We interviewed public health professionals from local and state health departments across the United States using a geographically stratified, purposive sample approach across the Health and Human Services regions. Eligible interviewees were involved in some component of the COVID-19 CICT continuum. We asked interviewees to describe their professional perspective working within a public health organization including reflecting on programmatic and organizational approaches to CICT. We refer to dominant and non-dominant language in the introduction since differences in language between public health organizations and members of our communities is universal. We will, however, be focusing on English specifically in this manuscript since the interviews were conducted within the United States and focused on the United States public health response to COVID-19 at local and state health departments. Interviewees were identified through a network of public health practitioners and health care providers, the North American Refugee Health Service Providers listserv, and the Association of Refugee Health Coordinators listservs. The perspectives of professionals within health systems and community experts/organizations are reported elsewhere (16, 17).

Interviews were conducted from September 2020 to February 2021. We developed a semi-structured interview guide (Supplementary Table 1) with input from public health professionals and extant CICT literature. Demographics were collected via REDcap (18, 19) for each interviewee. Interviews were conducted in English, audio recorded, transcribed by a professional transcription service and analyzed in Dedoose version 9.0.107 (20).

Organizational level descriptive statistics were computed. A multidisciplinary team followed the phases of thematic analysis outlined by Braun and Clarke (21). Three team members participated in identifying patterns in the data. The first five transcripts were independently coded by two coders, discussed and reconciled as needed, guiding the iterative codebook development. Subsequently, one transcript was selected for review by two team members independently, followed up by a group discussion. The remaining 16 interview transcripts were coded by one team member (one team member coded 5 and the other team member coded 11). The codes were reviewed and patterns in the data were discussed during weekly team meetings. Upon completion of coding, themes were identified from observed data patterning, iterative thematic mapping, summaries and revisions, discussions and naming. Members of the broader team were intermittently involved in reflexive discussions about analytic team memos and thematic interpretations (21, 22).

We identified promising practice examples within the interviews by team consensus and they were shared on the NRC-RIM website for rapid dissemination as the team learned about them (15). The majority of the promising practices on the NRC-RIM website were identified from this set of interviews with public health organizations, with interviews with health systems (16) and community organizations (17), from review of the media or shared by partner organizations. After the thematic analysis, two team members identified promising practices from the NRC-RIM website to link to the themes in this analysis in order to provide concrete examples of promising practices. First, promising practices that were from the interviews in this data set were selected. Then if a promising practice was not available from this data set that aligned with the theme then through consensus three team members identified another example from the NRC-RIM website.

We conducted 21, 45–60-min interviews with a total of 33 public health professionals, some interviews included more than one person (Table 1). Interviewees’ roles included: State Refugee Health Coordinators and Program Leads, Public Health Nurses, Epidemiologists, Program Leads for CICT, Medical Directors of Public Health Clinics, and City/County Health Officers.

Six themes were identified. Interview excerpts representing each of the six themes from this analysis are displayed in Table 2. In addition to the data examples supporting each theme, Table 2 links promising practices identified by interviewees from this data set and NRC-RIM website with the thematic analysis to provide concrete examples of these themes in action.

Interviewees described that public health organizations at the local and state level utilized their knowledge of community and public health system assets, needs, and challenges, leveraging existing resources to support a comprehensive CICT response to COVID-19.

Effective CICT is facilitated by cultivating existing and new relationships that are grounded in trust between public health and RIM communities at the individual, community, and organizational levels. Trusting relationships fostered by individual public health professionals with RIM communities sometimes supported CICT efforts when public health organizations did not have established relationships:

In some locations, public health teams already focusing on RIM communities were able to quickly build upon those community relationships, and those with strong established community-public health relationships could be further leveraged in the context of COVID-19:

Interviewees frequently reflected on the importance of organizations fostering trust to facilitate CICT, identifying trust as fundamental to cultivating relationships. They acknowledged the importance of repairing broken trust, bolstering existing trust, and intentionally building trust to facilitate CICT. To foster trust in the CICT process some public health organizations engaged community leaders in case investigation; yet, this was not seen as a way to facilitate trust in every context. One interviewee reported feedback from a community partner indicating,

The importance of building sustainable relationships between public health and RIM communities before they are needed in a fast-moving environment—like a pandemic response or another emergency—was highlighted across the interviews and well stated by an interviewee:

Importantly, the aforementioned examples illustrate how modifying existing or building new relationships facilitates trust and requires an ongoing focus on communication and understanding community contexts and preferences.

Ensuring linguistically and culturally concordant communication, services and support is essential to successful CICT with RIM communities. Interviewees explained that few systems had processes in place to identify languages spoken and/or preferred by COVID-19 positive community members they were attempting to engage in CICT. This gap in knowledge about language for CICT was due to multiple barriers such as language not being collected at the time of testing, or because language information did not have a field in their CICT software. These barriers frequently led to a best-guess approach to spoken language based on name or country of origin, if known. “[I]t’s an imperfect system but it’s kind of the best that we can work with at this time.”

Interviewees described operational adjustments during the early phases of the pandemic that allowed multilingual staff members to temporarily shift into roles where they were using their language skills to conduct interviews, or train others on how to use telephonic, video and in-person interpreter services. Eventually organizations shifted to hiring practices that intentionally sought individuals with community-matched language skills and cultural backgrounds, or contracting with staffing organizations with multilingual staff. Interviewees also highlighted the nuance between people who speak a language as their heritage (primary) language compared to non-heritage speakers, observing a stronger sense of community trust with people who were heritage speakers. Herein lay the importance of both linguistic concordance—speaking the same language as the person you are interviewing—and cultural concordance—understanding cultural relevance, preferences, variations in language, and a shared framework of expectations.

The interviewees also recognized the need to ensure health education materials were available in the language and form of media that is preferable and accessible to the audience (e.g., oral PSAs or videos might be preferable to written material). Interviewees highlighted the importance of understanding and reflecting on the breadth of languages spoken within their jurisdiction (a point of intersection with the Understanding Community and Public Health Context theme), and the importance of prioritizing the development and dissemination of linguistically and culturally relevant materials, especially given the gap could lead to inequity in information access for smaller and less common linguistic communities. “The weekly briefs from the mayor, they are always in English, so how do they get translated down to other languages … that real-time feedback from your mayor or leader during an emergency, that’s really tough.”

Intentional communication between public health organizations and RIM communities facilitated sharing and receiving information and promoted engagement in the CICT process. Interviewees described that public health organizations were messengers about CICT both at the individual level during CICT interactions, and at the community level disseminating information about COVID-19 and CICT. CICT interactions for COVID-19 needed to involve building trust with the person being investigated while simultaneously offering CICT process guidance, collecting information, providing COVID-19-specific resources, addressing concerns, and giving accurate messages with an emphasis on promoting community and individual health. As one interviewee described, “That care coordination piece in addition to [the] public health piece about ‘Here’s the things you have to do’, those two things in tandem are pretty important.”

Individually, interviewees described providing public health guidance in a systematic and factual manner as part of the CICT process, “sure, we use scripts. But we are not salespeople … We’re not trying to sell something. We’re not trying to get them to do something. We’re trying to provide public health guidance.” One trust-building communication strategy shared by an interviewee was intentionally framing the request for information that accompanies the initial CICT phone call as information that has the potential to benefit that individual, their family and the health of the community. Several interviewees described that after years of being advised not to share their personal information, RIM community members being contacted by public health practitioners asking for personal information over the phone was understandably not well received. Consequently, the need to effectively message the function and significance of CICT at the community level, via trusted community sources, was critical to successful CICT.

Additionally, iterative communication was needed within and between CBOs, employers, and public health to ensure everyone had up to date information; however, interviewees highlighted the challenges of making time for these “check-ins” during the pandemic and the “bureaucracy” that made getting the message out from public health slower than planned. As with many of the system-level tensions that became apparent or exacerbated during COVID-19, these became pivot points for public health as the response evolved. For example one interviewee described an appreciation for and recognition of the places where communities might be able to spread and receive messages more quickly than traditional public health messaging such as faith-based organizations: “The [redacted] Community Center is not faith-based but does work with a lot of the different churches and has built a lot of relationships and rapport over time. Their director actually recorded a message about COVID-19 and health education … So the church leaders played it on Sunday during their Zoom services across – to disseminate information from this single place and trusted source.” Other interviewees also emphasized the value of public health getting messages out via social media in partnership with “community level influencers and CBOs and then also being receptive to the feedback, creating that dialogue and being receptive to the feedback.”

The approach to CICT evolved over the COVID-19 response and required ongoing adjustment of public health roles, processes, and infrastructure to address organizational and community needs. Public health professionals experienced tension between stressed resources and the ability to innovate at the pace and in the ways that they wanted to for effective and comprehensive CICT. Organizations were unable to provide CICT for every person, and in many scenarios needed to prioritize case investigation, leaving contact notification to individual cases. Many interviewees described the urgent needs and emerging challenges RIM community members shared as the response evolved (e.g., feeling unsafe in their home, or having concerns of job loss while in quarantine and isolation). These challenges led to the development of approaches to support people through the CICT process such as explaining quarantine and isolation in detailed and culturally relevant ways, while also identifying financial or food resources, housing, or other supportive services.

To meet staffing needs, public health professionals utilized their knowledge of existing resources to identify other roles within their system (i.e., navigators or people who conduct CICT for tuberculosis), partner with other organizations (i.e., students at universities), and/or hire from contract agencies and recruited people from retirement. Ideally, public health organizations would have preferred to hire more staff from RIM communities; however, they described challenges finding time to navigate recruitment and hiring policy and procedure challenges, especially early in the pandemic. Public health organizations needed to adapt when engaging with workers in seasonal industries such as farms, food packing, and fishing, for example how to provide housing if an outbreak happened in communal housing. The ongoing evolution of the response also meant public health employees frequently shifted roles. Interviewees spoke about the energy and time their organizations required to continuously shift resources and staff, which contributed to staff stress and burnout, as described by one interviewee, “…the public health folks are exhausted. Everybody’s exhausted. It’s been a year, and people are tired, and now we are trying to get vaccine out as fast as possible.” Similarly, another interviewee states“It’s the most intense professionally and personally [I have worked in] my life … we need to learn to adjust to this new reality, and that does not just include the health department … all of healthcare and all of society for that matter.”

Public health systems varied in their emphasis on equity in implementing comprehensive CICT and supportive processes. Notably, this theme was not directly asked about in the interview guide, however, all of the interviews describe awareness of equity or inequity, and varying levels of equity in action. Within some public health organizations, interviewees identified specific people and teams who were focused on health and/or language equity that were trying to improve and enhance communication with immigrant communities. Interviewees also identified structural factors within the broader public health COVID-19 response that were contributing to inequities in data collection, testing and vaccine distribution, and characteristics of leadership and team structures. Collecting language at the time of testing was highlighted as a key area where health departments should improve their data collection. One interviewee explained

Interviewees provided several examples of missed opportunities for language collection at the time of testing potentially contributing to their inability to identify individuals and communities who were being disproportionately impacted by COVID-19 infection, but underrepresented in the data because it was not being collected. Additionally, access to testing was limited for some communities because it was only done at drive up sites, making it inaccessible to anyone without a car.

Interviewees identified key areas where they sought support both outside and within their organizations to ensure equitable support for immigrant communities. In settings where employers provided housing such as for seasonal work, public health organizations played active roles in identifying sites for quarantine and isolation, and supporting on site testing and vaccination. Interviewees described that many people were facing challenges with meeting basic needs due to loss of wages, jobs or missing work due to illness. One interviewee emphasized, “Assuring that the distribution of those social supports and financial resources was equitable, I think, is a really big challenge, and one of the challenges for folks accessing that support was language on the phone when they called for help.” A few public health professionals noted that teams that met weekly to debrief, reflect, and learn from one another were well positioned to identify equity concerns and raise them to leadership. Interviewees highlighted that training about discrimination, bias and cultural humility was important to be effective in comprehensive CICT and all public health activities.

Some interviewees also described the need to engage in advocacy within their organization to ensure funding could be allocated to CBOs. In many cases CBOs focused on communities disproportionately impacted by COVID-19 were doing the bulk of the public health work without a commensurate amount of funding. To address this barrier, some public health organizations sought creative ways to support partnerships, including one example of funding a health equity center led by a CBO and an academic medical center:

The continuum of equity awareness and implementation varied across public health, indicating a need for an ongoing, multilevel support for teams and systems to expand equity efforts.

The interviewees in this analysis were from professionals working within public health organizations, therefore the identified perspectives are from this vantage point and may be different than recommendations from community based organizations or health systems. These perspectives were described elsewhere (16, 17). The interviewees who participated had the bandwidth to participate in an interview during the early part of the COVID-19 response, and may not represent the perspectives of significantly burdened systems. Additionally, though findings and dissemination materials from this project might not be generalizable beyond the scope of this project, they might be transferable in some contexts/populations, with consideration of the project limitations.