Data were abstracted from a total of 18 included articles (Appendix 2). Figure 1 shows how the inclusion and exclusion criteria were applied to articles identified in the literature searches.
Figure 1. Application of inclusion and exclusion criteria to articles identified in literature searches
Only one article reported an evaluation study. This included pre- and post-intervention data on selected outcomes.(10) All other articles were commentaries,(11–25) including one narrative review(26) and two opinion pieces.(23, 27) Ten articles were published in scientific journals,(10, 15, 16, 21–24, 26–28) eight were news articles.(11–14, 17–20) The core components and outcomes of these programs (where reported) are outlined in Table 1 and described as follows:
Table 1
Description of programs with community health workers disseminating COVID-19 information to support prevention and control
Community health worker program | Does program pre-date COVID-19? | Location | Scope | Community health worker intervention | Intervention implementation period | Reach and impact |
Programs with quantitative evaluation |
Uganda |
Village Health Worker (VHW) program | Yes | Kisoro district | 52 villages and 48 VHWs | VHWs delivered 4,308 COVID-19 home talks that each lasted 30 minutes to > 14,000 adults with minimal formal education and answered their questions. The control group were not visited by VHWs with COVID-19 information.(10) | 20 April to 16 June 2020 | Intervention group scored 30% higher on COVID-19 knowledge test than controls (p < 0.0001). Significant learning was noted on: COVID-19 symptoms, mechanisms of spread, disease prevention, and risks of mortality, but not about when to go to the hospital with symptoms.(10) Most participants (82%) in the intervention group reported understanding and valuing information from the home talk more than information they heard via the radio.(10) |
Programs without formal evaluation with data |
United States |
Korean Community Services of Metropolitan New York (KSC) program | Yes | New York and New Jersey | Korean American immigrants (numbers not specified) | CHWs partnered with health professionals to share COVID-19 information virtually, answered questions, promoted testing and vaccination, distributed PPE at outreach sessions. (25) | From March 2020 | Online meetings and videos reached > 32,000 social media viewers in November 2021. > 1,000 people tested for COVID-19 across four events in May 2020. Reported increase in COVID-19 vaccine uptake including by offering more than 160 appointments daily, seven days a week.(25) |
New York –Presbyterian Hospital and the NYU Grossman School of Medicine program | Yes | New York City | 50 CHWs worked with underserved culturally and linguistically diverse communities | CHWs contacted socially isolated patients with COVID-19, shared COVID-19 information and connected them with support services.(21) | Not stated | From early March to August 2020, CHWs conducted over 9,600 wellness checks via phone, helped nearly 3,400 people enrol in online patient portals and prepare for upcoming telehealth appointments, and conducted virtual health coaching sessions with > 600 patients.(21) |
South Asian Council for Social Services program | Yes | New York, Queens | > 50,000 clients: underserved South Asians and the broader immigrant community | CHWs disseminated COVID-19 information, distributed masks and sanitiser, promoted testing and vaccination services. (25) | Not reported | Between February and May 2021, CHWs provided an average of seven support groups, 187 wellness calls, and 79 counselling sessions/month to community members who had low English-language proficiency. During this period 169 vaccinations/month were provided. (25) |
Unhoused peer ambassador (PA) COVID-19 vaccine outreach program | No | Los Angeles homeless communities | CHWs worked with PAs in pairs (numbers not specified) | PAs introduced CHW to potential homeless clients, distributed food, water, harm reduction supplies and assessed interest in a COVID-19 vaccine, then guided interested people to a nearby mobile vaccine clinic.(22) | 2020 and early 2021 | PA were valued as vaccine outreach team members and nearly all the 19 CHW participants felt the program was successful’.(22) |
India |
Unaccredited community health worker (CHW) training program | Yes | Bihar state | 15,000 rural CHWs | A one-day training module taught unaccredited CHWs to: identify possible COVID-19 cases, arrange testing and treatment, monitor cases in home isolation, refer patients with serious symptoms to dedicated health centres, maintain records and co-ordinate activities with the local district control centre.(16) | From May 2021 | CHW satisfaction: 81/102 (79%) agreed that their training needs were being met and they had received information from reliable sources.(16) Three-fold increase in people with COVID-19 symptoms referred to primary health centres following the training module (from five people per day to 15 per day, although the time period of observation was not defined).(16) |
Accredited Social Health Activist (ASHA) program | Yes | Nationwide | > 900,000 ASHAs nationwide | ASHAs conducted 30–50 home visits/day performing contact tracing, taking travel histories, documenting health profiles, providing home isolation instructions and case monitoring, administering routine medications, maintaining records and sharing COVID-19 information. In various provinces ASHAs also distributed facemasks and performed symptom screening. (11, 12, 14, 15) | From March 2020 | ASHAs performed COVID-19 symptom screening and checked on high risk people in over 15.9 million households in Karnataka (as of 4 July 2020).(15) Over 3,800 people placed in home quarantine with ASHAs support in Paravur (as of March 2020).(11) |
Myanmar |
UN-Habitat Myanmar program | Yes | Yangon (‘slum’ settlements) | 61 CHWs in five settlements | CHWs contacted households, provided COVID-19 information and distributed facemasks.(18) | From 2020 (first half) | CHWs contacted > 13,200 households, distributed 102,000 facemasks.(18) |
Thailand |
Village Health Volunteers (VHV) program | Yes | Nationwide | > 1 million VHVs nationwide | VHVs conducted door-to-door visits sharing COVID-19 information, distributed facemasks and hand sanitiser, conducted case follow-up, supported cases and vulnerable people in home isolation, performed temperature screening and contact tracing, organised testing, monitored community gatherings and movements.(17, 19, 26) | From January 2020 | VHVs visited > 11 million homes in March and April 2020.(17) A narrative review concludes VHVs were instrumental in reducing COVID-19 transmission and averting a severe hospital burden.(26) |
Programs without data (commentaries) |
United States |
Apicha Community Health Centre program | Yes | New York | Underserved communities, especially Asian immigrants | CHWs shared COVID-19 information, PPE, promoted testing and vaccination.(25) | Not stated | Not stated(25) |
National Tongan American Society program | Yes | Utah | Pacific Islander communities especially Tongan community | CHWs provided language assistance including for COVID-19 information.(25) | Not stated | Not stated(25) |
Navajo Nation Community Health Representative (CHR) program | Yes | Navajo Nation | > 100 CHRs serve the Dine’ people | CHRs shared COVID-19 information, performed contract tracing and supported community members, including those in home isolation.(23) | Not stated | Not stated.(23) |
Centre for Pan Asian Community Services program | Yes | Atlanta, Georgia | Underserved communities, especially Asian immigrants | CHWs provided COVID-19 information and testing materials.(25) | Not stated | Not stated(25) |
The Asian Pacific Community in Action program | Yes | Arizona, Phoenix | Underserved communities, especially Asian immigrants | CHWs addressed COVID-19 vaccine misinformation, facilitated testing and vaccination appointments.(25) | Not stated | Not stated(25) |
Bangladesh |
United Nations High Commissioner for Refugees Rohingya program | Yes | Rohingya refugee settlements | > 1,400 Rohingya refugees trained as CHWs | CHWs went door-to-door sharing COVID-19 information, promoting testing, supporting cases in home isolation.(20) | Late January 2020 | Not stated.(20) |
India |
Brihanmumbai Municipal Corporation program | Yes | India, Mumbai | 4,000 CHWs | CHWs conducted door-to-door visits to share COVID-19 information and conduct contract tracing.(13) | Not reported. | Not reported.(13) |
Liberia |
National Community Health Assistant Program | Yes | Nationwide | CHWs nationwide | CHWs trained to: share COVID-19 information, conduct community surveillance, contact tracing, testing, support cases in home isolation, refer severe cases.(27) | Not stated | Not stated(27) |
Zambia |
Neri/i4life clinic | Yes | Linda township | CHWs serving epilepsy patients | CHWs provided COVID-19 information during home visits, answered questions.(24) | From 2020 early March | Not provided.(24) |
To what extent have CHWs been used in the response to COVID-19 and in what capacities?
A total of 18 relevant CHW programs were identified from the included articles. Multiple programs were reported from the United States (US; n = 9) and India (3), with one program in each of Bangladesh, Liberia, Myanmar, Thailand, Uganda, and Zambia (Table 1).
The only article reporting quantitative data on program effectiveness described a Ugandan program which increased participants’ understanding of COVID-19 safety.(10)
Eight programs lacked a formal evaluation, but reports presented data indicating reach and effectiveness. In the US, these programs targeted minority and underserved populations.(25, 29, 30) Two Asian American community program were identified, both used mobile vans staffed with bilingual CHWs to increase access to COVID-19 testing and vaccination.(25) The collaboration between the South Asian Council for Social Services and New York City Health + Hospitals also provided free, walk-in COVID-19 PCR testing and vaccination. CHWs at Korean Community Services provided free COVID-19 testing, vaccination, and antibody screening. Partnerships with Uber and faith-based organisations increased the accessibility and acceptability of these COVID-19 services.(25) Another US program involved multilingual CHW teams delivering health coaching, support, and health system navigation services to underserved culturally diverse communities throughout New York City. This article concluded these CHWs formed a critical bridge between vulnerable communities and the health system.(21) In Los Angeles, a program paired CHWs with experience of homelessness with ‘peer ambassadors’ from homeless communities.(22)
A program in India’s third most populous state, Bihar, described a COVID-19 training module delivered to unaccredited CHWs which coincided with a three-fold increase in referrals to primary care,(16) although this could reflect an increase in case numbers. India’s nationwide Accredited Social Health Activist (ASHA) Program, which commenced in 2005, was also described.(11, 12, 14, 15) ASHAs are local women trained to work as health educators and promoters in their communities.(31) (32) ASHAs were reported to have a considerable reach and impact on the Indian COVID-19 response.(11, 15)
Thailand expanded its nationwide cadre of village health volunteers (VHVs) to over one million personnel. VHVs are a critical point of contact between the community and public health officials.(17, 19, 26)On average, during the pandemic, each VHV was responsible for 10 households.(26) A narrative review suggested that without VHVs, the Thai health system may have been overburdened from COVID-19.(26)
UN-Habitat supported a team of volunteer CHWs in five informal ‘slum’ settlements in Myanmar’s largest city Yangon. These CHWs’ COVID-19 response was reported to have had considerable reach.(18)
The remaining nine programs were described in positive terms by commentaries which included anecdotal evidence and expert opinion.(25) For example, in the Navajo Nation, CHWs are selected by tribal leaders to work in the Navajo-owned-and-run community health program. They receive training from the New Mexico Department of Health.(23) A program in Mumbai, India, involved a workforce of around 4,000 volunteers who were described as the ‘…backbone of the Brihanmumbai Municipal Corporation’s health workers…’.(13)
In Bangladesh > 1,400 Rohingya refugees were trained by the United Nations (UN) to become CHWs. The article identified them as ‘leading the COVID-19 battle’ as a critical community information source.(20)
CHWs in Liberia were able to share COVID-19 information through the National Community Health Assistant Program. A March 2020 BMJ Opinion Piece concludes that strategies to rapidly expand healthcare teams with CHWs and develop COVID-19 services were urgently required in Liberia. The authors noted that many countries in sub-Saharan Africa were engaging CHWs in the manner described, and CHWs had been critical in limiting transmission during previous epidemics.(27)
In 2019, a CHW program for pediatric epilepsy was launched in a very low-income community and expanded to include provision of COVID-19 information to clients. The authors stated that although the Zambian Ministry of Health provided guidance on hygiene and social distancing measures, many of the people they served were illiterate and otherwise had limited access to information.(24)
Key facilitators and barriers that affected CHWs’ effectiveness in the COVID-19 response
Facilitators
Trusted relationships
Communities having trusted relationships with CHWs was consistently described as a major facilitator of the CHWs’ COVID-19 response work. To illustrate, a Thai VHV was quoted as saying ‘We know everyone here and we have their trust and confidence.’(17) The selection of CHWs by the community, or by tribal leaders, may have helped to facilitate trust in these relationships.(23, 26) In several cases, articles noted that community leaders (including religious leaders) would endorse CHWs’ health messages and help disseminate their messages.(20, 23, 25) Trust and rapport was often described as being built by the CHWs leveraging their cultural connectedness and shared life experiences. To illustrate, bicultural CHWs were able to connect with community members who were severely affected by the COVID-19 pandemic in New York and engage them with health and support services,(21) and unhoused peer ambassadors were valued by vaccine outreach teams working in homeless communities.(22) CHWs in India were sometimes perceived to be doctors by community members, and were the first point of reference for medical ailments.(13, 15) During the COVID-19 pandemic, CHWs were described as ‘the most trusted health care provider in the Navajo Nation’.(23) Knowing the community, understanding their needs and having rapport enabled people to 'open up' to CHWs(11) and undergo COVID-19 testing without fear of stigma.(20) CHWs’ knowledge of community informed clinicians’ understandings of patients’ needs. Speaking about India’s ASHAs, a spokesperson at Public Services International was quoted as saying ‘The skills and the capacity these women have, the way in which they are familiar with each community’s members — the sick, the elderly, the children — the ASHAs are the most likely to know when someone is displaying symptoms of coronavirus, has been traveling abroad or is missing from the home. Without them, doctors will be operating blind.’(14)
Dedication to helping community
Articles frequently praised CHWs’ dedication to helping their communities through COVID-19. This dedication often existed in spite of difficult and dangerous working conditions. CHWs conducted home visits despite high community COVID-19 transmission and facing stigma due to being perceived as an infection risk themselves.(15),33 CHWs quoted in the literature would often speak about the sense of duty and reward they felt helping their communities.(12, 20)
Responsive service provision
With the exception of the unhoused peer ambassador-CHW program, all programs we identified were already established as health services when the pandemic eventuated (Table 1). Not only did this mean that trusted relationships and reporting mechanisms were already in place, but CHWs already had experience and knowledge of surveillance pathways and community health needs. Pre-existing CHW programs mobilised rapidly in the pandemic response, in some cases following only one or two days of CHW training.(10, 13, 23–27) Having a thorough knowledge of community needs enabled CHWs to provide a responsive service. In the Navajo Nation, CHWs were able to quickly identify the most vulnerable and underserved to ensure resources made it to families with the highest need.(23) It is possible that having the ability to discuss COVID-19 and ask CHWs questions during education sessions made community members more receptive to their health messages.(10, 15, 25)
Partnerships with service providers
Community health organisations and CHWs partnered with local public health authorities, clinical service providers and laboratories to co-ordinate the COVID-19 response. CHWs were able to link their community with the partnering organisations/service providers. These partnerships supported public health surveillance and enhanced community access to testing, vaccination and treatment. Partnerships with community organisations enabled other health and wellbeing supports to be delivered.(15, 20–23, 25, 26) To illustrate, in New York, a partnership between the Korean Community Services organisation and Uber enabled less mobile community members to be brought to testing and vaccination providers with encouragement from CHWs, who helped share COVID-19 information in language.(25)
Barriers
Program funding and CHW salary
Underfunding was identified as a key barrier to the effectiveness of CHWs’ services in India and Thailand; underfunding may have posed issues in the other included programs but were not reported. ASHAs in India took on COVID-19 work in addition to already heavy workloads. Initially they were not financially compensated for COVID-19 duties. Being considered volunteers, rather than employees, meant ASHAs missed out on employment benefits, including sick leave and carer’s leave. Underfunding may have been related to a lack of recognition from community and government around the value of CHW’s work, which has been noted regarding the ASHA program.(11, 14, 15)
Occupational risk of infection
ASHAs were at high risk of acquiring COVID-19 through occupational exposure. This risk was compounded by not being provided with adequate PPE and hand sanitiser.
Occupational risk of stigma
Racism and sexism were sometimes directed against this female and predominantly low-caste workforce. Communities sometimes responded to ASHAs with hostility and in some cases they were subjected to physical violence. This hostility may have been driven by stigma due to ASHAs themselves being perceived as a COVID-19 infection risk. In some cases, ASHAs were stigmatised by their own families due to this perception and excluded from their own homes.(11, 14, 15)
Communication
In Thailand, VHVs disseminated facemasks to community members which they had needed to hand sew themselves.(17) Reported barriers to these VHVs’ effectiveness included a lack of adequate systemic communication between provinces to share and customise good practices for COVID-19 prevention and control. This limited the responsiveness of their service provision. Rural Thai VHVs have stronger community links than their urban counterparts, who may struggle more to connect with communities and subsequently those communities may be less receptive to them.(26)
CHW burnout
Reports on the ASHA program in India and the Navajo Nation CHW program identified CHWs working long hours, with night and weekend work, as sometimes needed to provide a responsive service. This put CHWs at risk of chronic stress and burn-out.(15, 23) The Navajo report noted that CHWs’ close ties to community meant that they grieved when community members died from COVID-19. Consequently they required time out and support when this happened.(23)
CHWs’ impact on community trust in COVID-19 public health strategies
We noted a lack of empirical data on CHWs’ impact on community trust, with the exception of the Ugandan study which showed that participants valued CHWs’ COVID-19 home talks more than the information they heard on the radio.(10) Anecdotally, trust in the Thai VHVs led to increased trust in local health centers, which in turn empowered people to seek care, even when they were fearful of being stigmatised for having COVID-19.(17, 20) The Navajo Nation report described a person deciding to disobey public heath orders to collect supplies, but then agreeing to receive deliveries at home after arranging this with a CHW who provided them with much needed reassurance.(23)
CHWs’ impact on uptake of community COVID-19 testing
CHWs’ impact on testing uptake is difficult to ascertain, particularly in times of increasing community cases. Almost all the included CHW programs had a strong focus on CHWs either performing COVID-19 testing themselves,(26, 27) or guiding symptomatic people to testing facilities.(10–17, 19–21, 23, 24, 26–28) In Thailand, community compliance with COVID-19 testing and government guidelines was described as ‘mostly successful,’ which was partly attributed to the VHVs who facilitated testing.(26) The partnerships between the New York Test & Trace Corps and Korean Community Services reportedly resulted in over 1,000 people undergoing COVID-19 testing in May 2020 alone.(25) A WHO staff member is quoted as saying that in Bangladesh refugee settlements (where people had feared being stigmatised if found to have COVID-19), “the biggest challenge we are facing is convincing people to get tested. The volunteers [CHWs] help us to reach the community and discuss with them the necessity of getting tested and how to prevent further spread of the disease.”(20)
CHWs’ impact on community COVID-19 vaccine uptake
We noted a lack of empirical data demonstrating CHWs’ impact on community COVID-19 vaccine uptake. In Liberia, CHWs were reported to prepare their communities for the introduction of COVID-19 vaccines, although how was not specified.(27) Partnerships between Korean Community Services, the Korean American Physicians Association of New York, Uber, faith-based organisations and vaccine outreach services were reported to have successfully increased COVID-19 vaccine uptake, including among the local senior and immigrant populations. The extent to which uptake was increased is not stated, however the demand was presumably sufficient to warrant vaccine providers making more than 160 appointments available daily with language support, seven days a week.(25)