Background: COVID-19 is a highly contagious pandemic disease. This study aims to identify neighborhood-level sociodemographic, health behaviors, adherence to social distancing policies, and healthcare access factors associated with geographic variability of COVID-19 testing, case incidence, and mortality in the U.S. state of Indiana.

Methods: The study population included all Indiana residents. Geographic distribution of COVID-19 testing, positive cases, and mortality were estimated for each county and plotted using choropleth maps. Generalized bivariate and multivariable negative binomial regression were used to estimate effects of county-level factors.

Results: Higher rates of testing, case detection, and mortality were associated with a greater proportion of non-white residents. Counties with better scores in social distancing and greater proportion of older residents had lower incidence of laboratory testing. We found the highest socioeconomic tertile was associated with higher rates of cases, but no difference in testing or mortality. Improved social distancing lowered the incidence of COVID-19 testing and cases. Densely populated counties had higher testing and incidence of COVID-19 cases per capita, however, higher mortality rates were observed in rural/mixed counties.

Conclusion: Differences in COVID-19 testing, case detection, and mortality in Indiana are associated with neighborhood-level characteristics. Local contexts should be considered in COVID-19 response planning.