Contextual factors affecting the integration of community health workers into the health system in Limpopo Province, South Africa.

BACKGROUND: Community health workers (CHWs) are an essential cadre in the health systems of many low- and middle-income countries. These workers provide a wide variety of services and are key to ongoing processes of task shifting within human immunodeficiency virus programmes in particular. Ward-based outreach teams (WBOTs) are South Africa's latest iteration of the CHW programme and have been introduced as part of the National Department of Health's Primary Health Care Re-engineering programme. METHODS: In order to assess the perceived effectiveness of the WBOTs in supporting the ongoing rollout of antiretroviral therapy, tuberculosis care and patient support, we conducted a qualitative investigation focusing on the perceived successes and challenges of the programme among CHWs, community leaders, healthcare workers and community members in the Mopani district, Limpopo province, South Africa. RESULTS: The CHW programme operates across these contexts, each associated with its own set of challenges and opportunities. CONCLUSIONS: While these challenges may be interrelated, a contextual analysis provides a useful means of understanding the programme's implementation as part of ongoing decision-making processes.

Community-based strategies to identify the unmet need for care of individuals with sexually transmitted infection-associated symptoms in rural South Africa.

OBJECTIVES: To determine the unmet need for care and barriers for consulting sexually transmitted infection (STI) services at six primary healthcare (PHC) facilities in rural South Africa. METHODS: Cross-sectional study using three community-based strategies to mobilise adult individuals with STI-associated symptoms to access care. Participants were mobilised through clinic posters and referral by community healthcare workers (CHWs) and traditional leaders after training. Men with male urethritis syndrome and women with vaginal discharge syndrome were mobilised to visit participating PHC facilities on two designated days when an expert team visited the facility. Questionnaires were completed and HIV rapid tests offered. The minimal unmet need for care of individuals with STI-associated symptoms was calculated by dividing the number of cases over the adult catchment population of each PHC facility. RESULTS: We successfully mobilised 177 symptomatic individuals: 134 (76%) women and 43 (24%) men. The estimated minimal unmet need for STI care was 1:364 (95% CI 1:350-1:380) individuals in this region; the rate was higher in village than township facilities, and among women. Mobilisation through clinic posters (57%) and by CHWs (23%) was most successful. Three-quarters of individuals (132/177) reported symptoms that had been present for >30 days; 49% (87/177) had symptoms >6 months. In addition, we identified 14 individuals with untreated HIV infection amounting to a 7% HIV testing yield. Lack of awareness of symptoms (34%), and disappointment in care due to persistent (23%) or recurrent (15%) symptoms after previous treatment, or disappointment with health services in general during previous visit(s) for any reason (10%) was the most common reasons for not consulting health care. CONCLUSIONS: We demonstrate a high unmet need for care of individuals with STI-associated symptoms in rural South Africa that requires urgent attention. A multidisciplinary approach that creates service demand through community awareness and information provision by healthcare workers combined with strengthening the quality of STI services is required to improve reproductive health and prevent complications of untreated STIs in this population.

OBJECTIFS: Déterminer les besoins non satisfaits en matière de soins et les obstacles à la consultation des services pour IST dans six établissements de soins de santé primaires (SSP) en milieu rural en Afrique du Sud. MÉTHODES: Etude transversale utilisant trois stratégies communautaires pour mobiliser les individus adultes présentant des symptômes associés aux IST afin qu'ils puissent accéder aux soins. Les participants ont été mobilisés à travers des affiches dans les cliniques et sur recommandation des agents de santé communautaires (ASC) et des chefs traditionnels après une formation. Les hommes atteints du syndrome d'urétrite masculin et les femmes atteintes du syndrome de pertes vaginales ont été mobilisés à visiter les établissements de SSP participants, au cours de deux jours choisis lorsqu'une équipe d'experts était présente dans l'établissement. Des questionnaires ont été remplis et des tests de dépistage rapides du VIH ont été proposés. Le besoin minimal non satisfait de soins pour les personnes présentant des symptômes associés aux IST a été calculé en divisant le nombre de cas par la population adulte de la zone de chaque établissement de SSP. RÉSULTATS: Nous avons réussi à mobiliser 177 personnes symptomatiques: 134 (76%) femmes et 43 (24%) hommes. Le besoin minimal non satisfait en matière de soins IST était de 1:364 (IC95%: 1:350 - 1:380) individus dans cette région; le taux était plus élevé dans les villages que dans les installations des bidonvilles et chez les femmes. La mobilisation par le biais d'affiches de cliniques (57%) et par les ASC (23%) a eu le plus de succès. Les trois quarts des personnes (132/177) ont signalé des symptômes présents depuis >30 jours; 49% (87/177) présentaient des symptômes > 6 mois. En outre, nous avons identifié 14 personnes présentant une infection par le VIH, non traitée, ce qui représente un rendement de dépistage du VIH de 7%. Le manque de prise de conscience des symptômes (34%) et la déception avec les soins en raison de symptômes persistants (23%) ou récurrents (15%) après un traitement précédent, ou la déception avec les services de santé en général lors de visites précédentes pour une raison quelconque (10 %) étaient les raisons les plus courantes de ne pas consulter les soins de santé. CONCLUSIONS: Dans les zones rurales d'Afrique du Sud, nous démontrons un besoin élevé de soins non satisfaits pour les personnes présentant des symptômes associés aux IST et nécessitant une attention urgente. Une approche multidisciplinaire qui crée une demande de services par le biais de la sensibilisation de la communauté et de la fourniture d'informations par les agents de santé, associée au renforcement de la qualité des services IST, est nécessaire pour améliorer la santé reproductive et prévenir les complications des IST non traitées dans cette population.

Fidelity of HIV programme implementation by community health workers in rural Mopani district, South Africa: a community survey.

BACKGROUND: South Africa has implemented a community health programme delivered by community health workers (CHWs) to strengthen primary healthcare services. Provision of community Human Immunodeficiency Virus (HIV) services constitutes an important component of this programme. To support effectiveness, we assessed fidelity of HIV programme implementation by CHWs from the community's perspective in a rural South African setting. METHODS: A cross-sectional study was conducted targeting 900 randomly selected households in twelve wards of two sub-districts (Greater Giyani and Greater Letaba) of Mopani District (Limpopo Province, South Africa). Questionnaires were administered to the traditionally most appropriate adult member of the household. Included were questions related to the four standard components to measure implementation fidelity against local guidelines: coverage, frequency, duration and content of HIV programme implementation. RESULTS: Participants were enrolled at 534 households; in most other cases there was nobody or no adult member at home (n = 291). Reported coverage of 55% (141/253) and a frequency of 47% (66/140) were higher in Greater Giyani as compared to Greater Letaba (44%; 122/278 and 29%; 33/112, respectively, p = 0.007 for both comparisons). Coverage was not associated with the distance from the participant's household to the facility (p = 0.93). Duration of programme delivery was reported to be high, where all CHW visits (253/253; 100%) were conducted within the last 6 months and the content delivered was adequate (242/253; 96%). Individuals reporting a CHW visit were more likely to know their HIV status than those not visited (OR = 2.0; 95% CI 1.06-3.8; p = 0.032). Among those visited by the CHW discussion of HIV was associated with knowing the HIV status (OR = 2.2; 95% CI 1.02-4.6; p = 0.044); in particular for women (OR = 2.9; 95% CI 1.5-5.4; p = 0.001). CONCLUSIONS: This study demonstrates promising HIV programme implementation fidelity by CHWs in rural South Africa. Programme coverage and frequency should be improved whilst maintaining the good levels of duration and content. Resource investment, strengthening of operational structure, and research to identify other facilitators of programme implementation are warranted to improve programme effectiveness and impact.

Qualitative assessment of facilitators and barriers to HIV programme implementation by community health workers in Mopani district, South Africa.

South Africa has implemented a community-based HIV programme (CBHP) in its primary healthcare (PHC) re-engineering strategy that aims to improve public healthcare delivery. This CBHP is delivered by ward-based outreach teams (WBOTs); provision of community HIV services comprises an important component of this programme. We conducted an exploratory study to determine the facilitators and barriers to successful implementation of this CBHP in rural Mopani District, South Africa. Focus group discussions were conducted with the community health workers (CHWs) and PHC nurses; participant interviews were conducted with community members who access these health services, community leaders, and social workers. We conducted a thematic content analysis and based on the key themes reported, we identified the Consolidated Framework for Implementation Research, consisting of five domains, as the most appropriate model to interpret our findings. First, in terms of intervention characteristics, community members generally valued the HIV services provided, but the variable needs impacted on programme implementation. Outer setting challenges include inability to meet the need of patients as a result of stigma, non-disclosure of HIV status and social factors. In terms of the inner setting, CHWs were grateful for the equipment and training received but expressed the need for better support of management and the provision of additional resources. With regard to characteristics of the implementers, the CHWs expressed the desire for further training despite reporting having sufficient knowledge to conduct their HIV work. Finally, in terms of the implementation process, the importance of relationship building between CHWs and community members was emphasised. In conclusion, these data underline the positive receipt and potential of the CBHP in this rural district and identify areas to further strengthen the programme. The success and sustainability of the CBHP requires ongoing commitment of resources, training, supervision, and organisational support in order to operate effectively and efficiently.

Making ward-based outreach teams an effective component of human immunodeficiency virus programmes in South Africa.

The implementation of ward-based outreach teams (WBOTs), comprised of community health workers (CHWs), is one of the three interventions of the South African National Department of Health's (NDoH) Primary Health Care (PHC) Re-engineering strategy for improving health outcomes. CHWs provide a necessary structure to contribute to successful implementation of the human immunodeficiency virus (HIV) programme in four ways: (1) prevention of HIV infection by health education, (2) linkage to care by health education and referrals, (3) adherence support and (4) identification of individuals who are failing treatment. However, CHW programme and HIV programme-specific barriers exist that need to be resolved in order to achieve maximum impact. These include a lack of stakeholder and community support for WBOTs, challenging work and operational environments, a lack of in-depth knowledge and skills, and socio-cultural barriers such as HIV-related stigma. Considering its promising structure, documentation of the WBOT contribution to healthcare overall, and the HIV programme in particular, is urgently warranted to successfully and sustainably incorporate it into the South African healthcare system.