Characteristics of the study sample
Between May 25 and July 9, 2020, we telephoned 64 cases and 83 contacts of which 35 cases and 38 contacts answered or called back, and 21 cases and 12 contacts agreed to participate. Three contacts had tested positive for COVID-19 at the time of the study interview. The median age of participants was 41 years, 61% were female, and the largest racial/ethnic group in our sample was Hispanic/Latinx (48%) (Table 1), which is roughly representative of the population of NHHD clients during this period. .
Themes, enablers and barriers
We identified seven themes that cut across the four behaviors and three COM-B domains (Table 2). While the themes were broadly similar across the case and contact clusters, below we note relevant differences where applicable, summarize the individual themes within each COM-B domain, and present supporting citations in the table. 3.
We have identified two themes, Severity of symptoms and Essential knowledgerelated to participants’ ability to participate in contact tracing. Severity of symptoms describes how symptoms of COVID-19 influenced their Physical capacity. Essential knowledge describes how knowledge of the purpose and procedures of testing and tracing influenced their Psychological capacity.
Symptom Severity Theme
Several participants described how symptoms, such as shortness of breath, made it difficult or impossible to answer phone calls or talk to contact tracers. One case was hospitalized at the time of the contact tracing call and her daughter spoke on her behalf. Other participants noted that moderate or severe symptoms also made isolation particularly difficult.
Core Knowledge Theme
Limited knowledge of COVID-19 symptoms, testing locations, or contact tracing procedures was a barrier to engaging in contact tracing for several participants. For example, not knowing how personal data would be used or protected caused some participants, especially cases, to be wary of fully engaging in the interview, although some contact tracers managed to answer to these concerns. Other attendees were baffled by the quarantine and isolation instructions.
Area of Opportunity
We have identified two themes, Structural context and Interpersonal linksrelated to the possibility for participants to participate in contact tracing. Structural context describes how structural factors (fixed economic, social and political factors) have influenced Physical and Social opportunity participate in contact tracing. Interpersonal links describes the ways in which social roles and connections to family, friends or co-workers further influenced their Social opportunity.
Structural Context Theme
Participants identified several structural factors, including lack of transportation or receiving research calls at inconvenient times that hindered or delayed participant engagement. Although NHHD had a referral system to meet the food, housing, and other needs of clients, study participants frequently cited concerns about loss of income, housing instability, and food insecurity as barriers to isolation/quarantine. Isolation and quarantine were even more difficult in homes with insufficient space for household members to effectively separate from each other. Several participants received food from clinics and volunteer organizations, and some had access to paid time off from work. A system-level facilitator identified by several participants was policy-mandated testing, requiring testing to enter health care clinics or travel internationally.
Social opportunity as engagement in contact tracing was influenced by access to medical care providers and language services. Those without health insurance or established relationships with healthcare providers faced challenges accessing care during isolation/quarantine. For participants whose preferred language was not English, language barriers made it impossible or difficult to answer calls and participate in contact tracing interviews, although some noted that multilingual outreach workers or services translation allowed for successful interaction with the program.
Theme of interpersonal bonds
Participants often described how relationships with family or friends could encourage testing and seeking behaviors and reassure participants about the contact tracing experience. Peers frequently encouraged engagement in testing or tracing, with some cases even alerting their contacts to expect tracing calls. As previously reported, family members often assisted by answering phone calls for symptomatic cases and caring for those in isolation or quarantine. People-to-people ties have also hampered contact tracing efforts. Some cases did not provide contact information (names and phone numbers) to tracers, preventing the health service from reaching them. Home care responsibilities (e.g. for children) posed additional barriers to compliance with isolation/quarantine guidelines.
We have identified some aspects of Severity of symptoms and three additional themes, Expected results, Trust in authorityand Emotional responsesthat related to participants’ motivation to participate in contact tracing. Severity of symptoms describes the ways in which the symptoms, or lack thereof, influenced their Reflective Motivation. Expected results describes the ways in which their beliefs in the consequences of participation, whether positive, negative or neutral, also influenced Reflective motivation. Trust in authority is the last theme associated with Reflective Motivationand it describes the influence of participants’ trust in health care providers and systems. Emotional responses describes the ways in which participants’ emotions influenced their Automatic motivation.
Symptom Severity Theme
Participants frequently described how symptoms prompted testing or isolation. In contrast, a contact with no symptoms described the quarantine experience as feeling “so abstract” because the absence of symptoms made it “hard to keep telling myself that it’s real.”
Themes of expected results
Participants varied in their expectations regarding the consequences of participating in contact tracing. Several tested or answered phone calls to ensure they were receiving adequate social or medical support, even when asymptomatic. One participant tested out of curiosity, while others assumed their status was positive based on known exposures and chose not to test. Some participants said they took part in testing and tracing primarily to prevent transmission to others. In contrast, skepticism about the benefits of testing or fear of undesirable consequences (eg, mandatory isolation) reduced engagement.
Trust in authority theme
Trust in the healthcare system and guidelines motivated many to participate in contact tracing, while fears of misuse of data or mismanagement of medical care were barriers. Signs of disorganization in outreach efforts, such as duplicate calls, also diminished program credibility and led to customer frustration and mistrust. Several strategies (eg, a tracer capable of confirming a case’s date of birth, using caller ID) counteracted these tendencies and may have increased motivation to engage in contact tracing. While trust in health systems was often low, participants cited their pre-established relationships with known medical providers as reasons for engaging in contact tracing.
Theme of emotional responses
Many participants described feeling shocked or anxious after receiving a positive test result or notification of exposure, and others expected to be stigmatized by other members of the community. These emotions could distract participants during the contact tracing call, but tracers who communicated clearly and with empathy helped some stay calm. Others found the calls frustrating, especially when they were numerous, repeated, or timely. A participant “did not proceed with the call” because she received multiple calls from separate tracers due to an error in which she appeared in the database under multiple unique entries. Other emotions that affected participants during isolation/quarantine were loneliness and boredom. Coping strategies such as communicating electronically with family and friends and maintaining physical activity alleviated these feelings and made isolation/quarantine more tolerable.