A scoping review of the roles, challenges, and strategies for enhancing the performance of community health workers in the response against COVID-19 in low- and middle-income countries

A scoping review of the roles, challenges, and strategies for enhancing the performance of community health workers in the response against COVID-19 in low- and middle-income countries | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A scoping review of the roles, challenges, and strategies for enhancing the performance of community health workers in the response against COVID-19 in low- and middle-income countries Joseph Mumba Zulu, Adam Silumbwe, Margarate Munakampe, Malizgani Paul Chavula, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3851192/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 14 May, 2025 Read the published version in BMC Primary Care → Version 1 posted 4 You are reading this latest preprint version Abstract Background: With the spread of COVID-19 to most low-and middle- income countries (LMICs), global concerns arose on how to respond to the pandemic. While studies have documented the experience of community actors and in particular community health workers (CHWs) in responding to COVID-19 in LMICs, critical appraisal and synthesis of research data on the same is still lacking. We aimed to highlight, the roles and challenges of CHWs in the fight against COVID-19, and strategies to address these challenges. Methodology: Using a scoping review design, we systematically searched the following electronic databases: PubMed, HINARI, Cochrane Library (Reviews and Trials), Science Direct and Google Scholar. Three authors searched literature on CHWs and COVID-19 as well as CHWs and the COVID-19 vaccine. After critical appraisal of studies, informed by Arksey and O’Malley, twenty-five articles were included in the final analysis. Results : Community health workers assisted with and contributed to health promotion and education tasks, surveillance, contact tracing and quarantine, maintaining essential primary health services, linking people to services through referrals, advocating for clients and communities, supporting planning and coordination of vaccination, as well as participated in vaccine rollout tracking and follow-up. Challenges experienced by CHWs in the COVID-19 response included stigma and discrimination by community members, inadequate infection prevention and control preparedness, lack of supplies and commodities, limited supportive policies and inadequate remuneration and incentives. The performance of CHWs during COVID-19 pandemic response could be enhanced by harnessing digital technology (mHealth) to support CHWs, establishing collaborative groups via mobile-messaging platforms, prioritizing CHWs in receiving the COVID-19 vaccine, and periodically training CHWs in preventive measures of the COVID-19 response. It was also noted that implementing wellness programs for CHWs including the provision of adequate and quality protective equipment was vital. Conclusion: CHWs were found to be critical community actors and integral members of the health system during the COVID-19 pandemic. This calls for increased investments that will ensure greater support for the integration of CHWs into health systems as this could also ultimately contribute to maintaining the credibility and sustainment of CHW programs, as well as promoting more inclusive health systems. Community health workers health system COVID-19 LMICs Figures Figure 1 Background The importance of community health workers (CHWs) in providing integrated, quality and people-cantered primary healthcare is widely recognized[ 1 , 2 ]. Over the last decades, low and middle income countries (LMICs) have recorded various health gains, attributable to the contributions of CHWs [ 3 ]. Many LMICs continue to rely on CHWs to achieve effective delivery of maternal, new born, child health, malaria and HIV/AIDS interventions, especially among marginalized and hard to reach populations [ 4 ]. The use of CHWs is not unique to LMICs only, as high-income countries such as Sweden have also reported the engagement of CHWs to activate virtual health rooms for rural communities. In the USA and Australia, the use of CHWs in dealing with high-risk group behavioural change has equally been reported [ 5 ]. The collective use of community resources, including CHWs, to create better health for all has been coined as ‘reactivating the community health systems’ [ 6 ]. A community health system (CHS) is defined as “ a set of local actors, relationships, and processes engaged in producing, advocating for, and supporting health in communities, but existing in relationship to established health structures ” [ 7 ]. Indeed, calls for strengthening the conceptual linkages between the formal health system and the community health system are building up as demonstrated in a recent research agenda on CHS [ 8 ]. The focus on CHSs in the era of COVID-19 is of paramount importance as reflected in the Policy Brief issued by the World Health Organisation (WHO) on 1st April 2020, which outlined 16 recommendations for strengthening health system response to COVID-19 [ 9 ]. In this brief, it was stated that the early experience in countries with large-scale community transmission showed that COVID-19 required unprecedented mobilization of health systems. The first recommendation was for health systems to consider an expansion of their capacity to communicate COVID-19-related information, and proactively manage the flow of this information. The use of CHWs to supplement such communication of information was warranted, and critical to tackle the widespread misinformation on COVID-19 that quickly created another battlefield, referred to as the COVID-19 ‘infodemic’ by the WHO chief [ 10 ]. A publication in the Lancet called for development of a large-scale emergency programme to train community CHWs on how to respond to the COVID-19 pandemic [ 11 ]. Ballard et al., also add that given that COVID-19 disproportionately affects the poor and vulnerable, CHWs played a pivotal role in fighting the pandemic, especially in countries with less resilient health systems[ 12 ]. It has been suggested that investment in community health systems is vital in averting and managing COVID-19, and subsequent similar emergent crises [ 13 ]. CHWs matter and are at the centre of community health because they are trusted members of the community who are often the most accessible point of care[ 14 ]. Investment in community health systems will help achieve the following pandemic control goals: protect healthcare workers, interrupt the virus, maintain existing healthcare services while surging their capacity, and shield the most vulnerable from socioeconomic shocks [ 12 ]. While it has been recognised that CHWs play a vital role in addressing the COVID- 19 pandemic, evidence suggests that despite their position within communities, they were not provided clear guidance about their role in the pandemic response. A publication about CHWs’ experiences during COVID-19 in India, Bangladesh, Pakistan, Sierra Leone, Kenya and Ethiopia showed that overall, support towards CHWs in responding to the COVID − 19 pandemic varied between countries and among different CHWs [ 15 ]. They were significant gaps including disruption of medical supply chains, high workloads, leaving CHWs vulnerable to infection and stress [ 15 ]. Some countries such as Brazil published contradictory recommendations on community engagement[ 16 ]. Although there is policy guidance to involve community health workers in the COVID-19 response, clear indication of what specific roles, responsibilities, challenges, and support systems should be addressed to ensue resilient community health systems during COVID-19 and other future infectious pandemics is inadequate[ 16 ]. We aimed to synthesize literature on the roles and challenges that community health workers (CHWs) experienced in the fight against COVID-19 and propose strategies to address the challenges. Methods The Search Strategy We systematically searched the databases including PubMed, HINARI, Cochrane Library (Reviews and Trials), Science Direct and Google Scholar. The review targeted literature on the roles, responsibilities, and challenges that community health workers (CHWs) experienced in the fight against COVID-19, as well as strategies and supportive structures for addressing the stated challenges. To ensure that we did not omit important literature, we used varied terms for CHW (e.g. ‘community health worker*’ and alternate terms for ‘CHWs’) and COVID − 19” and “COVID − 19 Vaccine” We used the alternative names for CHWs as outlined in a systematic review of definitions of CHWs (Accredited social health activist; Lady health worker; Community health advisor; Patient navigator; Lay health worker; Community-based health provider; Peer educator; Community health representative; Care facilitator; Community health agent; Community-based reproductive health agent; Auxiliary nurse midwife; Village health worker; Health extension worker; Lay health promoter; Care guide; Peer health advisor; Community health development agent; Community health promoter; Lay health educator; Community-based health worker; Community health coach; Village health volunteer; Community midwife; Community health assistant; Community-based educator; and Health surveillance assistant) [ 17 ] . Inclusion and Exclusion Criteria To ensure inclusion of relevant, high-quality papers in this review, our inclusion criteria for documents comprised: peer-reviewed publications and reports/guidelines from WHO and United Nations Organizations on the study topic. Studies had to have been conducted between December 2019 and January July 2023. We included papers from 2019 as this was the period when the pandemic started. Considering that this is a scoping review, we included papers with different study designs including qualitative, quantitative, mixed-methods, reviews, and CHW program evaluations, reports as well as commentaries. Papers on the COVID-19 pandemic that did not discuss CHW roles, challenges, and strategies for enhancing the performance of CHWs’ in the response against COVID-19 were excluded from the review. Papers on CHWs and the COVID − 19 from high income countries were also excluded from the scoping review. Study Selection and Quality Assessment We followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines in selecting the studies (Fig. 1 ) [ 29 ]. In accordance with the guidelines, we first excluded all duplicates 259 from the 894 search outcomes initially identified. Then we reviewed all the titles of the remaining 635 research, of which we excluded 512 because they focused either on the wrong topic or region or both. We then remained with 123 outcomes. Subsequently we retrieved and assessed the abstracts of the − 123 papers, of which we excluded 85 because they did not address the subject of roles, challenges, or strategies for improving the performance of CHWs in preventing and managing the COVID − 19. Finally, we retrieved 38 full-length papers that were shortlisted after abstract review, to screen them in accordance with the inclusion criteria. At this stage, we also subjected the papers to the main elements of the Critical Appraisal Skills Programme (CASP) quality assessment that has been used to appraise studies, and especially those that use qualitative approaches. This process resulted into the final 25 papers that were considered for final analysis (Table 2 ). Table 1 Key thematic categories from the literature Main Themes Sub-themes Roles for community health workers Health promotions and education Assisting with surveillance Maintaining essential health services Support planning and coordination of vaccination The challenges faced by CHWs during the COVID-19 response. Stigma and discrimination Limited incentives The lack of training for CHWs during the COVID-19 response Inadequate infection prevention and control preparedness Limited supportive policies Strategies for enhancing the performance of CHWs during COVID Harnessing digital technology (mHealth) Training for CHWs in pandemic response Health information management: collection and dissemination Wellness and safeguarding CHWs Table 2: Study characteristics: A scoping review of the roles, challenges, and strategies for enhancing the performance of community health workers in the response against COVID-19 in low-and middle-income countries. No 1st Author/ year/ country [citation] Study type/design Study title/aim Study participants/ Primary source of information Key issues/findings 1 Lotta G, et al., (2021) Document Review This paper analyses how the Brazilian government regulated the reorganization of Primary Health Care (PHC) and how FLW responded to these initiatives, comparing the roles played by nurses and community health workers. Documents ▪ Given the multilevel health system, it was expected that the high level of ambiguity would stimulate innovations. ▪ However, data show that the ambiguity created different situations for each profession. ▪ While nurses were able to adapt their work and act with more autonomy, CHW lost their role in the policy. 2 Ballard et al., (2020) Prioritising the role of community health workers in the COVID-19 response. ▪ Community health workers (CHWs) are poised to play a pivotal role in fighting the pandemic, especially in low-income countries with vulnerable health systems. ▪ The COVID-19 response must build on existing platforms, infrastructure, and relationships where are possible; the focus should be on supporting the Ministries of Health and regional authorities as they lead coordinated responses. ▪ achieving these goals will require targeted actions at different stages of the pandemic. These actions are delineated in the article. 3 Mayfield-Johnson et al., (2020) Qualitative study This study aimed at assessing the effect of the COVID-19-related lockdown on Tunisian women’s mental health and gender-based violence Female-exclusive social group on Facebook ▪ A focus group with CHW leaders from 7 states revealed 8 major themes: CHW identity, CHW resiliency, self-care, unintended positives outcomes of COVID-19, technology, resources, stressors, and consequences of COVID-19. ▪ Understanding the pandemic's impact on CHWs has implications for workforce development, training, and health policies. 4 Ajisegiri, et al., (2020) Nigeria m COVID-19 Outbreak Situation in Nigeria and the Need for Effective Engagement of Community Health Workers for Epidemic Response ▪ We recommended that the government needs to promptly bring community health workers on board, deploy rapid epidemic intelligence and scale up the use of mobile Apps for contact tracing. ▪ This will result in an effective and coordinated response to the ongoing outbreak, sustain routine health services especially at the community level. 5 Bezbaruah et al., (2021) South-East Asia Qualitative study Roles of community health workers in advancing health security and resilient health systems: emerging lessons from the COVID-19 response in the South-East Asia Region Review journal articles, policy documents, national guidelines, reports, and online publications ▪ The regular role of a CHW in health education and promotion focused on awareness-raising and the promotion of “new normal” behaviours; CHWs also played critical roles in assisting in surveillance and contact tracing, and in ensuring that people followed isolation and quarantine guidelines. ▪ Development and implementation of long-term plans across the region to strengthen and support CHWs and recognize CHWs as an integral component of resilient health systems. ▪ Planning for CHWs as part of the primary health care system will enable local authorities to ensure that an adequate level of resources (including capacity-building, incentives, necessary equipment, and consumables) is allocated to CHWs. 6 Mistry et al. (2021) Qualitative study Community health workers can provide psychosocial support to the people during COVID-19 and beyond in low-and middle-income countries. Frontiers in Public Health Documents ▪ The CHWs can be effectively engaged to provide psychosocial support at the community level. Engaging them can also be cost saving as they are already in place and may cost less compared to other health professionals. However, they need training and supervision and their safety and security need to be protected during this COVID-19. ▪ While many LMICs have mental health policies but their enactment is limited due to the fragility of health systems and limited health care resources. ▪ CHWs can contribute in this regard and help to address the psychosocial vulnerabilities of affected population in LMICs during COVID-19 and beyond. 7 Roy et al., (2020) Bangladesh Mixed methods Examining Roles, Support, and Experiences of Community Health Workers During the COVID-19 Pandemic in Bangladesh. Policy makers, program managers, CHW supervisors, and CHWs. ▪ During the first wave of the coronavirus disease (COVID-19) pandemic in Bangladesh, across all health areas, community health workers (CHWs) described a slight decrease in the routine services they were able to provide due to restrictions in movement posed by lockdowns and other challenges. ▪ The government and various nongovernmental organizations provided supportive mechanisms to CHWs through training, supplies, and supportive supervision; however, these supports were not always uniformly distributed across cadres, leading to some discontent among CHWs. ▪ CHWs were crucial actors in the government’s COVID-19 response, as they took on new pandemic-related responsibilities in their communities to prevent the spread of the disease while continuing their routine work. 8 Fernandez et al., (2020) Brazil Quantitative How community health workers are facing COVID-19 pandemic in Brazil: personal feelings, access to resources and working process. Archive of Family Medicine and General Practice. Online Survey ▪ HWs feel scared and unprepared in the face of the COVID-19 pandemic. The fear of COVID-19 is related to being prepared and to receiving support from federal government. The feeling of preparedness is associated with the lack of ▪ material working conditions, such as PPEs, guidance from managers and support from superiors and federal government. 9 Nepomnyashchiy et al., (2020) Qualitative study Africa needs unprecedented attention to strengthen community health systems. ▪ CHWs matter because they are trusted members of the community who are often the most accessible point of care. ▪ Ongoing efforts to leverage CHWs for the COVID-19 response must not be one-offs in the face of an emergency. CHWs must be equipped, trained, and supported in the long term as a crucial human resource for health. 10 Fernanda et al., (2020) South Africa Qualitative study Community health workers: reflections on the health work process in Covid-19 pandemic times. Literature review ▪ CHW work, especially cultural competence, and community orientation, aiming to discuss the changes introduced in this work regarding the following aspects: 1) health teams support, 2) use of telehealth, and 3) health education. 11 Chitungo et al., (2021) A rapid review Utility of telemedicine in sub-Saharan Africa during the COVID‐19 pandemic. A rapid review. Human behavior and emerging technologies. A rapid review ▪ Challenges to the implementation of telemedicine on the continent were lack of supporting telemedicine framework and policies, digital barriers, and patient and healthcare personnel biases. ▪ Telemedicine use by all stakeholders, including medical insurance organizations, the introduction of telemedicine training of medical workers, educational awareness programs for the public, and improvement of digital platforms access and affordability. 12 Kaseje et al., (2020) Kenya Quantitative and qualitative methods Engaging community health workers, technology, and youth in the COVID-19 response with concurrent critical care capacity building: A protocol for an integrated community and health system intervention to reduce mortality related to COVID-19 infection in Western Kenya ▪ the intervention will consist of training youth, community health assistants and community health workers in screening, case detection, prevention, management, and referral of COVID-19 cases with maintenance of essential health services. ▪ The community intervention will be enhanced by youth and use of digital tools. 13 Feroz et al,. (2021) LMICs Equipping community health workers with digital tools for pandemic response in LMICs ▪ CHWs are playing a huge role in providing essential health care services and Covid-19 related healthcare to the communities. ▪ CHWs are overburdened as they are expected to accomplish more although they are not getting the required support to perform their duties well, such as training, remuneration, protective gear, etc. 14 Bhaumik et al., (2020) Systematic review Community health workers for pandemic response: a rapid evidence synthesis. Articles ▪ CHW roles and tasks change substantially during pandemics. Clear guidance, training for changed roles and definition of what constitutes essential activities (i.e., those that must be sustained) is required. ▪ Most common additional activities during pandemics were community awareness, engagement, and sensitisation (including for countering stigma) and contact tracing. ▪ CHWs were reported to be involved in all aspects of contact tracing - this was reported to affect routine service delivery. CHWs have often been stigmatised or been socially ostracised during pandemics. 15 Boyce et al., (2020) Community Health Workers and Pandemic Preparedness: Current and Prospective Roles . ▪ CHWs promoted pandemic preparedness by acting as community-level educators and mobilizers, contributing to surveillance systems, and filling health service gaps. Acknowledging the success CHWs have had in these roles and in previous interventions, we propose that the cadre may be better engaged in pandemic preparedness in the future. ▪ Some practical strategies for achieving this include training and using CHWs to communicate One Health information to at-risk communities prior to outbreaks, pooling them into a reserve health corps to be used during public health emergencies, and formalizing agreements and strategies to promote the early engagement of CHWs in response actions. 16 Sudhipongpracha et al., (2020) Qualitative study Community health workers as street-level quasi-bureaucrats in the COVID-19 Pandemic: The cases of Kenya and Thailand. Journal of Comparative Policy Analysis: Research and Practice.. Literature review ▪ Findings show that how a public health system is organized (decentralization versus centralization) affects CHWs’ initial responses to the outbreak. ▪ While CHWs in Thailand’s centralized system conform to the “state agent” tradition by referring to the hierarchical chain of command, those in Kenya’s decentralized system follow the “citizen agent” tradition by prioritizing community safety. 17 Jalali, F., Fischer, H., & Nichols, C. (2022). Mixed methods Corona warriors”? Experiences of India's community health workers (ASHAs) in India's COVID-19 response. Political Geography , 99 . CHWs ▪ CHWs (ASHAs) were both proud ‘warriors’ and compelled to work due to the risk of letting down their community. ▪ While many CHWs felt deep fear and that they were ill-prepared- ▪ CHWs reported their sacrifices made both to their own personal health as well as their families, while expressing 18 Niyigena, A., Girukubonye, I., Barnhart, D. A., Cubaka, V. K., Niyigena, P. C., Nshunguyabahizi, M., ... & Bitalabeho, F. A. (2022). Mixed-method study Rwanda’s community health workers at the front line: a mixed-method study on perceived needs and challenges for community-based healthcare delivery during COVID-19 pandemic. BMJ open , 12 (4), e055119. ▪ supervision during the lockdown was low. ▪ CHWs additionally described increases in workload, lack of personal protective equipment and COVID-specific training, fear of COVID-19, and difficult working conditions. 19 Sripad, P., Gottert, A., Abuya, T., Casseus, A., Hossain, S., Agarwal, S., & Warren, C. E. (2022). This mixed methods Confirming—and testing—bonds of trust: A mixed methods study exploring community health workers’ experiences during the COVID-19 pandemic in Bangladesh, Haiti and Kenya. PLOS global public health, 2(10), e0000595. CHWs ▪ CHWs reported high levels of community trust (8/10 in Bangladesh and Kenya; 6/10 in Haiti). ▪ with over 60% reporting client relief in seeing their CHWs. ▪ CHWs reporting more positive and fewer negative experiences is consistently associated with continuing routine work, doing COVID-19-related work, and greater community trust. Qualitative interviews showed that CHW-community and CHW-health system actor trust is strengthened when CHWs are well-resourced. ▪ CHW-community trust is strained by public frustration at the pandemic, associated restrictions, and socio-political stressors. 20 Dhaliwal, B. K., Singh, S., Sullivan, L., Banerjee, P., Seth, R., Sengupta, P., ... & Shet, A. (2021). Rapid qualitative evaluation Love, labor and loss on the frontlines: India’s community health workers straddle life and the COVID-19 pandemic. Journal of global health , 11 . CHWs ▪ CHWs faced increased workloads, decreased compensation, and stated that their work had shifted to focus on COVID-related work, as opposed to routine care. ▪ CHWs also shared that their needs included improved mental health services, financial payment that was not tied to incentives, and consistent access to PPE. ▪ CHW experiences through the context of the COVID-19 pandemic have not been well-explored. 21 Monreal, T. J., Falcão de Oliveira, E., Araujo Ajalla, M. E., Adania Zanoni, D., & Du Bocage Santos-Pinto, C. (2022). A descriptive cross-sectional study Community health workers and COVID-19 in a Brazilian state capital. Sociological Spectrum , 42 (3), 217–230. CHWs ▪ Around 40% of the sample reported at least one risk factor for COVID-19, 44% had experienced at least one COVID-19 symptom, and 76% had experienced symptoms of mental suffering during the first year of the pandemic. Mental suffering was associated with the onset of flu-like symptoms after the start of the pandemic and changes in work processes. Knowledge gaps were observed, mainly related to forms of transmission and disease prevention. In view of the uncertainty about how long this health emergency will last and the vital role CHWs play in the Brazilian Health System, health managers and society need to pay greater attention to these professionals to improve the effectiveness of the country’s COVID-19 response. 22 Gibson, E., Zameer, M., Alban, R., & Kouwanou, L. M. (2023). A Rapid Review Community health workers as vaccinators: a rapid review of the global landscape, 2000–2021. Global Health: Science and Practice, 11(1). Peer-reviewed literature ▪ Community health worker (CHW) cadres administered vaccines in 20 of the 75 countries with documented CHW programs, improving access to immunization services for under-reached communities. ▪ The review identified several countries where CHWs with brief clinical training and experience were taught to vaccinate, suggesting the feasibility of task-shifting administering vaccines to CHWs with limited experience. 23 Olateju e al., (2022).. qualitative study Community health workers experiences and perceptions of working during the COVID-19 pandemic in Lagos, Nigeria—A qualitative study. CHWs ▪ Trust and COVID-19 knowledge were found to aid Community Health Workers in their work. However, challenges included exhaustion due to an increased workload, public misconceptions about COVID-19, stigmatisation of COVID-19 patients, delayed access to care and lack of transportation. ▪ Influences on willingness to work in COVID-19 Role : Community Health Workers’ perceptions of COVID-19, attitudes towards responsibility for COVID-19 risk at work, commitment and faith appeared to increase willingness to work. ▪ Financial incentives, provision of adequate personal protective equipment, transportation, and increasing staff numbers were seen as potential strategies to address many of the challenges faced. 24 Salve, S., Raven, J., Das, P., Srinivasan, S., Khaled, A., Hayee, M., ... & Gooding, K. (2023). Synthesis of evidence Community health workers and Covid-19: Cross-country evidence on their roles, experiences, challenges and adaptive strategies. CHWs ▪ CHWs made important contributions to the COVID-19 response, including in surveillance, community education, and support for people with COVID-19. ▪ There was some support for CHWs’ work, including training, personal protective equipment, and financial incentives. ▪ However, support varied between countries, cadres and individual CHWs, and there were significant gaps, leaving CHWs vulnerable to infection and stress. ▪ CHWs also faced a range of other challenges, including health system issues such as disrupted medical supply chains, insufficient staff and high workloads, a particular difficulty for female CHWs who were balancing domestic responsibilities. ▪ CHWs demonstrated commitment in adapting their work, for example ensuring patients had adequate drugs in advance of lockdowns and using their own money and time to address increased transport costs and higher workloads. 25 World Health Organization. (2021). Evidence synthesis The role of community health workers in COVID-19 vaccination. Reports and articles ▪ This guide is intended to support national governments in developing their national deployment and vaccination plans (NDVP) for COVID-19 vaccines by outlining the roles, needs and opportunities for community health workers (CHWs) (International Labour Organization, 2007) 1 to contribute. ▪ Identifying CHW contributing roles at each stage of COVID-19 vaccines rollout. ▪ Counting and vaccinating CHWs within initial vaccine allocation as part of the essential health ▪ Workforce to optimally support the COVID-19 response and continuity of essential health services. ▪ Recognizing and remunerating CHWs commensurate to tasks undertaken and training. ▪ CHWs who are linked to health systems through regular compensation, dedicated supervision and accreditation are best placed to support an effective pandemic response and to prevent the next one. ▪ Considering community-based health worker representation on national coordinating committees. Data Analysis and Synthesis We used thematic analysis, using NVivo 12 Pro Software (QSR international, Melbourne, Australia). The final full articles were downloaded to NVivo and individually coded into various thematic areas. We created a coding structure of broad themes and subcategories to support the coding process. The development of coding framework was informed by the main objective of this study. As such, the coding framework focused on three broad themes namely roles , challenges , and strategies in the context of community health worker performance in the response against COVID-19 in low- and middle-income countries (Table 1 ). With these three themes in mind, we read through the abstracts of respective articles to develop a codebook. The codes were discussed by the review team to arrive at the final codes that were used as we reviewed the selected articles. The codebook was then imported into NVivo and where a detailed coding of articles was completed. The coding was conducted by two research team members AS and PMC who regularly met with the entire team to give an update on the process. This was followed by an iterative grouping of codes to identify patterns, that yielded sub-themes under the three earlier on identified themes. The draft sub-themes and themes were shared with all the authors for a discussion to yield a common understanding of what each of the sub-themes and themes represented and linkages therein. Once this process was completed, we maintained the three pre-determined themes and arrived at 12 sub-themes as indicated in Table 1 respectively. This led us to the final stage of drafting the findings and sharing them with all co-authors for review and agreement which led us to the results presented in this article. Results In this section, we present the results of published data on the involvement of CHWs in the COVID − 19 pandemic. We first start by highlighting the roles that CHWs played in the COVID − 19 pandemic and then the challenges CHWs faced while performing these roles. The final part of the results section outlines strategies for enhancing the performance of CHWs during the pandemic period. Roles for community health workers Health promotions and education Community health workers played a key role in COVID-19 related health promotion and education activities[ 18 ]. In India, Bangladesh, Kenya and Ethiopia, CHWs promoted the acceptability of COVID − 19 prevention measures at the community level by first adopting preventive measures themselves for example mask wearing and physical distancing in communities [ 19 , 20 ]. Similarly, they also played a critical role in delivering culturally sensitive information to counter practices, social norms and misinformation that could propagate the spread of COVID-19[ 19 , 20 ]. This included disseminating messages that addressed context specific myths such as the view that the COVID-19 virus could not be transmitted in areas with hot and humid climates, mosquito bites could transmit the virus and that the virus only affected certain populations or categories of people in a population [ 19 , 20 ]. This was important given the high levels of misinformation at the global level. Through providing health education on the nature and prevention of COVID- 19, CHWs contributed towards eradicating social stigma or superstitions associated with the disease and prevented spreading of hate discrimination against patients and their families[ 15 ]. Relatedly, as role models, they also acted as behavioural change agents by for example readily accepting vaccines and getting (ahead of other community members) vaccinated once vaccines became available [ 15 ]. The CHWs used different strategies to facilitate accessibility to information on protection against COVID-19 [ 21 ]. The approaches included home visits and public information initiatives such as megaphones as observed in Kenya, India, and Thailand. Megaphones and audio messages were also employed in Ethiopia[ 22 ]. In Indonesia, digital technology was used to fight COVID-19 misinformation [ 18 , 22 ]. Indeed, health promotion was integrated into the national Community Health Worker (CHW) guidelines in India and Thailand [ 18 ]. While, in Bangladesh, CHWs acted as a bridge between refugee communities and health facilities thereby addressing fears and rumours[ 23 ]. Assisting with surveillance Community health workers being permanent residents in communities helped in supporting disease surveillance activities such as contact tracing and enforcement of quarantine directives [ 18 ]. Overall, CHWs were characterized as ‘natural researchers. For instance, Kenya, Liberia, India, and Rwanda are some of the countries that started leveraging CHWs for COVID-19 infection case detection [ 15 ]. In Bangladesh, India, Nepal, and Thailand, CHWs conducted symptomatic screening to detect COVID-19 infection. In India as internal migrants returned home after lockdown, CHWs screened 30–50 households per day for symptoms [ 15 , 18 ]. In terms of enforcing quarantine directives, CHWs worked with local communities to encourage voluntary quarantine and supported full integration of recovered patients into the communities [ 15 ]. Additionally, CHWs successfully encouraged voluntary quarantine in dedicated facilities and significantly reduced the stigma associated with individuals who had recovered from COVID-19. They utilized local expertise to effectively implement safety measures during disease surveillance. For example, in India, Bangladesh, and Ethiopia, CHWs facilitated the willingness of family members exhibiting COVID-19 symptoms to agree to their admission to a treatment centre [ 15 ]. Moreover, through community collaboration, the CHWs achieved significant progress by educating individuals about quarantine protocols and effectively identified potential cases of COVID-19 [ 15 ]. In so doing, they significantly reduced stigma against those who had recovered by educating communities and demystifying COVID-19 infections [ 15 ]. Maintaining essential primary health care services CHWs played a vital role in distributing commodities such as essential household products and medical supplies to those who were self-isolating. CHWs arranged transport and lodging for vaccinators and identified outreach locations that were likely to reach vulnerable populations. Using trusted networks, CHWs in Bangladesh, Haiti and Kenya, supported COVID-19-related and unrelated health services tasks such supporting referrals for maternal health services [ 20 , 23 ]. In Malawi, the CHWs conducted social mobilization to promote HPV vaccines when schools closed during the COVID-19 pandemic [ 15 , 24 ]. While CHWs played a role in supporting established essential services, it's imperative to acknowledge the emergence of vital healthcare needs [ 18 ]. This was particularly evident in the heightened demand for mental health services across various settings worldwide, largely due to the impact of the COVID-19 pandemic [ 25 ]. It has been documented that CHWs were very crucial in providing psychosocial support in India, Uganda, Nepal and Pakistan to the people amid COVID-19 pandemic [ 18 , 25 ]. The sharp increase in cases of stress, anxiety, fear, depression and anger was documented in many contexts, providing an emergent role for CHWs to play within their communities [ 25 , 26 ]. Support planning and coordination of vaccination The CHW representation in vaccination planning teams aided in identifying target or priority populations by mapping out locations for vaccination [ 27 ]. For example in Pakistan CHWs registered households to ensure accurate forecasting, mobilized target populations and accompanied them to immunization sites[ 24 ]. Relatedly, they contributed to the promotion of the COVID-19 vaccine by delivering pertinent and context-specific information during the preparatory and planning stages [ 24 ]. They promoted vaccine acceptance though mobilizing community influencer, acted as the link between the community and the vaccination centres and supported the vaccine scheduling process. CHWs organized the reception flow or users of vaccines, in person and by teleconsultation [ 20 ]. The challenges faced by CHWs during the COVID-19 response Stigma and discrimination The interaction of CHWs with individuals infected with COVID-19 made them susceptible to both stigma and the virus itself. In India a mob of 100 people assaulted CHWs who were collecting data on people with COVID-19-like symptoms [ 18 ]. CHWs were scared and unprepared due to lack of protective equipment. In Nigeria, social stigmatisation of COVID-19 patients made many people not to disclose their COVID-19 infection thus making it difficult for CHWs to identify COVID-19 cases in the community [ 28 ]. Limited incentives There were challenges with regular payment of sufficient CHW remuneration and incentives, during the pandemic in many countries such as India, Bangladesh, Pakistan, Sierra Leone, Kenya and Ethiopia[ 15 , 29 ]. Without a more harmonized approach to CHW remuneration and incentives, their motivation and performance in COVID-19 prevention processes was inconsistent [ 29 ]. In some countries such as India, Bangladesh, and Pakistan, additional financial incentive schemes for CHWs were introduced as a result of the COVID-19 related additional work or risks[ 15 ]. Despite these additional financial incentives, gaps existed with regard to the provision of incentives resulting into disrupting of routine service delivery[ 15 ]. In India for example, the CHWs were unaware of these additional incentives while incentives were not paid in other cases [ 15 ]. Further, there was variation between CHW cadres in India resulting into some CHWs being demotivated, and others going on strike due to lack of incentives for COVID-19 [ 15 ]. In Ethiopia, CHWs spent additional money out of their own pocket to provide services during COVID-19, without compensation[ 15 ]. In Nigeria, the lack of transportation among CHWs in rural areas during the lockdown affected their ability to perform services [ 20 ]. The precarious remuneration of CHWs affected their ability to deliver services in India [ 15 , 28 , 30 , 31 ]. The lack of training for CHWs during the COVID-19 response The type and level of COVID-19 training provided to CHWs varied, was not always adequate, regular, and appropriate [ 29 ]. In Brazil, for example, it was reported that although CHWs’ roles in fighting the pandemic were essential, early response and capacity building focused mostly on the frontline health workers, leaving out the CHWs. Thus, CHWs were not initially oriented on their pandemic control action roles, and much less was done to safeguard them against COVID-19 while performing these roles in the community [ 13 ]. Given that health workers are much fewer than the CHWs, this was noted as a missed opportunity during initial response [ 32 ]. Inadequate infection prevention and control preparedness In the beginning of the pandemic, the most important dilemma faced by CHWs in Kenya and Thailand was a mismatch between what needed to be done to prevent the outbreak and the availability of resources [ 33 ]. All CHWs in Kenya and Thailand reported that even with the government’s non-pharmaceutical intervention guidance, no resources and equipment were available for them. When the national governments in Kenya and Thailand made it compulsory to wear masks in public, shortages of face masks and N95 respirator masks followed. Funding for personal protective equipment and related materials, such as face masks, soaps, and hand sanitizers, was a challenging problem for CHWs in Kenya [ 33 ]. The national and county governments in Kenya did not provide sufficient resources for CHWs to work with[ 33 ]. In Rwanda, lack of personal protective equipment coupled with inadequate COVID-specific training and increased workload affected the ability by CHWs to deliver services during the COVID-19 pandemic [ 34 ]. Relatedly the lack of appropriate low risk technology to use when conducting health education during the pandemic was noted [ 35 ]. Given the highly infectious nature of the COVID 19, the lack of tools and systems through which CHWs could use to continue providing health education with minimal contact with community affected CHWs’ ability to deliver health messages [ 36 ]. In cases where tools and systems (mHealth) existed, limited knowledge and capacity affected the CHWs abilities to use them [ 22 , 36 ]. Limited supportive policies The challenges of limited guidelines to support CHW participation in COVID- 19 prevention services were evident at the beginning of the pandemic[ 33 ]. COVID − 19 was novel, dynamic and unfolded fast, which made it even more difficult for policy makers to craft appropriate and responsive policies fast enough [ 33 ]. In Kenya and Thailand, the CHWs highlighted the ambiguity and uncertainty of the policy environment [ 33 ]. In Thailand, India, Bangladesh, Pakistan, Sierra Leone, Kenya and Ethiopia, there were no clear policy guidelines with regard to roles of CHWs in preventing COVID 19, making COVID − 19 referrals, participation in supporting vaccination as well as accessibility to COVID 19 prevention materials difficult [ 33 ]. Lack of such guidelines affected the ability of CHWs to effectively deliver primary health care including health promotion and education activities, surveillance, contact tracing and quarantine, and maintaining essential health services [ 33 ]. Interestingly, the CHWs from Kenya also noted that despite the lack of guidelines at the start of the pandemic, the need for action at community level made them relay on the protocols used during the Ebola epidemic and attempted to do the best they could to prevent the outbreak in their communities[ 33 ]. Strategies for enhancing the performance of CHWs during COVID Harnessing digital technology (mHealth) Harnessing digital technology (mHealth) to support CHWs in the Covid-19 response could enhance the performance of CHWs in addressing the pandemic [ 35 ]. The technology can include the use of short message service (SMS) and voice message for health education, digital megaphones for encouraging behaviour change, digital contact tracing and facilitating case recording as well as use of mHealth for CHW education, training and supervision [ 35 , 36 ]. One platform that CHWs can access information through their mobile phones is the WHO COVID-19 online training resource. CHWs in Uganda and Ghana for example established collaborative groups via mobile-messaging apps, such as WhatsApp [ 35 , 36 ]. It should be noted, however, that more work needs to be done to increase overall feasibility and acceptability of digital tools for CHWs, as they are sometimes not adequately trained, and may face other challenges such as weak technical support and poor internet connectivity [ 22 ]. Despite these limitations, countries such as Uganda and Ethiopia have been successful in using digital platforms and best practices can be learnt from these examples, especially for future pandemic response [ 35 , 36 ]. Training for CHWs in pandemic response In Brazil and India, the need for organised health education and orientation as initial pandemic response was noted, accompanied by culturally accessible communication mechanisms were seen as necessary in fighting the COVID-19 and future pandemics [ 37 ]. Boyce et al, also add that given that most emerging infectious diseases are zoonotic in origin, training and using CHWs to communicate one health information to at-risk communities prior to outbreaks may enhance future pandemic preparedness[ 30 , 38 ]. Health information management: collection and dissemination While health information dissemination is viewed as one major gap that CHWs can fill, as was seen in Bangladesh, their contact with the community members also provides opportunities to collect contextually driven misinformation and misconceptions from the public that can be targeted directly with health messaging [ 32 ]. The COVID-19 pandemic experience showed the importance of properly managing information, and CHWs can play a role in correction of myths and misconceptions, while disseminating correct and accurate information to communities [ 38 ]. Wellness and safeguarding CHWs While it is noted that CHWs can help in servicing and protecting vulnerable populations, especially in times of crisis, it should be mentioned that their health and wellbeing was also under threat, due to lack of motivation, remuneration and protection against the pandemic [ 33 ]. It is therefore important to implement wellness programs for CHWs including adequate and quality protective equipment [ 33 ]. To adequately undertake these strategies, there is need to develop supportive policies and regulation that recognize the role of CHWs in addressing the COVID- 19 pandemic[ 38 ]. These could include pooling CHWs into a reserve health corps to be used during public health emergencies, and formalizing agreements and strategies to promote the early engagement of CHWs in response actions[ 38 ]. Further CHWs just like other healthcare providers could have been prioritized for earlier vaccination access during COVID-19. And as noted earlier, prioritized for regular training in keeping with the evolving nature of pandemics such COVID-19. In addition, providing adequate institutional support could enhance bonds of trust between CHWs and the community and also promote resilient community health systems during public health crises[ 23 ]. Discussion We observe that CHWs played many roles in the COVID-19 response. The roles included being mobilizers, role models, and health promoters for behavioural change, providers of essential service and surveillance personnel. The CHWs provide valuable support to health systems during pandemics as they have some unique capabilities which some formal health workers might not have. For example, as trusted and valued members of the community, CHWs can easily navigate through the community, help address myths and misconceptions regarding the pandemic as well as successfully manage referrals. Historical experience indicates that community actors have for example played a key role in promoting sensitive health messages such as vaccine acceptance across the globe during pandemics[ 39 , 40 ]. Indeed, the involvement of CHWs in promoting community acceptance of vaccines is vital [ 40 ], through advocating for and countering the widespread scepticism with accurate information [ 4 , 41 , 42 ]. We note that through performing these roles, CHWs could contribute towards equitable universal primary health care during pandemics [ 39 , 40 ]. Especially given their unique capabilities to facilitate health promotion and delivery of services and information to remote areas [ 40 ]. For example, being situated within their communities, their health services are easily trusted by the communities they serve [ 4 , 41 , 42 ]. Trust is an important capability that CHWs can leverage on to address mistrusts and misconceptions associated with pandemics [ 4 , 41 , 42 ]. Additionally, given that CHWs are selected by community leaders, they tend to enjoy support from these leaders [ 43 , 44 ]. This support creates legitimacy of CHW services which is vital in enhancing acceptance of primary health care services during pandemics [ 43 , 44 ]. Further, support from traditional leaders makes it possible for CHWs to easily integrate their messages within the community or traditional leadership communication systems [ 45 ]. A combination of CHW trust and community leadership support during the pandemics can simultaneously contribute to building resilient community health systems [ 46 ]. We note that nurturing such trust could further trigger a sense of community and common responsibility, which according to WHO was critical in the fight against COVID-19 [ 47 ]. Against a reality of present and future “infodemics”, we thus suggest that effective use of community actors will be critical in enhancing the benefits of a multifaceted approach to communicating behavioural change messages for the COVID-19, and future pandemics, as well as maintaining the delivery and accessibility to primary health care services[ 32 , 33 ]. We have also documented that performing these roles was met with challenges [ 18 ]. These challenges included, ambiguity and stigma from the community members, the lack of adequate training, inadequate infection prevention and control preparedness, lack of supplies and commodities, limited supportive policies and inadequate remuneration and incentives [ 18 ]. These challenges affected their performance by exposing them to infection risks, limiting their coverage and capacity to deliver information and services[ 18 ]. While some of the challenge such as COVID − 19 related stigma and discrimination by community members and lack of enough infection prevention and control preparedness were new, others such as inadequate incentives are historical challenges that health system have continuously grappled with[ 18 ]. These historical challenges are largely due inadequate prioritisation and integration of CHW incentives into the health systems[ 48 ]. The stress that the COVID-19 pandemic put on the health system worsened this situation as CHWs had to work even more to support health systems responsiveness to the COVID − 19 challenges. Competing health needs made some health systems to neglect CHW financial incentives [ 15 ]. We therefore agree with others that addressing these challenges will require integrating standardised incentives for CHWs within the national budget in line with WHO recommendations[ 49 ]. The WHO recommends that Governments should provide a financial package that corresponds to CHW job demands, complexity, and number of hours worked, training, and the roles they undertake[ 48 ]. We are agree with others that it is important that CHWs are not viewed as panacea for weak health systems[ 50 ]. Overall there has been an increased call for health systems in LIMICs to invest in CHWs if health systems are to effectively respond to pandemics such as the COVID – 19 pandemic as well as maintain delivery of essential primary health care during pandemics [ 48 ]. Similar challenges and investments have been noted and called for respectively in high-income settings where volunteers (part of community health systems) were used to support efforts in the fight against COVID-19, such as in Canada [ 51 ]. This underscores the critical role that community health systems play in supporting the formal health system not just in pandemics but in everyday service delivery efforts too[ 8 ]. Regarding the new challenges that CHWs experiences, it is important that CHW health systems integrate innovative approaches to addressing the COVID − 19 pandemic and similar pandemic in CHW training and work performance [ 52 ]. For example to address the challenge of lack of appropriate low risk technology to use when conducting health education, health systems should consider adopting use of mhealth tools to support health promotion activities, monitoring and reporting uptake of services [ 52 ]. The mhealth tools are vital for enhancing, professionalism, quality and performance, and scaling up of health services given mobility restrictions associated with pandemics[ 52 ]. To address ambiguity and uncertainty of the policy environment regarding the roles of CHWs, as well as accessibility to COVID 19 prevention materials, policy makers need to adapt CHWs programmes to local needs through undertaking national consultative CHW policy development processes[ 53 ]. Further, it is important to consider evolving mechanisms for governing programs in the contexts of pandemics [ 53 ]. For example, policies should prioritize CHWs in receiving the COVID-19 vaccine, and periodically train CHWs in preventive measures of the COVID-19 response [ 49 ]. Its however important to note that the COVID-19 policy landscape across the world was volatile given the novel, dynamic and fast paced nature of COVID-19 (ref). Being responsive and staying balanced and providing consistent messaging to ensure that communities and support systems such community health workers continue to operate without creating unintended consequences such as demoralizing workers amidst dynamic situations is difficult but critical[ 54 ]. Strengths and limitations One main strength of the scoping review lies in the extensive search of the literature on the role of the CHWs in the response against COVID-19. The inclusion of papers utilizing different methodological approaches from different parts of the world on COVID − 19, including mixed-methods papers and reviews, provided in-depth insights into roles, challenges, and strategies for enhancing the performance of CHWs in the response against COVID-19. One of the limitations of this scoping review, was the possibility of missing out some publications. We tried to mitigate this by conducting several searches, and searching the references of publications that we included in the review. Conclusion We observed that there is general evidence that support that CHWs are critical community actors and were integral members of the health system during the COVID-19 pandemic. The engagement of community actors as critical trusted messengers in the COVID − 19-prevention process seems to have been necessary in building sustainable and resilient community-based response against COVID-19 and other infectious diseases through promoting community level behavioural change. Specific roles performed by CHWs during the pandemic included conducting health promotion and education tasks, surveillance, contact tracing and quarantine, maintaining essential primary health services, linking people to services through referrals, advocating for clients and communities and supporting the vaccination rollout process. While CHWs have performed many important roles, they also experienced many challenges which affected their performance. Some CHWs were stigmatised and discriminated by community members, lacked enough infection prevention and control preparedness, had inadequate incentives as well as supplies and commodities. Addressing these challenges requires investments that will ensure greater support for the integration of CHWs into health systems as this could also ultimately contribute to maintaining the credibility and sustainment of CHW programs. There is also needed to adopt new innovative approaches such as the use of mhealth tools to support performance and supervision of CHWs in delivering pandemic related services as well as maintaining routine primary health care. It is also important to prioritize CHWs in receiving the COVID-19 vaccine, and periodically training CHWs in preventive measures of the COVID-19 response. We recommend that future studies assess the degree of success in prevention of COVID-19 in countries that will have strongly implemented community engagement strategies in preventing and managing COVID-19. Declarations The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions, or policies of the institutions with which they are affiliated. At the time of submission, Joseph M Zulu was a Guest Editor for the special issue on the role of community health workers in primary care in this journal. All publication related decisions for this manuscript were made by a different editor. Ethics approval and consent to participate Not applicable Consent for publication Not applicable Availability of data and material Not applicable Competing interests The authors declare that they have no competing interests. Joseph M Zulu was a Guest Editors for this special issue at the time of submission. All decisions on this manuscript were made by another Guest Editors. Funding No funding was received for this study Authors’ contributions J.M.Z., M.T., C.M.U., C.M.I., and N.S. conceived and designed the review. 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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-3851192","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":266850344,"identity":"edf7397f-56a2-4800-81f7-77b3527435d0","order_by":0,"name":"Joseph Mumba Zulu","email":"","orcid":"","institution":"University of Zambia","correspondingAuthor":false,"prefix":"","firstName":"Joseph","middleName":"Mumba","lastName":"Zulu","suffix":""},{"id":266850345,"identity":"4887b204-726e-41ce-a9f4-bbd8d01919b5","order_by":1,"name":"Adam 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Sciences","correspondingAuthor":false,"prefix":"","firstName":"Nathanael","middleName":"","lastName":"Sirili","suffix":""},{"id":266850350,"identity":"b0618147-7f56-452b-9cbc-393326f4c68d","order_by":6,"name":"Wanga Zulu","email":"","orcid":"","institution":"University of Zambia","correspondingAuthor":false,"prefix":"","firstName":"Wanga","middleName":"","lastName":"Zulu","suffix":""},{"id":266850351,"identity":"938bea8f-7606-4f54-82b0-137c682e53da","order_by":7,"name":"Charles Michelo","email":"","orcid":"","institution":"Nkwazi Research University","correspondingAuthor":false,"prefix":"","firstName":"Charles","middleName":"","lastName":"Michelo","suffix":""},{"id":266850352,"identity":"8ca9cf45-cdb8-4baf-bb63-7a6cbe5ca992","order_by":8,"name":"Moses Tetui","email":"","orcid":"","institution":"Umeå University","correspondingAuthor":false,"prefix":"","firstName":"Moses","middleName":"","lastName":"Tetui","suffix":""}],"badges":[],"createdAt":"2024-01-10 18:44:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3851192/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3851192/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12875-025-02853-7","type":"published","date":"2025-05-14T15:57:33+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":49663821,"identity":"0f98a867-a314-4bf9-8d0d-b825b669414a","added_by":"auto","created_at":"2024-01-16 06:32:57","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":24490,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA Flow Diagram of the scoping review\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-3851192/v1/362f90b7d1d8988b5d1dbd39.png"},{"id":83067809,"identity":"4d5adcc8-5905-49aa-a8b1-7dbf7b18ee5b","added_by":"auto","created_at":"2025-05-19 16:06:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2323849,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3851192/v1/0639c7b1-0db9-420a-b703-3c39c12ff6f8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A scoping review of the roles, challenges, and strategies for enhancing the performance of community health workers in the response against COVID-19 in low- and middle-income countries","fulltext":[{"header":"Background","content":"\u003cp\u003eThe importance of community health workers (CHWs) in providing integrated, quality and people-cantered primary healthcare is widely recognized[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Over the last decades, low and middle income countries (LMICs) have recorded various health gains, attributable to the contributions of CHWs [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Many LMICs continue to rely on CHWs to achieve effective delivery of maternal, new born, child health, malaria and HIV/AIDS interventions, especially among marginalized and hard to reach populations [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The use of CHWs is not unique to LMICs only, as high-income countries such as Sweden have also reported the engagement of CHWs to activate virtual health rooms for rural communities. In the USA and Australia, the use of CHWs in dealing with high-risk group behavioural change has equally been reported [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The collective use of community resources, including CHWs, to create better health for all has been coined as \u0026lsquo;reactivating the community health systems\u0026rsquo; [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. A community health system (CHS) is defined as \u0026ldquo;\u003cem\u003ea set of local actors, relationships, and processes engaged in producing, advocating for, and supporting health in communities, but existing in relationship to established health structures\u003c/em\u003e\u0026rdquo; [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Indeed, calls for strengthening the conceptual linkages between the formal health system and the community health system are building up as demonstrated in a recent research agenda on CHS [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe focus on CHSs in the era of COVID-19 is of paramount importance as reflected in the Policy Brief issued by the World Health Organisation (WHO) on 1st April 2020, which outlined 16 recommendations for strengthening health system response to COVID-19 [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In this brief, it was stated that the early experience in countries with large-scale community transmission showed that COVID-19 required unprecedented mobilization of health systems. The first recommendation was for health systems to consider an expansion of their capacity to communicate COVID-19-related information, and proactively manage the flow of this information. The use of CHWs to supplement such communication of information was warranted, and critical to tackle the widespread misinformation on COVID-19 that quickly created another battlefield, referred to as the COVID-19 \u0026lsquo;infodemic\u0026rsquo; by the WHO chief [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA publication in the Lancet called for development of a large-scale emergency programme to train community CHWs on how to respond to the COVID-19 pandemic [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBallard et al., also add that given that COVID-19 disproportionately affects the poor and vulnerable, CHWs played a pivotal role in fighting the pandemic, especially in countries with less resilient health systems[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. It has been suggested that investment in community health systems is vital in averting and managing COVID-19, and subsequent similar emergent crises [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. CHWs matter and are at the centre of community health because they are trusted members of the community who are often the most accessible point of care[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Investment in community health systems will help achieve the following pandemic control goals: protect healthcare workers, interrupt the virus, maintain existing healthcare services while surging their capacity, and shield the most vulnerable from socioeconomic shocks [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile it has been recognised that CHWs play a vital role in addressing the COVID- 19 pandemic, evidence suggests that despite their position within communities, they were not provided clear guidance about their role in the pandemic response. A publication about CHWs\u0026rsquo; experiences during COVID-19 in India, Bangladesh, Pakistan, Sierra Leone, Kenya and Ethiopia showed that overall, support towards CHWs in responding to the COVID \u0026minus;\u0026thinsp;19 pandemic varied between countries and among different CHWs [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. They were significant gaps including disruption of medical supply chains, high workloads, leaving CHWs vulnerable to infection and stress [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Some countries such as Brazil published contradictory recommendations on community engagement[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough there is policy guidance to involve community health workers in the COVID-19 response, clear indication of what specific roles, responsibilities, challenges, and support systems should be addressed to ensue resilient community health systems during COVID-19 and other future infectious pandemics is inadequate[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. We aimed to synthesize literature on the roles and challenges that community health workers (CHWs) experienced in the fight against COVID-19 and propose strategies to address the challenges.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n\u003ch2\u003eThe Search Strategy\u003c/h2\u003e\n\u003cp\u003eWe systematically searched the databases including PubMed, HINARI, Cochrane Library (Reviews and Trials), Science Direct and Google Scholar. The review targeted literature on the roles, responsibilities, and challenges that community health workers (CHWs) experienced in the fight against COVID-19, as well as strategies and supportive structures for addressing the stated challenges. To ensure that we did not omit important literature, we used varied terms for CHW (e.g. \u0026lsquo;community health worker*\u0026rsquo; and alternate terms for \u0026lsquo;CHWs\u0026rsquo;) and COVID \u0026minus;\u0026thinsp;19\u0026rdquo; and \u0026ldquo;COVID \u0026minus;\u0026thinsp;19 Vaccine\u0026rdquo; We used the alternative names for CHWs as outlined in a systematic review of definitions of CHWs (Accredited social health activist; Lady health worker; Community health advisor; Patient navigator; Lay health worker; Community-based health provider; Peer educator; Community health representative; Care facilitator; Community health agent; Community-based reproductive health agent; Auxiliary nurse midwife; Village health worker; Health extension worker; Lay health promoter; Care guide; Peer health advisor; Community health development agent; Community health promoter; Lay health educator; Community-based health worker; Community health coach; Village health volunteer; Community midwife; Community health assistant; Community-based educator; and Health surveillance assistant) [\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e] .\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n\u003ch2\u003eInclusion and Exclusion Criteria\u003c/h2\u003e\n\u003cp\u003eTo ensure inclusion of relevant, high-quality papers in this review, our inclusion criteria for documents comprised: peer-reviewed publications and reports/guidelines from WHO and United Nations Organizations on the study topic. Studies had to have been conducted between December 2019 and January July 2023. We included papers from 2019 as this was the period when the pandemic started. Considering that this is a scoping review, we included papers with different study designs including qualitative, quantitative, mixed-methods, reviews, and CHW program evaluations, reports as well as commentaries. Papers on the COVID-19 pandemic that did not discuss CHW roles, challenges, and strategies for enhancing the performance of CHWs\u0026rsquo; in the response against COVID-19 were excluded from the review. Papers on CHWs and the COVID \u0026minus;\u0026thinsp;19 from high income countries were also excluded from the scoping review.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n\u003ch2\u003eStudy Selection and Quality Assessment\u003c/h2\u003e\n\u003cp\u003eWe followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines in selecting the studies (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cspan class=\"Underline\"\u003e)\u003c/span\u003e [\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e]. In accordance with the guidelines, we first excluded all duplicates 259 from the 894 search outcomes initially identified. Then we reviewed all the titles of the remaining 635 research, of which we excluded 512 because they focused either on the wrong topic or region or both. We then remained with 123 outcomes. Subsequently we retrieved and assessed the abstracts of the \u0026minus;\u0026thinsp;123 papers, of which we excluded 85 because they did not address the subject of roles, challenges, or strategies for improving the performance of CHWs in preventing and managing the COVID \u0026minus;\u0026thinsp;19. Finally, we retrieved 38 full-length papers that were shortlisted after abstract review, to screen them in accordance with the inclusion criteria. At this stage, we also subjected the papers to the main elements of the Critical Appraisal Skills Programme (CASP) quality assessment that has been used to appraise studies, and especially those that use qualitative approaches. This process resulted into the final 25 papers that were considered for final analysis (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable\u0026nbsp;1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eKey thematic categories from the literature\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eMain Themes\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eSub-themes\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"4\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eRoles for community health workers\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHealth promotions and education\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAssisting with surveillance\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMaintaining essential health services\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSupport planning and coordination of vaccination\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"5\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eThe challenges faced by CHWs during the COVID-19 response.\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eStigma and discrimination\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLimited incentives\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe lack of training for CHWs during the COVID-19 response\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eInadequate infection prevention and control preparedness\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLimited supportive policies\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"4\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eStrategies for enhancing the performance of CHWs during COVID\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHarnessing digital technology (mHealth)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTraining for CHWs in pandemic response\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHealth information management: collection and dissemination\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eWellness and safeguarding CHWs\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\n\u003cp\u003e\u003cstrong\u003eTable 2:\u003c/strong\u003e Study characteristics: A scoping review of the roles, challenges, and strategies for enhancing the performance of community health workers in the response against COVID-19 in low-and middle-income countries.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Taba\" border=\"1\"\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e1st Author/\u003c/p\u003e\n\u003cp\u003eyear/\u003c/p\u003e\n\u003cp\u003ecountry\u003c/p\u003e\n\u003cp\u003e[citation]\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eStudy type/design\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eStudy title/aim\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eStudy participants/\u003c/p\u003e\n\u003cp\u003ePrimary source of information\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eKey issues/findings\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\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLotta G, et al.,\u003c/p\u003e\n\u003cp\u003e(2021)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDocument Review\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThis paper analyses how the Brazilian government regulated the reorganization of Primary Health Care (PHC) and how FLW responded to these initiatives, comparing the roles played by nurses and community health workers.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDocuments\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e▪ Given the multilevel health system, it was expected that the high level of ambiguity would stimulate innovations.\u003c/p\u003e\n\u003cp\u003e▪ However, data show that the ambiguity created different situations for each profession.\u003c/p\u003e\n\u003cp\u003e▪ While nurses were able to adapt their work and act with more autonomy, CHW lost their role in the policy.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBallard et al., (2020)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePrioritising the role of community health workers in the COVID-19 response.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e▪ Community health workers (CHWs) are poised to play a pivotal role in fighting the pandemic, especially in low-income countries with vulnerable health systems.\u003c/p\u003e\n\u003cp\u003e▪ The COVID-19 response must build on existing platforms, infrastructure, and relationships where are possible; the focus should be on supporting the Ministries of Health and regional authorities as they lead coordinated responses.\u003c/p\u003e\n\u003cp\u003e▪ achieving these goals will require targeted actions at different stages of the pandemic. These actions are delineated in the article.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMayfield-Johnson et al.,\u003c/p\u003e\n\u003cp\u003e(2020)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eQualitative study\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThis study aimed at assessing the effect of the COVID-19-related lockdown on Tunisian women\u0026rsquo;s mental health and gender-based violence\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFemale-exclusive social group on Facebook\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e▪ A focus group with CHW leaders from 7 states revealed 8 major themes: CHW identity, CHW resiliency, self-care, unintended positives outcomes of COVID-19, technology, resources, stressors, and consequences of COVID-19.\u003c/p\u003e\n\u003cp\u003e▪ Understanding the pandemic's impact on CHWs has implications for workforce development, training, and health policies.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAjisegiri, et al., (2020)\u003c/p\u003e\n\u003cp\u003eNigeria\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003em\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCOVID-19 Outbreak Situation in Nigeria and the Need for Effective Engagement of Community Health Workers for Epidemic Response\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e▪ We recommended that the government needs to promptly bring community health workers on board, deploy rapid epidemic intelligence and scale up the use of mobile Apps for contact tracing.\u003c/p\u003e\n\u003cp\u003e▪ This will result in an effective and coordinated response to the ongoing outbreak, sustain routine health services especially at the community level.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBezbaruah et al.,\u003c/p\u003e\n\u003cp\u003e(2021)\u003c/p\u003e\n\u003cp\u003eSouth-East Asia\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eQualitative study\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRoles of community health workers in advancing health security and resilient health systems: emerging lessons from the COVID-19 response in the South-East Asia Region\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eReview journal articles, policy documents, national guidelines, reports, and online publications\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e▪ The regular role of a CHW in health education and promotion focused on awareness-raising and the promotion of \u0026ldquo;new normal\u0026rdquo; behaviours; CHWs also played critical roles in assisting in surveillance and contact tracing, and in ensuring that people followed isolation and quarantine guidelines.\u003c/p\u003e\n\u003cp\u003e▪ Development and implementation of long-term plans across the region to strengthen and support CHWs and recognize CHWs as an integral component of resilient health systems.\u003c/p\u003e\n\u003cp\u003e▪ Planning for CHWs as part of the primary health care system will enable local authorities to ensure that an adequate level of resources (including capacity-building, incentives, necessary equipment, and consumables) is allocated to CHWs.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMistry et al. (2021)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eQualitative study\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCommunity health workers can provide psychosocial support to the people during COVID-19 and beyond in low-and middle-income countries. Frontiers in Public Health\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDocuments\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e▪ The CHWs can be effectively engaged to provide psychosocial support at the community level. Engaging them can also be cost saving as they are already in place and may cost less compared to other health professionals. However, they need training and supervision and their safety and security need to be protected during this COVID-19.\u003c/p\u003e\n\u003cp\u003e▪ While many LMICs have mental health policies but their enactment is limited due to the fragility of health systems and limited health care resources.\u003c/p\u003e\n\u003cp\u003e▪ CHWs can contribute in this regard and help to address the psychosocial vulnerabilities of affected population in LMICs during COVID-19 and beyond.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRoy et al., (2020)\u003c/p\u003e\n\u003cp\u003eBangladesh\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMixed methods\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eExamining Roles, Support, and Experiences of Community Health Workers During the COVID-19 Pandemic in Bangladesh.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePolicy makers, program managers, CHW supervisors, and CHWs.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e▪ During the first wave of the coronavirus disease (COVID-19) pandemic in Bangladesh, across all health areas, community health workers (CHWs) described a slight decrease in the routine services they were able to provide due to restrictions in movement posed by lockdowns and other challenges.\u003c/p\u003e\n\u003cp\u003e▪ The government and various nongovernmental organizations provided supportive mechanisms to CHWs through training, supplies, and supportive supervision; however, these supports were not always uniformly distributed across cadres, leading to some discontent among CHWs.\u003c/p\u003e\n\u003cp\u003e▪ CHWs were crucial actors in the government\u0026rsquo;s COVID-19 response, as they took on new pandemic-related responsibilities in their communities to prevent the spread of the disease while continuing their routine work.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFernandez et al., (2020)\u003c/p\u003e\n\u003cp\u003eBrazil\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eQuantitative\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHow community health workers are facing COVID-19 pandemic in Brazil: personal feelings, access to resources and working process. Archive of Family Medicine and General Practice.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOnline Survey\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e▪ HWs feel scared and unprepared in the face of the COVID-19 pandemic. The fear of COVID-19 is related to being prepared and to receiving support from federal government. The feeling of preparedness is associated with the lack of\u003c/p\u003e\n\u003cp\u003e▪ material working conditions, such as PPEs, guidance from managers and support from superiors and federal government.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNepomnyashchiy et al.,\u003c/p\u003e\n\u003cp\u003e(2020)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eQualitative study\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAfrica needs unprecedented attention to strengthen community health systems.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e▪ CHWs matter because they are trusted members of the community who are often the most accessible point of care.\u003c/p\u003e\n\u003cp\u003e▪ Ongoing efforts to leverage CHWs for the COVID-19 response must not be one-offs in the face of an emergency. CHWs must be equipped, trained, and supported in the long term as a crucial human resource for health.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFernanda et al.,\u003c/p\u003e\n\u003cp\u003e(2020)\u003c/p\u003e\n\u003cp\u003eSouth Africa\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eQualitative study\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCommunity health workers: reflections on the health work process in Covid-19 pandemic times.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLiterature review\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e▪ CHW work, especially cultural competence, and community orientation, aiming to discuss the changes introduced in this work regarding the following aspects: 1) health teams support, 2) use of telehealth, and 3) health education.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eChitungo et al., (2021)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eA rapid review\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eUtility of telemedicine in sub-Saharan Africa during the COVID‐19 pandemic. A rapid review. Human behavior and emerging technologies.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eA rapid review\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e▪ Challenges to the implementation of telemedicine on the continent were lack of supporting telemedicine framework and policies, digital barriers, and patient and healthcare personnel biases.\u003c/p\u003e\n\u003cp\u003e▪ Telemedicine use by all stakeholders, including medical insurance organizations, the introduction of telemedicine training of medical workers, educational awareness programs for the public, and improvement of digital platforms access and affordability.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eKaseje et al., (2020)\u003c/p\u003e\n\u003cp\u003eKenya\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eQuantitative and qualitative methods\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEngaging community health workers, technology, and youth in the COVID-19 response with concurrent critical care capacity building: A protocol for an integrated community and health system intervention to reduce mortality related to COVID-19 infection in Western Kenya\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e▪ the intervention will consist of training youth, community health assistants and community health workers in screening, case detection, prevention, management, and referral of COVID-19 cases with maintenance of essential health services.\u003c/p\u003e\n\u003cp\u003e▪ The community intervention will be enhanced by youth and use of digital tools.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFeroz et al,. (2021)\u003c/p\u003e\n\u003cp\u003eLMICs\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEquipping community health workers with digital tools for pandemic response in LMICs\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e▪ CHWs are playing a huge role in providing essential health care services and Covid-19 related healthcare to the communities.\u003c/p\u003e\n\u003cp\u003e▪ CHWs are overburdened as they are expected to accomplish more although they are not getting the required support to perform their duties well, such as training, remuneration, protective gear, etc.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBhaumik et al.,\u003c/p\u003e\n\u003cp\u003e(2020)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSystematic review\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCommunity health workers for pandemic response: a rapid evidence synthesis.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eArticles\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e▪ CHW roles and tasks change substantially during pandemics. Clear guidance, training for changed roles and definition of what constitutes essential activities (i.e., those that must be sustained) is required.\u003c/p\u003e\n\u003cp\u003e▪ Most common additional activities during pandemics were community awareness, engagement, and sensitisation (including for countering stigma) and contact tracing.\u003c/p\u003e\n\u003cp\u003e▪ CHWs were reported to be involved in all aspects of contact tracing - this was reported to affect routine service delivery. CHWs have often been stigmatised or been socially ostracised during pandemics.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBoyce et al.,\u003c/p\u003e\n\u003cp\u003e(2020)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCommunity Health Workers and Pandemic Preparedness: Current and Prospective Roles\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e▪ CHWs promoted pandemic preparedness by acting as community-level educators and mobilizers, contributing to surveillance systems, and filling health service gaps. Acknowledging the success CHWs have had in these roles and in previous interventions, we propose that the cadre may be better engaged in pandemic preparedness in the future.\u003c/p\u003e\n\u003cp\u003e▪ Some practical strategies for achieving this include training and using CHWs to communicate One Health information to at-risk communities prior to outbreaks, pooling them into a reserve health corps to be used during public health emergencies, and formalizing agreements and strategies to promote the early engagement of CHWs in response actions.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e16\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSudhipongpracha et al., (2020)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eQualitative study\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCommunity health workers as street-level quasi-bureaucrats in the COVID-19 Pandemic: The cases of Kenya and Thailand. Journal of Comparative Policy Analysis: Research and Practice..\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLiterature review\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e▪ Findings show that how a public health system is organized (decentralization versus centralization) affects CHWs\u0026rsquo; initial responses to the outbreak.\u003c/p\u003e\n\u003cp\u003e▪ While CHWs in Thailand\u0026rsquo;s centralized system conform to the \u0026ldquo;state agent\u0026rdquo; tradition by referring to the hierarchical chain of command, those in Kenya\u0026rsquo;s decentralized system follow the \u0026ldquo;citizen agent\u0026rdquo; tradition by prioritizing community safety.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e17\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eJalali, F., Fischer, H., \u0026amp; Nichols, C. (2022).\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMixed methods\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCorona warriors\u0026rdquo;? Experiences of India's community health workers (ASHAs) in India's COVID-19 response.\u0026nbsp;\u003cem\u003ePolitical Geography\u003c/em\u003e,\u0026nbsp;\u003cem\u003e99\u003c/em\u003e.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCHWs\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e▪ CHWs (ASHAs) were both proud \u0026lsquo;warriors\u0026rsquo; and compelled to work due to the risk of letting down their community.\u003c/p\u003e\n\u003cp\u003e▪ While many CHWs felt deep fear and that they were ill-prepared-\u003c/p\u003e\n\u003cp\u003e▪ CHWs reported their sacrifices made both to their own personal health as well as their families, while expressing\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNiyigena, A., Girukubonye, I., Barnhart, D. A., Cubaka, V. K., Niyigena, P. C., Nshunguyabahizi, M., ... \u0026amp; Bitalabeho, F. A. (2022).\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMixed-method study\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRwanda\u0026rsquo;s community health workers at the front line: a mixed-method study on perceived needs and challenges for community-based healthcare delivery during COVID-19 pandemic.\u0026nbsp;\u003cem\u003eBMJ open\u003c/em\u003e,\u0026nbsp;\u003cem\u003e12\u003c/em\u003e(4), e055119.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e▪ supervision during the lockdown was low.\u003c/p\u003e\n\u003cp\u003e▪ CHWs additionally described increases in workload, lack of personal protective equipment and COVID-specific training, fear of COVID-19, and difficult working conditions.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e19\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSripad, P., Gottert, A., Abuya, T., Casseus, A., Hossain, S., Agarwal, S., \u0026amp; Warren, C. E. (2022).\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThis mixed methods\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eConfirming\u0026mdash;and testing\u0026mdash;bonds of trust: A mixed methods study exploring community health workers\u0026rsquo; experiences during the COVID-19 pandemic in Bangladesh, Haiti and Kenya. PLOS global public health, 2(10), e0000595.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCHWs\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e▪ CHWs reported high levels of community trust (8/10 in Bangladesh and Kenya; 6/10 in Haiti).\u003c/p\u003e\n\u003cp\u003e▪ with over 60% reporting client relief in seeing their CHWs.\u003c/p\u003e\n\u003cp\u003e▪ CHWs reporting more positive and fewer negative experiences is consistently associated with continuing routine work, doing COVID-19-related work, and greater community trust. Qualitative interviews showed that CHW-community and CHW-health system actor trust is strengthened when CHWs are well-resourced.\u003c/p\u003e\n\u003cp\u003e▪ CHW-community trust is strained by public frustration at the pandemic, associated restrictions, and socio-political stressors.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e20\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDhaliwal, B. K., Singh, S., Sullivan, L., Banerjee, P., Seth, R., Sengupta, P., ... \u0026amp; Shet, A. (2021).\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRapid qualitative evaluation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLove, labor and loss on the frontlines: India\u0026rsquo;s community health workers straddle life and the COVID-19 pandemic.\u0026nbsp;\u003cem\u003eJournal of global health\u003c/em\u003e,\u0026nbsp;\u003cem\u003e11\u003c/em\u003e.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCHWs\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e▪ CHWs faced increased workloads, decreased compensation, and stated that their work had shifted to focus on COVID-related work, as opposed to routine care.\u003c/p\u003e\n\u003cp\u003e▪ CHWs also shared that their needs included improved mental health services, financial payment that was not tied to incentives, and consistent access to PPE.\u003c/p\u003e\n\u003cp\u003e▪ CHW experiences through the context of the COVID-19 pandemic have not been well-explored.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e21\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMonreal, T. J., Falc\u0026atilde;o de Oliveira, E., Araujo Ajalla, M. E., Adania Zanoni, D., \u0026amp; Du Bocage Santos-Pinto, C. (2022).\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eA descriptive cross-sectional study\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCommunity health workers and COVID-19 in a Brazilian state capital.\u0026nbsp;\u003cem\u003eSociological Spectrum\u003c/em\u003e,\u0026nbsp;\u003cem\u003e42\u003c/em\u003e(3), 217\u0026ndash;230.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCHWs\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e▪ Around 40% of the sample reported at least one risk factor for COVID-19, 44% had experienced at least one COVID-19 symptom, and 76% had experienced symptoms of mental suffering during the first year of the pandemic. Mental suffering was associated with the onset of flu-like symptoms after the start of the pandemic and changes in work processes. Knowledge gaps were observed, mainly related to forms of transmission and disease prevention. In view of the uncertainty about how long this health emergency will last and the vital role CHWs play in the Brazilian Health System, health managers and society need to pay greater attention to these professionals to improve the effectiveness of the country\u0026rsquo;s COVID-19 response.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e22\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGibson, E., Zameer, M., Alban, R., \u0026amp; Kouwanou, L. M. (2023).\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eA Rapid Review\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCommunity health workers as vaccinators: a rapid review of the global landscape, 2000\u0026ndash;2021. Global Health: Science and Practice, 11(1).\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePeer-reviewed literature\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e▪ Community health worker (CHW) cadres administered vaccines in 20 of the 75 countries with documented CHW programs, improving access to immunization services for under-reached communities.\u003c/p\u003e\n\u003cp\u003e▪ The review identified several countries where CHWs with brief clinical training and experience were taught to vaccinate, suggesting the feasibility of task-shifting administering vaccines to CHWs with limited experience.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e23\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOlateju e al., (2022)..\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003equalitative study\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCommunity health workers experiences and perceptions of working during the COVID-19 pandemic in Lagos, Nigeria\u0026mdash;A qualitative study.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCHWs\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e▪ Trust and COVID-19 knowledge were found to aid Community Health Workers in their work. However, challenges included exhaustion due to an increased workload, public misconceptions about COVID-19, stigmatisation of COVID-19 patients, delayed access to care and lack of transportation.\u003c/p\u003e\n\u003cp\u003e▪ \u003cem\u003eInfluences on willingness to work in COVID-19 Role\u003c/em\u003e: Community Health Workers\u0026rsquo; perceptions of COVID-19, attitudes towards responsibility for COVID-19 risk at work, commitment and faith appeared to increase willingness to work.\u003c/p\u003e\n\u003cp\u003e▪ Financial incentives, provision of adequate personal protective equipment, transportation, and increasing staff numbers were seen as potential strategies to address many of the challenges faced.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e24\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSalve, S., Raven, J., Das, P., Srinivasan, S., Khaled, A., Hayee, M., ... \u0026amp; Gooding, K. (2023).\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSynthesis of evidence\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCommunity health workers and Covid-19: Cross-country evidence on their roles, experiences, challenges and adaptive strategies.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCHWs\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e▪ CHWs made important contributions to the COVID-19 response, including in surveillance, community education, and support for people with COVID-19.\u003c/p\u003e\n\u003cp\u003e▪ There was some support for CHWs\u0026rsquo; work, including training, personal protective equipment, and financial incentives.\u003c/p\u003e\n\u003cp\u003e▪ However, support varied between countries, cadres and individual CHWs, and there were significant gaps, leaving CHWs vulnerable to infection and stress.\u003c/p\u003e\n\u003cp\u003e▪ CHWs also faced a range of other challenges, including health system issues such as disrupted medical supply chains, insufficient staff and high workloads, a particular difficulty for female CHWs who were balancing domestic responsibilities.\u003c/p\u003e\n\u003cp\u003e▪ CHWs demonstrated commitment in adapting their work, for example ensuring patients had adequate drugs in advance of lockdowns and using their own money and time to address increased transport costs and higher workloads.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e25\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eWorld Health Organization. (2021).\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEvidence synthesis\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe role of community health workers in COVID-19 vaccination.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eReports and articles\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e▪ This guide is intended to support national governments in developing their national deployment and vaccination plans (NDVP) for COVID-19 vaccines by outlining the roles, needs and opportunities for community health workers (CHWs) (International Labour Organization, 2007) 1 to contribute.\u003c/p\u003e\n\u003cp\u003e▪ Identifying CHW contributing roles at each stage of COVID-19 vaccines rollout.\u003c/p\u003e\n\u003cp\u003e▪ Counting and vaccinating CHWs within initial vaccine allocation as part of the essential health\u003c/p\u003e\n\u003cp\u003e▪ Workforce to optimally support the COVID-19 response and continuity of essential health services.\u003c/p\u003e\n\u003cp\u003e▪ Recognizing and remunerating CHWs commensurate to tasks undertaken and training.\u003c/p\u003e\n\u003cp\u003e▪ CHWs who are linked to health systems through regular compensation, dedicated supervision and accreditation are best placed to support an effective pandemic response and to prevent the next one.\u003c/p\u003e\n\u003cp\u003e▪ Considering community-based health worker representation on national coordinating committees.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n\u003ch2\u003eData Analysis and Synthesis\u003c/h2\u003e\n\u003cp\u003eWe used thematic analysis, using NVivo 12 Pro Software (QSR international, Melbourne, Australia). The final full articles were downloaded to NVivo and individually coded into various thematic areas. We created a coding structure of broad themes and subcategories to support the coding process. The development of coding framework was informed by the main objective of this study. As such, the coding framework focused on three broad themes namely \u003cstrong\u003eroles\u003c/strong\u003e, \u003cstrong\u003echallenges\u003c/strong\u003e, \u003cem\u003eand\u003c/em\u003e \u003cstrong\u003estrategies\u003c/strong\u003e in the context of community health worker performance in the response against COVID-19 in low- and middle-income countries (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). With these three themes in mind, we read through the abstracts of respective articles to develop a codebook. The codes were discussed by the review team to arrive at the final codes that were used as we reviewed the selected articles. The codebook was then imported into NVivo and where a detailed coding of articles was completed. The coding was conducted by two research team members AS and PMC who regularly met with the entire team to give an update on the process. This was followed by an iterative grouping of codes to identify patterns, that yielded sub-themes under the three earlier on identified themes. The draft sub-themes and themes were shared with all the authors for a discussion to yield a common understanding of what each of the sub-themes and themes represented and linkages therein. Once this process was completed, we maintained the three pre-determined themes and arrived at 12 sub-themes as indicated in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e respectively. This led us to the final stage of drafting the findings and sharing them with all co-authors for review and agreement which led us to the results presented in this article.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eIn this section, we present the results of published data on the involvement of CHWs in the COVID \u0026minus;\u0026thinsp;19 pandemic. We first start by highlighting the roles that CHWs played in the COVID \u0026minus;\u0026thinsp;19 pandemic and then the challenges CHWs faced while performing these roles. The final part of the \u003cspan refid=\"Sec7\" class=\"InternalRef\"\u003eresults\u003c/span\u003e section outlines strategies for enhancing the performance of CHWs during the pandemic period.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eRoles for community health workers\u003c/h2\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003eHealth promotions and education\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eCommunity health workers played a key role in COVID-19 related health promotion and education activities[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In India, Bangladesh, Kenya and Ethiopia, CHWs promoted the acceptability of COVID \u0026minus;\u0026thinsp;19 prevention measures at the community level by first adopting preventive measures themselves for example mask wearing and physical distancing in communities [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Similarly, they also played a critical role in delivering culturally sensitive information to counter practices, social norms and misinformation that could propagate the spread of COVID-19[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. This included disseminating messages that addressed context specific myths such as the view that the COVID-19 virus could not be transmitted in areas with hot and humid climates, mosquito bites could transmit the virus and that the virus only affected certain populations or categories of people in a population [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. This was important given the high levels of misinformation at the global level. Through providing health education on the nature and prevention of COVID- 19, CHWs contributed towards eradicating social stigma or superstitions associated with the disease and prevented spreading of hate discrimination against patients and their families[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Relatedly, as role models, they also acted as behavioural change agents by for example readily accepting vaccines and getting (ahead of other community members) vaccinated once vaccines became available [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe CHWs used different strategies to facilitate accessibility to information on protection against COVID-19 [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The approaches included home visits and public information initiatives such as megaphones as observed in Kenya, India, and Thailand. Megaphones and audio messages were also employed in Ethiopia[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. In Indonesia, digital technology was used to fight COVID-19 misinformation [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIndeed, health promotion was integrated into the national Community Health Worker (CHW) guidelines in India and Thailand [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. While, in Bangladesh, CHWs acted as a bridge between refugee communities and health facilities thereby addressing fears and rumours[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eAssisting with surveillance\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eCommunity health workers being permanent residents in communities helped in supporting disease surveillance activities such as contact tracing and enforcement of quarantine directives [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Overall, CHWs were characterized as \u0026lsquo;natural researchers. For instance, Kenya, Liberia, India, and Rwanda are some of the countries that started leveraging CHWs for COVID-19 infection case detection [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In Bangladesh, India, Nepal, and Thailand, CHWs conducted symptomatic screening to detect COVID-19 infection. In India as internal migrants returned home after lockdown, CHWs screened 30\u0026ndash;50 households per day for symptoms [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In terms of enforcing quarantine directives, CHWs worked with local communities to encourage voluntary quarantine and supported full integration of recovered patients into the communities [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAdditionally, CHWs successfully encouraged voluntary quarantine in dedicated facilities and significantly reduced the stigma associated with individuals who had recovered from COVID-19. They utilized local expertise to effectively implement safety measures during disease surveillance. For example, in India, Bangladesh, and Ethiopia, CHWs facilitated the willingness of family members exhibiting COVID-19 symptoms to agree to their admission to a treatment centre [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Moreover, through community collaboration, the CHWs achieved significant progress by educating individuals about quarantine protocols and effectively identified potential cases of COVID-19 [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In so doing, they significantly reduced stigma against those who had recovered by educating communities and demystifying COVID-19 infections [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eMaintaining essential primary health care services\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eCHWs played a vital role in distributing commodities such as essential household products and medical supplies to those who were self-isolating. CHWs arranged transport and lodging for vaccinators and identified outreach locations that were likely to reach vulnerable populations. Using trusted networks, CHWs in Bangladesh, Haiti and Kenya, supported COVID-19-related and unrelated health services tasks such supporting referrals for maternal health services [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. In Malawi, the CHWs conducted social mobilization to promote HPV vaccines when schools closed during the COVID-19 pandemic [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile CHWs played a role in supporting established essential services, it's imperative to acknowledge the emergence of vital healthcare needs [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. This was particularly evident in the heightened demand for mental health services across various settings worldwide, largely due to the impact of the COVID-19 pandemic [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. It has been documented that CHWs were very crucial in providing psychosocial support in India, Uganda, Nepal and Pakistan to the people amid COVID-19 pandemic [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The sharp increase in cases of stress, anxiety, fear, depression and anger was documented in many contexts, providing an emergent role for CHWs to play within their communities [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eSupport planning and coordination of vaccination\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe CHW representation in vaccination planning teams aided in identifying target or priority populations by mapping out locations for vaccination [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. For example in Pakistan CHWs registered households to ensure accurate forecasting, mobilized target populations and accompanied them to immunization sites[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Relatedly, they contributed to the promotion of the COVID-19 vaccine by delivering pertinent and context-specific information during the preparatory and planning stages [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. They promoted vaccine acceptance though mobilizing community influencer, acted as the link between the community and the vaccination centres and supported the vaccine scheduling process. CHWs organized the reception flow or users of vaccines, in person and by teleconsultation [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eThe challenges faced by CHWs during the COVID-19 response\u003c/h2\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003eStigma and discrimination\u003c/h2\u003e \u003cp\u003eThe interaction of CHWs with individuals infected with COVID-19 made them susceptible to both stigma and the virus itself. In India a mob of 100 people assaulted CHWs who were collecting data on people with COVID-19-like symptoms [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. CHWs were scared and unprepared due to lack of protective equipment. In Nigeria, social stigmatisation of COVID-19 patients made many people not to disclose their COVID-19 infection thus making it difficult for CHWs to identify COVID-19 cases in the community [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eLimited incentives\u003c/h2\u003e \u003cp\u003eThere were challenges with regular payment of sufficient CHW remuneration and incentives, during the pandemic in many countries such as India, Bangladesh, Pakistan, Sierra Leone, Kenya and Ethiopia[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Without a more harmonized approach to CHW remuneration and incentives, their motivation and performance in COVID-19 prevention processes was inconsistent [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. In some countries such as India, Bangladesh, and Pakistan, additional financial incentive schemes for CHWs were introduced as a result of the COVID-19 related additional work or risks[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Despite these additional financial incentives, gaps existed with regard to the provision of incentives resulting into disrupting of routine service delivery[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn India for example, the CHWs were unaware of these additional incentives while incentives were not paid in other cases [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Further, there was variation between CHW cadres in India resulting into some CHWs being demotivated, and others going on strike due to lack of incentives for COVID-19 [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In Ethiopia, CHWs spent additional money out of their own pocket to provide services during COVID-19, without compensation[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In Nigeria, the lack of transportation among CHWs in rural areas during the lockdown affected their ability to perform services [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The precarious remuneration of CHWs affected their ability to deliver services in India [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eThe lack of training for CHWs during the COVID-19 response\u003c/h2\u003e \u003cp\u003eThe type and level of COVID-19 training provided to CHWs varied, was not always adequate, regular, and appropriate [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. In Brazil, for example, it was reported that although CHWs\u0026rsquo; roles in fighting the pandemic were essential, early response and capacity building focused mostly on the frontline health workers, leaving out the CHWs. Thus, CHWs were not initially oriented on their pandemic control action roles, and much less was done to safeguard them against COVID-19 while performing these roles in the community [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Given that health workers are much fewer than the CHWs, this was noted as a missed opportunity during initial response [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eInadequate infection prevention and control preparedness\u003c/h2\u003e \u003cp\u003eIn the beginning of the pandemic, the most important dilemma faced by CHWs in Kenya and Thailand was a mismatch between what needed to be done to prevent the outbreak and the availability of resources [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. All CHWs in Kenya and Thailand reported that even with the government\u0026rsquo;s non-pharmaceutical intervention guidance, no resources and equipment were available for them. When the national governments in Kenya and Thailand made it compulsory to wear masks in public, shortages of face masks and N95 respirator masks followed. Funding for personal protective equipment and related materials, such as face masks, soaps, and hand sanitizers, was a challenging problem for CHWs in Kenya [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe national and county governments in Kenya did not provide sufficient resources for CHWs to work with[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. In Rwanda, lack of personal protective equipment coupled with inadequate COVID-specific training and increased workload affected the ability by CHWs to deliver services during the COVID-19 pandemic [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Relatedly the lack of appropriate low risk technology to use when conducting health education during the pandemic was noted [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Given the highly infectious nature of the COVID 19, the lack of tools and systems through which CHWs could use to continue providing health education with minimal contact with community affected CHWs\u0026rsquo; ability to deliver health messages [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. In cases where tools and systems (mHealth) existed, limited knowledge and capacity affected the CHWs abilities to use them [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eLimited supportive policies\u003c/h2\u003e \u003cp\u003eThe challenges of limited guidelines to support CHW participation in COVID- 19 prevention services were evident at the beginning of the pandemic[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. COVID \u0026minus;\u0026thinsp;19 was novel, dynamic and unfolded fast, which made it even more difficult for policy makers to craft appropriate and responsive policies fast enough [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. In Kenya and Thailand, the CHWs highlighted the ambiguity and uncertainty of the policy environment [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. In Thailand, India, Bangladesh, Pakistan, Sierra Leone, Kenya and Ethiopia, there were no clear policy guidelines with regard to roles of CHWs in preventing COVID 19, making COVID \u0026minus;\u0026thinsp;19 referrals, participation in supporting vaccination as well as accessibility to COVID 19 prevention materials difficult [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Lack of such guidelines affected the ability of CHWs to effectively deliver primary health care including health promotion and education activities, surveillance, contact tracing and quarantine, and maintaining essential health services [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Interestingly, the CHWs from Kenya also noted that despite the lack of guidelines at the start of the pandemic, the need for action at community level made them relay on the protocols used during the Ebola epidemic and attempted to do the best they could to prevent the outbreak in their communities[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eStrategies for enhancing the performance of CHWs during COVID\u003c/h2\u003e \u003cdiv id=\"Sec20\" class=\"Section3\"\u003e \u003ch2\u003eHarnessing digital technology (mHealth)\u003c/h2\u003e \u003cp\u003eHarnessing digital technology (mHealth) to support CHWs in the Covid-19 response could enhance the performance of CHWs in addressing the pandemic [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. The technology can include the use of short message service (SMS) and voice message for health education, digital megaphones for encouraging behaviour change, digital contact tracing and facilitating case recording as well as use of mHealth for CHW education, training and supervision [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. One platform that CHWs can access information through their mobile phones is the WHO COVID-19 online training resource. CHWs in Uganda and Ghana for example established collaborative groups via mobile-messaging apps, such as WhatsApp [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIt should be noted, however, that more work needs to be done to increase overall feasibility and acceptability of digital tools for CHWs, as they are sometimes not adequately trained, and may face other challenges such as weak technical support and poor internet connectivity [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Despite these limitations, countries such as Uganda and Ethiopia have been successful in using digital platforms and best practices can be learnt from these examples, especially for future pandemic response [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eTraining for CHWs in pandemic response\u003c/h2\u003e \u003cp\u003eIn Brazil and India, the need for organised health education and orientation as initial pandemic response was noted, accompanied by culturally accessible communication mechanisms were seen as necessary in fighting the COVID-19 and future pandemics [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Boyce et al, also add that given that most emerging infectious diseases are zoonotic in origin, training and using CHWs to communicate one health information to at-risk communities prior to outbreaks may enhance future pandemic preparedness[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eHealth information management: collection and dissemination\u003c/h2\u003e \u003cp\u003eWhile health information dissemination is viewed as one major gap that CHWs can fill, as was seen in Bangladesh, their contact with the community members also provides opportunities to collect contextually driven misinformation and misconceptions from the public that can be targeted directly with health messaging [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. The COVID-19 pandemic experience showed the importance of properly managing information, and CHWs can play a role in correction of myths and misconceptions, while disseminating correct and accurate information to communities [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eWellness and safeguarding CHWs\u003c/h2\u003e \u003cp\u003eWhile it is noted that CHWs can help in servicing and protecting vulnerable populations, especially in times of crisis, it should be mentioned that their health and wellbeing was also under threat, due to lack of motivation, remuneration and protection against the pandemic [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. It is therefore important to implement wellness programs for CHWs including adequate and quality protective equipment [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. To adequately undertake these strategies, there is need to develop supportive policies and regulation that recognize the role of CHWs in addressing the COVID- 19 pandemic[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. These could include pooling CHWs into a reserve health corps to be used during public health emergencies, and formalizing agreements and strategies to promote the early engagement of CHWs in response actions[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Further CHWs just like other healthcare providers could have been prioritized for earlier vaccination access during COVID-19. And as noted earlier, prioritized for regular training in keeping with the evolving nature of pandemics such COVID-19. In addition, providing adequate institutional support could enhance bonds of trust between CHWs and the community and also promote resilient community health systems during public health crises[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eWe observe that CHWs played many roles in the COVID-19 response. The roles included being mobilizers, role models, and health promoters for behavioural change, providers of essential service and surveillance personnel. The CHWs provide valuable support to health systems during pandemics as they have some unique capabilities which some formal health workers might not have. For example, as trusted and valued members of the community, CHWs can easily navigate through the community, help address myths and misconceptions regarding the pandemic as well as successfully manage referrals. Historical experience indicates that community actors have for example played a key role in promoting sensitive health messages such as vaccine acceptance across the globe during pandemics[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Indeed, the involvement of CHWs in promoting community acceptance of vaccines is vital [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e], through advocating for and countering the widespread scepticism with accurate information [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe note that through performing these roles, CHWs could contribute towards equitable universal primary health care during pandemics [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Especially given their unique capabilities to facilitate health promotion and delivery of services and information to remote areas [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. For example, being situated within their communities, their health services are easily trusted by the communities they serve [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Trust is an important capability that CHWs can leverage on to address mistrusts and misconceptions associated with pandemics [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Additionally, given that CHWs are selected by community leaders, they tend to enjoy support from these leaders [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. This support creates legitimacy of CHW services which is vital in enhancing acceptance of primary health care services during pandemics [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Further, support from traditional leaders makes it possible for CHWs to easily integrate their messages within the community or traditional leadership communication systems [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA combination of CHW trust and community leadership support during the pandemics can simultaneously contribute to building resilient community health systems [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. We note that nurturing such trust could further trigger a sense of community and common responsibility, which according to WHO was critical in the fight against COVID-19 [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Against a reality of present and future \u0026ldquo;infodemics\u0026rdquo;, we thus suggest that effective use of community actors will be critical in enhancing the benefits of a multifaceted approach to communicating behavioural change messages for the COVID-19, and future pandemics, as well as maintaining the delivery and accessibility to primary health care services[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe have also documented that performing these roles was met with challenges [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. These challenges included, ambiguity and stigma from the community members, the lack of adequate training, inadequate infection prevention and control preparedness, lack of supplies and commodities, limited supportive policies and inadequate remuneration and incentives [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. These challenges affected their performance by exposing them to infection risks, limiting their coverage and capacity to deliver information and services[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile some of the challenge such as COVID \u0026minus;\u0026thinsp;19 related stigma and discrimination by community members and lack of enough infection prevention and control preparedness were new, others such as inadequate incentives are historical challenges that health system have continuously grappled with[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. These historical challenges are largely due inadequate prioritisation and integration of CHW incentives into the health systems[\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. The stress that the COVID-19 pandemic put on the health system worsened this situation as CHWs had to work even more to support health systems responsiveness to the COVID \u0026minus;\u0026thinsp;19 challenges. Competing health needs made some health systems to neglect CHW financial incentives [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. We therefore agree with others that addressing these challenges will require integrating standardised incentives for CHWs within the national budget in line with WHO recommendations[\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. The WHO recommends that Governments should provide a financial package that corresponds to CHW job demands, complexity, and number of hours worked, training, and the roles they undertake[\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. We are agree with others that it is important that CHWs are not viewed as panacea for weak health systems[\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOverall there has been an increased call for health systems in LIMICs to invest in CHWs if health systems are to effectively respond to pandemics such as the COVID \u0026ndash; 19 pandemic as well as maintain delivery of essential primary health care during pandemics [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. Similar challenges and investments have been noted and called for respectively in high-income settings where volunteers (part of community health systems) were used to support efforts in the fight against COVID-19, such as in Canada [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. This underscores the critical role that community health systems play in supporting the formal health system not just in pandemics but in everyday service delivery efforts too[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRegarding the new challenges that CHWs experiences, it is important that CHW health systems integrate innovative approaches to addressing the COVID \u0026minus;\u0026thinsp;19 pandemic and similar pandemic in CHW training and work performance [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. For example to address the challenge of lack of appropriate low risk technology to use when conducting health education, health systems should consider adopting use of mhealth tools to support health promotion activities, monitoring and reporting uptake of services [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. The mhealth tools are vital for enhancing, professionalism, quality and performance, and scaling up of health services given mobility restrictions associated with pandemics[\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo address ambiguity and uncertainty of the policy environment regarding the roles of CHWs, as well as accessibility to COVID 19 prevention materials, policy makers need to adapt CHWs programmes to local needs through undertaking national consultative CHW policy development processes[\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. Further, it is important to consider evolving mechanisms for governing programs in the contexts of pandemics [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. For example, policies should prioritize CHWs in receiving the COVID-19 vaccine, and periodically train CHWs in preventive measures of the COVID-19 response [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. Its however important to note that the COVID-19 policy landscape across the world was volatile given the novel, dynamic and fast paced nature of COVID-19 (ref). Being responsive and staying balanced and providing consistent messaging to ensure that communities and support systems such community health workers continue to operate without creating unintended consequences such as demoralizing workers amidst dynamic situations is difficult but critical[\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eOne main strength of the scoping review lies in the extensive search of the literature on the role of the CHWs in the response against COVID-19. The inclusion of papers utilizing different methodological approaches from different parts of the world on COVID \u0026minus;\u0026thinsp;19, including mixed-methods papers and reviews, provided in-depth insights into roles, challenges, and strategies for enhancing the performance of CHWs in the response against COVID-19. One of the limitations of this scoping review, was the possibility of missing out some publications. We tried to mitigate this by conducting several searches, and searching the references of publications that we included in the review.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eWe observed that there is general evidence that support that CHWs are critical community actors and were integral members of the health system during the COVID-19 pandemic. The engagement of community actors as critical trusted messengers in the COVID \u0026minus;\u0026thinsp;19-prevention process seems to have been necessary in building sustainable and resilient community-based response against COVID-19 and other infectious diseases through promoting community level behavioural change. Specific roles performed by CHWs during the pandemic included conducting health promotion and education tasks, surveillance, contact tracing and quarantine, maintaining essential primary health services, linking people to services through referrals, advocating for clients and communities and supporting the vaccination rollout process.\u003c/p\u003e \u003cp\u003eWhile CHWs have performed many important roles, they also experienced many challenges which affected their performance. Some CHWs were stigmatised and discriminated by community members, lacked enough infection prevention and control preparedness, had inadequate incentives as well as supplies and commodities.\u003c/p\u003e \u003cp\u003eAddressing these challenges requires investments that will ensure greater support for the integration of CHWs into health systems as this could also ultimately contribute to maintaining the credibility and sustainment of CHW programs. There is also needed to adopt new innovative approaches such as the use of mhealth tools to support performance and supervision of CHWs in delivering pandemic related services as well as maintaining routine primary health care. It is also important to prioritize CHWs in receiving the COVID-19 vaccine, and periodically training CHWs in preventive measures of the COVID-19 response. We recommend that future studies assess the degree of success in prevention of COVID-19 in countries that will have strongly implemented community engagement strategies in preventing and managing COVID-19.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eThe authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions, or policies of the institutions with which they are affiliated.\u0026nbsp;At the time of submission,\u0026nbsp;Joseph M Zulu was a Guest Editor for the special issue on the role of community health workers in primary care in this journal. All publication related decisions for this manuscript were made by a different editor.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u0026nbsp;Joseph M Zulu was a Guest Editors for this special issue at the time of submission. All decisions on this manuscript were made by another Guest Editors. \u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eNo funding was received for this study\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eJ.M.Z., M.T., C.M.U., C.M.I., and N.S. conceived and designed the review. \u0026nbsp;J.M.Z., A.S., and M.P.C. conducted the literature review. A.S. and M.P.C. coded the literature. J.M.Z., A.S., M.M., W.Z., and M.P.C. drafted the manuscript. M.T. provided the overall scientific guidance for the development of the manuscript. \u0026nbsp; All authors critically reviewed, revised, and approved the final manuscript for submission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to acknowledge the four institutions \u0026ndash; the University of Zambia, University of Waterloo, Ume\u0026aring; University, and Muhimbili University to which the authors are affiliated for creating the necessary environment to facilitate such a collaborative effort. \u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHirschhorn LR, Govender I, Zulu JM. Community health workers: essential in ensuring primary health care for equitable universal health coverage, but more knowledge and action is needed. 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Unintended consequences of communicating rapid COVID-19 vaccine policy changes\u0026ndash;a qualitative study of health policy communication in Ontario, Canada. BMC Public Health. 2023;23(1):1\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e\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":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Community health workers, health system, COVID-19, LMICs","lastPublishedDoi":"10.21203/rs.3.rs-3851192/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3851192/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eWith the spread of COVID-19 to most low-and middle- income countries (LMICs), global concerns arose on how to respond to the pandemic. While studies have documented the experience of community actors and in particular community health workers (CHWs) in responding to COVID-19 in LMICs, critical appraisal and synthesis of research data on the same is still lacking. \u0026nbsp;We aimed to highlight, the roles and challenges of CHWs in the fight against COVID-19, and strategies to address these challenges.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethodology:\u003c/strong\u003e Using a scoping review design, we systematically searched the following electronic databases: PubMed, HINARI, Cochrane Library (Reviews and Trials), Science Direct and Google Scholar. Three authors searched literature on CHWs and COVID-19 as well as CHWs and the COVID-19 vaccine. After critical appraisal of studies, informed by Arksey and O’Malley, twenty-five articles were included in the final analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Community health workers assisted with and contributed to health promotion and education tasks, surveillance, contact tracing and quarantine, maintaining essential primary health services, linking people to services through referrals, advocating for clients and communities, supporting planning and coordination of vaccination, as well as participated in vaccine rollout tracking and follow-up. Challenges experienced by CHWs in the COVID-19 response included stigma and discrimination by community members, inadequate infection prevention and control preparedness, lack of supplies and commodities, limited supportive policies and inadequate remuneration and incentives.\u003c/p\u003e\n\u003cp\u003eThe performance of CHWs during COVID-19 pandemic response could be enhanced by harnessing digital technology (mHealth) to support CHWs, establishing collaborative groups via mobile-messaging platforms, prioritizing CHWs in receiving the COVID-19 vaccine, and periodically training CHWs in preventive measures of the COVID-19 response. It was also noted that implementing wellness programs for CHWs including the provision of adequate and quality protective equipment was vital.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e \u0026nbsp;CHWs were found to be critical community actors and integral members of the health system during the COVID-19 pandemic. This calls for increased investments that will ensure greater support for the integration of CHWs into health systems as this could also ultimately contribute to maintaining the credibility and sustainment of CHW programs, as well as promoting more inclusive health systems.\u003c/p\u003e","manuscriptTitle":"A scoping review of the roles, challenges, and strategies for enhancing the performance of community health workers in the response against COVID-19 in low- and middle-income countries","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-16 06:32:52","doi":"10.21203/rs.3.rs-3851192/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-01-16T07:40:15+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-01-16T04:32:01+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-01-13T11:19:32+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Primary Care","date":"2024-01-10T18:36:19+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"af0862a3-608f-467b-a12d-44f4e125d209","owner":[],"postedDate":"January 16th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-05-19T16:00:46+00:00","versionOfRecord":{"articleIdentity":"rs-3851192","link":"https://doi.org/10.1186/s12875-025-02853-7","journal":{"identity":"bmc-primary-care","isVorOnly":false,"title":"BMC Primary Care"},"publishedOn":"2025-05-14 15:57:33","publishedOnDateReadable":"May 14th, 2025"},"versionCreatedAt":"2024-01-16 06:32:52","video":"","vorDoi":"10.1186/s12875-025-02853-7","vorDoiUrl":"https://doi.org/10.1186/s12875-025-02853-7","workflowStages":[]},"version":"v1","identity":"rs-3851192","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3851192","identity":"rs-3851192","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}