Menu
Menu
Menu
Menu
Background: Community health workers (CHWs) are a component of the health system in many countries, providing effective community-based services to mothers and infants. However, implementation of CHW programmes at scale has been challenging in many settings. Aim: To explore the acceptability of CHWs conducting household visits to mothers and infants during pregnancy and after delivery, from the perspective of community members, professional nurses and CHWs themselves. Setting: Primary health care clinics in five rural districts in KwaZulu-Natal, South Africa. Methods: A qualitative exploratory study was conducted where participants were purposively selected to participate in 19 focus group discussions based on their experience with CHWs or child rearing. Results: Poor confidentiality and trust emerged as key barriers to CHW acceptability in delivering maternal and child health services in the home. Most community members felt that CHWs could not be trusted because of their lack of professionalism and inability to maintain confidentiality. Familiarity and the complex relationships between household members and CHWs caused difficulties in developing and maintaining a relationship of trust, particularly in high HIV prevalence settings. Professional staff at the clinic were crucial in supporting the CHW’s role; if they appeared to question the CHW’s competency or trustworthiness, this seriously undermined CHW credibility in the eyes of the community. Conclusion: Understanding the complex contextual challenges faced by CHWs and community members can strengthen community-based interventions. CHWs require training, support and supervision to develop competencies navigating complex relationships within the community and the health system to provide effective care in communities.
The study adopted an exploratory qualitative research design to access rich accounts of participants’ perceptions of CHW acceptability in the proposed community-based MCH intervention. A qualitative approach was most appropriate to explore the complexities, context or underlying themes of discourse,19 and focus group discussions (FGDs) were the most appropriate method to identify and explore the range of perceptions, attitudes and experiences of participants in relation to CHWs. South Africa is a middle-income country with vast inequalities.20 This study was conducted in PHC clinics in five rural districts in KwaZulu-Natal (KZN) province, South Africa, between August and October 2012. KZN has the highest HIV prevalence in South Africa, with 37.4% of pregnant women attending government antenatal clinics testing HIV positive in 2012,21 and the highest infant and under-five mortality ratios in the country.22 KZN comprises 11 districts, of which 9 are rural. Health facilities are challenged by limited staffing, resources and infrastructure, and access to PHC clinics is affected by distance, financial constraints and transport availability. The main language spoken in the province is isiZulu. There were approximately 10 600 CHWs employed by the South African DoH in KZN at the time of this study. CHWs received a two-week training to develop the skills to provide care and support to pregnant women, mothers, newborns and children in the community. CHWs were expected to provide appropriate health and nutrition education and implement simple, cost-effective interventions to identify and address common causes of illness and death among mothers and children. Participants were community members, professional nurses (PNs) and CHWs. Participants were purposively selected for inclusion in the FGDs based on their involvement with CHWs or child rearing. Eight clinics in five districts were selected to participate based on convenience and accessibility of CHWs. One PN from each clinic was purposively selected to participate for their knowledge and experience of working with CHWs. The PN then selected one CHW from the clinic catchment area. Community members willing to participate in a discussion were purposively selected at clinics on the basis that they were the mother, father or grandmother of a child aged under 5 years, and therefore able to comment on the acceptability of CHW providing MCH services in the household (Table 1). Focus group participants by category and gender. All participants received an information sheet explaining the purpose of the study and were given time to ask questions and provided written informed consent. All FGDs were digitally audio-recorded. FGDs took place in a private room at the clinics and were facilitated by two trained interviewers. FGDs were convened according to the type of participant, with separate groups for CHWs, PNs and community members. Community groups were further separated into mothers, grandmothers and men. This was done to minimise the power dynamic that may arise from participants’ age, gender or professional status23,24 and to ensure that all voices were heard in the discussions.25 FGDs with CHWs and community members were conducted in isiZulu and those with PNs were conducted in English. A semi-structured interview guide including scenarios or vignettes was used. Scenarios were used as a technique to explore the situational context of the proposed intervention, including sensitive issues like the disclosure of HIV status to the CHW, whether it was acceptable to visit a mother immediately after her baby’s birth or for a male CHW to visit at this time. Scenarios can allow participants greater control over the interaction by enabling them to determine at what stage, if at all, they introduce their own experiences to illuminate their abstract responses.26 Examples of scenarios used are shown in Figure 1. Issues around confidentiality, HIV disclosure, CHW gender and postnatal care were explored in all groups, with additional questions included specific to the category of participants being interviewed. Example of scenarios used during focus group discussions. All FGDs were transcribed verbatim, translated into English where necessary, and coded by two experienced social scientists. An inductive approach was used and interpretive thematic coding was the primary analytic strategy.24 Transcripts were entered into qualitative data analysis software (NVivo version 10). After reading two transcripts, a codebook of themes was developed based on interview topics as well as new themes emerging from the data. This was repeated until all 19 transcripts had been reviewed and the codebook reached saturation where no new themes emerged. The analysis team worked together to resolve any interpretation discrepancies in the analysis process.
N/A
