Research: In Rural Mexico, Building Trust Is Key To COVID-19 Response

In The Lancet Global Health: Community health workers key to contact tracing

Posted on Apr 29, 2021

A doctor teaches a nurse how to wear a face mask as part of a larger training on how to manage triage areas in Chiapas, Mexico.
Dr. Doris Altuzar teaches a nurse how to properly wear a face mask as part of a larger training on how to manage triage areas in the community clinic of Honduras, one of the communities in Chiapas, Mexico where PIH works. Photo by Paola Rodriguez / Partners In Health.

In much of the world, contact tracers pick up the phone. But in places like Chiapas, Mexico, they knock on doors.

That’s because phone and internet service are hard to come by in Mexico’s southernmost state, where more than 75% of the population lives in poverty. That makes contact tracing a complex and challenging process—but not impossible.

In fact, new research published in The Lancet Global Health and presented in the Consortium of Universities for Global Health's 12th Annual Global Health Conference as a poster in March shows how Partners In Health supported hundreds of people in Chiapas with contact tracing, medical care, and essential resources over the past year, mounting an effective COVID-19 response despite structural barriers.

The research demonstrates the value of PIH’s approach worldwide: building long-term relationships with local communities and strengthening health systems, before disaster strikes, so that patients receive the care they need, when they need it most.

“We, through the community members, have built a contact tracing force,” says Zeus Aranda, a research coordinator at Compañeros En Salud, as PIH is known locally, and co-author of the Lancet Global Health abstract. “At the end of the day, the people who know the community best…are the community members.”

Responding In Rural Chiapas

When the pandemic struck Chiapas in March of last year, the case count was low at first, hovering in the single digits. But then the surge came. Between March 2020 and January 2021, the state of 5.2 million recorded 8,745 positive cases and 1,259 deaths from the virus.

Even as case counts soared, critical resources—such as COVID-19 tests and oxygen concentrators—were in short supply. And in Chiapas’ rural communities in the Sierra Madre region, where Compañeros En Salud works, disinformation spread, along with the disease.

Despite these challenges, Compañeros En Salud was able to mount an effective response in the communities where it works, detecting and supporting 287 suspected cases and 1,111 of their contacts through its contact tracing program and providing groceries and hygiene products for 650 households.

But that success didn’t happen overnight.

In the Lancet Global Health research, authors Dr. Ariwame Jiménez, Dr. Bruno Vargas, and Zeus Aranda describe Compañeros En Salud’s COVID-19 response in rural Chiapas—and how its impact could reach far beyond the Sierra Madre.

“It’s such great news that this abstract is being shared in a journal that has such a large impact,” says Laura Martinez, who supported the research as Compañeros En Salud’s contact tracing coordinator. “What was undertaken here in Chiapas is something that a lot of communities with similar characteristics can reproduce and adapt to their contexts.”

‘Contact Tracing Is Possible’

Compañeros En Salud has been working in Chiapas since 2011, and its decade of work building relationships and operating programs there made it a trusted partner in the Ministry of Health’s COVID-19 response. But it had never run a contact tracing program before.

To accomplish that, it enlisted members of one of its longest-running programs.

“Community health workers have been the bridge between the clinic and the community for years,” says Jiménez, who coordinates Compañeros En Salud’s community health program and served as a first-year doctor in the community clinic in Soledad.

Dr. Ariwame Jiménez meets with a patient at a clinic in Soledad in 2017.
Compañeros En Salud has been working in Chiapas' rural Sierra Madre communities for nearly a decade. Dr. Ariwame Jiménez meets with a patient at a clinic in Soledad in 2017. Photo by Cecile Joan Avila / Partners In Health.

A cornerstone of public health programs worldwide, community health workers are local residents who are recruited, trained, and then dispatched throughout their communities to provide a range of basic health information and services, medications, and social support.

Compañeros En Salud’s community health workers have been knocking on doors in Chiapas’ Sierra Madre communities for nearly a decade, checking in on patients and becoming familiar faces in areas where paved roads and nearby clinics are few and far between.

That track record of building trust with the community made them a natural fit for the contact tracing program. Each community that accepted support was assigned one or two community health workers for contact tracing efforts. These community health workers followed a careful set of protocols. First, a check in with the local clinic for a list of suspected cases in their area. Then, door-knocking to follow up with the cases and their contacts. Finally, collecting and entering the data in a centralized database.

As COVID-19 intensified in the region, these trusted residents became a lifeline and, for the researchers, proof of an important concept.

“Contact tracing is possible, no matter how hard the context is or the conditions in that specific area,” says Jiménez.

It wasn’t always seamless.

In the early days of the pandemic, Compañeros En Salud’s workforce of community health workers halved, plummeting from 84 to 43 people. Two communities declined to participate in the contact tracing program due to skepticism and misinformation about the pandemic. And many community health workers have only basic literacy skills, complicating data collection.

But the program moved forward, undaunted.

As the pandemic became less novel and more detailed health guidance was released, the vast majority of community health workers returned to work, eventually bringing the staff to 80. Jiménez and her team, along with the infection control and prevention team, met with the communities that declined contact tracing to discuss other ways to provide support. And community health workers without literacy skills found other ways to record their data, often with the help of their supervisors or facility staff.

The pandemic is far from over, and Compañeros En Salud continues to battle the virus in Chiapas. But for the researchers, the Lancet Global Health abstract shows that an effective pandemic response is possible, even in the most rural and under-resourced settings. And it taps into another resource that has, at times, felt scarce: hope.

“What was done is possible in similar contexts around the world. So many communities are very similar to where we work,” says Martinez. “It’s really motivating and inspiring.

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