Individual, community, and structural determinants of diagnostic testing decisions during public health crises:...

One important aspect of the efforts to stop the spread of COVID-19 was widespread testing. The objective of this study was to examine how individuals make diagnostic testing decisions during a public health crisis by evaluating the trade-offs between travel burden, dynamically changing access to testing, and individual, community, and structural factors.

We combined individual-level all-payer claims data with COVID-19 testing results, community characteristics, and time-varying testing site availability. Using a person-day panel design, we estimated repeated logit models to assess how dynamically changing travel burden and access conditions interact with individual, community, and structural factors to shape testing decisions. Models included time fixed effects to account for the evolving testing landscape.

Testing decisions were sensitive to both travel time and changes in travel time to the nearest available testing site. Increases in travel burden and fluctuations in access reduced the likelihood of testing. Testing behaviour also varied systematically by individual characteristics, community context, and local pandemic conditions, reflecting heterogeneous responses to access constraints.

By integrating multiple data sources across individual, community, and structural levels, this study demonstrates how individuals respond to changing access conditions and make trade-offs when deciding whether to seek testing. These findings provide actionable insights for designing adaptive and equitable testing strategies during public health crises. Testing behaviour during public health crises reflects dynamic decision-making under constraints. Policies should focus not only on reducing travel burden but also on maintaining stable access and clearly communicating available options over time. Accounting for these behavioural trade-offs is critical for equitable and effective testing infrastructure planning in future emergencies.