Engaging Community Health Workers to Support Home-based Care for People with COVID-19 in Low-Resource Non-U.S. Settings

Community health workers (CHWs) are valuable assets to public health in low resource settings. Broadly, CHWs work as community advocates, conduct outreach and community engagement for public health programs, and provide health education and services. Home-based care supported by CHWs can help relieve the substantial burden the COVID-19 pandemic has placed on healthcare systems worldwide. CHWs are well-suited to provide the necessary sensitization, training, and support to communities to allow people with COVID-19 to be cared for safely at home.

Protecting CHWs’ health and safety is critical, including during the COVID-19 pandemic. With training about prevention and appropriate infection prevention and control measures, CHWs can protect their own health while serving as good examples for how to prevent COVID-19 in the communities they serve. Relying on CHWs can help maximize available resources for managing and caring for people with more severe illness and can help maintain essential health services. The following considerations are intended for program managers and other public health officials supporting the COVID-19 response in low-resource non-US settings.

CHW Level of Support for COVID-19 Activities Varies

The level and type of CHWs’ engagement with COVID-19 activities will depend on many factors, including available resources, the skill, ability, and interest level of CHWs to participate in various activities, and the level of transmission in a specific community. The following four scenarios are examples of how CHWs can support the COVID-19 pandemic response and how different mitigation activities may be layered to serve multiple functions.

• Scenario 1: CHWs who are not engaged in COVID-19 response activities. These include CHWs who are engaged in non-COVID-19 response activities, such as general health promotion or management of people with chronic illnesses (e.g., HIV).
• Scenario 2: CHWs who have limited engagement in some COVID-19 activities (e.g., community education and sensitization),but are primarily focused on delivering other health services to people with no COVID-19 symptoms.
• Scenario 3: CHWs who have moderate engagement in COVID-19 response activities.  These CHWs incorporate COVID-19 community education and prevention messages into their primary non-COVID-19 duties, such as during health campaigns in the community. This allows CHWs to continue providing other essential health services and prevents duplication of effort.
• Scenario 4: CHWs who are fully engaged in COVID-19-related activities. These CHWs are working primarily on COVID-19 activities, such as COVID-19 symptom monitoring and supporting home-based care for COVID-19 patients.

The risk level for CHWs working in each scenario should be assessed to determine the appropriate type of protection needed. CHWs working with the public should always wear a well-fitting mask and maintain social distancing (> 2 meters).  CHWs who provide direct care or assistance to people with COVID-19, symptoms of COVID-19, or who might have been exposed to COVID-19 should use appropriate personal protective equipment (PPE).  CHWs with moderate community engagement who are in situations in which they could be exposed to people with COVID-19 might need to use additional protection. It is important to carefully assess risk and keep in mind that the overuse or misuse of certain types of PPE could lead to supply shortages (also see World Health Organization (WHO) guidanceexternal icon). When personal contact between the CHW and a patient with COVID-19 or exposure to COVID-19 is not required (e.g., scenarios 1, 2, and in most cases 3), other prevention measures should be used and PPE should not be used. CHWs in scenario 4 especially should be encouraged to be vaccinated when the vaccine becomes available to them.

CHW Support for Community Education and Prevention of COVID-19

General COVID-19 community education and prevention activities can be integrated into the routine activities CHWs performed. These activities are ideal for CHWs with limited hours to work, CHWs with less clinical experience, or those who have extra capacity to integrate these activities into the non-COVID-19 services they already provide to the community.

Activities

• Educate communities on symptoms of COVID-19external icon, and how it spreads.
• Answer questions raised by community members and address myths, rumors, and misinformation circulating in the community. Monitor misinformation within the community in order to inform response activities so that these can be addressed.
• Provide education to combat stigma against community members who are diagnosed with COVID-19, in contact with someone who was diagnosed with COVID-19 or their family members, and healthcare providers and other COVID-19 response workers. Speak out against negative behaviors and statements and encourage empathy and support to community members who are isolating or quarantining.
• Promote COVID-19 prevention measures such as social distancing (>2 meters), wearing a well-fitting mask, frequent hand washing, and respiratory hygiene (coughing/sneezing into elbow). People should understand that most people with COVID-19 have mild symptoms or no symptoms at all, and using a mask prevents people who might not realize they are infected from spreading the virus to others.
• Encourage community members to seek testing or clinical care if they develop symptoms consistent with COVID-19 or are a close contact to someone with COVID-19, according to the country’s Ministry of Health guidance.
• Screen for COVID-19 symptomsexternal icon when household or community visits are already included as part of routine duties. People who are experiencing symptoms, or have been in close contact with someone with COVID-19, should be referred for testing. WHO provides guidance for prioritizing testing when diagnostic capacity is limitedexternal icon.
• Provide awareness and support for prevention of indirect impacts of COVID-19 (e.g., violence, food insecurity, lack of routine health care, including childhood immunizations).
• Undertake social media activities, including posting factual information and dispelling rumors or false information

Examples of materials needed for implementation of home-based care

• Informational fliers or leaflets targeted to an audience with lower literacy
• Hand washing stations with water and soap
• Alcohol-based hand rub with at least 60% alcohol (for CHWs to use in the field when soap and water are not available)
• Masks
• Informational, educational, or communication (IEC) materials for COVID-19-infected people and their caregivers on safe home-based care, including hygiene practices and when to seek emergency medical attention
• Misinformation/rumor tracking monitoring data collection tools, as part of routine surveillance
• Mobile phone and airtime to call if a person in the community needs healthcare referral or for social media posting/dispelling rumor
• Pulse oximeter for measuring blood oxygen saturation

Operational considerations and challenges

• If CHWs typically communicate going door-to-door, provide training for using methods such as a bullhorn or microphone.
• Encourage CHWs to model behaviors they are promoting during educational sessions.
• Develop a system that CHWs can use to refer and connect people to COVID-19 testing and treatment facilities.
• A referral system or hotline should be in place and pilot tested before promoting social support for community members experiencing violence/abuse or having other needs
• CHWs could be tasked with delivering test results for people they have referred for testing or those in the community as part of the referral and assessment pathway.

Operationalization of CHW Support for Home-based Care

With training in infection prevention and control and sufficient supplies, CHWs can support home-based careexternal icon for eligible people with confirmed or probable COVID-19. The level and type of CHW support for home-based care will vary by location, available resources, and the CHW management structure. Program managers and other public health officials may need to consider recruiting, training, and supervising CHWs who support home-based care for COVID-19.

Recruiting CHWs

• Conduct an assessment of the existing number and technical capacity of available CHWs.
• To maintain continuity of services and not overburden CHWs already working to provide essential health services, consider hiring additional CHWs to support the COVID-19 response.
• Depending on the level of spread of COVID-19, consider adding tasks to existing CHWs or adding a new cadre of CHWs specifically to address COVID-19.

 Training CHWs on COVID-19 and home-based care

• Provide CHWs with training relevant for additional roles and responsibilities. For example, this might include training on confidentiality related to patient medical information and testing results.
• Conduct virtual trainings through mobile or online platforms, whenever possible. Provide easy-to-use job aids translated into local languages when possible. Training modules have been or are being developed by numerous organizations, including WHOexternal icon, Africa CDC through their Partnership to Accelerate COVID-19 Testing (PACT) Initiativeexternal icon, and Johns Hopkins Universityexternal icon.
• Follow strict physical distancing protocols for any necessary in-person trainings in addition to requiring all attendees to use masks.

 Supervising CHWs

• Supervisory meetings (individual and group) can be conducted remotely and in collaboration with lowest administrative level health office/department.
  • Individual meetings can be held by phone. If in-person meetings are necessary, enforce physical distancing precautions and wear masks. If possible, conduct meetings outdoors or in well-ventilated areas.
  • Group meetings can be held by virtual platform.
  • The level of supervision can be modified based on the CHW’s need for technical and psychosocial support.
• Supervisors can initiate daily temperature and symptom checks for CHWs, to be reported via SMS, a phone call, email, or a mobile or web-based application. Refer CHWs reporting a temperature above 38 °C (100.4 °F) or other symptoms consistent with COVID-19 for COVID-19 testing. If a CHW tests positive, he/she should stop working and self-isolate for at least 10 days after symptom onset, until at least 24 hours without fever and other symptoms have improved, or national criteria for discontinuation of isolation have been met. In areas where COVID-19 testing is not possible, but a CHW meets the case definition for a suspected case, the CHW should still isolate based on national guidelines.

Strategies for CHWs to Use to Support Home-based Care

People with mild to moderate COVID-19 symptoms who are not at risk of severe illness can recover at homeexternal icon, if they are able to safely isolate. CHWs can support home-based care through three main strategies. The activities associated with these strategies may be better suited for CHWs with experience in community surveillance, integrated management of childhood illnesses, or other clinical expertise (e.g., HIV/AIDS, malaria, tuberculosis). Most activities can be conducted remotely (i.e., by phone) or in-person.

Strategy 1. Assessing eligibility for home-based care

Activities

Assess people with confirmed or probable COVID-19 for eligibility for home-based care. People with confirmed or probable COVID-19 might be eligible for home-based care (rather than clinic-based care) if they:

• Are aged < 65 years
• Are not at increased risk for severe illness from COVID-19

Assess homes/residential setting for suitability for home-based care, which should include the following criteria:

• The patient is stable enough to receive care at home
• Appropriate caregiver(s) are available. Caregivers, when possible, should not be at increased risk for severe illness from COVID-19 (i.e. no chronic medical conditions, not immunocompromised, not elderly, not pregnant). To minimize risk of transmission, designate one person as a caregiver until the patient recovers.
• CHW or caregiver has the ability to monitor changes in the patient’s clinical status at home
• A separate bedroom and bathroom is available for the person who is sick. If this is not an option, ensure the patient can be separate from other household members as much as possible. Prevention measures for high-density households might include:
  • Opening a window, if possible and if safe to do so.
  • Maintaining at least 6 feet between beds. If this is not possible, sleep head to toe.
  • Placing a curtain around or using another physical divider (e.g., shower curtain, large cardboard poster board, heavy blanket) to separate the patient’s bed from others.
  • Keeping people at increased risk separated from anyone who is sick. “House swaps,” in which neighboring patients are cohorted together and cared for by one person or set of people dedicated to providing care, are one feasible solution.
• Access to food, water, medicine, and other basic necessities is reliable. In certain contexts, CHWs may help ensure access by providing delivery of these necessities.
• Patients and their household members have access to adequate supplies for transmission-based precautions (at a minimum, masks and gloves) and for cleaning and disinfecting (re-usable or disposable gloves, and lined trash bin) for the duration of recovery. Disposable gloves should be used for taking out the trash. For cleaning, if no thick gloves are available, any kind of gloves can be used.
• Patient is able to wear a face mask and wash hands with soap or use alcohol-based hand sanitizer.
• Household has access and ability to conduct frequent (at least daily) cleaning and disinfectionexternal icon of household surfaces. (Note: might not be necessary if patient lives alone)

Examples of resources for implementation of home-based care

• COVID-19 symptom assessment tool
• Surveillance data collection tools
• Home-based care individual eligibility assessment tool
• Home-based care household/residence eligibility assessment tool
• Alcohol-based hand rub (for CHWs to use when in the field)
• Mask
• PPE (e.g., gloves, gown, masks)
• Referral system(s) to
  • Report people with probable COVID-19 for symptom assessment or testing
  • Link CHWs to people with confirmed or probable COVID-19
  • Refer patient to healthcare facility or community isolation center if setting is unsuitable for home care
  • Link to contact tracing team (for identification/monitoring of contacts outside the household)

Operational considerations and challenges

• Assessing availability for home-based care depends on the existence of a data and referral system that identifies people with confirmed or probable COVID-19 to be assessed for home-based care. The system(s) will vary by location and resource availability and should be in place and operational before activating CHWs for eligibility assessment activities. Examples of possible referral systems include:
  • Local/national COVID-19 hotline
  • Rapid response teams
  • Testing center
  • Community-based surveillance
  • Self-referral (i.e., per education/awareness campaigns listed above, the patient reaches out directly to health facility or directly to CHW)
  • Detection by CHW or referral by another CHW while in community
  • House-to-house or route-based visits (active case search)
  • Contact tracing team
• If patients are not eligible for home-based care, they need to be linked to care in a community isolation center, health facility, hospital, etc. CHWs could also help organize and support “house swaps” if a person meets criteria but their living space does not.
• Home isolation might contribute to an increase in violence (possibly due to stress or increased time in the same space as an abuser). When assessing patients and homes for suitability of home-based care, look for and consider signs and symptomsexternal icon of violence and abuse.

Strategy 2. Advising, training, and supporting households and caregivers to provide home-based care

Activities

Advise and train households and caregivers to provide home-based care for people with COVID-19, including:

• Infection prevention and control, including personal hygiene and how caretakers can protect themselves and others in the household when caring for someone with COVID-19.
• Signs and symptoms of severe illnessexternal icon requiring referral to health facility (e.g., light headedness, difficulty breathing, chest pain, dehydration, confusion, or other severe sign or symptom).
• Distribute home-based care kits or refer household to where home-based kits are available.
• Provide leaflet on How to care for someone with COVID-19 symptoms. This leaflet might need to be translated into the local language.
• Provide support to households and community members affected by indirect impacts of COVID-19 (e.g., food insecurity, interpersonal violence, abuse).
  • Promote local resources (e.g., a confidential referral network or hotline) for community members to call if they or others are experiencing violence or abuse
  • Distribute food, water, medicine, hygiene materials, and household essentials.

Example of resources for implementation of home-based care

• Handwashing station materials and soap
• Low-literacy job aids/informational materials available in local languages on:

• • How to make a handwashing station (instructions for various designs can be found hereexternal icon)
  • How to make disinfecting solutions
  • How to care for someone with COVID-19 symptoms
  • How to make handwashing solution
  • How to dispose of waste

• Home-based care kits include supplies for cleaning, disinfecting, handwashing, and patient care for the duration of recovery:
  • Paracetamol
  • Soap
  • Disinfectant
  • Disposable gloves
  • Wash cloth
  • Face masks
  • Mobile phone and airtime

Operational considerations and challenges

• Advisory and training activities can be conducted remotely (e.g., phone or message-based), but distribution of home-based care kits and other household support have to be conducted in-person. The CHW should wear a mask and practice physical distancing. Supplies can be left at the household entrance.
• A referral system or hotline for community members to call if they are experiencing violence/abuse or need social support should be in place before promoting violence-related support.
• There will be costs associated with distribution of handwashing station materials, home hygiene kits, PPE, and basic household essentials. It might be difficult to determine who qualifies for this support, but ideally this would be based on existing social safety net lists and discussed with the community beforehand.

Strategy 3. Monitoring patients receiving home-based care and referring patients for treatment if their symptoms worsen

Activities

• CHWs can assist with daily symptom monitoring of patients until recovery, defined as at least 10 days since symptoms first appeared, at least 24 hours have passed since last fever without the use of fever-reducing medications, and symptoms (e.g., cough, shortness of breath) have improved.
• CHW evaluates patient and refers to treatment, if necessary and if appropriate PPE/skillset is available.
• Consider having CHW perform daily pulse oximetryexternal icon monitoring of patients,^[1],[2] where available, prioritizing monitoring on days 4–7 after onset of symptoms. Pulse oximeters might have suboptimal accuracy in certain populations, especially those with more skin pigmentation. It is therefore important to assess the accuracy of pulse oximeters on the local population before procuring them. This also highlights the importance of assessing observed signs and symptoms (e.g., trouble breathing, persistent pain or pressure in the chest, new confusion, inability to wake or stay awake, and pale, gray, or blue-colored [depending on skin tone] skin, lips, or nail beds) when assessing, triaging, and managing patients).
• If a patient’s symptoms worsen, CHWs are available to educate patients or their caregivers on symptoms requiring immediate medical attention (e.g., light headedness, difficulty breathing, chest pain, dehydration).
• CHW provides linkage to emergency transportation, if needed and available.

Examples of resources for implementation

• Patient symptom monitoring checklist and tool (paper or mobile app)
• Decision tree for referral to health provider or emergency medical attention (for patients experiencing worsening symptoms)
• Alcohol-based hand rub (for CHWs to use when in the field)
• Mask, gloves
• Pulse oximeter
• Referral system to link patients to contact tracing team
• Communication/data system to share patient symptom monitoring data with community contact tracing team
• Hotline or other referral system for patients to call in the event of worsening symptoms after daily check-in with CHWs
• Referral system to link patients with worsening symptoms to care

Operational considerations and challenges

• Home-based care relies on daily symptom monitoring. The patient, a designated household member, or the CHW can assist with daily monitoring. When feasible, CHWs should conduct daily symptom monitoring remotely by phone. In-person visits can be done for households without access to a mobile phone. CHWs should take steps to protect themselves (e.g., wear a mask, conduct frequent hand hygiene, practice physical distancing) when conducting in-person visits.
• CHWs should avoid entering the home to take pulse oximetry readings; the patient can come to the doorway to be assessed. The CHW should wear a mask and disposable gloves to set the pulse oximeter on the floor for the patient (or caregiver) to pick up and put it on his/her own finger for assessment. In cases where the patient cannot bend down to pick up the pulse oximeter, the CHW can hand the pulse oximeter to the patient while remaining two arms lengths away. The CHW should wash his/her hands with soap and water for 20 seconds or use alcohol-based hand rub before putting on gloves and after taking them off, and safely dispose of gloves after use. The pulse oximeter should be properly sanitized after each use according to the manufacturer’s instructions or with alcohol-based wipes or sprays containing at least 70% alcohol to disinfect screens/electronics. Surfaces should be dried thoroughly to avoid pooling of liquids.
• For continuity, contextual awareness, and rapport, to the extent possible, the same CHW should monitor the same patients (and potentially their household contacts) for the duration of the recovery period.

Community Health Worker Safety

To ensure the safety of CHWs and the patients and people they work with, CHWs should:

• Wear a mask at all times in the community.  When coming into close contact (less than 2 meters) with patients, a medical mask is needed.
• Stay at least 2 meters away from other people, when possible.
• Engage community members in an outside, open area.
• Avoid typical physical greetings. Instead, practice no-contact greetings, such as waving, bowing, or head nodding.
• Have a sufficient supply of materials – including masks and enough soap, and/or alcohol-based hand rub (at least 60% alcohol) – needed to conduct their assigned tasks and properly protect themselves. Alcohol-based hand rub should be provided when running water is not available for handwashing.
• Have appropriate personal protective equipment (PPE) for their responsibilities. CHWs should be trained in the proper use and disposal of PPE and other materials.

 CHWs should NOT:

• Meet with or bring groups of people together
• Enter homes unless necessary to provide care while using appropriate PPE
• Touch anyone during the course of their duties without appropriate PPE

Additional safety precautions:

• Community health workers should be provided training on COVID-19 transmission, clinical presentation of cases (including the occurrence of mild and asymptomatic infections that might not be recognized), and prevention strategies (e.g., face masks, physical distancing, hand hygiene). CHWs should understand that infected children might have mild or no symptoms but can spread the virus to others. Training should also address approaches for triaging patients and community members who develop symptoms of COVID-19 or might have had close contact with someone with COVID-19.
• Community health workers who are at increased risk for severe illness from COVID-19 should be provided options that limit their risk of exposure (e.g., be assigned to duties with less risk for contact with a person with confirmed or suspected COVID-19, such as virtual symptom monitoring). CHWs living with family members at increased risk for severe COVID-19 disease outcomes might also want to consider other duties.
• If a CHW must have direct contact with someone as part of providing care (e.g., to provide a patient a pulse oximeter or other supplies), the CHW should wear, disposable gloves and a medical mask. The person being tested should also wear a mask. CHWs should always wash hands with alcohol-based hand rub or soap and water before and after touching someone, even if disposable gloves are used. The COVID-19 pandemic has resulted in global shortages of PPE. A consistent, adequate supply of PPE might be challenging, particularly in remote and low-resource areas. Strategies to optimize PPE, including limited re-use of medical masks, should be explored.