Table 2 Study characteristics: A scoping review of the roles, challenges, and strategies for enhancing the performance of community health workers in the response against COVID-19 in low-and middle-income countries

1

Lotta G, et al., (2021)

Journal of Comparative Policy Analysis: Research and Practice 23.1 (2021): 63–73.

Document Review

Brazil

How COVID-19 has affected frontline workers in Brazil: a comparative analysis of nurses and community health workers.

To analyse how the Brazilian government regulated the reorganization of Primary Health Care (PHC) and how frontline workers responded to these initiatives, comparing the roles played by nurses and community health workers.

Documents

• Given the multilevel health system, it was expected that the high level of ambiguity would stimulate innovations.

• However, data showed that the ambiguity created different situations for each profession.

• While nurses were able to adapt their work and act with more autonomy, CHWs lost their role in the policy.

2

Ballard et al., (2020)

BMJ global health, 5(6), e002550.

Document Review

Low and middle income countries

Prioritising the role of community health workers in the COVID-19 response.

Examining prioritising the role of community health workers in the COVID-19 response.

Documents

• Community health workers (CHWs) are poised to play a pivotal role in fighting the pandemic, especially in low-income countries with vulnerable health systems.

• The COVID-19 response must build on existing platforms, infrastructure, and relationships; the focus should be on supporting the Ministries of Health and regional authorities as they lead coordinated responses.

• Achieving these goals will require targeted actions at different stages of the pandemic.

3

Ajisegiri, et al., (2020)

Global Biosecurity. 2020;2(1).

Systematic review

Nigeria

COVID-19 outbreak situation in Nigeria and the need for effective engagement of community health workers for epidemic response.

Examining COVID-19 outbreak situation in nigeria and the need for effective engagement of CHWs for epidemic response.

Published articles from the website of the Nigeria Centre for Disease Control

• Recommended that the government needs to promptly bring community health workers on board, deploy rapid epidemic intelligence and scale up the use of mobile Apps for contact tracing.

• These changes will result in an effective and coordinated response to the outbreak, sustain routine health services especially at the community level.

4

Bezbaruah et al.,

(2021)

Journal of Public Health. 2021;10(3):41.

Rapid review of documents

South-East Asia

Roles of community health workers in advancing health security and resilient health systems: emerging lessons from the COVID-19 response in the South-East Asia Region. WHO South-East Asia.

To explore the roles of community health workers in advancing health security and resilient health systems: emerging lessons from the COVID-19 response in the South-East Asia Region.

Review journal articles, policy documents, national guidelines, reports, and online publications

• The regular role of a CHW in health education and promotion focused on awareness-raising and the promotion of “new normal” behaviours. CHWs also played critical roles in assisting in surveillance and contact tracing, and in ensuring that people followed isolation and quarantine guidelines.

• Development and implementation of long-term plans across the region to strengthen and support CHWs and recognize CHWs as an integral component of resilient health systems.

• Planning for CHWs as part of the primary health care system will enable local authorities to ensure that an adequate level of resources (including capacity-building, incentives, necessary equipment, and consumables) is allocated to CHWs.

5

Mistry et al. (2021)

Frontiers in Public Health. 2021:800.

Document Review

Low and middle income countries

Community health workers can provide psychosocial support to the people during COVID-19 and beyond in low-and middle-income countries.

To explore community health workers’ role in providing psychosocial support to the people during COVID-19 and beyond in low-and middle-income countries.

Documents

• The CHWs can be effectively engaged to provide psychosocial support at the community level. Engaging them can also be cost saving as they are already in place and may cost less compared to other health professionals. However, they need training and supervision and their safety and security need to be protected during this COVID-19.

• While many LMICs have mental health policies, their enactment is limited due to the fragility of health systems and limited health care resources.

• CHWs can contribute in this regard and help to address the psychosocial vulnerabilities of affected population in LMICs during COVID-19 and beyond.

6

Roy et al., (2020)

Global Health: Science and Practice. 2022;10(4).

Mixed methods

Bangladesh

Examining Roles, Support, and Experiences of Community Health Workers During the COVID-19 Pandemic in Bangladesh: A Mixed Methods Study.

Examining roles, support, and experiences of community health workers during the COVID-19 pandemic in Bangladesh.

Policy makers, program managers, CHW supervisors, and CHWs

• During the first wave of the coronavirus disease (COVID-19) pandemic in Bangladesh, across all health areas, community health workers (CHWs) described a slight decrease in the routine services they were able to provide due to restrictions in movement posed by lockdowns and other challenges.

• The government and various nongovernmental organizations provided supportive mechanisms to CHWs through training, supplies, and supportive supervision; however, this support were not always uniformly distributed across cadres, leading to some discontent among CHWs.

• CHWs were crucial actors in the government’s COVID-19 response, as they took on new pandemic-related responsibilities in their communities to prevent the spread of the disease while continuing their routine work.

7

Fernandez et al., (2020)

Archive of Family Medicine and General Practice. 2020;5(1):115 − 22

Quantitative

Brazil

How community health workers are facing COVID-19 pandemic in Brazil: personal feelings, access to resources and working process.

To examine how community health workers are facing COVID-19 pandemic in Brazil.

Online Survey

• CHWs feel scared and unprepared in the face of the COVID-19 pandemic. The fear of COVID-19 is related to being prepared and to receiving support from federal government. The feeling of preparedness is associated with the lack of material working conditions, such as PPEs, guidance from managers and support from superiors and federal government.

8

Nepomnyashchiy et al., (2020)

The Lancet. 2020;396(10245):150-2.

Review of documents

Africa

COVID-19: Africa needs unprecedented attention to strengthen community health systems.

To discuss the importance of unprecedented attention to strengthen community health systems during the COVID-19 pandemic.

Review of documents

• CHWs matter because they are trusted members of the community who are often the most accessible point of care.

• Ongoing efforts to leverage CHWs for the COVID-19 response must not be one-off in the face of an emergency. CHWs must be equipped, trained, and supported in the long term as a crucial human resource for health.

9

Maciel FBM.,

(2020)

Ciência & Saúde Coletiva. 2020;25:4185-95.

Qualitative study

Community health workers: reflections on the health work process in Covid-19 pandemic times.

Literature review

• CHW work, especially cultural competence, and community orientation, aiming to discuss the changes introduced in this work regarding the following aspects: (1) health teams support, (2) use of telehealth, and (3) health education.

10

Chitungo et al., (2021)

Human behavior and emerging technologies. 2021;3(5):843 − 53.

A rapid review

Sub-Saharan Africa

Utility of telemedicine in sub-Saharan Africa during the COVID‐19 pandemic. A rapid review.

The article aimed to propose the development of policy frameworks that fosters telemedicine use by all stakeholders.

A rapid review

• Challenges to the implementation of telemedicine on the continent were lack of supporting telemedicine framework and policies, digital barriers, and patient and healthcare personnel biases.

• To enhance the use of telemedicine, policies should be developed to support the use of telemedicine by all stakeholders, including medical insurance organizations, the introduction of telemedicine training of medical workers, educational awareness programs for the public, and improvement of digital platforms access and affordability.

11

Feroz et al.,.

(2021)

Archives of Public Health. 2021;79(1):1–4.

Review of documents

Equipping community health workers with digital tools for pandemic response in LMICs.

The article aimed to discuss ways of supporting CHWs with digital technology to ensure an appropriate pandemic response.

Review of documents

• CHWs are playing a huge role in providing essential health care services and Covid-19 related healthcare to the communities.

• CHWs are overburdened as they are expected to accomplish more although they are not getting the required support to perform their duties well, such as training, remuneration, protective gear, etc.

12

Bhaumik et al.,

(2020)

BMJ Global Health. 2020;5(6):e002769.

Systematic review

Low-and middle-income countries

Community health workers for pandemic response: a rapid evidence synthesis

The review aimed to conduct a rapid evidence synthesis on community health workers (CHWs) for COVID-19 prevention and control.

Articles

• CHW roles and tasks change substantially during pandemics. Clear guidance, training for changed roles and definition of what constitutes essential activities (i.e., those that must be sustained) is required.

• Most common additional activities during pandemics were community awareness, engagement, and sensitisation (including for countering stigma) and contact tracing.

• CHWs were reported to be involved in all aspects of contact tracing - this was reported to affect routine service delivery. CHWs have often been stigmatised or been socially ostracised during pandemics.

13

Sudhipongpracha et al., (2020)

Journal of Comparative Policy Analysis: Research and Practice. 2021;23(2):234 − 49.

Qualitative study

Kenya and Thailand

Community health workers as street-level quasi-bureaucrats in the COVID-19 Pandemic: The cases of Kenya and Thailand.

This article used cross-country comparative analysis to explore how community health workers (CHWs) deal with the COVID-19 pandemic.

Semi structured interviews

• Findings show that how a public health system is organized (decentralization versus centralization) affects CHWs’ initial responses to the outbreak.

• While CHWs in Thailand’s centralized system conform to the “state agent” tradition by referring to the hierarchical chain of command, those in Kenya’s decentralized system follow the “citizen agent” tradition by prioritizing community safety.

14

Jalali, F., Fischer, H., & Nichols, C. (2022).

Political Geography, 99.

Qualitative study

India

Corona warriors”? Experiences of India’s community health workers (ASHAs) in India’s COVID-19 response.

This paper aimed to explore the ways that nationalist COVID-19 war rhetoric promulgated from Delhi worked as a technology of health governance to propel ASHAs into certain forms of action.

In-depth telephone interviews with CHWs

• CHWs (ASHAs) were both proud ‘warriors’ and compelled to work due to the risk of letting down their community.

• While many CHWs however felt deep fear and that they were ill-prepared.

• CHWs reported that they made sacrifices both to their own personal health as well as their families.

15

Niyigena, A., Girukubonye, I., Barnhart, D. A., Cubaka, V. K., Niyigena, P. C., Nshunguyabahizi, M.,… & Bitalabeho, F. A. (2022).

BMJ open. 2022;12(4):e055119.

Mixed-method study

Rwanda

Rwanda’s community health workers at the front line: a mixed-method study on perceived needs and challenges for community-based healthcare delivery during COVID-19 pandemic.

The paper aimed to understand challenges faced by Rwanda’s CHWs during a nationwide COVID-19 lockdown.

CHWs

• Supervision during the lockdown was low.

• CHWs additionally described increases in workload, lack of personal protective equipment and COVID-specific training, fear of COVID-19, and difficult working conditions.

16

Sripad, P., Gottert, A., Abuya, T., Casseus, A., Hossain, S., Agarwal, S., & Warren, C. E. (2022).

PLOS global public health 2, no. 10 (2022): e0000595.

This mixed methods

Bangladesh, Haiti and Kenya

Confirming—and testing—bonds of trust: A mixed methods study exploring community health workers’ experiences during the COVID-19 pandemic in Bangladesh, Haiti and Kenya.

The study explored trust through the evolving COVID-19 crisis in Bangladesh, Haiti, and Kenya.

Interviews with CHWs

• CHWs reported high levels of community trust (8/10 in Bangladesh and Kenya; 6/10 in Haiti).

• Over 60% reported client relief in seeing their CHWs.

• CHWs reporting more positive and fewer negative experiences is consistently associated with continuing routine work, doing COVID-19-related work, and greater community trust. Qualitative interviews showed that CHW-community and CHW-health system actor trust is strengthened when CHWs are well-resourced.

• CHW-community trust is strained by public frustration at the pandemic, associated restrictions, and socio-political stressors.

17

Dhaliwal, B. K., Singh, S., Sullivan, L., Banerjee, P., Seth, R., Sengupta, P.,… & Shet, A. (2021).

Journal of global health, 11.

Rapid qualitative evaluation

India

Love, labor and loss on the frontlines: India’s community health workers straddle life and the COVID-19 pandemic

The study aimed to understand how the pandemic impacted the professional and personal experiences of CHWs in India during the pandemic.

Interviews with CHWs

• CHWs faced increased workloads, decreased compensation, and stated that their work had shifted to focus on COVID-related work, as opposed to routine care.

• CHWs also shared that their needs included improved mental health services, financial payment that was not tied to incentives, and consistent access to PPE.

• CHW experiences through the context of the COVID-19 pandemic have not been well-explored.

18

Monreal, T. J., Falcão de Oliveira, E., Araujo Ajalla, M. E., Adania Zanoni, D., & Du Bocage Santos-Pinto, C. (2022).

Sociological Spectrum, 42(3), 217–230.

A descriptive cross-sectional study- quantitative

Brazil

Community health workers and COVID-19 in a Brazilian state capital.

The aim of this study was to determine the COVID-19-related health status of CHWs, their basic knowledge of the disease and the role they played in the pandemic response.

Questionnaires with CHWs

• Around 40% of the sample reported at least one risk factor for COVID-19, 44% had experienced at least one COVID-19 symptom, and 76% had experienced symptoms of mental suffering during the first year of the pandemic. Mental suffering was associated with the onset of flu-like symptoms after the start of the pandemic and changes in work processes. Knowledge gaps were observed, mainly related to forms of transmission and disease prevention. In view of the uncertainty about how long this health emergency will last and the vital role CHWs play in the Brazilian Health System, health managers and society need to pay greater attention to these professionals to improve the effectiveness of the country’s COVID-19 response.

19

Gibson, E., Zameer, M., Alban, R., & Kouwanou, L. M. (2023).

Global Health: Science and Practice, 11(1).

A rapid review

Global landscape

Community health workers as vaccinators: a rapid review of the global landscape, 2000–2021.

This rapid review aimed to identify countries where CHWs administered vaccines and synthesize health systems factors that may contribute to or detract from the feasibility of CHWs administering vaccines.

Peer-reviewed literature

• Community health worker (CHW) cadres administered vaccines in 20 of the 75 countries with documented CHW programs, improving access to immunization services for under-reached communities.

• The review identified several countries where CHWs with brief clinical training and experience were taught to vaccinate, suggesting the feasibility of task-shifting administering vaccines to CHWs with limited experience.

20

Olateju e al., (2022).

PloS one. 2022;17(3):e0265092.

Qualitative study

Nigeria

Community health workers experiences and perceptions of working during the COVID-19 pandemic in Lagos, Nigeria—A qualitative study.

To explore community health workers’ experiences and perceptions of working during the COVID-19 pandemic in Lagos, Nigeria

Interviews with CHWs

• Trust and COVID-19 knowledge were found to aid CHWs in their work. However, challenges included exhaustion due to an increased workload, public misconceptions about COVID-19, stigmatisation of COVID-19 patients, delayed access to care and lack of transportation.

• Influences on willingness to work in COVID-19 included CHWs ’ perceptions of COVID-19, attitudes towards responsibility for COVID-19 risk at work, commitment and faith.

• Financial incentives, provision of adequate personal protective equipment, transportation, and increasing staff numbers were seen as potential strategies to address many of the challenges faced.

21

Salve, S., Raven, J., Das, P., Srinivasan, S., Khaled, A., Hayee, M.,… & Gooding, K. (2023).

PLOS Global Public Health, 3(1), e0001447.

Synthesis of evidence

India, Bangladesh, Pakistan, Sierra Leone, Kenya and Ethiopia

Community health workers and Covid-19: Cross-country evidence on their roles, experiences, challenges and adaptive strategies.

The paper aimed contribute to learning about CHWs’ experiences during COVID-19, based on evidence from India, Bangladesh, Pakistan, Sierra Leone, Kenya and Ethiopia.

Synthesises evidence from a set of research projects

• CHWs made important contributions to the COVID-19 response, including in surveillance, community education, and support for people with COVID-19.

• There was some support for CHWs’ work, including training, personal protective equipment, and financial incentives.

• However, support varied between countries, cadres and individual CHWs, and there were significant gaps, leaving CHWs vulnerable to infection and stress.

• CHWs also faced a range of other challenges, including health system issues such as disrupted medical supply chains, insufficient staff and high workloads, a particular difficulty for female CHWs who were balancing domestic responsibilities.

• CHWs demonstrated commitment in adapting their work, for example ensuring patients had adequate drugs in advance of lockdowns and using their own money and time to address increased transport costs and higher workloads.

22

World Health Organization. (2021).

World Health Organization Website

Report

Global landscape

The role of community health workers in COVID-19 vaccination.

The guide intended to support national governments in developing their national deployment and vaccination plans (NDVP) for COVID-19 vaccines by outlining the roles, needs and opportunities for (CHWs).

Reports and articles

• This guide is intended to support national governments in developing their national deployment and vaccination plans (NDVP) for COVID-19 vaccines by outlining the roles, needs and opportunities for community health workers (CHWs).

• Identifying CHW contributing roles at each stage of COVID-19 vaccines rollout.

• Counting and vaccinating CHWs within initial vaccine allocation as part of the essential health

• Workforce to optimally support the COVID-19 response and continuity of essential health services.

• Recognizing and remunerating CHWs commensurate to tasks undertaken and training.

• CHWs who are linked to health systems through regular compensation, dedicated supervision and accreditation are best placed to support an effective pandemic response and to prevent the next one.

• Considering community-based health worker representation on national coordinating committees.