Safety Trade-Offs in Home Care During COVID-19: A Mixed Methods Study Capturing the Perspective of Frontline Workers
Keywords:home care, COVID-19, frontline staff, focus groups
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.
Nguyen LH, Drew DA, Graham MS, et al. Risk of COVID-19 Among Front-Line Health Care Workers and the General Community: A Prospective Cohort Study. Lancet. 2020;5(9):475-483. doi:10.1016/S2468-2667(20)30164-X
Shah ASV, Wood R, Gribben C, et al. Risk of Hospital Admission With Coronavirus Disease 2019 in Healthcare Workers and Their Households: Nationwide Linkage Cohort Study. BMJ. 2020;371:m3582.
Sun N, Wei L, Shi S, et al. A Qualitative Study on the Psychological Experience of Caregivers of COVID-19 Patients. Am J Infect Control. 2020;48(6):592-598. doi:10.1016/j.ajic.2020.03.018.
Galehdar N, Kamran A, Toulabi T, et al. Exploring Nurses’ Experiences of Psychological Distress During Care of Patients With COVID-19: A Qualitative Study. BMC Psychiatry. 2020;20(1):489. https://doi.org/10.1186/s12888-020-02898-1.
Cabarkapa S, Nadjidai SE, Murgier J, Ng CH. The Psychological Impact of COVID-19 and Other Viral Epidemics on Frontline Healthcare Workers and Ways to Address It: A Rapid Systematic Review. Brain Behav Immun Health. 2020;8:100144. doi: 10.1016/j.bbih.2020.100144.
Shaukat N, Ali DM, Razzak J. (2020). Physical and Mental Health Impacts of COVID-19 on Healthcare Workers: A Scoping Review. Int J Emerg Med. 2020:13(40). doi: 10.1186/s12245-020-00299-5.
Lai J, Ma S, Wang Y, et al. Factors Associated With Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease 2019. JAMA Netw Open. 2020;3(3):e203976.
Reckrey JM, Tsui EK, Morrison RS, et al. Beyond Functional Support: The Range of Health-Related Tasks Performed in the Home by Paid Caregivers in New York. Health Aff. 2019;38(6):927–933. doi:10.1377/hlthaff.2019.00004.
Bureau of Labor Statistics, U.S. Department of Labor. Occupational Outlook Handbook, Home Health Aides and Personal Care Aides. https://www.bls.gov/ooh/healthcare/home-health-aides-and-personal-care-aides.htm. Updated 9 April 2021. Accessed 23 March 2021.
Sterling MR, Silva AF, Leung PBK, et al. “It’s Like They Forget That the Word ‘Health’ Is in ‘Home Health Aide’”: Understanding the Perspectives of Home Care Workers Who Care for Adults With Heart Failure. J Am Heart Assoc. 2018;7(23):e010134. doi:10.1161/JAHA.118.010134.
Franzosa E, Tsui EK, Baron S. Home Health Aides’ Perceptions of Quality Care: Goals, Challenges, and Implications for a Rapidly Changing Industry. New Solut. 2018;27(4):629-647. doi:10.1177/1048291117740818.
Sterling MR, Tseng E, Poon A, et al. Experiences of Home Health Care Workers in New York City During the Coronavirus Disease 2019 Pandemic: A Qualitative Analysis. JAMA Intern Med. 2020;180(11):1453-1459. doi:10.1001/jamainternmed.2020.3930.
Boškoski I, Gallo C, Wallace MB, et al. COVID-19 Pandemic and Personal Protective Equipment Shortage: Protective Efficacy Comparing Masks and Scientific Methods for Respirator Reuse. Gastrointest Endosc. 2020;92(3):519-523. doi:10.1016/j.gie.2020.04.048.
Kim H, Hegde S, LaFiura C, et al. Access to Personal Protective Equipment in Exposed Healthcare Workers and COVID-19 Illness, Severity, Symptoms and Duration: A Population-Based Case-Control Study in Six Countries. BMJ Glob Health. 2021;6(1):e004611. Doi:10.1136/bmjgh-2020-004611.
Chu DK, Akl EA, Duda S, et al. Physical Distancing, Face Masks, and Eye Protection to Prevent Person-to-Person Transmission of SARS-CoV-2 and COVID-19: A Systematic Review and Meta-Analysis. Lancet. 2020;395:1973-1987.
Leiss JK, Sitzman KL, Kendra MA. Provision and Use of Personal Protective Equipment Among Home Care and Hospice Nurses in North Carolina. Am J Infect Control. 2011;39(2):123-128. Doi:10.1016/j.ajic.2010.05.021.
Polivka BJ, Wills CE, Darragh A, et al. Environmental Health and Safety Hazards Experienced by Home Health Care Providers: A Room-by-Room Analysis. Workplace Health Saf. 2015;63(11):512-522. doi:10.1177/2165079915595925.
National Employment Law Project. Data Brief. Surveying the Home Care Workforce: Their Challenges and the Positive Impact of Unionization. https://s27147.pcdn.co/wp-content/uploads/surveying-home-care-workforce.pdf. Published September 2017.
Sama SR, Quinn MM, Galligan CJ, et al. Impacts of the COVID-19 Pandemic on Home Health and Home Care Agency Managers, Clients, and Aides: A Cross-Sectional Survey, March to June, 2020. Home Health Care Manag Pract. 2021;33(2):125-129. Doi:10.1177/1084822320980415.
Markkanen P, Quinn M, Galligan C, et al. There’s No Place Like Home: A Qualitative Study of the Working Conditions of Home Health Care Providers. J Occup Environ Med. 2007;49(3):327-337. doi:10.1097/JOM.0b013e3180326552.
Shang J, Chastain AM, Perera UGE, et al. COVID-19 Preparedness in US Home Health Care Agencies. J Am Med Dir Assoc. 2020;21(7):924-927. doi:10.1016/j.jamda.2020.06.002.
Home Care Association of New York State. Phase II COVID-19 Survey: Summary of Impact on Home and Community-Based Entities, Staff and Patients in New York State [eLetter] https://hca-nys.org/wp-content/uploads/2020/04/HCA-Phase-II-Survey-Summary-Final.pdf. Published 6 April 2020.
Rowe TA, Patel M, O’Conor R, et al. COVID-19 Exposures and Infection Control Among Home Care Agencies. Arch Gerontol Geriatr. 2020;91. doi:10.1016/j.archger.2020.104214.
Cabin W. Pre-Existing Inequality: The Impact of COVID-19 on Medicare Home Health Beneficiaries. Home Health Care Manag Pract. 2021;1-7. doi:10.1177/1084822321992380.
Fain BA, Koonin LM, Stoto MA, et al. Facilitating Access to Antiviral Medications and Information During an Influenza Pandemic: Engaging With the Public on Possible New Strategies. Biosecur Bioterror. 2014;12(1):8-19. doi:10.1089/bsp.2013.0058.
Li G, DiMaggio C, Abramson, et al. The COVID-19 Healthcare Personnel Study (CHPS): A Rapid Longitudinal Workforce Study of NYS Providers and Allied Health Personnel in the Time of a Pandemic. medRxiv. 2021. doi:10.1101/2020.10.29.20222372. Published 12 February 2021.
Savoia E, Argentini G, Gori D, et al. Factors Associated With Access and Use of PPE During COVID-19: A Cross-Sectional Study of Italian Physicians. PLoS One. 2020;15(10):e0239024. doi:10.1371/journal.pone.0239024.
Nowell LS, Norris JM, White DE, et al. Thematic Analysis: Striving to Meet the Trustworthiness Criteria. Int J Qual Methods. 2017;16:1-13. doi:10.1177/1609406917733847.
PHI. Workforce Data Center. https://phinational.org/policy-research/workforce-data-center/#var=Gender&states=25. Accessed February 26, 2021.
Scales K. It’s Time to Care: A Detailed Profile of America’s Direct Care Workforce. PHI. https://phinational.org/resource/its-time-to-care-a-detailed-profile-of-americas-direct-care-workforce/ Published January 21, 2020. Accessed June 3, 2021.
Cox C. Older Adults and COVID 19: Social Justice, Disparities, and Social Work Practice. J Gerontol Soc Work. 2020;63(6-7):611-624. Doi:10.1080/01634372.2020.1808141.
Yau B, Vijh R, Prairie J, et al. Lived Experiences of Frontline Workers and Leaders During COVID-19 Outbreaks in Long-Term Care: A Qualitative Study. Am J Infect Control. 2021;S0196-6553(21):00138-3. doi:10.1016/j.ajic.2021.03.006.
Massachusetts’ COVID-19 Vaccination Phases. Mass.gov. https://www.mass.gov/info-details/massachusetts-covid-19-vaccination-phases#phased-vaccine-distribution-plan-. Accessed April 27, 2021.
State COVID-19 Vaccine Priority Populations. Kaiser Family Foundation. https://www.kff.org/other/state-indicator/state-covid-19-vaccine-priority-populations/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D. Updated April 19, 2021. Accessed April 27, 2021.
Bercovitz A, Moss A, Sengupta M, et al. An Overview of Home Health Aides: United States, 2007. Natl Health Stat Report. 2011;(34):1-31. https://www.cdc.gov/nchs/data/nhsr/nhsr034.pdf.
Seavey D, Marquand A. Caring in America, A Comprehensive Analysis of the Nation’s Fastest-Growing Jobs: Home Health and Personal Care Aides. PHI. http://www.phinational.org/wp-content/uploads/legacy/clearinghouse/caringinamerica-20111212.pdf. Published December 2011.
Forum on Aging, Disability, and Independence; Board on Health Sciences Policy; Division on Behavioral and Social Sciences and Education; Institute of Medicine; National Research Council. The Future of Home Health Care: Workshop Summary. Washington (DC): National Academies Press; August 4, 2015. doi:10.17226/21662.
Beales JL, Edes T. Veteran’s Affairs Home Based Primary Care. Clin Geriatr Med. 2009;25(1):149-154. doi:10.1016/j.cger.2008.11.002.
De Jonge KE, Jamshed N, Gilden D, Kubisiak J, Broce SR, Taler G. Effects of Home-Based Primary Care on Medicare Costs in High-Risk Elders. J Am Geriatr Soc. 2014;62(10):1825-1831. doi:10.1111/jgs.12974.