Implementation of a volunteer contact tracing program for COVID-19 in the United States: A qualitative focus group study.

BACKGROUND: Contact tracing is an important tool for suppressing COVID-19 but has been difficult to adapt to the conditions of a public health emergency. This study explored the experiences and perspectives of volunteer contact tracers in order to identify facilitators, challenges, and novel solutions for implementing COVID-19 contact tracing.
METHODS: As part of a study to evaluate an emergently established volunteer contact tracing program for COVID-19 in New Haven, Connecticut, April-June 2020, we conducted focus groups with 36 volunteer contact tracers, thematically analyzed the data, and synthesized the findings using the RE-AIM implementation framework.
RESULTS: To successfully reach cases and contacts, participants recommended identifying clients' outreach preferences, engaging clients authentically, and addressing sources of mistrust. Participants felt that the effectiveness of successful isolation and quarantine was contingent on minimizing delays in reaching clients and on systematically assessing and addressing their nutritional, financial, and housing needs. They felt that successful adoption of a volunteer-driven contact tracing model depended on the ability to recruit self-motivated contact tracers and provide rapid training and consistent, supportive supervision. Participants noted that implementation could be enhanced with better management tools, such as more engaging interview scripts, user-friendly data management software, and protocols for special situations and populations. They also emphasized the value of coordinating outreach efforts with other involved providers and agencies. Finally, they believed that long-term maintenance of a volunteer-driven program requires monetary or educational incentives to sustain participation.
CONCLUSIONS: This is one of the first studies to qualitatively examine implementation of a volunteer-run COVID-19 contact tracing program. Participants identified facilitators, barriers, and potential solutions for improving implementation of COVID-19 contact tracing in this context. These included standardized communication skills training, supportive supervision, and peer networking to improve implementation, as well as greater cooperation with outside agencies, flexible scheduling, and volunteer incentives to promote sustainability.

Background

The arrival of the coronavirus disease 2019 (COVID-19) pandemic in the US will be long remembered for its suddenness and severity. In the first six months following its arrival in the US [1], there were over three million cases and over 100,000 deaths [2]. As vaccine hesitancy and new viral variants raise the possibility that COVID-19 will become an endemic disease, contact tracing will continue to play a critical role in suppressing local epidemics and lessen the need for stay-at-home orders or other forms of strict physical distancing restrictions. However, the magnitude of the COVID-19 crisis and rate of its spread throughout the US has posed a challenge to implementing contact tracing at the required scale [3]. The high reproductive number [4], lengthy incubation period [5], frequency of pre-symptomatic transmission [6, 7], occurrence of super-spreader events [8], and large proportion of asymptomatic cases [9] have set COVID-19 apart from most other infectious diseases for which contact tracing is used, such as foodborne illnesses [10, 11], sexually transmitted infections [12], tuberculosis [13], and others [14-16]. These, the defining characteristics of the COVID-19 pandemic, have ensured that there would be huge numbers of cases and contacts and a resulting need for extremely large tracing workforces to investigate exposures and interrupt the many chains of transmission [17, 18]. Meanwhile, the lack of feasibility and acceptability of the best alternative, digital contact tracing, has ensured that person-led strategies will likely remain the first-line approach in most settings [19].

In response to these challenges, many states and local health departments rapidly expanded capacity for COVID-19 contact tracing early in the pandemic [20]. Massachusetts, Ohio, Indiana, and Maryland partnered with vendors to facilitate the hiring and management of thousands of new contact tracers, while Washington, Alabama, California, and Tennessee reassigned state employees to this role. Some states such as Rhode Island, West Virginia, North Dakota, and Washington activated their National Guard, and still other states engaged volunteers to fill the role of contact tracers, including Oklahoma, Kansas, Michigan, Arizona, and Connecticut. Learning from prior efforts is paramount given the continued role that contact tracing will play in helping us exit the pandemic.

Implementation science frameworks can aid in systematically identifying and understanding the relationships between factors that influence implementation successes and failures. The RE-AIM framework has been employed extensively for this purpose [21, 22] and contains five dimensions: (1) reach, which focuses on the population an intervention targets and the process of engaging them, (2) effectiveness, which focuses on the intended impact of an intervention and potential barriers to that impact, (3) adoption, which focuses on the setting and individuals delivering the intervention, (4) implementation, which focuses on intervention protocols and strategy, and (5) maintenance, which focuses on intervention sustainability and scalability. Because volunteers were and still are key stakeholders in many contact tracing programs, learning about their experiences is vital for sustaining and scaling up contact tracing. To this end, we conducted focus group discussions (FGDs) with volunteers participating in a contact tracing program in Connecticut. We sought to characterize their perspectives and experiences using the RE-AIM framework in order to understand facilitators of, barriers to, and potential solutions for improving implementation.

Methods

This qualitative study was part of a larger multiple methods evaluation of a volunteer-driven contact tracing program established in a partnership between the New Haven Health Department, hereafter referred to as the “Health Department”, and Yale School of Public Health (YSPH) in March 2020. We report our methods below in accordance with the Consolidated Criteria for Reporting Qualitative Research (CO-REQ, see S1 Table).

Setting and procedures

New Haven is home to nearly 130,000 residents and is part of the New York Metropolitan area. The Health Department established a partnership with Yale University for volunteer contact tracing on March 27, 2020, as previously described [23]. Briefly, over 150 volunteer students, staff, and faculty from Yale’s public health, medical, physician assistant, and nursing programs participated in the program. Volunteers began making contact tracing calls on April 4, 2020, prior to New Haven’s initial peak of COVID-19 cases around April 21 [24]. In mid-April, the Health Department assigned 40 public health nurses to assist with contact tracing. By mid-May, the program had responded to over 2,000 lab-confirmed cases of COVID-19.

Volunteers worked remotely and were divided into two teams. One team (“case investigators”) interviewed cases to identify contacts and counsel self-isolation, while the other team (“contact notifiers”) notified contacts about their exposure to COVID-19 and recommended self-quarantine. The case investigation team was supervised jointly by the Health Department and YSPH, and the contact notification team was supervised by YSPH faculty and staff. Volunteers participated in a one-hour, virtual training session on contact tracing that covered US Centers for Disease Control and Prevention (CDC) guidelines [25], local case- or contact-specific protocols for implementing contact tracing, and regulations for protecting confidentiality. All case investigator volunteers received training on basic communication and interviewing skills, except medical students who all had prior training in this area. Volunteers used email and GroupMe (Microsoft, New York, NY), a mobile group chat application that hosts discussion threads, to communicate with supervisors or other team members as needed.

Each day, the Health Department’s lead epidemiologist identified new positive COVID-19 cases from the state’s reportable disease database and shared their corresponding outreach information with the case investigation team. Case investigators used New Haven’s existing emergency management software (Veoci, New Haven, CT) to record call attempts and responses to the interview questions. The case investigator team shared a daily list of reported contacts, without any information regarding their respective cases, with the contact notification team via email. This team then used a free-text template (Microsoft Word, Redmond, WA) to record notes and outcomes of call attempts to contacts. These data were then entered into a master spreadsheet (Microsoft Excel, Redmond, WA) by volunteers assigned to data management tasks. Case investigators routinely asked cases about food or housing insecurities, ability to isolate within homes, access to medical care, and other social needs, while providing numbers to local support organizations or free clinics when applicable. Contact notifiers also provided links to resources when applicable but did not routinely assess contacts for the same needs. Team leads communicated changes in guidelines and protocols to volunteers via email and modified data collection forms appropriately.

Eligibility and recruitment of volunteers

Eligibility criteria included being a volunteer in the case investigation or contact notification teams. We excluded the less experienced case investigators, defined as being in the lowest 25th percentile of total case assignments (<7 assignments). We did not exclude any contact notifiers because all assignments were distributed equally among this team, whereas case investigators were able to adjust their availability each week. We emailed invitations to all eligible volunteers to participate in the study. We set an initial recruitment goal of 18 participants from each team based on estimates of the number of focus groups required for thematic saturation [26]. We enrolled participants consecutively until the target sample size was reached, ensuring balanced representation of volunteers from different schools and university positions (i.e., students, faculty, and staff).

Data collection

Three members of the research team (TS, a male MD/PhD student; KC, a female research associate with a master’s degree in public health; LG, a female social scientist and faculty researcher with a doctorate in psychology) conducted the focus groups. KC and LG led the case investigation discussions as moderator and scribe, respectively. TS and LG led the contact notification discussions, each serving as moderator or scribe. All had previous training or experience in conducting qualitative interviews. Because several participants knew TS as a fellow student and volunteer assistant coordinator of the case investigation team, he participated in the contact notification FGDs only. All participants were informed at the start of the discussions of the researchers’ role in evaluating the volunteer contact tracing program. The FGDs were held via videoconferencing (Zoom, San Jose, CA) and conducted separately for case investigators and contact notifiers. The semi-structured FGD guide, developed around our primary purpose statement, included four domains: 1) experiences volunteering with the program, 2) successes and challenges related to contact tracing activities, 3) training and unforeseen experiences, and 4) perspectives on how to improve and sustain the program. After each FGD, participants received a follow-up survey inviting them to provide demographic information and any additional thoughts or comments they had.

We transcribed session recordings using an automated transcription service (Trint, London, United Kingdom). Additional researchers (AM, RH, CS) reviewed transcripts for accuracy against the audio and video recordings. Two moderators (TS and LG) iteratively assessed the content of case investigator sessions until no new themes emerged (i.e., saturation had been reached), and separately followed the same process for contact notifier sessions [26]. We did not conduct follow-up interviews or discussions and did not have participants review the transcripts.

Analysis

The coding team (TS, RH, LG) independently reviewed one case investigator and one contact notifier transcript and met to discuss and develop the codebook inductively. They discussed and resolved all coding discrepancies by consensus. Once acceptable inter-coder agreement [27] was reached, TS and RH divided the remaining transcripts and free-text responses from the follow-up surveys between themselves for independent coding. The full coding team continued to meet regularly to resolve any remaining coding questions. The coding team initially used Microsoft Word for coding, and the data were subsequently entered into ATLAS.ti (Version 8, Berlin, Germany) and analyzed iteratively using thematic analysis [28]. Study participants did not provide feedback on the findings.

After the themes had been identified, we used the RE-AIM framework [21, 22] to deductively organize emergent themes. We assigned themes related to contacting and engaging clients to the reach dimension, challenges to achieving public health outcomes (i.e., isolation for cases and quarantine for contacts) to the effectiveness dimension, volunteer delivery of the intervention and the setting in which they operated to the adoption dimension, and feasibility and acceptability of the program to the implementation dimension. The final theme concerning the sustainability of a volunteer-driven contact tracing program was assigned to the maintenance dimension. Once organized according to the RE-AIM framework, we identified specific barriers, facilitators, and solutions within each RE-AIM dimension.

Ethics statement and consent procedures

The study protocol was approved by the Yale Human Subjects Committee (Institutional Review Board Panel A for Social, Behavioral, and Educational Research) and the New Haven Health Department. A waiver of written consent was approved by the Human Subjects Committee because the study posed no greater than minimal risk and did not involve any procedures that would require written consent in a non-research context. Before video-recording the session, the group facilitators read the consent form aloud and obtained verbal consent from all participants to be in the study and be recorded.

Results

Characteristics of the study sample

At the time of study recruitment, there were 106 case investigation volunteers and 36 contact notification volunteers involved in the program. We emailed 83 eligible volunteers from the case investigation team and 36 from the contact notification team, excluding 23 case investigators who made too few calls. We consecutively enrolled all participants who replied to the initial recruitment emails, sending reminder emails until we recruited a sample of 18 participants from each group. The six FGDs (three with case investigators and three with contact notifiers) ranged from 73 to 85 minutes in duration and occurred May 6–12, 2020. Six participants attended each session. Table 1 describes the sample characteristics. School affiliations within the sample were similar to the those on the volunteer team overall, with a slightly lower representation of nursing students and a higher representation of faculty and staff in the study sample.

Table 1

Participant characteristics.

Characteristics	Case Investigators (n = 16) *	Contact Notifiers (n = 17) *
	n (%)†	n (%)†
Age, median years (Q1, Q3) §	28 (27, 29) §	25 (22, 28) §
Female	12 (75)	14 (82)
Race/Ethnicity
Non-Hispanic White	12 (75)	13 (76)
Asian	3 (19)	1 (5.9)
Hispanic/Latinx	1 (6.3)	3 (18)
University Affiliation*
Public Health Student	6 (33)	16 (89)
Medical Student	9 (50)	0 (0)
Nursing Student	1 (5.6)	0 (0)
Post-graduate	1 (5.6)	0 (0)
Faculty / Staff	1 (5.6)	2 (11)
Bilingual¶	3 (0.19)	3 (0.18)

*Only 33 of the participants completed the follow-up demographic surveys, thus demographic and language information about three participants is not included in this table. University affiliation was available for all participants.

† Unless otherwise specified.

§ Median (quartiles 1 and 3).

¶ Conducted interviews/notifications in Spanish in addition to English.

Identified themes

We identified 12 themes across the five RE-AIM dimensions. There were no differences in themes expressed by volunteer type or by participant demographics or between the FGDs and follow-up free-text surveys.

Reach dimension

We identified two themes, Making Contact and Establishing Rapport, under the reach dimension. These captured volunteers’ experiences attempting to get in touch with and engage the target population.

Making contact theme

Participants detailed their experiences calling and attempting to reach cases and contacts and described the challenges they faced with this early step of the contact tracing process. They noted the difficulty in getting the target individuals to answer their calls and reported that it was rare for their unanswered calls to be returned. However, some succeeded by either leaving voicemails or using text messaging in addition to voicemails.

“The hard part is getting them on the phone in the first place, to answer the phone or return the voicemail.” (Participant 1:6, Case Investigator)

“When they don’t have [a voice mailbox], I’ve just been sending them a text with information from the callback scripts. I don’t know whether that is appropriate or inappropriate, but I felt that that would be how I would want to get the information.” (Participant 5:1, Contact Notifier)

Several also noted that calls made in the afternoon or evening were more likely to be answered than those made in the morning.

“I found that a lot of cases don’t like being called in the morning. As I started, I would call at 9:00 or 10:00 in the morning, cause I just felt like maybe that would be a reliable time to get people and was also convenient for me. More than once I was basically told [by cases] ‘don’t call before noon.’ So, I no longer call before noon.” (Participant 1:5, Case Investigator)

Establishing rapport theme

Volunteers repeatedly emphasized the importance of engaging with clients authentically. Participants felt that finding the most convenient times for the conversation, showing empathy, and addressing sources of mistrust were effective in building trust and rapport. Some volunteers developed these approaches by drawing on prior experiences in patient care or other client-related work, while others did so by trial and error.

“I’ve personally gotten a few of those calls where they don’t appreciate the call. They don’t want to talk to you. It’s been interesting [figuring out] how exactly do you handle those, because at first, I was really nervous making those calls but now it’s been a lot more natural and it’s been a very interesting process, kind of learning how to do that.” (Participant 6:5, Contact Notifier)

“I think that’s why it’s so critical to have been in the health care profession beforehand, because a lot of these questions are very sensitive, and you have to kind of know how to deal with that and make it okay. So, I would say yeah, training through med school has helped.” (Participant 1:2; Case Investigator)

Some call recipients seemed suspicious of callers, and participants occasionally felt “awkward” trying to convince these individuals that they were authorized representatives of the Health Department. Others described the process of eliciting information about contacts from cases as particularly difficult because many cases either felt uncomfortable providing or simply did not know the necessary information about their contacts. One participant stated that a few cases disclosed their status as undocumented immigrants and were fearful about providing information about themselves or their contacts. Despite these challenges, participants stated that most cases and contacts appeared to be “very receptive” to providing information and following the recommended guidelines.

“People are very guarded about who’s in their house…But I think half the time it’s the person. They’re just a little bit wary. And half the time it’s just the situation. Like, they would love to tell you, but they’re also scared. And the other portion of the time people are just really open and they’re trusting and then it’s not a big deal.” (Participant 1:2, Case Investigator)

Effectiveness dimension

We identified two themes within the effectiveness dimension, Delays and Community Needs. Both concerned barriers to achieving the desired outcomes of isolation for cases and quarantine for contacts.

Delays theme

Participants discussed several types of delays that prevented them from reaching cases and contacts within an epidemiologically relevant timeframe. There were delays in receiving test results and delays when a volunteer could not speak the client’s preferred language, requiring reassignment to a volunteer proficient in the preferred language on the following day. These delays sometimes resulted in reaching contacts after the two-week window for effective quarantine had expired. Others described the frustration of reaching contacts only to discover that they had already been diagnosed with COVID-19.

“We have no idea when things are getting reported to the state, when the state then goes to the city, when the city forwards that result along to our coordinators, and then when they finally put it on our list…there are some health clinics that seem to be slower reporters.” (Participant 1:5, Case Investigator)

While some delays in the overall contact tracing process were beyond the control of the program, such as cases choosing to delay seeking COVID testing or slow reporting of test results, participants felt that identifying cases in need of translators before the first call was an actionable way to prevent additional delay.

“I know that they’re pulling the data from the state database but having a flag for language would really cut down in terms of time, because we’re talking about an extra 24 hours.” (Participant 4:1, Case Investigator)

Community needs theme

Even when reached in time, participants stated that many cases and contacts indicated that they were either experiencing or expecting difficulties in adhering to isolation or quarantine recommendations. These challenges stemmed from job or wage loss, difficulties providing food for themselves or their families, and for some, a lack of housing. Participants observed that these challenges occurred more frequently among contacts from Hispanic communities and that contact tracing calls provided a unique opportunity to identify additional needs for support or resources.

“I had one case or contact that I called, and they said, ‘There’s no one else in my house who can get groceries. I’m the only one who can go out. I don’t know how we’re going to get food. My husband is very sick and I’m trying to take care of him.’” (Participant 4:5, Contact Notifier)

“When I speak to Spanish-[speaking] contacts…what I hear more often is, ‘I can’t not go to work.’ And I don’t hear that as much when I [call] other contacts that I receive. I just hear people panicking essentially over the phone.” (Participant 5:5, Contact Notifier)

Participants appreciated that the Health Department instructed volunteers to routinely assess these needs and thought many cases and contacts viewed this needs assessment as a sign of the city’s concern for its residents. However, some participants were unsure whether these needs would ultimately be addressed by the city and questioned the utility of assessing needs when they could offer cases and contacts little assurance that the needs would be satisfied.

“The other thing that was added actually fairly recently was [a prompt asking if] they have a need for housing support, food support, financial assistance, any of those things…it just adds a human element to the interview because, by asking that, it shows that we’re not only doing this to use the participants as a source of information, but also we’re here because we care about them as part of the community. So, it adds that element that I think people are very receptive to.” (Participant 2:2, Case Investigator)

Adoption dimension

We identified five themes that fit under the adoption dimension: Volunteer Motivations, Time Management, Knowledge, Skills, and Collaborative Learning. They addressed the dimension’s focus on the individuals delivering the intervention (e.g., what their motivations were for volunteering); the time, knowledge and skills required of those individuals; and key characteristics of the setting in which they functioned.

Volunteer motivations theme

Most participants reported a strong desire to help their community combat the COVID-19 pandemic. The effects of the pandemic had simultaneously suspended in-person classes, clinical training, and routine work, leaving participants feeling idle and powerless. The contact tracing program offered a chance to respond to the pandemic by applying their knowledge and skills as budding or established practitioners, teachers, or researchers in the health sciences. Some noted that the safety of being able work remotely made telephone contact tracing more attractive than other volunteer opportunities that required physical interaction.

“As someone who’s going into this field, I’ve always wanted to do outbreak investigation and outbreak response kind of stuff. And it was really hard to feel powerless. And so, when this opportunity came up, I was like, this is something that I can do, like using my education and my skills.” (Participant 4:1, Contact Notifier)

“I heard about this [volunteer opportunity] and how it could really use the skill sets of people who are trained to interview patients. And I thought that was one of the best ways I could help.” (Participant 1:3, Case Investigator)

Time management theme

Balancing contact tracing duties against other responsibilities was easy for some yet challenging for others. Unpredictable schedules, especially for students during examination periods, made it difficult for some to keep up with their tracing responsibilities. Case investigation volunteers were allowed to adjust their assigned case load every week to match their availability and used this flexibility to better manage their time and level of involvement. In contrast, contact notification volunteers were given fixed case assignments on a rotating basis and noted that their inability to control their workload could be stressful.

“It’s really hard to just get an email all of a sudden [that says] ‘you have to call this person within 24 hours.’ And I wasn’t able to do all of them in the right timeframe because of that. I had too much other work to do.” (Participant 6:2, Contact Notifier)

In addition, participants from both teams reported that the sporadic workflow was challenging. Many said that they felt out of practice making calls after even a few days’ hiatus, while others felt “burnt out” after making many calls in a short period.

“I think the issue is just that the current inconsistency of not being as well-practiced in the ability to do the interview as well as you might have been doing them when you had a more consistent stream of calls.” (Participant 2:1, Case Investigator)

“I found that if I was doing this for four hours a day, I got kind of pretty burned out by it… the next day I was like, I don’t want to do this.” (Participant 2:4, Case Investigator)

Knowledge theme

Participants highlighted the importance of knowing and effectively applying current CDC COVID-19 recommendations and other policies regarding confidentiality and privacy protection. Because the tracing scripts changed frequently during the early phase of the pandemic to meet the changing CDC guidelines, participants found it challenging both to stay current and to feel confident that they were providing accurate guidance to cases or contacts in every situation.

“[CDC guidelines] are very fuzzy and always evolving in terms of the recommendations. That makes it really hard to feel confident in what we’re telling people.” (Participant 2:2, Case Investigator)

They also often found privacy protection policies difficult to apply due to the unique circumstances of each call. Participants said they were often required to speak with family members or other proxies in tense or emotional circumstances when cases or contacts were severely ill or unavailable to speak. A lack of familiarity with navigating and applying privacy policies within these unpredictable scenarios made it difficult for some participants to discern how much information they could appropriately share with proxies.

“More information on [privacy and confidentiality], who we can and cannot tell certain things to, how to deal with proxies. I think that would have been really helpful.” (Participant 3:3, Case Investigator)

In addition, participants occasionally struggled to answer questions from cases about why certain data, such as information about contacts (name, phone number, age, gender) or current health status, needed to be collected. On the other hand, contacts frequently questioned where callers obtained such information. Participants believed that cases were hesitant to provide information when they were unsure what the city would do with it or thought that it would intrude on the privacy of their contacts. Although the importance and utility of each part of the script was covered in the volunteer training, participants felt that providing refresher sessions or opportunities to clarify how data would be used could have increased their ability to adequately answer case and contact questions in order to better promote faith and trust.

“People would ask ‘well, why do you need the information from my husband’s phone number? He’s here. He’s listening to this conversation. He knows that I have COVID and that he’s been exposed to COVID. So now I need to give the health department his phone number [so] that someone else can call him and tell him that I have COVID?’ or, similarly, they’ll say, ‘Oh, everyone knows. I’ve told [my close contacts]. So why do I need to [give you their number]? They wouldn’t want me giving [their phone number] so that you can bother them.’” (Participant 2:2; Case Investigator)

“I got a lot of ‘where’s this data [personal data about the individual] coming from, where are you getting this information?’ And I think it would have been helpful to have known exactly where that information was coming from so that I could have a better answer for that.” (Participant 6:2, Contact Notifier)

Skills theme

All participants strongly agreed that effective communication skills were critical to establishing rapport with those facing a new and potentially frightening illness. Many adapted the interview script to this end. For example, rather than starting with standardized questions about demographics and specific symptoms, several participants found that beginning by asking open-ended questions about the client’s current situation and setting expectations about content and length of the call helped engage some individuals.

“I do a little bit more signposting in the interview than is included in the script. What I mean by that is setting an expectation about what are what are all the things we’re going to talk about…I’ve found that sometimes cases are surprised by how long [the interview] is going, that they start to check out a little bit. Whereas if the expectation is very clear from the get-go, then I think people let their guard down a little bit and also just feel a little bit more comfortable with the interview.” (Participant 1:5, Case Investigator)

Applying techniques to communicate effectively and adapting messages in real-time was especially critical during moments of high emotion or conflict. For example, volunteers described unexpectedly being the first to inform cases about their positive test results or learning from those answering that the case had died or speaking to individuals who did not wish to participate. In one instance the participant had felt obligated to call 9-1-1 for emergency medical assistance for a case who was in physical distress. As discussed below, participants repeatedly suggested that role-playing exercises be included in their training to build skills and confidence in navigating these emotionally charged or unanticipated situations.

“In the training, I [would] definitely [add] like a role player, an initial call, for both a standard case and a nonstandard case. So, for instance, I’ve had a call where someone just started swearing at me on the phone, which is not something you expect and then I had another call where I had to call 9-1-1 on that person’s behalf… So, I think, because we’re calling sick people, getting [new trainees] ready for what a normal case looks like and what an abnormal case looks like, or just to get them able to think on their feet, would probably be important.” (Participant 1:4, Case Investigator)

Collaborative learning theme

Participants frequently mentioned a need for internal communication structures to better promote information exchange, shared learning, and timely adaptation to periodic changes in guidelines or programmatic priorities.

Having direct communications with program supervisors was very important to participants, and they especially appreciated quick responses to their questions. They felt it was important for supervisors to communicate changes in CDC guidelines and programmatic priorities, as well as to be responsive to volunteers’ concerns, suggestions, and requests for changes or clarifications in protocols. These “two-way communications” were viewed as critical to maintaining “morale and faith” in the mission and promoting team solidarity. They described the chat application GroupMe as being “so helpful” in providing a direct mechanism to reach the supervisors with questions and view other volunteers’ comments. However, several participants also noted that discussion threads were often basic and repetitive, reducing their value.

“[The leaders] have been really responsive if I send the GroupMe message. People are pretty happy to respond, and they do that very quickly. That’s been good.” (Participant 3:2, Case Investigator)

“I am on the GroupMe, I’ve been on it for since I started, but I basically ignore it because there’s so many messages that go into it and so many of them are, ‘so I’m a new volunteer, how do I use [the interview software]?’ And then it’s a 20-message thread and everyone has to see it. So I check it like every few days and I just kind of scroll through.” (Participant 3:6, Case Investigator)

While the messaging app served as a useful hotline to request help from supervisors, many felt that other mechanisms were needed to provide peer-support, foster community, and learn from the experiences of their peers. Several mentioned that they thought that hearing about other volunteers’ thoughts and experiences during the FGDs had been helpful. They advocated establishing a “buddy system” or regular meetings with small groups of peers for volunteers to share experiences, learn from one another, and debrief after difficult calls. They felt that such meetings could help to provide regular updates on changing protocols as well as promote a sense of community in an environment where in-person interactions were impossible.

“At the moment I feel very comfortable doing a few practice calls with someone who’s just starting, going through some of the situations I’ve been through, a regular one, a few difficult ones and literally spending 20 minutes, half an hour doing those things. If someone had done that for me at the start, I would’ve felt a lot more comfortable than I originally did.” (Participant 5:1, Contact Notifier)

“I don’t think that I necessarily need more training, but the GroupMe, [or] having a short meeting once a week with small groups to discuss newer things I think would be helpful.” (Participant 4:2, Contact Notifier)

Implementation dimension

Two themes emerged that concerned the implementation dimension: Tools and External Coordination. Each focused on key aspects of the feasibility of implementing a volunteer-based contact tracing program.

Tools theme

Participants described several tools that were essential to their tasks, and the one most frequently discussed was the script. Many thought it was difficult to deliver the words verbatim because doing so made them sound “like a robot.” As previously noted, many adapted the script language or individualized their introductions in an attempt to rectify this problem. However, when asked if replacing the script with a bulleted list of objectives would be preferable, most said that a word-for-word script was necessary as a training aid, especially during a tracer’s first few calls. Other useful tools that participants regularly consulted included guidance documents provided by the program and a list of frequently asked questions. Participants appeared enthusiastic to add to and update these materials based on their own experiences. Some even suggested compiling examples of challenging call scenarios and response strategies into a reference document.

“I don’t think [any] amount of training can really prepare [you] for that first call. I know that sounds, I mean, yes, there was training to prepare for the first call, but I think you’d need that script just as that safety net.” (Participant 5:2, Contact Notifier)

“It would be helpful to have a repository of what these possible [call scenarios] are based on experience, real experience, and we could all contribute to that.” (Participant 1:2, Case Investigator)

Participants also identified a need to adapt scripts and protocols for asymptomatic cases, minors, non-English speakers, and cases residing in congregate settings such as nursing homes. Calls to individuals in congregate settings were especially challenging to navigate because cases were often severely ill or otherwise incapacitated, caseloads were high, staff were already overwhelmed and overloaded with calls, and other factors. These cases were redirected to the Health Department for follow-up.

In addition to these specific contexts, participants felt that the contact notification process should be modified for members of a case’s household and offered examples to support this suggestion. First, cases were often reluctant to provide information about their family members, possibly due to mistrust of the caller, fatigue and annoyance from being called by multiple agencies, or a desire to prevent additional calls to their household contacts. Second, even when this information was successfully collected by case investigators, they stated that it could be “a bit of a puzzle” to correctly identify cases and contacts at the beginning of a call without compromising privacy. When incorrect assumptions were inadvertently made or participants found themselves duplicating a call because a case had given the same phone number for multiple contacts (e.g., phones shared within households), participants on the contact notification team said the calls felt like “a mess” and that they lost credibility with the contacts. Last, participants often struggled to identify a single exposure date for contacts who were living with a case and hence continuously exposed, whereas it was simpler to identify a discrete date for non-household contacts. All these experiences led volunteers to recommend conducting household contact notification together with the case interview.

“There should be a separate [protocol] for household contacts. A household contact represents an ongoing exposure dynamic that is different than non-household contacts. If possible, the person calling the cases should contact the household contacts.” (Participant 4:2, Contact Notifier)

Data entry software was also identified as a critical contact tracing tool. Many case investigator participants appreciated the flexibility of New Haven’s emergency-management software, as it allowed them to scroll through the questions and enter data in a smooth yet flexible order. This feature was highlighted as important when interviews did not follow the planned order of questions. With regard to data management, however, the free-text data collection tools used by the contact notification team were challenging to process, and several participants responsible for entering these data felt that they “should be updated” and recommended the use of a standardized form. Another tool that volunteers discovered to be helpful was dialer software (Doximity, San Francisco, CA) to mask their personal information, display the Health Department’s phone number or a leave a virtual callback number (Google Voice, Mountain View, CA).

“So, the number they see on their caller I.D. is from the [health department]… And then the number we leave [for] voicemail is my Google Voice number that will forward to my cell phone. So, they don’t know who we are, they don’t have our name or our personal information any more than what we say in the voicemail.” (Participant 1:4, Case Investigator)

External coordination theme

Participants from both teams spoke often about how the activities of external organizations affected their own activities. Cases and contacts often reported receiving numerous calls from various organizations, such as healthcare providers, testing facilities, and insurance companies, and were often “annoyed” at hearing the “same things from multiple different people.” In some instances, different organizations provided conflicting advice about isolation and quarantine periods. Ultimately, these experiences often led to call recipients being less receptive to engaging with the caller, thereby making it more difficult to collect the necessary information.

“When there are multiple people who are giving [the case] recommendations that are not the same, it becomes challenging to feel like you are authoritative and for people to feel like they know what’s going on.” (Participant 2:4, Case Investigator)

“Because they’ve tested positive, their doctor has given them a lot of recommendations already and they’re hearing it from us again…I think lately I’ve been getting more people who’ve tested positive and they’ve been annoyed with my call, more so I think because they’ve heard kind of the same things from multiple different people.” (Participant 5:4, Contact Notifier)

Maintenance dimension

The final theme, Sustainability, focused on long-term threats to the volunteer-driven contact tracing program and aligned well with the maintenance dimension of RE-AIM.

Sustainability theme

Several participants considered a volunteer-driven workforce as ideal for the “crisis phase” of an epidemic, allowing an accelerated response without the delays inherent in formal hiring or when re-assigning existing employees to contact tracing was not possible. However, participants did not see a volunteer-driven program as sustainable during the “maintenance phase” following the crisis. Some participants had recently graduated and were departing for jobs or further training, and others planned to soon return to class or to other responsibilities.

“I think that you just unfortunately have to account for the fact that [volunteers] who are trained might be gone two months later and then [training and volunteer turnover] keeps going on and on again.” (Participant 6:6, Contact Notifier)

As nearby states began hiring and paying contact tracers, other volunteers reported feeling frustrated, underappreciated, or less inclined to continue with the program. Participants suggested several strategies to maintain long-term involvement of contact tracers such as hiring them into part- or full-time paid positions or incentivizing student volunteers by offering academic credit for their work.

“I think it’s a great idea for an acute crisis emergency for those first few weeks. Now this is an ongoing thing, I feel putting in a long-term solution, and maybe this counts as a practicum for the incoming students or for the continuing students or finding a way you can either weave this into the program… [or] They should be paying us to do it, not exorbitant amounts. But like 10 or 12 dollars an hour…I think that not doing that is a real disservice.” (Participant 5:1, Contact Notifier)

Synthesis of barriers, facilitators, and proposed solutions across themes and RE-AIM dimensions

Table 2 summarizes the facilitators, barriers, and potential solutions for improving implementation of contact tracing as reported by participants, mapped to their respective themes, and synthesized within the RE-AIM dimensions.

Table 2

Summary of findings organized by themes within the RE-AIM dimensions.

Dimensions	Themes	Facilitators	Barriers	Potential Solutions
Reach	Making Contact	Dialer software used to replace caller’s personal phone number with a health department number	Low answer rate	Introduce text messages to introduce phone calls; obtain outreach preferences at testing
	Establishing Rapport	Dialer software used to replace caller’s personal phone number with a health department number	Lack of trust in an unknown caller	Routinely address privacy concerns
		Many cases and contacts willing to participate out of a desire to help their community	Low public unawareness of contact tracing leading to lack of interest or comfort in providing information about contacts	Organize public awareness campaigns; provide thorough explanations for why contact tracing is important for the community
Effectiveness	Delays	--	Late reporting of test results	Automate test reporting and transfer of information to contact tracers
			Unknown language preferences	Verify language preferences at point-of-testing
	Community Needs	Health department routinely assesses needs as part of outreach	Lack of money, or adequate food & housing to help cases to adhere to isolation & quarantine	Increase funding for financial, nutritional, and housing supports; better inform tracers about how such needs can be met
Adoption	Volunteer Motivations	Partnerships with academic institutions and students	--	Reward non-employed tracers with academic credit or certificates of experience
	Time Management	Weekly availability survey used for case investigation team	Shifting volunteer availability	Offer flexible, volunteer-driven scheduling
			Inconsistent workload due to varying case incidence with skill loss from inactivity	Ensure consistent baseline involvement with longitudinal skill refreshers
	Knowledge	Brief, targeted training provided to new volunteer tracers	Need for broad mastery of diverse content areas including biology, guidelines, procedures	Offer self-directed, online training modules to obtain baseline and knowledge
		Many volunteers had previous education or experiences in health sciences	Frequent changes to guidelines due to evolving understanding of COVID-19 transmission dynamics	Frequently revise protocols to reflect changing guidelines, and rapidly communicate of these changes to the tracers; provide repository of potential call scenarios for outreach workers to learn from.
	Skills	Many volunteers previously trained in patient communication skills	Need for effective communication skills for building rapport	Incorporate role-plays and simulations to build up communication skills during training
	Collaborative Learning	Leaders regularly responded to questions by e-mail or GroupMe*	Lack of communication with leadership and feedback to ensure quality performance	Integrate two-way communication via messaging apps, email, and supervisory support
			Sense of isolation and lack of community while working remotely	Encourage peer mentorship, buddy systems, and regular, small-group peer meetings
Implementation	Tools	Software was flexible and allowed case investigators to adapt it to the interview at-hand.	Impersonal, non-conversational script	Personalize script and allow for adaptation to the clients’ needs.
			Lack of interoperability of electronic systems	Provide simple and standardized data collection tools
		Health department adapted script according to volunteer suggestions	Loss of volunteer privacy	Offer and/or require use of call masking software
			Need for specialized protocols for key populations†	Develop and apply specialized protocols
	External Coordination	--	Duplicate calls to the same cases or contacts, leading to frustration and decreased engagement	Coordination with other clinics, laboratories, and health organizations to streamline and integrate communication
Maintenance	Sustainability	--	High volunteer turnover; decreasing motivation over time	Offer payment or other compensation and acknowledgement such as academic credit or certificates of experience

*Mobile app for hosting chat-groups

†Asymptomatic cases, residents of congregate settings, minors, non-English speakers, household contact.

Discussion

This is among the first studies to comprehensively describe the implementation context of COVID-19 contact tracing and provides a unique window into the rich experiences and perspectives of volunteers involved in a high-volume program at the peak of the April-June 2020 surge in the northeastern US. We identified many barriers to delivering this complex intervention in the midst of a public health emergency, but also several facilitators and many potential solutions for improving implementation, both in general and in the context of a volunteer program. Many insights echo the prior literature on contact tracing for other diseases, while others remain unique to the context of COVID-19 and the crisis scenario of a rapidly emerging pandemic. Categorizing our findings according to the RE-AIM framework allowed us to group many disparate themes into discrete, well-validated dimensions for improving implementation [21, 22].

The reach and effectiveness of COVID-19 contact tracing vary across settings, with proportions of cases successfully interviewed ranging from 53% - 99% [29, 30] and adherence to self-isolation instructions reported as low as 25% [30]. While the specific mechanisms driving these outcomes are not yet fully understood in the context of COVID-19, challenges to the reach and effectiveness of contact tracing in other settings have been associated with several client factors including anticipated stigma and loss of privacy [31-34], language barriers [31], and low public awareness of the importance of contact tracing [31, 33, 35, 36]. The apparent reluctance to answer our participants’ calls may relate to several of these barriers. The RE-AIM framework suggests that COVID-19 contact tracing programs might consider engagement strategies to enhance uptake such as using the initial point-of-testing interaction to identify optimal times to call and to document language preferences, and possibly using text messaging to identify and introduce outreach workers prior to calling. Our participants also highlighted the role of financial, nutritional, and social supports for those expecting or disclosing difficulties with isolation or quarantine as another way to potentially enhance the impact of contact tracing. Similar supports are commonly provided to tuberculosis cases to enhance patient outcomes and acceptance of contact tracing [37]. This notion is further reinforced by a recent anonymous survey study conducted in the UK which found that increased adherence to COVID-19 self-isolation and lockdown instructions was associated with having received help from anybody outside of the household [30].

A shortage of human resources is a major challenge to adoption of contact tracing for COVID-19 and other communicable diseases [31, 33, 38–41], both because many contact tracers are needed and because this capacity must be flexible enough to expand and contract with the waves and surges of the epidemic. In addition, as noted above, outreach workers must have good communication skills and a detailed knowledge of program policies and guidelines [35, 38, 42, 43]. Engaging/hiring volunteers is one option for rapidly scaling a pandemic contact tracing workforce [44] and was a strength identified by our study participants. There are also several personal benefits that might be highlighted to attract volunteers to such a workforce, including the anticipated satisfaction of contributing to the pandemic response and opportunity to gain practical experience in a health science field. Yet several challenges to a volunteer-driven workforce remain, such as managing shifting schedules and training lay persons from diverse backgrounds to act as public health agents. Allowing volunteers some degree of flexibility in their scheduling may allow programs to accommodate volunteers’ external responsibilities, while using self-directed, online training modules [45] would decrease the initial training burden on local programs and allow them to focus their efforts in this area on ongoing education about local guidelines and practices, and on skill-building exercises such as role plays.

Another important insight from our participants about adoption of a volunteer contact tracing model included their suggestion to create a learning community to help them overcome their relative inexperience with outreach work. In other settings, pairing new trainees with those who are more experienced and/or facilitating an environment in which trainees can learn alongside their peers and support one another has been shown to increase trainee confidence and skill [46]. This sense of community seemed particularly important in the context of COVID-19 when requirements to work remotely made it more difficult to learn new skills because it was harder to receive feedback from peers or supervisors. We strongly recommend that COVID-19 contact tracing programs develop and promote robust communication and support structures within their organizations, using strategies such as peer-mentorship and regular, small-group meetings.

Within the implementation dimension, we found that properly designed tools for data collection and storage, specialized protocols for key populations, and coordination with external organizations were thought to be critical to success. These implementation factors may also have positive spillover effects for adoption, reach, and effectiveness in that efficient, user-friendly, non-redundant systems benefit call recipients and contact tracers alike. Two simple suggestions for improving efficiency included adopting more accessible tools for data collection and management, as shown with contact tracing for other diseases [33, 38, 39, 41, 47], and coordinating case and contact interviews within the same household as is commonly done in tuberculosis contact investigation [48, 49]. A threat that participants identified, poor inter-agency communication, has also been described during tuberculosis contact investigation in border regions [39]. In contrast, close coordination of Ebola contact tracing teams led to faster and greater uptake in the target populations [33, 50]. Further benefit was realized by these response teams when they integrated services across disciplines, including social supports for basic needs and mental health, information-sharing with local community leaders, and public health interventions including active case-finding and quarantine. The experiences of our participants, combined with evidence from other contact tracing studies from contexts beyond COVID-19, emphasize the importance of coordinated, multidimensional outreach and support of cases and contacts.

Lastly, our study raises concerns about the maintenance of volunteer-driven contact tracing programs, with particular regard to sustainability. Our study participants noted that the initial motivations to volunteer out of altruism and/or a desire for practical experience can wane over time, particularly when neighboring programs began hiring full-time contact tracers. We found that volunteer availability can also change over time, especially for students and those under-employed as a consequence of physical lockdowns. These factors can make it difficult to establish and maintain a stable workforce. Payment or other forms of reward have been shown to increase motivation and commitment of tracers in other settings [31, 35, 38, 51], and our participants echoed the importance of feeling valued and appreciated for their efforts. We recommend that programs unable to hire employees for contact tracing consider providing academic credit or certificates to volunteers to acknowledge their critical contributions to pandemic response.

Strengths and limitations

A key strength of this study is its timeliness in providing insight into how to respond more effectively to an ongoing, global pandemic. This is the first qualitative evaluation we know of for COVID-19 contact tracing, despite the wealth of media attention devoted to this topic. Obtaining such direct feedback from key stakeholders in the COVID-19 crisis is critical for understanding the complexities of implementation. Second, the use of an established implementation framework adds strength and clarity to our findings and eases interpretability for broader contexts. Third, volunteer contact tracing is a feasible and adaptable solution to COVID-19 contact tracing, and this article provides several strategic recommendations specific to volunteer-driven programs that may increase effectiveness and efficiency. Fourth, the participants in this study were all experienced in health care or public health settings and as such were able to reflect deeply on their experiences and provide specific recommendations. Many of the recommended solutions to challenges were swiftly incorporated into practice by the Health Department, and future studies may evaluate the impact of these changes on contact tracing outcomes. Last, while video conferencing platforms are typically not used to conduct FGDs, this study demonstrates that this methodological approach is acceptable to participants and feasible, except for occasional reductions in audio quality. Those using this technology should provide written and verbal instructions to participants on best practices to optimize audio quality and maintain courtesy during the sessions.

There are several study limitations to note. First, participants’ responses may have been influenced by group dynamics or social desirability bias. To partially compensate for this limitation, our analysis incorporated comments from a follow-up survey of participants soliciting additional comments that they might have felt uncomfortable sharing in a group setting, or simply forgotten to mention. Second, insights about barriers and facilitators of a volunteer-driven program may not apply to a professional-driven contact tracing program. Similarly, our experience with health sciences students may not be generalizable to other volunteer groups. However, several findings likely apply to other types of contact tracing programs, including strategies for reaching and engaging cases and contacts, the importance of adapting protocols and support systems to the needs of the local community, and the potential value in communication and coordination among different health agencies. Third, our findings include only the perspectives of volunteer tracers and not those of cases and contacts which will be explored in a subsequent analysis. Finally, while the insights and suggestions of the participants were used to modify the program, we unfortunately were not able evaluate their impact. With declining case numbers in Connecticut in June 2020, local health departments transitioned contact tracing responsibility to the state department of public health, and this program was discontinued.

Conclusions

The unique experiences of the FGD participants highlight several strategies for improving volunteer-driven COVID-19 contact tracing programs, including adopting flexible approaches to training and scheduling volunteers and fostering networks to facilitate support and learning among volunteers. While a largely volunteer-driven contact tracing program was feasible and acceptable in the context of a public health crisis, its greatest challenge was achieving sustainability after the initial case surge. Despite the difficulties of implementing COVID-19 contact tracing, our findings suggest that a workforce that is well-capacitated, networked with its surrounding organizations, and able to adapt its services to the unique needs of its clients can overcome many of these challenges.

CO-REQ reporting guidelines.

(DOCX)

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Semi-structured focus group discussion guide.

(DOCX)

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9 Feb 2021

PONE-D-20-29667

Implementation of a Volunteer Contact Tracing Program for COVID-19 in the United States: A Qualitative Focus Group Study

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Reviewer #1: This manuscript was a pleasure to read and provided valuable insights into facilitators and barriers to conventional COVID-19 tracing in a volunteer program. The organization of results by theme, RE-AIM dimension, and facilitators/barriers/solutions is particularly helpful to allow the reader to digest the examples from study focus groups. There are two areas in particular in which the authors may improve this manuscript: 1) providing more detail about the program and its processes, and 2) incorporating more COVID-19 related literature into the discussion. Suggestions regarding these two topics, as well as some additional minor comments, are listed below.

Background:

A brief introduction to the benefits and/or appropriate use of conventional contact tracing, as compared to digital contact tracing, may be helpful to place this research in the context of the larger literature regarding contact tracing for COVID-19.

Please note typo: In the absence of a vaccine (3).

Methods:

Please provide some additional information about how the volunteer contact tracing program operated:

What was the source and process through which clients (i.e., positive cases) were brought to the attention of the contact tracing program?

How were changes in guidelines/recommendations communicated to volunteers over the course of the program?

Please describe the needs assessment process and the actions taken by contact tracers in response to identified needs.

Please clarify the number of eligible volunteers for the study. The authors mention 190 volunteers in the program, but only 142 available participants for the focus groups. Did these available participants exclude the 40 public health nurses added to the program in April (it does seem so since all participants reported a university affiliation in Table 1)? If so, why? Also, how did the authors choose the number of volunteers to exclude due to low case load?

Please clarify the consent process. The authors’ statement, “After obtaining verbal consent, the session recording was transcribed using an automated transcription service,” makes it sound as if consent was provided after the focus group was concluded. Please reword this statement to make it clear that participants provided consent prior to the start of the focus groups.

The authors state the use of inductive content analysis, but also categorized their findings based on deductive categorization surrounding facilitators/barriers/solutions (derived from the interview guide) and RE-AIM dimensions. Can the authors please elaborate on the use of both inductive and deductive coding and their coding process as it relates to the categorization of themes (presumably inductive), RE-AIM dimensions (presumably deductive), and facilitators/barriers/solutions (presumably deductive). What was the order in which these categorizations were made during data analysis?

Please note typo: we used the RE-AIM framework(21)

Results:

It would be helpful to split up Table 1 into the two study groups–case interviewers and contact notifiers–to assess differences in the study population based on role.

The free-text portion of the survey provided data in addition to the focus group transcripts. Were significant, unique findings revealed in the free-text responses that were not found in the focus study discussions?

For the adoption dimension, the authors state that information about “volunteers’ experiences” were allocated to this category. This seems a vague description, as all responses of the volunteers will reflect the perspectives of their experiences. Is there another way to describe the allocation of comments to the adoption dimension that provides greater specificity?

The authors state delays were at times related to “cases seeking testing.” It is not clear what this means in the context of the examples provided. Can the authors elaborate on this statement to communicate what this example is describing?

Please define “FGD”.

Discussion:

As Table 4 represents a synthesis of analyzed data it seems more appropriate to include it in the Results section, with additional statements about the identification of these additional themes (facilitators, barriers, solutions) in the text. Some of the information in this table is new information, not previously mentioned in the results analysis.

In Table 4, should the “Establishing rapport” label be merged with the empty cell below to denote its relevance to examples in both rows for this theme?

In Table 4, can “Automate data transfer” be more specific? Automate the communication of testing results?

While the discussion uses examples from contact tracing of other diseases, this section appears to lack references to citations regarding the proposal, implementation, or evaluation of contact tracing for COVID-19. It would be useful to include literature that can place the findings of this study in the context of what others have learned about the implementation, impact, or efficacy of contact tracing specific to COVID-19.

References:

Some reference information appears to be incomplete.

Reviewer #2: This article presents the findings from a timely study on the effectiveness of a volunteer contact tracing program for COVID-19. The study provides useful, concrete findings about constraints and how similar programs can be improved. The manuscript is clearly written and well organized.

Main comments:

• Pg. 10 on RE-AIM framework – It would be helpful to give more information about the RE-AIM framework and why you chose to use it since readers may not be familiar with it. I think the framework makes sense to use, but it is not well explained up front and is only explained in pieces in the results section. Please define each of the domains and how they are applicable to the contact tracing program. This will provide a stronger grounding for the data collected, the results, and how you will use the findings to make program recommendations.

• Pg. 26 table 4 – A lack of compensation was not discussed in the results section. Please include to support what is in the table or revise the table.

Other comments:

• Pg 4. Contributions to Science box – Note that these findings are about a specific context and the extent to which these findings may or may not be applicable to other parts of the US (e.g., where there is greater skepticism around COVID-19 for instance than in CT) or other countries (e.g., what types of similarities in the public health system would make the results applicable).

• Pg. 8 – Are there any methodological notes about conducting the focus groups over Zoom? Would be worth stating if no major challenges were faced at least since it’s newer to do over Zoom.

• Pg. 8 last full sentence – Edit for clarity.

• Pg. 8 end – May want to refer to the guide as a focus group guide rather than interview guide for clarity.

• Pg. 9 paragraph on transcripts – Edit paragraph for flow.

• Pg. 9 on saturation – Did you assess saturation for the case volunteers and contact volunteers separately? Also edit the sentence for clarity (e.g., iteratively reviewed the transcripts and conducted additional focus group discussions until no new themes emerged).

• Pg. 9 on ATLAS.ti – The current description sounds like you coded the data and then entered the data into ATLAS.ti rather than coding the data in ATLAS.ti. If you did code the data on paper or in some other program, specify that and clarify what you mean by “entering the data” into ATLAS.ti.

• Pg. 10 on study sample – Why did you select the first people who responded instead of using other purposive criteria? Do you know how the demographic characteristics of your sample compare to broader group of volunteers?

• Pg. 11 after table – Missing header for shift to discussing identified themes.

• Pg. 13-14 table 3 – It would be helpful to split up the table and include in each dimension so you can see the table with the results for that dimension. The content of the table is useful, but it is a bit out of context to see the themes and quotes before the presentation of the results for the dimension. Splitting it up would also allow you to easily see the themes for the domain and reference illustrative quotes.

• Pg. 14 table 3 – I am not sure I understand the purpose of the legend text. It doesn’t seem needed.

• Pg. 18 – Inconsistent use of FGD acronym.

• Pg. 20 – I wonder if a different label would make sense instead of community of practice. It seems that this theme is more about having supportive supervision and peer-learning/support. Community of practice is more often referred to network going across programs or organizations rather than communication within a program.

• Pg. 31 last paragraph – Would clarify that sending the survey afterwards would not mitigate social desirability bias, but may have given you some insight into potential sources of bias.

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Reviewer #1: Yes: Sarah R. MacEwan

Reviewer #2: No

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6 Mar 2021

March 6, 2021

Dear Editors and Reviewers:

We would like to thank you for giving us the opportunity to revise and resubmit our manuscript entitled “Implementation of a Volunteer Contact Tracing Program for COVID-19 in the United States: A Qualitative Study.”

We have addressed all the points mentioned by the editors and reviewers and have included our detailed, point-by-point responses below. We feel that your constructive feedback has greatly strengthened this article. Please do not hesitate to contact us if you need further information or clarification.

Sincerely,

J. Lucian (Luke) Davis, MD, MAS, Corresponding Author

Editor Comments and Responses

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming.

a. Response: We have reviewed PLOS ONE’s style/formatting requirements and made several changes, including:

i. Reducing abstract word count to below the limit

ii. Removed footnotes from the Manuscript

iii. Added a Short Title to the Manuscript’s Title Page

iv. Added a new Methods sub-section detailing IRB approval and consent procedures.

2. Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please ensure that you have specified how verbal consent was documented and witnessed.

a. Response: Additional details and clarifications regarding consent have been added to the “Ethics Statement and Consent Procedures” section of the Methods:

i. Page 11, Line 213: “The study protocol was approved by the Yale Human Subjects Committee (Institutional Review Board Panel A for Social, Behavioral, and Educational Research) and the New Haven Health Department. A waiver of written consent was approved by the Human Subjects Committee because the study posed no greater than minimal risk and did not involve any procedures that would require written consent in a non-research context. Before video-recording the session, the group facilitators read the consent form aloud and obtained verbal consent from all participants to participate in the study and be recorded.”

3. Please provide the interview guide used as supporting information.

a. Response: The guide has now been provided as “Supplemental Text 1.”

4. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions.

a. In your revised cover letter, please address the following prompts:

i. If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.

ii. If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories.

iii. We will update your Data Availability statement on your behalf to reflect the information you provide.

1. Response: Regarding the request to deposit source data in an online repository, there are a number of ethical and legal reasons which prevent us from doing so. First, participants did not provide consent for the transcripts to be deposited publicly. Second, because the focus groups describe personal experiences, it is not possible to fully deidentify the transcripts, and there is a risk of loss of confidentiality for participants given the modest size of the contact tracing program and of the community. Third, the New Haven Health Department provides oversight for the data collected by and for its contact tracing program, and by policy requires any use of this data to be directly approved by the Health Department. For these reasons, data may only be made available upon request made to the Corresponding Author and the New Haven Health Department.

5. Thank you for stating the following in the Competing Interests section: "JLD and TS declare a contract with the state of Connecticut to assist with the state's contact tracing program. "

a. Please confirm that this does not alter your adherence to all PLOS ONE policies on sharing data and materials, by including the following statement: "This does not alter our adherence to PLOS ONE policies on sharing data and materials.” (as detailed online in our guide for authors http://journals.plos.org/plosone/s/competing-interests). If there are restrictions on sharing of data and/or materials, please state these. Please note that we cannot proceed with consideration of your article until this information has been declared.

b. Please include your updated Competing Interests statement in your cover letter; we will change the online submission form on your behalf.

c. Please know it is PLOS ONE policy for corresponding authors to declare, on behalf of all authors, all potential competing interests for the purposes of transparency. PLOS defines a competing interest as anything that interferes with, or could reasonably be perceived as interfering with, the full and objective presentation, peer review, editorial decision-making, or publication of research or non-research articles submitted to one of the journals. Competing interests can be financial or non-financial, professional, or personal. Competing interests can arise in relationship to an organization or another person.

i. Response: Our new Competing Interests statement is as follows:

1. JLD and TS declare a contract with the state of Connecticut to assist with the state's contact tracing program. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

6. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please move it to the Methods section and delete it from any other section. Please ensure that your ethics statement is included in your manuscript, as the ethics statement entered into the online submission form will not be published alongside your manuscript.

a. Response: The ethics statement covering approval from Yale IRB and the New Haven Health Department, as well as consent processes, has been added to the Methods section, and is quote above in response to Editor Comment #2.

7. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information.

a. Response: We have added captions for the two Supporting Information items uploaded (CO-REQ Checklist and FGD Guide)

Reviewer #1 Comments and Responses

General Comment: This manuscript was a pleasure to read and provided valuable insights into facilitators and barriers to conventional COVID-19 tracing in a volunteer program. The organization of results by theme, RE-AIM dimension, and facilitators/barriers/solutions is particularly helpful to allow the reader to digest the examples from study focus groups. There are two areas in particular in which the authors may improve this manuscript: 1) providing more detail about the program and its processes, and 2) incorporating more COVID-19 related literature into the discussion. Suggestions regarding these two topics, as well as some additional minor comments, are listed below.

Background:

1. A brief introduction to the benefits and/or appropriate use of conventional contact tracing, as compared to digital contact tracing, may be helpful to place this research in the context of the larger literature regarding contact tracing for COVID-19.

a. Response: Good point; we have added a summative sentence to the end of the first Background paragraph.

i. Page 5, Line 80: “Meanwhile, the lack of feasibility and acceptability of the best alternative, digital contact tracing, has ensured that person-led strategies will likely remain the first-line approach in most settings (19).”

2. Please note typo: In the absence of a vaccine (3).

a. Response: We have updated this sentence in the first Background paragraph to reflect changes in vaccine development/deployment and the typo is resolved.

Methods:

3. Please provide some additional information about how the volunteer contact tracing program operated:

i. What was the source and process through which clients (i.e., positive cases) were brought to the attention of the contact tracing program?

ii. How were changes in guidelines/recommendations communicated to volunteers over the course of the program?

iii. Please describe the needs assessment process and the actions taken by contact tracers in response to identified needs.

b. Response: Thank you for the suggestions. We added a new citation to an article we published in AJPH that describes the program itself in more detail, and also added several sentences to the “Setting and Procedures” section:

i. Page 7, Line 117: “The Health Department established a partnership with Yale University for volunteer contact tracing on March 27, 2020, as previously described (22).”

ii. Page 8, Line 137: “Each day, the Health Department’s lead epidemiologist identified new positive COVID-19 cases from the state’s reportable disease database and shared their corresponding outreach information with the case investigation team.”

iii. Page 8, Line 142: “The case investigator team shared a daily list of reported contacts, without any information regarding their respective cases, with the contact notification team via email.”

iv. Page 8, Line 146: “Case investigators routinely asked cases about food or housing insecurities, ability to isolate within homes, access to medical care, and other social needs, while providing numbers to local support organizations or free clinics when applicable. Contact notifiers also provided links to resources when applicable but did not routinely assess contacts for the same needs.”

v. Page 8, Line 150: “Team leads communicated changes in guidelines and protocols to volunteers via email and modified data collection forms appropriately.”

4. Please clarify the number of eligible volunteers for the study. The authors mention 190 volunteers in the program, but only 142 available participants for the focus groups. Did these available participants exclude the 40 public health nurses added to the program in April (it does seem so since all participants reported a university affiliation in Table 1)? If so, why? Also, how did the authors choose the number of volunteers to exclude due to low case load?

a. Response: Thank you for the suggested clarification. We have revised this section to increase clarity:

i. Page 8, Line 155: “Eligibility criteria included being a volunteer in the case investigator or contact notification teams. We excluded the less experienced case investigators, defined as being in the lowest 25th percentile of total case assignments (<7 assignments). We did not exclude any contact notifiers because all assignments were distributed equally among this team, whereas case investigators were able to adjust their availability each week. We emailed invitations to all eligible volunteers to participate in the study. We set an initial recruitment goal of 18 participants from each team based on estimates of the number of focus groups required for thematic saturation (25).”

b. We excluded nurses given the focus of the manuscript on the experiences of new volunteers, as stated on Page 6, Line 101:

i. “Because volunteers were and still are key stakeholders in many contact tracing programs, learning about their experiences is vital for sustaining and scaling up contact tracing. To this end, we conducted focus group discussions (FGDs) with volunteers participating in a contact tracing program in Connecticut.”

5. Please clarify the consent process. The authors’ statement, “After obtaining verbal consent, the session recording was transcribed using an automated transcription service,” makes it sound as if consent was provided after the focus group was concluded. Please reword this statement to make it clear that participants provided consent prior to the start of the focus groups.

a. Response: Good point, we moved content regarding consent procedures to the Ethics Statement and Consent Procedures sub-section of the Methods and clarified.

i. Page 11, Line 217: “Before video-recording the session, the group facilitators read the consent form aloud and obtained verbal consent from all participants to be in the study and be recorded.”

6. The authors state the use of inductive content analysis, but also categorized their findings based on deductive categorization surrounding facilitators/barriers/solutions (derived from the interview guide) and RE-AIM dimensions. Can the authors please elaborate on the use of both inductive and deductive coding and their coding process as it relates to the categorization of themes (presumably inductive), RE-AIM dimensions (presumably deductive), and facilitators/barriers/solutions (presumably deductive). What was the order in which these categorizations were made during data analysis?

i. Response: Valid points. We began with inductive codebook development and thematic analysis, followed by deductive categorization of themes according to RE-AIM dimension followed by identification of facilitators, barriers, and solutions within each RE-AIM dimension. These steps are now clarified as follows:

1. Page 10, Line 192: “The coding team (TS, RH, LG) independently reviewed one case and one contact transcript and met to discuss and develop the codebook inductively.”

2. Page 10, Line 198: “the data were subsequently entered into ATLAS.ti (Version 8) and analyzed iteratively using thematic analysis (27)”

3. Page 10, Line 202: “After the themes had been identified, we used the RE-AIM framework (21, 28) to deductively organize emergent themes”

4. Page 11, Line 208: “Once organized according to the RE-AIM framework, we identified specific barriers, facilitators, and solutions within each RE-AIM dimension.”

7. Please note typo: we used the RE-AIM framework(21)

a. Response: Thank you for noticing this error; we have fixed the typo.

Results:

8. It would be helpful to split up Table 1 into the two study groups–case interviewers and contact notifiers–to assess differences in the study population based on role.

a. Response: We appreciate this suggestion and have modified the table accordingly. Note that there was an incorrect labeling of one participant as “staff” rather than “student” in the prior table, which was now been corrected.

9. The free-text portion of the survey provided data in addition to the focus group transcripts. Were significant, unique findings revealed in the free-text responses that were not found in the focus study discussions?

a. Response: This is an excellent point, and we have added a sentence to note that no differences in themes were noted across participant characteristics or between responses from the FGDs vs. survey responses:

i. Page 13, Line 242: “There were no differences in themes expressed by volunteer type or by participant demographics or between the FGDs and follow-up free-text surveys.”

10. For the adoption dimension, the authors state that information about “volunteers’ experiences” were allocated to this category. This seems a vague description, as all responses of the volunteers will reflect the perspectives of their experiences. Is there another way to describe the allocation of comments to the adoption dimension that provides greater specificity?

a. Response: Thank you for the suggestion; we have adjusted the wording in the Methods section to more accurately describe what type of content was categorized within the Adoption dimension:

i. Page 10, Line 205: “[themes about] volunteer delivery of the intervention and the setting in which they operated to the adoption dimension”

11. The authors state delays were at times related to “cases seeking testing.” It is not clear what this means in the context of the examples provided. Can the authors elaborate on this statement to communicate what this example is describing?

a. Response: We modified this sentence to increase the clarity of the message:

i. Page 18, Line 286: “While some delays in the overall contact tracing process were beyond the control of the program, such as cases choosing to delay seeking COVID testing or slow reporting of test results, participants felt that identifying cases in need of translators before the first call was an actionable way to prevent additional delay.”

12. Please define “FGD”.

a. Response: We now define FGD in the last Background paragraph.

Discussion:

13. As Table 4 represents a synthesis of analyzed data it seems more appropriate to include it in the Results section, with additional statements about the identification of these additional themes (facilitators, barriers, solutions) in the text. Some of the information in this table is new information, not previously mentioned in the results analysis.

a. Response: We agree and have moved the table and a brief paragraph introducing it into the Results section.

14. In Table 4, should the “Establishing rapport” label be merged with the empty cell below to denote its relevance to examples in both rows for this theme?

a. Response: This is a good suggestion and we have made this correction.

15. In Table 4, can “Automate data transfer” be more specific? Automate the communication of testing results?

a. Response: We adjusted the wording to be more specific per the reviewer’s suggestion:

i. Table 7: “Automate test reporting and transfer of information to contact tracers”

16. While the discussion uses examples from contact tracing of other diseases, this section appears to lack references to citations regarding the proposal, implementation, or evaluation of contact tracing for COVID-19. It would be useful to include literature that can place the findings of this study in the context of what others have learned about the implementation, impact, or efficacy of contact tracing specific to COVID-19.

a. Response: Thank you for this suggestion; we have added several new citations alongside adjusted wording in the Discussion to place our findings better within the context of COVID-19 when possible. Examples include:

i. Page 34, Line 488: “The reach and effectiveness of COVID-19 contact tracing vary across settings, with proportions of cases successfully interviewed ranging from 53% - 99% (29, 30) and adherence to self-isolation instructions reported as low as 25% (30).”

ii. Page 35, Line 503: “This notion [need for support with quarantine] is further reinforced by a recent anonymous survey study conducted in the UK which found that increased adherence to COVID-19 self-isolation and lockdown instructions was associated with having received help from anybody outside of the household (30).”

iii. “Engaging/hiring volunteers is one option for rapidly scaling a pandemic contact tracing workforce (44)”

References:

17. Some reference information appears to be incomplete.

a. Response: We have reviewed the references and added updated several references to include their respective urls and access/citation dates.

Reviewer #2 Comments and Responses

General Comment: This article presents the findings from a timely study on the effectiveness of a volunteer contact tracing program for COVID-19. The study provides useful, concrete findings about constraints and how similar programs can be improved. The manuscript is clearly written and well organized.

Main comments:

1. Pg. 10 on RE-AIM framework – It would be helpful to give more information about the RE-AIM framework and why you chose to use it since readers may not be familiar with it. I think the framework makes sense to use, but it is not well explained up front and is only explained in pieces in the results section. Please define each of the domains and how they are applicable to the contact tracing program. This will provide a stronger grounding for the data collected, the results, and how you will use the findings to make program recommendations.

a. Response: Good point. We added additional content and a new reference in the Background following the first mention of RE-AIM in order to define each dimension:

i. Page 6, Line 95: “The RE-AIM framework has been employed extensively for this purpose (21) and contains five dimensions: (1) reach, which focuses on the population an intervention targets and the process of engaging them, (2) effectiveness, which focuses on the intended impact of an intervention and potential barriers to that impact, (3) adoption, which focuses on the setting and individuals delivering the intervention, (4) implementation, which focuses on intervention protocols and strategy, and (5) maintenance, which focuses on intervention sustainability and scalability.”

2. Pg. 26 table 4 – A lack of compensation was not discussed in the results section. Please include to support what is in the table or revise the table.

a. Response: We previously discussed lack of compensation in the Maintenance theme but recognize that you are correct in pointing out that Table 4 also mentions this as a barrier in the Adoption theme. We removed it from the Adoption theme so that Table 4 now aligns with the text and prior thematic categorizations.

Other comments:

3. Pg 4. Contributions to Science box – Note that these findings are about a specific context and the extent to which these findings may or may not be applicable to other parts of the US (e.g., where there is greater skepticism around COVID-19 for instance than in CT) or other countries (e.g., what types of similarities in the public health system would make the results applicable).

a. Response: We have added an additional bullet-point to this box describing how the findings may apply beyond volunteer-driven programs, but likely not to all contact tracing programs due to differences in program practices and community engagement across different locations:

i. Contributions to Science Box: “While many of the findings from this study likely apply beyond the context of volunteer-driven, phone-based contact tracing programs, they may not be wholly applicable to other parts of the US or world that feature differences in public health infrastructure, use of technology for contact tracing, or community skepticism regarding COVID-19.”

4. Pg. 8 – Are there any methodological notes about conducting the focus groups over Zoom? Would be worth stating if no major challenges were faced at least since it’s newer to do over Zoom.

a. Response: Thank you for this suggestion; we have added new sentences in the Discussion:

i. Page 38, Line 580: “Lastly, while video conferencing platforms are typically not used to conduct FGDs, this study demonstrates this methodological approach to be acceptable to participants and feasible, except for occasional reductions in audio quality. Those using this technology should provide written and verbal instructions to participants on best practices to optimize audio quality and courtesy during the sessions.”

5. Pg. 8 last full sentence – Edit for clarity.

a. Response: We edited the sentence to remove duplicate words and increase clarity.

6. Pg. 8 end – May want to refer to the guide as a focus group guide rather than interview guide for clarity.

a. Response: Thank you, we have made the change in the text.

7. Pg. 9 paragraph on transcripts – Edit paragraph for flow.

a. Response: We modified the beginning of this paragraph to move the consent material to its own section and switched from passive voice to active when appropriate.

8. Pg. 9 on saturation – Did you assess saturation for the case volunteers and contact volunteers separately? Also edit the sentence for clarity (e.g., iteratively reviewed the transcripts and conducted additional focus group discussions until no new themes emerged).

a. Response: We modified this sentence to clarify:

i. Page 10, Line 186: “Two moderators (TS and LG) iteratively assessed the content of case sessions until no new themes emerged (i.e., saturation had been reached), and separately followed the same process for contact sessions (25).”

9. Pg. 9 on ATLAS.ti – The current description sounds like you coded the data and then entered the data into ATLAS.ti rather than coding the data in ATLAS.ti. If you did code the data on paper or in some other program, specify that and clarify what you mean by “entering the data” into ATLAS.ti.

a. Response: We clarified in the revised draft that initial coding was done using Microsoft Word and subsequently transferred into ATLAS.ti.

i. Page 10, Line 197: “The coding team initially used Microsoft Word for coding, and the data were subsequently entered into ATLAS.ti (Version 8)”

10. Pg. 10 on study sample – Why did you select the first people who responded instead of using other purposive criteria? Do you know how the demographic characteristics of your sample compare to broader group of volunteers?

a. Response: Thank you for suggesting these clarifications. We updated the wording in the Methods to clarify our enrollment strategy and procedures.

i. Page 9, Line 159: “We emailed invitations to all eligible volunteers to participate in the study. We set an initial recruitment goal of 18 participants from each team based on estimates of the number of focus groups required for thematic saturation [25]. We enrolled participants consecutively until the target sample size was reached, ensuring balanced representation of volunteers from different schools and university positions (i.e. students, faculty, and staff).”

b. We also added a sentence regarding the representativeness of the study sample to the larger volunteer population.

i. Page 12, Line 229: “School affiliations within the sample were similar to the those on the volunteer team overall, with a slightly lower representation of nursing students and a higher representation of faculty and staff in the study sample.”

11. Pg. 11 after table – Missing header for shift to discussing identified themes.

a. Response: We have added a heading per the reviewer’s suggestion.

12. Pg. 13-14 table 3 – It would be helpful to split up the table and include in each dimension so you can see the table with the results for that dimension. The content of the table is useful, but it is a bit out of context to see the themes and quotes before the presentation of the results for the dimension. Splitting it up would also allow you to easily see the themes for the domain and reference illustrative quotes.

a. Response: We agree with this suggestion and have split both Tables 2 and 3 so that each RE-AIM dimension now has its own table. However, if the editors prefer a smaller number of tables we can recombine.

13. Pg. 14 table 3 – I am not sure I understand the purpose of the legend text. It doesn’t seem needed.

a. Response: Upon revisiting the legend, we agree with the reviewer and have removed the legend as a similar statement appears elsewhere in the manuscript.

14. Pg. 18 – Inconsistent use of FGD acronym.

a. Response: Thank you for attention to detail. We now define FGD in the Background and more consistently use the acronym throughout.

15. Pg. 20 – I wonder if a different label would make sense instead of community of practice. It seems that this theme is more about having supportive supervision and peer-learning/support. Community of practice is more often referred to network going across programs or organizations rather than communication within a program.

a. Response: This is a valid point. We agree that using a term that more specifically encompasses peer learning would be a better fit. Thus, we changed “community of practice” to “collaborative learning” given the participants’ emphasis that learning from more experienced volunteers and team leaders could facilitate new volunteers’ work. We revised the Discussion accordingly:

i. Page 36, Line 527: “In other settings, pairing new trainees with those more experienced and/or facilitating an environment in which trainees can learn alongside their peers and support one another has been shown to increase trainee confidence and skill (47).”

16. Pg. 31 last paragraph – Would clarify that sending the survey afterwards would not mitigate social desirability bias, but may have given you some insight into potential sources of bias.

a. Response: We added an additional sentence to clarify that the survey may have reduced bias due to the group dynamics but was less likely to have reduced social desirability bias due to participant perceptions of the research team:

i. Page 38, Line 588: “The follow-up survey sent to each participant was intended to reduce social desirability unique to the group discussion context. However, we note that it may not have reduced social desirability bias when interacting with the group facilitators.”

Submitted filename: Responses to Reviewers.docx

Click here for additional data file.

22 Mar 2021

PONE-D-20-29667R1

Implementation of a Volunteer Contact Tracing Program for COVID-19 in the United States: A Qualitative Focus Group Study

PLOS ONE

Dear Dr. Davis,

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We look forward to receiving your revised manuscript.

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Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments (if provided):

Thank you for addressing the reviewer comments. Please integrate the quotes from Tables 2 - 6 into the text in the Results section and eliminate those tables. Table 7 is a nice summary and should remain (renumbered as Table 2).

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[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

8 Apr 2021

April 8, 2021

Editorial Board

PLoS ONE

Dear Editors:

We would like to thank you again for giving us the opportunity to revise and resubmit our manuscript entitled “Implementation of a Volunteer Contact Tracing Program for COVID-19 in the United States: A Qualitative Study, ” (PONE-D-20-29667R1).

We have now addressed all the points requested by the editors and have included our detailed, point-by-point responses below. We have also made very modest edits to the first and third sentences of the manuscript to better align with the current circumstances of the pandemic. Please do not hesitate to contact us if you need further information or clarification.

Sincerely,

J. Lucian (Luke) Davis, MD, MAS, Corresponding Author

Journal Requirements, Editor Comments and Responses

(Note that Line Numbers reference the Tracked Changes version of the manuscript, with changes visible)

1. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

a. Response: Thank you for noticing this error. There were three references related to “Communities of Practice” literature that are no longer relevant following our previous revisions. The citations were previously removed from the text but remained in the reference list; we corrected this by removing them from the reference list and adjusting the citation numbers accordingly.

2. Thank you for addressing the reviewer comments. Please integrate the quotes from Tables 2 - 6 into the text in the Results section and eliminate those tables. Table 7 is a nice summary and should remain (renumbered as Table 2).

a. Response: We moved all quotes from the table into the text within the relevant sections for each Theme and relabeled Table 7 as Table 2. In order to properly make the transition from table-to-text presentation of quotes, we made some minor adjustments to the text and added several new quotes that more directly reflect the content in the text. The additional changes are noted below:

i. Line 297: This quote was relocated from the Skills Theme to the Establishing Rapport Theme, as it more accurately captures the lack of prior work experience which is a topic in the prior paragraph (line 295).

ii. Line 302: We added a new quote to reflect the importance of prior work experience which is a topic in the prior paragraph (line 294)

iii. Line 455: We edited this paragraph to better describe the previously included quote that reflects questions that contacts ask regarding the information that callers have. “On the other hand, contacts frequently questioned where callers obtained such information.”

iv. Line 457: We also added minor text changes to describe additional reasons why cases were hesitant to provide information about cases: “or thought that it would intrude on the privacy of their contacts.”

(a) Line 463: we added a new quote to reflect this finding.

v. Line 500: We added a new quote to reflect the discussion of role plays noted in the prior paragraph (line 497)

vi. Line 527: We added a new quote to reflect some participants’ feelings that the GroupMe was repetitive, as described in the prior paragraph (line 521)

vii. Line 612: We added a minor in-paragraph quotation to describe how participants felt about the free-text data collection tools: “felt that they “should be updated”

viii. Line 614: We updated the text about dialer software to accommodate the addition of an accompanying quote (line 618)

19 Apr 2021

Implementation of a Volunteer Contact Tracing Program for COVID-19 in the United States: A Qualitative Focus Group Study

PONE-D-20-29667R2

Dear Dr. Davis,

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Jennifer Yourkavitch

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PLOS ONE

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28 Apr 2021

PONE-D-20-29667R2

Implementation of a volunteer contact tracing program for COVID-19 in the United States: A qualitative focus group study

Dear Dr. Davis:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

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Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Jennifer Yourkavitch

Academic Editor

PLOS ONE