Engaging Community Health Workers to Support Home-based care for people with COVID-19 in low-resource settings

Activities

Educate communities on signs, symptomsexternal iconexternal icon, and transmission routes of COVID-19. Answer questions raised by community members and address myths, rumors, and misinformation circulating in the community.

Monitor myths, rumors and misinformation within the community and inform local surveillance officer.

Provide education to combat stigma against community members (e.g. people with cases of COVID-19 and their contacts; frontline or essential workers such as healthcare workers, contact tracers, truck drivers). Speak out against negative behaviors and statements and encourage empathy and support to community members who are quarantining or isolating.

Promote COVID-19 prevention measures such as physical distancing (>2 meters), wearing a mask, hand washing and respiratory hygiene (coughing/sneezing into elbow).  People should understand that most people with COVID-19 have mild symptoms or no symptoms at all, and using a mask prevents people who do not realize they are sick from spreading the virus to others.

Encourage community members to seek testing or clinical care for symptoms consistent with COVID-19 or close contact to someone with COVID-19 per Ministry of Health guidance.

For households or communities already supported by a CHW, screen for COVID-19 symptomsexternal iconexternal icon as part of routine duties.  Refer any individuals experiencing symptoms, or who have been in close contact with someone with COVID-19, for testing. WHO provides guidance for prioritizing testing when diagnostic capacity is limitedexternal iconexternal icon.

Provide awareness and support for prevention of secondary impacts of COVID-19 (e.g. violence, food insecurity, lack of routine health care including childhood immunizations).

Undertake social media activities including dispelling rumors or false information and posting factual information

Examples of materials needed for implementation

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

Operational considerations and challenges

If CHWs typically communicate going door to door, adapting to using bullhorn/microphone may be challenging.

CHWs can model the behaviors they are promoting during educational sessions.

Develop a system for CHWs to refer and connect people to COVID-19 testing and treatment facilities.

A referral system or hotline for community members to call if they are experiencing violence/abuse or need social support should be in place before promoting this support.

CHWs may be tasked with delivering test results for people they have referred for testing or those in the community as part of the referral and assessment pathway.

Operational considerations and challenges

• If CHWs typically communicate going door to door, adapting to using bullhorn/microphone may be challenging.
• CHWs can model the behaviors they are promoting during educational sessions.
• Develop a system for CHWs to refer and connect people to COVID-19 testing and treatment facilities.
• A referral system or hotline for community members to call if they are experiencing violence/abuse or need social support should be in place before promoting this support.
• CHWs may be tasked with delivering test results for people they have referred for testing or those in the community as part of the referral and assessment pathway.

Activities

Assess people with confirmed or probable COVID-19 for eligibility for home-based care. People with confirmed or probable COVID-19 might be eligible for home-based care if they have:

• mild to moderate illness, including low-grade fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, or diarrhea
• age < 65 years
• no co-morbidities (e.g. chronic heart disease, chronic respiratory disease, kidney failure, serious heart conditions, sickle cell disease, adult onset diabetes, obesity, or immunocompromising conditions such as cancer, HIV, TB or other auto-immune diseases).  Additional conditions should be assessed that might put people be at increased risk for severe illness should also be considered (for example, asthma, hypertension or high blood pressure, pregnancy, smoking, liver disease, thalassemia, type 1 diabetes mellitus)

Assess homes/residential setting for suitability for home-based care either by phone or home visit, based on the following conditions:

• The patient is stable enough to receive care at home
• Availability of appropriate caregiver(s). Caregiver, when possible, should not be at “higher-risk” for severe illness from COVID-19 (i.e. no chronic medical conditions, not immunocompromised, not elderly, not pregnant). To minimize risk of transmission, designate one person as a caregiver until the patient recovers.
• Ability to monitor changes in the patient’s clinical status at home
• A separate bedroom and bathroom for the person who is sick, if possible. If that’s not possible, try to separate them from other household members as much as you can. Possible mitigation measures for high-density households may include:
  •  Opening a window, if possible and if safe to do so.
  • Maintaining at least 6 feet between beds, if possible. If this isn’t possible, sleep head to toe.
  • Putting a curtain around or place another physical divider (e.g., shower curtain, large cardboard poster board, heavy blanket) to separate the sick person’s bed.
  • Keeping people at higher risk separated from anyone who is sick. “House swaps,” in which neighboring patients are cohorted together and cared for by one person or set of people dedicated to providing care
• Reliable access to food, water, medicine, and other basic necessities. In certain contexts, CHWs may help ensure access by providing delivery of these necessities.
• Patients and their household members have access to adequate supplies for transmission-based precautions (at a minimum, masks and gloves) and for cleaning and disinfecting (re-usable or disposable gloves, and lined trash bin) for the duration of recovery. Disposable gloves should be used for taking out the trash. For cleaning, if no thick gloves are available, any kind of gloves can be used.
• Patient can adhere to respiratory and hand hygiene precautions
• Household has access and ability to conduct frequent (at least daily) cleaning and disinfectionpdf iconexternal icon pdf icon[580 KB, 4 pages]external icon of household surfaces (Note: may not be necessary if patient lives alone)

When assessing the eligibility of a setting for home-based care, considerations should also include if there are household members who may be at increased riskexternal icon of severe illness from COVID-19 infection. If the patient or household is not suitable for home-based care, refer the patient to the local healthcare facility or community isolation center.

Examples of resources for implementation

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

Operational considerations and challenges

This strategy depends on the existence of a data and referral system that identifies people with confirmed or probable COVID-19 to be assessed for home-based care. The system(s) will vary by location and resource availability and should be in place and operational prior to activation of CHWs for eligibility assessment activities. Examples of possible referral systems include:

• Local/national COVID-19 hotline
• Rapid response teams
• Testing center
• Community-based surveillance
• Self-referral (i.e. per education/awareness campaigns listed above, the patient reaches out directly to health facility or directly to CHW)
• Noticed by CHW or referred by another CHW while in community
• House-to-house or route-based visits (active case search)
• Contact tracing team

COVID-19 testing may not be available everywhere, or may be limited. Referring people for testing when not available or clinically indicated may contribute to the spread of COVID-19. National or local recommendations regarding testing criteria and considerations for handling probable cases should be followed.

If patients are not eligible for home-based care, link them to care in a community isolation center, health facility, hospital, etc. CHWs could also help organize and support “house swaps”, as described in the leftmost column, if a person meets criteria but their living space does not.

It may be difficult to determine who qualifies for food aid and distribution of locally recommended hygiene materials.

PPE and hygiene supplies may be difficult to obtain due to supply chain issues as the COVID-19 outbreak progresses.

Home isolation may contribute to an increase in violence (e.g. due to stress or increased time in the same space as an abuser). When assessing patients and homes for suitability of home-based care, look for and consider signs and symptomsexternal iconexternal icon of violence and abuse.

Activities

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

• Infection prevention and control, including personal hygiene and how caretakers can protect themselves and others in the household when caring for someone with COVID-19
• Signs and symptoms of severe illnessexternal iconexternal icon requiring referral to health facility (e.g. light headedness, difficulty breathing, chest pain, dehydration, confusion or other severe sign or symptom).
• Distribute home-based care kits or refer household to where home-based kits are available
• Provide leaflet on How to care for someone with COVID-19 symptomspdf icon pdf icon[480 KB, page 1].  This leaflet may need to be translated into local language.
• Provide support to households and community members affected by secondary impacts of COVID-19 (e.g. food insecurity, interpersonal violence, abuse)
  • Promote local resources (e.g. a confidential referral network or hotline) for community members to call if they or others are experiencing violence or abuse
  • Distribute food, water, medicine, hygiene materials, and household essentials.

Materials needed for implementation

• Distribution of handwashing station materials and soap

Low-literacy job aids / informational materials available in local languages on:

• How to make a handwashing station (instructions for various designs can be found herepdf iconexternal icon pdf icon[5.00 MB, 39 pages]external icon)
• How to make disinfecting solutionspdf icon pdf icon[412 KB, 1 page]
• How to care for someone with COVID-19 symptomspdf icon pdf icon[480 KB, 1 page]
• How to make handwashing solutionpdf icon pdf icon[440 KB, 1 page]
• How to dispose of waste

Home-based care kitspdf icon include supplies for cleaning, disinfecting, handwashing, and patient care for the duration of recovery:

• Paracetamol
• Soap
• Disinfectant
• Disposable gloves
• Wash cloth
• Masks
• Mobile phone and airtime

Operational considerations and challenges

Advisory and training activities can be conducted remotely (e.g. phone or message-based), but distribution of home-based care kits and other household support would have to be conducted in-person. The CHW should wear a mask and practice physical distancing. Supplies can be left at the household entrance.

A referral system or hotline for community members to call if they are experiencing violence/abuse or need social support should be in place before promoting violence-related support.

There will be costs associated with distribution of handwashing station materials, home hygiene kits, PPE, and basic household essentials. It may be difficult to determine who qualifies for this support, but ideally this would be based on existing social safety net lists and discussed with the community beforehand.

Operational considerations and challenges

Advisory and training activities can be conducted remotely (e.g. phone or message-based), but distribution of home-based care kits and other household support would have to be conducted in-person. The CHW should wear a mask and practice physical distancing. Supplies can be left at the household entrance.

A referral system or hotline for community members to call if they are experiencing violence/abuse or need social support should be in place before promoting violence-related support.

There will be costs associated with distribution of handwashing station materials, home hygiene kits, PPE, and basic household essentials. It may be difficult to determine who qualifies for this support, but ideally this would be based on existing social safety net lists and discussed with the community beforehand.

Activities

• CHWs can assist with daily symptom monitoring of patients until recovery, defined as at least 10 days since symptoms first appeared, at least 24 hours have passed since last fever without the use of fever-reducing medications, and symptoms (e.g., cough, shortness of breath) have improved
• Patients who remain asymptomatic may discontinue isolation 10 days after the date of their first positive viral diagnostic test or according to local/national guidance
• Patient or their caregiver can call CHW if symptoms worsen, and be counseled on symptoms requiring immediate medical attention (e.g. light headedness, difficulty breathing, chest pain, dehydration, etc.)
• CHW evaluates patient and refers to treatment, if necessary and if appropriate PPE/skillset is available
• CHW provides linkage to emergency transportation, if needed and available

Consider having CHW perform daily pulse oximetryexternal iconexternal icon monitoring of patients,^[1],[2] where available, prioritizing monitoring on days 6-14 after onset of symptoms.

Instruct patients and caregivers how to seek care if symptoms worsen.

Materials needed for implementation

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

The CHW, caretakers, the patient themselves, or some combination of the former can conduct daily symptom monitoring. Daily symptom monitoring by a CHW can be done remotely, which is the preferred modality. In-person visits can be done for households without access to a mobile phone. CHWs should take steps to protect themselves (e.g. wear a mask, conduct frequent hand hygiene, practice physical distancing) when conducting in-person visits.

CHWs should avoid entering the home to take pulse oximetry readings; the patient can come to the doorway to be assessed. The CHW should wear a mask and disposable gloves to set the pulse oximeter on the floor for the patient (or caregiver) to pick up and put it on his/her own finger for assessment. In cases where the patient cannot bend down to pick up the pulse oximeter, the CHW can hand the pulse oximeter to the patient while remaining two arms lengths away. The CHW should wash his/her hands with soap and water for 20 seconds or use alcohol-based hand rub before putting on gloves and after taking them off, and safely dispose of gloves after use.  The pulse oximeter should be properly sanitized after each use according to the manufacturer’s instructions or with alcohol-based wipes or sprays containing at least 70% alcohol to disinfect screens/electronics. Dry surfaces thoroughly to avoid pooling of liquids.

For continuity, contextual awareness, and rapport, to the extent possible, the same CHW should monitor the same patients (and potentially their household contacts) for the duration of the recovery period.