The Impact of the COVID-19 Pandemic on Community Health Workers from HIV Care Organizations in the Mid-South

Many community-based organizations serving people living with HIV were unprepared for the impact that the COVID-19 pandemic had on the United States (U.S.) healthcare and social service systems. Social distancing shut down much of the economy for months, overwhelming organizations and agencies that play an essential role in addressing the HIV epidemic forcing them to change the way they work with clients. In the U.S. COVID-19 disproportionately impacted vulnerable, low-income and minority communities already facing health disparities (Anyane-Yeboa et al., 2020; Centers for Disease Control and Prevention, 2020).

The Memphis metropolitan area and its surrounding counties is a region in the U.S. South with pervasive racial, economic and health disparities (Rajabiun et al., 2021). It has one of the highest rates of new HIV infections nationally, 27.2 per 100,000 in 2018, and that same year only 62% of people with HIV were virally suppressed making it one of the priority regions for the Ending the HIV Epidemic Initiative (End HIV 901, 2020). Economic inequality in the Memphis metropolitan area is evidenced by the differences between the poverty rates of minority groups (23.9% for African Americans and 28.2% for Hispanic Americans) compared to the poverty rate of 7.7% for White Americans (Delavega & Blumenthal, 2022). People living with HIV need access to essential medications to attain and maintain HIV viral suppression and many also require assistance with meeting their most basic needs (i.e., food and shelter). These conditions make reaching vulnerable populations of people with HIV in their own environments’ imperative, and the COVID-19 pandemic increased this necessity.

Frontline health and social services staff at clinics and community-based organizations operate as a bridge between people living with HIV and their needs for health and social services because they spend time with clients in their homes, in the community or in clinical settings, getting to know them and working to remove barriers to facilitate access to services. Community health workers function as members of interdisciplinary teams to provide culturally competent essential support services (American Public Health Association, 2014). This article uses the term “community health workers” or “CHWs” to refer to all staff that meet this role, regardless of their actual job title.

In the Memphis metropolitan area CHWs play a unique role in HIV service delivery by reaching out to those who are newly diagnosed or who have dropped out of medical care and connecting them to health and mental health services, assistance with obtaining antiretroviral medications, supporting treatment adherence, and managing life with HIV.

A challenge which faces the CHW workforce serving people living with HIV is the persistent occupational stress that accompanies providing care to clients with complex care needs and the intersecting psychosocial factors that impact clients’ ability to remain in care (Rowan et al., 2015). Client issues such as stigma, social isolation, and discrimination only add to provider stress by increasing the demand for their services (Rowan et al., 2015). The higher the level and frequency of the client’s needs can lead to provider emotional exhaustion increasing the risk of burnout and adversely affecting client quality of care (Benevides-Pereira & Das Neves Alves, 2007). Given the vulnerable clientele, the complex, multidimensional inequities already present in the region, and the notable concern of provider burnout, the COVID-19 pandemic presented pronounced challenges for CHWs working with people living with HIV.

Several studies described how the COVID-19 pandemic disrupted service delivery at health and human service organizations providing HIV prevention and care services and that professionals working in these settings have experienced considerable distress related to the abrupt social and occupational changes (Neely-Barnes et al., 2022; Morse & Dell, 2021; Reif et al., 2021). Most organizations were able to transition their services virtually to continue providing care for their clients. Yet, working remotely brought about unintended consequences such as changes in hours worked, an increase in work responsibilities, and difficulty in maintaining a work-life balance which furthered work-related stress (Magruder et al., 2022; Morse & Dell, 2021).

The rapid rise of technology utilization due to the social distancing norms and nationwide lockdowns created complications for CHWs and clients (Mayfield-Johnson, 2020). Frontline CHWs needed to learn how to communicate using technology and telehealth and support their clients with using it. Although services went virtual there were many clients without adequate access to internet service and technology, nor did they have the knowledge to use it (Senreich et al., 2021). Along with the fear of contracting COVID-19, CHWs experienced difficult emotional reactions and psychosocial consequences such as anxiety, depression, isolation, and exhaustion (Senreich et al., 2021). Studies have indicated that the COVID-19 pandemic created high levels of stress, a decline in emotional wellbeing, and a decrease in self-care practices (Magruder et al., 2022; Miller & Reddin Cassar, 2021).

Understanding the challenges of working during the COVID-19 pandemic from the perspective of CHWs who support people living with HIV may offer promising new strategies to promote the health and wellbeing of all CHWs and other frontline health and social service staff, yet these experiences have not been studied. The purpose of this study is to examine how CHWs, who work with people living with HIV in the Memphis metropolitan area, were impacted by the COVID-19 pandemic and ways in which the changes affected them. The following research question guided the investigation: What is the lived experience of community health workers, who work with people living with HIV in the Memphis metropolitan area, during the COVID-19 pandemic?

Methods

This qualitative research was part of a larger study examining the impact of a community health worker training intervention on improvements in viral suppression and self-management for people living with HIV in the Mid-South (Rajabiun et al., 2022). Qualitative inquiry is the preferred approach when research goals include developing a deep understanding of a phenomena (Padgett, 2017). Thus, a phenomenological approach to research design, data collection and data analysis was used to study how CHWs and supervisors made meaning of their common or shared experiences during the COVID-19 pandemic (Creswell & Poth, 2018).

Participants were from the workforce of early intervention specialists and other frontline health and social services staff who through their outreach and engagement with people living with HIV in the Memphis metropolitan area fit the American Public Health Association’s (APHA, 2014) definition of a community health worker. A recruitment email was sent to CHWs and supervisors who attended a 32-hour CHW training program focused on building HIV knowledge and skills (see Rajabiun et al., 2022). The email request invited CHWs to participate in a virtual interview with others from their agency in a group format. Individuals unable to attend with others from their agency were interviewed at a separate time. To allow participants to share more openly about their experience, supervisors were interviewed separately. Data collection occurred from April to July 2020 and participants were interviewed twice during this time. This back-and-forth interchange and prolonged engagement with CHWs and supervisors who were experiencing the impact of COVID-19 in their work with clients living with HIV in the Memphis metropolitan community enabled researchers to gain a better understanding of their perspective. All interviews were conducted and recorded via HIPAA Zoom, then transcribed and verified by members of the research team and entered into NVivo 12. Interviews were transcribed verbatim, and each participant was assigned a pseudonym to protect confidentiality. Research procedures were reviewed and approved by the University of Memphis institutional review board.

Data analysis proceeded in the following steps. One member of the research team did the first reading through of the interview transcripts and identified significant phrases or sentences and named codes. The remaining members of the team read and added units of text into the initial code classifications, making some additions and clustering them into categories. Codes were tested for reliability with more than one person on the research team, and any discrepancies were settled through coding meetings until consensus was reached. Once all interviews were coded, the common themes that arose from the data were narrowed down and excerpts of significant statements relevant to each theme were extracted.

Findings

Virtual qualitative interviews were conducted with 23 CHWs and supervisors across five organizations during the COVID-19 pandemic from April to July 2020. Participant demographics are described in Table 1. There were five themes that emerged from the interview data that describe the essence of the participants collective experiences: (a) virtual service delivery impact on the CHW-client relationship, (b) the use of technology to communicate with clients, (c) increased work responsibilities, (d) the need for support and self-care; and (e) the extra layer of trauma added onto the COVID-19 pandemic that was triggered by the murder of George Floyd. Together these themes illuminate the experiences of CHWs during the COVID-19 pandemic in the Memphis metropolitan area.

Table 1.

Demographics

Item	N (%)
Organization Type (n = 23)
County Health Department	5 (21.74%)
Community Based HIV Services	10 (43.48%)
Health Clinic with HIV Services	4 (17.39%)
Hospital with HIV Services	3 (13.04%)
Substance Abuse Services	1 (4.35%)
Supervisor (n = 23)
No	18 (78.26%)
Yes	5 (21.74%)
Years at Organization (n = 22)
Within the past month	1 (4.55%)
Less than 1 year	2 (9.10%)
More than 1 year but less than 5	11 (50.00%)
More than 5 years	8 (36.36%)
Years in Position (n = 22)
Within the past month	1 (4.55%)
Less than 1 year	3 (13.64%)
More than 1 year but less than 5	9 (40.90%)
More than 5 years	8 (36.36%)
Race (n = 23)
Black or African American	20 (86.96%)
White	3 (13.04%)

Virtual Service Delivery’s Impact on the CHW-Client Relationship

When COVID-19 grew into a pandemic many social service agencies and healthcare organizations in the Memphis metropolitan area responded by shutting down in-person services while some did a hybrid of in-person and telehealth services. Due to these restrictions, employers directed employees to work from home and CHWs had to make changes in how their services were delivered. Prior to the pandemic, HIV-serving CHWs had the flexibility to work with clients in the manner that worked best for the clients. An important part of CHWs distinctiveness is the trusting relationships they are able to establish with the clients that they serve (APHA, 2014). Thus, delivering client services remotely from home altered the relational aspect of their work considered key to their services.

When asked how the COVID-19 restrictions were affecting work with clients one CHW said:

Am I not going to be able to go back and visit clients in the home? So that’s been a big concern for me and like, how would that look, because I know a lot of the success that I’ve had with clients in the past was based on me being able to go to their homes because honestly when I’m able to go to their homes they see, like, I’m no different. I’m a person just like you are. It’s been, you know, clients who have opened up to me because they’re like, nobody’s ever come to my home.

(CHW, Hospital including HIV Services)

Another CHW explained:

Before the pandemic started, we were assisting clients face-to-face and going with them to their appointments. Right now, we have a few clients who have been newly diagnosed and we can’t go with them to their appointments.

(CHW, Community Based HIV Services)

The change to delivering services remotely to vulnerable people living with HIV caused concern for some CHWs who felt that not having the capacity to do home visits interfered with their ability to connect meaningfully with clients, particularly those who were newly diagnosed. Some CHWs felt that a strength of their services was the ability to meet the client in their homes or other preferred space, and with that option taken away, it was more difficult for them to provide client support. CHWs reported difficulty staying in contact with some of their clients due to their changing phone numbers or not having access to a phone. In some instances, CHWs were unable to contact their clients.

Use of Technology

Working from home, CHWs continued to provide services to clients using telephone, text, and video calling applications to check on their health status and to assess their needs. CHWs in this study were equipped with cell phones, laptop computers and internet service, yet contacting clients was difficult because most of them did not have internet access, devices to get online, or the knowledge to use such technology.

A lot of our clients don’t have the capacity to even do, you know, virtual sessions, they only have their phone and it’s a government phone, so they don’t really have the ability to be on a zoom call anyway.

(CHW, Community Based HIV Services)

Several clients who did have cell phones with cameras expressed that they would rather not be on camera. There were some clients who did not want to get on video because their partners did not know their HIV status. CHWs had to be creative about how they kept in contact with their clients, so in addition to phone calls they sent text messages or even messaged them on Facebook. A CHW in an HIV service agency affiliated with a local hospital system explained, “some clients are definitely hard to reach with telehealth. That population of clients are those that are hard to reach anyway.”

Despite the challenges there were benefits in using telehealth that were not present with in-person visits. One CHW explained:

I think telehealth has been extremely beneficial because you can kind of meet the client where they are which is a handy phone all the time so you’re more likely to get in touch with them and get what you need. And it takes the burden of having to be at a specific place at a specific time to talk to somebody …so you know telehealth has been very helpful.

(CHW, Hospital including HIV Services)

CHWs who had not used telehealth programs prior to the COVID-19 pandemic expressed that they could benefit from online trainings to bring themselves up to date with all the communication options available and how to use them. A CHW in a community-based HIV organization said, “I’m not very tech savvy, so for me to use these new technological things, I have to be trained in them.”

Increased Work Responsibilities

Most organizations, with some exceptions, were closed to receiving clients in person but this did not equate to a decreased client caseload. Many CHWs reported that the pandemic restrictions added new work burdens to support clients, and in some cases, resulted in increased work responsibilities. CHWs at several social service agencies were making home deliveries of food packages because in-person food pantry services had halted. One CHW said:

I’m doing a lot more home deliveries because our clients, you know, because of the bus system that only allows 10 people at a time. Our clients are having a hard time traveling to get the things they need from us. So, I’m having to do more driving to drop off food deliveries.

(CHW, Community Based HIV Services)

A supervisor explained why her workload became difficult:

We’re still going over and above…because the clients are not just clients when they are your caseload, you have relationships with your clients, and you want to make sure that they have everything that they need. So, you’re working extra hard from home, to provide a service, when all of your stuff is at your office…. And we work double from home than we do from the office. And it was like that wasn’t understood and it didn’t appear to be appreciated in the beginning.

(Supervisor, Community Based HIV Services)

The multiple challenges CHWs faced left some of them feeling emotionally overwhelmed and physically exhausted, yet they continued to perform as professionals by assisting clients with getting the information and support that they needed. One CHW admitted, “I’m ready to go back into the office. I never thought working from home would be so hard.”

Support and Self-Care

CHWs recognized that they themselves needed care. The changes in their physical work environment (i.e., working from home), the extra work responsibilities, and the expectations to continue work as usual with clients came at the expense of their own personal wellbeing. It was emotionally stressful for CHWs to support clients during the pandemic and to take care of themselves. Some found it difficult to maintain a work-life balance.

I feel like I need things for my own self-care and my own mental health. I have been under severe stress trying to maintain [my own mental health] and be there for the clients. We need some type of EAP services so we can take care of ourselves.

(CHW, Community Based HIV Services)

Participants expressed that they desired emotional support and appreciation from their organization’s leadership for working during the COVID-19 crisis despite uncertainty and fear for their own welfare.

You’re gonna only be as good as the person who is leading you. And if they can give you what you need, as far as self-motivation, encouragement, you know, just being supportive, sometimes that’s all [we] need is just [someone] to be supportive and just be quiet and listen. I think they appreciate but it just wasn’t communicated.

(Supervisor, Community Based HIV Services)

The work-related stress and difficulty in maintaining a work-life balance was compounded by the loss of social connection and support normally available in the workplace. The COVID-19 pandemic interrupted CHWs sense of being part of a professional community with which they regularly interacted and with the disruption they lost regular sources of social support.

The murder of George Floyd

Further stress on CHWs occurred with the murder of George Floyd and the worldwide focus on police brutality, violence and racial discrimination. Most CHWs and supervisors interviewed in this study identified as African American and they reported dealing with similar fears and feelings of trauma that their clients had to grapple with. One CHW said:

Clients that have children, that have sons, you know, they fear for their lives, for their futures and their safety in this world. As a Black woman, I can relate as well…It is kind of disheartening when you have to, you know, deal with it. And in this community, it can be kind of scary, especially when you have Black people that’s already scared to go to the doctor.

(CHW, Hospital with HIV Services)

Similarly, a supervisor stated:

Being an African American woman, especially being that I have a son in the house, and I have nephews and everything, I can empathize with the clients and understand why they feel the way they feel and what they’re feeling. … [Clients] have shared that [George Floyd’s murder] reminds them of a time when they were pulled over or when something happened to them. … Of course, they feel like it’s unfair. It’s been happening forever; they’ve been living with [racial discrimination by police] their entire lives. Some feel like it’s never gonna change.

(Supervisor, Community Based HIV Services)

Furthermore, CHWs acknowledged that some clients have become so accustomed to police violence such that hearing about it happening with George Floyd’s murder only reinforced the harsh reality of living in a racist society with which they were all too familiar.

All the aforementioned themes paint a picture of how COVID-19 impacted CHWs in the Memphis metropolitan area and affected their ability to deliver services to individuals living with HIV.

Discussion

This study sought to develop a deeper understanding of the lived experience of the 23 frontline CHWs and supervisors during the COVID-19 pandemic. Several findings of this current study are substantiated by studies that similarly reported frontline and essential workers experienced considerable distress related to the social and occupational changes that resulted from the pandemic (Neely-Barnes et al., 2022; Morse & Dell, 2021; Senreich et al., 2021).

Where previously CHWs were able to have client contact in any location preferred by the client, COVID-19 restricted interactions to more impersonal technology-based communication which impacted the CHW-client relationship. Making this adaption to deliver client services virtually, while they worked from home, interfered with the relational connection they were accustomed to having with clients and presented communication challenges in contacting some clients, gathering in-depth information to make assessments and to problem-solve with them to address barriers to care. With the use of more impersonal means of interaction, such as texting and email messages, conversations became briefer and more transactional. The use of technology not only changed the way services were provided, but it also hampered CHWs ability to build strong relationships with clients through in-person home visits and interactions. This was corroborated by other CHWs who felt that the changes impacted the ability to connect with clients (Mayfield-Johnson et al., 2020).

CHWs all through the U.S. found themselves needing to use the new types of telehealth platforms, some of which they were newly learning, as well as educate and support their clients with managing the technology (Mayfield-Johnson et al., 2020). Agency responses to the pandemic differed with varying levels of staff preparedness to work remotely and use telehealth (Senreich et al., 2021). CHWs and supervisors in the current study had varying degrees of tech literacy. Other difficulties encountered were clients’ lack of technology resources. Similar studies identified boundary problems brought about from working remotely and the use of telehealth, such as a lack of separation between professional and personal space (Senreich et al., 2021). Despite the reported challenges of the shift to technology-based communication, telehealth proved essential for reaching clients during the COVID-19 pandemic (Neely-Barnes et al., 2022). Benefits of telehealth mentioned were that clients were able to be in the comfort of their homes and it increased access to services for many clients without transportation.

Transitioning to working remotely and providing services virtually added work responsibilities and increased the risk of work-related stress and burnout for CHWs and supervisors. Few participants reported having organizational support to assist with the additional tasks and time in work that accompanied the transition to virtual service delivery. Other studies have reported similar findings regarding the need for workload accommodations to prevent burnout created by increased workload and increased number of hours worked (Magruder et al., 2022; Senreich et al., 2021).

Research similarly uncovered that CHWs experienced conflict with balancing the needs of clients with personal and family needs (Mayfield-Johnson et al., 2020). CHWs in this study often sacrificed their own needs to find solutions to clients’ problems. Acknowledging the high levels of stress and anxiety that they were experiencing had a negative impact on their mental health CHWs agreed that they were in need of ongoing social and emotional support to maintain their health and wellbeing. Job-related burnout was found to have significantly increased during the COVID-19 crisis while, at the same time, self-care was found to decrease among healthcare workers (Kulkarni et al., 2020; Miller & Reddin Cassar, 2021), making it difficult to maintain a beneficial work-life balance (Senreich et al., 2021). Social distancing restrictions resulted in some employees receiving less social support and social interaction at work than they desired which was harmful to their mental health (Breetzke & Wild, 2022). Supportive, positive statements of appreciation by organization management, supervisors and coworkers have been cited as important to the wellbeing of frontline staff who continued working during the COVID-19 pandemic (Morse & Dell, 2021).

Lastly, a unique discovery of this study that has not been addressed in other studies was that George Floyd’s murder added an extra layer of fear and exhaustion for CHWs on top of the stress of dealing with COVID-19. Collective experiences of systemic racism have burdened the Black community and impacted the health and wellbeing of persons of color (Garcia, 2021; LeMoult, 2021; Skerrett, 2020). To continue working and providing services during the COVID-19 pandemic CHWs had to compartmentalize their own strong emotional reactions to George Floyd’s killing, adding to the toll on their emotional and mental health.

Identifying the changes and challenges that impacted CHWs in the Memphis metropolitan area provides insight into strategies and actions that may mitigate the effects of another public health crisis. Adults spend more than one-third of their lives in organizational work settings. Likewise intervening with workplace programs and policies can improve the quality of life for American workers through the promotion of a healthy work environment (Centers for Disease Control and Prevention, 2016). Organizational and workplace structures and processes can have substantial influence on the health and wellbeing of employees particularly in a pandemic situation (Morse & Dell, 2021). In combination with the emerging research literature reporting the experiences of service workers during the COVID-19 pandemic our findings lead us to make the following organizational recommendations that are practical and feasible ways to support CHWs now and in the future.

Recommendations

Adopt Organizational Policies that Support a Work/Life Balance

Increased workload and number of work hours found in the current study and supported by others leads to the recommendation that agencies and organizations have plans in place to support a work-life balance for CHWs during public health crises (Senreich et al., 2021). Organizations should have policies and procedures that utilize best practices for working from home so that CHWs may achieve a satisfactory balance of work with family and leisure time (Birimoglu Okuyan & Begen, 2021). Organizations can also adopt regular training on strategies to reduce stress, avoid burnout and learn self-care techniques. Workplace plans can outline safety protocol and flexibility benefits (i.e., flexible hours, flexible job responsibilities) that prioritizes worker wellbeing (Magruder et al., 2022). This includes having standard work hours for CHWs and support for CHWs to establish work schedule boundaries with clients (Senreich et al., 2021).

Invest Resources in Technology and Training

CHWs in the current study, and corroborated by similar research, described technical difficulties and challenges they faced adjusting to working remotely. It is important that agencies and organizations ensure that CHWs not only have the tangible communication tools (cell phones, computers and internet), but also that they are prepared to deliver services virtually. This necessitates ongoing training regarding new technology and equipment to improve organizational readiness and ensure client confidentiality. The National Association of Community Health Workers suggests that “employers should provide protected, paid time for CHWs to participate in meetings, informational webinars, trainings, or other offerings provided by local, state, regional, and national CHW associations. Such activities may help ensure that CHWs have access to the latest science, develop new skills, gain knowledge about ever-evolving community resources, and receive emotional support” (Mayfield-Johnson et al., 2020, p. 274).

Social Support and Supervision

Findings from the current study and similar studies indicate that organizational settings should develop or strengthen social support systems for CHWs through increased opportunities for social interactions with colleagues and compassionate practices such as personal check-ins to prevent the negative mental health consequences of social distancing (Breetzke & Wild, 2022). Support networks and supervision may be useful to improve employees’ social connections and mental health (Breetzke & Wild, 2022). Remote work communities can facilitate virtual social support networks, including self-help groups, which encourage a culture of self-care practices (Miller & Reddin Cassar, 2021). Supervision and professional mentorship can be an important aspect of self-care practice (Miller & Reddin Cassar, 2021). Workers who received high quality supervision during the COVID-19 pandemic acknowledged that it helped them to feel part of a team and reduced their stress (Morse & Dell, 2021). The organizational dynamics of a workplace, such as those with effective communication, supportive supervision, and a strong teamwork environment, may provide a buffer against the occupational stress experienced by CHWs at the forefront of HIV service provision (Ginossar et al., 2014; Morse & Dell, 2021).

Limitations

The findings of this study are limited to this group of 23 CHWs and supervisors and may not be generalizable to all CHWs. However, the purpose of this qualitative research study was not to generalize but rather to understand the challenges of working during the COVID-19 pandemic from the perspective of CHWs who support people living with HIV.

Conclusion

This study sheds light on the importance of understanding the substantial influence that the social environment and organizational factors can have on the unique challenges that CHWs serving vulnerable populations face. The experiences of CHWs during the COVID-19 pandemic may inform agencies, organizations, and policymakers of how to best support the critical work of the frontline HIV workforce.