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

Shongkour Roy; Sarah Kennedy; Sharif Hossain; Charlotte E. Warren; Pooja Sripad

doi:10.9745/GHSP-D-21-00761

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FIGURE
Comparison of Responsibilities Between FWAs and HAs in Bangladesh
Abbreviations: ANC, antenatal care; EPI, Expanded Programme on Immunization; FP, family planning; FWA, family welfare assistant; HA, health assistant; NCD, noncommunicable disease; RTI, reproductive tract infection; STI, sexually transmitted infection; WASH, water, sanitation, and hygiene.

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TABLE 1.

Demographic Characteristics of Community Health Workers in Bangladesh

	FWA, % (n=204)	HA, % (n=166)	Total, % (N=370)	P Value
Gender
Female	100	56.6	80.5	<.001
Male	0	43.4	19.5	<.001
Age, years
<30	10.8	1.8	6.8	<.001
30–35	20.1	17.5	18.9
36–40	3.9	21.1	11.6
41–45	5.4	6.0	5.7
46–50	19.6	25.3	22.2
>50	40.2	28.3	34.8
Education level
Secondary (incomplete)	2.9	0.0	1.6	<.001
Secondary (complete)	41.7	0.6	23.2
Higher secondary and above	55.4	99.4	75.2
Time working as a CHW, years
<5	8.8	0.6	5.1	<.001
5–10	13.3	4.8	9.5
>10	77.9	94.6	85.4
Received incentives^a
Salary	100	100	100	NA
Event-related allowances (transport, lunch, airtime)	80.4	84.3	82.2	.32
Event-related nonfinancial (food, backpack)	70.1	81.9	75.4	.01
Location of work
Urban informal settlements	11.8	1.8	7.3	<.001
Peri-urban	9.8	31.3	19.5
Rural	78.4	66.9	73.2
Time to reach farthest household for CHWs that live in community,^b minutes
≤10	26.6	7.0	20.1	<.001
11–20	40.8	41.2	40.9
21–30	23.1	34.1	26.8
>30	9.5	17.7	12.2
Main mode of travel since pandemic
By foot	23.0	3.6	14.3	<.001
Bicycle	0.0	1.8	0.8
Motorbike	6.9	21.1	13.3
Bus	0.5	3.0	1.6
Taxi/compressed natural gas taxi	30.9	40.4	35.2
Easy bike/rickshaw/boat	38.7	30.1	34.8
Geographic working area
Rajshahi	24.0	31.3	27.2	.01
Khulna	23.5	18.7	21.4
Sylhet	26.0	38.0	31.4
Cox’s Bazar	26.5	12.0	20.0

Abbreviations: CHW, community health worker; FWA, family welfare assistant; HA, health assistant; NA, not applicable.
↵a Multiple responses.
↵b N=254.

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TABLE 2.

CHWs in Bangladesh Who Reported Undertaking Added Responsibilities Related to COVID-19 Prevention, Treatment, Referring, and Reporting

	FWA, % (n=204)	HA, % (n=166)	Total, % (N=370)	P Value
Educating community members about COVID-19 prevention/treatment	98.5	100	99.2	.11
Advising about signs/symptoms of COVID-19^a
Fever	98.5	96.9	97.8	.32
Dry cough	91.0	89.8	90.5	.67
Sore throat	58.7	62.7	60.5	.44
Nasal congestion	68.2	76.5	71.9	.07
Sneezing	39.3	25.3	32.9	.004
Headache	23.8	19.8	22.1	.35
Breathing difficulties	51.7	45.2	48.8	.21
Loss of taste	11.4	15.1	13.1	.30
Correctly advising signs/symptoms of COVID-19 (score≥90%)	25.5	20.5	23.2	.25
Advising community how COVID-19 can be transmitted^a
Coughing/sneezing by infected people	91.0	97.6	94.0	.008
Direct contact with infected people	74.6	82.5	78.2	.06
Being close to infected people	61.2	64.5	62.7	.52
Touching contaminated objects/surfaces/ disposable masks	30.4	29.5	29.9	.86
Correctly advising community how COVID-19 can be transmitted (score≥90%)	9.3	15.7	12.2	.06
Advising community how to prevent COVID-19
Stay at home	96.0	98.8	97.3	.10
Frequent hand washing	100	100	100	NA
Wearing mask	100	100	100	NA
Social distance	100	98.8	99.5	.11
Quarantine if exposure is suspected	97.0	99.4	98.1	.09
Self-isolate	99.5	100.0	99.7	.36
Correctly advising community how to prevent COVID-19 (score≥90%)	92.7	98.2	95.1	.02
Referring suspected COVID-19 cases for advanced care at facilities	56.4	84.3	68.9	<.001

Abbreviations: CHW, community health worker; COVID-19, coronavirus disease; FWA, family welfare assistant; HA, health assistant; NA, not applicable.
↵a N=367 (FWA, n=201; HA, n=166).

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TABLE 3.

COVID-19-Specific Training, Supplies, and Supportive Supervision Received by Community Health Workers in Bangladesh

	FWA, % (n=204)	HA, % (n=166)	Total, % (N=370)	P Value
COVID-19-related training provided to CHWs	65.7	97.6	80.0	<.001
Types of training^a
Preventive strategies (handwashing practices, social distance, self-quarantine, etc.)	100	100	100	NA
General information about COVID-19	100	100	100	NA
Correct use of PPE (masks, gloves, apron, etc.)	97.8	98.8	98.3	.50
Signs and symptoms of COVID-19	98.5	100	99.3	.11
Contact tracing and community surveillance	18.7	88.3	56.8	<.001
Home-based care of COVID-19 cases	80.6	87.7	84.5	.09
Continuity of community-based services	67.2	77.8	72.9	.04
Supplies provided to CHWs
Disposable masks	77.9	88.6	82.7	.007
Reusable masks	63.2	32.5	49.5	<.001
Hand sanitizer	96.1	88.5	92.7	.005
Gloves	97.1	86.1	92.2	<.001
Soap	8.3	69.9	35.9	<.001
Disinfect supplies	24.0	40.4	31.4	.008
Job aids for COVID-19	15.2	45.8	28.9	.001
Sufficient supplies (score≥90%)	5.9	18.1	11.4	.001
Methods of supportive supervision to CHWs
Regular in-person meeting	31.9	4.8	19.7	<.001
Scheduled team meeting (via phone)	97.1	97.6	97.3	.7
Digital communication (WhatsApp, text, etc.)	46.6	16.3	32.9	<.001
Ad hoc phone call	89.2	92.8	90.8	.2
Supportive supervision (score≥90%)	23.5	1.2	13.5	<.001

Abbreviations: CHW, community health worker; COVID-19, coronavirus disease; FWA, family welfare assistant; HA, health assistant.
↵a N=296 (FWA, n=134; HA, n=162).

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TABLE 4.

CHWs in Bangladesh Who Reported Undertaking These Activities Before^a and During the COVID-19 Pandemic

	FWA, % (n=204)		HA, % (n=166)		Total, % (N=370)		P Value
	Before	During	Before	During	Before	During	P Value
Home-based services for family planning	100	92.7	11.5	11.4	60.3	56.2	.38
Home-based visits for infectious disease prevention and management	53.4	41.7	99.4	98.8	74.1	67.3	.08
Home-based care for postpartum women and newborns	99.5	93.6	44.6	44.4	74.9	71.6	.38
Mental health counseling	91.2	81.3	75.3	72.9	77.3	73.2	.26
Immunizations for children	78.9	71.5	100	99.4	84.1	77.6	.04
Nutrition supplementation	97.6	89.2	99.4	97.5	88.4	84.1	.11
Make referrals to a health facility	98.5	90.2	100	99.4	98.4	92.9	.001
Discuss safe drinking water and/or handwashing	99.5	98	100	100	99.1	94.3	.001
Counseling and direct primary health service	100	92.6	100	99.4	100	98.9	.09

Abbreviations: CHW, community health worker; COVID-19, coronavirus disease; FWA, family welfare assistant; HA, health assistant.
↵a Before=before March 2020; during=March 2020 to November 2020.

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TABLE 5.

Multivariate Relationship Between Service Provision in Pandemic With CHWs in Bangladesh Who Received COVID-19-Related Training, Supportive Supervision, and Supplies^a

	Model 1		Model 2		Model 3		Model 4
Indicators	Advising Signs/ Symptoms of COVID-19		Advising Community How COVID-19 Can Be Transmitted		Referring Suspected COVID-19 Cases for Advanced Care at Facilities		Providing Routine Services
Indicators	OR(95% CI)	aOR (95% CI)	OR(95% CI)	aOR (95% CI)	OR(95% CI)	aOR (95% CI)	OR(95% CI)	aOR (95% CI)
Type of CHWs, HA (ref=FWA)	0.75 (0.46, 1.23)	0.44^b (0.23, 0.87)	1.80 (0.96, 3.39)	1.14 (.048, 2.71)	4.16^c (2.52, 6.88)	8.34^c (4.25, 16.4)	2.34^c (1.51, 3.61)	0.74 (0.38, 1.41)
Received COVID-19 training (ref=no)	4.19^b (1.75, 10.1)	6.49^c (2.58, 16.28)	2.81 (0.97, 8.12)	1.93 (0.61, 6.05)	1.25 (0.73, 2.15)	0.61 (0.32, 1.13)	6.62^c (3.71, 11.80)	6.16^c (3.22, 11.81)
Supportive supervision (ref=no)	0.80 (0.38, 1.68)	0.56 (0.25, 1.28)	0.98 (0.39, 2.45)	1.30 (0.46, 3.64)	2.64^b (1.19, 5.81)	5.7^c (2.46, 13.20)	0.33^b (0.18, 0.62)	0.32^b (0.15, 0.67)
Supplies status (ref=insufficient)	1.13 (0.48, 2.20)	1.26 (0.56, 2.80)	1.52 (0.63, 3.67)	1.36 (0.54, 3.42)	2.98^b (1.22, 7.30)	1.54 (0.60, 3.95)	1.94 (0.95, 4.0)	2.14 (0.95, 4.80)

Abbreviations: aOR, adjusted odds ratio; CHW, community health worker; CI, confidence interval; COVID-19, coronavirus disease; FWA, family welfare assistant; HA, health assistant; OR, odds ratio.
↵a Models are adjusted with CHWs’ working experience and level of education (primary, secondary, etc.).
↵b P<.01.
↵c P<.001.