The County of San Diego (COSD) Health and Human Services Agency (HHSA) serves as the local health department for the entire San Diego region and all 3.3 million residents. San Diego is home to an incredibly diverse population, with 18 municipalities, 36 unincorporated towns, 18 tribal nations, and 42 school districts. In San Diego, over 100 languages are spoken, there is a large military and veteran presence, it is the second largest refugee resettlement site in California, and it is home to the busiest land port in the world, sharing a border with Mexico.

 The COVID-19 pandemic in San Diego County and nationwide has only highlighted health inequities that have always been present in our community. The County of San Diego worked across departments to create a collaborative model for working with community-based organizations and non-profits who understand the needs of their individual communities. The County of San Diego released a request for proposals for Community Health Worker Communication and Outreach Services (CHWCOS) with the goal of working closely with organizations to provide COVID-19 outreach in a culturally and linguistically appropriate manner, ensuring that all residents, no matter their country or language of origin, have the opportunity to receive accurate and up-to-date information. In San Diego County, data shows that the African American, Asian Pacific Islander, Latinx/o, and Refugee communities have been disproportionately affected by COVID-19. Seven Community Health Worker Communication and Outreach Services contractors, or partners, were brought on to not only provide information translated into the appropriate language, but to engage each community of focus in a meaningful and impactful manner. The equitable distribution of information transcends translation, and communication should be inclusive of cultural references and take into account the history, religious background, social practices and lived experiences.

The goal of the CHWCOS practice is to ensure all San Diegans have access to accurate information and resources to keep them safe during the pandemic and ongoing. Initial findings suggest cross collaboration between County of San Diego departments and community organizations lead to a comprehensive approach to increase communication and outreach efforts among communities who have been disproportionately affected by COVID-19. CHWs have provided information throughout the diverse communities of San Diego and have received positive feedback from residents grateful for COVID-19 information, as well as the personal interactions and resources such as food, housing, and basic needs that CHWs are able to assist with.  Factors that led to the success of this practice has been the partnership with CHWCOS partners, bringing them together to collaborate, working closely with each contractor, and providing a platform for partners and County technical advisors for each focus community to connect and discuss strategies. Providing information for a diverse population in a variety of languages increases the number of San Diego residents that are able to receive accurate updates on COVID-19 prevention, testing, tracing and treatment efforts, and gives the opportunity for residents to speak with a peer about any concerns they may have. 

The collaboration between the CHWCOS partners and County of San Diego is a new strategy to further educate and engage with the diverse communities in San Diego in an effort to slow the spread of COVID-19 and will be used as a tactic moving forward to address health disparities and disseminate information in a manner that is relevant to all populations. The communities of focus are African American, Refugee, Asian and Pacific Islander and Latinx/o populations.

The CHWCOS partners are trusted organizations within the community, and are tasked with disseminating accurate, up-to-date information on COVID-19 in a linguistically and culturally appropriate manner to best achieve an increase in COVID-19 testing and an overall decrease in COVID-19 incidence in each community of focus, as well as throughout San Diego County. There are two groups of CHWs that are a part of this effort: the CHW Communication and Outreach Services partners and the CHW Contact Tracing partners.

CHW Communication and Outreach Services partners focus on developing culturally and linguistically appropriate education and outreach messaging as well as materials communities at increased risk for COVID-19. CHW Contact Tracing partners follow close contacts of confirmed COVID-19 cases by conducting home visits and assisting with disease control activities in coordination with the County of San Diego Epidemiology Unit.

CHW Contact Tracing partners are able to connect with community members who have not been reachable by other means to provide health education, resources and make referrals for COVID-19 testing. This trusting relationship enables the CHW to serve as a liaison between health and social services and the community to facilitate access to resources and improve the quality of service delivery. The two groups of CHWs are brought together for a weekly Collaborative meeting, where Contact Tracing partners are able to share common questions and needs from the community with the Communication and Outreach Services partners, who can use the information to guide their messaging.

The communities of focus were based on Race/Ethnicity Census Tract Level Data provided by the Epidemiology and Immunization Services Branch (EISB). In addition to the general public, market research was conducted to further tailor efforts to increase outreach among high-risk populations, such as those who have underlying medical conditions, and/or encounter language barriers among the identified communities.

The County of San Diego has previously utilized translation services and has worked closely with the community through dedicated staff and departments, this has been the first effort to work collaboratively with community-based organizations to implement activities that are translated and tailored to specific populations, as well as provide a platform to receive updates and share collective knowledge and ideas.

Once the CHWCOS partners were brought on, the County team and partners quickly and creatively adapted to the emergence of COVID-19 by establishing open communication and sharing of resources between CHWCOS Contractors and the County of San Diego to better understand and serve the communities in need. Based on COVID-19 incidence cases and other data, revisions to established contracts such as changes to the CHW workforce, implementation of home visits, and adjusting to data exchange between organizations to best respond to the emergence of COVID-19 was necessary. Given the urgency of the situation in San Diego and rising cases, partners quickly hired CHWs, implemented action plans and began messaging. COVID-19 has brought many changes to the way we live and work, and each day brings new information; County staff and CHWCOS partners have been nimble in changing direction, response and updating messaging on an ongoing basis so that the community has the information and resources they need to stay healthy and safe.

Through the CHWCOS project, new and existing digital platforms were utilized to increase participant engagement, staff across departments were reassigned to support the project, and relevant department representatives were asked to participate to lend expertise. Staff with diverse skillsets were assigned to assist with the project to create a well-rounded team that could communicate data, medical expertise, communication expertise, resource knowledge, and more to partners. Existing platforms such as Zoom served as a platform to host weekly meetings, while the Microsoft Teams channel served as an additional forum to continue conversations outside of scheduled meetings. Alternatively, during meetings, Google Jamboard served as an interactive platform for partners to collaborate and brainstorm strategies to best meet the needs of the community. CHWCOS partners promoted the use of phone applications not traditionally utilized to share public health information with community members.

As the number of COVID-19 community outbreaks was identified and the number of cases increased the County of San Diego scaled up its contact tracing efforts to protect communities from further spread of the virus. Early in the pandemic, data showed the virus was disproportionately impacting Latinos and other communities of color, for this reason, an increase in outreach efforts was implemented. Due to high COVID-19 incidence rates among these communities, the need for CHWs to reflect the diversity of the community was in high demand. In the early stages of the pandemic ensuring accurate information was disseminated from credible sources to the communities presented a challenge due to the rapidly evolving information about the virus, guidelines, and local public health orders.  

The County of San Diego further analyzed and released COVID-19 data by zip code, race, and ethnicity prompted the County to partner with community organizations to leverage and tailor outreach strategies to the identified geographic areas. Efforts included increased dissemination of accurate COVID-19 information, increased access to COVID-19 testing sites, tailored contact tracing efforts according to age and language, and the promotion of COVID-19 resources. The County team receives feedback on an ongoing basis, and is connected to all COVID-19 staff and is able to relay questions or concerns to the necessary branches to enhance COVID-19 response.

The CHW model has been historically used in public health efforts. For this reason, the Collaborative implemented the CHW model to address the COVID-19 disproportionality among communities in San Diego.

The goals of the CHWCOS project are to provide information to residents in a linguistically and culturally appropriate manner, promote the sharing of best practices, leverage partnership opportunities and collectively address the challenges in the community related to COVID-19. To achieve these goals, coordination between the County of San Diego and community partners was essential to form a comprehensive network to effectively reach communities who are disproportionately affected by COVID-19. The CHWCOS partners were brought on as representative of healthcare, academia, and other entities who serve communities who had been disproportionately affected by COVID-19. The County of San Diego provides a digital space for all CHWCOS partners, along with CHW Contact Tracing partners to gather and share ideas, bring community perspectives, share challenges, solutions and successes, and provide feedback to the County and each other for the improvement of ongoing COVID-19 outreach and education efforts.

Community partners are the backbone to the CHWCOS project. The County of San Diego provides overarching strategy and COVID-19 factual information, but entrusts the partners with the method of distribution and forming partnerships on the ground.  The County team requests partner input related to logistics such as frequency of meetings, topics of discussion, meeting structure, and overall approach to better respond to the COVID-19 pandemic in a manner that resonates with all San Diego residents.

The CHWCOS Contractors role in the implementation process consisted of continuous feedback regarding County developed COVID-19 materials and guidelines to best improve outreach and education in a culturally and linguistically appropriate manner.

To foster collaboration with community partners, the weekly Collaborative meeting serves as a weekly digital platform to encourage cross-collaboration amongst partners and the County of San Diego. In addition, a distribution e-mailing list was created to continue ongoing conversations outside of the Collaborative meetings. A Microsoft Teams channel was created to share ideas, upcoming events, announcements, and resources.

Through the fostered collaboration, open communication, and built successful partnerships within the CHWCOS Contractors and the County of San Diego have led to the expansion of tailored outreach and education efforts. Partner Connect, a 30-minute additional dedicated space after the meeting has advanced trust among the CHWCOS Contractors and the County of San Diego to discuss challenges and explore solutions. For example, expressed concerns about long lines and safety concerns regarding County COVID-19 testing sites. As a result, the County of San Diego adjusted their approach related to the County drive up testing sites by temporarily requiring an appointment to reduce wait times and ensure safety.

Many new partnerships have emerged to plan and implement this practice. CHWCOS partners were encouraged to subcontract and/or form partnerships with organizations who work closely with the affected communities. Partners have brought on other small non-profits, community-based organizations and ethnic community-based organizations (ECBOs) to help communicate and outreach to the different populations that make up San Diego County. These partnerships benefitted the process by bringing on their expertise and knowledge of the population they served. Partners were able to bridge the gap in knowledge and keep their communities informed in a trauma-informed manner. They were able to provide feedback to the County on what communities need most, what resources are lacking, and the information they need. This knowledge has helped the County better strategize messaging and communication efforts, and in turn, the County has been able to provide partners resources and information to help the families that they serve.

To keep a health equity lens, strategic partnerships included the active participation of all CHWCOS partners, who provide digital community events and other online communication tools to offer an opportunity for community members to ask questions, express their concerns, and provide their feedback related to COVID-19 related efforts in their own language, and to CHW peers who may have similar background or experiences, which foster understanding and trust. Collaboration with the seven CHWCOS partners provide information in over 19 languages and serve those San Diego residents from different countries of origin.

As COVID-19 incidence cases increased as indicated by data provided by the County of San Diego Epidemiology branch, the Collaborative quickly adapted and continues to adapt to meet the needs of the target population. CHWCOS Contractors ensured their CHWs represent the cultural and linguistic diversity of San Diego County. To ensure underserved communities are being reached, CHWCOS Contractors assessed their workforce to ensure CHWs are representing the communities most in need based on data provided by the County of San Diego. The practice also adapted using different digital tools to increase collaboration. Due to the inability to connect in person, the Collaborative established and provided an opportunity for contracted partners to connect. For example, Zoom was utilized for weekly meetings and dedicated space for partners to share best practices and bring forth community concerns. To adequately meet the needs of the communities being served, Jamboard, a digital interactive whiteboard system was introduced to Collaborative to gather live feedback on processes, guidelines, material development, etc. The use of Microsoft Teams, a chat-based collaboration platform for document sharing, and other useful features was used to further encourage communication between contracted community partners.

As challenges arose, different experts and County departments were invited to Collaborative meetings to answer questions quickly. For example, the Test, Trace, Treat (T3) team began attending meetings as more questions arose regarding testing facilities and capacity. Medical experts and communications/media staff are a large part of the meetings, so partners may hear the latest medical updates and ensure communication is streamlined.

At the request of the partners, a Partner Connect space was formed, where partners had the opportunity to connect with each other, talk about challenges and solutions, brainstorm different ideas on reaching different demographics and work together on projects. 

To reduce inequitable health outcomes, the development of materials and messaging takes into consideration racial, ethnic, and diverse cultural populations and backgrounds, language, diverse age groups, and rural communities, and other experiences each community may have. Populations of focus were determined based on COVID-19 data provided by the County of San Diego Epidemiology branch. Additionally, CHWCOS partners are able to conduct services in English and at-minimum 19 non-English languages which include the five threshold languages of San Diego County (English, Spanish, Arabic, Vietnamese, Tagalog). To address hard to reach individuals who may have been exposed to COVID-19, the CHWs conducted home visits to connect, educate, and provide resources throughout San Diego County. The weekly Collaborative meeting serves as a forum to share and promote established County programs, such as the Temporary Lodging program and COVID-19 testing sites to help reduce the spread of COVID-19. Other tools include the CHW resource guide, a guide developed to provide the CHWs an outline of the frequently requested services in the community. This guide serves as a quick reference of resources available in the region. The guide highlights the most current resources such as food distribution sites, housing information, and financial assistance opportunities.

To maintain the practice, dedicated County of San Diego staff provided support in several ways which included direct support, programmatic knowledge, and guidance. Adaptability was critical to the practice to support communities who are disproportionately affected by COVID-19. Also, the value of continuous partnerships and acceptance of feedback was important to improve programs and/or established guidelines to best meet the needs of the communities being served. The CHWCOS project was a bottom-up effort that was driven by the community and community partners, utilizing the expertise of those working closest with residents to assist the County in providing quality services.

Post-pandemic, the integration of various features of the practice is anticipated to be applied and adapted in other County of San Diego programs to tailor programs and projects to the unique needs of the diverse population of the County. Aspects that will be sustained are encouraging subcontracting of CBOs, ECBOs and local service-providers, ensuring translation is accurate and culturally appropriate, and continually collaborating and bringing partners together to share best practices. This practice can be put into place beyond COVID-19, and will be utilized to address health disparities in San Diego County. Partnering and working closely with local providers to disseminate information in a culturally and linguistically appropriate manner is crucial to health education and disease prevention. Programs will continue to work closely with local constituents and continually receive feedback and implement improvements to best serve the community.

CHWCOS partners supplement existing County of San Diego outreach and education efforts by adopting the CHW model and engaging CHWs to serve as a liaison/link/intermediary between health services and the community to facilitate access to services and improve the quality of service delivery and ongoing epidemiology disease investigations that help control the community spread of COVID-19. The CHW model expands the County of San Diego’s health strategy in protecting public health in communities adversely impacted by COVID-19 and other public health concerns.