The COVID-19 pandemic significantly impacted healthcare workers (HCWs), causing increased workload and mental health challenges. While studies have examined the mental health of HCWs in medical centers, little is known about community health workers (CHWs), particularly those working in HIV care. CHWs play a crucial role in HIV care and prevention, especially in areas with limited access to public services. The COVID-19 pandemic added a dual burden for these workers, requiring them to maintain HIV services while simultaneously addressing the pandemic. This study aimed to investigate the mental health outcomes and resilience factors among CHWs working in HIV non-governmental organizations (NGOs) across multiple countries during the COVID-19 pandemic. The study's importance lies in understanding the resilience of this critical workforce and identifying support needs for future health emergencies. Previous research has highlighted the strain on HCWs during the pandemic, with evidence suggesting nurses experience higher stress and lower resilience compared to other HCW categories. Studies in various countries reported high levels of anxiety and stress among HCWs, underscoring the need to examine mental health outcomes in diverse healthcare settings and among different worker groups. This research specifically focuses on CHWs in the HIV field, who have unique challenges and responsibilities.

Existing literature extensively documents the negative impact of the COVID-19 pandemic on the mental health of healthcare workers (HCWs), particularly nurses, who reported high levels of stress and low resilience. Studies from various countries, including the US, Indonesia, and Spain, reported high rates of anxiety, depression, and post-traumatic stress symptoms among HCWs. However, research specifically focused on the mental health of community health workers (CHWs), especially those in HIV care, remains limited. A few studies have started to emerge, highlighting the challenges faced by CHWs during the pandemic, including concerns about personal protective equipment (PPE), financial incentives, and disruptions to services. The existing evidence emphasizes the need for further research to understand the mental health and resilience of CHWs, particularly given their critical role in maintaining essential health services during crises.

This study utilized a multi-country, cross-sectional design within the framework of the EPIC research program, a community-based mixed-methods program implemented by Coalition PLUS. The study included quantitative data collected from CHWs in Benin, Colombia, Guatemala, and Spain between March and December 2021. Data were collected through an anonymous online questionnaire using Voxco® survey software. The questionnaire included sections on sociodemographics, COVID-19 experiences, psychological well-being, and the impact of the crisis on work. Three scales were used to assess mental health: the 6-item Brief Resilience Scale (BRS), the 9-item Patient Health Questionnaire (PHQ-9) for depression, and the 7-item Generalized Anxiety Disorder (GAD-7) scale. Data analysis involved descriptive statistics, Spearman's correlation to examine associations between resilience and psychological well-being, and logistic regression to identify factors associated with low resilience. The study employed a convenience sample of CHWs from organizations participating in the EPIC program. Ethical approval was obtained from local ethics committees in each participating country. The study acknowledges several limitations, including convenience sampling, the possibility of selection bias (CHW who chose to participate may differ from those who declined), and the lack of a pre-pandemic baseline resilience score. The flexible nature of the EPIC program also resulted in optional sections within the questionnaire, impacting the number of countries and the breadth of data collected.

A total of 295 CHWs participated in the study, with the majority (76%) exhibiting normal or high resilience scores on the BRS. The median standardized resilience score was 58.33 (IQR = [50.0-75.0]), while median standardized depression and anxiety scores were 18.52 (IQR = [7.4-33.3]) and 19.05 (IQR = [4.8-33.3]), respectively. Resilience scores were negatively correlated with both depression and anxiety scores. Multivariate analysis revealed that several factors were significantly associated with low resilience compared to normal or high resilience: living in an urban area (aOR = 2.29, p = 0.024); not developing new professional skills during the pandemic (aOR = 2.01, p = 0.041); not having to separate from loved ones for COVID-19 protection (aOR = 4.69, p = 0.003); and experiencing discrimination or rejection due to COVID-19 risk in public spaces (aOR = 2.62, p = 0.015). There were no significant differences in resilience scores based on country of residence.

The findings of this study demonstrate that despite the significant challenges presented by the COVID-19 pandemic, a substantial proportion of CHWs working in HIV care displayed normal or high levels of resilience. This highlights the inherent resilience within community-based HIV care systems. The identified factors associated with low resilience provide valuable insights for improving support systems for CHWs. The association between urban residence and lower resilience could be attributed to increased exposure to COVID-19 and higher workload. The importance of acquiring new skills during the pandemic underscores the benefit of providing relevant training and professional development opportunities. The finding that CHWs who were able to protect their loved ones exhibited higher resilience highlights the importance of supportive policies that enable workers to balance their professional and personal lives. The significant association between COVID-19 related discrimination and low resilience points to the need for measures to combat stigma and discrimination faced by HCWs. These findings are consistent with existing literature on the protective effect of resilience on mental health outcomes during crises.

This multi-country study demonstrates the considerable resilience of CHWs in HIV care during the COVID-19 pandemic, while also identifying key factors associated with lower resilience. The findings underscore the need for targeted interventions to enhance CHW well-being, including skills training, strategies for self-care and work-life balance, and measures to address discrimination. Future research could explore the long-term impact of the pandemic on CHW mental health, investigate the effectiveness of specific interventions to promote resilience, and examine the role of organizational factors in supporting CHW well-being.

The study's limitations include the use of a convenience sample, which may not be fully representative of all CHWs in the participating countries. The lack of a pre-pandemic baseline measure of resilience limits the ability to assess the true impact of the pandemic. The optional nature of certain sections in the questionnaire also limited the generalizability of some findings. The cross-sectional design prevents causal inferences from being made, and potential selection bias due to self-selection into the study is acknowledged.