Expanding Community Health Worker decision space: learning from a Participatory Action Research training intervention in a rural South African district

From Springer Nature via Jisc Publications RouterHistory: received 2022-12-17, accepted 2023-08-08, registration 2023-08-09, epub 2023-08-18, online 2023-08-18, collection 2023-12Acknowledgements: The authors dedicate this paper to Professor Peter Byass, who died suddenly in 2020. Peter’s death had profound personal and professional impacts on the team. His death has also galvanised us to continue his work on information systems in South Africa and globally. The authors would also like to thank community, government, and non-governmental stakeholder participants for agreeing to be part of the process, and for sharing their time, knowledge, and perspectives. Thanks also to the Verbal Autopsy with Participatory Action Research (VAPAR) team and staff of the Medical Research Council (MRC)/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), especially Mr Simon Khoza, Dr Rhian Twine and Professors Stephen Tollman and Kathleen Kahn. Thanks to Hanna-Mari Van Der Merwe for preparing the Google Map contained in Fig. 1.Publication status: PublishedFunder: Medical Research Council; doi: http://dx.doi.org/10.13039/501100000265; Grant(s): MR/P014844/1Sophie Witter - ORCID: 0000-0002-7656-6188 https://orcid.org/0000-0002-7656-6188Background: While integral to decentralising health reforms, Community Health Workers (CHWs) in South Africa experience many challenges. During COVID-19, CHW roles changed rapidly, shifting from communities to clinics. In the contexts of new roles and re-engineered primary healthcare (PHC), the objectives were to: (a) implement a training intervention to support local decision-making capability of CHWs; and (b) assess learning and impacts from the perspectives of CHWs. Methods: CHWs from three rural villages (n = 9) were trained in rapid Participatory Action Research (PAR) with peers and community stakeholders (n = 33). Training equipped CHWs with tools and techniques to convene community groups, raise and/or respond to local health concerns, understand concerns from different perspectives, and facilitate action in communities and public services. CHWs’ perspectives before and after the intervention were gained through semi-structured interviews. Data were collected and analysed using the decision space framework to understand local actors’ power to affect devolved decision-making. Results: CHWs demonstrated significant resilience and commitment in the face of COVID-19. They experienced multiple, intersecting challenges including: limited financial, logistical and health systems support, poor role clarity, precarious employment, low and no pay, unstable organisational capacity, fragile accountability mechanisms and belittling treatment in clinics. Together, these restricted decision space and were seen to reflect a low valuing of the cadre in the system. CHWs saw the training as a welcome opportunity to assert themselves as a recognised cadre. Regular, spaces for dialogue and mutual learning supported CHWs to gain tools and skills to rework their agency in more empowered ways. The training improved management capacity, capabilities for dialogue, which expanded role clarity, and strengthened community mobilisation, facilitation and analysis skills. Development of public speaking skills was especially valued. CHWs reported an overall ‘tripe-benefit’ from the training: community-acceptance; peer support; and dialogue with and recognition by the system. The training intervention was recommended for scale-up by the health authority as an implementation support strategy for PHC. Conclusions: Lack of recognition of CHWs is coupled with limited opportunities for communication and trust-building. The training supported CHWs to find and amplify their voices in strategic partnerships, and helped build functionality for local decision-making.The study was funded by the Joint Health Systems Research Initiative from the Department for International Development/MRC/Welcome Trust/Economic and Social Research Council (MR/P014844/1). Funders had no role in any part of the work including design and conduct of the study, data collection, data management, data analysis and interpretation, preparation, review, and approval of the manuscript.pubpu

Additional file 2 of Expanding Community Health Worker decision space: learning from a Participatory Action Research training intervention in a rural South African district

Additional file 2. VAPAR Mpumalanga health policy and systems research learning platform, Mpumalanga Department of Health. Community health workers community mobilisation training manual (siTsonga version). VAPAR Mpumalanga Health Policy and Systems Learning Platform; 2022. https://www.vapar.org/_files/ugd/532615_1384f348491e422c9080e4d28e70d4a9.pdf

Additional file 1 of Expanding Community Health Worker decision space: learning from a Participatory Action Research training intervention in a rural South African district

Additional file 1. VAPAR Mpumalanga health policy and systems research learning platform, Mpumalanga department of health. Community health workers community mobilisation training manual (english version). VAPAR Mpumalanga health policy and systems learning platform; 2022. https://www.vapar.org/_files/ugd/532615_d50539e3dc82416980f5c4732e11eb10.pdf

Expanding Community Health Worker decision space: learning from a Participatory Action Research training intervention in a rural South African district

Abstract Background While integral to decentralising health reforms, Community Health Workers (CHWs) in South Africa experience many challenges. During COVID-19, CHW roles changed rapidly, shifting from communities to clinics. In the contexts of new roles and re-engineered primary healthcare (PHC), the objectives were to: (a) implement a training intervention to support local decision-making capability of CHWs; and (b) assess learning and impacts from the perspectives of CHWs. Methods CHWs from three rural villages (n = 9) were trained in rapid Participatory Action Research (PAR) with peers and community stakeholders (n = 33). Training equipped CHWs with tools and techniques to convene community groups, raise and/or respond to local health concerns, understand concerns from different perspectives, and facilitate action in communities and public services. CHWs’ perspectives before and after the intervention were gained through semi-structured interviews. Data were collected and analysed using the decision space framework to understand local actors’ power to affect devolved decision-making. Results CHWs demonstrated significant resilience and commitment in the face of COVID-19. They experienced multiple, intersecting challenges including: limited financial, logistical and health systems support, poor role clarity, precarious employment, low and no pay, unstable organisational capacity, fragile accountability mechanisms and belittling treatment in clinics. Together, these restricted decision space and were seen to reflect a low valuing of the cadre in the system. CHWs saw the training as a welcome opportunity to assert themselves as a recognised cadre. Regular, spaces for dialogue and mutual learning supported CHWs to gain tools and skills to rework their agency in more empowered ways. The training improved management capacity, capabilities for dialogue, which expanded role clarity, and strengthened community mobilisation, facilitation and analysis skills. Development of public speaking skills was especially valued. CHWs reported an overall ‘tripe-benefit’ from the training: community-acceptance; peer support; and dialogue with and recognition by the system. The training intervention was recommended for scale-up by the health authority as an implementation support strategy for PHC. Conclusions Lack of recognition of CHWs is coupled with limited opportunities for communication and trust-building. The training supported CHWs to find and amplify their voices in strategic partnerships, and helped build functionality for local decision-making