Emerging from the Shadows: Intrinsic and Extrinsic Factors Facing Community Health Workers in Western Cape, South Africa

Workload and emerging challenges of community health workers in low- and middle-income countries: A mixed-methods systematic review

BACKGROUND

Community health workers (CHWs) play an important role in improving access to health services to a broader population; particularly to communities living in remote areas. However, the productivity of CHWs is affected by the workload they have. We aimed to summarize and present CHWs' perceived workload in low-and middle-income countries (LMICs).

METHODS

We searched three electronic databases (PubMed, Scopus, and Embase). A search strategy customized for the three electronic databases was developed using the two key terms of the review (CHWs and workload). Primary studies conducted in LMICs that explicitly measured workload of CHWs and published in English were included, without date restrictions. Methodological quality of the articles was assessed by two reviewers independently using mixed-methods appraisal tool. We applied a convergent integrated approach to synthesize the data. This study is registered on PROSPERO, number CRD42021291133.

RESULTS

Of 632 unique records, 44 met our inclusion criteria, and 43 (20 qualitative, 13 mixed-methods, and 10 quantitative studies) passed the methodological quality assessment and were included in this review. In 97.7% (n = 42) of the articles, CHWs reported that they have a high workload. Having multiple tasks was the most commonly reported subcomponent of workload, followed by lack of transport; which was reported in 77.6% (n = 33) and 25.6% (n = 11) of the articles respectively.

CONCLUSION

CHWs in LMICs reported that they have a high workload; mainly related to having to manage multiple tasks and the lack of transport to access households. Program managers need to make careful consideration when additional tasks are shifted to CHWs and the practicability to be performed in the environment they work in. Further research is also required to make a comprehensive measure of the workload of CHWs in LMICs.

Qualitative assessment of community health workers' perspective on their motivation in community-based primary health care in rural Malawi

BACKGROUND

Community Health Workers (CHWs) have a positive impact on the provision of community-based primary health care through screening, treatment, referral, psychosocial support, and accompaniment. With a broad scope of work, CHW programs must balance the breadth and depth of tasks to maintain CHW motivation for high-quality care delivery. Few studies have described the CHW perspective on intrinsic and extrinsic motivation to enhance their programmatic activities.

METHODS

We utilized an exploratory qualitative study design with CHWs employed in the household model in Neno District, Malawi, to explore their perspectives on intrinsic and extrinsic motivators and dissatisfiers in their work. Data was collected in 8 focus group discussions with 90 CHWs in October 2018 and March-April 2019 in seven purposively selected catchment areas. All interviews were audiotaped, transcribed verbatim, coded, and analyzed using Dedoose.

RESULTS

Themes of complex intrinsic and extrinsic factors were generated from the perspectives of the CHWs in the focus group discussions. Study results indicate that enabling factors are primarily intrinsic factors such as positive patient outcomes, community respect, and recognition by the formal health care system but can lead to the challenge of increased scope and workload. Extrinsic factors can provide challenges, including an increased scope and workload from original expectations, lack of resources to utilize in their work, and rugged geography. However, a positive work environment through supportive relationships between CHWs and supervisors enables the CHWs.

CONCLUSION

This study demonstrated enabling factors and challenges for CHW performance from their perspective within the dual-factor theory. We can mitigate challenges through focused efforts to limit geographical distance, manage workload, and strengthen CHW support to reinforce their recognition and trust. Such programmatic emphasis can  focus on enhancing motivational factors found in this study to improve the CHWs' experience in their role. The engagement of CHWs, the communities, and the formal health care system is critical to improving the care provided to the patients and communities, along with building supportive systems to recognize the work done by CHWs for the primary health care systems.

Challenges experienced by community health workers and their motivation to attend a self-management programme

Background: Community health workers (CHWs) are change agents expected to assist in decreasing the global burden of disease in the communities they serve. However, they themselves have health risk behaviours, which predispose them to non-communicable diseases and thus need to be empowered to make better health choices. There is a gap in literature detailing the challenges faced by CHWs in addressing their own health risk behaviours.Aim: This study aimed to explore the challenges experienced by CHWs in carrying out their daily duties and the motivating factors to join a self-management programme.Setting: The study was conducted in a low socio-economic urban area of the Western Cape, South Africa.Methods: This study used a qualitative exploratory design using in-depth interviews to obtain rich data about the personal and professional challenges that CHWs experience on a daily basis.Results: Five themes emerged with regard to professional challenges (social conditions, mental health of patients, work environment, patient adherence and communication). This cadre identified ineffective self-management as a personal challenge and two themes emerged as motivation for participating in a self-management programme: empowerment and widening perspective.Conclusion: The challenges raised by the CHWs have a direct impact on their role in communities. This study therefore highlights an urgent need for policymakers and leaders who plan training programmes to take intentional strategic action to address their health challenges and to consider utilising a self-management intervention model to improve their overall health status.

Barriers and facilitators of rendering HIV services by community health workers in sub-Saharan Africa: a meta-synthesis

Objectives

To synthesise qualitative studies that address the barriers to and facilitators of providing HIV services by community health workers (CHWs) in sub-Saharan Africa (SSA).

Design

This meta-synthesis was guided by Preferred Reporting Items for Systematic Reviews and Meta-Analyses. We included studies that were published between 2009 and 2019. The Ritchie and Spencer framework and the Supporting the Use of Research Evidence framework were used for thematic analysis and framework analysis, respectively. The Qualitative Assessment and Review Instrument was used to assess the quality of selected studies.

Eligibility criteria

Qualitative studies published between 2009 and 2019, that included CHWs linked directly or indirectly to the Ministry of Health and providing HIV services in the communities.

Information sources

An extensive search was conducted on the following databases: EBSCOhost- (ERIC; Health Source-Nursing/Academic Edition; MEDLINE Full Text), Google Scholar and PubMed.

Results

Barriers to rendering of HIV services by CHWs were community HIV stigma; lack of CHW respect, CHWs’ poor education and training; poor stakeholders’ involvement; poor access to the communities; shortage of CHWs; unsatisfactory incentives; lack of CHW support and supervision, lack of equipment and supplies and social barriers due to culture, language and political structures. The altruistic behaviour of CHWs and the availability of job facilitated the provision of HIV services.

Conclusion

The delivery of HIV services by CHWs in SSA is faced by more lingering barriers than facilitators. Planners and policymakers can minimise the barriers by investing in both CHW and community training regarding HIV services. Furthermore, sufficient funding should be allocated to the programme to ensure its efficiency.

PROSPERO registration number

CRD42020160012.