Examining the barriers and facilitators needed to support front line workers critical to community prevention and management of #COVID-19
A key strategy for managing COVID-19 is mitigating community transmission via awareness and preventive methods, for which it is critical to strengthen frontline worker (FLW) preparedness. This is particularly necessary for dealing with this health emergency to reach out to populations in remote and rural parts of India. Literature on the management of previous communicable-disease outbreaks indicates that FLWs’ embeddedness in the community can support the health system in generating awareness, implementing prevention strategies, and support with contact tracing and isolation of potential cases – a strategy that was extensively used to control the spread of the Ebola virus disease (EVD) in West Africa.
In India, FLWs are currently required to (a) undertake information, education, and communication (IEC) efforts at the community-level, and (b) identify and refer potential COVID-19 cases. We have reviewed select policy documents (national guidelines on the role of health workers in the COVID-19 response. Documents include operational guidelines, rational use of personal protective equipment), literature peer-reviewed, reports and media articles. We also conducted informal discussions with Accredited Social Health Activists (ASHA), Auxiliary Nurse Midwives (ANM), Anganwadi Workers (AWW), and Block Community Mobilisers (BCM) from Bihar, Jharkhand, and Rajasthan to present a snapshot view on existing guidelines, protocols, and their implementation, to identify gaps and opportunities to support the health system response to COVID-19.
Routine service delivery is negatively affected, risking severe adverse secondary consequences:
The WHO operational guidelines for maintaining essential health services during an outbreak recommend establishing protocols to indicate a roadmap for progressive phased reduction and targeted supply of other specific essential services. Findings suggest that routine service delivery has largely paused for several reasons – guidelines against group gatherings (cancelling routine immunisation), challenges of travel (making it hard for women to visit facilities to give birth), unwillingness of FLWs to accompany women to facilities to give birth, supply chain disruption (distribution of resources for take-home rations is suspended) and an unwillingness of community members to let FLWs visit them in their homes. It is likely that the secondary health effects of the response will be highly adverse.
The change in routine service delivery was seen in Rajasthan where an enumerator reported an ASHA’s comment on the change in her schedule, “ASHA went to another village (other than her own) with the ANM yesterday. The medical officer called her in the morning when she was working in the farm and had to leave everything and go accompany the ANM. She can’t do any housework when the medical officer calls. All her regular ASHA work is currently suspended such as immunisation. A mother came to her for paracetamol for her child’s fever, so she referred her to the primary health centre because she has run out of medicines.”
Further, the ASHA’s role in the prevention and management of COVID-19 is an additional task. While some recommendations have called for sufficient financial compensation for the excess workload and the emotional burden on the FLWs, these have not been acknowledged in the national guidelines. The challenges associated with increased workload were summarised during our interaction with an ASHA from Bihar:
“The government announced one month's salary as bonus to the paid staff who worked in these difficult situations. We are also working but will not get any money (ASHAs are volunteers). Routine immunisation and sterilisation are closed too. If ASHAs Day happens, then we will receive money, otherwise nothing.”
Frontline worker knowledge on COVID-19 largely acquired through personal effort and exposure:
Whilst the guidelines clearly articulated the role and responsibilities of the FLW, discussions with FLWs indicated not all of them are trained or given adequate formal information on COVID-19. Many relied on the internet, WhatsApp, and television as sources of information.
“I got a call from the block worker. She told me that this has to be done. I also read about it on WhatsApp and the (news)paper. I have not received any training and read everything online through messages on WhatsApp. I have circulated the information through message and phone calls.” – An ASHA in Jharkhand
Further, instances of misinformation about the illness and its cure appeared to persist amongst respondents, for example use of neem leaves and water for treatment, darkroom for quarantine, etc. These cases of misinformation indicate an urgent need to inform and educate the FLWs. Rapid deployment of multimedia and phone-based training should be considered as solutions to fill the gap in communication and capacity building of FLWs.
Adverse community behaviours and response are being observed:
Previous experience with the EVD pandemic reveals evidence of stigmatisation of FLWs who were viewed as a carrier of the illness. This was also seen in Rajasthan where beneficiaries denied the ASHAs entry to their homes as they could potentially carry the disease during visits to other households. Our interactions with a BCM in Bihar revealed many beneficiaries refused to use the ambulance from the health centre as it was seen to be infected and carrying other affected persons.
“There is so much fear among the villagers if any outsider does not want to be screened, the community informs Mukhiya (village-head)/ ASHA/Medical Officer in Charge (MOIC)/BCM. Communities resist entry of people who have not been screened.”
These findings indicate widespread misinformation and panic at the community level regarding the spread of the virus. Stronger efforts are needed to educate the communities, and this would necessarily seek greater engagement with the local bodies like the panchayats (elected representatives from the village) and the supervisory cadre.
Health and safety of frontline workers and her family– preventive measures lie with front line workers
Guidelines place FLWs at low-levels of risk to exposure to COVID-19 and accordingly recommend PPE to include a triple-layered mask and a pair of gloves. However, media reports and discussions with FLWs indicated that thus far, there was limited or no access and availability to basic PPE (masks and hand sanitisers). This places them and community members at risk and may reduce their willingness to provide services. In addition, prior investigations by OPM have suggested that many ASHAs in Bihar and Rajasthan appear to rely on family support to carry out tasks like home visits, documentations etc. This social nuance currently evades policy discussions and in light of the surge in workload and the absence of PPE, the family members of the FLWs also risk infection. An ASHA in Jharkhand expressed:
“I was given no training, no sanitisers or masks. But I have to work, there is no other source of income and everything is closed (in the present lockdown).”
The findings point to several barriers in the effective engagement of FLWs in responding to the COVID-19 outbreak in India which can potentially upend the prevention efforts. Strategies to support the role of FLWs in pandemic response need to target preparedness and maintain routine service delivery.
Firstly, strengthen preparedness by ensuring adequate training and use of safety gear (PPEs) to help FLWs undertake their tasks more effectively. Rapid deployment of videos and phone-based training can be used to train FLWs in service delivery, and for tracking and documenting data, and identify potential COVID-19 cases. Financial incentives or non-performance based incentives, should also be considered to address the absence of financial and non-financial levers to sustain performance in times of crisis.
Secondly, maintain routine reproductive, maternal, newborn, and child health (RMNCH) service delivery as best as possible through state-specific protocols and roadmaps will be crucial to avoid service backlog and adverse secondary effects on the health systems.
There is also an opportunity to improve and leverage the role, and convergence with self-help groups and other community groups. This is especially critical in creating awareness on COVID-19, in dispelling myths that can help safeguard FLWs and their families and provide community support to prevent and manage COVID-19.
By Shuchi Srinivasan, Radhika Arora, Rajiv Bhardwaj, Bhagwati Pandey, Arpana Kullu, Neha Raykar, Jasmeet Khanuja, Divya Nambiar, and Tom Newton-Lewis