In March, when COVID-19 rapidly spread across the United States, countries that had already experienced mass exposure were leaning on contact-tracing efforts to acknowledge, track, and prevent further spread of the virus. As a trained epidemiologist with a background in public health, I knew the importance of disease investigation. As a researcher at Mathematica, I knew that effective contact tracing meant reaching people where they are, building trust, and being flexible about the approaches used. And as a Californian, I felt compelled to help.
When I heard that the California Department of Public Health was partnering with the University of California, San Francisco, and the University of California, Los Angeles, to train and deploy thousands of case investigators and contact tracers across the state, I reached out to friends and former colleagues to ask how I could be useful. Since May, I have been working with a group of skilled educators from the COVID-19 Virtual Training Academy to support contact tracers learning the basics of their jobs and to help them practice case investigation and contact-tracing interviews.
With limited resources and a blank slate, California and many other states needed to develop plans in real time and rapidly adjust to the changing environment. And as we learn more about what works and what doesn’t, there’s a huge opportunity for states to learn from one another as they implement and improve their contact-tracing efforts. Alongside the lessons my colleague Candace Miller shared, the takeaways from my experience training case investigators and contact tracers – many of whom are serving California’s most vulnerable communities – can support states building their contact-tracing efforts.
COVID-19 presents unique challenges and calls for targeted solutions
Contact tracing is not a new concept. Public health workers have used these techniques for decades to track and contain HIV/AIDS, foodborne illnesses, and a host of other diseases. The basic concepts are the same, which is why California’s COVID-19 contact-tracing training starts with an overview of contact tracing, why it’s essential, and how we adapt what we know.
This pandemic, however, presents unique challenges, one of which is how quickly and easily COVID-19 spreads. An infected person might have had close contact with many other people during the period when they were most infectious, especially if they didn’t feel sick or if it took a long time for them to get tested and receive a positive diagnosis. Case investigators and contact tracers have to try to identify all of those close contacts and inform them of their exposure. The nature of the pandemic requires us to conduct most of this work virtually, which hinders the kind of in-person connections that can build rapport and facilitate sensitive conversations.
The virus impacts people of color at a higher rate than the White population. In California, we see that the hardest-hit communities are communities of color, especially our Latinx communities; many are native Spanish speakers and aren’t necessarily comfortable speaking English. We see a greater urgency for language support and cultural competence in these hardest-hit communities that are already in need of public health and social services.
Flexibility and adaptability are essential for gaining trust and encouraging participation
No two people are alike. When you’re contacting people to assess their symptoms and interactions and to ask them to isolate or quarantine for a lengthy period, you must consider the possibility that you will encounter resistance. People could be worried you’ll inform their employer, or they might be concerned about their ability to stay at home for several weeks. But in these moments, it’s important to be empathetic and compassionate, and be flexible enough to respond to their concerns. For some people, that means appealing to their sense of community and the need to protect those around them, but for others, the appeal could be completely different.
In California, we repeatedly heard concerns about how we were going to use a case or contact’s information. Many of our case investigators and contact tracers didn’t feel equipped to answer those questions. Because of the feedback we received, our training group put together comprehensive resources for the people who make contact-tracing calls. The resources included a fact sheet that clarifies public charge rules limiting some immigrants’ access to public benefits, explains who is likely to be subject to those rules, and identifies the implications of seeking COVID-related services. It was essential for contact tracers to emphasize that we never share contacts’ information with anyone, including Immigration and Customs Enforcement or other immigration authorities.
Being able to quickly adapt to responses and adjust approaches on the fly has been critical to gaining more information on what is and is not working, which then gets baked into how we are training new people each week.
Technical processes should be built around cultural humility and empathy
One of the most helpful aspects of California’s effort is the focus on engaging on a deeper level to build trust. California concentrated training on concepts like motivational interviewing, cultural humility, and empathy. In many ways, the technical components of contact tracing—making phone calls and entering information into a database—are relatively easy to train. But it’s challenging to train someone to connect with people who are sick and scared for various reasons and invite them to trust you and give you the information you need. Even though we’ve done a good job with these harder issues, we continue to struggle with connecting with vulnerable communities. When contact tracers are from the communities they’re trying to serve, they tend to better relate to and communicate with that population. I’ve been impressed by California’s recent focus on expanding our case investigation and contact-tracing workforce to serve these populations.
As a result of these experiences, leaders at the University of California, San Francisco, and the University of California, Los Angeles, are working closely with local organizations to learn more about what vulnerable communities need and how we can better serve them. In Alameda County in particular, I have seen genuine efforts to collaborate with existing health services and organizations that serve vulnerable populations so that we can involve them more directly in contact tracing.
I’m excited to be a part of California’s contract-tracing efforts. I’m proud that my colleagues at Mathematica have volunteered their expertise, and that together we’re helping new efforts. But I’m most excited about the opportunity for state and local leaders, philanthropic organizations, and researchers to quickly learn from one another as we continue to improve strategies to combat this virus. To be effective, we must constantly learn and adjust—and share what we find. Our upcoming webinar, Early Lessons for Effective and Equitable Contact Tracing, is designed to do just that, and we look forward to sharing concrete lessons for state and local leaders as they build and sustain their own contact-tracing efforts.
Read related fact sheets here.