Trustworthiness

The data analysis was carried out in a precise, consistent and exhaustive manner through recording, systematising and disclosing the technique of analysis with enough detail to enable the reader to determine whether the process is credible. Four researchers collected the data and prepared the transcripts. After reading the transcripts from all interviews in detail, the first and second authors (SNBKT and BZI) independently coded the data that were deemed to be relevant to the current study. Disagreements were discussed with the senior author (SMA). The next step was to group related codes into potential themes (SNBKT and BZI). Subsequently, four authors (SNBKT, BZI, MRI and SMA) jointly reviewed the themes to ensure that (1) the codes in each theme were coherent and that (2) the codes in different themes could be distinguished. Finally, the themes were defined and named by two authors (SNBKT and BZI), and a narrative structure with accompanying descriptions was produced by all authors. Moreover, the four key components of data trustworthiness, such as credibility, transferability, dependability and conformability, are ensured by the senior author (SMA).21

Patient and public involvement

Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.

Sociodemographic profile of the FLWs

Of the total 41 FLWs, 54% were male, and 46% were 30–39 years old. The majority (71%) were from public facilities located in the rural areas, and almost one-third (29%) of the respondents were physicians by training. Fifty-six per cent of the FLWs had more than 5 years of working experience, and about 46% of the FLWs were responsible for providing services in the inpatient care unit (table 2).

Division-wise distribution of FLWs

About one-third, 28% of the FLWs were from the Dhaka division, including the capital (Dhaka) city. The lowest 3% of participants were selected from Barisal and Mymensingh divisions. Division-wise distribution of the FLWs is illustrated in figure 3.

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Figure 3

Division-wise selection of FLWs. FLW, frontline health worker.

Thematic analysis of FLWs’ KAP and experience in professional and personal lives during the early days of the COVID-19 pandemic are presented further.

Basic concepts, signs, symptoms, mode of transmission and preventive measurements

Physicians from both urban and rural settings were more knowledgeable and well informed regarding the basic concepts of COVID-19 than other FLWs. They were cognisant of the signs, symptoms, mode of transmission of the virus and prevention measures against the virus announced by WHO. They expressed that handwashing with soap/sanitising with alcohol, maintain distancing, using masks, covering the mouth while sneezing and appropriate use of PPE in the hospital settings were the standard preventive measures for the disease.

Physicians are learning about the disease. Its sign, symptoms, prevention measures are important to know providing the treatment in this pandemic situation. (Female physician)

Mixed knowledge was observed among nurses, paramedics and CHWs (rural/root level FLWs). Some of them were not acquainted with the prevention measurements of COVID-19, as one of them said

There is no supply of hand wash in our facility, we wash our hands using soap. I have no idea whether the soap can kill this deadly virus. (Female, FWV)

The support staff was the confusing workforce among all in terms of knowledge related to COVID-19. They lacked knowledge of its transmission or prevention measurements. One of the word boy from a rural facility expressed:

I have heard that fever is the symptom of this disease, but I don’t know how does the virus transmit or what are the actual preventive measures (Male, ward boy (WB))

Sources of knowledge and training on COVID-19

Urban physicians underwent formal training on COVID-19 prevention and its management from the Director-General of Health Services (DGHS) and the Institute of Epidemiology Disease Control and Research, and were self-trained following online platforms like the WHO or national guidelines for DGHS websites. On the other hand, the rural providers could not undergo any institutional training due to the sudden lockdown in the country. Nurses had received training on COVID-19 management from their respective facility or authority. Physicians and nurses who underwent the training had learnt the infection prevention, control, triage and screening of COVID-19 in the training session, which facilitated them to improve their knowledge regarding the mysterious virus. A physician said,

I am the only person in this facility who received training on COVID-19 from IEDCR. I had to go to Dhaka for the training. Due to sudden lockdown, other staff of our facility could not receive the training. (Male physician)

Unfortunately, the other FLWs like subassistant community medical officer (SACMOs), medical technologists, Family Welfare Visitors (FWVs) and WBs did get any opportunity to receive formal training. They received simply verbal instruction from physicians or other staff of their respective facilities. Social media was found to be the common source for the rest of the FLWs. One of the community level healthcare providers expressed:

I have not received any formal training, however, I have seen a video uploaded by our SACMO on a Facebook group, where I have learned how to manage the patients infected with the coronavirus. (Female, FWV)

PPE training, correct methods for donning and doffing PPE

Similar to basic training on COVID-19, the FLWs did not undergo any training approaching the proper and effective usage of PPE. The physicians acquired the least ideas of PPE use while undergoing training on COVID-19 patient management from different organisations. They reported that the donning, doffing and discarding of PPE were demonstrated in the training. Also, a separate session and practical demonstration on how to use and discard PPE was included in the training session. Others received virtual training on the use of PPE from the WHO or other institutional websites, social media and YouTube channels. One of the physicians from an urban facility articulated:

However, I did not receive any formal training from my organisation on PPE but I have managed to learn all these from WHO guidelines and national guidelines. (Male physician)

FLWs posted at rural stations were the ignored ones in case of receiving training on PPE too. Only verbal instruction from the hospital senior was provided to them in many cases. Support staff from a rural facility uttered:

We have not received any training on PPE yet. Our higher officials just told us how to deal with a suspected case, and how to wear and dispose of the PPE… ….but a proper training would make us more confident on providing services. (Male, WB)

All levels of FLWs expressed that proper training could guide them in handling patients carefully and in providing treatment confidently. Some of the providers were not convinced with the information provided by some internet sources or confused about the authenticity of the information. Physicians and nurses preferred authentic online sources of information regarding emerging diseases including the current pandemic, whereas the community-level staff prefer hands-on training over internet sources.

Attitude towards preventive measures and willingness to work during the COVID-19 era

The physicians and nurses believed that standard precautions could protect them from the risks of COVID-19. Other FLWs showed a mixed attitude towards the preventive measurements. They perceived that the disease was preventable or curable. Yet, deeming the disease was not curable was found among them as well. One of the nurses from an urban facility confidently expressed:

If we use appropriate PPE and follow the other preventative measurements like handwashing practice, maintaining social distances inside and outside the hospital settings, I believe that we would be safe from COVID-19. (Female nurse)

The FLWs expressed their courage, willingness and dedication to work during this terrible pandemic. They uttered they were ready to face any of the challenges and would continue fighting against the virus. A rural provider said,

Whatever happened to us, we have nothing to do…. we will provide services to the people until we die… it’s our duty…. We are the caregivers, we can’t deny our duties neither can leave the job. (Male SACMO)

Fear of becoming infected, fear of death

The FLWs although showed their courage and determination to perform their duties perfectly in this pandemic, but expressing fear of getting infected or dying due to COVID-19 infection was found among them too. The paramedics, community healthcare providers and support staff showed a negative attitude towards the viral infection and were panicked about getting infected. Perception of long sufferings and death due to the virus was commonly found among them. All levels of FLWs assumed that the number of COVID-19 cases was increasing and would continue to increase in the upcoming days. They also believed that anyone could be infected regardless of age, sex and location in the country. Moreover, according to the FLWs, the infection and mortality rate was higher among FLWs than among common people. Providers expressed:

Anyone can be infected or dies of this virus… virus doesn’t know who is a doctor or who is not…so I am not out of danger too. (Female physician)

As I directly handle the samples, probably I have more chances of getting infected, many people are getting infected and dying in front of my eyes, no treatment is known to recover from covid-19, so no exception will happen to me, too….if I get infected, probably I will die as well. (Male medical technologist)

Managing patients following protocol, coping mechanism

Apart from using personally purchased PPEs, urban FLWs were dealing with all cases of suspected patients quite according to the protocol (triage and screening). Private facilities in urban areas follow the more structured and advanced protocol as they usually had the option of proper triage and screening. One of the providers from private sector vividly described:

We have triage and screening protocol… we try to isolate the COVID-19 suspected patient at emergency… there is a specific corner in our hospital, we try to treat them there. If those corona dedicated rooms or intensive care unit (ICU) is not vacant, we refer them to another hospital. (Male physician)

At the grassroot level, the FLWs were aware of ways of dealing with patients during the pandemic crisis. Although triage was not possible there, they asked the patients whether they had any symptoms of COVID-19 or not. Counselling the patients also came up as a strategy to deal with the suspected cases. One of the rural FLWs thus expressed:

Nowadays we try to handle every patient equally, we consider them as they are already infected and counsel them accordingly. (Female Health Assistant (HA)

Shortage of personal protective equipment, lack of supply from the facility

The shortage of proper protective equipment was the biggest challenge faced by FLWs at all levels. It was hindering their physical and familial situation as well as hampering their mental health at both personal and professional levels. The quality of PPE was a matter of concern, too. They assumed the PPEs were not protecting them properly since many of their colleagues were frequently getting infected with the virus. Moreover, they had to reuse PPEs due to the shortage of supplies from the facility. Even after requesting the local authorities like assistant commissioners/Upazila Nirbahi officers, many of them could not manage to get any PPE. In rural areas, PPE was hardly available. Pharmaceutical companies or civil society organisations donated PPEs to a limited number of FLWs and which were administered once in a facility. Considering the risk scenario, they had to purchase their PPEs out of their self-awareness. Purchasing PPE on a regular basis on their own was also challenging for them on account of the high market price during the pandemic. FLWs vividly expressed:

We are facing trouble because of not getting proper and adequate PPE. PPE provided by the authority is basically for one-time use. As we are reusing it, eventually we can be infected…. (Male physician)

I have received one set of PPE once from the facility…I am reusing the gown daily…but I had to buy some N95 masks myself. (Female midwife)

The rural FLWs were facing trouble because of the shortage or no supply of hand soap or sanitiser inside the facilities. Also, the KN95 masks and gloves were rare in rural markets.

We are not getting enough PPE, hand wash, and hand sanitizer. When patients come to us, we cannot tell them to wash their hands first then enter the facility. Because we don't have running water outside the center. Tube well is also far from here. (Female, FWV)

Patients lacked awareness of COVID-19, risking FLWs’ lives

The FLWs of all levels expressed that the patients lacked knowledge of COVID-19 and thus they did not follow any precautions for COVID-19. The FLWs face hurdles during handling, such ignorant patients in the early days of the COVID-19 pandemic. Wearing masks and keeping social distances were not maintained by patients. The scenario was even worst in the rural community. The FLWs stated that patients’ unawareness and ignorance towards COVID-19 precautions eventually made their lives extremely vulnerable and they were getting infected within a short period due to such ignorance of community people. Some illustrative quotes by the FLWs are as follows:

People wander around keeping the masks in their pockets. Even if they come to the hospital they don't use masks. If the whole family comes to the hospital, one of them wears a mask and the others don't. (Female physician)

As they don’t know about this pandemic, they don’t follow any preventive measurement and behaves like the virus is nothing serious…. (Male SACMO)

Patients scared of being isolated and socially stigmatised, FLWs facing trouble

Hiding histories among the suspected patients were among the rural community, mentioned by the FLWs. The urban patients had certain misconceptions regarding the disease as well. While the people detected with COVID-19 were positive, they were fearful of being isolated, socially stigmatised and frightened of not getting treatment from the facilities. The FLWs also expressed that the people tend to hide history/symptoms from fear/phobia about being quarantined or the term ‘quarantine’. Also, neglect by society and neighbours was the prime concern for the community people. Besides, they assumed that police and local authorities will lock them. Eventually, the situation made all levels of FLWs scared to provide treatment to the suspected cases at the beginning of the uncertain times of the COVID-19 pandemic. One of the FLWs from an urban facility expressed:

They (covid-19 suspected or patients) have a fear of not getting proper treatment and social harassment if they express their histories… as they are hiding their histories, we are eventually at risk. (Male physician)

The FLWs from rural facilities said,

Corona suspected people are neglected by society. Villagers think this kind of people is not good human beings…so they humiliate the infected people. (Female nurse)

They don't have enough idea about quarantine, again they think they might be harassed by the administration or the villagers if they reveal any sign or symptoms. (Male SACMO)

FLWs’ mental health fallout, shortage of staff and high workload

Anxiety and panic became common among FLWs at the beginning of the COVID-19 pandemic. The major threat to the mental health of these FLWs was the fear for their families’ safety as they were frequently exposed and had to return home at the end of the day. The FLWs had to serve for a 24-hour-long hospital duty wearing the same PPE. They did not discard it during the day; rather, they tried to preserve the PPE for another day. Sometimes they could not even go to the washroom because of the deficit of PPE. They were worried as this consequence might end up with other health issues. Moreover, they experienced a shortage of workforce in the facilities. Consequently, there was high workload than the normal days during the pandemic state. No policy of 7/14 quarantine was followed accordingly. Most of them did not get any separate accommodation after COVID-19 duty. They FLWs were frightened and worried about their family members’ health and safety issues. One of them stated,

I am not frightened if I get infected, I am scared of what would happen if my family get infected… I would not forgive myself and such though are making me mentally upset. (Female physician)

Socially ostracised

The FLWs were neglected and ostracised by neighbours. The community people deeming their speculations of being infected with COVID-19 through the FLWs. Both the urban and rural FLWs experienced remarkable indifference from society. Neighbours or homeowners of the physicians residing in urban areas at times refused to allow them to return home after duty. The rural FLWs equally were humiliated by the local shopkeepers who denied to vend their products to them. Consequently, emotional distress and negligence by society made their lives more depressing, as they expressed:

Homeowner and neighbours do not want us to go back to home after hospital duty … they are concerned about their health issues and considering their safety, sometimes the homeowner even locked the main gate, so that we cannot enter the house. (Male physician)

I went to buy food in the local market, the vendor misbehaved with me and directly told me not to visit his shop anymore….I felt so devastated and couldn’t decide where to go to purchase the essential goods at midnight. (Male SACMO)