INTRODUCTION

Coronavirus disease 2019 (COVID-19) is an infectious disease caused by SARS-CoV-2, which has infected millions of people worldwide. Infected persons will experience symptoms ranging from mild respiratory disorders, such as flu, to severe respiratory disorders, such as lung infections^1,2. COVID-19 is transmitted rapidly to humans and can cause severe diseases particularly in vulnerable populations, such as the elderly with comorbidities^3,4.

By July 2021, the number of confirmed cases worldwide has reached 197,943,446, of which 4,222,934 died^5).Indonesia has continued to experience an increase in confirmed cases, and the accumulated number of cases reached 3,409,658; of which, 94,119 (3%) died, and 2,770,092 (81%) were cured⁶. In response to the COVID-19 pandemic, many countries have utilized a combination of control strategies to contain the spread of the virus while protecting the most vulnerable groups from the infection, including the elderly and individuals with comorbidities. Most countries adopt a spread control strategy through a health promotion approach⁷. Health promotion is a key intervention in disease prevention and a way for every individual or community to adopt optimal health behavior⁸. Information about COVID-19 needs to be disseminated to the public so they will know how to protect themselves from infection and be aware of the importance of social responsibility and correct preventive behavior⁹. The other prevention and control measures in suppressing the spread of the virus include diligently washing hands, maintaining social distance, increasing contact tracing, isolation or self-quarantine, and postponing large-scale public gatherings^10).

Indonesian community health workers (CHWs), known askaders, are community members who are willing and able to carry out health promotion activities¹¹. CHWs are critical to liaison between the community and primary health centers. CHWs actively support the health centers to limit the spread of disease outbreaks by early detection of cases and rapid response. They control outbreaks by involving and educating the public to implement preventive measures^12,13.

Many countries have developed strategies to control this pandemic by involving CHWs as key populations in the community. For example, in the US, when COVID-19 hit the New York City, the disease became an initial and worrying threat to public health; the government developed a strategy by empowering CHWs to overcome misinformation, fear, and stigma on COVID-19 circulating in the community by providing information about how the virus is transmitted, precautions people can take to protect themselves and their families, and ways to gain support and access to health services^14,15. Other countries such as Bangladesh, India, and Thailand also involved CHWs in the pandemic response through education, including promotion of adaptation of new habits, assisting in surveillance, contact tracing and quarantine efforts, and maintaining essential health services^16).

From our preliminary study, we found that the District Health Office has proactively carried out health promotion of COVID-19 prevention and trained CHWs to actively participate in breaking the chain of COVID-19 transmission in the community. Understanding the CHWs' point of view about their participation in the program is important given that working with the community in pandemic situation is considered a risky task. Limited information is known about the experience of CHWs in efforts to contain COVID-19, particularly in the Indonesian context. Hence, we conducted this study to explore the experience of CHWs in the COVID-19 pandemic response in the country. We expect that the findings will be useful to inform stakeholders in enhancing the strategy of community empowerment to handle an infectious disease outbreak in the community.

METHODS

RESULTS

Thirteen CHWs participated in the study. The characteristics of the participants are shown inTable 1.

Table 1.  Characteristics of participants (n=13) 

Six themes emerged from the study: (1) self-motivation, (2) valuable benefits, (3) noble duties, (4) perceived challenges, (5) meaningful support, and (6) way forward.

DISCUSSION

We conducted this study to understand the experience of CHWs in responding to the COVID-19 pandemic. One of the reasons why CHWs are involved in responding to the COVID-19 pandemic is due to their strong self-motivation. Motivation is a central concept in behavior change and an inner desire that drives a person to work with a high level of commitment²⁰. The motivation described in Self-Determination Theory (SDT) is divided into extrinsic and intrinsic factors. Extrinsic factors are the desire of someone who works because of external contingencies, such as wages or bonuses obtained for the performance done. Intrinsic factors are motivations that arise within themselves due to the intention to achieve certain goals²¹. The present study reveals an intrinsic factor, that is, CHWs have willingness or motivation to contribute and be involved in handling and controlling the COVID-19 pandemic. This finding is in line with the meta-synthesis study conducted by Mohajer & Singh (2018), who identified factors, including call to serve, assist, and empower the community, which enable CHWs to bring about behavior change²². Another study stated that the existence of a high sense of empathy and concern is the reason why CHWs build relationships with stigmatized people in the context of AIDS intervention^23).

In the implementation process, our study shows that the participants received many benefits in carrying out their duties in responding to the COVID-19 pandemic. A qualitative study was conducted by Carroll et al. (2020) on strategies to cope with change during the pandemic; the results showed that some respondents reported the coping strategies they used to manage stress and lifestyle changes due to restrictions due to COVID-19, and they were more aware and wiser in facing the pandemic and focused on the positive aspects that can be done²⁴. In addition, another study conducted by Balkhi et al., (2020) stated that more than three quarters of respondents admitted a change in their behavior to maintain health and ensure safety from COVID-19 transmission²⁵. The health behavior/practices carried out by respondents include reducing physical contact as much as possible (86.5%), canceling activity plans (84.5%), and more often washing of hands (87%)²⁵.

During the COVID-19 pandemic, CHWs are mandated with two tasks, namely, special tasks and routine tasks. The special task is the task of handling the pandemic, while the routine task comprises any activities to ensure that essential health programs are delivered to the community. CHWs actively conduct health education and share information about the dangers of COVID-19 to the community in their respective areas of residence. According to Ervin (2002), health promotion is a health intervention carried out directly to the community to change lifestyle and environmental behavior toward better health²⁶. A qualitative study conducted by Sawee et al. (2021) showed that during the pandemic, CHWs in Vietnam were actively responsible for conveying information about COVID-19 to the public and advising them on how to protect themselves from transmission of the virus²⁷.

In addition, our study indicates that the primary care centers ensure the continuous provision of essential health services even with some modifications, one of which is through the approach of CHW empowerment. Our study corroborates with a previous work that stated that the role of CHWs during the pandemic is not only to take infection prevention and control measures but also to help maintaining primary health services, such as vaccination and integrated case management of children with malaria, pneumonia, and diarrhea²⁸.

In implementing the COVID-19 response initiatives, CHWs encounter many challenges. The challenge is in the form of the community's attitudes that tend to be negative. For example, some CHWs reveal that many people are indifferent when educated, do not believe in COVID-19, and think it is only an artificial disease; moreover, many hoax news circulate in the community, and CHWs have been bullied. This is in line with the findings of the Center for Indonesia's Strategic Development Initiatives (CISDI), which indicates that the common challenges in changing people's behavior include the following: health protocols that are only considered a formality so that they are applied only during inspections or raids; people continue to ignore health protocols despite knowing the dangers of COVID-19 because they are urged by other interests, such as having to sell, work, etc.; and people are increasingly ignoring the implementation of health protocols because there is no law enforcement for violators, especially in public places, such as markets²⁹.

Despite these challenges, CHWs also receive various supports, including information support regarding prevention and COVID-19 efforts, financial support, supporting facilities in efforts to prevent COVID-19, motivational support from primary health centers, and social support from the community. This finding is reinforced by the study of Rosalia (2017), who reported the effect of refreshing CHWs' training on knowledge and skills in the implementation of health services³⁰. Another study showed that the provision of basic health information could significantly increase the knowledge of CHWs^31).In addition, a qualitative study identified several sources of CHWs motivation, one of which is financial and material support, including service fees and money for transportation³².

During this pandemic, CHWs have a lot of expectations to facilitate activities in the community. Greenspan et al. (2013) stated that moral support and material support are the main sources that motivate CHWs in carrying out their roles in the community³². Another study stated that internal factors that affect the performance of CHWs include motivation, recognition from the government, and award given by the health office to CHWs in carrying out their duties and responsibilities^33).

CONCLUSION

CHWs play an important role in response to the COVID-19 pandemic. The participants have shown their dedication in assisting the government and the community in handling COVID-19. Despite the challenges they encounter, CHWs have carried out various health promotion activities with a sense of responsibility. Comprehensive support must be provided to maintain the performance and well-being of CHWs. The findings of this study are expected to provide a rich description surrounding CHWs' involvement in the COVID-19 pandemic disaster so related stakeholders can increase their understanding when engaging with CHWs in similar programs and contexts.