Community Care Workers Research Articles

Empowering or Exhausting? COVID-19 Experiences of Accredited Social Health Activists (ASHA) in Kerala

The study aims to understand the nature and intensity of Accredited Social Health Activists’ (ASHAs) work and its gendered significance in social and healthcare contexts, specifically during the COVID-19 scenario, by critically exploring the family, community and state responses as well as the work’s impact on their personal, relational and environmental levels. Employing a qualitative survey method, in-depth interviews were carried out with 52 ASHAs shortly after the pandemic. The findings reveal that while ASHAs view the altruistic, community service aspect of their work as empowering, the state must recognise the burden of underpaid community care work on women, which is exhausting and contributes to time poverty and a lack of leisure. This study advocates for policy interventions to regularise ASHAs’ services and increase their remuneration from a gender justice perspective.

Health and Community Care Workers' Knowledge and Perceptions of Social Prescribing in Singapore.

This study aimed to survey knowledge and perceptions of social prescribing (SP) amongst health and community care workers, and is a cross-sectional online survey conducted in November 2023. The survey on basic demographics, awareness, knowledge, and practices of SP was completed by 123 health and community care workers. The mean age of respondents was 39.0 years. Nearly two-thirds had heard of SP. A lower proportion of acute hospital doctors (55.6%) and nurses (56.8%) had heard of SP compared with primary and subacute care doctors (75.0%). The majority agreed that SP benefits patients' mental health and reduces healthcare utilization. Primary care physicians, community nurses, and active ageing centres were the top three professionals selected as most responsible for SP by survey respondents. The most commonly cited barriers to SP were seniors' reluctance (63.4%), lacking knowledge on how to refer (59.3%), lack of time (44.7%), and cost to seniors (44.7%). Overall, health and community care workers demonstrated positive attitudes toward SP and were keen to refer patients for SP. However, additional efforts are needed to improve knowledge about how to refer to and provide training on SP.

Environmental Risk Assessment in Community Care: A Scoping Review.

Community care encompasses inherent risks for both clients and healthcare providers. Maintaining a safe environment for the delivery of care services ensures that any risk of unintentional or intentional personal harm is minimised. The aim of this scoping review is to (a) provide an overview of existing knowledge by summarising the current literature and (b) identify gaps pertaining to understanding and managing environmental risk in community care settings. Guided by the Population/Concept/Context approach and PRISMA guidelines, this paper used two questions to answer how a score-based tool for assessing client suitability in community care is developed and how an environmental screening tool assists with reducing risk to community care workers. Literature searches of CINAHL, PubMed (Medline), Web of Science and PsychINFO databases were conducted between September 2023 and November 2023. We included full text articles published from 2018 to 2023. The following four broad areas were identified as key components in the structure of an environmental screening tool: environmental factors, health factors, socioeconomic factors and cultural factors. The results of this review provide valuable information which can be utilised by care organisations to develop and/or refine tools to ensure the safety and wellbeing of workers within the community care sector.

Narrative Review on Endemic Communicable Diseases in Africa: Mortality and Morbidity Trends, Impacts on Families, and the Way Forward

African nations have experienced various environmental and anthropological changes, including climate change, natural disasters, food safety issues, and increased industrial waste. These changes have increased the risk of emerging endemic microorganisms and intensified the transmission and impact of existing endemic communicable diseases (ECDs). This paper reviews the literature on the repercussions of ECDs, such as malaria, neglected tropical diseases (NTDs), human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), tuberculosis (TB), and viral hepatitis diseases (VHD) in Africa. The narrative review involved an extensive search of published articles and grey literature on these selected ECDs in Africa between January 2000 and December 2022. Through case studies on malaria, NTDs, HIV/AIDS, TB, and VHD, the effects of these ECDs on public health, economic development, and social systems in Africa were demonstrated, as they continue to be major causes of morbidity and mortality in the African region. It was emphasized that underlying social and economic factors contribute to the vulnerabilities associated with these diseases. In conclusion, providing services through community care workers can improve families’ trust, awareness of social support, and recognition of domestic vulnerabilities.

“You can’t die here”: an exploration of the barriers to dying-in-place for structurally vulnerable populations in an urban centre in British Columbia, Canada

BackgroundOne measure of quality in palliative care involves ensuring people approaching the end of life are able to receive care, and ultimately die, in the places they choose. Canadian palliative care policy directives stem from this tenet of autonomy, acknowledging that most people prefer to die at home, where they feel safe and comfortable. Limited research, however, considers the lack of ‘choice’ people positioned as structurally vulnerable (e.g., experiencing extreme poverty, homelessness, substance-use/criminalization, etc.) have in regard to places of care and death, with the option of dying-in-place most often denied.MethodsDrawing from ethnographic and participatory action research data collected during two studies that took place from 2014 to 2019 in an urban centre in British Columbia, Canada, this analysis explores barriers preventing people who experience social and structural inequity the option to die-in-place. Participants include: (1) people positioned as structurally vulnerable on a palliative trajectory; (2) their informal support persons/family caregivers (e.g., street family); (3) community service providers (e.g., housing workers, medical professionals); and (4) key informants (e.g., managers, medical directors, executive directors). Data includes observational fieldnotes, focus group and interviews transcripts. Interpretive thematic analytic techniques were employed.ResultsParticipants on a palliative trajectory lacked access to stable, affordable, or permanent housing, yet expressed their desire to stay ‘in-place’ at the end of life. Analysis reveals three main barriers impeding their ‘choice’ to remain in-place at the end of life: (1) Misaligned perceptions of risk and safety; (2) Challenges managing pain in the context of substance use, stigma, and discrimination; and (3) Gaps between protocols, policies, and procedures for health teams.ConclusionsFindings demonstrate how the rhetoric of ‘choice’ in regard to preferred place of death is ethically problematic because experienced inequities are produced and constrained by socio-structural forces that reach beyond individuals’ control. Ultimately, our findings contribute suggestions for policy, programs and practice to enhance inclusiveness in palliative care. Re-defining ‘home’ within palliative care, enhancing supports, education, and training for community care workers, integrating palliative approaches to care into the everyday work of non-health care providers, and acknowledging, valuing, and building upon existing relations of care can help to overcome existing barriers to delivering palliative care in various settings and increase the opportunity for all to spend their end of life in the places that they prefer.

Experience of utilizing a human-centered design approach to create a patient navigation program in Ontario, Canada

Background: Navigation programs are being prioritized world-wide as a solution to achieving integrated care. However, designing a health and social care navigation program that is person-centered is challenging, especially when the structure of the health care system continues to change. In 2019, the province of Ontario in Canada began restructuring the health care system in an attempt to move towards integrated care. Multiple Ontario Health Teams (OHT) were created with the vision that every person in Ontario will be able to access care through the OHT that they are attributed to. To reach this vision, one of the mandates of OHTs is to implement localized care navigation programs. 
 Methods: Human-centered design is a methodology and creative process to problem-solving that involves users in the co-design of a program. It is a framework that has been previously utilized by product designers but is now being leveraged in health care as it allows for person-centered care programs to be developed where patient experience is at the forefront. The process being followed by Central West OHT (CW OHT) includes three iterative steps: inspiration, ideation, and implementation. In the inspiration or problem identification stage, the Integrated Navigation Working Group (consisting of patients, caregivers, health care service providers, home and community care, nurses, project managers, researchers, and social workers) reviewed the literature and policy context, conducted descriptive data analysis (census data, hospitalization data, and data obtained from system partners), and elicited data from the public and local care organizations using quantitative cross-sectional surveys (22 survey responses from care organizations and 16 responses from patients/caregivers), semi-structured interviews with experts (11 organizations), and three focus groups with service providers, patients, and general community members. Qualitative data was analyzed using thematic analysis. 
 Results: Findings showed that navigation is particularly difficult for vulnerable populations in the community including seniors and/or those who do not have a regular care provider. At the system level, it was found that many organizations do not have a formal navigation role or service in place. Using this information, the team is now in the ideation phase and has sketched a design prototype that includes a) having a patient navigator who would be responsible for connecting patients and their caregivers to local resources and information, and b) patients having a health care navigation "passport" that outlines the patient's profile, services they used, and their preferences. Given that human-centered design is iterative, the next step for this program is to test the prototype (i.e., do a pilot) in the community, ask users about their experiences, and evaluate results with established metrics. The program will then be implemented and scaled up in March 2023.
 Discussion: This work highlights how beneficial human-centered design is to the complex field of integrated care using a case study of the patient navigation program in CW OHT. Along with describing the program, our findings, and the process we used, I will also share the lessons we learned at ICIC23 given that they can be applied to several health care challenges.

Challenges of accessing hygiene facilities when on the move: an exploratory interview study with UK mobile workers

BackgroundAccess to hygiene facilities is essential for health and well-being, and in many countries, employers are legally obliged to ensure that hygiene facilities are readily available. This interview study considers how being on the move impacts the ability of mobile workers (such as community care workers, police, delivery drivers, gardeners, cleaners, utility workers) to access hygiene facilities, and the challenges they face.MethodsUsing a qualitative exploratory research design, we investigate through semi-structured interviews with 22 United Kingdom (UK) mobile workers (1) what influences their access to hygiene facilities, (2) their hygiene needs, and (3) where mobile workers are accessing hygiene facilities. The interview data was analysed qualitatively using a coding framework developed from a literature review of hand hygiene in fixed workplaces.ResultsMobile workers’ access to hygiene facilities is influenced by the wider cultural environment, the biological environment, the organisational environment, the physical environment, the facility owner, the worker’s role, and the individual themselves, all underpinned by social norms. Our participants needed hygiene facilities so they could use the toilet, clean themselves, and do their work, and for First Aid. Access to facilities is challenging, and our participants needed to access facilities where they were working, travel to find them, or use hygiene kits. The quality of facilities is frequently poor, and mobile workers must often seek permission and may incur financial costs. Our participants often had to rely on the goodwill of people in private homes. In the absence of facilities, workers often resort to strategies that may affect their health (such as restricting drinking and eating, and ignoring urges) or their dignity (such as relieving themselves outdoors or even soiling their clothes).ConclusionsThe lack of hygiene facilities available to mobile workers is a serious health and well-being concern. Given that there are many occupations where workers are mobile at least some of the time, the scale of the problem needs to be recognised. This study adds to our understanding of hygiene in workplaces and highlights the inadequacy of current legislation, which appears to serve primarily those working in fixed workplaces such as offices. Recommendations are made to policy makers and organisations.

Counter-Stories in the way of caste: towards an anti-casteist public health praxis in contemporary India

How can ethnographic methods track implicit & explicit forms of structural casteism in Indian public health policy and praxis? How can a critical attention to ordinary stories and subjectivities of casted lives reveal the underlying Brahmanical moralities, assumptions and imaginations of public health but equally also unravel anti-caste counter-framings/counter-theorizations of symptoms, afflictions, injuries and chronic wounds wrought by caste? How, in other words, can the horizons of anti-colonial theory-making be expanded to capaciously conceptualize casteism as a core determinant of community health outcomes and life-chances in India? By mobilizing ‘counter-storytelling’ as a concept and method for critical medical anthropology from the Global South, and case studies from longitudinal ethnography in northern India, this paper provides a dual critique of: 1. Public health praxis in relation to questions of caste, addiction, respiratory debilitation, air pollution and TB. And, 2. Epistemologies of health policy making pertaining to wellness for ‘the poor’ and the gendered and casted labour of community care workers like ASHAs and non-institutionalized health actors.

Introduction: How Mental Health Matters

Abstract The underpinnings of today's mental health crisis include both social structural inequities and neurobiological vulnerabilities. The COVID-19 pandemic has compounded and escalated a long-standing problem, rendering the mental health crisis and its dangerous consequences visible and exigent. We now possess a clearer and more nuanced understanding of the broken mental health care system and its serious inadequacies, as well as its potential for effective caregiving. The professional forms of knowledge and practice are paralleled by an even more substantial system of care involving families, networks, communities, and, of course, those living with mental health conditions themselves. Even when delivered by community care workers, psychotherapy can be as effective as somatic treatments for some mental health conditions. Harm reduction and other public health approaches offer means of preventing or mitigating the disastrous human toll of the substance use disorder epidemic. Social technology offers new opportunities for enhancing mental health and well-being. With these informal systems alongside standardized health care systems, the future could realize a mental health care system with much greater potential to avert the worst harms and offer effective care to many more.

“That’s what we think of as activism”: Solidarity through care in queer Desi diaspora

This article examines a framing of solidarity as both activism and community care work in diasporic South Asian (sometimes referred to as “Desi”) communities in the US and the UK. From the vantage point of the researcher as a pansexual Indian-American activist herself, this article draws conclusions based on ethnographic research and interviews conducted with lesbian, gay, queer, and trans activists during the height of the COVID-19 pandemic and Black-led uprisings against police and state violence in the US and the UK. These conversations and this article particularly examine the participation of Desi activists and their peers in these movements, and their explorations of different modes of solidarity, from joint struggle to allyship to coconspiratorship and community transformation. They ultimately argue that queerness in Desi diaspora fosters solidarity through care that nurtures relationships across and between the diverse groups that make up LGBTQ + communities and the Desi diaspora, as well as between Desi, Black, and other racialized and diasporic communities. By examining lesbian, gay, trans, and broadly queer South Asian activists’ relationships to each other and to other racialized groups in struggle, this article conceptualizes a framing of solidarity and Black and Brown liberation together that transcends difference, transphobia and TERFism, and anti-Blackness through centering kinship and care. Through the intimacies borne out of months and years on the frontlines of struggle together, this article argues that deepening an understanding of activism, kinship, and care together in Desi diasporic organizing is key to building a solidarity that imagines and moves toward new and liberated worlds.

Performance in the management of malaria: the case of community care workers in Leona, Sakal District, Senegal

Performance in the management of malaria: the case of community care workers in Leona, Sakal District, Senegal

The Mixed Impact of Care Work on the Finances of Low-income Canadians: Insights from the Canadian Financial Diaries Research Project

Family and community care work – mentoring, feeding, and nurturing – is a critical activity in any society. It is, and it enables, productive and reproductive acts that hold society together and enable economies to function. Its importance is magnified for people with low income in that their economic options, outside the home, are more limited than for people with higher incomes. We conducted a year-long financial diaries project with twenty-eight mainly low-income Canadians and found that care work was critically important for them and their families and communities. However, we found that this work was often stigmatised: it is not well paid (if at all;, it involves costs to the provider; and it can lead people to become dependent on predatory loans. We argue that Canadian social policy must broaden its conception of care work and expand support for persons, particularly women, who have older children, and community commitments.

The role of patient navigation in supporting low-income older adults in their housing needs during hospital to home transitions: A qualitative descriptive study from Ontario, Canada

Introduction Housing is an important determinant of health. Little research has explored hospital and community agency staff perspectives on how to support the housing needs of low-income older adults. Therefore, this paper examines the challenges associated with supporting low-income seniors as they transition from hospital to home and explores what role, if any, patient navigation models of care could have in addressing housing needs. Methods A thematic secondary analysis that triangulated data from two qualitative studies was used. In total, interviews and/or focus groups with 109 hospital and community care workers were re-analyzed, applying a new interpretive lens to the data to reveal new insights. Data were collected in Ontario, Canada. Results Participants described how low-income older adults have increasing complex care needs that influence their housing, but housing supports are limited and difficult to navigate. Participants believed further support was needed and suggested that a housing-specific patient navigation model of care may be beneficial, but difficult to implement due to the limitations of existing services. Discussion Our findings provide a unique perspective on the challenges hospital and community staff face in caring for older adults with housing needs. Patient navigation with a focus on housing may support these older adults. Further work needs to be undertaken to better understand how to best implement sustainable housing patient navigation models of care.

Occupational Violence Experienced by Care Workers in the Australian Home Care Sector When Assisting People with Dementia.

People with advancing dementia may be dependent on community services from home care workers and nurses to be supported at home. However, these care workers face difficulty undertaking their roles due to challenging behaviours or occupational violence. This study aimed to explore the challenges faced by home care workers and nurses working with people diagnosed with dementia in the community, to identify job demands contributing to their vulnerability to occupational violence, and to determine ways to help manage occupational violence. A qualitative descriptive study was conducted by interviewing 10 homecare workers and six registered nurses from agencies in South Australia and New South Wales, Australia. Interviews were audiotaped, transcribed and inductive thematic data analysis was conducted. The following themes were identified: (i) sources of threats; (ii) categories of violent, threatening or challenging behaviour; (iii) aggravating factors; (iv) early warning signs; (v) education and training; (vi) managing occupational violence, (vii) resources, (viii) outcomes associated with exposure to occupational violence. Serious issues were identified by participants, yet very little is known about occupational violence for these community care workers. Findings can inform what aspects of work design can be improved to moderate the effects of occupational violence exposure or mitigate rates of exposure, to enable long-term services for people with dementia.

Climate change can be seen through a disaster medicine lens.

Climate change can be seen through a disaster medicine lens.

COVID-19 Cases Among Congregate Care Facility Staff by Neighborhood of Residence and Social and Structural Determinants: Observational Study.

BackgroundDisproportionate risks of COVID-19 in congregate care facilities including long-term care homes, retirement homes, and shelters both affect and are affected by SARS-CoV-2 infections among facility staff. In cities across Canada, there has been a consistent trend of geographic clustering of COVID-19 cases. However, there is limited information on how COVID-19 among facility staff reflects urban neighborhood disparities, particularly when stratified by the social and structural determinants of community-level transmission.ObjectiveThis study aimed to compare the concentration of cumulative cases by geography and social and structural determinants across 3 mutually exclusive subgroups in the Greater Toronto Area (population: 7.1 million): community, facility staff, and health care workers (HCWs) in other settings.MethodsWe conducted a retrospective, observational study using surveillance data on laboratory-confirmed COVID-19 cases (January 23 to December 13, 2020; prior to vaccination rollout). We derived neighborhood-level social and structural determinants from census data and generated Lorenz curves, Gini coefficients, and the Hoover index to visualize and quantify inequalities in cases.ResultsThe hardest-hit neighborhoods (comprising 20% of the population) accounted for 53.87% (44,937/83,419) of community cases, 48.59% (2356/4849) of facility staff cases, and 42.34% (1669/3942) of other HCW cases. Compared with other HCWs, cases among facility staff reflected the distribution of community cases more closely. Cases among facility staff reflected greater social and structural inequalities (larger Gini coefficients) than those of other HCWs across all determinants. Facility staff cases were also more likely than community cases to be concentrated in lower-income neighborhoods (Gini 0.24, 95% CI 0.15-0.38 vs 0.14, 95% CI 0.08-0.21) with a higher household density (Gini 0.23, 95% CI 0.17-0.29 vs 0.17, 95% CI 0.12-0.22) and with a greater proportion working in other essential services (Gini 0.29, 95% CI 0.21-0.40 vs 0.22, 95% CI 0.17-0.28).ConclusionsCOVID-19 cases among facility staff largely reflect neighborhood-level heterogeneity and disparities, even more so than cases among other HCWs. The findings signal the importance of interventions prioritized and tailored to the home geographies of facility staff in addition to workplace measures, including prioritization and reach of vaccination at home (neighborhood level) and at work.

A mixed methods study on effectiveness and appropriateness of face shield use as COVID-19 PPE in middle income countries

BackgroundFace shields were widely used in 2020-2021 as facial personal protective equipment (PPE). Laboratory evidence about how protective face shields might be and whether real world user priorities and usage habits conflicted with best practice for maximum possible protection was lacking – especially in limited resource settings. MethodsRelative protective potential of 13 face shield designs were tested in a controlled laboratory setting. Community and health care workers were surveyed in middle income country cities (Brazil and Nigeria) about their preferences and perspectives on face shields as facial PPE. Priorities about facial PPE held by survey participants were compared with the implications of the laboratory-generated test results. ResultsNo face shield tested totally eliminated exposure. Head orientation and design features influenced the level of protection. Over 600 individuals were interviewed in Brazil and Nigeria (including 240 health care workers) in March-April 2021. Respondents commented on what influenced their preferred forms of facial PPE, how they tended to clean face shields, and their priorities in choosing a face cover product. Surveyed health care workers commonly bought personal protection equipment for use at work. ConclusionsAll face shields provided some protection but none gave high levels of protection against external droplet contamination. Respondents wanted facial PPE that considered good communication, secure fixture, good visibility, comfort, fashion, and has validated protectiveness.

The health impact of an innovative summer camp for older adults: a pilot study using an interdisciplinary collaborative approach

BackgroundHealthy aging with dignity and aging in place are important for Taiwanese individuals. Although Taiwan did not experience COVID-19 outbreaks prior to May 2021, many older adults have been encouraged to stay at home since the beginning of the global pandemic in January 2020. Such shelter-in-place recommendations have resulted in significant lifestyle changes, limiting activities associated with aging with dignity such as exercise and community engagement. Few studies have explored how to promote or maintain holistic health practices and physical fitness in older adults residing in rural communities during the COVID-19 pandemic. This pilot study aimed to establish an interdisciplinary collaboration with community care workers (CCWs) and evaluate the impact of an innovative summer camp (ISC) program for older adults residing in rural areas.MethodsA quasi-experimental pre-post-test design with an interdisciplinary collaborative approach was implemented. The ISC program was based on a standardized protocol of modified Baduanjin exercise combined with three recreational breathing games. Participants were recruited from three community centers around the western coastal region of Yunlin County between June and August 2020. The ISC program was designed and executed by a nurse-led health promotion research team that collaborated with trained CCWs for 90 min per day, five days per week, for 12 weeks. Participants and CCWs wore facemasks during all activities. Paired t-test was used to measure changes in physical biomarkers, pulmonary lung function, and health-related fitness changes.ResultsSixty-eight participants completed the ISC program. The ISC program significantly improved the participants’ physiological biomarkers and health-related fitness, including reduced body weight, waistline, and systolic blood pressure, and increased forced vital capacity, biceps arm flexion, and ability to sit and stand from a chair, step with a knee up in situ, and stand on one foot with eyes open. Most participants reported that they felt happy, satisfied, and hoped that this program would be continued in their community center.ConclusionsThis interdisciplinary, collaborative ISC program improved physical biomarkers and health-related fitness in older adults. Despite limitations, results strongly suggested that primary healthcare providers and CCWs can employ the described ISC program to promote wellness in older adults.

Validation of a Mobile Health Technology Platform (FeverTracker) for Malaria Surveillance in India: Development and Usability Study.

BackgroundA surveillance system is the foundation for disease prevention and control. Malaria surveillance is crucial for tracking regional and temporal patterns in disease incidence, assisting in recorded details, timely reporting, and frequency of analysis.ObjectiveIn this study, we aim to develop an integrated surveillance graphical app called FeverTracker, which has been designed to assist the community and health care workers in digital surveillance and thereby contribute toward malaria control and elimination.MethodsFeverTracker uses a geographic information system and is linked to a web app with automated data digitization, SMS text messaging, and advisory instructions, thereby allowing immediate notification of individual cases to district and state health authorities in real time.ResultsThe use of FeverTracker for malaria surveillance is evident, given the archaic paper-based surveillance tools used currently. The use of the app in 19 tribal villages of the Dhalai district in Tripura, India, assisted in the surveillance of 1880 suspected malaria patients and confirmed malaria infection in 93.4% (114/122; Plasmodium falciparum), 4.9% (6/122; P vivax), and 1.6% (2/122; P falciparum/P vivax mixed infection) of cases. Digital tools such as FeverTracker will be critical in integrating disease surveillance, and they offer instant data digitization for downstream processing.ConclusionsThe use of this technology in health care and research will strengthen the ongoing efforts to eliminate malaria. Moreover, FeverTracker provides a modifiable template for deployment in other disease systems.

Differential T-Cell Reactivity to Endemic Coronaviruses and SARS-CoV-2 in Community and Health Care Workers.

Herein we measured CD4+ T-cell responses against common cold coronaviruses (CCC) and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in high-risk health care workers (HCW) and community controls. We observed higher levels of CCC-reactive T cells in SARS-CoV-2–seronegative HCW compared to community donors, consistent with potential higher occupational exposure of HCW to CCC. We further show that SARS-CoV-2 T-cell reactivity of seronegative HCW was higher than community controls and correlation between CCC and SARS-CoV-2 responses is consistent with cross-reactivity and not associated with recent in vivo activation. Surprisingly, CCC T-cell reactivity was decreased in SARS-CoV-2–infected HCW, suggesting that exposure to SARS-CoV-2 might interfere with CCC responses, either directly or indirectly. This result was unexpected, but consistently detected in independent cohorts derived from Miami and San Diego.CD4+ T-cell responses against common cold coronaviruses (CCC) are elevated in SARS-CoV-2 seronegative high-risk health care workers (HCW) compared to COVID-19 convalescent HCW, suggesting that exposure to SARS-CoV-2 might interfere with CCC responses and/or cross-reactivity associated with a protective effect.