Can Public Health Innovation Reduce Stress Among Community Health Workers? Lessons from a Philippine City Health Department

Article information

Cleofas, J., Andrada-Poa, M. R. J., & Jabal, R. (2024). The influence of COVID-19 program innovativeness on occupational stress outcomes of community health workers in a selected City Health Department in the Philippines. Social Work in Public Health, 39(2), 156–168. https://doi.org/10.1080/19371918.2024.2320794 

What this study is about

During the COVID-19 pandemic, local health systems had to work under enormous pressure. Community health workers were expected to continue public health services while also responding to a fast-moving infectious disease crisis. In the Philippines, local government units and city health departments became central to COVID-19 response because public health work is highly devolved to local settings. 

This study looked at one city health department in the National Capital Region that introduced a new public health program during the pandemic. Before COVID-19, community health workers regularly collected health data through home visits and consultations in community health centers. But because of lockdowns, social distancing, and fear of infection, fewer residents were visiting health centers, and routine public health data collection was disrupted. 

At the same time, more residents were going to designated sites for free COVID-19 RT-PCR testing. The city health department used this opportunity to innovate. Instead of only testing residents for COVID-19, they also conducted health risk assessments for other diseases at the same testing sites. 

In simple terms: the program combined COVID-19 testing and broader health surveillance in one place.

Why this matters

The innovation was designed to help both residents and health workers.

For residents, it allowed them to access COVID-19 testing while also being assessed for other health risks. For the city health department, it helped restore the health data that had been interrupted by the pandemic. For community health workers, it reduced the need to move around different homes and centers while COVID-19 transmission risks were still high. 

The visual diagram in Figure 1 on page 4 explains this process clearly. Before the pandemic, community health workers regularly collected data through surveillance and health risk assessments. At the start of the pandemic, home and health center visits decreased, while visits to COVID-19 testing centers increased. During implementation, disease and health risk data were collected from residents while they were already visiting designated centers for free COVID-19 testing. 

The study asks: Did community health workers see this program as innovative, and was this perception linked to occupational stress outcomes?

What the researchers did

This was a quantitative cross-sectional descriptive study with comparative and correlational components. The researchers surveyed 128 community health workers involved in implementing the program. The survey was conducted online from late December 2020 to early January 2021. 

In this study, community health workers included administrators, nonprofessional community health staff, and health practitioners such as social workers, nurses, and midwives who were engaged in the program. 

The researchers measured two main things.

First, they measured perceived program innovativeness using five characteristics from Rogers’ Diffusion of Innovations Theory:

• observability,
• complexity,
• relative advantage,
• compatibility,
• and trialability. 

Second, they measured occupational stress outcomes before and during program implementation:

• perceived personal stress,
• demand,
• control,
• and social support. 

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What the study found

1) The program was perceived as highly innovative

Community health workers rated the program highly across all five innovation dimensions. The overall perceived innovativeness score was also high. 

Among the five dimensions, compatibility had the highest score. This means the program fit well with the existing values, needs, and work practices of the community health workers. This makes sense because the program did not ask workers to do something completely unrelated to their usual roles. It combined activities already familiar to them: COVID-19 testing support, history taking, health risk assessment, and public health data collection. 

The second highest dimension was relative advantage, meaning the workers saw the new program as better than the previous arrangement. One likely reason is that it allowed them to perform multiple tasks in one location, reducing mobility and possibly reducing unnecessary exposure in the community. 

2) Older, female, longer-serving, and permanent workers perceived the program as more innovative

The study found that age, gender, years of service, and employment status were significantly associated with perceived innovativeness. Older community health workers, female workers, those with longer service, and those with permanent employment status rated the program as more innovative. 

The authors explain that older and longer-serving workers may better appreciate innovation because they have more experience with the department’s previous systems. They may be more able to recognize when a new process makes work easier or safer. 

Permanent workers may also have had more access to training, role stability, and institutional involvement than contractual workers. This is important because innovation is not experienced equally by everyone. Workers with less job security may not feel the same sense of ownership or benefit.

3) Personal stress decreased during program implementation

The study compared occupational stress outcomes before and during implementation. The most important finding was that perceived personal stress significantly decreased, from a moderate level before implementation to a low level during implementation. 

This suggests that the program may have made workers’ experience of stress lighter, at least in terms of personal stress.

This does not mean the pandemic became easy. Community health workers were still operating during a crisis. But the program may have reduced some stress by streamlining tasks, reducing movement across different settings, improving operational clarity, and allowing workers to perform public health duties in a more organized way.

4) Demand, control, and social support did not significantly change before and during implementation

The study found no significant before-and-during differences in demand, control, or social support. 

This is useful to note because innovation does not automatically improve every work condition. The tasks themselves may have remained demanding. Workers may still have had limited control because COVID-19 protocols were strict and had to be followed. Social support stayed moderate, but did not significantly increase based on the before-and-during comparison. 

5) Higher perceived innovativeness was linked to lower stress and higher support

The study also examined whether perceived innovativeness was related to occupational stress outcomes during implementation.

Two significant relationships appeared:

• Higher perceived innovativeness was linked to lower personal stress.
• Higher perceived innovativeness was linked to higher social support. 

In everyday language: when community health workers saw the program as more innovative, they also tended to feel less personally stressed and more supported at work.

The study suggests that innovative programs may improve not only service delivery, but also the work experience of frontline public health workers. Innovation can create clearer workflows, better coordination, shared purpose, and opportunities for workers to support one another.

6) Innovation did not significantly relate to demand or control

Perceived innovativeness was not significantly related to demand or control. 

This makes sense. The program changed how tasks were organized, but it may not have reduced the amount of work itself. It also may not have increased workers’ control because pandemic programs operate within strict public health rules, protocols, and mandates.

This is a realistic finding. Innovation can reduce stress and strengthen support, but it may not automatically reduce workload or increase autonomy unless those goals are deliberately built into the program design.

The important caution

The authors are careful not to overstate the findings. This was a single-city study, focused on one specific program, with a mostly female sample. Because the study is correlational, it cannot prove that the innovation caused stress reduction. The program was also designed in early pandemic conditions, before vaccines were widely available in the Philippines and before later changes in scientific guidance. 

The paper also notes that keeping workers longer in testing sites to conduct additional risk assessments could raise safety concerns. This means other health organizations should not copy the model uncritically. They should adapt any similar innovation based on current evidence, local risk conditions, and worker safety.

Bottom line

This study shows that public health innovation does not have to be dramatic or high-tech. Sometimes innovation is a practical reorganization of existing work: combining related services, reducing unnecessary movement, using available opportunities, and making systems work better under crisis conditions. 

For community health workers, such innovations may matter not only because they improve services for residents, but because they can reduce personal stress and strengthen social support at work.

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Policy/practice recommendations

1. Design public health innovations with worker wellbeing in mind
   Health programs should not only ask, “Will this help the public?” They should also ask, “Will this make work safer, clearer, and less stressful for community health workers?”
2. Use simple operational innovations when resources are limited
   Innovation does not always require new technology. Combining related tasks, relocating services, and streamlining workflows can already improve public health operations. 
3. Monitor stress during program implementation
   City health offices should track personal stress, workload, control, and social support when new programs are launched.
4. Engage younger, male, and contractual workers more intentionally
   The study found that these groups rated innovativeness lower. Program managers should involve them in planning, feedback, training, and decision-making. 
5. Protect contractual community health workers
   Innovation will be uneven if contractual workers have less training, weaker job security, and less institutional voice. Support should include training access, protection, benefits, and meaningful participation.
6. Strengthen team-based support during crisis programs
   Since innovativeness was linked with social support, program designs should include clear coordination, shared workspaces where safe, communication routines, and peer support mechanisms.
7. Update innovations as evidence changes
   COVID-19 science changed quickly. Public health innovations should be regularly reviewed against current evidence, vaccination status, transmission risks, and local conditions. 

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Glossary of key terms

• Public health innovation — A new or improved policy, system, service, product, technology, or delivery method designed to improve health or respond to unmet needs. 
• Program innovativeness — The extent to which a program is perceived as new, useful, appropriate, testable, and beneficial.
• Community health workers / CHWs — Workers involved in local public health services, including community health staff, social workers, nurses, midwives, administrators, and other health personnel in this study. 
• Occupational stress — Stress related to one’s job, work environment, workload, role demands, and available support.
• Perceived personal stress — A worker’s own sense of feeling stressed, nervous, overloaded, or unable to cope.
• Demand — Work-related pressures or external stressors that can increase occupational stress.
• Control — The extent to which workers feel they have autonomy, learning opportunities, and influence over their work.
• Social support — Help, cooperation, encouragement, and support from colleagues or supervisors.
• Diffusion of Innovations Theory — A theory explaining how new ideas, practices, or technologies spread and are adopted.
• Observability — How visible or noticeable the results of an innovation are. 
• Complexity — How easy or difficult an innovation is to understand and use.
• Relative advantage — The extent to which a new program is seen as better than the previous one.
• Compatibility — How well an innovation fits existing values, needs, routines, and work practices.
• Trialability — The extent to which an innovation can be tested or tried before full implementation.
• RT-PCR test — A laboratory test used to detect COVID-19 infection by identifying viral genetic material.
• Health risk assessment — A process of collecting information about a person’s health risks, symptoms, conditions, or needs.
• Harmonized surveillance — Combining data collection or monitoring for multiple health concerns within one coordinated system.
• Local government unit / LGU — A local administrative unit in the Philippines, such as a city or municipality, responsible for delivering many public services, including local health programs.
• Cross-sectional study — A study that collects data at one point in time. It can show associations but cannot prove cause and effect.