Protecting Native Families from COVID-19: Radx Initiative

PROJECT Summary: White Mountain Apache-Navajo-JHU research partners are uniquely positioned and prepared to advance COVID-19prevention science through the Emergency Competitive Revisions for Community-Engaged Research on COVID-19Testing among Underserved and/or Vulnerable Populations (NOT-OD-20-121). Since April 2020, we have implementedcomprehensive COVID-19 mitigation activities with Navajo and White Mountain Apache nations, who have had thehighest rates in the US, and honed capacity for home-testing and obtaining rapid results. Our experience and datareview with tribal divisions of health and the Indian Health Service has uncovered barriers to testing, protectivebehaviors, isolation and care-seeking among two high risk sub-groups that must be addressed for successfulmitigation. The first group are elders, ages >65, who have the highest case fatality rate in both communities and aredeeply revered as teachers of cultural practices and languages. A significant portion of elders are currently resistant totesting due to cultural beliefs and fear, and slow to seek care when symptoms worsen. The second group are youngadults, ages 18-34, using substances, who have the highest proportion of cases per capita, are less likely to social-distance or isolate, and are more transient, moving among multi-generational households. This project will apply a 2x2factorial design to evaluate two interventions for these high-risk groups: 1) a culturally tailored, age-specificMotivational Interviewing (MI) intervention to promote testing, protective behaviors and appropriate isolation andcare-seeking, and 2) a COVID-19 symptom (CS) text-based monitoring system designed to shorten time betweensymptom onset and testing, while incorporating GIS to assist with route-mapping for home-based follow-up. MI hasstrong evidence in American Indian communities, including our team's proven MI intervention for improved STI/HIVtesting. The CS System builds on our experience with mobile health surveillance and embedded GIS/GPS tracking. Ourthree primary aims are: 1: Use Community Based Participatory Research to apply knowledge of relevant facilitators andbarriers to create, pilot, implement, and evaluate through an RCT a culturally tailored brief MI intervention to promoteCOVID-19 testing when experiencing symptoms, appropriate preventive behaviors, and isolation and care-seeking whenpositive among elders (ages >65 years) and young adults with a recent history of substance misuse; 2: Implement andevaluate through a RCT a daily CS monitoring system with alerts, mechanisms for participants to request home-testingwhen experiencing first symptoms, and GIS routing for those responding to text-based alerts; and 3: Evaluate therelative merits of MI or CS alone or combined on testing and time to testing when experiencing symptoms, andadherence to isolation and care-seeking recommendations when positive using a 2x2 factorial design. Our secondaryaims will explore if a) cultural identity and connectedness; b) substance use or mental health factors (depression,anxiety, suicidality); and c) age and sex moderate intervention response. If aims are achieved, we will make rapidadvances in diagnostic testing strategies for the most underserved and high-risk populations in the US.