The Gendered Experience of Close to Community Providers during COVID-19 Response in Fragile Settings: A Multi-Country Analysis

Abstract

Many countries, and particularly those including fragile contexts, have a shortage of formal health workers and are increasingly looking to close-to-community (CTC) providers to fill the gap. The experiences of CTC providers are shaped by context-embedded gender roles and relations. This qualitative research study in Lebanon, Nepal, Myanmar and Sierra Leone explored the gendered experiences of CTC providers during the COVID-19 pandemic in fragile settings. We used document review, in-depth interviews or focus group discussions with CTC providers, and key informant interviews with local stakeholders to generate in-depth and contextual information. The COVID-19-associated lockdowns and school closures brought additional stresses, with a gendered division of labour acutely felt by women CTC providers. Their work is poorly or not remunerated and is seen as risky. CTC providers are embedded within their communities with a strong willingness to serve. However, they experienced fractures in community trust and were sometimes viewed as a COVID-19 risk. During COVID-19, CTC providers experienced additional responsibilities on top of their routine work and family commitments, shaped by gender, and were not always receiving the support required. Understanding their experience through a gender lens is critical to developing equitable and inclusive approaches to support the COVID-19 response and future crises.

From policy to practice: a qualitive study exploring the role of community health workers during the COVID-19 response in Sierra Leone

“…CHWs were trusted with these responsibilities as they were recognized as being knowledgeable about the community, were able to communicate effectively with community members and had experience of dealing with other outbreaks. In Sierra Leone and in other settings, CHWs have been useful in dealing with disease outbreaks and making health systems stronger, by building bridges between community and formal healthcare systems [8,10,16].…”

“…It has highlighted the strategic position CHWs manage between communities and health systems, often in contexts where mistrust exists between service users and the formal health system [8,9]. Recent studies highlighted clear roles and responsibilities, training, supportive supervision, work satisfaction, health and well-being as critical in maintaining CHWs' roles during the response to emergencies such as the COVID-19 pandemic [5,10].…”

“…During the COVID-19 outbreak in Sierra Leone, CHWs were required to support their communities to respond to the outbreak, drawing from their experiences during the Ebola outbreak [10]. With the onset of the pandemic in 2020, the Government of Sierra Leone (GoSL) released an interim guidance which identified the specific role of CHWs in the pandemic context and outlined adaptations to their role and support needed to maintain continuity of essential services and ensure an effective response to COVID-19 (Government of Sierra Leone COVID-19 Response: Interim Guidance for Community Health Workers (CHW) Program in COVID-19 context, Unpublished).…”

“…There is little evidence on the experiences of CHWs in their response to COVID-19 at the community level in Sierra Leone [10]. Learning from how CHWs adapted their role and were assisted is critical to supporting CHWs in Sierra Leone and in other settings as they navigate new and existing challenges.…”

A qualitative study examining the health system’s response to COVID-19 in Sierra Leone

“…The response at community level was also supported by community health workers who served as social mobilisers and contact tracers by providing community education through proper communication in a culturally appropriate way (mirroring events during Ebola where most community health workers also played this role [41]). Additionally, during COVID-19, they worked in quarantine homes [42]. Again, as described during the Ebola response, the role of community engagement in communication, combating fear and building relationships of trust were crucial [43], as the efforts of community health workers directly impacted the numbers of patients accessing facilities.…”