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Background: Community health workers (CHWs) provide maternal and child health services to communities in many low and middle-income countries, including South Africa (SA). CHWs can improve access to important health interventions for isolated and vulnerable communities. In this study we explored the performance of CHWs providing maternal and child health services at household level and the quality of the CHW-mother interaction. Methods: A qualitative study design was employed using observations and in-depth interviews to explore the content of household interactions, and experiences and perceptions of mothers and CHWs. Fifteen CHWs and 30 mothers/pregnant women were purposively selected in three rural districts of KwaZulu-Natal, SA. CHW household visits to mothers were observed and field notes taken, followed by in-depth interviews with mothers and CHWs. Observations and interviews were audio-recorded. We performed thematic analysis on transcribed discussions, and content analysis on observational data. Results: CHWs provided appropriate and correct health information but there were important gaps in the content provided. Mothers expressed satisfaction with CHW visits and appreciation that CHWs understood their life experiences and therefore provided advice and support that was relevant and accessible. CHWs expressed concern that they did not have the knowledge required to undertake all activities in the household, and requested training and support from supervisors during household visits. Conclusions: Key building blocks for a successful CHW programme are in place to provide services for mothers and children in households but further training and supervision is required if the gaps in CHW knowledge and skills are to be filled.
This study was conducted in three predominantly rural districts of the eleven health districts in KwaZulu-Natal (KZN), SA. The three districts were purposively selected by the KZN Department of Health based on availability of CHWs working in ward-based outreach teams in these areas. The three districts serve a population in excess of 2.3 million inhabitants. Health care is provided through the district health system, based on a primary health approach. In the study areas CHWs worked within a ward-based outreach team, and were supervised by a community-based registered nurse. CHWs are linked to their local PHC clinic, where they receive referrals and to which they refer when necessary. This study employed a qualitative design to explore the quality of MCH services and health promotion messages provided to women and infants by CHWs visiting households. A CHW visit to a mother or pregnant woman was observed by a field worker, followed by an in-depth interview with the participating women and CHWs. Observations and interviews were collected over a series of visits to each community and each household (Fig. (Fig.11). Flow diagram of participants included in the study Five communities were selected in the three districts in partnership with the KZN Department of Health (DoH), using a convenience sample based on availability of CHWs in these areas. CHWs were approached by researchers and informed about the study. CHWs were selected based on their willingness to participate and on their having two eligible women residing in the households they served. Women were eligible to participate if they were pregnant or had babies under the age of one year, and were residing in households visited by participating CHWs. Three CHWs from each community were selected to participate. Thus, 15 CHWs and 30 women were included in the study. Of the 30 women selected for observation, 10 were pregnant and 20 had delivered their baby, eight of whom had a baby younger than 28 days. As a result, 10 mothers received antenatal visits, 8 mothers received postnatal visits and 12 mothers received child visits. All household visits and interviews were conducted in isiZulu. A researcher observed the household visit undertaken by the CHW, and all verbal interactions between the CHW and mother during the visit were audio recorded [13, 14]. During the household visit, the researcher took field notes to record the activities undertaken during the visit that may not be identified from the audio-recording, for example non-verbal communication and clinical examination. In-depth interviews were conducted with participating women and CHWs at a later visit to explore perceptions, experiences and attitudes about the CHW visit, the context in which CHWs operate, their perceived competencies, and the support and supervision given to CHWs (Fig. 1). All interviews were audio recorded. A content checklist was developed to assess the quality of the visit, including the information provided and activities undertaken. This checklist was based on the SA DoH policy for community-based health interventions for mothers and children and the training that CHWs received in caring for mothers and infants in the household [13]. These documents set out clearly the expected activities of CHWs during household visits. Audio-recordings of the CHW- mother interaction were coded for content by a registered nurse using the relevant content checklist for the type of interaction (antenatal, postnatal or child visit). All interviews were transcribed verbatim, translated into English and exported to NVivo version 10. Thematic content analysis was performed on the interview transcripts. The themes that emerged from the analysis of the transcripts were reviewed independently by two researchers, and were then triangulated with the content analysis coding of the observation data. Field notes were used during the analysis to contextualise the content analysis of the household visit and the interview findings.
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