Assessing community health workers contributions to pandemic preparedness using lessons from COVID19 outbreak in rural Uganda

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Community Health Workers (CHWs) play a critical role in pandemic preparedness and response, especially in resource-limited settings like Uganda's Bwindi-Mgahinga Conservation Area (BMCA), where human-wildlife coexistence heightens the risks of emerging and re-emerging infectious diseases. Unfortunately, CHWs face significant challenges exacerbated by limited resources. This study examined the roles and challenges of CHWs during the COVID-19 pandemic in BMCA-adjacent communities. Methods The CHWs from sub-counties bordering BMCA were purposively selected and involved in 12 Focus Group Discussions in Kisoro, 8 in Rubanda, and 15 in Kanungu districts. The qualitative data obtained were analyzed using QDA Miner Lite to generate key themes. Results The findings revealed that CHWs ensured uninterrupted healthcare delivery by raising community awareness about COVID-19 transmission risks, facilitating contact tracing, promoting adherence to infection prevention guidelines, supporting vaccine awareness campaigns, and coordinating medical referrals to foster collaborative pandemic response networks. However, they faced challenges, including inadequate personal protective equipment (PPE), limited pandemic-specific training, community resistance, stigma, insufficient transportation, and inadequate incentives. Conclusion Optimizing CHWs' services through strategic deployment and resolving the challenges they face is essential to enhance pandemic preparedness and mitigate COVID-19 transmission risks to both human and wildlife populations. Integrating CHWs into the health system, developing streamlined policies, increasing recruitment, providing transportation and incentives, enhancing pandemic-focused training, conducting regular program evaluations, raising community awareness, and ensuring equitable resource allocation can boost management of disease outbreaks. Community health workers South-western Uganda COVID 19 Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 1. Background Primary health care (PHC) is a cornerstone for achieving universal health coverage, offering a strong, community-based system that reduces the burden on hospitals. By providing accessible care and empowering individuals to be involved in managing their health, PHC plays a critical role in preventing and controlling disease outbreaks, particularly in vulnerable communities where early detection and response are vital [ 1 ]. In many low- and middle-income countries (LMICs), the adoption and implementation of the PHC approach is done by Community Health Workers (CHWs). Globally, the COVID-19 pandemic highlighted the essential role of CHWs in pandemic preparedness and response, particularly in remote and hard-to-reach areas. Community Health Workers played a crucial role in pandemic preparedness, response, contact tracing, symptom screening, and health education during the outbreak. In some cases, they have been the only healthcare providers available in their communities [ 2 ]. Community Health Workers are lay people selected by and from the community they serve and are trained to provide basic health education, promote healthy behaviours, and deliver certain health services [ 3 ]. They are volunteers who are selected by their communities to provide accurate health information and link community members with available health services. They play an essential role in providing health care services to vulnerable populations living in remote areas, they promote health service uptake, provide health education and psychosocial support, record-keeping, provide linkage between the health system and community members [ 4 ], [ 5 ]. Despite not being integrated into the formal health system and recognised as part of the formal health workforce in many countries, they contribute towards achieving universal health coverage, particularly in low- and middle-income countries where there is a shortage of health workers (WHO, 2017). In LMICs, where formal healthcare facilities may be scarce or overwhelmed during outbreaks, CHWs help bridge the gap by providing continuity of care and ensuring that routine health services are maintained. (Ballard et al, 2022). Uganda's healthcare system bears reasonable vulnerabilities, partly due to a shortage of healthcare personnel. The doctor-patient and nurse-patient ratios stand at approximately 1:25,000 and 1:11,000, respectively. These ratios fall below WHO recommendations for doctor-patient ratio of 1:1,000 [ 7 ]–[ 9 ]. Compounding the issue is the underfunding of the health sector, with only approximately 3.21% of the national budget allocated to health by 2022, falling short of the Abuja Declaration standard of 15%. The country's readiness to handle pandemics like COVID-19 is further strained by a limited number of referral hospitals equipped to manage such diseases, coupled with an inadequate supply of ICU beds, laboratory consumables and ventilators [ 7 ], [ 10 ]. The Bwindi-Mgahinga Conservation Area is among the rural areas of Uganda where access to healthcare emerges as a pressing concern, stemming from a scarcity of hospital as well as diagnostic facilities and a shortage of healthcare workers partly because of the remoteness of the area and the hilly landscape. Although community health workers are instrumental in filling this gap by delivering basic healthcare services, particularly during disease outbreaks, they face significant challenges. Unfortunately, no in-depth studies have been conducted to better understand their roles in some communities and the challenges they fac and yet this information is critical in improving pandemic preparedness efforts. Therefore, the objectives of this study was to investigate the roles and challenges of CHWs during the COVID-19 pandemic in BMCA-adjacent communities. 2. Methods Study sites This cross-sectional study was conducted from November to December 2023 in Kisoro, Kanungu, and Rubanda districts which neighbor the Bwindi-Mgahinga Conservation Area. The districts of Kanungu, Rubanda, and Kisoro, characterized by a savannah climate with moderate and well-distributed rainfall, support diverse land use types, including farmland, tropical forests, grasslands, and water bodies. Their economies are primarily driven by subsistence farming, with key crops such as bananas, tea, coffee, beans, maize, and Irish potatoes, alongside a thriving tourism industry. The Bwindi Mgahinga Conservation Area (BMCA) is located in Uganda's Kigezi Sub-region, covering 2,663.9 Km 2 between Kisoro (1.2209° S, 29.6499° E), Kanungu (0.8897° S, 29.7831° E), and Rubanda districts (00), bordering Rwanda to the south and the Democratic Republic of Congo to the west. The BMCA is a biodiversity hotspot in western Uganda known for being home for the endangered mountain gorillas and a popular destination for ecotourism [ 11 ]. The communities at this interface are at a high risk of emerging and re-emerging zoonotic diseases due to proximity of human and animal/wildlife populations. The region has inadequate healthcare infrastructure with limited access to healthcare facilities and resources. These factors combined increase the likelihood of disease transmission and exacerbate the impact of outbreaks and spill-over events. The arrival of local and international tourists from different regions also increases the risk of transboundary disease transmission to local communities. Study Design All CHWs operating in the sub-counties of Rubanda, Kisoro, and Kanungu districts near the BMCA and who had participated in the COVID-19 response were purposively selected to take part in this study. The participating CHWs were identified and mobilized by the District Health Officers. The selected CHWs were invited to participate in focus group discussions (FGDs) conducted at their respective District Headquarters. Data collection The FGDs comprised of 8–10 males and female CHWs per group, all of whom participated voluntarily in the sessions. A total of 12 FGDs were conducted in Kisoro District, 8 in Rubanda District, and 15 in Kanungu District, each lasting approximately two hours (Table 1 ). The number of FGDs was determined based on data saturation, and all discussions were conducted by two moderators (JMK and JBG) with aid of a recording audio device for later transcription. Table 1 Sub-counties where focus group discussions (FGDs)were conducted in different districts. District. Sub-counties. No. of FGDs Kanungu Kayonza(KN1), Kanungu T.C(KN2), Kihihi(KN3), Kirima(KN4), Nyanga(KN5), Mpungu(KN6), Kinaaba(KN7), Rutenga(KN8) 15 Kisoro Bukimbiri(KR1), Muramba(KR2), Nyarusiza(KR3), Chahi(KR4), Kisoro T.C(KR5) 12 Rubanda Muko(RB1), Ikumba(RB2), Ruhija(RB3), Bubare(RB4), Rubanda TC(RB5) 8 Data Analysis The audio files recorded during the focus group discussions were translated into English and later transcribed into MS Word files by JBN and JMK, then transferred to QDA Minor Lite (version1.4.1) [ 12 ] for coding and synthesis into themes as per the objectives of the study (coded data has been provided as a supplementary file). Screenshorts of the emerging themes during the analysis are presented in Figs. 3 and 4 . Key illustrative quotations of the FGDs have also been noted under the various generated themes. 3. Results Demographic characteristics of participants Table 2 shows the demographic and socioeconomic characteristics of the participants from all study districts. Most of the CHWs in the study were > 50 years old and mainly practiced subsistence farming. Almost two thirds of the study population had completed primary education. Table 2 Demographic and socioeconomic characteristics of community health workers participating in focus group discussions on response to COVID-19 in Kanungu, Kisoro and Rubanda districts of Uganda, November-December 2023. Characteristic Details Proportion Age Range Less than 50 years 60% Above 50 years 40% Economic activity subsistence farming 90% cattle keeping 7% charcoal burning 1% casual labour 1%, < 1% art and craft < 1% < 1% Education Primary Education 70% Secondary Education 25% No formal education 5% Roles played by Community Health Workers during the COVID-19 pandemic. The frequency of codes under different themes varied in the different FGDs across all districts. During the data analysis, five main themes were generated from the FGDs, with community education and awareness creation emerging as the major roles of CHWs (Fig. 5). Community education and promotion of awareness about COVID-19. This was reported to be the most highly performed role from the analysis of FGD transcripts, overall, based on the number of significant codes associated with this theme across all study districts. CHWs in Kanungu were most involved in community education activities, with 53% codes generated, followed by those from Kisoro with 30% codes, and least performed by CHWs in Rubanda District, with 16% codes generated. This role wasn’t reported in only one FGD in Kanungu. Community Health Workers reported that they got involved in a range of activities aimed at providing accurate information, fostering understanding, and encouraging preventive behaviours within a community to mitigate the spread of the virus during the COVID-19 pandemic. During the initial days of the lockdown, CHWs collaborated with various community-based NGOs which trained them to deliver health education to communities. They actively engaged in outreach activities, visiting homes, farms, and factories, to emphasize the significance of wearing masks, maintaining physical distancing, and practicing hand hygiene. “Officials from Conservation Through Public Health whenever they could come to us sometimes, they used to tell us that we should warn the community members not to interact with wild animals like Gorillas. While in a meeting at the district, they advised us to tell people that hunting and eating wild animals cause diseases to humans” - Male FGD participant RB5 Together, they developed and disseminated culturally appropriate educational materials and Public Service Announcements (PSAs) to reduce the burdens faced by marginalized and vulnerable populations. These CHWs acted as cultural mediators between patients and healthcare systems, providing culturally sensitive health education, information, and direct services. They played a significant part in promoting the COVID-19 vaccination program by encouraging community members to get vaccinated. Their status as trusted members of the community were instrumental in effectively addressing misinformation, fear, and stigma related to COVID-19 and its vaccine. "We worked hard to dispel the misconception in the community that vaccines cause COVID-19 and it was our responsibility to educate the community that COVID-19 affects all individuals, regardless of ethnicity, similar to how it affects people of other backgrounds." - Male FGD Kisoro TC Additionally, during health education programs and data collection for several…., some CHWs served as linguistic and cultural translators for multicultural communities, facilitating better communication and understanding. As reported by the CHWs, the community gradually embraced COVID-19 infection prevention and control (IPC) measures due to the continuous awareness-raising efforts and collaborative strategies employed by various stakeholders. Community, youth, women, and religious leaders, along with the Ministry of Health, CHWs, and other community-based actors, worked together to effectively promote and implement these measures. Contact Tracing and Disease Surveillance This was reported to be the second most highly performed role from the analysis of FGD transcripts, overall, based on the number of significant codes associated with this theme across all study districts. The CHWs in Kanungu were most involved in contact tracing and disease surveillance activities, with 47% of codes generated, followed by those from Kisoro (32%), and Rubanda District (21%) of all codes generated. This role wasn’t only reported in all FGDs. Community Health Workers reported to have participated in the public health measures aimed at identifying, Monitoring and Controlling the spread of COVID-19. They assisted in tracing and recording of contacts to suspected and confirmed cases of COVID-19, creating comprehensive lists of all individuals associated with these cases. The CHWs also closely monitored some of these contacts to identify any signs and symptoms of COVID-19. If any contact displayed symptoms such as cough, difficulty in breathing increased body temperature and other symptoms, they promptly reported them to health centres for further management and treatment. Community Health Workers actively conducted symptomatic screening in households, effectively identifying potential COVID-19 infections. Government health workers and NGOs collaborated to train the CHWs in identifying and locating ill individuals. When found, CHWs would isolate them and refer them to the district's health officials for further management. They also encouraged community members to report contacts and communicated the significance of reporting the contacts in preventing further transmission of COVID-19. “I always kept the District Health Officer busy with phone calls, I could even report a merely coughing person to the DHO and it was my duty to teach the community members about the danger of not reporting patients” - Female FGD participant, RB4 Additionally, CHWs played a crucial role in communicating the significance of reporting contacts, adhering to quarantine and isolation procedures, and educating community members and families on preventive measures against the virus. Their trusted status in the community fostered better cooperation, with people more likely to provide accurate information and follow recommended measures when communicating with CHWs. Provision of psychosocial support to community members Community health workers reported that they played a pivotal role in supporting the mental and emotional well-being of community members amid the COVID-19 pandemic. CHWs from Kanungu provided the most psychosocial support to COVID-19 victims, generating the highest number of codes (48.3%). Conversely, CHWs in Rubanda offered the least psychosocial support (13%). Psychosocial support provision was reported in all other FGDs except two in Rubanda, one in Kisoro, and one in Kanungu. This role ranked as the third most performed. Participants in FGDs consistently noted that the trust established between them and the community members fostered an environment conducive to open communication. The emphasis was on expressing empathy and offering support to all individuals affected by COVID-19. “We were trusted by the community members in most areas and this gave them a room to communicate their grievances brought about by COVID-19 pandemic”- Male FGD participant RB3 These health workers actively worked to raise awareness against stigma and discrimination surrounding COVID-19. They advised community members to destigmatize seeking help, particularly for those who had received medical care after contracting the virus. Through their regular home visits, they provided essential social support and a listening ear to those affected by the COVID-19 outbreak. During these visits, they shared positive and hopeful stories, highlighting the experiences of individuals who had successfully recovered from COVID-19. “I always encouraged the family members of the infected people I visited in their homes to always support the sick people and told their neighbours that its normal for someone to take COVID-19 treatment and that many people have recovered from COVID-19” - Male FGD participant RB1 Community health workers in FGDs reported that they contributed to fostering community solidarity by encouraging mutual support among individuals, creating a tangible sense of unity within the community. Their efforts extended to promoting healthy coping strategies by educating community members about engaging in physical exercises and other activities conducive to maintaining good mental well-being. "It was our obligation to foster community unity by encouraging neighbours to support each other. also encouraging beneficial coping strategies, such as engaging in exercises and activities." – Female FGD participant, KR1 Continuity of the provision of Health services during the COVID-19 pandemic This was the second least performed role overall, based on the number of codes associated with this theme across all study districts. CHWs in Kanungu were most involved in this role, with 48% of codes generated, followed by those from Kisoro with 32.3% of codes, and least performed by CHWs in Rubanda District, with 16% of codes generated. This role was reported in all the districts except one FGD in Rubanda, one in Kisoro, and two FGDs in Kanungu. The majority of CHWs reported that they were willing to continue with service delivery on a regular basis during the COVID-19 outbreak because of their desire to be part of the solution. In all three study districts, the effectiveness of CHWs decreased due to the rising number of COVID-19 cases detected, quarantine measures, fear of infection, limited transport support, and reduced community cooperation resulting from financial difficulties during the lockdown. We worked tirelessly and wholeheartedly to make sure that the health services were provided continuously to the community members” -Female FGD participant KR3 Community Health Workers were recognised as being at risk of contracting COVID-19 due to their extensive movements within the community. The Ministry of Health taught and encouraged them to observe SOPs, including maintaining a 1-meter "social distance" and regular hand washing with soap after attending to individuals. However, one CHW from Kisoro admitted that some community members often failed to implement preventive guidelines due to a lack of awareness. “Some women in a savings group (SACCO) used always to meet every week in different homes in crowded rooms, when I told them that the government doesn’t allow gatherings, they said they didn’t know about it”- Female FGD participant KR2. During the COVID-19 outbreak, CHWs focused primarily on COVID-19-related tasks and were encouraged to refer individuals showing symptoms to nearby health facilities. Community Health Workers (CHWs) received assistance from community leaders in fostering and strengthening their relationship with the community. They consistently emphasized the importance of community leaders, such as village Local Council 1 chairpersons, in carrying out their duties effectively. These leaders utilized their political authority and influence to mobilize the community members and ensure they received the health services provided by the CHWs. Moreover, community leaders played a crucial role in enforcing community laws, creating an environment conducive for the CHWs to operate successfully. “The village chairman has a lot of power, whenever he told people to obey COVID guidelines, they could obey, this is how he was helpful in my role”- Female FGD participant RB4. After a decline in the number of COVID-19 cases, CHWs began to gradually transition back to their regular activities, which included advocating for Maternal, New-born, and Child Health (MNCH), promoting improved reproductive health services, and assisting in Malaria control programs. Referrals for the Complicated Medical conditions Community health workers played a valuable role in facilitating referrals for complicated medical conditions by acting as a bridge between the community and healthcare system. This was the least performed role overall, based on the number of significant codes associated with this theme across all study districts. CHWs in Kanungu were most involved in medical, with 48% of codes generated, followed by those from Kisoro (36%), and least performed by CHWs in Rubanda District (15%). Participation in the medical referrals was reported in other FGDs except two in Rubanda, one in Kisoro, and three FGDs in Kanungu. The majority of CHWs acknowledged that community members occasionally hesitated to trust them with slightly complex medical conditions, such as providing first aid for common illnesses like malaria, high fever, respiratory issues, and other unfamiliar clinical signs and symptoms. In such cases, they were able to refer all observed complicated cases directly to nearby health centres for medical care. “A woman to trust you with her child to treat malaria! That can’t happen and I cannot also accept, the best I can do is to coordinate and have the child taken to the hospital ”- Female FGD participant KR4 However, CHWs were still trusted to handle less complicated health-related activities, including the distribution of mosquito nets and face masks, as well as assisting in deworming and vaccination operations and projects. Their expertise and reliability in managing these less complex tasks made them valuable assets in supporting community health initiatives. Community Health Workers (CHWs) reported that Traditional Healers greatly contributed to the increasing spread of COVID-19 due to their practices which do not follow standard operating procedures related to handling of patients; the government issued directives prohibiting the Traditional Healers from handling COVID-19 suspected cases. CHWs sensitized the Traditional Healers about the signs and symptoms of COVID-19 and encouraged them not to attend to clients with such symptoms encouraging them to refer such cases to the nearby health centre for comprehensive monitoring and treatment. "We directed complex cases to health centres and urged traditional healers to refer patients with COVID-19 symptoms to hospitals." - Female FGD participant RB4. Challenges faced by community health workers during the COVID-19 pandemic. Nine themes were generated from the analysis of the data about the challenges faced by CHWs during the COVID-19 Pandemic response. The frequency of codes varied in the different FGDs across all districts; the overall frequency of the codes that constituted the different themes is directly proportional to the size of the themes as indicated in the word cloud (Fig. 6 ) and code tree (Fig. 7). The main challenge reported was insufficient training and capacity building and the least was mistrust in the healthcare system and the CHWs by the community members in the study area. Insufficient training and capacity building From the thematic data analysis, the most commonly reported challenge across all FGDs, except for only one FGD in Kanungu, was the insufficiency in training programs and capacity-building opportunities for community health workers to equip them with relevant knowledge about pandemic preparedness and management. It was highly reported in the FGDs conducted in Kanungu, with 48%, followed by Kisoro (34%), and least reported in Rubanda District (18%). This indicated a knowledge gap among the participants; CHWs often reported serving as caretakers for COVID-19 suspects while awaiting medical care. Most of them reported not receiving training on caring for COVID-19 positive cases; however, a few mentioned having received such training. They noted a lack of follow-up after training during disease outbreaks. According to reports from all FGDs conducted, there was no existing systematic and programmatic approach to equipping them with skills and knowledge to respond to disease outbreaks. Trainings were only conducted in response to outbreaks, limiting their ability to respond effectively. "We recognized the need for training in caring for COVID-19 patients prior to their hospitalization. Unfortunately, such training was notably lacking ."- Male FGD Muko Inadequate incentives and motivation Of all the codes, 7.2% of the codes from data regarding challenges faced by CHWs were related to inadequate incentives for work, leading to low motivation across all Focus Group Discussions (FGDs) conducted in all districts. This made this challenge the second most frequently reported in this study, with Kanungu district reporting it most frequently at 44% of codes (n = 93) under the inadequate incentives and motivation theme…., followed by Kisoro (41%) and least reported in Rubanda District (15%). Participants reported that there was limited remuneration to the CHWs due to limited funds and lack of transparency which led to decreased satisfaction with the volunteerism in the COVID-19 response programs. The government had promised them a package at the end of the response programs which was not fulfilled. CHWs reported a lack of motivation in the form of incentives to facilitate their work. They suggested that the minimum monthly allowance should be provided to facilitate their work. "Although we actively participated in government initiatives, we frequently encountered a lack of the promised allowances. Additionally, certain funds were mismanaged by local officials."- Male FGD KN4 Stigma, discrimination, and Harassment Stigma, discrimination, and harassment from community members emerged as the third most reported challenge by the CHWs. It was mentioned in 91% of the FGDs conducted across all districts. Among the 86 codes generated under this theme, 48% (n = 86) originated from Kanungu District, where the challenge was not reported in two FGDs. Additionally, 38% were generated from Kisoro District, with the challenge being reported in all FGDs. Rubanda District contributed 14%, with the challenge not reported in only one group. Community Health Workers reported discrimination and stigma from the community members who considered them as COVID-19 carriers this was through behaviours such as refusal to talk to them and refusal of their children to associate and play with other village children. Community members accused the CHWs of earning a lot of money from the government and NGOs involved in the COVID-19 response. Community Health workers reported that they constantly faced harassment from the families of symptomatic patients for having reported them to the authorities. Their own families were angry because their involvement in the COVID-19 response was putting family members at risk of COVID-19 infection. They were accused by their family members of not fulfilling their responsibilities such as farming, harvesting, and grazing due to them spending a lot of time in COVID-19 response activities and ignoring their household obligations. “When I got so busy with Community Mobilization, my husband was not happy, he was always quarrelling about it. He often complained that I abandoned the crops in our garden and taking care of our goats for free volunteer work, onetime he tried beating me up after an argument over the same issue, but I ran to the village chairman”- Female FGD, Nyarusiiza. Some participants reported that COVID-19 positive individuals were stigmatised by community members, and this hindered many suspects from reporting to the health care facilities after developing COVID-19 signs and symptoms. The psychological impact was highlighted by one participant who reported that COVID-19 was considered as “a death sentence” relating to how some patients reported symptoms of depression following diagnosis. Some confirmed COVID-19 positive individuals kept it a secret due to fear of stigmatisation. Community Health Workers reported that during the first few months of the lockdown, many patients did not visit health facilities due to fear of being diagnosed or infected. This rendered some patients unreachable necessitating more frequent community health worker visits. Patients were also reported to frequently present late with more severe symptoms making their management more complicated. However, participants acknowledged that access to healthcare was significantly increased because of their community sensitization and health education "People tended to avoid those who were diagnosed with COVID-19, which discouraged affected individuals from seeking necessary medical attention. Furthermore, we encountered harassment from family members of suspected cases we reported to health workers. COVID-19 was perceived as a severe threat by many." - Male FGD participant, KN3. Public misconceptions about COVID-19 disease and the vaccination Participants in all FGDs reported that public misconceptions about COVID-19 were among the major challenges except for only one FGD per district. This was the fourth most reported challenge faced by CHWs. Of the 86 codes generated about these themes, 48% were generated from Kanungu District, 38% from Kisoro District and 14% from Rubanda District. It was reported that some community members were in denial about the existence of COVID-19, which made it harder for CHWs to promote adherence to government regulations. Additionally, certain individuals believed that COVID-19 was present only in other countries and not in Uganda. Community Health Workers reported that there was a group of people in the population who held myths that COVID-19 does not affect African/Black people and that it only affects the elderly. They also believed that COVID-19 was deliberately designed to intentionally kill people and reduce the world’s population. Consequently, these beliefs led to fear and their reluctance to seek medical care. Furthermore, some community members confused COVID-19 with traditional/spiritual diseases/attacks. These misconceptions added to the complexities faced by CHWs in their efforts to educate and raise awareness about COVID-19 in the community. It was reported that the Community members were reluctant to adopt the COVID-19 infection Prevention and Control measures because they were against their culture for example gathering for burials, weddings and the traditional worshipping and isolating the sick; they believed that the sick were meant to be taken care of and not isolated. Community Health Workers (CHWs) reported that during the last months of the lockdown, the prevalence of myths surrounding COVID-19 vaccines had increased. Common misconceptions included concerns about vaccine risks such as blood clots, post-vaccination infections, and the erroneous belief that vaccinated individuals are exempt from taking preventive measures. Many CHWs emphasized the necessity for ongoing education to provide communities with accurate information to counteract the impact of these beliefs. Some community members viewed social media as a primary source of public misinformation. "We repeatedly countered misinformation propagated through social media. Some individuals even believed that COVID-19 was intentionally spread by health workers." - Female FGD participant, KN8 Focus Group Discussions participants reported that some individuals believed that COVID-19 was used by the government to prevent some politicians from conducting their campaigns and to “scam” electorates. "Youths alleged that COVID-19 was a government strategy aimed at financial exploitation and impeding specific politicians' interactions with voters.” - Female FGD participant, Kisoro TC Exhaustion due to extra workload This challenge was reported in 31 out of the l 35 FGDs conducted in all districts. Of the 59 codes generated about this challenge, 42% were from Kanungu District, with the challenge not being reported in 2 FGDs. Upto 34% of codes were generated from Kisoro District, with the challenge not reported in 2 FGDs. Only 24% of the codes were generated from Rubanda district, and the challenge was reported in all the FGDs. Exhaustion due to an increased workload was evident among CHWs; participants reported feeling physically and emotionally drained due to the additional responsibilities added onto them during COVID-19 response. Before the COVID-19 outbreak, the CHWs were involved in Primary Health Care activities such as supporting immunization programs, Children deworming, Malaria testing & provision of basic treatment, health education, monitoring and reporting, and others. The COVID-19 pandemic brought forth various new tasks, including community sensitization, case tracing, distributing masks, and providing regular reports. Balancing these extra responsibilities with their pre-pandemic routine proved to be a challenging task, affecting their personal lives and economic activities. This led to burnout and exhaustion during the COVID-19 outbreak response. "Juggling COVID-19 tasks, our regular community health responsibilities, and personal life proved to be a challenging and fatiguing endeavour." - Female, FGD participant KN1. However, some CHWs expressed pride in the additional work they undertook, as it allowed them to acquire new skills in writing, public speaking, and performing basic health procedures like medication distribution. This highlights the impact of the pandemic-induced workload on CHWs, affecting their overall well-being and work-life balance. Lack of transportation The challenge of transportation was highlighted in 30 out of the 35 FGDs (86%) across all districts, being reported in every FGD in Kanungu. It was absent in only one FGD in Kisoro and in four FGDs in Rubanda District. Of the 58 codes generated under this theme, 53% originated from Kanungu, 33% from Kisoro district, and 14% from Rubanda District. Kisoro, Kanungu and Rubanda are mainly rural districts with a mountainous terrain. CHWs Working in these rural areas reported that during the early days of the lockdown, finding reliable transport means to reach out to the communities was extremely difficult because the public transportation were stopped from working as a government protocol to minimise the spread of COVID-19. Majority of the CHWs did not have their own vehicles to enable them reach out to community members, they had to walk long distances to reach Community members and attend the supervision meetings at the health facilities and their transport costs were exceeding the transport refunds they received at rare cases. There were barriers to the referral systems because they had to travel long distance from home to the health facilities, also poor road network in the area limited some transport means such as bicycles and the motor bikes leading to a high cost of transport. Inadequate Personal Protective Equipment ( PPE) and Disinfection Supplies Insufficiency of PPE and disinfection supplies was reported to be a challenge in 86% of FGDs conducted with the exception of 2 FGDs in Kanungu and 3 FGDs in Kisoro District. Of the 58 codes generated under this theme, 48% were from Kanungu district, 26% from Kisoro, and 26% from the Rubanda district. Community Health Workers in Kanungu and Kisoro reported more about the challenge of insufficient PPE and disinfection supplies than the CHWs in Rubanda district. Participants in FGDs reported a lack of essential supplies like detergents, alcohol-based sanitizers, Sodium Hypochlorite (JIK), soap, and others, and PPE, such as raincoats, gumboots, masks, and gloves. Additionally, one participant in an FGD in Ruhija disclosed an instance of discrimination in the distribution process of PPE among community workers, where only a few were selected to receive gumboots, leading to discontent among the rest. "The majority of us lacked essential rain gear and gumboots. These resources were only provided to one individual. Government-supplied masks proved to be inadequate and were often unsuitable for reuse due to safety concerns." - Female FGD participant RB3 Inconsistency in Government authorities’ response efforts towards COVID-19 This challenge was reported in 83% of the FGDsbut was not reported in the 4 FGDs in Kanungu, one FGD in Kisoro and not in any FGD in Rubanda, out of the 79 codes generated about this challenge, 50% were generated from FGDs conducted in Kanungu, 34% were generated from FGDs conducted from Kisoro, 16% were generated from FGDs conducted from Rubanda District and this was the fifth most reported challenge in this study. While recognizing certain COVID-19 response measures undertaken by the government, participants expressed dissatisfaction with the insufficiency of the distribution of free face masks. Additionally, although the government attempted to raise awareness through mainstream media and provided home care kits for infected individuals, participants felt that these efforts fell short of effectively addressing the challenges posed by the pandemic. Several participants disclosed that more could have been done to ensure that the government leads by example as they were instances where some individuals with authority failed to follow COVID-19 protocols. This could be significant in encouraging public adherence to COVID-19 guidelines as well as CHW’s willingness to work. They specifically mentioned that during election campaigns some leaders were not following COVID-19 guidelines. "While politicians organized rallies against COVID-19 guidelines, they simultaneously advised us to avoid gatherings. Their actions were inconsistent with their messages." - Female FGD participant KR. Lack of trust in the Healthcare system and CHWs by the community members Overall, lack of trust by community members was the least reported across all FGDs. It was mentioned in only 66% of the FGDs. The highest frequency of reporting was observed in Kanungu, with 55% of the codes in 11 out of 14 FGDs. Conversely, it was least reported in Kisoro, mentioned in only 5 out of 12 FGDs conducted, accounting for 22% of the codes generated. Some participants noted that they have a pre-existing level of trust with their community members, which significantly aided them in fulfilling their duties. They could easily interact with the community members, obtain information, and educate the community about COVID-19 and its prevention. However, participants reported that some community members perceive the healthcare system as poor, discouraging them from seeking medical attention at healthcare facilities. Instead, they resort to traditional healers and local herbalists, other community members practised self-medication with some traditional methods such as “Steaming ” due to this lack of trust. Additionally, there was a belief among some community members that government-provided vaccines and medications may cause disease outbreaks like COVID-19. "People rely on us for advice, yet they question our ability to manage medical procedures due to our non-medical background. This undermines our morale to effectively assist them." - Female FGD participant RB3. 4. Discussion The primary objectives of this study was to assess the role played by Community Health Workers (CHWs) during the COVID-19 pandemic in communities surrounding the Bwindi-Mgahinga Conservation Areas, as well as to identify the challenges they faced and the gaps in pandemic preparedness. The findings revealed that CHWs were instrumental in community engagement and education, promoting awareness about COVID-19, conducting contact tracing, and providing psychosocial support. However, they encountered significant challenges, including inadequate personal protective equipment (PPE), insufficient training, lack of transport, and public misconceptions about the virus. These challenges hindered their ability to effectively implement COVID-19 prevention and control measures. Contributions to Disease Detection and Response Disease outbreak preparedness requires coordinated efforts at every level, ensuring rapid detection and response to emerging threats [ 13 ], [ 14 ]. CHWs played a vital role in identifying suspected COVID-19 cases in their communities by recognizing symptoms such as fever, cough, and difficulty breathing. They managed mild cases at home and referred those with severe illness to health facilities, providing a vital link between the community and formal healthcare. Evidence from South Africa shows that equipping CHWs with rapid diagnostic tools and training further improved case detection, management, and referral during the pandemic (Ramukumba, 2020). This experience underscores the value of supporting CHWs with resources and skills to strengthen community-based disease surveillance and response. We found that CHWs played a key role in educating communities, addressing misinformation, and promoting vaccine uptake—often serving as cultural mediators. These findings align with WHO and other studies that highlight CHWs’ impact on improving public compliance with infection control measures [ 15 ] [ 16 ], [ 17 ]. CHWs in Kanungu were especially active, likely due to stronger government involvement in health promotion compared to Kisoro and Rubanda. Trust, misconceptions, and collaborations Community health workers (CHWs) often built strong relationships with local residents, but lingering distrust in the broader health system sometimes led people to prefer traditional healers or self-treatment. These attitudes limited CHWs’ reach and echoed findings from other countries, where community members occasionally resisted guidance from CHWs [ 18 ]. In Rubanda, Kanungu, and Kisoro districts, this lack of trust often stemmed from limited awareness about the benefits of modern healthcare. To address these barriers, CHWs partnered with traditional healers, raising their awareness about COVID-19 symptoms and encouraging referrals to health centers. This collaboration improved service uptake and reflects models seen in the Democratic Republic of Congo, where traditional healers acted as de facto CHWs and bridged gaps to formal healthcare [ 19 ]. Considering that traditional medicine remains widely used during outbreaks, such partnerships can help decrease misconceptions about infectious diseases among rural communities [ 20 ]. Social stigma and even violence against health workers was also reported in other countries, with healthcare providers facing discrimination and threats in Nepal [ 21 ], India, the USA, and Australia [ 22 ], [ 23 ], often driven by misinformation about COVID-19 transmission. Challenges with denial and misinformation were common: some community members did not believe COVID-19 was real, or felt it only affected people in other countries, attributing symptoms to malaria. Such patterns were observed not only in Uganda but also in Nigeria [ 24 ], while in Sub-Saharan Africa, myths about COVID-19 policies and its impact complicated outbreak response and medical seeking behaviors [ 25 ][ 26 ]. Cultural practices, including reluctance to isolate the sick and the importance placed on gatherings, further hindered public health interventions [ 27 ]–[ 29 ]. These findings all highlight the need for targeted education and culturally sensitive outreach to build trust and improve health outcomes. Community health workers also played a crucial role in offering psychosocial support for the mental and emotional well-being of community members amidst the COVID-19 pandemic. This is in agreement with Mistry et al. (2021) that training and involving CHWs in managing mental health issues can be a cost-effective and efficient method to deliver psychosocial support at the local level in low- and middle-income countries (LMICs) with fragile health systems. Challenges and systemic constraints During the COVID-19 pandemic, CHWs faced exhaustion from increased workloads combining routine tasks with pandemic response activities like community mobilization and contact tracing. Similar burnout was reported in India and Indonesia [ 30 ], [ 31 ]. This strain affected both their mental health and service quality, making support for CHW resilience vital [ 32 ]. Transportation challenges due to lockdowns, lack of vehicles, and difficult terrain limited CHWs’ access to remote communities, as observed in other LMICs [ 33 ]–[ 38 ]. Persistent underfunding worsens this issue, delaying timely service delivery [ 39 ]. Participants expressed dissatisfaction with volunteerism due to low pay, poor incentives, and unmet promises, consistent with global findings linking low compensation to reduced motivation and attrition [ 40 ]. Improved financial and non-financial incentives are needed to sustain CHW performance.. PPE shortages—masks, gloves, sanitizers—raised infection risks and forced reuse, reflecting similar shortages in Sub-Saharan Africa [ 41 ]. Scarce PPE was a major barrier also reported elsewhere [ 42 ] [ 43 ] [ 44 ], underscoring the need to prioritize CHWs for protective supplies. Despite challenges, CHWs maintained essential services and showed resilience, supported by community trust and open communication, which helped reduce stigma [ 45 ]–[ 47 ]. Yet limited mental health training sometimes hindered their ability to address related issues and stigma [ 48 ]. Thus, enhanced training and task-sharing would be beneficial. Through home visits, CHWs provided emotional support and shared recovery stories, improving well-being and fostering community solidarity—paralleling findings from the US [ 49 ]. They also promoted coping strategies for mental health and community resilience. 5. Conclusion The research emphasizes the vital contribution of Community Health Workers in rural Uganda during the COVID-19 pandemic, emphasizing their pivotal role in the country's pandemic preparedness and response within the communities surrounding the Bwindi-Mgahinga Conservation Area. As a country with frequent disease outbreaks CHWs form an important part of the frontline, therefore urgent changes to ease their strenuous work are needed to continue supporting their communities. CHWs need adequate resources, managerial and financial support, and recognition of their role and challenges at all stages of the policy cycle. More extensive studies need to be undertaken to comprehensively elucidate the role of Community Health Workers (CHWs) in pandemic preparedness on a broader scale encompassing diverse regions of Uganda and globally, allowing for a nuanced understanding of the challenges faced by CHWs in responding to outbreaks of infectious diseases. Abbreviations FGD: Focus group discussion. Declarations Data Availability Data used to write-up this study is provided within the manuscript. Acknowledgements We thank all the participants for having willingly provided data during this study. We are also grateful to Isaac of Kanungu district, Machumu Majolo of Rubanda district, Edison of Kisoro district for the support they offered during the data collection process. Author Contributions JMK, JBN conceived and designed the study, collected and analyzed the data, prepared figures and/or tables, drafted and approved submission of the final manuscript. JBG, DM, AO, JN, JO, collected data, analyzed the data, prepared figures and/or tables, drafted and approved submission of the final manuscript. Funding John B Nizeyi, Government of Uganda through the Makerere University Research and innovation fund. Ethics approval and accordance This study was approved by Uganda Virus Research Institute Research Ethics Committee (UVRIREC-2023-12). 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Cite Share Download PDF Status: Published Journal Publication published 11 Feb, 2026 Read the published version in Discover Public Health → Version 1 posted Editorial decision: Revision requested 08 Dec, 2025 Reviewers agreed at journal 08 Dec, 2025 Reviews received at journal 06 Dec, 2025 Reviewers agreed at journal 06 Dec, 2025 Reviews received at journal 27 Nov, 2025 Reviewers agreed at journal 18 Nov, 2025 Reviewers agreed at journal 18 Nov, 2025 Reviewers agreed at journal 16 Nov, 2025 Reviewers invited by journal 10 Nov, 2025 Editor assigned by journal 06 Nov, 2025 Editor invited by journal 04 Nov, 2025 Submission checks completed at journal 03 Nov, 2025 First submitted to journal 03 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7999881","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":546721802,"identity":"78240c30-dc74-48bd-8945-528e2ea60621","order_by":0,"name":"Joseph M 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18:33:04","extension":"html","order_by":16,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":136945,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7999881/v1/8cc7c5cec302d1723d764f78.html"},{"id":96319327,"identity":"1772522f-5eff-4544-85f5-eac196e8a1e3","added_by":"auto","created_at":"2025-11-19 18:33:03","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":174142,"visible":true,"origin":"","legend":"\u003cp\u003eA Map showing location of the study area (Bwindi-Mgahinga conservation area).\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7999881/v1/80fe5a82df6cd234d9b57fa8.png"},{"id":96366244,"identity":"8692c623-9eac-455b-879a-cfcb2da6dace","added_by":"auto","created_at":"2025-11-20 10:11:18","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":680656,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure 3: \u003c/strong\u003eScreenshot of QDA Miner Lite Data analysis software showing codes identified from the data.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7999881/v1/05836c7bec3fe40084200fbd.png"},{"id":96319329,"identity":"22a33cae-96bc-4cfc-a288-ffade18f6528","added_by":"auto","created_at":"2025-11-19 18:33:03","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":564902,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure 4: \u003c/strong\u003eScreenshot of QDA Miner Lite Data analysis software showing themes generated from the data.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-7999881/v1/00508cf364f8522238ac53e0.png"},{"id":96319331,"identity":"8f454075-7908-4208-9866-465404d7d4d7","added_by":"auto","created_at":"2025-11-19 18:33:03","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":198503,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure 5: \u003c/strong\u003eCode tree showing the code frequency in themes generated about the role played by CHWs.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-7999881/v1/bed52119f078bb0e9912ac74.png"},{"id":96319332,"identity":"3b7b8d29-77a9-42b2-9325-5738098e173c","added_by":"auto","created_at":"2025-11-19 18:33:03","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":385524,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure 6: \u003c/strong\u003eWord cloud of the themes generated using QDA Minor Lite software about the challenges faced by CHWs in pandemic response.\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-7999881/v1/2df154e51f9917a2fd3c0133.png"},{"id":96319336,"identity":"17a9b81d-64af-495d-a27b-227d54bcc775","added_by":"auto","created_at":"2025-11-19 18:33:03","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":326936,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure 7 :\u003c/strong\u003e A code tree of challenges faced by CHWs and distribution of the codes in the different FGDs .\u003c/p\u003e","description":"","filename":"7.png","url":"https://assets-eu.researchsquare.com/files/rs-7999881/v1/f8a2b8d64cd393b5c4ede540.png"},{"id":102785602,"identity":"f4b1305a-d9e0-4619-b7ee-33bc47de1549","added_by":"auto","created_at":"2026-02-16 16:08:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3177986,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7999881/v1/f8513486-4349-4b17-adeb-52867090fd5b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Assessing community health workers contributions to pandemic preparedness using lessons from COVID19 outbreak in rural Uganda","fulltext":[{"header":"1. Background","content":"\u003cp\u003ePrimary health care (PHC) is a cornerstone for achieving universal health coverage, offering a strong, community-based system that reduces the burden on hospitals. By providing accessible care and empowering individuals to be involved in managing their health, PHC plays a critical role in preventing and controlling disease outbreaks, particularly in vulnerable communities where early detection and response are vital [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In many low- and middle-income countries (LMICs), the adoption and implementation of the PHC approach is done by Community Health Workers (CHWs).\u003c/p\u003e\u003cp\u003eGlobally, the COVID-19 pandemic highlighted the essential role of CHWs in pandemic preparedness and response, particularly in remote and hard-to-reach areas. Community Health Workers played a crucial role in pandemic preparedness, response, contact tracing, symptom screening, and health education during the outbreak. In some cases, they have been the only healthcare providers available in their communities [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eCommunity Health Workers are lay people selected by and from the community they serve and are trained to provide basic health education, promote healthy behaviours, and deliver certain health services [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. They are volunteers who are selected by their communities to provide accurate health information and link community members with available health services. They play an essential role in providing health care services to vulnerable populations living in remote areas, they promote health service uptake, provide health education and psychosocial support, record-keeping, provide linkage between the health system and community members [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Despite not being integrated into the formal health system and recognised as part of the formal health workforce in many countries, they contribute towards achieving universal health coverage, particularly in low- and middle-income countries where there is a shortage of health workers (WHO, 2017). In LMICs, where formal healthcare facilities may be scarce or overwhelmed during outbreaks, CHWs help bridge the gap by providing continuity of care and ensuring that routine health services are maintained. (Ballard et al, 2022).\u003c/p\u003e\u003cp\u003eUganda's healthcare system bears reasonable vulnerabilities, partly due to a shortage of healthcare personnel. The doctor-patient and nurse-patient ratios stand at approximately 1:25,000 and 1:11,000, respectively. These ratios fall below WHO recommendations for doctor-patient ratio of 1:1,000 [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u0026ndash;[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Compounding the issue is the underfunding of the health sector, with only approximately 3.21% of the national budget allocated to health by 2022, falling short of the Abuja Declaration standard of 15%. The country's readiness to handle pandemics like COVID-19 is further strained by a limited number of referral hospitals equipped to manage such diseases, coupled with an inadequate supply of ICU beds, laboratory consumables and ventilators [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe Bwindi-Mgahinga Conservation Area is among the rural areas of Uganda where access to healthcare emerges as a pressing concern, stemming from a scarcity of hospital as well as diagnostic facilities and a shortage of healthcare workers partly because of the remoteness of the area and the hilly landscape. Although community health workers are instrumental in filling this gap by delivering basic healthcare services, particularly during disease outbreaks, they face significant challenges. Unfortunately, no in-depth studies have been conducted to better understand their roles in some communities and the challenges they fac and yet this information is critical in improving pandemic preparedness efforts. Therefore, the objectives of this study was to investigate the roles and challenges of CHWs during the COVID-19 pandemic in BMCA-adjacent communities.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003e\u003cb\u003eStudy sites\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis cross-sectional study was conducted from November to December 2023 in Kisoro, Kanungu, and Rubanda districts which neighbor the Bwindi-Mgahinga Conservation Area. The districts of Kanungu, Rubanda, and Kisoro, characterized by a savannah climate with moderate and well-distributed rainfall, support diverse land use types, including farmland, tropical forests, grasslands, and water bodies. Their economies are primarily driven by subsistence farming, with key crops such as bananas, tea, coffee, beans, maize, and Irish potatoes, alongside a thriving tourism industry.\u003c/p\u003e\u003cp\u003eThe Bwindi Mgahinga Conservation Area (BMCA) is located in Uganda's Kigezi Sub-region, covering 2,663.9 Km\u003csup\u003e2\u003c/sup\u003e between Kisoro (1.2209\u0026deg; S, 29.6499\u0026deg; E), Kanungu (0.8897\u0026deg; S, 29.7831\u0026deg; E), and Rubanda districts (00), bordering Rwanda to the south and the Democratic Republic of Congo to the west.\u003c/p\u003e\u003cp\u003eThe BMCA is a biodiversity hotspot in western Uganda known for being home for the endangered mountain gorillas and a popular destination for ecotourism [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The communities at this interface are at a high risk of emerging and re-emerging zoonotic diseases due to proximity of human and animal/wildlife populations. The region has inadequate healthcare infrastructure with limited access to healthcare facilities and resources. These factors combined increase the likelihood of disease transmission and exacerbate the impact of outbreaks and spill-over events. The arrival of local and international tourists from different regions also increases the risk of transboundary disease transmission to local communities.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eStudy Design\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAll CHWs operating in the sub-counties of Rubanda, Kisoro, and Kanungu districts near the BMCA and who had participated in the COVID-19 response were purposively selected to take part in this study. The participating CHWs were identified and mobilized by the District Health Officers. The selected CHWs were invited to participate in focus group discussions (FGDs) conducted at their respective District Headquarters.\u003c/p\u003e\u003cp\u003e\u003cb\u003eData collection\u003c/b\u003e\u003c/p\u003e\u003cp\u003e The FGDs comprised of 8\u0026ndash;10 males and female CHWs per group, all of whom participated voluntarily in the sessions. A total of 12 FGDs were conducted in Kisoro District, 8 in Rubanda District, and 15 in Kanungu District, each lasting approximately two hours (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The number of FGDs was determined based on data saturation, and all discussions were conducted by two moderators (JMK and JBG) with aid of a recording audio device for later transcription.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSub-counties where focus group discussions (FGDs)were conducted in different districts.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDistrict.\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSub-counties.\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo. of FGDs\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKanungu\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eKayonza(KN1), Kanungu T.C(KN2), Kihihi(KN3), Kirima(KN4), Nyanga(KN5), Mpungu(KN6), Kinaaba(KN7), Rutenga(KN8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKisoro\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBukimbiri(KR1), Muramba(KR2), Nyarusiza(KR3), Chahi(KR4), Kisoro T.C(KR5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRubanda\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMuko(RB1), Ikumba(RB2), Ruhija(RB3), Bubare(RB4), Rubanda TC(RB5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eData Analysis\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe audio files recorded during the focus group discussions were translated into English and later transcribed into MS Word files by JBN and JMK, then transferred to QDA Minor Lite (version1.4.1) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] for coding and synthesis into themes as per the objectives of the study (coded data has been provided as a supplementary file). Screenshorts of the emerging themes during the analysis are presented in Figs.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e3\u003c/span\u003e and \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e4\u003c/span\u003e. Key illustrative quotations of the FGDs have also been noted under the various generated themes.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003e\u003cstrong\u003eDemographic characteristics of participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e shows the demographic and socioeconomic characteristics of the participants from all study districts. Most of the CHWs in the study were \u0026gt;\u0026thinsp;50 years old and mainly practiced subsistence farming. Almost two thirds of the study population had completed primary education.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eDemographic and socioeconomic characteristics of community health workers participating in focus group discussions on response to COVID-19 in Kanungu, Kisoro and Rubanda districts of Uganda, November-December 2023.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCharacteristic\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDetails\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eProportion\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eAge Range\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLess than 50 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e60%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAbove 50 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"5\"\u003e\n \u003cp\u003eEconomic activity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003esubsistence farming\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e90%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ecattle keeping\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003echarcoal burning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ecasual labour 1%,\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eart and craft\u0026thinsp;\u0026lt;\u0026thinsp;1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003eEducation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrimary Education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e70%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSecondary Education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo formal education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eRoles played by Community Health Workers during the COVID-19 pandemic.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe frequency of codes under different themes varied in the different FGDs across all districts. During the data analysis, five main themes were generated from the FGDs, with community education and awareness creation emerging as the major roles of CHWs (Fig. 5).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCommunity education and promotion of awareness about COVID-19.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis was reported to be the most highly performed role from the analysis of FGD transcripts, overall, based on the number of significant codes associated with this theme across all study districts. CHWs in Kanungu were most involved in community education activities, with 53% codes generated, followed by those from Kisoro with 30% codes, and least performed by CHWs in Rubanda District, with 16% codes generated. This role wasn\u0026rsquo;t reported in only one FGD in Kanungu.\u003c/p\u003e\n\u003cp\u003eCommunity Health Workers reported that they got involved in a range of activities aimed at providing accurate information, fostering understanding, and encouraging preventive behaviours within a community to mitigate the spread of the virus during the COVID-19 pandemic.\u003c/p\u003e\n\u003cp\u003eDuring the initial days of the lockdown, CHWs collaborated with various community-based NGOs which trained them to deliver health education to communities. They actively engaged in outreach activities, visiting homes, farms, and factories, to emphasize the significance of wearing masks, maintaining physical distancing, and practicing hand hygiene.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Officials from Conservation Through Public Health whenever they could come to us sometimes, they used to tell us that we should warn the community members not to interact with wild animals like Gorillas. While in a meeting at the district, they advised us to tell people that hunting and eating wild animals cause diseases to humans\u0026rdquo;\u003c/em\u003e \u003cstrong\u003e-\u003c/strong\u003eMale FGD participant RB5\u003c/p\u003e\n\u003cp\u003eTogether, they developed and disseminated culturally appropriate educational materials and Public Service Announcements (PSAs) to reduce the burdens faced by marginalized and vulnerable populations. These CHWs acted as cultural mediators between patients and healthcare systems, providing culturally sensitive health education, information, and direct services. They played a significant part in promoting the COVID-19 vaccination program by encouraging community members to get vaccinated. Their status as trusted members of the community were instrumental in effectively addressing misinformation, fear, and stigma related to COVID-19 and its vaccine.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;We worked hard to dispel the misconception in the community that vaccines cause COVID-19 and it was our responsibility to educate the community that COVID-19 affects all individuals, regardless of ethnicity, similar to how it affects people of other backgrounds.\u0026quot;\u003c/em\u003e \u003cstrong\u003e-\u003c/strong\u003eMale FGD Kisoro TC\u003c/p\u003e\n\u003cp\u003eAdditionally, during health education programs and data collection for several\u0026hellip;., some CHWs served as linguistic and cultural translators for multicultural communities, facilitating better communication and understanding.\u003c/p\u003e\n\u003cp\u003eAs reported by the CHWs, the community gradually embraced COVID-19 infection prevention and control (IPC) measures due to the continuous awareness-raising efforts and collaborative strategies employed by various stakeholders. Community, youth, women, and religious leaders, along with the Ministry of Health, CHWs, and other community-based actors, worked together to effectively promote and implement these measures.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContact Tracing and Disease Surveillance\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis was reported to be the second most highly performed role from the analysis of FGD transcripts, overall, based on the number of significant codes associated with this theme across all study districts. The CHWs in Kanungu were most involved in contact tracing and disease surveillance activities, with 47% of codes generated, followed by those from Kisoro (32%), and Rubanda District (21%) of all codes generated. This role wasn\u0026rsquo;t only reported in all FGDs.\u003c/p\u003e\n\u003cp\u003eCommunity Health Workers reported to have participated in the public health measures aimed at identifying, Monitoring and Controlling the spread of COVID-19. They assisted in tracing and recording of contacts to suspected and confirmed cases of COVID-19, creating comprehensive lists of all individuals associated with these cases. The CHWs also closely monitored some of these contacts to identify any signs and symptoms of COVID-19. If any contact displayed symptoms such as cough, difficulty in breathing increased body temperature and other symptoms, they promptly reported them to health centres for further management and treatment.\u003c/p\u003e\n\u003cp\u003eCommunity Health Workers actively conducted symptomatic screening in households, effectively identifying potential COVID-19 infections. Government health workers and NGOs collaborated to train the CHWs in identifying and locating ill individuals. When found, CHWs would isolate them and refer them to the district\u0026apos;s health officials for further management. They also encouraged community members to report contacts and communicated the significance of reporting the contacts in preventing further transmission of COVID-19.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I always kept the District Health Officer busy with phone calls, I could even report a merely coughing person to the DHO and it was my duty to teach the community members about the danger of not reporting patients\u0026rdquo;\u003c/em\u003e\u003cstrong\u003e-\u003c/strong\u003eFemale FGD participant, RB4\u003c/p\u003e\n\u003cp\u003eAdditionally, CHWs played a crucial role in communicating the significance of reporting contacts, adhering to quarantine and isolation procedures, and educating community members and families on preventive measures against the virus. Their trusted status in the community fostered better cooperation, with people more likely to provide accurate information and follow recommended measures when communicating with CHWs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProvision of psychosocial support to community members\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCommunity health workers reported that they played a pivotal role in supporting the mental and emotional well-being of community members amid the COVID-19 pandemic. CHWs from Kanungu provided the most psychosocial support to COVID-19 victims, generating the highest number of codes (48.3%). Conversely, CHWs in Rubanda offered the least psychosocial support (13%). Psychosocial support provision was reported in all other FGDs except two in Rubanda, one in Kisoro, and one in Kanungu. This role ranked as the third most performed. Participants in FGDs consistently noted that the trust established between them and the community members fostered an environment conducive to open communication. The emphasis was on expressing empathy and offering support to all individuals affected by COVID-19.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We were trusted by the community members in most areas and this gave them a room to communicate their grievances brought about by COVID-19 pandemic\u0026rdquo;-\u003c/em\u003eMale FGD participant RB3\u003c/p\u003e\n\u003cp\u003eThese health workers actively worked to raise awareness against stigma and discrimination surrounding COVID-19. They advised community members to destigmatize seeking help, particularly for those who had received medical care after contracting the virus. Through their regular home visits, they provided essential social support and a listening ear to those affected by the COVID-19 outbreak. During these visits, they shared positive and hopeful stories, highlighting the experiences of individuals who had successfully recovered from COVID-19.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I always encouraged the family members of the infected people I visited in their homes to always support the sick people and told their neighbours that its normal for someone to take COVID-19 treatment and that many people have recovered from COVID-19\u0026rdquo;\u003c/em\u003e \u003cstrong\u003e-\u003c/strong\u003eMale FGD participant RB1\u003c/p\u003e\n\u003cp\u003eCommunity health workers in FGDs reported that they contributed to fostering community solidarity by encouraging mutual support among individuals, creating a tangible sense of unity within the community. Their efforts extended to promoting healthy coping strategies by educating community members about engaging in physical exercises and other activities conducive to maintaining good mental well-being.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;It was our obligation to foster community unity by encouraging neighbours to support each other. also encouraging beneficial coping strategies, such as engaging in exercises and activities.\u0026quot;\u003c/em\u003e \u003cstrong\u003e\u0026ndash;\u003c/strong\u003eFemale FGD participant, KR1\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContinuity of the provision of Health services during the COVID-19 pandemic\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis was the second least performed role overall, based on the number of codes associated with this theme across all study districts. CHWs in Kanungu were most involved in this role, with 48% of codes generated, followed by those from Kisoro with 32.3% of codes, and least performed by CHWs in Rubanda District, with 16% of codes generated. This role was reported in all the districts except one FGD in Rubanda, one in Kisoro, and two FGDs in Kanungu.\u003c/p\u003e\n\u003cp\u003eThe majority of CHWs reported that they were willing to continue with service delivery on a regular basis during the COVID-19 outbreak because of their desire to be part of the solution.\u003c/p\u003e\n\u003cp\u003eIn all three study districts, the effectiveness of CHWs decreased due to the rising number of COVID-19 cases detected, quarantine measures, fear of infection, limited transport support, and reduced community cooperation resulting from financial difficulties during the lockdown.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWe worked tirelessly and wholeheartedly to make sure that the health services were provided continuously to the community members\u0026rdquo;\u003c/em\u003e -Female FGD participant KR3\u003c/p\u003e\n\u003cp\u003eCommunity Health Workers were recognised as being at risk of contracting COVID-19 due to their extensive movements within the community. The Ministry of Health taught and encouraged them to observe SOPs, including maintaining a 1-meter \u0026quot;social distance\u0026quot; and regular hand washing with soap after attending to individuals. However, one CHW from Kisoro admitted that some community members often failed to implement preventive guidelines due to a lack of awareness.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Some women in a savings group (SACCO) used always to meet every week in different homes in crowded rooms, when I told them that the government doesn\u0026rsquo;t allow gatherings, they said they didn\u0026rsquo;t know about it\u0026rdquo;-\u003c/em\u003eFemale FGD participant KR2.\u003c/p\u003e\n\u003cp\u003eDuring the COVID-19 outbreak, CHWs focused primarily on COVID-19-related tasks and were encouraged to refer individuals showing symptoms to nearby health facilities.\u003c/p\u003e\n\u003cp\u003eCommunity Health Workers (CHWs) received assistance from community leaders in fostering and strengthening their relationship with the community. They consistently emphasized the importance of community leaders, such as village Local Council 1 chairpersons, in carrying out their duties effectively. These leaders utilized their political authority and influence to mobilize the community members and ensure they received the health services provided by the CHWs. Moreover, community leaders played a crucial role in enforcing community laws, creating an environment conducive for the CHWs to operate successfully.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The village chairman has a lot of power, whenever he told people to obey COVID guidelines, they could obey, this is how he was helpful in my role\u0026rdquo;-\u003c/em\u003e Female FGD participant RB4.\u003c/p\u003e\n\u003cp\u003eAfter a decline in the number of COVID-19 cases, CHWs began to gradually transition back to their regular activities, which included advocating for Maternal, New-born, and Child Health (MNCH), promoting improved reproductive health services, and assisting in Malaria control programs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReferrals for the Complicated Medical conditions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCommunity health workers played a valuable role in facilitating referrals for complicated medical conditions by acting as a bridge between the community and healthcare system.\u003c/p\u003e\n\u003cp\u003eThis was the least performed role overall, based on the number of significant codes associated with this theme across all study districts. CHWs in Kanungu were most involved in medical, with 48% of codes generated, followed by those from Kisoro (36%), and least performed by CHWs in Rubanda District (15%). Participation in the medical referrals was reported in other FGDs except two in Rubanda, one in Kisoro, and three FGDs in Kanungu.\u003c/p\u003e\n\u003cp\u003eThe majority of CHWs acknowledged that community members occasionally hesitated to trust them with slightly complex medical conditions, such as providing first aid for common illnesses like malaria, high fever, respiratory issues, and other unfamiliar clinical signs and symptoms. In such cases, they were able to refer all observed complicated cases directly to nearby health centres for medical care.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;A woman to trust you with her child to treat malaria! That can\u0026rsquo;t happen and I cannot also accept, the best I can do is to coordinate and have the child taken to the hospital\u003c/em\u003e\u0026rdquo;- Female FGD participant KR4\u003c/p\u003e\n\u003cp\u003eHowever, CHWs were still trusted to handle less complicated health-related activities, including the distribution of mosquito nets and face masks, as well as assisting in deworming and vaccination operations and projects. Their expertise and reliability in managing these less complex tasks made them valuable assets in supporting community health initiatives.\u003c/p\u003e\n\u003cp\u003eCommunity Health Workers (CHWs) reported that Traditional Healers greatly contributed to the increasing spread of COVID-19 due to their practices which do not follow standard operating procedures related to handling of patients; the government issued directives prohibiting the Traditional Healers from handling COVID-19 suspected cases. CHWs sensitized the Traditional Healers about the signs and symptoms of COVID-19 and encouraged them not to attend to clients with such symptoms encouraging them to refer such cases to the nearby health centre for comprehensive monitoring and treatment.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;We directed complex cases to health centres and urged traditional healers to refer patients with COVID-19 symptoms to hospitals.\u0026quot;\u003c/em\u003e \u003cstrong\u003e-\u003c/strong\u003eFemale FGD participant RB4.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eChallenges faced by community health workers during the COVID-19 pandemic.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNine themes were generated from the analysis of the data about the challenges faced by CHWs during the COVID-19 Pandemic response. The frequency of codes varied in the different FGDs across all districts; the overall frequency of the codes that constituted the different themes is directly proportional to the size of the themes as indicated in the word cloud (Fig. \u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003e) and code tree (Fig. 7). The main challenge reported was insufficient training and capacity building and the least was mistrust in the healthcare system and the CHWs by the community members in the study area.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInsufficient training and capacity building\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFrom the thematic data analysis, the most commonly reported challenge across all FGDs, except for only one FGD in Kanungu, was the insufficiency in training programs and capacity-building opportunities for community health workers to equip them with relevant knowledge about pandemic preparedness and management. It was highly reported in the FGDs conducted in Kanungu, with 48%, followed by Kisoro (34%), and least reported in Rubanda District (18%).\u003c/p\u003e\n\u003cp\u003eThis indicated a knowledge gap among the participants; CHWs often reported serving as caretakers for COVID-19 suspects while awaiting medical care. Most of them reported not receiving training on caring for COVID-19 positive cases; however, a few mentioned having received such training. They noted a lack of follow-up after training during disease outbreaks. According to reports from all FGDs conducted, there was no existing systematic and programmatic approach to equipping them with skills and knowledge to respond to disease outbreaks. Trainings were only conducted in response to outbreaks, limiting their ability to respond effectively.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;We recognized the need for training in caring for COVID-19 patients prior to their hospitalization. Unfortunately, such training was notably lacking\u003c/em\u003e.\u0026quot;- Male FGD Muko\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInadequate incentives and motivation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOf all the codes, 7.2% of the codes from data regarding challenges faced by CHWs were related to inadequate incentives for work, leading to low motivation across all Focus Group Discussions (FGDs) conducted in all districts. This made this challenge the second most frequently reported in this study, with Kanungu district reporting it most frequently at 44% of codes (n\u0026thinsp;=\u0026thinsp;93) under the inadequate incentives and motivation theme\u0026hellip;., followed by Kisoro (41%) and least reported in Rubanda District (15%).\u003c/p\u003e\n\u003cp\u003eParticipants reported that there was limited remuneration to the CHWs due to limited funds and lack of transparency which led to decreased satisfaction with the volunteerism in the COVID-19 response programs. The government had promised them a package at the end of the response programs which was not fulfilled. CHWs reported a lack of motivation in the form of incentives to facilitate their work. They suggested that the minimum monthly allowance should be provided to facilitate their work.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Although we actively participated in government initiatives, we frequently encountered a lack of the promised allowances. Additionally, certain funds were mismanaged by local officials.\u0026quot;-\u003c/em\u003e Male FGD KN4\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStigma, discrimination, and Harassment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStigma, discrimination, and harassment from community members emerged as the third most reported challenge by the CHWs. It was mentioned in 91% of the FGDs conducted across all districts. Among the 86 codes generated under this theme, 48% (n\u0026thinsp;=\u0026thinsp;86) originated from Kanungu District, where the challenge was not reported in two FGDs. Additionally, 38% were generated from Kisoro District, with the challenge being reported in all FGDs. Rubanda District contributed 14%, with the challenge not reported in only one group.\u003c/p\u003e\n\u003cp\u003eCommunity Health Workers reported discrimination and stigma from the community members who considered them as COVID-19 carriers this was through behaviours such as refusal to talk to them and refusal of their children to associate and play with other village children. Community members accused the CHWs of earning a lot of money from the government and NGOs involved in the COVID-19 response.\u003c/p\u003e\n\u003cp\u003eCommunity Health workers reported that they constantly faced harassment from the families of symptomatic patients for having reported them to the authorities. Their own families were angry because their involvement in the COVID-19 response was putting family members at risk of COVID-19 infection. They were accused by their family members of not fulfilling their responsibilities such as farming, harvesting, and grazing due to them spending a lot of time in COVID-19 response activities and ignoring their household obligations.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;When I got so busy with Community Mobilization, my husband was not happy, he was always quarrelling about it. He often complained that I abandoned the crops in our garden and taking care of our goats for free volunteer work, onetime he tried beating me up after an argument over the same issue, but I ran to the village chairman\u0026rdquo;-\u003c/em\u003eFemale FGD, Nyarusiiza.\u003c/p\u003e\n\u003cp\u003eSome participants reported that COVID-19 positive individuals were stigmatised by community members, and this hindered many suspects from reporting to the health care facilities after developing COVID-19 signs and symptoms. The psychological impact was highlighted by one participant who reported that COVID-19 was considered as \u0026ldquo;a death sentence\u0026rdquo; relating to how some patients reported symptoms of depression following diagnosis. Some confirmed COVID-19 positive individuals kept it a secret due to fear of stigmatisation.\u003c/p\u003e\n\u003cp\u003eCommunity Health Workers reported that during the first few months of the lockdown, many patients did not visit health facilities due to fear of being diagnosed or infected. This rendered some patients unreachable necessitating more frequent community health worker visits. Patients were also reported to frequently present late with more severe symptoms making their management more complicated. However, participants acknowledged that access to healthcare was significantly increased because of their community sensitization and health education\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;People tended to avoid those who were diagnosed with COVID-19, which discouraged affected individuals from seeking necessary medical attention. Furthermore, we encountered harassment from family members of suspected cases we reported to health workers. COVID-19 was perceived as a severe threat by many.\u0026quot;\u003c/em\u003e - Male FGD participant, KN3.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePublic misconceptions about COVID-19 disease and the vaccination\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants in all FGDs reported that public misconceptions about COVID-19 were among the major challenges except for only one FGD per district. This was the fourth most reported challenge faced by CHWs. Of the 86 codes generated about these themes, 48% were generated from Kanungu District, 38% from Kisoro District and 14% from Rubanda District.\u003c/p\u003e\n\u003cp\u003eIt was reported that some community members were in denial about the existence of COVID-19, which made it harder for CHWs to promote adherence to government regulations. Additionally, certain individuals believed that COVID-19 was present only in other countries and not in Uganda.\u003c/p\u003e\n\u003cp\u003eCommunity Health Workers reported that there was a group of people in the population who held myths that COVID-19 does not affect African/Black people and that it only affects the elderly. They also believed that COVID-19 was deliberately designed to intentionally kill people and reduce the world\u0026rsquo;s population. Consequently, these beliefs led to fear and their reluctance to seek medical care. Furthermore, some community members confused COVID-19 with traditional/spiritual diseases/attacks. These misconceptions added to the complexities faced by CHWs in their efforts to educate and raise awareness about COVID-19 in the community.\u003c/p\u003e\n\u003cp\u003eIt was reported that the Community members were reluctant to adopt the COVID-19 infection Prevention and Control measures because they were against their culture for example gathering for burials, weddings and the traditional worshipping and isolating the sick; they believed that the sick were meant to be taken care of and not isolated.\u003c/p\u003e\n\u003cp\u003eCommunity Health Workers (CHWs) reported that during the last months of the lockdown, the prevalence of myths surrounding COVID-19 vaccines had increased. Common misconceptions included concerns about vaccine risks such as blood clots, post-vaccination infections, and the erroneous belief that vaccinated individuals are exempt from taking preventive measures. Many CHWs emphasized the necessity for ongoing education to provide communities with accurate information to counteract the impact of these beliefs. Some community members viewed social media as a primary source of public misinformation.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;We repeatedly countered misinformation propagated through social media. Some individuals even believed that COVID-19 was intentionally spread by health workers.\u0026quot;\u003c/em\u003e\u003cstrong\u003e-\u003c/strong\u003e Female FGD participant, KN8\u003c/p\u003e\n\u003cp\u003eFocus Group Discussions participants reported that some individuals believed that COVID-19 was used by the government to prevent some politicians from conducting their campaigns and to \u0026ldquo;scam\u0026rdquo; electorates.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Youths alleged that COVID-19 was a government strategy aimed at financial exploitation and impeding specific politicians\u0026apos; interactions with voters.\u0026rdquo;\u003c/em\u003e - Female FGD participant, Kisoro TC\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExhaustion due to extra workload\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis challenge was reported in 31 out of the l 35 FGDs conducted in all districts. Of the 59 codes generated about this challenge, 42% were from Kanungu District, with the challenge not being reported in 2 FGDs. Upto 34% of codes were generated from Kisoro District, with the challenge not reported in 2 FGDs. Only 24% of the codes were generated from Rubanda district, and the challenge was reported in all the FGDs.\u003c/p\u003e\n\u003cp\u003eExhaustion due to an increased workload was evident among CHWs; participants reported feeling physically and emotionally drained due to the additional responsibilities added onto them during COVID-19 response. Before the COVID-19 outbreak, the CHWs were involved in Primary Health Care activities such as supporting immunization programs, Children deworming, Malaria testing \u0026amp; provision of basic treatment, health education, monitoring and reporting, and others. The COVID-19 pandemic brought forth various new tasks, including community sensitization, case tracing, distributing masks, and providing regular reports. Balancing these extra responsibilities with their pre-pandemic routine proved to be a challenging task, affecting their personal lives and economic activities. This led to burnout and exhaustion during the COVID-19 outbreak response.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Juggling COVID-19 tasks, our regular community health responsibilities, and personal life proved to be a challenging and fatiguing endeavour.\u0026quot;\u003c/em\u003e \u003cstrong\u003e-\u003c/strong\u003e Female, FGD participant KN1.\u003c/p\u003e\n\u003cp\u003eHowever, some CHWs expressed pride in the additional work they undertook, as it allowed them to acquire new skills in writing, public speaking, and performing basic health procedures like medication distribution. This highlights the impact of the pandemic-induced workload on CHWs, affecting their overall well-being and work-life balance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLack of transportation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe challenge of transportation was highlighted in 30 out of the 35 FGDs (86%) across all districts, being reported in every FGD in Kanungu. It was absent in only one FGD in Kisoro and in four FGDs in Rubanda District. Of the 58 codes generated under this theme, 53% originated from Kanungu, 33% from Kisoro district, and 14% from Rubanda District.\u003c/p\u003e\n\u003cp\u003eKisoro, Kanungu and Rubanda are mainly rural districts with a mountainous terrain. CHWs Working in these rural areas reported that during the early days of the lockdown, finding reliable transport means to reach out to the communities was extremely difficult because the public transportation were stopped from working as a government protocol to minimise the spread of COVID-19. Majority of the CHWs did not have their own vehicles to enable them reach out to community members, they had to walk long distances to reach Community members and attend the supervision meetings at the health facilities and their transport costs were exceeding the transport refunds they received at rare cases.\u003c/p\u003e\n\u003cp\u003eThere were barriers to the referral systems because they had to travel long distance from home to the health facilities, also poor road network in the area limited some transport means such as bicycles and the motor bikes leading to a high cost of transport.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInadequate Personal Protective Equipment\u003c/strong\u003e \u003cstrong\u003e(\u003c/strong\u003e\u003cstrong\u003ePPE) and Disinfection Supplies\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInsufficiency of PPE and disinfection supplies was reported to be a challenge in 86% of FGDs conducted with the exception of 2 FGDs in Kanungu and 3 FGDs in Kisoro District. Of the 58 codes generated under this theme, 48% were from Kanungu district, 26% from Kisoro, and 26% from the Rubanda district.\u003c/p\u003e\n\u003cp\u003eCommunity Health Workers in Kanungu and Kisoro reported more about the challenge of insufficient PPE and disinfection supplies than the CHWs in Rubanda district.\u003c/p\u003e\n\u003cp\u003eParticipants in FGDs reported a lack of essential supplies like detergents, alcohol-based sanitizers, Sodium Hypochlorite (JIK), soap, and others, and PPE, such as raincoats, gumboots, masks, and gloves. Additionally, one participant in an FGD in Ruhija disclosed an instance of discrimination in the distribution process of PPE among community workers, where only a few were selected to receive gumboots, leading to discontent among the rest.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;The majority of us lacked essential rain gear and gumboots. These resources were only provided to one individual. Government-supplied masks proved to be inadequate and were often unsuitable for reuse due to safety concerns.\u0026quot;\u003c/em\u003e \u003cstrong\u003e-\u003c/strong\u003e Female FGD participant RB3\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInconsistency in Government authorities\u0026rsquo; response efforts towards COVID-19\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis challenge was reported in 83% of the FGDsbut was not reported in the 4 FGDs in Kanungu, one FGD in Kisoro and not in any FGD in Rubanda, out of the 79 codes generated about this challenge, 50% were generated from FGDs conducted in Kanungu, 34% were generated from FGDs conducted from Kisoro, 16% were generated from FGDs conducted from Rubanda District and this was the fifth most reported challenge in this study.\u003c/p\u003e\n\u003cp\u003eWhile recognizing certain COVID-19 response measures undertaken by the government, participants expressed dissatisfaction with the insufficiency of the distribution of free face masks. Additionally, although the government attempted to raise awareness through mainstream media and provided home care kits for infected individuals, participants felt that these efforts fell short of effectively addressing the challenges posed by the pandemic.\u003c/p\u003e\n\u003cp\u003eSeveral participants disclosed that more could have been done to ensure that the government leads by example as they were instances where some individuals with authority failed to follow COVID-19 protocols. This could be significant in encouraging public adherence to COVID-19 guidelines as well as CHW\u0026rsquo;s willingness to work. They specifically mentioned that during election campaigns some leaders were not following COVID-19 guidelines.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u0026quot;While politicians organized rallies against COVID-19 guidelines, they simultaneously advised us to avoid gatherings. Their actions were inconsistent with their messages.\u0026quot;\u003c/em\u003e\u003cstrong\u003e-\u003c/strong\u003e Female FGD participant KR.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLack of trust in the Healthcare system and CHWs by the community members\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOverall, lack of trust by community members was the least reported across all FGDs. It was mentioned in only 66% of the FGDs. The highest frequency of reporting was observed in Kanungu, with 55% of the codes in 11 out of 14 FGDs. Conversely, it was least reported in Kisoro, mentioned in only 5 out of 12 FGDs conducted, accounting for 22% of the codes generated.\u003c/p\u003e\n\u003cp\u003eSome participants noted that they have a pre-existing level of trust with their community members, which significantly aided them in fulfilling their duties. They could easily interact with the community members, obtain information, and educate the community about COVID-19 and its prevention. However, participants reported that some community members perceive the healthcare system as poor, discouraging them from seeking medical attention at healthcare facilities. Instead, they resort to traditional healers and local herbalists, other community members practised self-medication with some traditional methods such as \u003cem\u003e\u0026ldquo;Steaming\u003c/em\u003e\u0026rdquo; due to this lack of trust. Additionally, there was a belief among some community members that government-provided vaccines and medications may cause disease outbreaks like COVID-19.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;People rely on us for advice, yet they question our ability to manage medical procedures due to our non-medical background. This undermines our morale to effectively assist them.\u0026quot;\u003c/em\u003e \u003cstrong\u003e-\u003c/strong\u003e Female FGD participant RB3.\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThe primary objectives of this study was to assess the role played by Community Health Workers (CHWs) during the COVID-19 pandemic in communities surrounding the Bwindi-Mgahinga Conservation Areas, as well as to identify the challenges they faced and the gaps in pandemic preparedness. The findings revealed that CHWs were instrumental in community engagement and education, promoting awareness about COVID-19, conducting contact tracing, and providing psychosocial support. However, they encountered significant challenges, including inadequate personal protective equipment (PPE), insufficient training, lack of transport, and public misconceptions about the virus. These challenges hindered their ability to effectively implement COVID-19 prevention and control measures.\u003c/p\u003e\u003cp\u003e\u003cb\u003eContributions to Disease Detection and Response\u003c/b\u003e\u003c/p\u003e\u003cp\u003eDisease outbreak preparedness requires coordinated efforts at every level, ensuring rapid detection and response to emerging threats [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eCHWs played a vital role in identifying suspected COVID-19 cases in their communities by recognizing symptoms such as fever, cough, and difficulty breathing. They managed mild cases at home and referred those with severe illness to health facilities, providing a vital link between the community and formal healthcare.\u003c/p\u003e\u003cp\u003eEvidence from South Africa shows that equipping CHWs with rapid diagnostic tools and training further improved case detection, management, and referral during the pandemic (Ramukumba, 2020). This experience underscores the value of supporting CHWs with resources and skills to strengthen community-based disease surveillance and response.\u003c/p\u003e\u003cp\u003eWe found that CHWs played a key role in educating communities, addressing misinformation, and promoting vaccine uptake—often serving as cultural mediators. These findings align with WHO and other studies that highlight CHWs’ impact on improving public compliance with infection control measures [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. CHWs in Kanungu were especially active, likely due to stronger government involvement in health promotion compared to Kisoro and Rubanda.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTrust, misconceptions, and collaborations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eCommunity health workers (CHWs) often built strong relationships with local residents, but lingering distrust in the broader health system sometimes led people to prefer traditional healers or self-treatment. These attitudes limited CHWs’ reach and echoed findings from other countries, where community members occasionally resisted guidance from CHWs [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In Rubanda, Kanungu, and Kisoro districts, this lack of trust often stemmed from limited awareness about the benefits of modern healthcare.\u003c/p\u003e\u003cp\u003eTo address these barriers, CHWs partnered with traditional healers, raising their awareness about COVID-19 symptoms and encouraging referrals to health centers. This collaboration improved service uptake and reflects models seen in the Democratic Republic of Congo, where traditional healers acted as de facto CHWs and bridged gaps to formal healthcare [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Considering that traditional medicine remains widely used during outbreaks, such partnerships can help decrease misconceptions about infectious diseases among rural communities [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSocial stigma and even violence against health workers was also reported in other countries, with healthcare providers facing discrimination and threats in Nepal [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], India, the USA, and Australia [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], often driven by misinformation about COVID-19 transmission.\u003c/p\u003e\u003cp\u003eChallenges with denial and misinformation were common: some community members did not believe COVID-19 was real, or felt it only affected people in other countries, attributing symptoms to malaria. Such patterns were observed not only in Uganda but also in Nigeria [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], while in Sub-Saharan Africa, myths about COVID-19 policies and its impact complicated outbreak response and medical seeking behaviors [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e][\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Cultural practices, including reluctance to isolate the sick and the importance placed on gatherings, further hindered public health interventions [\u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]–[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. These findings all highlight the need for targeted education and culturally sensitive outreach to build trust and improve health outcomes.\u003c/p\u003e\u003cp\u003eCommunity health workers also played a crucial role in offering psychosocial support for the mental and emotional well-being of community members amidst the COVID-19 pandemic. This is in agreement with Mistry et al. (2021) that training and involving CHWs in managing mental health issues can be a cost-effective and efficient method to deliver psychosocial support at the local level in low- and middle-income countries (LMICs) with fragile health systems.\u003c/p\u003e\u003cp\u003e\u003cb\u003eChallenges and systemic constraints\u003c/b\u003e\u003c/p\u003e\u003cp\u003eDuring the COVID-19 pandemic, CHWs faced exhaustion from increased workloads combining routine tasks with pandemic response activities like community mobilization and contact tracing. Similar burnout was reported in India and Indonesia [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. This strain affected both their mental health and service quality, making support for CHW resilience vital [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTransportation challenges due to lockdowns, lack of vehicles, and difficult terrain limited CHWs’ access to remote communities, as observed in other LMICs [\u003cspan additionalcitationids=\"CR34 CR35 CR36 CR37\" citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]–[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Persistent underfunding worsens this issue, delaying timely service delivery [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eParticipants expressed dissatisfaction with volunteerism due to low pay, poor incentives, and unmet promises, consistent with global findings linking low compensation to reduced motivation and attrition [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Improved financial and non-financial incentives are needed to sustain CHW performance..\u003c/p\u003e\u003cp\u003ePPE shortages—masks, gloves, sanitizers—raised infection risks and forced reuse, reflecting similar shortages in Sub-Saharan Africa [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Scarce PPE was a major barrier also reported elsewhere [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e] [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e] [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e], underscoring the need to prioritize CHWs for protective supplies.\u003c/p\u003e\u003cp\u003eDespite challenges, CHWs maintained essential services and showed resilience, supported by community trust and open communication, which helped reduce stigma [\u003cspan additionalcitationids=\"CR46\" citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]–[\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Yet limited mental health training sometimes hindered their ability to address related issues and stigma [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. Thus, enhanced training and task-sharing would be beneficial.\u003c/p\u003e\u003cp\u003eThrough home visits, CHWs provided emotional support and shared recovery stories, improving well-being and fostering community solidarity—paralleling findings from the US [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. They also promoted coping strategies for mental health and community resilience.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThe research emphasizes the vital contribution of Community Health Workers in rural Uganda during the COVID-19 pandemic, emphasizing their pivotal role in the country's pandemic preparedness and response within the communities surrounding the Bwindi-Mgahinga Conservation Area.\u003c/p\u003e\u003cp\u003eAs a country with frequent disease outbreaks CHWs form an important part of the frontline, therefore urgent changes to ease their strenuous work are needed to continue supporting their communities. CHWs need adequate resources, managerial and financial support, and recognition of their role and challenges at all stages of the policy cycle. More extensive studies need to be undertaken to comprehensively elucidate the role of Community Health Workers (CHWs) in pandemic preparedness on a broader scale encompassing diverse regions of Uganda and globally, allowing for a nuanced understanding of the challenges faced by CHWs in responding to outbreaks of infectious diseases.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eFGD: Focus group discussion.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData Availability\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData used to write-up this study is provided within the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank all the participants for having willingly provided data during this study. We are also grateful to Isaac of Kanungu district, Machumu Majolo of Rubanda district, Edison of Kisoro district for the support they offered during the data collection process.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthor Contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJMK, JBN conceived and designed the study, collected and analyzed the data, prepared figures and/or tables, drafted and approved submission of the final manuscript. \u0026nbsp;JBG, DM, AO, JN, JO, collected data, analyzed the data, prepared figures and/or tables, drafted and approved submission of the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJohn B Nizeyi, Government of Uganda through the Makerere University Research and innovation fund.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and accordance\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by Uganda Virus Research Institute Research Ethics Committee (UVRIREC-2023-12). All methods were performed in accordance with the relevant guidelines and regulations of the journal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent to participate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all subjects before their participation in the study. Participants\u0026apos; details were kept confidential by using special data codes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWHO, \u0026ldquo;Report of the International Conference on primary health care,\u0026rdquo; \u003cem\u003eAlma Ata, USSR Geneva WHO\u003c/em\u003e, 1978.\u003c/li\u003e\n\u003cli\u003eL. Nepomnyashchiy, B. Dahn, R. Saykpah, and M. Raghavan, \u0026ldquo;COVID-19: Africa needs unprecedented attention to strengthen community health systems,\u0026rdquo; \u003cem\u003eLancet\u003c/em\u003e, vol. 396, no. 10245, pp. 150\u0026ndash;152, 2020.\u003c/li\u003e\n\u003cli\u003eM. 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Public Health\u003c/em\u003e, vol. 20, no. 4, p. 2766, 2023.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Community health workers, South-western Uganda, COVID 19","lastPublishedDoi":"10.21203/rs.3.rs-7999881/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7999881/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003ePandemics pose significant global threats, often causing panic due to poor preparedness and inadequate planning. Community Health Workers (CHWs) play a critical role in pandemic preparedness and response, especially in resource-limited settings like Uganda's Bwindi-Mgahinga Conservation Area (BMCA), where human-wildlife coexistence heightens the risks of emerging and re-emerging infectious diseases. Unfortunately, CHWs face significant challenges exacerbated by limited resources. This study examined the roles and challenges of CHWs during the COVID-19 pandemic in BMCA-adjacent communities.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThe CHWs from sub-counties bordering BMCA were purposively selected and involved in 12 Focus Group Discussions in Kisoro, 8 in Rubanda, and 15 in Kanungu districts. The qualitative data obtained were analyzed using QDA Miner Lite to generate key themes.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003e The findings revealed that CHWs ensured uninterrupted healthcare delivery by raising community awareness about COVID-19 transmission risks, facilitating contact tracing, promoting adherence to infection prevention guidelines, supporting vaccine awareness campaigns, and coordinating medical referrals to foster collaborative pandemic response networks. However, they faced challenges, including inadequate personal protective equipment (PPE), limited pandemic-specific training, community resistance, stigma, insufficient transportation, and inadequate incentives.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eOptimizing CHWs' services through strategic deployment and resolving the challenges they face is essential to enhance pandemic preparedness and mitigate COVID-19 transmission risks to both human and wildlife populations. Integrating CHWs into the health system, developing streamlined policies, increasing recruitment, providing transportation and incentives, enhancing pandemic-focused training, conducting regular program evaluations, raising community awareness, and ensuring equitable resource allocation can boost management of disease outbreaks.\u003c/p\u003e","manuscriptTitle":"Assessing community health workers contributions to pandemic preparedness using lessons from COVID19 outbreak in rural Uganda","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-19 18:32:59","doi":"10.21203/rs.3.rs-7999881/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-08T11:35:46+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"49208217269838257229956703692833941218","date":"2025-12-08T08:55:10+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-07T00:31:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"143747043557095232379626293246757973348","date":"2025-12-06T11:06:26+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-27T15:10:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"67100222235058745322056459515765600323","date":"2025-11-18T06:35:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"85596247138576272574081380642563016646","date":"2025-11-18T06:29:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"127325175777019480281193951890725487130","date":"2025-11-16T17:31:50+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-10T15:45:32+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-06T16:12:16+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-04T07:15:10+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-03T12:06:26+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Public Health","date":"2025-11-03T12:02:34+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"448a7e2a-ad48-4054-87fd-0e1b4082bb81","owner":[],"postedDate":"November 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-16T16:06:29+00:00","versionOfRecord":{"articleIdentity":"rs-7999881","link":"https://doi.org/10.1186/s12982-026-01493-1","journal":{"identity":"discover-public-health","isVorOnly":false,"title":"Discover Public Health"},"publishedOn":"2026-02-11 15:58:14","publishedOnDateReadable":"February 11th, 2026"},"versionCreatedAt":"2025-11-19 18:32:59","video":"","vorDoi":"10.1186/s12982-026-01493-1","vorDoiUrl":"https://doi.org/10.1186/s12982-026-01493-1","workflowStages":[]},"version":"v1","identity":"rs-7999881","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7999881","identity":"rs-7999881","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}