This study leverages data collected during Project PEACH 1: Promoting Engagement and
COVID-19 Testing for Health, a Rapid Acceleration of Diagnostics - Underserved
Populations (RADx-UP) funded study to understand barriers to effective and equitable
coronavirus disease 2019 (COVID-19) testing in high-risk and minority populations in
Georgia that are affected by diabetes. PEACH 1 applied mixed-methods (quantitative,
qualitative, geographic and spatial analysis) to gather evidence to describe COVID-19
epidemiology, locate regions and populations with low testing and vaccine uptake, and
targeting key informant interviewing and monitoring social and news media, to identify
barriers, motivators, and perceptions around COVID-19 as well as related behaviors among
different populations and regions.

Analysis of Project PEACH 1 data collected from key informants and community partners
indicated gaps in capacity for and commitment to community testing when vaccines became
available, and sites were pivoting to prioritize vaccinations even as they continued to
provide COVID-19 testing. However, COVID-19 testing can be a key tool to address the
pandemic, particularly in areas with low vaccination rates and high diabetes rates such
as Georgia. People with diabetes, prediabetes, and obesity have elevated risk for
COVID-19 infection and are more likely to suffer in-hospital complications. Further,
Diabetes is 2.4 times more common in socioeconomically vulnerable and minority
populations. Throughout the pandemic, counties with predominantly Black communities had a
6-fold COVID-19 death rate compared to those that are predominantly White. For these
reasons, finding sustainable, easy to disseminate, and acceptable ways to increase and
sustain COVID-19 testing is needed. Further, understanding the relationship between
attitudes toward testing in situations of continued vaccine hesitancy and resistance and
developing insights in how to address them in a dynamic pandemic situation will be
fundamental to future pandemic response.

COVID-19 testing, both home-based testing and clinic testing, must remain a key feature
for diabetes management and prevention to reduce secondary complications associated with
infection. Home-based testing may help people overcome barriers to testing (identifying
where to get tested, scheduling and attending appointments, stigma). However, in order
for it to be successful there is a need to understand the feasibility, acceptability, and
sustainability of at-home testing as well as the perceived advantages and disadvantages
of home-based testing compared to clinic-based testing among the high-risk population of
individuals affected by or at risk for diabetes. This information can be used to create
targeted behavioral "nudges". Nudges are indirect suggestions and positive reinforcements
designed to encourage certain choices. They may be a useful means of promoting
acceptability and usage of COVID-19 testing as well as increasing an understanding of and
acceptability of other key preventive behaviors like COVID-19 vaccination. Behavioral
nudges have been shown to have a noticeable effect on health behaviors and study
recruitment, however, research testing the application of behavioral nudges relating to
behavior change around disease prevention in a pandemic situation is needed.

Study participants will be randomized into the PEACH2 Intervention Arm or the Control
Arm. At baseline, all participants will be asked to complete a baseline survey to collect
demographic data, history of COVID-19, diabetes, and diabetes risk factors, views of
COVID-19, COVID-19 preventive behaviors (including vaccination), and experiences with
COVID-19 testing. Participants will be asked to report, using a simple text-based data
reporting tool, any COVID-19 testing during the 12-month study. Participants are
administered surveys at Baseline, after completing the 16 week intervention and at Month
12 to collect information on COVID-19 testing, prevention, and vaccine behaviors and
views.

In addition, Project PEACH2 Intervention participants will be sent weekly personalized
behavioral nudges via mobile phone text message during the 16 week long intervention to
encourage adherence to COVID-19 testing and preventive behaviors as well as share
important tips for diabetes management, prevention or care. Nudges targeting testing
behaviors will be delivered whereby participants who have not reported (1) having
symptoms indicative of a possible infection with a viral disease and (2) a COVID-19 test
in the past four weeks will receive a nudge to encourage COVID-19 testing. Other
behavioral nudges will target other COVID-19 related preventive behaviors (e.g., staying
home when sick, wear a mask, etc.) and diabetes management/prevention/care behaviors
(e.g., increasing physical activity, improving diet, decreasing stress, etc). Nudge
personalization targeting relationship with diabetes, age group, sex, vaccine and testing
history, and race/ethnicity will be based on data collected in PEACH 1 as well as ongoing
social media and data analysis in PEACH2.