Community health workers’ efforts to build health system trust in marginalised communities: a qualitative study from South Africa

Abstract

IntroductionCommunity health workers (CHWs) enable marginalised communities, often experiencing structural poverty, to access healthcare. Trust, important in all patient–provider relationships, is difficult to build in such communities, particularly when stigma associated with HIV/AIDS, tuberculosis and now COVID-19, is widespread. CHWs, responsible for bringing people back into care, must repair trust. In South Africa, where a national CHW programme is being rolled out, marginalised communities have high levels of unemployment, domestic violence and injury.ObjectivesIn this complex social environment, we explored CHW workplace trust, interpersonal trust between the patient and CHW, and the institutional trust patients place in the health system.Design, participants, settingWithin the observation phase of a 3-year intervention study, we conducted interviews, focus groups and observations with patients, CHWs, their supervisors and, facility managers in Sedibeng.ResultsCHWs had low levels of workplace trust. They had recently been on strike demanding better pay, employment conditions and recognition of their work. They did not have the equipment to perform their work safely, and some colleagues did not trust, or value, their contribution. There was considerable interpersonal trust between CHWs and patients, however, CHWs’ efforts were hampered by structural poverty, alcohol abuse and no identification documents among long-term migrants. Those supervisors who understood the extent of the poverty supported CHW efforts to help the community. When patients had withdrawn from care, often due to nurses’ insensitive behaviour, the CHWs’ attempts to repair patients’ institutional trust often failed due to the vulnerabilities of the community, and lack of support from the health system.ConclusionStrategies are needed to build workplace trust including supportive supervision for CHWs and better working conditions, and to build interpersonal and institutional trust by ensuring sensitivity to social inequalities and the effects of structural poverty among healthcare providers. Societies need to care for everyone.

Leveraging HIV Care Infrastructures for Integrated Chronic Disease and Pandemic Management in Sub-Saharan Africa

“…Many HIV services in other settings have already made the transition to broad-based NCD care and are actively working to engage the whole patient population in addition to the PLHIV they originally served [107,108]. Throughout the continent, African Ministries of Health have called upon their HIV/AIDS-capacitated laboratories, public health experts, and clinicians to address health service stresses from emerging pandemic threats, whether Ebola virus in West Africa and Congo or COVID-19 in South Africa or Nigeria [19,109,110]. Similarly, NCDs and pandemic preparedness efforts can draw upon the capacity-building accomplished in the HIV/AIDS response.…”

Understanding Trustful Relationships between Community Health Workers and Vulnerable Citizens during the COVID-19 Pandemic: A Realist Evaluation

“…Considerable evidence confirms that CHWs’ role in enabling vulnerable communities to access care is underpinned by the trustful relationships with their clients [ 17 , 18 ]. In addition, existing literature states that CHWs perceive ‘building trust with the community’ (beyond trust in health services) as a critical component of their practice [ 19 , 20 , 21 , 22 , 23 , 24 ].…”

Role of Socio-Demographic and Environmental Determinants on Performance of Community Health Workers in Western Kenya

“…In terms of lack of support, it was shown in the study of [ 22 ] that the physical condition at the health facilities of CHWs were challenging in South Africa. The CHWs were challenged in many complexes.…”

“…The CHWs require recognition, support, and respect from the community and the formal health system for them to be effective in administering their duties. According to [ 22 ], a hierarchy played out in the health facilities, where the CHWs in South Africa were seen at the lowest level of the hierarchy. In South Africa, the CHWs are the lowest level in the health system, including their conditions of employment and their working environment, and they also lack the necessary equipment to perform their work safely.…”

“…In South Africa, the CHWs are the lowest level in the health system, including their conditions of employment and their working environment, and they also lack the necessary equipment to perform their work safely. The kind of treatment they receive from the other healthcare workers indicated that their work was unrecognized and their contribution untrusted [ 22 ].…”