Review scope

This scoping review was conducted between July and August 2023, using a methodology registered on the Open Science Framework (OSF) and available at https://osf.io. The review followed Arksey and O’Malley’s framework, encompassing the formulation of the research question, identification of relevant studies, selection of studies, data charting, synthesis, and presentation of findings [13]. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework was employed to guide the paper selection process [14] (S1 Table).

Inclusion and exclusion criteria

Studies were included if they met the following criteria: peer-reviewed research investigating factors influencing the uptake of self- and provider-delivered COVID-19 testing in Sub-Saharan Africa (SSA) using qualitative methods (e.g., focus groups, interviews, ethnography, and case studies). Mixed-methods studies incorporating qualitative research alongside clinical trials were also eligible. Studies were excluded if they were quantitative research, literature reviews, or duplicates. Only studies published in English, conducted in SSA, and published between January 2020 (onset of the COVID-19 pandemic) and July 2023 were included. A detailed summary of inclusion and exclusion criteria is provided in Table 1.

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Table 1. Inclusion and exclusion criteria.

https://doi.org/10.1371/journal.pone.0305512.t001

Search strategy

We conducted a systematic search using Google Scholar, PubMed, Web of Science, Medline, and Africa-Wide Information databases. A combination of keywords and Boolean operators (“AND,” “OR”) was employed to identify relevant studies. Key terms included COVID-19, coronavirus, testing, diagnostics, behaviour, perception, cultural, sociocultural, social science, qualitative, and mixed methods. The search terms were applied individually and in combination, with filters limiting the results to primary research articles in English, conducted in SSA, and published between January 2020 and July 2023 (Table 2).

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Table 2. Search Query and Filters.

https://doi.org/10.1371/journal.pone.0305512.t002

Study selection and data extraction

Studies were initially screened based on titles and abstracts. If the abstract lacked sufficient detail, the full text was reviewed using the search terms described above. A research appraisal tool developed by Hawker et al., (2002) was employed to assess the quality and relevance of eligible studies [15] (S2 Table).

Duplicates were manually identified and removed by one author during the search process. Due to the relatively small number of eligible articles, data extraction was conducted collaboratively by three authors who worked together to chart the data. This included extracting details such as author, publication year, location, study design, sample size, and key conclusions (S3 Table). The collaborative extraction process allowed real-time consensus on all data points, eliminating the need for independent extractions or discrepancy resolution.

Effective political leadership

Strong political leadership was critical in determining the direction of the national COVID-19 response. Ha et al., (2022) and Yamanis et al., (2023) described that in areas where government officials viewed COVID-19 as a threat to public health, there was a strong political commitment to develop and implement disease containment measures including diagnostics. For example, in Ghana, the government gathered financial and material support to increase its diagnostic capacity through multisectoral partnerships with development partners. This allowed the country’s health system to expand the number of COVID-19 testing facilities nationwide, improving access and coverage of testing services, according to one of the nation’s laboratory managers:

“We did not have enough testing centres and PPE at the beginning of the pandemic. But, now, we have enough facilities, adequate PPE, and other consumables supported by the Ghana government, international organizations, and other donors for COVID-19 testing”. [9]

Yamanis et al., (2023) described Tanzania making a similar commitment to empowering the health system and acknowledging the existence of COVID-19 after a period of denial when the new president, Hassan, acknowledged COVID-19 as a public health emergency relying on collaboration with local and international partners to improve control measures, including promoting testing uptake.

Both Ha et al., (2022) and Yamanis et al., (2023) described the influence of government in public responses to COVID-19 services. Political leaders not only made investments in health system capacity for COVID-19 monitoring activities, but took on a pro-public health advocacy role, urging people to get tested as well as follow the rest of the controls set in place. Some government representatives underwent COVID-19 testing or vaccination in public to legitimize and encourage improved public response, motivating testing:

“We received lots of hope from the government and the president. Our president was really keen on tackling the pandemic […] We were highly encouraged to get tested by the president, and his leadership uplifted the motivation of getting tested”. [9].

Public confidence in organizations providing testing

Public perceptions of the organizations tasked with carrying out testing activities were central to participation. In South Africa, Brumwell et al., (2022) found that people were more inclined to test for COVID-19 if they knew and trusted the providers:

“I think people do trust their pastors, their healthcare workers, nurses and general practitioners, pharmacists, principles…They generally don’t trust politicians. So, I wouldn’t include them there. But, generally, the community leaders, non-politically aligned, I think would be people that would be trustworthy”. [18].

COVID-19 testing was more acceptable when spearheaded by people that community members were used to and had some form of prior association or interaction.

Novel COVID-19 testing modalities

Perspectives on self-testing were discussed in two studies by Brumwell et al., (2022) and Chabeda et al., (2022), and participants expressed a preference for self-testing over facility-based testing in both cases. Brumwell et al., (2022) claimed that this was due to testing flexibility, privacy, and confidentiality for socially excluded groups such as the homeless and drug users, whereas facility-based testing was felt to exacerbate stigma. However, some participants in the same study raised concerns about self-testing potentially negatively impacting the public health response. They noted that it could hinder effective surveillance and contact tracing, as individuals might not report their results or follow isolation protocols. Participants in Kenya in Chabeda et al., (2022) study described decision-makers perspectives that self-testing was crucial for physically vulnerable populations such as the elderly, the sick, those with impairments, and people living in isolated locations. However, they did not interview end users of self-testing.

“For me one of the biggest things is: If you self-test at home, there’s nobody that is recording that you are positive. And that whole thing again about ‘Oh, I don’t want to deal with it’. So, you know you’re positive. Nobody else does. Who’s going to actually monitor your contacts and ensure that you actually then do isolate and do quarantine? If you leave the responsibility solely on the patient”. [18]

Public health communication

Knowledge of COVID-19 and its risks preceded the public adoption of testing. Eight of the studies reflected the usefulness of public health communication in generating demand for testing [9,17–19,21,24,26,28]. The studies frequently ascribed the uptake of testing to ongoing public health communication, which participants said was helpful in dispelling initial pandemic myths in the communities. Asare et al., (2023) mentioned that in Ghana finding contacts to test early in the pandemic was difficult, and awareness campaigns were seen to help communities respond more effectively:

“During the first wave of COVID-19, contact tracing was difficult because most people did not get enough information with regard to the disease. People who were contacts with a positive case did not understand the reason why they had to be quarantined for you to come and pick samples. You get to a contact’s home and the person is already gone instead of staying in the house […] So, the first phase of COVID-19 contact tracing awas very difficult”. [21]

Health system capacity

Nine of the studies identified that healthcare systems in SSA lacked the diagnostic tools and equipment necessary to identify COVID-19 patients, which impacted testing availability [9,18,19,21–24,26,27]. There was common recognition that systemic underfunding of healthcare systems, pre-existent to the pandemic, translated to a lack of preparedness for COVID-19. Problems included the paucity of test kits, disinfectants, and safety equipment in laboratories. Some hospitals lacked laboratory facilities altogether. For instance, in Tanzania Yamanis et al., (2023) revealed there was no laboratory to conduct testing, medical professionals merely checked suspects’ body temperatures, blood pressure, and heart rates. Inadequate laboratory readiness led to frequent backlogs in testing COVID-19 samples. Five of the studies reported protracted processing times ranging from several days [18,22,26,28] to more than a month [21] from sample collection, affecting COVID-19 public health response such as contact tracing.

“The testing centre is a challenge to us as a district. We have sent about 27 samples, and it is almost one and a half months now the results are not in yet. One of them was sick, but we don’t know the status of that person till now. Although we have testing centres here, they are doing internal testing, so we have to send our samples to […] the capital before they are sent to the central laboratory, which delays a lot”. [21]

Human resource constraints

The availability of human capital also affected the availability of COVID-19 diagnostic testing in SSA. Four of the studies [9,20,22,23] discussed the lack of skilled medical personnel to support testing and surveillance interventions. For example, a laboratory manager in Ghana described increased work burden due to staff shortages:

“We have only one person at the lab who runs the test. Despite our support, he ran samples until late. I also feel too exhausted […] when testing many people. The human personnel is fewer [...}”. [9].

This shortage was also reported in South Africa and Nigeria [20,23]. Solutions suggested included retraining HIV service providers to reduce the supply-demand gap for COVID-19 testing.

Mental exhaustion and distress impacted staff capacity to respond to testing demands. Fears expressed included contracting COVID-19 through interaction with positive patients, where lack of access to personal protective equipment (PPE) and antiseptics for sanitizing surfaces was sub-optimal. Participants also felt underappreciated without support to address these issues. Fears were exacerbated when colleagues died of COVID-19. These factors all contributed to mental exhaustion.

Supply-chain issues

Five of the studies identified supply problems that impacted the availability and distribution of COVID-19 diagnostic services [9,18,21,22,24]. Mohammed et al. 2021 drew attention to budgetary constraints that impacted the purchase of medical necessities in Ethiopia, leading to inconsistent supply and frequent stockouts of test kits. Ha et al., (2022) described similar supply challenges such as irregular provision of personal protective equipment (PPE), making it difficult for surveillance teams to effectively conduct contact tracing:

“When COVID-19 [] came, we [the Ghana Health Service] were not prepared, which is why we faced a lot of challenges with contact tracing in the beginning. The PPEs were not there, yet we had to work. So, if the authorities could learn their lessons, I think we will be better prepared for the future”. [9]

Accessibility of testing

Access to COVID-19 testing was geographically unevenly distributed across urban and rural settings. In one study, supply was better in urban centres than in rural ones, even when testing was supposedly available. Asare et al., (2023) in Ghana, for instance, described participants feeling that metropolitan facilities had more resources than their rural counterparts, making it simpler to receive services there. In this context, Brumwell et al., (2022) and Chabeda et al., (2022) demonstrated that self-testing could increase testing accessibility, helping to solve the issue of people failing to test because of large distances to facilities, which had an impact on both supply and demand. However, since patients had to travel to pick up the test kits, the supply was constrained by the central distribution of test kits through healthcare facilities. Participants in Brumwell et al., (2022) and Chabeda et al., (2022) believed that this posed the same challenges as facility-based testing.

“The barriers […] to conventional facility-based testing were diverse. The expense of COVID-19 testing […]incurred either from lost wages while waiting in queues for government testing or the cost of private testing. The cost of transportation was a barrier […] where testing facilities are geographically dispersed. RCSs feared that the same barriers to facility-based testing would apply to self-testing. Financial considerations could cause difficulty in obtaining self-testing”. [18]

Psycho-social and economic obstacles

Testing decisions were also shaped by risk perceptions and the economic and psychosocial ramifications of undergoing a test and being diagnosed with the disease. Six studies [9,17–19,22,25,26] reported prevalent pandemic-related dread among community members, worrying about contracting and developing problems. Both Asiimwe et al., (2021) and Nxumalo et al., (2021) described these worries as stemming from social media rumours claiming that foreign locations had a high death rate. Carlitz et al., (2021) described that COVID-19 fatalities were being buried as Ebola victims, stories that increased fears of the pandemic and the social repercussions of receiving a COVID-19-positive diagnosis. In Brumwell et al., (2022) South African study, participants claimed that clients who tested positive experienced stigma because neighbours thought they were spreading the disease and held them responsible for new infections or fatalities.

Relating to economic costs, the two self-testing studies by Brumwell et al., (2022) and Chabeda et al., (2022) demonstrated that testing uptake was discouraged by the negative financial consequences of being diagnosed with COVID-19 and disclosure requirements. For the majority of those who tested positive, isolation requirements meant missing work. Failure to report for duty would also result in pay loss for jobs without sick days and participants believed that people’s fear of losing their income prevented them from testing and disclosing their status to prevent isolation. As mentioned earlier, transport costs incurred when accessing self-testing centrally distributed through facilities also dissuaded uptake [16,18].

“[…] stigma and fear were the most cited social barriers to testing. Stigma was associated with the fear of being seen testing, of a positive result, and of disclosing positive results to contacts. Fears of being separated from family, losing income, and isolation were also cited […] As with reporting self-test results, informants were unsure whether people would disclose their results to contacts, whether due to fear of stigma or being blamed for another person’s illness or death”. [18]

False claims and beliefs

Nine studies reported how misinformation fuelled through social media encouraged negative perceptions of COVID-19, with a detrimental impact on demand for testing [9,17–19,21,24,26,28,29].. Mohammed et al., (2021) described a prevalent false claim that hospitals fabricated test results to increase the number of verified cases to demonstrate the reality of COVID-19.

Following the introduction of vaccination, rumours related to vaccines also impacted COVID-19 testing uptake. For example, Schmidt et al., (2020) highlighted refusal to uptake door-to-door screening and testing by medical personnel due to beliefs around vaccination in South Africa: “Like as clinic staff we go in door-to-door, there are incidences where a house owner would refuse for us to go in, saying we don’t want your vaccines because they have Corona. Then we had to explain that we are not injecting people, we are just screening and asking questions. People are really scared, because of what they heard...” [17]

Carlitz et al., (2021); Chabeda et al., (2022) and Schmidt et al., (2020) all described spiritual beliefs and religious beliefs that prevented the public from using tests and other interventions, compounding misconceptions spreading through social media. Chabeda et al., (2022) described belief in COVID-19 as a sign of devil worship in Kenya. Schmidt et al., (2020) described how COVID-19 was seen as testament that God was angry with humanity in South Africa.

Political exploitation of COVID-19 in SSA

Seven studies demonstrated how COVID-19 testing was highly politicized [21–24,26,27]. Studies in Tanzania by both Carlitz et al., (2021) and Yamanis et al., (2023) described political figures explicitly denouncing the pandemic’s existence, encouraging the public to seek herbal remedies. This, alongside the Tanzanian government’s decision to remove the country’s laboratory manager and end its monitoring program influenced willingness to adopt public health strategies including testing [26].

The strength of perceived association between political agendas and COVID-19, fuelled through social media contributed to public mistrust of organizations providing health responses. In Ghana, Asare et al., (2023) highlighted the relationship between political affiliation and testing engagement where the public ‘screened’ providers of testing according to political views: “Politicising the disease is a challenge to us [contact tracers]. This is because you will get to a contact’s home, and they start to politicise the entire process [of contact tracing] and they begin to ask you which party you belong to”.