“I Have to Push Him with a Wheelbarrow to the Clinic”: Community Health Workers' Roles, Needs, and Strategies to Improve HIV Care in Rural South Africa

Abstract

With a 19.2% HIV prevalence, South Africa has the largest HIV/AIDS epidemic worldwide. Despite a recent scale-up of public sector HIV resources, including community-based programs to expand HIV care, suboptimal rates of antiretroviral therapy (ART) initiation and adherence persist. As community stakeholders with basic healthcare training, community health workers (CHWs) are uniquely positioned to provide healthcare and insight into potential strategies to improve HIV treatment outcomes. The study goal was to qualitatively explore the self-perceived role of the CHW, unmet CHW needs, and strategies to improve HIV care in rural KwaZulu-Natal, South Africa. Focus groups were conducted in May-August 2014, with 21 CHWs working in Msinga subdistrict. Interviews were audio-recorded, transcribed, and translated from Zulu into English. A hybrid deductive and inductive analytical method borrowed from grounded theory was applied to identify emergent themes. CHWs felt they substantially contributed to HIV care provision but were inadequately supported by the healthcare system. CHWs' recommendations included: (1) sufficiently equipping CHWs to provide education, counseling, social support, routine antiretroviral medication, and basic emergency care, (2) modifying clinical practice to provide less stigmatizing, more patient-centered care, (3) collaborating with traditional healers and church leaders to reduce competition with ART and provide more holistic care, and (4) offsetting socioeconomic barriers to HIV care. In conclusion, CHWs can serve as resources when designing and implementing interventions to improve HIV care. As HIV/AIDS policy and practice evolves in South Africa, it will be important to recognize and formally expand CHWs' roles supporting the healthcare system.

“I will not stop visiting!” a qualitative study of community health workers’ reluctance to withdraw household support following the end of a community-based intervention in Zimbabwe

“…As noted by others, we found CHWs developed close personal relationships with households [ 25 , 26 ]. CHWs expressed gleaning pride and validation through emotional engagement, describing it as more uplifting than exhausting, even when their efforts to support families went beyond job requirements.…”

The Health Promotion Model in HIV Care

“…Other factors that can contribute to message acceptance are a physician's concern, interest, friendliness or empathy toward the patient and the alliance that may form once trust is established (24). Thus, through the use of communication theory, a provider can influence and create positive behavioral change that might significantly improve patient adherence to daily medications and medical appointments (25). Before initiating ART, providers should take the time to discuss with the patient the advantages and disadvantages, risks and benefits of each medication protocol (26).…”

The cost of the training and supervision of community health workers to improve exclusive breastfeeding amongst mothers in a cluster randomised controlled trial in South Africa

“…CHWs focus primarily on community engagement, risk identification, and referral to public health facilities [6]. The comparative advantage of utilising CHWs remains that they are from the community and are therefore closer to the patient and their families and more accessible compared to facility based health personnel [7,8]. CHWs can assist in bridging the gaps present in the delivery of integrated care at the health facility level [9] with several studies highlighting the potential role of CHWs in increasing access to health care for individuals living in underserved locations in South Africa [10,11].…”

“…Although CHWs may be considered a less expensive alternative to other professional health cadres, with regard to salary, they should not be seen as a cheap solution for weak health systems as they require support and supervision to be effective and sustainable [1]. Literature has pronounced on this health cadre's lack of supervision as a key impediment to optimising their utility [1,12], with further studies confirming the lack of support afforded to CHWs by the health system [8] as well as how providers readily offload responsibilities to them without assuming a supervisory role [10]. Many health facility managers similarly have not assumed their supervisory role and provided inadequate support to CHWs [12].…”