COVID-19 Symptom Tracking and Exposure Notification Tools Developed by the University of Alabama at Birmingham Extend Awareness and Access to Rural Communities in Alabama

What Happened

On March 14, 2020, one day after the first COVID-19 case was documented in the state of Alabama, researchers at the University of Alabama at Birmingham (UAB) initiated several projects to address the mounting pandemic that had already affected major cities across the globe. Dr. Sue Feldman, a nurse by training, as well as a professor and the Director of Graduate Programs in Health Informatics for the School of Health Professions at UAB, served as the Principal Investigator for 3 COVID-19 mitigation and prevention initiatives. The first project, Map It Zap It, was a crowdsourced initiative that allowed people to self-report symptoms, in order to identify hotspots in the state. The self-report survey gathered socio-demographic data, including where people lived, in what type of household environment, and with how many other people. Through social media, the Map It Zap It project expanded beyond Alabama and became a national resource for COVID-19 hotspot monitoring.

Out of Map It Zap It emerged the second project, Healthcheck, which included the Passport app. Healthcheck and Passport were both essential for primary, secondary, and post-secondary education systems in Alabama as a method to help keep students in classrooms. The project served as a daily symptom checking tool; before coming to campus, faculty and students would check their symptoms in the app and would receive a “passport” indicating whether they could attend classes that day. The third project was the GuideSafe Exposure Notification App, a resource available for download on smartphones for Alabama residents. This resource, developed in partnership with the Alabama Department of Public Health, served as an alert system to inform individuals when they had come in contact with someone, within 14 days, who later tested positive for COVID-19.

The main focus of these 3 projects was behavioral change. Since symptoms caused by SARS-CoV-2 are not symptoms that people associated with being contagious prior to the pandemic, using the apps and tools to check symptoms daily, identify hotspots and potential exposures, and self-report positive COVID-19 test results helped people change their behaviors and their thought processes related to symptoms.

These symptom tracking tools benefit rural communities by increasing awareness and access to the resources needed to keep individuals safe. According to Dr. Feldman, rural versus urban patterns of socialization require different approaches. In rural Alabama communities, houses tend to be spaced further apart from each other, while urban communities tend to have housing complexes with higher densities of residents. Socialization in rural spaces relies more heavily on congregation and can increase the spread of infectious diseases through a false sense of security created by the distance between which people live. Through tools like Map It Zap It, Dr. Feldman's team hoped to raise awareness in Alabama's rural communities of the need for social distancing and self-isolation when symptoms arise, and to counter the notion that COVID-19 was only going to affect large metro areas like New York City. Feldman's team focused on behavioral change by providing access to knowledge and resources about COVID-19 to help shift the mindset of communities.

Feldman's team ensured accessibility to COVID-19 mitigation resources through a tiered approach, starting with Map It Zap It. Despite pressure to turn Map It Zap It into a smartphone app, the UAB research team made a conscious decision to keep the project as a web-based app. That way, explains Feldman, anyone with a computer and internet access could use the tool. It could also be accessed on a smartphone; however, it did not have to be. The GuideSafe Exposure Notification App was the next most accessible project and required a newer, more recent operating system to use on smartphones. This tool only works within the state of Alabama, although 26 other states have developed similar apps. Through connections with the Association of Public Health Laboratories, travel between these 27 states offers equal notification. Finally, Healthcheck and Passport were designed primarily for schools and businesses and were not intended for use by the general public. They sit behind the organization's single sign-on (SSO) access, allowing for input of a minimal amount of data for a maximum amount of information delivery and guidance.

Lessons Learned

While developing the apps, Dr. Feldman's team determined rural communities must know where their resources are located, how to access them, and the associated costs to have an effective emergency response. UAB has rural community centers, a Rural Medicine Program, and multiple centers for health education, specialty diagnoses and treatments, and other resources specially tailored to the rural communities of Alabama. These types of services are commonly hosted by large state universities and private colleges. Such resources, notes Dr. Feldman, may not always be located within the communities that they are intended to serve — therefore, relationships must be established before a disaster or public health emergency occurs so that a “turn-key” response can take place.

Further, Dr. Feldman's team urges rural communities to not dismiss potential disasters. The COVID-19 pandemic in the United States initially emerged in large metropolitan areas. However, its spread was nondiscriminatory, and took smaller communities by surprise. Best practices in emergency preparedness encourage proactive planning, including for the provision of disaster funds. While rural communities are often distanced from the hub of state resources, Dr. Feldman emphasized that “being disconnected geographically is not the same as being disconnected.” Access to resources for planning and response initiatives is vital to rural community emergency management.

Finally, it is important for rural communities, as well as their university points of contact, to have a realistic understanding of the socio-demographic makeup of the community. Importantly, communities must take into consideration older residents who are “aging in place” — understanding what physical limitations may exist and what resources residents rely on daily, such as formal food programs like Meals on Wheels or informal support from their neighbors and family members, is an important aspect in community-led disaster response.

Person(s) Interviewed

Sue Feldman, Professor and Director of Graduate Programs in Health Informatics
University of Alabama at Birmingham