Household coverage, quality and costs of care provided by community health worker teams and the determining factors: findings from a mixed methods study in South Africa

Goudge, Jane; Kadt, Julia de; Babalola, Olukemi; Muteba, Michel; Tseng, Yu-Hwei; Malatji, Hlologelo; Rwafa-Ponela, Teurai; Nxumalo, Nonhlanhla; Levin, Jonathan; Thorogood, Margaret; Daviaud, Emmanuelle; Watkins, Jocelyn Anstey; Griffiths, Frances

doi:10.1136/bmjopen-2019-035578

Cited by 17 publications

(30 citation statements)

References 20 publications

(21 reference statements)

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“…Interview guides and observation templates (see online supplemental material ) were revised after piloting and feedback from the FWs. 36 FWs (none of whom were from the community), introduced themselves to participants as working for the study under the University of the Witwatersrand. Interviews were 15–60 min and focus group discussions (FGDs) 60–90 min in duration.…”

Section: Methodsmentioning

confidence: 99%

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

2021

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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.

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Section: Methodsmentioning

confidence: 99%

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

2021

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“…Our situation analysis showed the programme was under-resources, and when a CHW team was led by a junior nurse, there was insu cient supervision, and the programme was often under-resourced and poorly integrated into healthcare system and community structures (9). This resulted in poor quality of care and low household coverage (18). In contrast, teams led by an experienced nurse were well integrated in the healthcare system, had access to equipment and CHWs received supportive supervision (9).…”

Section: Our Initial Programme Theorymentioning

confidence: 99%

“…Each CHW was expected to register new households to identify individuals or families in need of care. Prior to the intervention, the registration of households was low with only 20% households in both sites ever having been visited by a CHW (18). Moreover, CHW asked less than half of the nine household registration questions, partly due di culties in understanding the questions as they are written in English, or the purpose of the questions.…”

Section: Prior To Interventionmentioning

confidence: 99%

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Piloting a roving nurse mentor into community-based health programmes to capacitate community health workers: Findings from a realist evaluation in South Africa

Malatji

Goudge

Griffiths

2021

Preprint

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Background Many low- and middle- income countries (LMICs) are repositioning community health workers (CHW) programmes to provide promotive and preventive services and referrals to the formal health service. However, the CHW low literacy levels, insufficient supervision and fragmented programmes result in the under-performance of the programmes in many settings. In this paper, we report on the realist evaluation of an intervention to explain mechanisms that led to a change in CHW care and household coverage in a semi-rural area of South Africa. Methods Using a case study approach, we conducted in-depth interviews, focus group discussions and observations to document the experiences of CHWs, their supervisors, clients, facility staff and community representatives prior to the intervention, during, and after a 6 month post-intervention gap to assess how the benefits were generated and sustained. Results The nurse mentor (senior nurse) intervention operated in a complex and dynamic environment with resource shortages, conflicts between CHWs and facility staff, and a disruptive CHW labour union. Over 15 months, the mentor was able to overcome these issues and (1) create learning platforms for the CHWs and their supervisors to learn and practice new skills relating to priority activities, (2) address their fears of failing and (3) establish operational systems to address inefficiencies in the CHWs’ activities, resulting in improved service provision and household coverage. An increase in the CHWs’ stipend to the minimum wage improved their motivation, and their direct employment by the Department of Health led to their formal integration into the health care team working at their ‘home’ facility. However, given the volatile communities in which the teams operated, and the communities focus on demanding government housing, the nurse mentor was not able to establish a collaboration with the community structures. Conclusions A roving nurse mentor overseeing several CHW teams within a district healthcare system is a feasible option, particularly in a context where there is a shortage of qualified supervisors. However, the long term sustainability of the effects of intervention is dependent on CHWs’ formal employment by the Department of Health.

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“…Moreover, the CHWs provided care to a greater range of people and performed a greater range of more complex tasks. For further papers on the situational analysis see [ 9 , 18 ], and tool development see [ 13 ].…”

Section: Introductionmentioning

confidence: 99%

Supportive supervision from a roving nurse mentor in a community health worker programme: a process evaluation in South Africa

Malatji

Griffiths

Goudge

2022

BMC Health Serv Res

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Background Many low and middle- income countries (LMICs) are repositioning community health worker (CHW) programmes to provide a more comprehensive range of promotive and preventive services and referrals to the formal health service. However, insufficient supervision, fragmented programmes, and the low literacy levels of CHWs often result in the under-performance of the programmes. We evaluate the impact of a roving nurse mentor working with CHW teams proving supportive supervision in a semi-rural area of South Africa. Methods We conducted a longitudinal process evaluation, using in-depth interviews, focus groups and observations prior to the intervention, during the intervention, and 6 months post-intervention to assess how the effects of the intervention were generated and sustained. Our participants were CHWs, their supervisors, clients and facility staff members and community representatives. Results The nurse mentor operated in an environment of resource shortages, conflicts between CHWs and facility staff, and an active CHW labour union. Over 15 months, the mentor was able to (1) support and train CHWs and their supervisors to gain and practice new skills, (2) address their fears of failing and (3) establish operational systems to address inefficiencies in the CHWs’ activities, resulting in improved service provision. Towards the end of the intervention the direct employment of the CHWs by the Department of Health and an increase in their stipend added to their motivation and integration into the local primary care clinic team. However, given the communities’ focus on accessing government housing, rather than better healthcare, and volatile nature of the communities, the nurse mentor was not able to establish a collaboration with local structures. Conclusions A roving nurse mentor overseeing several CHW teams within a district healthcare system is a feasible option, particularly in a context where there is a shortage of qualified supervisors to support CHWs activities. A roving nurse mentor can contribute to the knowledge and skills development of the CHWs and enhance the capacity of junior supervisors. However, the long-term sustainability of the effects of intervention is dependent on CHWs’ formal employment by the Department of Health.

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Household coverage, quality and costs of care provided by community health worker teams and the determining factors: findings from a mixed methods study in South Africa

Cited by 17 publications

References 20 publications

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

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

Piloting a roving nurse mentor into community-based health programmes to capacitate community health workers: Findings from a realist evaluation in South Africa

Supportive supervision from a roving nurse mentor in a community health worker programme: a process evaluation in South Africa

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