Barriers to COVID-19 Testing Among Urban American Indian and Alaska Native Peoples: A Cross-Sectional Survey of Five Tribal Healthcare Organizations

American Indian and Alaska Native (AI/AN) communities experienced disproportionately severe COVID-19 outcomes, underscoring the importance of accessible testing. To understand barriers to COVID-19 testing among urban AI/AN peoples, we surveyed 788 patients from five geographically dispersed Tribal healthcare organizations between January and May 2021. Participants completed questionnaires assessing healthcare access and concerns about barriers to COVID-19 testing, as well as social determinants of health including age, gender, relationship status, education, and income. The most commonly reported concern was contracting COVID-19 during clinic visits, with 43% of respondents expressing this concern. Difficulty reaching the clinic during business hours and difficulty traveling to the clinic were reported by 20% and 14% of participants, respectively, while 19% expressed concern about the cost of testing. Higher income was associated with lower levels of concern across all four barriers. These results suggest that healthcare organizations serving AI/AN populations should proactively address concerns about infection risk during testing appointments, both for COVID-19 and for future infectious disease outbreaks. Our results also underscore the value of at-home testing, particularly when provided free of charge, as it directly addresses all barriers to in-person testing assessed in this study and may inform testing strategies in future infectious disease outbreaks.