Developing an Equitable COVID-19 Pandemic Response: Lessons Learned From a Multisectoral Public Health Partnership in Guadalupe, Arizona

Abstract

The COVID-19 pandemic has disproportionately impacted communities that are medically underserved across the United States, including the 6,700 Hispanic and Pascua Yaqui residents of Guadalupe, Arizona. In May 2020, Guadalupe experienced new COVID-19 cases at a rate 13.9 times as high as its surrounding county, urging town leadership to establish the Guadalupe Community Response Team (GCRT), a multisectoral network of community, academic, and public health partners. The objectives of the GCRT were to: (a) increase access to health and support services; (b) develop novel and intensive outreach efforts; and (c) build partnerships to strengthen public health capacity. From June 2020 to December 2021, the GCRT provided door-to-door case investigation and resource provision, coordinated testing and vaccination events, created public health communications, and developed COVID-19 guidance for cultural gatherings. These interventions were implemented in an effort to reduce community transmission of SARS-CoV-2 and increase equitable access to testing, vaccination, and social support resources. Cultural leaders, such as promotores de salud and Yaqui Cultural Specialists, were integral in building trust among community members. The GCRT provides valuable lessons learned on the importance of implementing a culturally grounded approach to COVID-19 mitigation to increase equitable access to health services during a public health emergency.

Introduction

Communities that are medically underserved are suffering disproportionately from the COVID-19 pandemic as a result of historical trauma and long-standing structural and racial inequities that adversely impact health outcomes (Hatcher et al., 2020). These disparities are particularly visible in Arizona, where communities that are historically marginalized are the most likely to experience greater morbidity and mortality related to COVID-19 (Barry et al., 2021). In particular, Hispanic and American Indian/Alaskan Native individuals in Arizona have developed COVID-19 at a rate 1.4 and 1.8 times higher than White individuals, respectively (Barry et al., 2021). Several factors that exacerbate these disparities in COVID-19 health outcomes include poverty, barriers to health care access, incidence of chronic disease, housing insecurity, multigenerational households, transportation barriers, and high-exposure employment (Deschine Parkhurst et al., 2020; Tai et al., 2021; Yellow Horse et al., 2020, 2021).

Case investigation and contact tracing are well-established public health mitigation strategies that have been key in addressing disease outbreaks such as the COVID-19 pandemic (Centers for Disease Control and Prevention [CDC], 2021a; Kwok et al., 2019; Lewis, 2020; Maduka et al., 2016). Although these strategies have been effective in mitigating the spread of disease during previous epidemics, there are still gaps in equitable public health capacity; this may be due to a lack of culturally appropriate methods for engaging communities in case investigation and a lack of accessible testing resources needed to facilitate accurate surveillance (Chugg et al., 2021; Page & Flores-Miller, 2021). Moreover, the COVID-19 pandemic has significantly stressed our existing public health infrastructure, placing an inequitable physical and mental health burden on the communities that are medically underserved (Chapman, 2020). The provision of adequate and equitable health programs to these communities is an essential goal of the broader public health response (Chapman, 2020).

Community-Based Health Programs

Community-based health programs (CBHPs), which often integrate community health workers (CHWs) and culturally grounded interventions, are designed to provide accessible, high-quality health care to communities that are medically underserved to improve health outcomes (Anderson et al., 2015; Hussen et al., 2020). Establishing CBHPs has been shown to foster more collaboration and lead to a more sustained and successful implementation of public health interventions and policies (Ivanich et al., 2020; Johnson-Jennings et al., 2021; Stanley et al., 2020). Integration of key stakeholders during program development can increase cultural relevance, reduce barriers to community participation, and help inform a reflexive and community-driven response (Hussen et al., 2020). Moreover, a body of literature calls for better integration of humanism in health care, emphasizing how care that acknowledges social, spiritual, and mental well-being can promote better provider–patient relationships and reduce barriers to quality health care (Branch et al., 2001; Miller & Schmidt, 1999; Weissmann et al., 2006). These practices are essential to public health responses in culturally diverse and medically underserved communities in Arizona. The establishment of evidence-based interventions that build upon the many perspectives, ways of knowing, and experiences of indigenous communities is especially essential for supporting communities who have experienced historical oppression and have justified mistrust in the biomedical and research systems (Guadagnolo et al., 2009; Pacheco et al., 2013). Public health practices that include CHWs or promotores de salud, door-to-door outreach, and a family-centered approach have been shown to increase case identification in indigenous and Hispanic communities (Chugg et al., 2021; Close & Stone, 2020) and fill gaps in traditional public health case investigation and contact tracing (Jehn et al., 2022).

Despite the support for community-based practice, there is an ongoing knowledge-practice gap where many public health efforts are limited in their integration of community perspectives and thus limited in their ability to uphold principles of equity throughout the implementation of public health interventions (Heinzmann et al., 2019). These limitations create challenges to optimally allocating and mobilizing existing community-based public health resources and strategies to enhance access, awareness, and uptake of preventive measures amid an unprecedented emergency such as COVID-19 (Purnell et al., 2016).

Context in Guadalupe, Arizona

The town of Guadalupe is a uniquely diverse community of 6,700 residents in Maricopa County, Arizona, composed of three distinct cultures: Pascua Yaqui (“Yaqui”), Sonoran Mexican, and descendants of the original farmers of Arizona (Trujillo, 2007). Approximately 36% of the residents of Guadalupe identify as Yaqui and 71% identify as residents of Hispanic descent (U.S. Census Bureau, 2020a). The Pascua Yaqui Tribe is a sovereign nation governed by a Tribal Council, with approximately 4,000 enrolled members across five communities throughout Tucson and southeastern Phoenix, including Guadalupe. All Pascua Yaqui members are eligible for free health care through the Indian Health Service (IHS) and tribal-managed health care facilities.

Guadalupe residents may be more vulnerable to negative impacts of COVID-19 due to structural-level health inequities within the community; compared with the surrounding Maricopa County (the fourth most populous county in the country with a population of approximately 4.5 million) (U.S. Census Bureau, 2021), Guadalupe residents experience a higher incidence of poverty, higher housing density, and lower access to technology (Table 1; U.S. Census Bureau, 2019a, 2019b). Most notably, residents in Guadalupe face poverty at a rate that is more than three times the rate in the surrounding county, and Guadalupe has nearly 16.5 times more residents per square mile than the surrounding county (U.S. Census Bureau, 2019a, 2019b). The town of Guadalupe is rated 0.986 on the CDC Social Vulnerability Index, indicating high vulnerability to potential negative effects from external stresses on human health, such as disease outbreaks (possible scores range from 0, lowest vulnerability, to 1, highest vulnerability; CDC/Agency for Toxic Substances and Disease Registry [ATSDR]/Geospatial Research, Analysis, and Services Program, 2018).

Table 1.

Measures of Social Vulnerability in Guadalupe and the Surrounding Maricopa County.

Measure of Social Vulnerability	Maricopa County, AZ	Guadalupe, AZ	Difference Guadalupe compared to Maricopa County
Population, 2021 estimate	4,496,588	6,700	—
Average household size, 2015–2019	2.75	3.68	34% higher
Population per square mile, 2010	414.9	6,833.00	16.5 times higher
Median household income, 2015–2019 (in 2019 dollars)	$64,468	$38,125	41% lower
Persons in poverty (Human Poverty Index), 2019	11.60%	35.60%	3 times higher
Subscription to broadband internet, 2015-2019	83.60%	53.10%	36.5% lower
CDC Vulnerability Indexa, 2018	0.635	0.986	—

Note. All figures are pulled the most recent US Census data available for each measure. CDC = Centers for Disease Control and Prevention.

^aPossible scores range from 0 (lowest vulnerability) to 1 (highest vulnerability).

Guadalupe, however, is a remarkably resilient community that is woven of families who have built and resided in the town for generations. Throughout their history, Guadalupanos have honed their strengths as an intergenerational community and drawn upon the rich history and culture of their ancestors to overcome injustices, advocate for equity, and adapt to uphold the vitality of their community (Meeks, 1998; Wieck, 2010). The ways of knowing of the Yaqui people, particularly, rely heavily on storytelling from elders and conversations with families in their homes; these means are imperative for cultural preservation in the community (Pascua Yaqui MSPI, 2020). Both reflection of past adversity endured and conquered by Guadalupanos and the continued goal of cultural preservation have laid a foundation for a unified community response to the pandemic that emphasized the Yaqui core principle of including all and excluding none.

Response Coordination: The Guadalupe Community Response Team

The first confirmed positive COVID-19 case in the town of Guadalupe was reported the week of April 19, 2020. Ongoing wastewater surveillance testing by the City of Tempe detected elevated levels of SARS-CoV-2 above baseline in the town of Guadalupe in the first week of May (Fontenele et al., 2021), which served as a clear indicator that COVID-19 was spreading rapidly in the community. On June 3, 2020, in response to this substantial rise in new cases, the Town declared a State of Emergency and activated an Incident Command Structure. On June 5, 2020, a network of community, academic, and public health partners came together to design and implement a pandemic response program called the Guadalupe COVID-19 Community Response Team (GCRT). The GCRT utilized this interdisciplinary network of partners to deliver a community-driven program that aimed to increase access to culturally, linguistically, and geographically attuned public health activities within the town.

The GCRT had three objectives: (a) increase equitable access to COVID-19 resources, including testing, home isolation support, health services, and social support services in the town of Guadalupe; (b) develop novel and intensive outreach efforts that were grounded in the culture of the community; and (c) build strategic partnerships with local health agencies to increase the collective capacity of partners to address disparities in COVID-19 morbidity and mortality rates among families living in Guadalupe. GCRT partners included the Town of Guadalupe leadership (ToG), the Pascua Yaqui Tribe (PYT), Native Health, the Maricopa County Department of Public Health (MCDPH), and the Arizona State University Student Outbreak Response Team (ASU SORT). It is important to emphasize that when developing the GCRT, key funding agencies of the response (MCPDH and PYT) advocated for equitable allocation of funds to the town in efforts to effectively mitigate the rapid spread of SARS-CoV-2 in Guadalupe, a medically underserved community in Maricopa County.

GCRT Partner Roles

Each of the five partner organizations played a crucial role in the design, implementation, and evaluation of the GCRT, collaborating with one another to strategically bolster each entity’s unique expertise and resources with the intention of equitable role delineation. For instance, MCDPH provided funding, public health expertise, technical and logistics support, and ongoing data analytics. ToG leadership was integral to identifying community needs and acted as a trusted bridge to community members, especially with two trained promotores de salud—“promotoras”—who were uniquely positioned to provide essential insight on and connection with the community. The ToG Public Information Officer also developed and delivered health communication materials regarding pandemic safety to the community. With expertise in the health care already embedded in this community, PYT and Native Health provided cultural sensitivity training to ASU SORT, ongoing medical surveillance, community education and outreach, and implemented vaccination and testing events. Importantly, PYT provided a $2 million gift to support the response in the Guadalupe community. Together, ToG and PYT leadership, including PYT Cultural Specialists, facilitated community engagement in GCRT activities and were crucial in conveying the gravity of the pandemic to community members, emphasizing the importance of protecting the elders and youth of the community for continued cultural preservation. Finally, ASU SORT supplied a door-to-door field epidemiology team, conducted case investigations and contact tracing, and supported COVID-19 testing and vaccination events in the town (Ledesma et al., 2022). Prior to the pandemic, this network of partners had established informal connections through years of collaborative projects, which allowed for a rapid scale-up, moving from stakeholder meetings to a community response in a matter of weeks.

Feedback and Response: How the Network Worked

To foster iterative reflection on community needs and the progression of the program, the GCRT established formal and informal channels for feedback between partners and with the community. First, GCRT partners established a formal, weekly planning meeting that was led by MCDPH to provide a platform for discussion and decision-making related to the implementation of programmatic activities. In facilitating these activities, especially regarding case investigation and contact tracing, the GCRT prioritized the creation of integrated, transparent data infrastructures in efforts to uphold the principles of indigenous data justice and sovereignty (Taylor et al., 2020; Taylor & Kukutai, 2016). These infrastructures included weekly case reports from MCDPH to GCRT partners and daily case reporting of PYT cases among ASU SORT, MCDPH, and PYT.

These formal channels fostered the growth of informal communication and support processes that became integral to the success of the project during implementation. Collaborators shared relevant training and expertise to support the project. For instance, ASU SORT and MCDPH shared pertinent public health knowledge with ToG, PYT, and Native Health; PYT provided tailored training on cultural sensitivity to ASU SORT; and ASU SORT supplied training on empathic communication to MCDPH. Decisions made at weekly meetings were foundational to the creation of informal, bidirectional channels for community feedback. These informal channels provided key insight on the impact of GCRT programmatic activities in real time. By reflecting on feedback brought forth by the community during events, Guadalupe Town Hall meetings, social media engagement, and in one-on-one interactions during case investigation calls and home visits, the GCRT implemented reflexive changes as needed to increase access to these resources on community, household, and individual levels.

In this article, we describe the COVID-19 outbreak response efforts implemented by the GCRT as well as the impacts of these efforts in the Guadalupe community during the period of June 2020 through December 2021.

Method for Assessing the Impact of GCRT Activities

To assess the impact of programmatic activities implemented by the GCRT, we utilize a mixed-method approach, combining analysis of public health evaluation metrics for case investigation and contact tracing (CDC, 2021b), vaccination uptake, resource provision, and thematic data from key informant interviews.

Public Health Evaluation Metrics Collection and Analysis

Public health evaluation metrics included are: (a) incidence of new cases in Guadalupe; (b) ratio of new COVID-19 cases/week in Guadalupe compared with that of Maricopa County; (c) total number of case investigation interviews completed by ASU SORT in Guadalupe; (d) total number of cases not reached; (e) average number of contacts elicited per case interview completed; (f) average time to complete a COVID-19 case investigation from assignment; (g) total number of needs-based assessments completed; (h) total number of household care packages provided; (i) number of referrals for at-home testing and isolation accommodations provided; (j) percentage of eligible Guadalupe residents vaccinated; (k) number of COVID-19 testing and vaccination events held; and (l) number of COVID-19 testing and vaccination event attendees. We utilized these metrics to determine the success of increasing access to COVID-19 resources within the community, which is defined in this article as a reduction of new cases in Guadalupe from the initial peak in May 2020, sustained provision of community- and household-centered resources (i.e., number of household care packages delivered throughout the response, enough referrals and COVID-19 testing and vaccination events to meet demand), and the development of local public health infrastructure and capacity.

Several of the metrics we present were collected by ASU SORT on behalf of MCDPH and PYT and required the integration of one or more datasets housed in online repositories. This project utilized a Microsoft SharePoint list in a secure data environment to import cases investigated by ASU SORT and to denote the outcome of each case interview. Each case was identified by a unique ID in the statewide, centralized Medical Electronic Disease Surveillance Intelligence System (MEDSIS).

We tracked the number of days between when the GCRT was assigned the case from MCDPH (i.e., import date) and when the case was closed by a member of the team (i.e., closing date). At the time of closing, each case was either marked “Interview Completed,” when a case investigator (CI) completed a full interview with the case, or “Lost to Follow-Up” when a CI was unable to complete an interview after at least two call attempts. Together, the number of Interviews Completed and Lost to Follow-Up is equal to the total number of cases closed.

To identify the number of case-reported close contacts (individuals who may have been exposed to COVID-19 by the case), we queried a Qualtrics database containing completed interview data using the MEDSIS IDs listed in the abovementioned SharePoint list. We tallied the number of contacts elicited for each Interview Completed and used this to calculate the weekly average number of case-reported close contacts for cases residing in Guadalupe.

To draw a comparison between Guadalupe and the surrounding Maricopa County, case rate ratios were generated by dividing the weekly rate of incident COVID-19 cases in Guadalupe by the weekly rate of incident COVID-19 cases in Maricopa County.

Data on the rates of vaccination in Guadalupe are captured by the Arizona State Immunization Information System. The cumulative percentage of town residents who were fully vaccinated is displayed weekly based on the population eligible. Fully vaccinated includes all persons who have completed the appropriate primary series of the Johnson & Johnson (one dose) or Moderna/Pfizer (two doses) COVID-19 vaccines.

Other relevant datasets, such as needs-based assessment data collected by ASU SORT, were stored in a Microsoft Access database in a secure computing environment. Data regarding the number of COVID-19 testing and vaccination events and the number of attendees at these events were provided by Native Health. All data regarding the number of events and attendees were de-identified and provided to the research team in aggregate.

GCRT Qualitative Data Collection and Analysis

We analyzed interview data from members of the GCRT representing all partnering organizations (n = 7) to identify salient themes regarding the perceived factors that impacted program implementation. All participants were recruited due to their expertise and role in the GCRT. We also utilized focus group discussion data collected by the ASU Southwest Interdisciplinary Research Center and MCDPH (Hamm et al., 2021). As part of a MCDPH-led effort to gauge the impact of the COVID-19 pandemic in the community, the MCDPH research team conducted 33 focus groups with 186 participants in 15 geographically distinct regions in Maricopa County. We utilized data from one focus group discussion conducted in May 2021 with six members of the Guadalupe community. The focus group discussion guide asked participants about the impact of COVID-19 on their family and perceptions of communication and messaging regarding COVID-19.

Two members of the research team transcribed the key informant interviews and focus group discussions. The coding team then developed the codebook inductively, iteratively meeting to discuss key themes that emerged from the data and refine the codebook. Once the team reached a consensus regarding the codebook, each member coded the rest of the transcripts independently. The codebook outlined partner and community member perceptions of the pandemic’s impact on Guadalupe, the success of the GCRT, and factors that contributed to and challenged the success of the program.

Authorship: An Equitable Approach to Determining Author Order

In a conscious effort to determine equitable authorship for this article, we utilized the process outlined by the Civic Laboratory for Environmental Action Research (CLEAR) for deciding author order. This process was developed in effort to challenge the traditional paradigm for authorship determination in academia where women, junior researchers, and people of color historically receive less credit for equal work (Liboiron et al., 2017).

Epidemiology and Outbreak Timeline

Throughout May 2020, the average weekly rate of COVID-19 cases in Guadalupe was 13.9 times as high as the surrounding Maricopa County rate, peaking at 25.4 times as high during the week of May 31, 2020. In May 2021, there was a distinct decrease in the case rate ratio comparing Guadalupe to Maricopa County, where the weekly case rate ratio, on average, was sustained at <3. By the week of September 26, 2021, the case rate ratio comparing Guadalupe to Maricopa County decreased further, with a weekly case rate ratio that remained at <1 (Figure 1).

Figure 1.

COVID-19 Case Rate Comparison in Guadalupe Versus Maricopa County, Arizona From April 2020 to December 2021.

GCRT Programmatic Activities

Programmatic activities implemented by the GCRT included enhanced public health case investigation and contact tracing, community-based testing and vaccination sites, and social support service provision (Table 2).

Table 2.

Guadalupe Community Response Team Activities Timeline.

Response measure	Activities	Initiation date
Emergency Response	Town of Guadalupe Mayor declares State of Emergency and activates Incident Command Structure	06/03/2020
	Establishment of Guadalupe Community Response Team	06/05/2020
Partnerships	Weekly strategic meetings for GCRT partners	06/05/2020
	Strategic meetings between ASU SORT and promatoras	07/09/2020
	Data sharing systems established among GCRT partners	07/16/2020
Communications	Town Council meeting—COVID-19 status reports as an agenda item	06/05/2020
	Health communication campaigns	06/19/2020
Epidemiology & Public Health Case Investigation & Contact Tracing	Weekly case report from MCDPH to all partners	06/08/2020
	Daily reporting of Guadalupe case data to ASU SORT	07/16/2020
	Enhanced door-to-door case investigation begins	07/22/2020
	ASU SORT becomes delegated authority for Pascua Yaqui Tribe case investigations	08/10/2020
	GCRT-led contact tracing efforts	11/17/2020
	Additional collection of close contacts at time of testing	02/13/2021
Infection Control & Prevention	Monthly collaborative COVID-19 testing events	05/28/2020
	Home testing made available by Native Health	02/03/2021
	Monthly collaborative COVID-19 vaccination events	03/10/2021
	Back-to-School COVID-19 Vaccination Event	07/24/2021
	Biweekly COVID-19 booster clinics	11/03/2021
	Monthly pediatric COVID-19 vaccination clinics	11/13/2021
Social Support & Resource Provision	Household needs-based assessments conducted with cases	07/22/2020
	Weekly home isolation care packages delivered	07/24/2020
	Guadalupe hotel contract established for quarantine and isolation	07/24/2020
Safe Practice for Community Gatherings & Events	Día de los Muertos commemoration	11/02/2020
	Thankful Saturday	11/21/2020
	Easter and Lenten ceremonies	03/30/2021
	Día del Niños	04/30/2021
	Navidad en Guadalupe	12/18/2021

Note. GCRT = Guadalupe Community Response Team; ASU SORT = Arizona State University Student Outbreak Response Team; MCDPH = Maricopa County Department of Public Health.

Given the rise in positive COVID-19 cases in the community, key partners reported that the primary goal for the GCRT was to utilize an equity-centered approach to limiting the spread of SARS-CoV-2 and providing resources to individuals impacted by COVID-19. In particular, key partners commented on the importance of tailoring the response to optimize the reach of services provided to all members of the community. Given the prevalence of multigenerational households in Guadalupe, GCRT partners implemented a door-to-door approach that offered resources to all members of a household to isolate and quarantine safely:

[Guadalupe] became this hotspot [for COVID-19] that the county [health department] really wanted to send additional resources to. One of the other unique components to Guadalupe is that they have a lot of multi-generational housing and living arrangements and so you have a really dangerous situation for an infectious disease, with crowding. . . so it really required kind of a more sort of delicate, culturally sensitive response [to limiting the spread of SARS-CoV-2]. (GCRT Partner 5)

These activities, although more resource intensive, were selected to overcome potential barriers to access, such as language and transportation barriers, external costs associated with obtaining COVID-19 testing and vaccination, and distrust of public health authorities.

Enhanced COVID-19 Mitigation: Door-to-Door Case Investigation and Contact Tracing

Under a data-sharing agreement between ASU SORT and MCDPH, and with the consent from PYT authority, ASU SORT was notified daily of new cases in the town starting July 2020. All three partners tracked case-based data through MEDSIS. ASU SORT conducted both telephonic and in-person case investigation and contact tracing in efforts to reach as many cases as possible. The team used a web-based questionnaire in Qualtrics to provide investigation information to MCDPH, including information on close contacts and their telephone numbers for contact tracing purposes. GCRT partners found that conducting interviews in person assisted with engaging directly with cases:

We can have a two way system of case investigation [in Guadalupe], which is both virtual and with in-person interviews, and getting to the people physically who need the help with the resources that we have and the ways that they see fit to reach them. (GCRT Partner 4)

In total, ASU SORT completed case investigations for 912 cases, with 572 (63%) cases that completed the interview and 340 (37%) cases that were lost-to-follow-up and mailed isolation and quarantine guidance. ASU SORT closed cases an average of 1.95 days from assignment to the team. Of the cases interviewed, 38% provided at least one close contact. On average, each case provided at least 1.07 close contacts during the contact elicitation portion of the interview. Figure 2 shows the number of cases supported by the GCRT compared with the number of positive COVID-19 cases in Guadalupe and the average number of contacts elicited from cases.

Figure 2.

Cases Closed and Close Contacts Elicitation Metrics From July 2020 to December 2021—Guadalupe, Arizona.

Needs-Based Assessments: Household-Level Resource Provision

A core component of the GCRT’s door-to-door approach was conducting a needs-based assessment in tandem with the case investigation interview to provide isolation care packages and other resources to assist households, which were often multigenerational, with safe isolation and quarantine practices.

The needs-based assessments covered the following topics: (1) case and household health; (2) the ability of other household members to care for the case during the isolation period; (3) household need for COVID-19 testing; (4) household need for isolation accomodations and; (5) food and household supplies needed to safely isolate. Once the assessment was completed, the promotoras and ASU SORT worked in partnership to gather the needed supplies and food and coordinate appropriate resources and services, such as COVID-19 testing or referrals for isolation accommodations, if indicated. In response to new needs voiced by community members who completed it, the needs-based assessment was iteratively updated to include additional services and supplies that could be offered in the community. Of the 572 cases that completed the case investigation interview, 474 (83%) completed needs-based assessments, indicating various services and referrals needed by household members.

Isolation Care Packages

Of the 474 needs-based assessments completed, 200 (42%) cases requested a care package to assist with safe isolation and quarantine practices in their household. Each care package included items households were unable to access during their isolation or quarantine period, including groceries, cleaning supplies, masks, hand sanitizer, and child care supplies (e.g., diapers and baby formula).

Isolation Accommodations

In responding to feedback provided by cases who lived in multigenerational households that made safe isolation difficult, the GCRT adapted the needs-based assessment to include questions regarding the need for isolation accommodations. Given the high transmissibility of SARS-CoV-2, MCDPH worked to secure isolation housing at hotels within the local area, and these accommodations were offered to cases of individuals infected with SARS-CoV-2 who did not have the means to isolate away from their families. Overall, 16 referrals were made for individuals to utilize these isolation accommodations.

At-Home COVID-19 Testing Kits

In December 2020, the field team observed that there was a disproportionate number of household members who were unable to access COVID-19 testing due to transportation barriers, especially among children, elders, and people living with disabilities. These observations were relayed to the GCRT during weekly meetings, where partners proposed avenues to provide at-home testing. In collaboration with Native Health and MCDPH, the needs-based assessment was updated in February 2021 to collect requests for nurses to visit households to provide polymerase chain reaction testing. In total, 26 individuals requested at-home COVID-19 testing services. Ten individuals received this at-home testing, while 16 were lost to follow-up or no longer required the service due to logistical difficulties.

COVID-19 Testing and Vaccination Events

All GCRT partners helped Native Health facilitate community-wide free COVID-19 testing events available for walk-ups and without appointments (Figure 3). Events were often coupled with additional medical and social support services, such as flu shots and the provision of care packages that included masks, hand sanitizer, and household cleaning supplies. In total, Native Health with the support of other GCRT partners held seven community COVID-19 testing events from June 2020 to December 2021, with a total of 690 Guadalupe residents attending these events.

Figure 3.

Family Attending a COVID-19 Testing Event in Guadalupe, Arizona.

The GCRT supported the expansion of access to COVID-19 vaccination within the Guadalupe community. Due to barriers in working internet, time, transportation, and accessible communication, Guadalupe community members were not always able to utilize the broader Arizona COVID-19 vaccine distribution system. In light of these barriers, the GCRT created walk-in opportunities for vaccination that were in close proximity to Guadalupe residents and maintained staff and volunteers who spoke Spanish (Figure 4). The GCRT also took care to tailor events based on up-to-date Food and Drug Administration vaccination recommendations to increase accessibility for each newly eligible demographic (i.e., minors who first became eligible on November 2, 2021).

Figure 4.

Native Health Staff Registering Community Members at a COVID-19 Vaccination Event in Guadalupe, Arizona.

In total, 2,300 individuals attended the 17 vaccination events held in Guadalupe from March 2021 to December 2021, of which 2,185 were Guadalupe residents. Since the first vaccination event on March 10, 2021, vaccine uptake among eligible Guadalupe residents increased from under 20% at the end of March 2021 to above 40% in September 2021. As more populations became eligible for vaccination, the percentage of eligible residents vaccinated remained above 40% through December 2021 (Figure 5).

Figure 5.

Percentage of Eligible Population Vaccinated Against COVID-19 From March to December 2021—Guadalupe, Arizona.

As the GCRT worked in the community to increase vaccine uptake, key partners discovered notable additional barriers: families reported waiting to receive the vaccine until every household member (including children) was eligible, and community members shared hesitancy in receiving the vaccine due to concerns about safety and effectiveness.

Culturally Grounded COVID-19 Health Communication

Public health messaging was a crucial component of the GCRT emergency response. The ToG Public Information Officer and PYT Cultural Specialists created relevant and accessible public health communication on COVID-19 safety protocols (e.g., quarantine and isolation guidance), vaccine appointment enrollment, and accessing resources through the promotoras. Different mediums and platforms were utilized for this messaging, including videos pertaining to the pandemic response in the community and infographics/fliers that communicated relevant public health information. The GCRT then used the town’s existing communication infrastructure, such as the Town of Guadalupe and Pascua Yaqui Tribe official Facebook pages, websites, and Town marquee, to post and amplify these deliverables.

In the creation of these materials, the ToG Public Information Officer considered the importance of utilizing key leadership within the community, such as elected officials and community leaders (Henrich, 2011). In the summer of 2020, the ToG began to relay public health information by way of public service announcements (PSAs) that featured elected officials. In these announcements, leadership, including the town’s elected state senator, encouraged people to adhere to safety protocols, such as mask wearing and provided information to residents on how to access external testing sites (Figure 6). PYT Cultural Specialists also created tribal-specific PSA videos that were sent to the community via social media. These 1- to 2-minute videos were created to highlight the strengths of the Tribe and convey the importance of unity in overcoming the pandemic. Consistent with all Maricopa County public health materials, communication materials were provided in both English and Spanish, to reflect the Spanish-speaking population in Guadalupe (Figure 7).

Figure 6.

#MaskUpGuadalupe Social Media Campaign Featuring Town of Guadalupe and Pascua Yaqui Leadership.

Figure 7.

Guadalupe COVID-19 Safe Practice Communication Materials in English and Spanish Developed by the Town of Guadalupe Public Information Officer.

Reducing Risk of Transmission at Cultural and Community Gatherings

Given the importance of the community’s cultural traditions such as holding wakes (velorios) and celebrating Día de los Muertos and the Lenten season (Trujillo, 2007), the GCRT applied a holistic, harm reduction approach to mitigating SARS-CoV-2 transmission at these gatherings that heavily relied on the promotoras’ and PYT Cultural Specialists’ expertise in navigating the provision of appropriate and relevant public health guidance while respecting the sanctity of these important cultural events.

Guidance was developed by PYT Cultural Specialists in consultation with ToG and PYT leadership and local public health to reduce the duration and intensity of exposure to SARS-CoV-2 aerosols. Wakes were moved out of private homes and relocated to an open-air tent near the town church. In addition to modifying the physical space, additional procedures were in place to reduce the risk of COVID-19 transmission during meal service, including proper handwashing or use of hand sanitizer before and after eating and expanding disinfection or sanitization practices to include makeshift food surfaces (such as tables) between each use. Food was prepared at home and served by a designated family member. Families were seated at tables with social distancing and faced in one direction to minimize face-to-face contact while eating unmasked. Family members were encouraged to wear masks during ceremonies and the length of ceremonies was reduced to a few hours, a marked departure from traditional cultural gatherings which can extend into the night. The promotoras alongside other GCRT volunteers attended these events to provide masks and hand sanitizer and support families.

The public health guidance was also provided at Día de los Muertos celebrations at the town cemetery on November 2, 2020, and subsequently at other community gatherings, such as Easter & Lenten ceremonies held throughout April 2021. The GCRT also held events such as “Thankful Saturday” (the weekend before Thanksgiving Day) on November 21, 2020, and Dìa del Niño (an annual celebration honoring children in Guadalupe) on April 30, 2021, where volunteers provided packages with masks, hand sanitizer, and food items in efforts to provide resources to help minimize the potential spread of COVID-19 at gatherings that may take place during important holidays in the community.

Lessons Learned: Important Considerations When Developing a Community-Driven Public Health Response

Building Trust in the Community: Promotoras de Salud and Tribal Leadership

The promotoras were instrumental in facilitating engagement with activities conducted by external partners such as ASU SORT and MCDPH, as they provided key cultural guidance and insight into best practices for visiting cases and families in their households. Because of their deep connection to and highly respected role in the community, the promotoras cultivated trust and mutual respect between community members and the GCRT, promoting community participation in public health case investigation activities. Members of the Guadalupe community confirmed this, expressing how their trust in the GCRT was facilitated by the promotoras’ active participation in GCRT activities, such as calling cases to gauge household needs for quarantine and isolation:

I’m going to tell you honestly, I had seen this flier [about the promotoras]. I had come across it and I didn’t think anything of it until [a promotora] called me. When [the promotora] called me and then she followed up with a text, I thought, okay, well, this is something (GCRT activities) I can trust. (Community Member 1)

In addition, key partners credited the promotoras with facilitating engagement with case investigation and resource provision activities, specifically noting how the promotoras provided key cultural insight, trust, and connection with members of the community:

We (ASU SORT) came as partners and in so doing, we work with two promotoras—these are residents within Guadalupe—who every time we’re in the field every day that we are in the field will work side by side. They know their neighbors and know the issues surrounding their neighbors. (GCRT Partner 4)

Representation from town and tribal leadership was also integral in facilitating initial trust between the GCRT and community members. Community members reported their appreciation for the prompt response from PYT and ToG leadership in addressing the rise in COVID-19 cases in the community during the summer of 2020: “I just thank God for the tribe (leadership), because they reacted. They didn’t wait for government. That was the biggest thing we don’t have to wait for government, we do what we’re going to do for our people” (Community Member 2).

Although the GCRT made strides in building trust among community members, there were initial barriers to the acceptance of GCRT partners and activities from the community. Some community members reported that there was not enough visibility of GCRT partners in Guadalupe and that this contributed to their initial hesitation to accept GCRT efforts:

There’s people that have come in and out, in and out of Guadalupe, but where are they? So maybe even showing your faces. . .coming down to the uh, the vaccine event, or when they give out the food on Tuesdays here at the town where people can start seeing, connecting a flier to a person. (Community Member 1)

GCRT partners addressed this initial resistance by utilizing the town’s well-established and frequented social media platforms to introduce GCRT partners via short videos. These videos were paired with field photographs of both the promotoras and members of ASU SORT conducting fieldwork such as delivering household care packages to families in quarantine and conducting case investigation interviews. Community members were also provided information about how to connect with the GCRT and promotoras if they had any questions or concerns throughout the duration of the program.

Community members emphasized the importance of external partners having a sustained presence in the community. Some members of the community described how external partners in past instances would show interest in providing resources but ultimately leave the community after a short period of time. Guadalupe community members expressed how the ability of partners to show genuine interest and sustained support can help maintain trust among those who are not part of the community:

Having a presence not just once in a while, but having that presence consistently helps build rapport, helps build trust, you know if you are consistent and genuine, and not just there, when you know one for your mandated session to meet some quota that would help [maintain trust in the community]. (Community Member 3)

Given the importance of continued presence, GCRT partners actively sought to establish a sustainable model for the program. This model included the extension of the promotoras’ work in the community for an additional year (until June 2022), which was unanimously determined by partners in December 2021 prior to subsequent increase in COVID-19 cases that occurred in Guadalupe and across the United States.

Initiating and Maintaining a Multisectoral Network of Partners

The majority of key partners reported that they believed the success of the program was largely due to the constant flow of information, knowledge, and distinct resources and expertise provided by each partner organization. Weekly meetings among key GCRT partners were cited as a means of facilitating sharing of information; key partners found that the frequency of these meetings assisted in the decision-making process, facilitating real-time decision-making grounded in data provided by MCDPH, ASU SORT, and PYT:

How do you put the band together to utilize their strengths? Once we started figuring that out, and getting a new rhythm, who is doing what, what resources you bring, what gaps need to be filled by whom, then it started rolling. (GCRT Partner 2)

Although the preexisting foundation of this network was instrumental in scaling up the response in Guadalupe, GCRT partners cited some initial hardships in determining partner roles and responsibilities, particularly regarding those for external partner organizations. When first establishing the team, GCRT partners cited difficulties in the initial decision-making for the response; each organization was cautious in their actions in efforts to avoid overstepping one another given that each partner provided important, relevant expertise in best practices to address the rise in cases in the community. One GCRT partner describes their thoughts about the initial scale-up of the response, stating,

In the beginning, I think it was a little rocky, we (the GCRT) didn’t know what anyone was doing. Sure. You know, I know we did it. But as time has gone by, and now we are just trying to stay ahead of the game. (GCRT Partner 6)

However, once the partners continued to work with one another, meeting iteratively to plan additional response activities in the community and developed more meaningful rapport, GCRT partners began to develop a feedback system that leveraged each organization’s capital and expertise to implement and provide appropriate health and social support resources to the community.

Challenges in Balancing COVID-19 Guidanceand Yaqui Cultural Preservation

Early in the pandemic, PYT cited challenges in balancing COVID-19 guidance provided by the CDC with guidance that was relevant to and adoptable by the community. Although PYT leadership seriously regarded every COVID-19 recommendation provided by public health authorities at the federal, state, and local levels, the Tribe also acted upon self-determination to adapt the provided guidance in efforts to ensure the safety of the community. PYT Cultural Specialists in the community spoke of the difficulties in adapting this COVID-19 guidance to both protect community members and allow families who had lost loved ones to grieve properly through holding velorios, expressing how navigating the novelty and unpredictability of the pandemic in relation to Yaqui cultural preservation was challenging. The prominent kinship networks of godparents (madrinas and padrinos) within the community are essential for velorios in Yaqui tradition; when those who have passed are unable to have a traditional velorio, madrinas, and padrinos are not given the opportunity to provide their blessings as the deceased makes their way to the Sewa Ania (the spirit world for the Yaqui people). PYT Cultural Specialists communicated guidance that prioritized not only the physical health of the community but also spiritual well-being for generations to come.

Residents of the town of Guadalupe experienced a high mental health burden as a result of the significant number of community members who had passed due to COVID-19 and carrying the emotional weight of balancing the potential risk to others in the community from both attending and hosting traditional burial practices. One GCRT partner explained the importance of holding these events in the community, describing the salience of Christianity and Catholicism to both Hispanic and Yaqui traditions: “In the Catholic heritage, funerals are big, changing that culture where you aren’t going to pay respect is incredibly difficult on a personal and spiritual level” (GCRT Partner 2). Although some Catholic services could be attended via web conferencing applications such as Zoom, many of those that took part among tribal members were unable to be viewed online; this was a conscious decision by many families in efforts to preserve tradition and avoid any potential exploitation of ceremonies.

Distinctly, community members expressed how difficult the summer of 2020 was for the town of Guadalupe due to the number of deaths resulting from COVID-19. One community member described,

I live right by the church and when a member of the tribe or somebody in the community passes away the bells ring at the Church. For us, it was the summer of the bells because we heard it. We kept hearing and hearing it. (Community Member 1)

For an additional overview of the GCRT, please visit our digital narrative website that includes photos of key stakeholders and program activities: (https://tinyurl.com/GCRTstory).

Photo permissions were obtained from all participants.

Discussion

The Town of Guadalupe and the Pascua Yaqui Tribe, a sovereign tribal nation, were disproportionately affected by the first three waves of the COVID-19 pandemic. Local partners came together to create a multisectoral COVID-19 response team focused on equitable and enhanced public health case investigation, culturally grounded interventions, and emergency response coordination and communication. These collective efforts aimed to reduce community transmission and increase access to COVID-19 testing, vaccination, and social support services.

A notable strength of the multisectoral collaboration was each partner’s ability to leverage their distinct social, cultural, or financial capital in bolstering the response in the community. In particular, social and cultural capital provided by partners from PYT and the ToG in the form of community leadership and connection were integral in the acceptance of the GCRT, as it was important for community members to see leaders from their community activities to support them during this public health crisis. GCRT partners also prioritized the inclusion of CHWs, the promotoras, in the GCRT model, which was found to be critical to the success of the program. The promotoras alongside PYT Cultural Specialists provided relevant knowledge regarding cultural customs and norms within the Guadalupe community and within the Pascua Yaqui Tribe. Specifically, without the promotoras, GCRT partners who were external to the town, such as MCDPH and ASU SORT, would have faced large hurdles to gaining acceptance and trust from community members. This is consistent with past literature that demonstrates the importance of community members leading interventions implemented in communities that are historically marginalized. This not only promotes equity within health promotion but also increases acceptance and accessibility of public health services among populations that may experience medical mistrust due to legacies of medical and scientific mistreatment (Anderson et al., 2015; Peteet et al., 2021).

An important component to the success of the response program was Guadalupe’s deeply embedded value of community interdependence and humanism. The town of Guadalupe is often described as a close-knit, resilient community, where residents have worked together to overcome historical adversity (Meeks, 1998). This ideology is exhibited throughout the response provided by the GCRT and is most notably demonstrated by ToG and PYT leadership who provided a strong, united front in addressing the pandemic and helping their community during this emergency. The strong leadership in Guadalupe is paralleled by the strengths of the community. Residents of Guadalupe, who generally hold more collectivist, humanistic views surrounding well-being (Meeks, 1998), quickly mobilized and engaged in the GCRT during this emerging crisis to protect their community. This engagement upheld a critical, bidirectional feedback loop between community members and GCRT partners, facilitating the successful implementation of the GCRT.

Both formal and informal channels of communication among key partners and with community members helped tailor a community-driven response that aimed to increase access to health and social support services at multiple levels; GCRT partners actively listened to needs voiced by the community and worked to provide effective timely support in response. Not only did this help inform an effective and relevant response within the community but in turn nurtured the presence and trust of GCRT partners and programmatic activities within the community. GCRT partners also found that weekly partner meetings facilitated real-time dissemination of data that informed programmatic activities implemented by the team. Future implementation of CBHPs should prioritize the creation of feedback systems to ensure that community stakeholder insight is embedded into the building of relevant and informed health promotion interventions.

The GCRT also supported the continuation of culturally significant traditions by providing guidance to minimize potential transmission during larger gatherings. In light of the mental and physical health burden placed on the Guadalupe community due to loss experienced during the pandemic, GCRT partners unanimously agreed that a humanistic approach to COVID-19 mitigation that respected long-standing traditions in the community was a priority. This was also in line with guidance from PYT Cultural Specialists, and the goal for cultural preservation during the pandemic. Past literature demonstrates the importance of respecting community cultural and social norms in designing and implementing CBHPs—lack of consideration of these norms has been found to negatively impact community acceptance of health programs designed to address the spread of disease for other epidemics such as Ebola and HIV (Manguvo & Mafuvadze, 2015; Mayer et al., 2021).

The GCRT took great care to reflexively incorporate feedback from the community into a pandemic response that emphasized humanistic care, supporting the establishment of a sustainable public health infrastructure in the town of Guadalupe. However, through the majority of the pandemic, case incidence rates in the town of Guadalupe remained above the county average and vaccine uptake was below that of the county, implying that vaccine hesitancy may remain an issue in the community. This highlights the critical need for continued, community-based efforts to address the gaps in access and engagement in health promotion interventions among communities that are historically marginalized and thus may have justifiable mistrust of biomedicine. Public health must continue to build trust through mutual respect and transparent, community-centered health communication to work collaboratively with these communities (Henrich, 2011).

Limitations

There are several limitations associated with our findings. First, due to the emergency nature of initiating the GCRT, we did not create an evaluation framework prior to implementing the project. Given resource and time constraints, we were unable to collect additional evaluation data post-implementation of the GCRT, thus limiting our analysis to secondary data collected as part of routine public health case investigation and other ongoing projects in the community. This implies that our findings may not fully capture the diversity of opinions regarding the impact of the GCRT within the Guadalupe community. We also cannot assume a casual association between the GCRT activities and reduction in new COVID-19 cases in the town. Nonetheless, these findings provide necessary insight into the real-time implementation of an emergency response program within this community. Finally, although we were able to capture several objective epidemiologic measures of impact, we acknowledge that we could not fully capture or report many of the immeasurable mental, spiritual, and social impacts of COVID-19 that will be felt in the community for generations.

Critical Reflexivity: Limitations in the Scope of Findings Presented

We are academic researchers from a social science (J.T.) and interdisciplinary public health research (M.J.) background who co-produced this work with nonacademic community collaborators. Our co-produced knowledge centered around community members’ pandemic experiences, highlighting implications for public health practice along dimensions that the promotoras and indigenous health experts knew to be most important. We used a conversational and critical reflective format as opposed to more conventional written drafts to ensure our collaborators’ voices were represented. Although our findings inform upon the critical role culturally grounded public health interventions play in mitigating the spread of COVID-19, we acknowledge that our personal and professional lived experiences inform how we approach theory and methods as public health researchers and thus our ability to tell the most representative story about the impacts of the COVID-19 pandemic within the Guadalupe community. Despite our best efforts to support the community in documenting how Guadalupanos were able to unite and effectively respond to the pandemic, our narrative is inherently shaped and biased by our identities as outsiders to the Pascua Yaqui Tribe and community.

Conclusion

The COVID-19 pandemic has highlighted inequities in access to and acceptance of public health interventions and resources. The experience in the town of Guadalupe, Arizona, has further illuminated the importance of public health mitigation measures and communications that are developed and implemented in partnership with the community.

Community embeddedness and humanistic care are grounded in the principles of mutual respect, bidirectional communication, and a shared interest in addressing gaps in access to health care services within the community. Establishing and sustaining a community presence is essential for cultivating the interpersonal relationships and trust that must underlie effective community-embedded work. Applying a humanistic perspective to community public health expanded the activities and support that the team provided, nurturing the GCRT’s presence and acceptance in the community and building sustainable public health infrastructure within the town.

Author Biographies

Jasmine Truong, MSPH served as a program manager for the Arizona State University Student Outbreak Response Team from July 2020 to August 2022. She is currently a research specialist at the University of Virginia School of Education and Human Development. She is passionate about health equity and access, particularly through the lens of community partnership development.

Laura G. Meyer, MSW served as the program manager of training and team development for the Arizona State University Student Outbreak Response Team from June 2020 to September 2022. Today, Laura is pursuing her PhD in Health and Behavioral Sciences from the University of Colorado, Denver. Her research centers on empathic communication interventions and experiences at the end of life.

Gloria Karirirwe is a public health practitioner who has previously worked at the Arizona State University Student Outbreak Response Team and CDC Foundation in Arizona. She currently lives in Massachusetts with her family and is working on projects that aim to improve health equity.

Clare Cory, PhD is a licensed clinical psychologist who has served as an associate director of the Pascua Yaqui Tribe’s Centered Spirit Behavioral Health Program for 26 years. She is proud to have assisted with efforts to combat COVID in Guadalupe.

Timothy J. Dennehy, PhD served as a research analyst for the Arizona State University Student Outbreak Response Team from February 2021 to April 2022. He received his PhD in anthropology from Arizona State University in December 2021.

Reggie Williams is a program supervisor at Maricopa County Department of Public Health.

Julia Jackman is a Native Arizonan and 2021 ASU Barrett graduate with degrees in global health and biochemistry. She now resides in Trondheim, Norway, where she is getting her master’s degree in global health and completing health disparities research with the support of a Fulbright grant.

Wayne Clement is the fire chief at the Guadalupe First Department Community Services.

Jennifer Collins, MPH is the epidemiology supervisor of communicable disease data, surveillance, and outbreak response at the Maricopa County Department of Public Health where she supervises and provides technical direction to staff epidemiologists.

Aaron Gettel is a senior epidemiologist with experience in the areas of climate and health, infant safe sleep, COVID, homelessness, and influenza.

Gracie Holguin served as a promatora working in the community of Guadalupe, Arizona.

Jeff Kulaga is the Town Manager of the Town of Guadalupe and has more than 30 years of Arizona municipal government experience.

Daniela Ledesma works as an epidemiologist who earned her MHS degree in epidemiology from Johns Hopkins Bloomberg School of Public Health and a BA in global health from Arizona State University. She served as a founding member and program manager for the Arizona State University COVID-19 Case Investigation and Community Response Team.

Susan Levy is a program manager and communications coordinator at Native Health Community Health Center.

Hanna Maroofi is an infectious disease surveillance epidemiologist at the Arizona Department of Health Services. She graduated with a master of health science degree in infectious disease epidemiology from the Johns Hopkins Bloomberg School of Public Health in 2022, and is an alum of Arizona State University where she received her BS in biological sciences and BA in global health.

Veronica Perez served as a promatora working in the community of Guadalupe, Arizona.

Kimberly Prete is a program coordinator for the Arizona State University Student Outbreak Response Team. In May 2020, she graduated from Arizona State University with degrees in biomedical sciences and family studies with a minor in global health.

Kip Schlum is an emergency planning supervisor at Maricopa County Public Health where he leads a team of public health professionals in developing plans to protect and improve the overall health and well-being of Maricopa County residents.

Camila Tompkins, MPH, MEd is currently pursuing a PhD in global health from Arizona State University. Her current work focuses community perceptions and adherence to dengue interventions in Saint Lucia.

Ricardo Vital is the vice mayor of the Town of Guadalupe. Mr. Vital was born and raised in Guadalupe, Arizona.

Stephanie Zamora was the public information officer at the Town of Guadalupe, Arizona. She earned her degree in Master of Public Administration from Arizona State University in 2022.

Megan Jehn is an infectious disease epidemiologist and an associate professor in the School of Human Evolution and Social Change at Arizona State University. Dr. Jehn is the founder and director of the ASU Student Outbreak Response Team, a large public health training program that provides students with hands-on training and experience in outbreak response and field epidemiology while simultaneously providing public health surge capacity for state, local, and tribal public health partners.