl79wj
authors: Shahrour, Ghada; Jaradat, Diana; Dardas, Latefa Ali
title: Barriers related to COVID‐19 testing intention
date: 2021-07-27
journal: Public Health Nurs
DOI: 10.1111/phn.12950
sha: 67fc001c5b00a6a6ec00caba0e76ee05afe736e6
doc_id: 935733
cord_uid: 80jl79wj

OBJECTIVES: Although vaccination against the COVID‐19 disease has recently become available, individuals are expressing fear and hesitancy towards receiving it. As a result, testing for COVID‐19 is still considered a vital method to contain infection. For testing to be effective, barriers towards testing intention need to be investigated; and available literature on the challenges are scarce. This study aimed to investigate barriers of COVID‐19 testing among a sample of Jordanian adults and predict testing intention within the context of these barriers. METHODS: A cross‐sectional, descriptive, and predictive design was employed in this study among a sample of 1074 Jordanian adults. RESULTS: Three clusters of barriers predicted testing intention; perceived discrimination at work, concerns of individual's privacy, and having negative feelings towards testing. While perceived discrimination at work and privacy concerns were negatively associated with individuals’ intention for testing, experiencing negative feelings towards COVID‐19 testing was a positive predictor. CONCLUSION: Within the context of the study findings, public health nurses need to promote safety at the workplace, protect an individual's privacy, and eliminate negative feelings towards testing uptake through the provision of accurate and up‐to‐date information regarding the COVID‐19 disease.

By the end of December, 2020, a vaccination against COVID-19 disease has been adopted by the Jordanian government. The vaccination drive aimed to inoculate around 2 million out of 10 million Jordanian citizens within the first 6 months of 2021.Although the priority of vaccination has been given to the elderly and healthcare workers, the vaccination drive invited all citizens to register for vaccine administration.

As of 24thDecember,only 200,000 citizens had signed up to receive the vaccination despite it being offered free of charge (Arab News, 2021) .

As is being seen in other countries, Jordanians have expressed fears over potential adverse effects of the inoculation, leading to vaccine hesitancy or refusal. Such fears stem from anti-vaccine misinforma-tion campaigns; although pro-vaccination campaigns have been vigorously carried out by the Jordanian government (The Jordan Times, 2020). A further challenge is that during the period of this survey and writing, there remains no available research data on whether the COVID-19 vaccine provides long-term protection against the susceptibility of infection recurrence. Vaccinated individuals remain required to undergo testing if they present with symptoms consistent with those of COVID-19 infection (World Health Organization, 2021) . testing and self-isolation of an individual when symptoms are present or a case is suspected, remains a vital strategy for containing the pan-patients early on in the pandemic, which resulted in low numbers of infections and a lower death rate (Heath, 2020) . To make testing the most effective strategy for controlling the COVID-19 outbreak, barriers towards it need to be investigated; and understanding an individual's testing intention within the context of existing barriers must be attained.

Available studies and media reports suggest the existence of personal and environmental barriers towards COVID-19 testing across countries. For example, in Tanzania, limited access to testing and fake testing kits have been reported (Nakkazi, 2020) . In the United States, the cost of testing has been a major issue as health insurance may not cover the testing, and minorities, including non-citizens and immigrants, may lack health insurance (Capps &Gelatt, 2020) . Poor health literacy in terms of low knowledge regarding which symptoms require testing to be performed and the processes to follow have been considered another barrier . Testing may also be limited to certain criteria, such as when the individual experiences symptoms regardless of exposure to COVID-19 cases (Frieden, 2020) .

Structural barriers were also noted. These included issues in delivering tests and transporting samples from remote areas (Bruton & Edwards, 2020) . In a developing country such as Bangladesh, structural barriers took a different form represented in insufficient testing centers and the extensive length of time it takes to deliver the results to tested individuals (Rahaman et al., 2020) . Personal factors are also represented in cognitive and emotional barriers to testing, including: fear of experiencing pain when tested, lack of knowledge as to how to obtain testing, and the worry that the individual may contract infection at the testing center .

Variability in sociodemographic profiles regarding perceived barriers of COVID-19 testing intention is not available in the current literature; however, certain groups were identified to be less likely to understand and act upon COVID-19 preventative measures. These groups include individuals with low health literacy, those whose language is different from English, young people, men, and those with low educational attainment .

Despite being a developing country, Jordan has taken several steps to manage and mitigate the COVID-19 outbreak. Since March 17th, 2020, Jordan enforced a complete lockdown after 48 positive COVID-19 cases were reported (Ministry of Health-Jordan [MOH], 2020).

Other preventative measures included halting travel between cities, banning international travel, implementing strict curfews where violators are fined, and testing individuals crossing overland borders (Negev et al., 2020) . The Jordanian government also emphasized undertaking testing of its residents if the individual presented with symptoms consistent with COVID-19 infection or if the individual had been in direct contact with a positive case (MOH, 2020).However, these strict measures resulted in a downturnin Jordan's economy.As a result, the government eased restrictions, including relaxing most of the governmental sectors, opening its borders, and allowing truck drivers to bring goods from neighboring countries where rates of infection were higher than within Jordan (Safi & Al-Tahat, 2020) . The relaxing of these control efforts in the governmental and private sectors in Jordan resulted in an increase in the number of infected COVID-19 cases. By March 22nd, the number of COVID-19 positive cases reached more than 500,000 (MOH, 2020) . Furthermore, at the beginning of the COVID-19 crisis in Jordan, internet users on social media widely shared the names and photos of Jordanian citizens who had tested positive for the disease [20] . This cyber chaos created significant fears and could have affected many Jordanian's intention for testing. Combined with people's hesitancy and fear of being vaccinated, testing for COVID-19 is still considered a crucial strategy for containing the pandemic. Therefore, this study aimed to investigate the barriers of COVID-19 testing and predict testing intention within the context of these barriers among a sample of Jordanian adults.

A quantitative, cross-sectional, descriptive, and predictive design was used in this study to explore the barriers toward COVID-19 testing and investigate the role of barriers in testing intention. A convenience sampling procedure was used where the survey was distributed on social media websites to a large number of people. The inclusion criteria were Jordanian individuals whose age is 18 years and older and who speak, understand, and write in Arabic. Those who are younger than 18 years old, who do not reside in Jordan, and who are illiterate were excluded from the study. Inclusion and exclusion criteria were written explicitly in the invitation letter and consent form. The survey was designed so responses were limited to one yielded response per individual. Participants who responded and met the criteria had their data included in the analysis, resulting in a total of 1074 Jordanian adults. The survey was created using Google Forms, a Web-based survey to distribute the study questionnaire.

The study was approved by the Institutional Review Board (IRB) of the principal investigator's institution. After approval, the survey link was distributed through various social media websites. An invitation letter explaining all aspects of the study including: its purpose, voluntary participation, confidentiality, length of survey, and potential benefits and risks was included in the survey. Furthermore, an online consent form where subjects were instructed to carefully read the informed consent and click on the agreement button if they were willing to take part in the study was included at the beginning of the e-survey. For the purposes of protecting participants' anonymity, no identifying information was gathered in the online survey, and participants were not identified by the e-survey software after the survey had been completed.

Completed surveys were automatically saved on Google Forms which is password protected and can only be accessed by the study authors and filled once by each recipient. The data were collected over a 3-month period; from July 1st, 2020 to October 1st, 2020 resulting in and rated separately the conceptual equivalence between the original and the adapted instrument. These experts also used the procedures of Brisling (1970) and Chapmen and Carter (1979) for the translation of the aforementioned measures to ensure the reliability, validity, and cultural sensitivity of the translation from English to Arabic language. After consensus was reached between the experts on the adapted instrument,

the survey was pilot-tested among 12 adults who verified the final version. In this study, the reliability of the adapted scale was satisfactory with Cronbach's α of .72.

A total of 1074 Jordanian adults completed and returned the online survey. The majority of participants were female (60.4%,n = 649), in the age group of 18 to 33 years old (59.8%, n = 642), and single (53.4%, n = 574). About 56.1% (n = 698) had a baccalaureate degree and 43.9%

(n = 472) had a monthly income ranging between JD 300 and 700(USD 423 to 988) (see Table 1 ).

The mean score of participants' intention for testing was 4.6 (SD = .78), ranging from 1-5. Regarding COVID-19 testing barriers, the mean score for each subscale was as follows: perceived discrimination at work 2.37 (SD = 1.22, range 1-5); negative feelings about testing 14.01 (SD = 2.89, range 4-20); privacy concerns 2.81 (SD = 1.38, range 1-5); and structural barriers 6.74 (SD = 2.14, range 1-10). Descriptive statistics are presented in Table 2 . 

Two hierarchal regression models were tested to explore predictors of testing intention. The first model (containing gender, age, marital status, educational level, and income) did not significantly predict participants' intention for testing (F (5, 1010) = 0.91, p = .47). However, the second model (containing gender, age, marital status, educational level, and income, in addition to testing barriers) showed that three barriers' subscales significantly predicted intention for COVID-19 uptake (F (9, 1006) = 3.93, p < .001). More specifically, the subscales of per- Table 3 . (Capps &Gelatt, 2020) . Contextual explanations for this study findings related to perceived discrimination at work as one of the challenges to testing can be related 

Potential implications for this study should be considered within the context of its limitations. The descriptive nature of studying the research variables and using a self-report questionnaire may introduce social bias. Therefore, future research needs to investigate challenges towards COVID-19 testing using qualitative or a mixedmethods design to obtain in-depth understanding of the studied phenomenon.

Despite these limitations, the study taps a significant gap in the literature and sheds light on important aspects related to COVID-19 testing. In the context of the challenges investigated in this study, public health nurses have essential roles and responsibility as leaders in the detection and control of COVID-19 pandemic. They can implement several strategies to mitigate and prevent the barriers of COVID-19

testing-intention reported in this study. At the workplace, public health nurses need to emphasize infection-control practices and policies for employees. They also need to engage in regular screening and case tracing of those individuals who have been in direct contact with positive cases, and ensure timely quarantine and adherence to quarantine of infected individuals. In terms of ensuring individuals' privacy, public health nurses need to act as advocates of the public through emphasizing the ethical right of protecting clients' privacy. This can be accomplished through monitoring health care organizations' adherence to clients' confidentiality of not breaching their privacy. They may collaborate with local and national officials to implement policies and laws prohibiting the disclosure of the identity of those who are infected. These laws should address the prohibition of privacy breaches, whether through formal or informal means of communication, including social media. Although they felt negatively towards COVID-19 testing, nonetheless, people chose to get tested. Providing accurate information regarding COVID-19, its symptoms, and management by public health nurses would help mitigate negative feelings and improve the psychological well-being of people before, during, and after testing. This goal can be achieved through conducting educational campaigns utilizing various means of communication.

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How to cite this article

Barriers related to COVID-19 testing intention

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

This research study was granted approval from the Institutional Review Boards (IRB) of Jordan University of Science and Technology with an IRB approval number of 325-2020.

The data that support the findings of this study are available from the corresponding author upon reasonable request ORCID Ghada Shahrour PhD, RN, PMH-CNS https://orcid.org/0000-0002-6929-3361