How to make COVID-19 contact tracing work

Imagine answering a call from an unknown number. A stranger announces you may have been exposed to coronavirus; you may or may not get seriously ill, and either way, you have to isolate yourself for two weeks while everyone else carries on. What goes through your mind? Are you scared? Who will take care of the kids? Will your boss give you sick leave if you feel healthy? Wouldn’t it be easier to go on as if the call had never come?

The answer to the last question could be the difference between coronavirus smoldering at low levels in the community until a vaccine is approved and a deadly second wave. It could be the difference between stories of communities that came together to face down an unexpected threat and heartbreaking tales of economic ruin and loved ones lost.

For the last three weeks, I have helped design and implement elements of the training of California’s new “army” of contact tracers. Contact tracers are key to our return to daily life because they call individuals exposed to coronavirus to keep them from mingling with unexposed individuals.

California Governor Gavin Newsom has set a goal of training 10,000 contact tracers statewide to minimize viral spread as California reopens, but the number of tracers is not the only issue. We must arm contact tracers with tools to empower contacts to change their behavior for two weeks. Health coaching, which has been shown in randomized controlled trials to improve people’s health, can provide those tools.

Health coaching is a set of tools to support people in gaining the knowledge, skills, and confidence to care for their health. Health coaches help patients set goals and support them in achieving those goals. We’ve all heard the saying that if you give someone a fish, she will eat for a day; if you teach her to fish, she will eat for a lifetime. Health coaching teaches people to fish.

Not surprisingly, contract-tracers-to-be, many with no healthcare background, arrive at the five-day, virtual training with trepidation, wondering if they can muster the courage to notify a stranger of exposure and persuade them to quarantine. Amazingly, by the end of the week, armed with health coaching skills, they start to see a path forward.

Solange Madriz, who began contact tracing in San Francisco in March, notes: “Health coaching skills, as well as rapport building, are important for contact tracers because we are reaching out to people to share bad news in an already stressful context.  Knowing how to phrase questions and communicating in a sensitive manner is crucial to ensure the contact is comfortable to share information with us and for us to provide support services.”

Let’s look at a more traditional way of assisting someone exposed to coronavirus vs. a new way using a health coaching skill called Ask-Tell-Ask:

Old way:

Contact tracer: Hello, I’m calling from the public health department. You have been in contact with someone with COVID-19.  You need to quarantine yourself for 14 days. That means stay home except for getting tested, have someone leave meals at the door, and clean the bathroom completely after you use it. This should start today.

Contact: Sorry, I just can’t do that. I have to go pick up my grandkids.

New way (Ask-Tell-Ask):

Contact tracer: You have been in contact with someone testing positive for COVID-19. What do you know about COVID-19?

Contact: I know a lot from the news. I’ve been exposed? What do I do?

Contact tracer: To reduce the spread of the virus, it makes a huge difference if people who have been around someone positive for COVID-19 get tested and quarantine themselves for 14 days. That’s a lot to ask. What do you think about that?

Contact: I’m not sure. What do you mean by quarantine?

Contact tracer: Ideally, it means staying home, having meals delivered to your door, and cleaning the bathroom thoroughly after you use it. How difficult would these things be for you, and what questions do you have?

Contact: That sounds so hard.

Contact tracer: I agree. What about it sounds most difficult to you?

The conversation would continue using the “ask-tell-ask” approach and other skills to troubleshoot myriad problems: what about making money, I care for my elderly mother, where do I get food, and many more.

While it warrants further research, this low-tech, communication tool is likely to be as effective in engaging COVID-19 contacts as it is for helping people manage other health conditions.  With evidence-based health coaching skills in their toolbox, contact tracers will be fully equipped to support exposed individuals to successfully quarantine and protect communities across the country.

Alicia DiGiammarino is a health educator who blogs at her self-titled site, Alicia DiGiammarino.

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