By: Pat M. Williams, MPH
Community health workers across the world served a pivotal role in combating the COVID-19 pandemic this year. Kenya’s First Lady Margaret Kenyatta was among many who commended CHWs for their essential role during the pandemic (Business Ghana, 2020). But kind words without supportive action contribute little to the challenges faced by CHWs. CHW programs and researchers consistently reported limited access to PPE, low wages, and disparities in the availability of other resources necessary for CHWs to perform their roles effectively.
CHW Central is marking a year in review by highlighting research and news describing the contributions of and challenges experienced by CHW in the fight against the global pandemic. The vast majority of resources made available on the CHW Central database emphasize the role of personal protective equipment (PPE) in ensuring the safety and effectiveness of CHWs in performing their roles. Accordingly, this feature highlights results from these findings. We first review initial CHW program responses to the virus. Then, we describe PPE resource shortages impacting CHW safety. Next, we highlight the need to recognize CHWs as an integral part of the health force. Finally, we summarize additional recommendations to improve CHW programming for the pandemic and beyond.
CHW’s Role in the Pandemic Response
Faced with the burden of the pandemic in addition to existing responsibilities, CHWs often felt torn between meeting the ongoing health needs of community members and the emergency response to the pandemic. CHWs in India feared that split prioritization between roles might lead to deficits in maternal health in exchange for a focus on COVID-19 services (Bharadwaj, 2020). One woman, Soreng, described her pre-pandemic experiences in maternal health as, “…always overworked and the money doesn’t do any justice to the amount of labour we put in.” Soreng’s role during the pandemic expanded to include door-to-door COVID-19 education, contact tracing, patient care, and other tasks that conflicted with routine care activities.
Soreng’s experience during the pandemic reflects research into the ways CHWs were included in early responses to the pandemic. Bhaumik, Moola, Tyagi, Nambiar, and Kakoti’s (2020) rapid research review showed an immense variety in CHW programming. Some CHWs performed contact tracing and visited sick or grieving community members, while others promoted community awareness, engagement, and sensitization to the virus. Unpaid workers left their regular duties in malaria case management to perform paid contact tracing. This shift in priorities suggests that saving lives from the impacts of the virus placed others at risk of succumbing to existing conditions due to a limited availability of personnel and the unintended consequences of disease-specific incentivization.
Relevant, tailored, and continuously updated guidance, training, and supportive supervision are required for CHW programming to be successful (Bhaumik et al., 2020). Bhaumik and colleagues noted that financial incentives, strong information management systems, and comprehensive training contribute to successful programing, but limited financing prevents CHWs in low- and middle-income countries from receiving adequate support to perform their duties.
Ill Equipped and At Risk
Throughout 2020, the global supply of personal protective equipment (PPE) remained at the forefront of conversations about the CHW-led pandemic response. PPE includes masks, gloves, medical gowns, and other resources that can help individuals protect themselves from contracting communicable diseases. Failure to provide adequate PPE increases risk of community transmission and decreased motivation to provide care. One CHW in Namibia, for example, described fear of treating a patient who was isolating after testing positive because they did not have the protective gear needed to reduce risk of transmission (China Daily, 2020). CHW advocates and researchers noted the importance of addressing global PPE shortages as early as April 2020. Ballard, Bancroft, et al. (2020) outlined immediate actions that governments could take to achieve protection of healthcare workers and vulnerable populations alike while also preventing the spread of the virus and maintaining existing health systems. They prioritized actions in four key areas: (1) protecting healthcare workers, (2) interrupting the virus, (3) maintaining health services while surging their capacity, and (4) shielding the vulnerable.
Sadly, the dangers of not equipping CHWs with PPE were borne out in real-world examples. The country of Brazil became a COVID-19 epicenter by July due to failure to adopt clear nationwide guidelines for how to respond to the virus (Lotta, Wenham, Nunes, & Pimenta, 2020). Many did not receive PPE because the government did not include CHWs in national planning or consider them among health professionals during the first several months of the pandemic (Ziegler, 2020). Yet policymakers issued broad guidelines for CHWs to continue to provide routine visits and care for the infected (Lotta et al., 2020). Only 9% of CHWs in the country received adequate infection control training and PPE. Similarly, other directives in Brazil were inconsistently applied. CHWs were asked to stay home in some regions while in others they were asked to establish a presence in public spaces to enforce physical distancing regulations. At least 50 CHWs had died from COVID-19 at the time of Lotta et al.’s publication, and this number is likely an underestimate due to lack of classification of CHW deaths as healthcare worker deaths.
Inadequate PPE not only impacted CHW health but also the people they served. CHWs in Brazil experienced hostility from local residents due to well-placed fears that inadequate PPE made CHWs potential carriers of the virus (Lotta et al., 2020). Hostility restricted CHWs from being able to perform the full scope of their duties, further limiting distribution of knowledge about how to prevent the spread of the virus. Similar fears were observed in Sub-Saharan African countries (Nepomnyaschchiy, Dahn, et al. 2020), India (Tiwari, 2020), and throughout the world (Bhaumik et al, 2020).
Ballard and colleagues (Ballard, 2020; Ballard, Westgate, & CHIC, 2020) followed up on Ballard et al. (2020) on May 4th, reporting limited improvements in PPE distribution between publications. Those who did receive PPE often received inadequate protection, such as a cloth mask instead of traditional PPE used in hospital settings like N95 respirators or surgical masks. The authors noted that CHWs are often left out of national planning.
In addition to the physical risk of contracting the virus, the pandemic took an emotional toll on CHWs (Maulik et al., 2020). A survey of 103 CHW programs revealed that organizations observed high rates of anxiety, depression, stress, and related symptomatology like fatigue, insomnia, and burnout among staff during the pandemic. About half of these organizations provided some form of mental health support, but half of those providing support took place in India, suggesting an inadequate distribution of mental health support resources for CHWs more broadly. The researchers speculate that low-cost, accessible, gender-sensitive, and easily implemented mental health services are required to better provide provision of care.
CHWs must receive formal designation as a part of the essential workforce so their support and supply needs can be integrated into national planning. As observed in Brazil (Lotta et al., 2020), failure to identify CHWs as essential prevents their prioritization for receipt of PPE and leads to mistrust of CHWs. It also might limit CHW’s access to the vaccine. Plans about who to prioritize during dissemination of the vaccine vary depending on country, state, and local decisions (Saleh et al.,2020).
As of December 22, 2020, community health workers were explicitly mentioned in only eight of the fifty US state COVID-19 vaccination distribution plans. These states are Alaska, California, Delaware, Florida, Maine, New Jersey, North Carolina, and Washington. CHWs are included as a priority group in phase 1 distribution in all of these regions, with the exception of Florida and Maine. Virginia includes “public health workers” as Phase 2 recipients of the vaccine without elaborating on what a public health worker is other than to say that they must be “patient facing.” But what is a patient? Some CHWs during the pandemic visited homes to provide routine COVID-19 surveillance, education, and patient check-ins (Columbia, 2020). Others helped the recently unemployed apply for food stamps and find food pantries. In both scenarios, a CHW is risking potential virus exposure to provide an essential public health service, but under the current Virginian vaccination plan, will these groups of CHW receive different prioritization? By formally designating CHWs as an essential workforce, ambiguities like these could be avoided.
Recommendations and Resources
So, what would it take to provide adequate PPE to CHWs? At a minimum, Ballard, Westgate, and CHIC (2020) recommend CHWs receive surgical masks or N95 masks; gloves for each patient encounter or the ability to sanitize hands, eye protection; and disposable gowns or the ability to launder uniforms. Nepomnyaschchiy, Westgate, et al. (2020) add to this list, describing a need for disposable bags to safely store and discard contaminated items.
Beyond PPE, researchers across the globe have proposed several solutions to recognize CHWs as part of the health care workforce and improve the CHW response to the pandemic. They have advocated for clear guidance on CHW roles and tasks (Bhattacharyya et al., 2020; Bhaumik et al., 2020), standardized training and hiring requirements (Ballard et al., 2020; Bhaumik et al., 2020; Haines et al., 2020), and a myriad of other evidence-based strategies. (See table below for a summary of proposed strategies.) Notably, Goldfield et al. (2020) described a framework for a new health system with CHWs at the center, both to address the pandemic in the present and also for future health system strengthening. Among strategies, the researchers include ongoing monitoring of changes in epidemiology and impact of mitigation activities, intensified active surveillance, and ongoing research and evaluation on the outbreak. Finally, greater care must be taken of CHWs to mitigate burnout and better support them to continue their work on the frontlines. To receive additional services like mental health support, governments must invest more into providing CHWs with universal healthcare.
Proposed strategies to improve CHW safety and efficacy during COVID-19:
Table references: Ballard (2020); Ballard et al. (2020); Ballard, Westgate, & CHIC (2020); Bhattacharyya et al. (2020); Bhaumik et al. (2020); Goldfield et al. (2020); Haines et al. (2020); Lotta et al. (2020); Maulik et al. (2020); Nepomnyashchiy, Dahn, et al. (2020); Nepomnyashchiy, Westgate, et al. (2020); Saleh et al. (2020)
Readers who might be interested in learning more about strategies to improve CHW safety can visit the COVID-19 Digital Classroom, a quality-assured COVID-19 library. This database offers a variety of medically reviewed educational materials regarding COVID-19. Visitors will find resources related to emergency response, risk mitigation and community engagement, case finding, surveillance, public health prevention measures, infection prevention and control, lab testing, case management, and societal response. Readers who might be interested in learning more about news focusing on CHWs can view the Year in Review News Database.
The global response to the COVID-19 pandemic has underscored the need for CHW programming to meet community needs for education, prevention, and treatment services. To effectively serve communities, CHWs need to be recognized as integral members of the health workforce, equipped to serve in ways that protect them as workers and the populations they serve, and provided with fair pay, mental health services, and other care to ensure their wellbeing and sustain their work. As vaccine distribution rolls out, we must clearly define the CHW role to ensure they receive timely access to protective and preventive commodities and to ameliorate their fears of providing care to patients infected with the virus. CHWs will play a pivotal role in educating individuals about mobilizing communities for vaccination if policy makers and program managers define their roles, place them at the front of the line for the vaccine and equip them with the information they need to inform community members. The lessons learned during 2020 about the role and needs of CHWs in fighting the pandemic must be considered as we prepare for the next phases of the COVID-19 fight and for future pandemics.
Pat M. Williams, MPH is a Fall 2020 intern at CHW Central. Contact: firstname.lastname@example.org