Rapid evidence synthesis on equipping community health workers for a pandemic response
With a sudden spike in COVID-19 cases in India in early March 2020, national and state-level government authorities ramped up measures to prevent a community spread of the virus. Decision-makers in the government rushed to scale up the health system’s response to the pandemic in the country.
The Rapid Evidence Synthesis (RES) unit at The George Institute for Global Health India (TGI) was set up in collaboration with the National Health Systems Resource Centre (NHSRC), with support from the World Health Organization (WHO) and Alliance for Health Policy and Systems Research (AHPSR). The unit – the first of its kind – develops and implements tools to produce a range of rapid evidence synthesis products on request from health policy and systems decision-makers in the country.
Mobilising India’s community health workers (CHWs) was one of the earliest strategies adopted by the government for preventing and controlling COVID-19 contagion at the community level. The National Health Systems Resource Centre, the technical support agency for the National Health Mission (NHM) under the Union Ministry of Health and Family Welfare, requested evidence on the role of CHWs in the pandemic response in the context of COVID-19. The decision-making need was in preparing an IEC (information, education and communication) booklet, training manuals and guidance documents to create awareness among India’s CHWs about the virus and ensure their safety while carrying out response activities in the community. The content of the materials needed to be evidence based. Given the urgency of the situation, the evidence was requested within a timeline of three days.
‘We had to hit the ground running because the Accredited Social Health Activists (ASHA) were already out there in the community doing things’, says Dr Rajani Ved, NHSRC.
The researchers, in consultation with Dr Ved, identified two components for this RES: i) key roles, issues, barriers and enablers for CHWs in the prevention and control of COVID-19; and ii) a list of resources to develop guidance, documents, training manuals and IEC materials for CHWs. Considering the novelty of the disease in early March 2020, there was ambiguity as well as limited literature available. Hence, the scope of the RES was expanded to include evidence from past pandemics such as Severe Acute Respiratory Syndrome (SARS), Swine Flu, Ebola Virus Disease (EVD) and Middle East Respiratory Syndrome (MERS-CoV).
‘I was quite challenged as this is something we have not done before. As they say in a pandemic, timing is everything’, says Dr Soumyadeep Bhaumik, the lead researcher in this RES.
A comprehensive search strategy ensured relevant studies were identified using a reliable high-quality evidence database. Additionally, 15 websites of different government, multinational agencies and COVID-19 resource aggregators were searched to collate resources and guidelines on COVID-19 for CHWs. On the third day after the request, the team completed the RES: ‘Frontline health workers in COVID-19 prevention and control: rapid evidence synthesis’. It comprised two products: a rapid policy brief in plain language and an inventory of resources and guidelines on COVID-19. The brief summarised findings from global evidence on the role, challenges and experience of CHWs in carrying out response activities during a pandemic. The inventory consisted of resources, guidelines and manuals with information on, for example, transmission modes of the virus, dos and don’ts, self-isolation and quarantine practices.
The findings showed that, during previous pandemics, frontline health workers (FLHWs) and CHWs working with non-governmental organisations (NGOs) were deployed for activities such as community sensitisation, and awareness and promotion of appropriate preventive practices. The evidence pointed towards high risk of virus transmission by CHWs simultaneously involved in contact tracing and routine medical service delivery. Some evidence also revealed that CHWs were not engaged in contract tracing and a separate cadre of health workers were deployed for that purpose. It was essential to provide CHWs with adequate personal protective equipment with proper training on its usage. The workers experienced stigma, discrimination and exclusion while carrying out their work, which called for the provision of adequate psycho-social support for them.
In the early stages of the pandemic, multiple myths about the virus and its spread were in rapid circulation on social media, so CHWs were also called on to disseminate accurate messaging to dispel these myths.
The National Health Systems Resource Centre was satisfied with the RES products delivered within the tight timeframe. An IEC booklet for CHWs titled ‘Role of frontline workers in prevention and management of coronavirus’ was released by the Union Ministry of Health towards the end of March 2020; its content was informed by the RES. It had information for CHWs on transmission modes of the virus, safety measures, risk factors, quarantine and isolation practices, as well as myth busters. ‘If we didn’t have the evidence, probably we could have gotten some of our facts wrong’, says Dr Ved.
The RES found further uptake shortly after its wide online dissemination amongst various health system workers and networks who were actively involved in steering COVID-19 response work in India and abroad. The policy suggestions in the RES were cited in an internal COVID-19 policy response document by the government of Odisha in India. Two documents released by the World Health Organization also referenced the RES: ‘COVID-19 and violence against women: what the health sector/system can do?’; and ‘Community-based health care, including outreach and campaigns, in the context of the COVID-19 pandemic’. The Department for International Development (DFID) in Nepal translated the policy suggestions into Nepali to guide response measures in the country. ‘Our work actually contributed to preventing and educating, and creating that awareness, especially among frontline health workers and stopping the disease spread’, says Dr Sandeep Moola, another researcher from the team.
Several evidence aggregators, not-for-profit organisations and advocacy groups included the RES in their resource repositories on COVID-19, including EvidenceAid, COVID-19 PHC Action Group, International Health Policies, Institute of Public Health (Bengaluru), EQUINET, Community Health Impact Coalition, and RedARETS.
It was the first time the RES team at TGI delivered an RES within days rather than weeks or months – and the team rose to the challenge. The RES platform’s sustained functioning in India stands as a testimony to the emerging space for evidence synthesis in low- and middle-income countries, informing policy decision-making.
Further Resources
Frontline health workers in COVID-19 prevention and control: rapid evidence synthesis
Community health workers for pandemic response: a rapid evidence synthesis
Community-based health care, including outreach and campaigns, in the context of the COVID-19 pandemic: https://www.who.int/publications/i/item/community-based-health-care-including-outreach-and-campaigns-in-the-context-of-the-covid-19-pandemic
COVID-19 and violence against women: what the health sector/system can do?
Authors
Sandeep Moola, Misimi Kakoti, Devaki Nambiar, Soumyadeep Bhaumik, Jyoti Tyagi
The George Institute for Global Health, New Delhi/Hyderabad, India
Disclaimer
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