Making contact theme.

Participants detailed their experiences calling and attempting to reach cases and contacts and described the challenges they faced with this early step of the contact tracing process. They noted the difficulty in getting the target individuals to answer their calls and reported that it was rare for their unanswered calls to be returned. However, some succeeded by either leaving voicemails or using text messaging in addition to voicemails.

“The hard part is getting them on the phone in the first place, to answer the phone or return the voicemail.” (Participant 1:6, Case Investigator)

“When they don’t have [a voice mailbox], I’ve just been sending them a text with information from the callback scripts. I don’t know whether that is appropriate or inappropriate, but I felt that that would be how I would want to get the information.” (Participant 5:1, Contact Notifier)

Several also noted that calls made in the afternoon or evening were more likely to be answered than those made in the morning.

“I found that a lot of cases don’t like being called in the morning. As I started, I would call at 9:00 or 10:00 in the morning, cause I just felt like maybe that would be a reliable time to get people and was also convenient for me. More than once I was basically told [by cases] ‘don’t call before noon.’ So, I no longer call before noon.” (Participant 1:5, Case Investigator)

Establishing rapport theme.

Volunteers repeatedly emphasized the importance of engaging with clients authentically. Participants felt that finding the most convenient times for the conversation, showing empathy, and addressing sources of mistrust were effective in building trust and rapport. Some volunteers developed these approaches by drawing on prior experiences in patient care or other client-related work, while others did so by trial and error.

“I’ve personally gotten a few of those calls where they don’t appreciate the call. They don’t want to talk to you. It’s been interesting [figuring out] how exactly do you handle those, because at first, I was really nervous making those calls but now it’s been a lot more natural and it’s been a very interesting process, kind of learning how to do that.” (Participant 6:5, Contact Notifier)

“I think that’s why it’s so critical to have been in the health care profession beforehand, because a lot of these questions are very sensitive, and you have to kind of know how to deal with that and make it okay. So, I would say yeah, training through med school has helped.” (Participant 1:2; Case Investigator)

Some call recipients seemed suspicious of callers, and participants occasionally felt “awkward” trying to convince these individuals that they were authorized representatives of the Health Department. Others described the process of eliciting information about contacts from cases as particularly difficult because many cases either felt uncomfortable providing or simply did not know the necessary information about their contacts. One participant stated that a few cases disclosed their status as undocumented immigrants and were fearful about providing information about themselves or their contacts. Despite these challenges, participants stated that most cases and contacts appeared to be “very receptive” to providing information and following the recommended guidelines.

“People are very guarded about who’s in their house…But I think half the time it’s the person. They’re just a little bit wary. And half the time it’s just the situation. Like, they would love to tell you, but they’re also scared. And the other portion of the time people are just really open and they’re trusting and then it’s not a big deal.” (Participant 1:2, Case Investigator)

Delays theme.

Participants discussed several types of delays that prevented them from reaching cases and contacts within an epidemiologically relevant timeframe. There were delays in receiving test results and delays when a volunteer could not speak the client’s preferred language, requiring reassignment to a volunteer proficient in the preferred language on the following day. These delays sometimes resulted in reaching contacts after the two-week window for effective quarantine had expired. Others described the frustration of reaching contacts only to discover that they had already been diagnosed with COVID-19.

“We have no idea when things are getting reported to the state, when the state then goes to the city, when the city forwards that result along to our coordinators, and then when they finally put it on our list…there are some health clinics that seem to be slower reporters.” (Participant 1:5, Case Investigator)

While some delays in the overall contact tracing process were beyond the control of the program, such as cases choosing to delay seeking COVID testing or slow reporting of test results, participants felt that identifying cases in need of translators before the first call was an actionable way to prevent additional delay.

“I know that they’re pulling the data from the state database but having a flag for language would really cut down in terms of time, because we’re talking about an extra 24 hours.” (Participant 4:1, Case Investigator)

Community needs theme.

Even when reached in time, participants stated that many cases and contacts indicated that they were either experiencing or expecting difficulties in adhering to isolation or quarantine recommendations. These challenges stemmed from job or wage loss, difficulties providing food for themselves or their families, and for some, a lack of housing. Participants observed that these challenges occurred more frequently among contacts from Hispanic communities and that contact tracing calls provided a unique opportunity to identify additional needs for support or resources.

“I had one case or contact that I called, and they said, ‘There’s no one else in my house who can get groceries. I’m the only one who can go out. I don’t know how we’re going to get food. My husband is very sick and I’m trying to take care of him.’” (Participant 4:5, Contact Notifier)

“When I speak to Spanish-[speaking] contacts…what I hear more often is, ‘I can’t not go to work.’ And I don’t hear that as much when I [call] other contacts that I receive. I just hear people panicking essentially over the phone.” (Participant 5:5, Contact Notifier)

Participants appreciated that the Health Department instructed volunteers to routinely assess these needs and thought many cases and contacts viewed this needs assessment as a sign of the city’s concern for its residents. However, some participants were unsure whether these needs would ultimately be addressed by the city and questioned the utility of assessing needs when they could offer cases and contacts little assurance that the needs would be satisfied.

“The other thing that was added actually fairly recently was [a prompt asking if] they have a need for housing support, food support, financial assistance, any of those things…it just adds a human element to the interview because, by asking that, it shows that we’re not only doing this to use the participants as a source of information, but also we’re here because we care about them as part of the community. So, it adds that element that I think people are very receptive to.” (Participant 2:2, Case Investigator)

Volunteer motivations theme.

Most participants reported a strong desire to help their community combat the COVID-19 pandemic. The effects of the pandemic had simultaneously suspended in-person classes, clinical training, and routine work, leaving participants feeling idle and powerless. The contact tracing program offered a chance to respond to the pandemic by applying their knowledge and skills as budding or established practitioners, teachers, or researchers in the health sciences. Some noted that the safety of being able work remotely made telephone contact tracing more attractive than other volunteer opportunities that required physical interaction.

“As someone who’s going into this field, I’ve always wanted to do outbreak investigation and outbreak response kind of stuff. And it was really hard to feel powerless. And so, when this opportunity came up, I was like, this is something that I can do, like using my education and my skills.” (Participant 4:1, Contact Notifier)

“I heard about this [volunteer opportunity] and how it could really use the skill sets of people who are trained to interview patients. And I thought that was one of the best ways I could help.” (Participant 1:3, Case Investigator)

Time management theme.

Balancing contact tracing duties against other responsibilities was easy for some yet challenging for others. Unpredictable schedules, especially for students during examination periods, made it difficult for some to keep up with their tracing responsibilities. Case investigation volunteers were allowed to adjust their assigned case load every week to match their availability and used this flexibility to better manage their time and level of involvement. In contrast, contact notification volunteers were given fixed case assignments on a rotating basis and noted that their inability to control their workload could be stressful.

“It’s really hard to just get an email all of a sudden [that says] ‘you have to call this person within 24 hours.’ And I wasn’t able to do all of them in the right timeframe because of that. I had too much other work to do.” (Participant 6:2, Contact Notifier)

In addition, participants from both teams reported that the sporadic workflow was challenging. Many said that they felt out of practice making calls after even a few days’ hiatus, while others felt “burnt out” after making many calls in a short period.

“I think the issue is just that the current inconsistency of not being as well-practiced in the ability to do the interview as well as you might have been doing them when you had a more consistent stream of calls.” (Participant 2:1, Case Investigator)

“I found that if I was doing this for four hours a day, I got kind of pretty burned out by it… the next day I was like, I don’t want to do this.” (Participant 2:4, Case Investigator)

Knowledge theme.

Participants highlighted the importance of knowing and effectively applying current CDC COVID-19 recommendations and other policies regarding confidentiality and privacy protection. Because the tracing scripts changed frequently during the early phase of the pandemic to meet the changing CDC guidelines, participants found it challenging both to stay current and to feel confident that they were providing accurate guidance to cases or contacts in every situation.

“[CDC guidelines] are very fuzzy and always evolving in terms of the recommendations. That makes it really hard to feel confident in what we’re telling people.” (Participant 2:2, Case Investigator)

They also often found privacy protection policies difficult to apply due to the unique circumstances of each call. Participants said they were often required to speak with family members or other proxies in tense or emotional circumstances when cases or contacts were severely ill or unavailable to speak. A lack of familiarity with navigating and applying privacy policies within these unpredictable scenarios made it difficult for some participants to discern how much information they could appropriately share with proxies.

“More information on [privacy and confidentiality], who we can and cannot tell certain things to, how to deal with proxies. I think that would have been really helpful.” (Participant 3:3, Case Investigator)

In addition, participants occasionally struggled to answer questions from cases about why certain data, such as information about contacts (name, phone number, age, gender) or current health status, needed to be collected. On the other hand, contacts frequently questioned where callers obtained such information. Participants believed that cases were hesitant to provide information when they were unsure what the city would do with it or thought that it would intrude on the privacy of their contacts. Although the importance and utility of each part of the script was covered in the volunteer training, participants felt that providing refresher sessions or opportunities to clarify how data would be used could have increased their ability to adequately answer case and contact questions in order to better promote faith and trust.

“People would ask ‘well, why do you need the information from my husband’s phone number? He’s here. He’s listening to this conversation. He knows that I have COVID and that he’s been exposed to COVID. So now I need to give the health department his phone number [so] that someone else can call him and tell him that I have COVID?’ or, similarly, they’ll say, ‘Oh, everyone knows. I’ve told [my close contacts]. So why do I need to [give you their number]? They wouldn’t want me giving [their phone number] so that you can bother them.’” (Participant 2:2; Case Investigator)

“I got a lot of ‘where’s this data [personal data about the individual] coming from, where are you getting this information?’ And I think it would have been helpful to have known exactly where that information was coming from so that I could have a better answer for that.” (Participant 6:2, Contact Notifier)

Skills theme.

All participants strongly agreed that effective communication skills were critical to establishing rapport with those facing a new and potentially frightening illness. Many adapted the interview script to this end. For example, rather than starting with standardized questions about demographics and specific symptoms, several participants found that beginning by asking open-ended questions about the client’s current situation and setting expectations about content and length of the call helped engage some individuals.

“I do a little bit more signposting in the interview than is included in the script. What I mean by that is setting an expectation about what are what are all the things we’re going to talk about…I’ve found that sometimes cases are surprised by how long [the interview] is going, that they start to check out a little bit. Whereas if the expectation is very clear from the get-go, then I think people let their guard down a little bit and also just feel a little bit more comfortable with the interview.” (Participant 1:5, Case Investigator)

Applying techniques to communicate effectively and adapting messages in real-time was especially critical during moments of high emotion or conflict. For example, volunteers described unexpectedly being the first to inform cases about their positive test results or learning from those answering that the case had died or speaking to individuals who did not wish to participate. In one instance the participant had felt obligated to call 9-1-1 for emergency medical assistance for a case who was in physical distress. As discussed below, participants repeatedly suggested that role-playing exercises be included in their training to build skills and confidence in navigating these emotionally charged or unanticipated situations.

“In the training, I [would] definitely [add] like a role player, an initial call, for both a standard case and a nonstandard case. So, for instance, I’ve had a call where someone just started swearing at me on the phone, which is not something you expect and then I had another call where I had to call 9-1-1 on that person’s behalf… So, I think, because we’re calling sick people, getting [new trainees] ready for what a normal case looks like and what an abnormal case looks like, or just to get them able to think on their feet, would probably be important.” (Participant 1:4, Case Investigator)

Collaborative learning theme.

Participants frequently mentioned a need for internal communication structures to better promote information exchange, shared learning, and timely adaptation to periodic changes in guidelines or programmatic priorities.

Having direct communications with program supervisors was very important to participants, and they especially appreciated quick responses to their questions. They felt it was important for supervisors to communicate changes in CDC guidelines and programmatic priorities, as well as to be responsive to volunteers’ concerns, suggestions, and requests for changes or clarifications in protocols. These “two-way communications” were viewed as critical to maintaining “morale and faith” in the mission and promoting team solidarity. They described the chat application GroupMe as being “so helpful” in providing a direct mechanism to reach the supervisors with questions and view other volunteers’ comments. However, several participants also noted that discussion threads were often basic and repetitive, reducing their value.

“[The leaders] have been really responsive if I send the GroupMe message. People are pretty happy to respond, and they do that very quickly. That’s been good.” (Participant 3:2, Case Investigator)

“I am on the GroupMe, I’ve been on it for since I started, but I basically ignore it because there’s so many messages that go into it and so many of them are, ‘so I’m a new volunteer, how do I use [the interview software]?’ And then it’s a 20-message thread and everyone has to see it. So I check it like every few days and I just kind of scroll through.” (Participant 3:6, Case Investigator)

While the messaging app served as a useful hotline to request help from supervisors, many felt that other mechanisms were needed to provide peer-support, foster community, and learn from the experiences of their peers. Several mentioned that they thought that hearing about other volunteers’ thoughts and experiences during the FGDs had been helpful. They advocated establishing a “buddy system” or regular meetings with small groups of peers for volunteers to share experiences, learn from one another, and debrief after difficult calls. They felt that such meetings could help to provide regular updates on changing protocols as well as promote a sense of community in an environment where in-person interactions were impossible.

“At the moment I feel very comfortable doing a few practice calls with someone who’s just starting, going through some of the situations I’ve been through, a regular one, a few difficult ones and literally spending 20 minutes, half an hour doing those things. If someone had done that for me at the start, I would’ve felt a lot more comfortable than I originally did.” (Participant 5:1, Contact Notifier)

“I don’t think that I necessarily need more training, but the GroupMe, [or] having a short meeting once a week with small groups to discuss newer things I think would be helpful.” (Participant 4:2, Contact Notifier)

Tools theme.

Participants described several tools that were essential to their tasks, and the one most frequently discussed was the script. Many thought it was difficult to deliver the words verbatim because doing so made them sound “like a robot.” As previously noted, many adapted the script language or individualized their introductions in an attempt to rectify this problem. However, when asked if replacing the script with a bulleted list of objectives would be preferable, most said that a word-for-word script was necessary as a training aid, especially during a tracer’s first few calls. Other useful tools that participants regularly consulted included guidance documents provided by the program and a list of frequently asked questions. Participants appeared enthusiastic to add to and update these materials based on their own experiences. Some even suggested compiling examples of challenging call scenarios and response strategies into a reference document.

“I don’t think [any] amount of training can really prepare [you] for that first call. I know that sounds, I mean, yes, there was training to prepare for the first call, but I think you’d need that script just as that safety net.” (Participant 5:2, Contact Notifier)

“It would be helpful to have a repository of what these possible [call scenarios] are based on experience, real experience, and we could all contribute to that.” (Participant 1:2, Case Investigator)

Participants also identified a need to adapt scripts and protocols for asymptomatic cases, minors, non-English speakers, and cases residing in congregate settings such as nursing homes. Calls to individuals in congregate settings were especially challenging to navigate because cases were often severely ill or otherwise incapacitated, caseloads were high, staff were already overwhelmed and overloaded with calls, and other factors. These cases were redirected to the Health Department for follow-up.

In addition to these specific contexts, participants felt that the contact notification process should be modified for members of a case’s household and offered examples to support this suggestion. First, cases were often reluctant to provide information about their family members, possibly due to mistrust of the caller, fatigue and annoyance from being called by multiple agencies, or a desire to prevent additional calls to their household contacts. Second, even when this information was successfully collected by case investigators, they stated that it could be “a bit of a puzzle” to correctly identify cases and contacts at the beginning of a call without compromising privacy. When incorrect assumptions were inadvertently made or participants found themselves duplicating a call because a case had given the same phone number for multiple contacts (e.g., phones shared within households), participants on the contact notification team said the calls felt like “a mess” and that they lost credibility with the contacts. Last, participants often struggled to identify a single exposure date for contacts who were living with a case and hence continuously exposed, whereas it was simpler to identify a discrete date for non-household contacts. All these experiences led volunteers to recommend conducting household contact notification together with the case interview.

“There should be a separate [protocol] for household contacts. A household contact represents an ongoing exposure dynamic that is different than non-household contacts. If possible, the person calling the cases should contact the household contacts.” (Participant 4:2, Contact Notifier)

Data entry software was also identified as a critical contact tracing tool. Many case investigator participants appreciated the flexibility of New Haven’s emergency-management software, as it allowed them to scroll through the questions and enter data in a smooth yet flexible order. This feature was highlighted as important when interviews did not follow the planned order of questions. With regard to data management, however, the free-text data collection tools used by the contact notification team were challenging to process, and several participants responsible for entering these data felt that they “should be updated” and recommended the use of a standardized form. Another tool that volunteers discovered to be helpful was dialer software (Doximity, San Francisco, CA) to mask their personal information, display the Health Department’s phone number or a leave a virtual callback number (Google Voice, Mountain View, CA).

“So, the number they see on their caller I.D. is from the [health department]… And then the number we leave [for] voicemail is my Google Voice number that will forward to my cell phone. So, they don’t know who we are, they don’t have our name or our personal information any more than what we say in the voicemail.” (Participant 1:4, Case Investigator)

External coordination theme.

Participants from both teams spoke often about how the activities of external organizations affected their own activities. Cases and contacts often reported receiving numerous calls from various organizations, such as healthcare providers, testing facilities, and insurance companies, and were often “annoyed” at hearing the “same things from multiple different people.” In some instances, different organizations provided conflicting advice about isolation and quarantine periods. Ultimately, these experiences often led to call recipients being less receptive to engaging with the caller, thereby making it more difficult to collect the necessary information.

“When there are multiple people who are giving [the case] recommendations that are not the same, it becomes challenging to feel like you are authoritative and for people to feel like they know what’s going on.” (Participant 2:4, Case Investigator)

“Because they’ve tested positive, their doctor has given them a lot of recommendations already and they’re hearing it from us again…I think lately I’ve been getting more people who’ve tested positive and they’ve been annoyed with my call, more so I think because they’ve heard kind of the same things from multiple different people.” (Participant 5:4, Contact Notifier)

Sustainability theme.

Several participants considered a volunteer-driven workforce as ideal for the “crisis phase” of an epidemic, allowing an accelerated response without the delays inherent in formal hiring or when re-assigning existing employees to contact tracing was not possible. However, participants did not see a volunteer-driven program as sustainable during the “maintenance phase” following the crisis. Some participants had recently graduated and were departing for jobs or further training, and others planned to soon return to class or to other responsibilities.

“I think that you just unfortunately have to account for the fact that [volunteers] who are trained might be gone two months later and then [training and volunteer turnover] keeps going on and on again.” (Participant 6:6, Contact Notifier)

As nearby states began hiring and paying contact tracers, other volunteers reported feeling frustrated, underappreciated, or less inclined to continue with the program. Participants suggested several strategies to maintain long-term involvement of contact tracers such as hiring them into part- or full-time paid positions or incentivizing student volunteers by offering academic credit for their work.

“I think it’s a great idea for an acute crisis emergency for those first few weeks. Now this is an ongoing thing, I feel putting in a long-term solution, and maybe this counts as a practicum for the incoming students or for the continuing students or finding a way you can either weave this into the program… [or] They should be paying us to do it, not exorbitant amounts. But like 10 or 12 dollars an hour…I think that not doing that is a real disservice.” (Participant 5:1, Contact Notifier)