Community Activation to TrAnsform Local sYSTems (CATALYST): A Qualitative Study Protocol

Abstract

Community Health Workers, promotores, and navigators (henceforth, CHWs) emerged as critical members of the public health workforce addressing social, economic, and health inequities worsened by the COVID-19 pandemic. While there is increased appreciation for and utilization of CHW models, and recognition of the importance of tailoring and innovating these models during the pandemic, few studies have examined the processes of change by which CHW models operated during the COVID-19 pandemic and factors that facilitated or constrained CHW health equity efforts. This protocol paper describes and reflects on the research methodology used in our qualitative study focused on CHWs. The CATALYST study aims to examine the roles that CHWs served during the COVID-19 pandemic and facilitators and barriers related to CHW health equity strategies. This qualitative study incorporates the lived experiences of CHWs, low-income communities of color whom CHWs engaged, and institutional representatives and policymakers familiar with locally implemented CHW models during the pandemic. Through a community-based participatory research process, this study involves an abductive qualitative approach to data collection and analysis. We integrate community member expertise alongside CHW and health equity frameworks in designing the research questions and data collection process. Additionally, we use an analytic approach that combines inductive (drawn from qualitative data) and deductive codes (drawn from theoretical frameworks and practice-based evidence integrated through a participatory research process) and nimbly leverages flexible coding to address inductive themes and practice-based questions. Our collaborative process offers concrete strategies to develop qualitative research protocols with community partners, with evidence used to inform policy, programmatic, and relational changes to support and amplify CHW models to promote community health and health equity.

Background

The COVID-19 pandemic worsened longstanding racial, social, and economic inequities within the United States, with disproportionate effects among low-income communities, communities of color, and immigrant communities (Shen et al., 2021; Tai et al., 2021; Webb Hooper et al., 2020; Williamson et al., 2020). Studying how COVID-19 inequities unfold and how communities respond to these inequities can illuminate the influence of systemic structural factors on health inequities and identify opportunities for structural change. The purpose of the Community Activation to TrAnsform Local sYSTems (CATALYST) study is to examine the role of promotores, navigators, and/or community health workers (henceforth, CHWs) in COVID-19 equity initiatives to address and mitigate the multi-level inequities that unfolded during the pandemic. In this protocol paper, developed in collaboration with community-based organizations (CBOs) that are partners in the CATALYST study, we describe the components and phases of the CATALYST study methodology and critical reflections on our research process.

Community Health Worker Models

The CHW model emerges from Latin America and is informed by Freirian concepts of popular education (Bracho et al., 2016). CHWs are trusted members of communities affected by social, economic, health, and other inequities (Ingram et al., 2008; Rosenthal et al., 2011). CHW models focus on relationship-building, discussion-based strategies, and the lived experiences of communities most affected by systems of oppression (Bracho et al., 2016), and are tailored to the unique strengths and needs of local communities and contexts. CHWs educate and accompany residents in addressing their immediate needs and work to build community power to address the upstream drivers of inequities in the structural and social determinants of health (Montiel et al., 2021; Otiniano et al., 2012). Many studies constrain CHW models to health education, systems navigation, and outreach efforts to connect communities with health care and public health services from which they are systematically excluded (Glenton et al., 2021). While these roles are important, this literature often overlooks other critical domains of CHW strategies, such as providing emotional support, fostering a sense of community, and building community power.

During the COVID-19 pandemic, CHWs played an essential role in addressing multilevel barriers to accessing information, testing, risk mitigation, and vaccination, while also alleviating social, economic, and political inequities worsened during the pandemic (Hernandez-Salinas et al., 2023; Nawaz et al., 2023; Rahman et al., 2021; Valeriani et al., 2022). There is growing interest in CHW models, as evidenced by efforts to establish CHW reimbursement structures to support low-income communities to address social determinants of chronic conditions (e.g., asthma). However, little is known about how CHWs managed their roles, considering enormous social, community, and political challenges. For example, one review of CHW efforts across 6 countries found that CHWs encountered many structural barriers (e.g., restrictions, supply disruptions, mistrust), and remained committed to meeting community needs, often drawing upon their own resources to mitigate social and economic barriers (Salve et al., 2023). Understanding the unique and dynamic roles of CHWs in COVID-19 equity efforts and facilitators and barriers to implementing CHW models remains timely and relevant to policymakers, CBOs, and public health practitioners. Such insights have the potential to inform and sustain CHW models beyond public health crises or disruptions as we prepare for future public health emergencies.

Theoretical Framework

The design and data collection methods of the CATALYST study are guided by two conceptual models: the NIMHD Research Framework (Alvidrez et al., 2019; Lafarga Previdi & Vélez Vega, 2020) and the Multisystemic Promotores/Community Health Worker Model (Montiel et al., 2021).

The NIMHD Framework provides a multilevel schema by organizing determinants of health inequities into five domains (i.e. biological, behavioral, physical/built environment, sociocultural, and healthcare system) across four levels of influence (individual, interpersonal, community, and societal). It is important to consider how domains vary across the life course, complex interactions between domains and levels of influence, and the inclusion of both risk and protective factors to understanding and addressing community and population-level health outcomes.

The Multisystemic Promotores/Community Health Worker Model captures the equity-focused orientation of CHWs who work to increase access to and quality of health and social services and advocate for community and systems change. Considerable research documents the positive impacts of CHWs in reducing risk behaviors and improving chronic disease detection and management through building trusting relationships, education, navigation, and referrals (Perry et al., 2014). However, less well understood are CHW’s concomitant community and societal-level roles, such as whether/how CHWs contribute to advocacy for policy and systems changes that affect the health outcomes they accompany residents in addressing.

Community-Academic Partnership Process

In May 2020, the Orange County Health Equity COVID-19 Community-Academic Partnership (OCHEC-CAP) formed with community-based health equity leaders and health equity academic partners to build collective power and community capacity to elevate the need for and guide local COVID-19 equity response and recovery initiatives (UCI Community Resilience, nd; Washburn et al., 2022). As the pandemic unfolded, our work evolved, first to inform strategic actions to improve equitable access to COVID-19 testing, data, and communication; support training for contact tracers and resident-led COVID-19 response; urge the implementation and maintenance of mask mandates (UCI Community Resilience, nd), and later to promote equitable vaccine distribution and allocation (Washburn et al., 2022). CHWs were central in these efforts, and in navigating rising anti-immigrant attitudes and promoting civic engagement for census complete count and elections turnout. Community partners who were experts in community-driven strategies and CHW models identified the importance of systematically studying CHW model innovations, contexts, supportive factors, and constraints, which led to the development of the CATALYST study.

Study Aim

The overarching goals of this study are to understand COVID-19-related inequities that informed the context of CHW-led strategies to mitigate these inequities, as well as factors that affected CHW-led health equity efforts. The CATALYST study aims to examine:

(1) The facilitators, barriers, and processes of delivering COVID-19 response and chronic disease management education throughout the COVID-19 pandemic in areas with the highest social vulnerability due to race-based occupational and residential segregation that shaped place-based inequities in COVID-19;

(2) Multi-level factors that enhanced or mitigated inequities in COVID-19 information, transmission, testing, morbidity, mortality, and social and economic outcomes; and

(3) How advocacy efforts implemented by CHWs and CBOs shaped changes in the COVID-19 response.

We examine these aims through a case study of these dynamics for communities in areas with the highest social vulnerability to COVID-19 in Orange County, California, the sixth most populous county in the country with 3.2 million residents, the majority of whom are people of color (Agency for Toxic Substances and Disease Registry, nd). We address these aims by conducting interviews and focus group discussions with a range of constituents: CHWs in Orange County, Orange County residents who worked with CHWs, institutional representatives and policymakers in Orange County, and CHWs across California (enabling an assessment of generalizability).

Given the practice-based focus of this study, a fourth aim is to develop a flexible dataset positioned to answer additional research questions that are timely and responsive to community priorities through a community-based participatory research process. This practice-based focus heeds calls for structural racism scholarship to inform policy, systems, and environmental changes to promote health equity (Adkins-Jackson et al., 2022). A key goal is to inform multi-pronged interventions to promote community health and health equity, capacity development initiatives, the equitable integration of CHWs into the public health ecosystem, systems-change strategies, and future crisis response efforts (e.g., pandemic, environmental or climate crisis).

Methods

Study Design

We use a qualitative research approach to examine the perspective of CHWs, residents, and institutional representatives and policymakers on the role of CHWs and the facilitators, barriers and processes of change they implemented for COVID-19 response throughout the pandemic. Qualitative methods, including semi-structured, in-depth interviews and focus groups, enable deep contextual understandings of the experiences and perspectives of individuals and center the voices of community members directly impacted by health inequities. In Orange County, community leaders advocated for reporting racial/ethnic, socioeconomic, and spatial patterning of testing, cases, and mortality. Largely missing in COVID-19 reporting, however, are community-led efforts to address these inequities. Qualitative methods are appropriate for understanding community-led efforts to address these inequities and the complex and dynamic settings in which they unfold. Our work progressed in three phases: (1) Partnership Process, (2) Recruitment and Data Collection, and (3) Data Handling and Analysis (Figure 1).

Figure 1.

Overview of CATALYST Study Process.

Study Setting

The study is conducted in Orange County, California. Mirroring nationwide trends, Orange County experienced significant racial/ethnic inequities in COVID-19 incidence and mortality (Bruckner et al., 2021; Yamaki et al., 2021). Conservative groups also fomented anti-government protests and smear campaigns, resulting in institutional turnover and loss of longstanding leadership that hindered health department efforts to implement equitable COVID-19 mitigation strategies (Fry & Money, 2020). Given this context, we developed the OCHEC-CAP to elevate the need for and guide equitable local COVID-19 responses and recovery initiatives.

Partnership Process

Community-Academic Partnership Process

We sought to address these questions through a community-based participatory research approach (Israel et al., 2013). The CATALYST study engages a subset of members of the OCHEC-CAP. Monthly community-academic partnership meetings enable partners to deepen relationships, guide the research process, interpret emerging findings, and discuss the larger implications of our collaborative power-building efforts. Ad hoc small group or one-on-one meetings between community and academic partners allow for in-depth discussions on crucial aspects of the research process. These meetings facilitate deeper conceptualization, reflection, and brainstorming, which are important for research decisions (e.g., Community Science Worker model, co-authorship process, unpacking nuanced emerging findings, considering policy implications) and practical action items (e.g., recruitment strategy).

RADx-UP

The CATALYST Study was established as part of the RADx-UP national consortium of 144 research teams incorporating underserved populations in the National Institutes of Health’s initiative to innovate on and accelerate the development and implementation of access to COVID-19 technologies (e.g., testing vaccinations). Our project is one of few primarily qualitative studies (Chu et al., 2024) in the RADx-UP consortium that examines the work of community health workers in addressing COVID-19 inequities.

Community Science Worker Model

We developed a Community Science Worker (CSW) model to integrate CHWs into each phase of the research process. This approach recognizes CHWs’ lived experience and expertise in authentically engaging residents to identify community priorities and drive change. The CSW model serves two important functions: (1) centering CHW expertise throughout the research process and (2) building collective capacity to develop and implement rigorous research approaches that align with community-centered inquiry and action. We invited CHWs identified by their organizations as being particularly interested and involved in COVID-19 CHW interventions, systems change, and community-engaged research to serve as CSWs.

CSWs participated in a popular education qualitative research training and design process, comprising 8 sessions focused on community data collection, analysis, and impact. Through this process, CSWs were able to guide the development of data collection and analysis activities with residents; co-interpret emerging findings; elucidate ways in which findings from Orange County data inform, align with, or complicate findings from state-wide CHW interviews; identify policy and practice implications of emerging findings; and recommend strategies to disseminate findings in ways that are timely with policy, programmatic, and grant opportunities.

Sampling and Recruitment

Participants

In community-academic partnership discussions, we refined inclusion and exclusion criteria and geographic and identity-based communities of focus, described in the sections that follow.

Institutional Representatives and Policymakers (IRPs)

To assess perspectives of institutional representatives, we recruited leaders of CBOs, health services organizations, and governmental representatives (involved in policymaking and/or policy implementation) to participate in key informant interviews. Participants in these roles interacted with factors at individual, family, neighborhood, community (e.g., geographic, identity-based), county, and/or state-levels that shape and/or ameliorate COVID-19 inequities. Given the highly sensitive and political nature of interview questions, we conducted individual interviews.

Inclusion criteria required key informants to be in leadership roles related to COVID-19 response within their organization and be 18 years of age or older. Eligible key informants included leaders from organizations that trained and/or employed CHWs or were familiar with the CHW model and officials from governmental agencies (e.g., local public health officials, city and county officials, school district administrators) focused on Orange County communities with the greatest social vulnerability to COVID-19 and actively involved in efforts to address and transform COVID-19 inequities.

CHWs

To understand CHW perspectives on the facilitators, barriers, and processes of change they implemented during the COVID-19 pandemic, as well as how their advocacy efforts shaped the COVID-19 response and their visions for equitable recovery, we recruited CHWs who served communities with the greatest social vulnerability in Orange County and state-wide. This approach enables us to assess the generalizability of findings from the multi-level analysis of CHW experiences in Orange County to responses and resiliencies among diverse populations state-wide.

Inclusion criteria for Orange County CHWs included that they practice as CHWs, are 18 years of age or older, work in Orange County, California communities with the greatest social vulnerability to COVID-19 and provided COVID-19-related support (e.g., education, risk prevention, testing, contact tracing, vaccination, systems transformations) during 2020–2022. While the primary focus was CHWs, CHW coordinators or managers who oversaw CHW activities were also eligible.

The same eligibility criteria applied for CHWs statewide, with the key difference that they practice as CHWs in California communities outside of Orange County, with high social vulnerability to COVID-19.

In some cases, CHWs were part of organizations with a regional approach (e.g., Southern California) and practiced in Orange County and other locales. When CHWs primarily practiced in Orange County, we focused on their experiences in Orange County and classified them as “Orange County CHWs.” For CHWs whose work was not primarily in Orange County, we centered the interview on their regional approach and/or other locales where they practiced and classified them as “California CHWs.”

Orange County Residents Who Worked with CHWs

To illuminate resident perspectives of the multi-level factors that shaped COVID-19-related inequities as well as individual, family, and community responses and CHW roles in supporting community recovery, trained CSWs and academic partners conducted interviews and focus groups with residents whom CHWs accompanied during that pandemic.

Inclusion criteria were that residents are 18 or older, reside in Orange County, California communities with greatest social vulnerability to COVID-19, have known telephone or email contacts, and worked with CHWs at one of CATALYST partner CBOs during the COVID-19 pandemic. We did not recruit clients who mainly received mental health services from licensed professionals (e.g., therapists) given our focus on CHW strategies.

Recruitment

Given this case study approach, we used purposive sampling (Patton, 2002) to recruit IRPs, CHWs, and residents. CATALYST community-academic partnership members and CSWs identified CHW networks and organizations in Orange County and across California for inclusion in the purposive sampling approach. Community and academic partners nominated IRPs who met inclusion criteria. CHWs from each community were largely identified and recruited by four CATALYST CBO partners: Latino Health Access, the Orange County Asian Pacific Islander Community Alliance, Getting Residents Engaged in Empowering Neighborhoods-Madison Park Neighborhood Association (GREEN-MPNA), and Radiate Consulting. Each of these partners employ and/or collaborate with organizations who employed about 375 CHWs in 2022.

For interviews and focus groups with CHWs, an academic partner sent an invitation email to each nominated person. This message included information about the purpose, process, and methods and a study information sheet, a video describing the study, and a study flier. For IRP interviews, the person who nominated the individual reached out to the nominee to introduce the study and let them know they would be nominated. An academic partner then sent an invitation email to participate in the study and to share about the overarching context and goals of the CATALYST study. Individuals interested in participating were asked to indicate via email their intention to coordinate an interview. Academic partners made up to three follow-up attempts with potential participants. Consistent with snowball sampling, upon completion of interview participation, we invited CHW and IRP participants to recommend others in their network with whom we might interview.

For community residents with whom CHWs worked, CSWs identified eligible participants from their own CHW experiences and/or in collaboration with colleagues within their organizations. While we originally intended to conduct only focus group discussions with residents, our collaborative process identified several rationales for providing residents with the opportunity to participate in an interview, including discomfort with group-based discussions, availability, and primary languages spoken. CSWs provided residents with a flier with study details and contact information for any questions. Largely, CSWs addressed resident recruitment questions given their familiarity with the study and the resident population.

Throughout the recruitment process and during interviews and focus groups, we assured participants that they would be assigned a de-identified code, and their names or other identifiable information would not be included in the analysis to ensure confidentiality. All participants were offered a $50 incentive as a token of appreciation for their participation.

Sample Size

In qualitative research, the number of participants does not determine the significance of the findings. Instead, the key factor is data saturation. Per well-established guidelines for achieving data saturation in theoretically informed studies, we anticipated exhausting the identification of new themes at n = 15 (Guest et al., 2006; Hennink & Kaiser, 2022). When we prepared to conduct the CATALYST study, we proposed completing qualitative data collection with 30 IRPs, 80 CHWs (across Orange County and California), and 168 residents who worked with CHWs during the pandemic. By the end of data collection (January 2023- January 2024), our study included 127 participants.

We completed 15 interviews with IRPs, including four appointed city leaders, two elected city leaders, two county public health department leaders, three county-serving non-profit leaders, two school district leaders, one CBO director, and one community organizer. Additionally, we completed 16 individual interviews and eight focus groups with 48 CHWs who primarily serve Latiné, Asian American, and/or Pacific Islander communities in Orange County, particularly in Santa Ana, California. We also interviewed 17 CHWs from across California (practiced in areas outside Orange County). For resident discussions, we conducted four focus groups with 29 participants (size ranged from 5 to 10 participants) and three individual interviews with residents who identified as Latiné, Vietnamese, and Korean living in Orange County. Further details are available in Table 1.

Table 1.

CATALYST Qualitative Dataset (n = 127 Participants).

Dataset	Data collection format	Mode	Number of participants	Languages	Interviewer/Facilitator	Duration average (Range)
Institutional Representatives and Policymakers	Individual SSI (n = 15)	All virtual (Zoom)	15	English	Academic partners	56 mins (32 to 86 mins)
Community Health Workers in Orange County	Individual SSI (n = 16)	SSI: 13 virtual (Zoom) & 3 in-person	63	English (10 SSI, 5 FGDs)	Academic partners	Interviews: 77 mins (59–89 mins)
	FGD (n = 8)	FGD: All in-person		Spanish (6 SSI, 3 FGDs)		FGD: 87 mins (68–113 mins)
Community Health Workers across California	Individual SSI (n = 17)	All virtual (Zoom)	17	Spanish (12)	Academic partners	62 mins (43–91 mins)
				English (5)
Orange County Residents who worked with CHWs	Individual SSI (n = 3)	All in-person	32	Spanish (3)	CSWs	54 mins (20–84 mins)
	FGD (n = 4)			Vietnamese (1)
				Korean (3)

Note. CHW: Community Health Worker; CSW: Community Science Worker; FGD: Focus group discussion; SSI: semi-structured interview.

Data Collection

We collectively developed and piloted the interview and focus group discussion guides. First, academic partners with expertise in qualitative research methods drafted the guides, informed by past discussions with community partners regarding key topic areas that aligned with the overarching research questions. Then, community partners and CSWs with deep contextual knowledge of the communities involved in the study reviewed and refined interview and focus group discussion guides. Semi-structured discussion guides (Appendixes 1-4) were open-ended and aimed to explore: the COVID-19 context and impacts on low-income communities of color from the perspective of participants; the role of CHWs in COVID-19 equity efforts; facilitators and barriers of CHW efforts during the pandemic; and recommendations for supporting CHW models during a public health emergency, sustaining CHW models beyond crises, and community rebuilding. Given the semi-structured nature, discussion questions were asked in a flexible order that suited the flow of each interview or focus group. The guides were designed to allow the interviewer/facilitator to adjust the sequence or skip questions if the participant already addressed them. Then, finalized interview and focus group discussion guides were professionally translated into Spanish, Korean, and Vietnamese.

CHW and IRP interviews and focus groups were conducted by academic partners with qualitative research experience who were fluent in the language participants preferred. Resident interviews and focus groups were conducted by trained CSWs fluent in the language preferred by the participants or by academic partners who conducted interviews or focus groups in-language. Every interview or focus group discussion included an interviewer (interviews) or facilitator (focus groups) and at minimum one support person for notetaking and technical elements (e.g., recording, logistical issues). Interviews and focus groups began with an introduction of the study and the facilitator.

Interviews were designed to last 60 minutes and ranged from 20 to 89 minutes. Focus groups were designed to last 90 minutes and ranged from 54 to 113 minutes. IRP interviews were offered as remote given the highly remote nature of work and data collection at the time (2023). Interviews and focus groups with Orange County CHWs and residents were offered in remote or in-person formats, according to participant preference. Interviews with CA CHWs were offered remotely. All in-person data collection events involved a meal for participants. Interviewers and notetakers developed a written memo within 48 hours of the data collection event to document their reactions, experience with, and reflection on the interview or focus group. Memos helped our research team to understand how to refine the interview and focus group guides and informed the creation of codebooks. At the end of each interview or focus group, we asked participants to complete a brief nine-question demographic survey to provide insight into the populations engaged in the CATALYST study.

Additionally, we invited all participants to complete an optional RADx-UP survey regarding COVID-19 experiences and social determinants of health. Participants who opted to complete the RADx-UP survey were offered an additional $50 incentive as appreciation for sharing their experiences and time.

Data Handling and Analysis

We asked participants for their consent to video or audio record the interview or focus group in which they were participating (using Zoom). Recordings were professionally transcribed and translated into English when needed. Identifying information was redacted by the transcriptionist and validated by qualitative student researchers. Final transcripts were uploaded into Atlas.ti (Version 23.2.1) qualitative data analysis software.

The qualitative analytical process follows an adapted flexible coding approach (Deterding & Waters, 2021) that has been described elsewhere (Michelen et al., 2024), resulting in key themes and sub-themes in each domain of inquiry (e.g., facilitators of CHW efforts, recommendations). Briefly, flexible coding begins with indexing, or a broad categorization or sorting of the transcript data at the onset of analysis guided by discussion guide questions (e.g., mental health, chronic diseases, vision for recovery). While indexing, coders generate memos to document the concepts arising from the data, which inform the analytical codebook.

The next step involves deriving a data subset, including only the data indexed under applicable index codes for each research question and developing a focused analytical codebook. The analytic codebook reflects an abductive approach (Vila-Henninger et al., 2024), integrating inductive codes from the data and deductive codes informed by theory and practice. The codebook is shaped by memos, data subset, consultation with community and academic partners, and relevant literature.

Two trained qualitative coders independently apply the analytical codebook to the data subset. Coders meet regularly to discuss and reconcile inconsistencies in coding and assess the reliability of the coding process, using intercoder agreement (ICA). Any coding disagreements are resolved through consensus. When consensus cannot be reached, a third researcher is consulted. The ICA is measured using Krippendorff’s α to calculate the reliability coefficient, with a score above 0.80 indicating high reliability. Once coders reach a 0.80 ICA, they can determine, based on timelines, whether to continue paired coding or conduct split coding for the remaining transcripts or indexed data. Coders also generate coding memos, which guides data interpretation and refinement.

Emerging themes for each research question are discussed with the community-academic partnership, including CSWs, to guide the analysis and interpretation of findings. As outcomes, our partnership will develop: (1) a theoretical framework of CHW health equity strategies during the pandemic; (2) recommendations for policy, programmatic, and relational changes; and (3) recommendations for centering community-based participatory approaches to qualitative study design, implementation, and dissemination.

Ethics

The CATALYST study was reviewed and approved by the university Institutional Review Board in 2020. The CATALYST study was developed to better understand and uplift the CHW model, leveraging the expertise of CHWs and support staff throughout the research process. Under our cooperative agreement with the funder (NIH RADx-UP), we harmonized our protocol and consent materials with RADx-UP specifications. This resulted in consent language that was more technical than we would recommend for a diverse audience. Therefore, we developed a short video to supplement the formal consent documents to describe the CATALYST study, participation opportunities, risks, and benefits, using concrete, accessible language. To strengthen and facilitate community-engaged research processes, we recommend that funders provide greater flexibility in informed consent processes.

All participants provided verbal informed consent before data collection. In advance of obtaining verbal consent, we shared with research participants the consent document (study information sheet) and a brief video describing the project. When discussing the risks and benefits of the study, we reminded potential research participants that they could decide whether to participate and that they could withdraw their participation at any time.

We conducted data collection activities at a time when COVID-19 protection protocols were largely lifted, yet community concern remained high about virus transmission. Accordingly, we began with data collection that could be completed remotely (e.g., IRPs, CHWs), and conducted focus group discussions towards the end of the data collection period. At in-person data collection events, we provided access to masks and COVID-19 tests.

Throughout our collaborative process, we discussed considerations for conducting research in a context in which community partners are both guiding the research process and can participate in the study or have colleagues participating in the study. We ensured that academic partners conducted interviews or focus groups with staff who worked at CATALYST partner CBOs. Additionally, all data presented during meetings to interpret findings is de-identified to maintain confidentiality.

Rigor

We employ several techniques to enhance the trustworthiness of our study and findings. Starting with the study design, our research question was informed by leaders in practice-based evidence, including CBOs with decades of expertise in CHW models and structural and community-level strategies to address health inequities. Our data collection process involved a collaborative design of interview and focus group discussion guides, integrating community and academic knowledge. During data collection, interviewer and notetaker memos provided the opportunity for the data collection team to reflect on their positionalities related to participant(s) and discussion topics. These reflective memos and the discussions that they catalyze informed changes to our research process. For example, for one focus group, the facilitator reflected that their racial and gender identities vis-a-vis the study participants (Asian and Pacific Islander-identifying women) created structural space that may have impeded the depth of discussion. Informed by the reflections on positionalities of the data collection team and implications for the trustworthiness of the data (Morrow, 2005), we modified our protocols to ensure that we carefully considered the composition of our data collection teams with a goal of fostering a space where participants felt comfortable fully sharing their experiences.

For data analysis, we utilize paired coding and measure inter-rater agreement to ensure the reliability of our codebooks. The flexible coding approach enhances our reliability by enabling researchers to focus on one research question at a time, examining specific segments of the transcripts, rather than entire datasets. Throughout data analysis, researchers iterate through the findings and produce multiple outputs, such as indexing memos, analytical memos, and coded data, enabling a diverse team to engage with the data at various points. Finally, to validate findings, we hold visioning and validation workshops with CBOs, community members, CHWs, CSWs, and healthcare providers.

Our core value is to disseminate findings to participants, academic audiences, CBOs, and policymakers. A precursor to dissemination involves working collaboratively to interpret findings and simultaneously discuss dissemination opportunities tailored to the emerging findings and dynamic context. We value identifying dissemination opportunities that are synergistic with existing opportunities (e.g., planned town halls hosted by CATALYST community partners; policy advocacy opportunities led by CBOs such as CHW reimbursement models for mental healthcare), as well as understanding dissemination opportunities that we would need to create (e.g., inviting CBOs and policymakers to a CATALYST-specific forum). Relatedly, our process of “checking” and unpacking the emerging findings (Morrow, 2005) with experts (e.g., a wider network of CHWs, mental health providers, CSWs) ensures high quality analysis of the data and provides an opportunity for timely dissemination of emerging findings.

Conclusions

Despite the longstanding existence of CHW models, the COVID-19 pandemic illuminated CHWs' critical role and innovative contributions in promoting community health and health equity. There is growing interest in leveraging the strengths of CHW models, as evidenced by increased efforts to reimburse CHWs for their roles in supporting residents in low-income communities and communities of color. Understanding the unique and dynamic roles of CHWs in COVID-19 equity efforts remains timely and relevant to policymakers, CBOs, and public health practitioners. The CATALYST Study will inform strategic visioning about CHW models and efforts to tailor and scale CHW models for community recovery, sustainability, and future crisis response, and to guide policies and processes to strengthen the integration of CHWs into the public health workforce. Sharing findings with study participants and networks of residents, CBOs, institutional representatives, and policymakers has potential to inform transformations to the integration of CHWs into public health efforts. Additionally, this research may inform future research seeking to integrate community-based participatory research and qualitative methods into projects focused on community priorities.

Supplemental Material

Supplemental Material - Community Activation to TrAnsform Local sYSTems (CATALYST): A Qualitative Study Protocol

Supplemental Material for Community Activation to TrAnsform Local sYSTems (CATALYST): A Qualitative Study Protocol by Alana M. W. LeBrón, Melina Michelen, Brittany Morey, Gloria I. Montiel Hernandez, Patricia Cantero, Salvador Zarate, Mary Anne Foo, Samantha Peralta, Jacqueline J. Chow, Julia Mangione, Sora Tanjasiri, and John Billimek in International Journal of Qualitative Methods.