Study design

The analysis presented in this paper adopted a phenomenological exploratory qualitative approach using focus group discussion (FGDs).

Study setting and local context

The study was conducted in Kiambu County, located in the central region of Kenya, covering an area of 2,543.5 km². According to the 2019 census, the average household size in the county is five individuals. At the time of the study, Kiambu had 795,241 households and 132 community health units (CHUs). The CHV-to-household ratio was 1:100, and the community unit-to-household ratio was 1:1,000 [5]. The county was served by 98 health facilities distributed across various levels of care, including three Tier 5 inter-county facilities, 13 Tier 4 hospitals, 24 Tier 3 health centers, and 70 Tier 2 dispensaries.

During the COVID-19 pandemic, Kiambu adopted a centralized approach to managing COVID-19 cases, designating Tigoni Level 4 Hospital as the sole facility for COVID-19 services [12]. As a result, all COVID-19 patients were referred to this hospital during the study period. At the time of the study, Kiambu County had the second-highest number of confirmed COVID-19 cases in Kenya [13]. The county reported its first COVID-19 case in March 2020, and by August 2022, the total number of confirmed cases had risen to 21,209, with 896 deaths [13], resulting in a case-fatality rate of 4.22%.

To be a CHV in Kenya, one needs to have been a member of the community where they are serving for a minimum of 5 years prior to their appointment [14]. They should not expect financial remuneration for their services from the government. They should be “willing and ready to provide services to the community without charging” the community members for the same services [14]. This was the general situation at the time of the study, but since October 2023, they receive a stipend for their services from the County Governments of Kenya (GOK).

CHVs in Kenya typically serve approximately 100–500 individuals depending on the county’s population density [15].

Sampling

To determine the number of CHVs in Kiambu County eligible for selection, the study examined the functional Community Health Units (CHUs) within the county from 2017 to 2020, as shown in Table 1 below.

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Table 1. The total number of functional CHUs within Kiambu County during the period under study. The data was derived from the Kenya Health Information System (KHIS).

https://doi.org/10.1371/journal.pone.0322642.t001

To participate in the FGDs, CHVs were required to meet the inclusion criterion below.

Inclusion criteria: To be eligible for participation in the FGD, a CHV had to have at least 5 years of experience, including the three years within the study period (2017–2020), have been actively involved in the pandemic response, and be available for the interview.

Exclusion criteria: Any CHV who did not meet the above stipulated qualifications was excluded.

However, identifying eligible CHVs was challenging due to the consistently low number of functional CHUs prior to 2020 (Table 1) alongside strict pandemic measures. The substantial increase in functional CHUs observed in 2020 reflects the increased demand for community health services driven by the COVID-19 pandemic and the GOK community health strategy during this period. After consultations with CHSCs, it was determined that only 50 CHVs met the inclusion criteria.

Participants were selected through convenience sampling. The pool of eligible participants restricted to 50 CHVs, ensuring a basis for comparison of experiences before and during the pandemic. Therefore, two FGDs were conducted: one comprising 12 women and the other comprising 12 men, resulting in a sample size that represented 48% of the eligible CHVs.

To ensure adequate representation of Kiambu County, which consists of 12 sub-counties, two CHVs were selected from each sub-county. This included 12 participants from upper Kiambu (a predominantly rural area), and 12 participants from lower Kiambu (which is more urbanized).

Focus group guide development

A literature review was conducted to explore the known impact of the COVID-19 pandemic on the CHVs to direct the content of the FGDs using four key papers [16–19].

Under the collaborative guidance of a sociologist affiliated with Mount Kenya University and MMK, a public health expert representing the County Government of Kiambu, an FGD guide was tailored to the objectives of the present study. This guide was developed in English.

The focus of the FGD was on the experiences of CHVs in performing their roles and responsibilities, particularly in light of the additional duties they were assigned during the pandemic. We aimed to explore whether they were able to effectively carry out their responsibilities under these new circumstances. Given that CHVs regularly interact closely with community members in their homes, we also sought to identify the strategies they employed to overcome the challenges they faced during the lockdown. Furthermore, due to their direct contact with the community, CHVs served as a proxy for understanding community perspectives on COVID-19, including views on its origins, spread, and preventive measures. Finally, recognizing that CHVs represent the first level of healthcare in Kenya (one that should have the broadest coverage), we inquired about their views on the government’s handling of the pandemic.

NW and BK then received training on qualitative data collection and conducted the FGDs. This content was collated in the form of an interview guide with six key questions targeting the public health measures for use in the focus groups:

1. Please share your experiences during the COVID lockdown. What challenges did you face, and how did you overcome them?
2. How did the community respond to the COVID-19 control measures?
3. How did the COVID-19 control measures impact community access to health facilities?
4. How did the COVID-19 control measures affect the community’s ability to manage other priority diseases?
5. What are the community’s views on COVID-19 regarding its origin, spread, and prevention?
6. Do you feel the county was prepared for the COVID pandemic, and is it prepared for another pandemic if it were to occur?

In addition to the development of the FGDs, a desk-based analysis was conducted, the details of which are available in the S2 File.

Data collection

All participants were given information about the study. All FGD interviews began after receiving signed written informed consent forms from each participant during recruitment. The participants were free to leave at any time during the FGD and this was communicated in the consent form.

In total, two FDGs were conducted on the 4th and 6th June 2021.

The responses to the FGD questions were allowed in either Kiswahili or English, depending on the participants’ preference, and the discussions were conducted in a private area of a convenient health facility to ensure free and uninterrupted conversation.

For anonymity, participants did not share their names or any personal identifiers. Instead, they were given numbers for transcription purposes.

All the FGDs were audio recorded. The duration of the FGDs ranged between 1–2 hours, followed by a debrief session.

Data management and analysis

The Principal Investigator (PI), MMK, served as the County Head of Clinical Research. NW, who conducted the data collection, was the Monitoring and Evaluation Coordinator for Kiambu County's Health Department. The transcriber, PKJ, has extensive experience in transcribing qualitative data.

Data from the audiotapes were transcribed verbatim and translated into English for analysis. Both inductive and deductive data analysis approaches were employed.

Initial transcription was performed by PKJ, with both PKJ and MMK independently reviewing the transcripts and generating initial codes. To ensure rigor and validity, the two researchers (PKJ and MMK) collaboratively reviewed the data during a subsequent meeting, further refining the codes through indexing and charting, and reached a consensus.

The finalized codes were used to categorize segments of the transcripts using MAXQDA 2020 (VERBI Software, Consult. Sozialforschung. GmbH, Berlin 2019), a qualitative data analysis software that facilitates systematic coding, categorization, and organization of textual data. The software also enabled quantification of code frequency, aiding in the identification of patterns within the dataset.

Finally, any discrepancies in the coding process were addressed through discussions among MMK, NW (who also generated their own independent codes), and PKJ, leading to an agreement on the emergent themes.

Ethical considerations

Ethical approval was sought and granted from The University of Eastern Africa Baraton Ethics Committee, approval number UEAB/REC/08/06/2020. Permission was also obtained from the County Health Department.

This work has been carried out in accordance with The Code of Ethics of the World Medical Association (Declaration of Helsinki) and aimed for the inclusion of representative human populations.

Informed consent was obtained from each participant and no private identifying information was collected before, during or after the study, and the study was voluntary, allowing participants to opt out at any time.

Participants

There were 24 participants in the FGDs. The male-to-female ratio was 1:1. The range of experience of the participants was 5–24 years.

Findings

Part A of this study presents the experiences of the CHVs during the COVID-19 lockdown. Part B presents the perspectives of the community regarding COVID-19 as reported by the CHVs. Part C covers the opinions of the CHVs on the county government’s preparedness for COVID as well as a future pandemic.

Part A: The experiences of the CHVs during the COVID-19 pandemic

Barriers to community health service delivery

The COVID-19 pandemic disrupted the ability of CHVs to perform their duties due to the implementation of public health measures aimed at curbing the spread of the virus. One of the key strategies employed by the government was the restriction of physical movement through the establishment of zonal roadblocks on major public routes. These restrictions had far-reaching consequences, not only limiting patients’ access to healthcare facilities for regular appointments but also restricting CHVs’ ability to reach their clients. This was particularly problematic for individuals with chronic conditions, such as those attending comprehensive care clinics (CCC) for HIV treatment.

“As a community volunteer … we didn’t go door-to-door to check for the clients that we had. We didn’t have equipment that we should have used for that period. And still, the community that needed us didn’t have any gathering [due to social distancing] to educate them in various ways.” (Resp.11)

“…like those patients who would come to CCC, many were far away and there were roadblocks. For instance, maybe they’re from Lari and they come to the facility in Tigoni, and now there was a road block at Mathore. So now will they really pass through?” (Resp.12)

“okay to add to that I can say that most of the community members found that since there was cessation of movement most transport or public means were not available to them. So, it was required to take a taxi or a motorbike and then also the fare was hiked. Then you get to the roadblock and you asked where you are going and you remove a paper from the hospital and say I am going to hospital. So, to avoid all that you just stay at home.” (Resp.7)

In addition to the movement restrictions and roadblocks, a curfew was imposed, further restricting people’s ability to seek emergency care outside of designated hours. As a result, even though alternative channels for emergency medical services were put in place, these measures were not widely known or accessible. This compounded the challenges of timely response to emergencies, as individuals were unable to receive prompt care during the restricted hours.

“Because curfew was enforced, even motorbikes didn’t go anywhere, cars were not on the road. To have an illness meant you had a lot of problems and not all of the people knew that 1196 number. Many people died because they didn’t get access to doctors. they just died.” (Resp.3)

When CHVs were able to visit patients at their homes, they faced additional challenges in providing care due to the need to observe social distancing and adhere to the government’s ‘low touch’ guidelines. This was further compounded by the lack of appropriate personal protective equipment (PPE) and essential Point of Care Diagnostic devices.

“You had to somehow keep distance while measuring that child’s temperature, and then you had to sanitize everything you used. Then the parents also had to sanitize. it was even better if you showed the mother how to check the temperature and they did it for you. Then after the mother checked the temperature you had to sanitize it again. It was hard work for parents to understand what you are saying, you see you are not close to them…” (Resp.8)

Part B: Community perspectives on and responses to the COVID-19 measures

Economic hardship

According to the CHVs’ opinions, initial adherence to COVID-19 requirements gradually decreased as a result of financial consequences. The general perception among the CHVs was that the government had neglected its sick citizens and failed to provide financial support during the pandemic. Additionally, gender-based violence was seen as a consequence of these financial challenges. There was also a belief that political leaders themselves did not adhere to the health protocols.

“...there was no money to buy food, there were no jobs, GBV increased again, gender-based violence. Because the husband didn’t have money and the wife didn’t have money, so you would just hear people were kicked out of their homes, people were fighting each other...” (Resp.5)

“... And it was expected that the government would provide their basic needs but then you aren’t at work the kiosk isn’t open and, in the evening, you have to eat something. So quite a number of them began to stop adhering to the stay-at-home orders.” (Resp.9)

“it reached a point politicians resumed political rallies so people, the community were relying on the leaders by watching how they operate. So, people saw the political rallies are ongoing, so they stopped adhering to the measures. People began to go to meetings. Like the meetings for dowry, those resumed.” (Resp.10)

Misinformation about COVID-19

The community members generally doubted information about COVID-19. It was a prevalent theme that the official narrative about the origins of COVID-19 was not entirely dependable, that the disease did not exist, or that it was a money-making scheme. In addition, according to the community, rural dwelling Kenyans were protected from contracting COVID-19 becauseit was a disease for the rich, foreigners, travellers, or urbanites.

“Even right now many people say that there is no such thing as COVID.” (Resp.3)

“Another side to it is that, the time it came here they believed it was a way for the government to make money. So, they didn’t care. Maybe only because of the police they complied with some of the measures.” (Resp.12)

“.. there was no person who worked like us CHVs did explaining to people about COVID. They would say this is a government project to look for money from us…” (Resp.1)

“about the community perspective about the origin of COVID, many said that it was a disease from China for Chinese and it can’t kill Kenyans…” (Resp.3)

They were also misinformed about the mode of transmission of the disease.

“In the bars, they would say they would say that you are drinking alcohol but you are also washing your hands with sanitizer, so you won’t get COVID.” (Resp.10)

Part C: CHVs perspective on county governmental readiness for the COVID-19 pandemic and future pandemics

CHV dedication

We found that the CHVs demonstrated unwavering perseverance to fulfill their duties in spite of their various constraints. From the emerging themes, this motivation arose from their intrinsic and altruistic desire to serve their community. This is similar to a study conducted in the United Kingdom, though this study collected anonymous data from front-line HWs who worked in hospitals [22]. Another comparative, qualitative study conducted in both Sierra Leone and Nepal reported individual determination, a sense of responsibility to the community and professional duty that compelled staff to stay or return to their workplace [23]. This corroborates the present study results and underpins the resilience possessed by HWs across all tiers of the health system.

However, our findings contrast with studies conducted in other settings, where HWs faced challenges that sometimes led to disengagement or burnout. A study conducted in Kenya highlighted that inadequate supportive supervision and insufficient resources and supplies were significant contributors to the demotivation of CHVs, ultimately leading to poor performance [24]. This phenomenon was not confined to LMIC settings. Similarly, a mixed-methods study conducted in Massachusetts reported that 37% of HWs in the study expressed intentions to leave the profession due to the mental health impacts and burnout due to the COVID-19 pandemic [25].

The dedication displayed by CHVs in this study could be the strong community foundation in rural and peri-urban settings in Kenya. CHVs often live in the same communities as their clients, fostering personal relationships that go beyond professional duties. This cultural connection likely contributed to the CHVs’ sense of responsibility to continue serving their communities. This intrinsic motivation has also been described in neighboring Tanzania [26]. Furthermore, support from government partners and NGOs in providing resources helped mitigate some of the challenges faced by CHVs and provided support for their duties.

Stigma was a barrier

The CHVs experiencing stigma from the community members. This is in tandem with the findings from studies conducted in Guinea, Liberia and Sierra Leone during the Ebola outbreak [27]. There were also similar findings from Uganda during the Marburg and Ebola outbreaks where HWs were ostracized by both the society and family members [21]. The reported effect in the latter study were so severe, one community HW had to defend himself on radio after recovering from Ebola. Although our study’s experiences did not go to that extreme, they do underscore the need for more government and public health professionals to concentrate on health advocacy and sensitization. In contrast to these findings, a study in Sierra Leone found that HWs felt supported by their communities [28]. This support was attributed to the recognition of the HWs’ essential roles and the collective effort to combat the outbreak.

Rampant misinformation within the community

The second-person accounts of the community perceptions of COVID-19 relayed fear of health facilities. A lot of these fears coexisted with misinformed beliefs about the pandemic. This is in line with a study conducted in the United States and Canada where respondents believed HWs should be isolated from their communities and families [29]. For fear of infection, more than a third of respondents avoided HWs in the latter study [29]. Similar to our study, the decay in adherence to COVID-19 public health protocols has also been described previously [30]. This necessitates increased efforts from stakeholders to address this issue in future pandemics, as it has significant implications for both mental health and adherence to health protocols [30].

Economic strife

The CHVs also highlighted the negative economic effects of the response to COVID-19 on the community members. This is corroborated by another study conducted in Poland where people relayed similar financial constraints as a result of the pandemic measures [31]. A similar impact was reported in a 2021 survey by the Ministry of Health in Kenya [32]. The survey revealed that among respondents who skipped meals, the percentage attributing this to the pandemic increased significantly, from 37% to 98% [32]. There was also a significant increase in the partial loss of income due to the pandemic measures in the latter report. These economic hardships within the community intensified feelings of abandonment by the government and contributed to a decline in adherence to COVID-19 protocols, as individuals struggled to meet basic needs, let alone afford masks and other PPE items. The need for targeted economic recovery efforts is pertinent and this finding highlights the importance of addressing the economic impacts in future pandemics to ensure compliance with public health measures and support for vulnerable populations.

Perceived shortcomings of the government

The respondents expressed reservations about the county government’s handling of COVID-19 and any potential future pandemics. This sentiment was also shared by nurses and doctors in Bangladesh during the COVID-19 pandemic and arose due to broken government promises [33]. In the Bangladesh study, the HWs were disregarded once they contracted COVID-19 and had to settle their hospital bills themselves despite the government promising to do the same. In the current study, respondents highlighted the county government’s failure to fulfill promises related to the provision of equipment, psychosocial support, and logistical resources, as outlined in the Government of Kenya’s Community Health Guidelines issued by the Ministry of Health [10]. This perceived neglect eroded trust and created doubts about the government’s capacity to manage pandemics effectively.

Contrasting this finding is a study from Singapore, where members of the public demonstrated high levels of trust in the government’s ability to manage the pandemic. This trust was attributed to the government’s transparency and open communication with the public [34]. As COVID-19 began to unfold in Singapore, key government officials in Singapore openly addressed the scientific uncertainties surrounding the virus in plain language. Furthermore, extensive contact tracing procedures, coupled with clear communication from credible sources, created a positive perception of the government’s risk management and established a high level of trust in its actions [34].

The contrasting sentiments between Kenya and Singapore, therefore, can be attributed to structural and logistical challenges that often hinder the ability of governments in LMIC settings to meet their commitments during health crises. Issues such as inadequate funding, supply chain difficulties, and competing priorities further exacerbate these challenges. Additionally, in our study, the perception of hypocrisy from government officials and instances of poor role modelling contributed significantly to the mistrust observed in the Kenyan context.

Limitations

A key limitation of this study is that only two FGDs were conducted; therefore, the findings and conclusions should be interpreted with caution, given the limited extent to which data saturation was achieved.

The limited sample size was primarily due to the availability of only 48% of eligible CHVs during the COVID-19 crisis, as pandemic-related restrictions made recruitment particularly challenging. Although participants were drawn from diverse settings within Kiambu County, the small number of FGDs limits the extent to which these findings can be extrapolated to the broader healthcare landscape in Kenya.

Nonetheless, this study provides a preliminary foundation for future research, particularly given the documented and longstanding systemic neglect of CHVs. Across counties, Level 1 services have been largely overlooked, CHVs have experienced high attrition rates and demoralization, stipends have not been consistently provided, and the policy framework for community health services remains in the process of institutionalization [35–37].

While we acknowledge the study’s limitations, the insights presented here contribute to a deeper understanding of the realities faced by CHVs and underscore the need for further research and policy attention.

Recommendations

Our findings reiterate well-documented barriers to achieving UHC at the community level in Kenya, particularly the challenges of stigma, misinformation, resource constraints, and public trust in government policies [38].

To address these challenges, the GOK should strengthen its public health communication strategies. Effective and culturally sensitive campaigns are essential to counter misinformation and reduce stigma, particularly during health crises. These campaigns should integrate clear, science-based messaging with community engagement efforts to build trust and enhance public adherence to health policies.

Given the pivotal role of CHVs in combating misinformation, ongoing training should emphasize empathy-based approaches to improve their ability to engage with community members.

Strengthening the community health strategy requires increasing both financial and emotional support for CHVs. Adequate compensation, access to mental health resources, and professional development opportunities are essential to reducing attrition and improving recruitment. The recognition of CHVs as community health promoters under the Primary Health Care Act, 2023 [7] is a significant milestone, but sustained investment in their welfare and training remains necessary. These interventions can serve to empower CHVs (now known as "Community Health Promoters"), reinforcing their role as frontline healthcare providers and enhancing the resilience of the healthcare system at the grassroots level.

Beyond CHV support, Kenya must address the persistent funding gaps within its healthcare system to strengthen infrastructure and human resources [39]. Increased investment is needed not only at the community level but also in expanding and equipping higher-tier health facilities that receive patient referrals. Current health budget allocations remain below the Abuja Declaration target, highlighting the urgent need for the government to prioritize healthcare in future fiscal planning [40].

Equipping CHVs with modern tools, such as the Electronic Community Health Information System (eCHIS), can improve community-level data collection, enhance service delivery, support monitoring and evaluation, and promote better integration into the national healthcare system.

Future research should aim to address the study’s limitations by employing broader methodologies across multiple counties to enable more generalizable and robust conclusions. A comparative study involving diverse regions and larger sample sizes would provide deeper insights into CHV experiences and inform more targeted policy interventions.