Safety Trade-Offs in Home Care During COVID-19: A Mixed Methods Study Capturing the Perspective of Frontline Workers




home care, COVID-19, frontline staff, focus groups


Home care visual abstract

Background: Home care workers help older individuals and those with disabilities with a variety of functional tasks. Despite their core role providing essential care to vulnerable populations, home care workers are often an invisible sector of the healthcare workforce. The transmission of COVID-19 and the nature of home care work raise several questions about the overall safety of these workers during the pandemic.

Objective: To examine the experiences of home care workers during COVID-19, particularly their access to information about infection status, to testing, and to personal protective equipment (PPE); their understanding of guidelines; and trade-offs associated with protecting workers’ safety.

Methods: A mixed methods study including qualitative analysis of guided discussion questions and quantitative analysis of multiple-choice survey questions was conducted. Eleven virtual focus groups in October and November 2020 involved 83 home care workers who care for clients/consumers in Massachusetts. Thirty-nine participants worked as personal care attendants (PCAs) employed directly by a consumer and 44 participants worked for an agency. Ninety percent self-identified as female and 54% had worked in home care for more than five years. Qualitative data was analyzed using thematic analysis, with identification of major and minor themes. Likert scale survey question data on perceptions of COVID-19 exposure, access to resources to prevent transmission, and perceptions of safety at work were dichotomized into agree or disagree.

Results: PCAs and agency-employed home care workers were regularly faced with trade-offs between meeting client/consumer needs and protecting themselves from COVID-19 exposure. Twenty-five percent of participants reported serving a client/consumer who had COVID-19, 75% reported worrying about getting COVID-19 at work, and 29% reported thinking about stopping their work in home care. Despite a low pay structure, participants reported opting to risk exposure rather than to leave their clients/consumers without essential care. However, workers often lacked the resources (e.g., PPE, testing) to feel truly protected. This scarcity of resources combined with insufficient guidance and policies specific to home care settings led many workers to informally collaborate with clients/consumers to assess exposure risks and agree upon safety protocols. Focus group participants expressed uncertainty as to whether workers were truly empowered to ask for changes if conditions seemed unsafe. The burden of determining safety protocols was felt more strongly by PCAs who operate more independently than agency-employed workers who have supervisors to consult.

Conclusions: Home care workers expressed deep commitment to continuing to care for their clients/consumers during COVID-19, but often had to operate with insufficient resources and under conditions that made their work environments feel unsafe. Their ability to identify exposure risks and make decisions on how to protect themselves often hinged on a transparent and trusting relationship with their clients/consumers. These relationships were particularly important for PCAs who did not have access to safety guidance from a home care agency.

Author Biographies

Godwin K. Osei-Poku, MBChB, MPH, Betsy Lehman Center for Patient Safety

Godwin K. Osei-Poku ( is a research analytics manager at the Betsy Lehman Center for Patient Safety, a Massachusetts state agency named for the Boston Globe health reporter whose death from a chemotherapy overdose in 1994 helped catalyze the patient safety movement. Previously, Osei-Poku worked at the Ministry of Health of Ghana, where he provided direct patient care, managed a community mental health program, and collaborated with policy leaders to design quality improvement initiatives for mothers and newborns. He holds a medical degree from the University of Ghana Medical School and a master’s in public health from Boston University.

Ola Szczerepa, MA, Betsy Lehman Center for Patient Safety

Ola Szczerepa is a research analytics manager at the Betsy Lehman Center. Prior to joining the Center, she worked in public health research at Massachusetts Health Quality Partners and in gambling addiction prevention at the Education Development Center. Szczerepa has also engaged in direct service and international research on disability. She holds a master’s degree in applied developmental and educational psychology and a bachelor’s degree in psychology from Boston College.

Alicia A. Potter, MFA, Betsy Lehman Center for Patient Safety

Alicia A. Potter is a copyeditor at the Betsy Lehman Center and senior science writer at Boston Children’s Hospital. She holds a Bachelor of Arts in English and communications from Simmons University and a Master of Fine Arts in writing for children and young adults from Vermont College of Fine Arts.

M.E. Malone, MPH, MS, Betsy Lehman Center for Patient Safety

M.E. Malone is deputy director of the Betsy Lehman Center. Together with the executive director, she sets strategic goals and priorities to advance the Center’s vital public health mission. Prior to joining the Center, she spent 25 years as a news journalist, including more than 10 as a staff reporter and assistant editor at the Boston Globe. Malone holds a master’s in public health and Master of Science from Tufts University, as well as a Bachelor of Arts in English from Boston College.

Barbara A. Fain, JD, MPP, Betsy Lehman Center for Patient Safety

Barbara A. Fain was appointed executive director of the Betsy Lehman Center in 2013. Her career has been devoted to health policy and includes directing a health policy research center at Harvard Law School and serving for over a decade as an assistant attorney general in Massachusetts. She received her Bachelor of Arts from Brown University; a Juris Doctor from the University of California, Berkeley; and a Master of Public Policy from Harvard Kennedy School.

Julia C. Prentice, PhD, Betsy Lehman Center for Patient Safety

Julia C. Prentice leads the research portfolio at the Betsy Lehman Center. Her projects focus on measuring the prevalence of adverse events, understanding the long-term impacts of medical error, and evaluating the effectiveness of key quality improvement initiatives. She previously worked at the U.S. Department of Veterans Affairs, advancing evidence-based policy and clinical practice. She holds a Bachelor of Science from Grinnell College as well as a doctorate and Master of Science in public health from the University of California, Los Angeles.


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How to Cite

Osei-Poku, G. K., Szczerepa , O., Potter, A. A., Malone, M., Fain, B. A., & Prentice, J. C. (2021). Safety Trade-Offs in Home Care During COVID-19: A Mixed Methods Study Capturing the Perspective of Frontline Workers. Patient Safety, 3(3), 6–17.



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