Pima County Health Department (PCHD), located in Southern Arizona, serves a population of approximately 1 million people, centered around Tucson’s metropolitan area and rural populations.  About 51% of the population is White, 38% Latinx, 4% Black, 4% Indigenous, and 3% Asian. Since the mid-1980’s, Pima County is home to approximately 12,000 resettled refugees. Approximately 50% of refugees speak one of four languages (Arabic, Somali, Nepali, Swahili). 18.3% of people live below the federal poverty line, higher than the national average. 

COVID-19 disproportionately impacts communities of color in Pima County. PCHD partnered with the International Rescue Committee (IRC), a non-profit working with refugees, to create the Mitigating COVID-19 in Communities of Color (MC3) program. 

 The MC3 program aims to increase access to COVID-19 testing for communities of color, provide care coordination and case management services, and provide community messaging around key topics.

 To date, the MC3 program has tested 6121 people across 30 sites. The top 5 zip codes served correspond to areas with the highest social vulnerability index scores. 56% of people receiving testing identify as Latinx (38% of the county population), 31% White (51% of the population), 4% as Black (equivalent to the population), 3% as Asian (equivalent to the population), and 1% Indigenous (3% of the population), with 5% Unknown. 

 The care coordination team at PCHD has served 4817 individuals, with 46% identifying as Latinx.

To date, MC3 developed 8 educational flyers, translated into 8 languages, and testing flyers, translated into 11 languages. MC3 also developed scripts to provide consistent COVID-19 guidance and health education.

 Factors leading to success include:

Collaboration with the IRC

The IRC provides strong partnership and technical expertise in reaching target populations.

Community Health Workers (CHWs)

CHWs build trust with communities. CHWs are from communities of color and speak a variety of languages.

The program takes steps to reduce inequities, including:

Training

CHWs undergo extensive training, including on implicit bias, health equity, CLAS standards, psychological first aid, and Johns Hopkins University COVID-19 training.

Prioritized Testing 

CHWs review Social Vulnerability Index and COVID-19 hotspot data to identify key testing sites. IRC also engages refugee resettlement agencies, community leaders, and partnering organizations to identify priority testing areas. Joint IRC and PCHD logos are displayed at testing sites to minimize mistrust of government agencies utilizing IRC’s name recognition as a trusted provider in refugee communities. Testing is free, minimal identification is required, walk-up only, and interpretation services provided to eliminate barriers to care. 

Targeted Outreach

Focus groups with communities of color revealed that family is the primary motivating factor for COVID-19 testing. MC3 developed “Get Tested. Protect Your Family.” materials featuring photos of refugee families getting tested. 

Culturally Competent Care Coordination 

 MC3 supports culturally and linguistically isolated refugee families in complying with isolation and quarantine directives. IRC provides case management services to address food insecurity, medical care, financial assistance, and mental health.

 The program will reduce COVID-19 inequities for communities of color. The program aims to serve as a model of equitable public health practice.   

COVID-19 has caused profound social and economic disruption across the globe and has long-ranging implications for the well-being of impacted individuals, families, and communities. In Pima County, the areas with the highest COVID-19 cases and deaths are the same areas with the highest Social Vulnerability scores, poverty rates, and concentrations of people of color. The county’s sizable refugee population - 12,000 resettled refugees since the mid 1980’s – also faces significant barriers due to COVID-19. An assessment conducted by the International Rescue Committee (IRC), a non-profit dedicated to serving resettled refugees, identified limited transportation options, unemployment, food insecurity, inadequate housing, lack of understandable information, limited English language ability, and stigma/historical trauma related to medical testing and treatment as barriers faced. The county’s higher-than-national-average poverty rates (18.3%) and low overall educational attainment create barriers to internet access, health literacy, and transportation needed to schedule and keep COVID-19 testing appointments. Given Pima County’s location in the U.S.-Mexico border region, bilingual/bicultural services are also needed. 

Realizing these barriers to testing services, responding to community demand for more testing sites in highly affected areas, and seeing the data showing clear inequities, the MC3 program was created.  Responding to the rapid onset of the COVID-19 pandemic, the MC3 program utilized the expertise of current Pima County Health Department (PCHD) staff seasoned in providing mobile sexual health testing to train in new MC3 staff dedicated to COVID-19 response. The MC3 program converted the county’s sprinter van into a mobile COVID-19 testing unit.

The MC3 program is innovative in working to eliminate barriers to testing services. Modeled off the evidence-based practice of low-barrier testing in the Mission District of San Francisco, the program sought to implement mobile based testing, using the model of place-based testing, testing regardless of symptoms, and connecting people to services needed to weather the pandemic (1). To address barriers such as lack of transportation, cost, lack of internet access, and low health literacy, the MC3 program provides free, walk-up testing with no appointment needed to increase access to testing services. Language access is provided by program staff, who speak 9 languages, and telephonic translation services are also available on site. 

The program also uses an innovative approach to selecting testing sites. The IRC conducted key informant interviews with leaders in the refugee community, refugee resettlement agencies, Ethnic Community Based Organizations, medical providers and partnering organizations to prioritize testing sites. After reviewing COVID-19 hotspot data and Social Vulnerability Index maps, community health workers (CHWs) also created a list of prioritized testing sites. IRC CHWs liaise with refugee and immigrant community leaders to provide COVID-19 health education and establish possible testing sites. All MC3 staff, including CHWs, meet regularly to prioritize testing site selection. 

The program is also innovative by seeking to build organizational capacity. Following best practices, MC3 hired seven CHWs from communities most impacted by COVID-19 across PCHD and IRC (2). CHWs lead the program with their expertise on testing site locations, community contacts, cultural and linguistic knowledge, and ability to create trusting, meaningful relationships with people receiving testing and case management services. CHWs speak Apache, Arabic, English, French, Kirundi, Kinyarwanda, Kiswahili, Nepali, and Spanish, providing culturally and linguistically appropriate services. During both onboarding and at least quarterly, CHWs are also provided with training in key areas, including social determinants of health, health equity, psychological first aid, continued COVID-19 training, cultural competency, ableism, implicit bias, LGBTQ+ identities, and refugee communities.

The program provides innovative, targeted marketing, educational materials, and outreach. Focus groups with communities of color revealed that family is the primary motivating factor for COVID-19 testing. MC3 developed “Get Tested. Protect Your Family.” materials featuring photos of refugee families getting tested. The program also provides books in a variety of languages as incentives, COVID-19-themed coloring sheets centering people of color, and crayons to children at testing sites to engage all members of families. Following best practices for targeted messaging for refugees and individuals with low literacy, the MC3 program revised existing PCHD and Centers for Disease Control and Prevention (CDC) educational materials to include pictorial-based messaging with people from communities most impacted. The program has translated and distributed materials in 8 languages thus far, including information on quarantine/isolation guidance, social distancing, wearing a mask,  handwashing,  managing symptoms, local housing resources, and holiday guidance. Apart from solely advertising on the PCHD website, the MC3 program seeks to truly center communities of color by tapping into existing partnerships. The MC3 program advertises testing sites via IRC/PCHD social media, partnering agencies’ listservs and social media, refugee WhatsApp groups, AmeriCorps listservs, neighborhood coalitions, multilingual canvassing of apartment complexes, religious centers, ethnic markets, and other targeted locations, and texting and calling refugee clients. The program has made 198 calls and sent 545 texts in 10 languages alerting communities to testing services thus far. CHWs also conduct outreach via door knocking during testing events to engage the local community. IRC has also translated safe holiday guidelines and face mask and curfew mandates and sent this information via text to 433 refugee/immigrant households. 

The program innovatively addresses the upstream social determinants of health, including housing and food security. Partnering with the Ending Poverty Now program in the Pima County Community Workforce Development Department, the MC3 program provides eviction prevention information at all of its testing sites. MC3 staff also attend weekly county-wide eviction prevention meetings. The MC3 program has partnered with Heirloom Farmers Market and the Community Food Bank of Southern Arizona to distribute farmers market vouchers at all testing sites, redeemable for $5 at sites across the county, to reduce food insecurity and increase access to healthy food options. IRC has also partnered with Tucson Food Share, the Community Food Bank, and Pivot Produce to deliver food to MC3 IRC Care Coordination enrollees who are COVID-19 positive and must abide by isolation guidelines. 

Sources:

 1. Initial Results of Mission District COVID-19 Testing Announced. https://www.ucsf.edu/news/2020/05/417356/initial-results-mission-district-COVID-19-19-testing-announced)

2.  Rosenthal EL et al. Community health workers: part of the solution. Health Aff (Millwood). 2010 Jul;29(7):1338-42. doi: 10.1377/hlthaff.2010.0081. PMID: 20606185.

The impact of the COVID19 pandemic requires a response equal to the challenge. With the disproportionate effects of the COVID-19 epidemic on vulnerable and marginalized populations, Pima County Health Department (PCHD) partnered with the International Rescue Committee (IRC) to develop a three-pronged strategy to rapidly react to the challenges of COVID19. The strategy focused on increased access to COVID-19 testing for communities of color, the provision of resources for individuals and families of highest need, and wide-spread multilingual community education.

MC3 originally set a goal of testing 2000 individuals via a mobile testing program. PCHD identified sites via existing community partnerships and IRC identified sites through key community contacts serving the refugee and immigrant community. PCHD utilized the county’s mobile sprinter van to reach the most vulnerable communities where they are at. Sites were advertised on the county website, via partnership channels, and via texting/social media campaigns.

During the planning process, the IRC, as PCHD’s community partner in the MC3 program, co-authored the program plan, collaborating to write the goals and objectives of the program. The IRC also led the direction of testing by identifying and prioritizing sites. The IRC interviewed key community leaders in refugee communities to identify sites. The Pima County Faith-Based Coordinator also collaborated with community faith-based organizations to identify sites for testing. During the implementation process, in order to focus on the upstream social determinant of health, strategically advance equity, and incentivize testing, MC3 partnered with AZ Health Zone, part of The University of Arizona Cooperative Extension, Heirloom Farmers Markets, and Community Food Bank of Southern Arizona to offer farmers’ market vouchers to attendees at all COVID-19 testing sites. 

For care coordination goals, PCHD first identified a short-term goal of partnering with 95 local agencies to build a secure care coordination database and system that offers free social, health and community resources for COVID19 patients and their families. The system includes food banks, mental health services, telehealth services, visiting nurses, and other community programs. The care coordination system was then aligned with PCHD’s contact tracing program to ensure that county residents reached by contact tracers would have equitable access to appropriate care and social services, as well as to incentivize individuals to participate in contact tracing. The system was also designed to track important demographic and social-need data that was then aggregated, mapped, and shared with county officials and community agencies to assist in identifying neighborhoods of highest need for free mobile testing and the provision of needed resources. 

During the development of the resource database, PCHD simultaneously partnered with the IRC to create a system for connecting individuals (whose primary language was not English or Spanish) with a case manager who provided culturally sensitive services tailored to the individual’s unique social, educational and economic needs. IRC’s MC3 Case Manager and Care Coordination Specialist provide rapid case management services and assist clients based on services requested during an initial intake. Services include food delivery, hygiene supply delivery, assistance applying for public benefits, provision of direct financial assistance, assistance applying for rental and utility assistance, health education, health literacy training, and medical and mental health care coordination.  

As the crisis continued, weekly calls were held with community partners to share data and trends, establish new goals, and identify new resources. New partners were also recruited as the need for new resources arose. For example, free legal services and discounted internet service needs led to the recruitment of representatives from Step Up To Justice and Cox Internet to join the care coordination team. The care coordination team also partnered with The University of Arizona UNIDOS program to connect interested participants to community health workers for long-term follow-up. 

In addition to partnerships with the IRC, The University of Arizona, local farmers markets, and faith-based organizations, PCHD also actively seeks to engage the community. The MC3 Program Manager participates in biweekly community engagement listening sessions to engage members of the community. Feedback from community members drives program implementation and quality improvement. Members in the community engagement group represent a variety of sectors including education, immigration, religious groups, non-profits, and government. Most of the members are people of color and reside in zip codes most heavily affected by COVID-19. 

Seeking to expand testing and care coordination, advance equity, and further center Indigenous communities, PCHD formed an unexpected partnership with the Tohono O’odham Nation. The MC3 program worked with PCHD’s Tribal Nations liaison to establish a partnership with Tohono O’odham Nation to offer mobile testing on the nation. Working alongside the Tohono O’odham Nation Emergency Operations Center staff allowed the MC3 program staff to incorporate improvements in testing site workflows, including a “pre-check” station with temperature checks. Tohono O’odham Nation staff reported improving the registration process based on requested technical assistance from MC3 staff. Working with Tohono O’odham Nation also allowed targeted outreach to Indigenous communities - communities historically and contemporary underserved in Pima County.   

Moving forward, the MC3 program seeks to broaden its community engagement. The program is developing a community stakeholder survey to recruit stakeholders for a vaccine advisory group. MC3 is also developing a monthly newsletter for partners and plans to create weekly updates on testing site data. While CHWs currently liaise with community leaders to identify any COVID-19 health education needs within their community, CHWs will further offer COVID-19 health education classes via a virtual setting based on community stakeholders requests. Seeking to further expand testing services to Indigenous communities, the program is currently formalizing a partnership with Tucson Indian Center. 

Program improvements allow MC3 to continue offering high quality testing and care coordination services. As the COVID-19 pandemic surges, the MC3 program continues to refine parameters for testing site prioritization. Originally focused on testing sites identified from Pima County Health Department (PCHD) staff, the program realized a more targeted approach needed to be made to center communities of color. The program shifted to utilizing a data-driven approach, with hotspot data and Social Vulnerability Index maps used to identify areas most affected by COVID-19 for testing. The program also used community-driven site selection, with community health workers (CHWs) and the International Rescue Committee (IRC)’s community partners identifying sites. As testing site data reveals favorable outcomes in targeting Latinx communities, but less success in reaching Black and Indigenous populations, the MC3 program continuously refines testing site selection processes to reach these communities. Improved data collection methods via the county’s electronic health record system will also allow the program to track language spoken by people receiving testing services, a proxy to measure and further refine efforts to reach refugee and immigrant communities. 

In addition to site prioritization, as testing COVID-19 cases surged, the program adapted by scaling up testing, including increasing staffing capacity, outreach materials assembly, and testing site frequency, to continue providing mobile testing to marginalized populations. From serving 68 people at its first event, the program tested 456 people at its peak, surpassing its original goal of serving 2000 people by 306% since July, 2020. To respond to the demand, testing sites now offer extended hours (six hour events rather than four) and staff have been increased from six to eight per testing event. Additional CHWs hired by IRC as well as prioritizing grant funds for staffing at testing events allowed staffing levels to increase.  

The MC3 program has used data to continuously refine its care coordination services. Since the start of the program, the MC3 program has collected data on referrals provided by the Care Resource Coordination team. This ongoing quantitative data collection allows the program to be agile as needs change during the pandemic progression. In fact, the program pivoted early on to include a more robust system of resource linkages beyond solely financial assistance, including food distribution, mental health services, COVID-19 hygiene kits, healthcare services, and more, that would empower those needing to quarantine to do so safely. Integrating both PCHD and IRC care coordination into PCHD’s contact tracing program now ensures that everyone called by PCHD contract tracers has equitable access to affordable, culturally and linguistically appropriate care and social services in a timely manner. 

To continuously improve education and outreach to priority populations, the MC3 program works to refine outreach strategies and education provided at testing sites. To prioritize the most effective outreach strategies, the program adapted registration sheets at testing to collect data on how individuals learned about the testing site. The program continues to refine data collection methods to most effectively guide program decisions. Additionally, the program continuously improves educational messaging to communities. Since the start of the program, MC3 developed talking points for staff to provide unified messaging to the public around COVID-19 during testing events. The program also developed an onboarding guide for program staff, with specific COVID-19 training provided by the Arizona Community Health Workers Association. To center equity, the onboarding guide also includes information on social determinants of health, implicit bias, ableism, LGBTQ+ communities, and health equity.

Existing resources provided through PCHD were enhanced with grant funds from the CDC’s Enhanced Laboratory Capacity program, which allowed staffing and resources to increase proportionate with community need. PCHD will continue to fund CHW positions beyond the grant period as a best practice, and will continue to enhance the program with supplemental funding as needed. The IRC has also secured additional funding to hire a staff member dedicated to holding focus group discussions to collect community feedback on outreach and educational materials to further refine targeted messaging. 

Beyond the COVID-19 pandemic, the MC3 program will continue to impact public health practice via lessons learned and sustained impact. Lessons learned include the importance of engaging communities themselves, including CHWs, for strategic prioritization of services and outreach; the importance of being able to swiftly and agilely shift priorities, especially during a pandemic; the importance of continuously refining data to most effectively capture program outcomes and guide decision making; and the need to continuously focus on organizational capacity of staff. As the PCHD MC3 program is housed in the Community Outreach, Prevention and Education (COPE) Division of the Health Department, a division responsible for programs involving community outreach and collaboration, aspects of the MC3 program will continue to be sustained. A focus on reducing inequities, targeted outreach to communities of color, and community engagement practices will all carry forward into additional divisional and departmental programming. The program onboarding guide will continue to be adapted for additional programs as a model for centering health equity in new staff training. The technical assistance and partnership formed with the IRC ensures that culturally and linguistically appropriate educational materials will continue to be developed using best practices for refugee and immigrant communities. MC3 aims to form the MC3 Community Partnership Group, a network of program stakeholders, to continue serving as a community advisory group for PCHD programmatic activities beyond the pandemic. 

In addition to reducing inequities in COVID-19, the MC3 program will have lasting effects beyond the pandemic. The program’s focus on addressing the upstream social determinants of health, prioritizing communities of color, and reducing inequities is a step in undoing systemic harms and creating equitable health outcomes for all.