Centering Health Equity within COVID-19 Contact Tracing in Connecticut
Recruiting a community-based workforce that reflects the cultural and language traditions of the targeted populations can help to increase community engagement, build trust, and improve reach within state contact tracing programs. Read our article “Centering Health Equity Within COVID-19 Contact Tracing: Connecticut’s Community Outreach Specialist Program” in the Journal of Public Health Management and Practice.
Early in the COVID-19 pandemic, contact tracing was identified as one of the most promising public health interventions to decrease community transmission. In this intervention, contact tracers representing public health agencies or health systems attempt to (1) reach newly diagnosed patients (“cases”) to identify and notify their close contacts from the two weeks prior to diagnosis of symptom onset, and then (2) counsel those cases and their close contacts to isolate/quarantine to reduce transmission. Initial studies found that early and effective contact tracing could greatly reduce the viral reproduction rate, leading to reduced incidence and mortality. Over time, implementation became more challenging due to more infectious SARS-COV2 variants, more social mixing, shorter latency between infection and disease, declining resources for contact tracing, and overall pandemic fatigue. As a result, contact tracing no longer appeared effective at reducing COVID-19 incidence and mortality. However, less is known about the impact of contact tracers on other key public health functions, including educating households about COVID-19 and connecting vulnerable individuals and families to social and material support. The food, housing, and income assistance delivered through such programs was widely appreciated for helping mitigate pandemic-related health and socio-economic disparities and enable residents to safely isolate and quarantine.
While contact tracing sounds straightforward, doing it effectively presents several well-documented challenges. First, getting someone to answer a call from an unknown number can be difficult. A 2020 Pew Research survey found that only 19% of US adults accepted calls from unknown numbers and >90% believed that callers “sometimes” or “often” try to steal their personal information over the phone. Similarly, mistrust in government institutions often limits acceptance and participation in contact tracing. The trust gap is especially pronounced in minority communities, where historical rights violations by state entities and healthcare institutions foster ongoing suspicion of outreach. Even when cases do answer such calls, mistrust and COVID-related stigma may prevent disclosure of essential information about themselves or their contacts. Finally, language and cultural barriers compound many of the above-noted challenges.
Our team at the Connecticut Department of Public Health Contact Tracing Program sought to address these challenges by introducing the Community Outreach Specialist (COS) Program. Designed to engage and support the state’s most vulnerable and disproportionately impacted communities, the program trained and employed a community-based contact tracing workforce recruited directly from affected communities.
What the COS Program Did:
In partnership with local health departments and community leaders, we identified 11 high need jurisdictions across the state, with high proportions of individuals from the Spanish, Portuguese, Polish, or Haitian Creole-speaking communities. We hired 25 bilingual contact tracers who lived in those 11 jurisdictions and trained them to offer culturally tailored contact tracing services to residents who spoke the same language and lived within the same communities. As many of these residents also had unmet needs that affected their ability to safely quarantine or isolate (e.g., food, health care, housing), the COS workers also provided “warm handoffs” to social service providers, in which they directly linked residents to the providers, provided translation services, and advocated on their behalf. Finally, the COS workers created and delivered health education and outreach activities, including a mass media campaign promoting contact tracing and community health educational workshops centered on COVID-19 prevention.
What We Found:
We conducted a process evaluation of the program during the period December 2020 to May 2021, using quantitative data from Connecticut’s contact tracing management software platform and qualitative documentary evidence including routine programmatic reports. Through this evaluation, we learned:
- The COS Program Increased our Ability to Reach Contacts
We were especially interested in seeing whether the COS program improved our ability to reach and interview COVID-19 cases and their contacts. After adjusting for client age, sex, race/ethnicity, language, and jurisdiction, the COS program was associated with increased reach for contacts (odds ratio [OR] = 1.52; 95% confidence interval [95% CI], 1.17-1.99) but not for cases (OR = 0.78; 95% CI, 0.70-0.88). Our findings suggest that the COS workers were able to draw on a shared language or cultural background and knowledge of their own communities to better engage vulnerable and non–English-speaking residents, engender trust, and encourage participation of contacts in the state DPH contact tracing program.
- The COS Program was Feasible and Acceptable to Residents in Target Communities
COS workers reported that their services were well-received and much appreciated by residents. Residents served by COS workers often told them that they felt more comfortable speaking to someone in their native language who shared a similar cultural background. COS workers also reported that the “warm handoffs” were critical in connecting vulnerable residents to needed services, particularly for undocumented residents who feared being detained by law enforcement after accessing those resources. Finally, the COS communication and education efforts were well received in target communities.
Through our evaluation, we found that recruiting a community-based workforce that reflected the cultural and language traditions of the targeted populations proved to be a feasible, acceptable, and effective strategy for increasing community engagement, building trust, and improving reach within the state contact tracing program. This model of culturally tailored outreach may help build long-term skills and workforce capacity of residents, eschewing the need for costly external consultants who are not from the communities. We recommend that future contact tracing programs adopt, expand, and evaluate similar models.
- Read our article “Centering Health Equity Within COVID-19 Contact Tracing: Connecticut’s Community Outreach Specialist Program”
Dr. Kelly Johnson is a Research Scholar at the Global Health Justice Partnership at Yale Law School. She previously served as the Health Equity Lead for the Connecticut DPH Contact Tracing Program where she directed the Community Outreach Specialist Program. Her research focuses on increasing health equity among marginalized populations.
Dr. Luke Davis is an epidemiologist and pulmonary physician and Associate Professor at the Yale School of Public Health and the Yale School of Medicine. His research uses implementation science to improve care and prevention of tuberculosis and other respiratory infections in resource-constrained settings.