Harmonizing community-based health worker programs for HIV: a narrative review and analytic framework

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.

Nurse Support on Health Cadre Empowerment and the Influence on the Ability of Women’s Mentoring Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome

BACKGROUND: In the context of community empowerment, the role of nurses as health workers is very important to transform the knowledge and skills of cadres. However, the support of nurses in empowering human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) health cadres has not been widely explained. AIM: This study examines the effect of nurse support and empowerment on the ability of HIV/AIDS cadres to assist mothers with HIV/AIDS. METHODS: This study used a cross-sectional approach. We involved 119 HIV/AIDS cadres including local residents who care about AIDS (WPA, n = 90), facilitators of families of hope (PKH, n = 17), and peer support groups (KDS, n = 12). Data collection was carried out from February to April 2020, the sample was selected using multistage cluster sampling in Kudus Regency, Central Java, Indonesia. Multiple linear regression analysis was conducted to determine the support of nurses, empowerment of HIV/AIDS cadres, and its effect on the ability of cadres in assisting women with HIV/AIDS. RESULTS: We found that nurses’ support for the empowerment of HIV/AIDS cadres was low in almost all aspects (instrumental, informational, emotional, and affiliation). Nurse support and cadre empowerment affect the ability of HIV/AIDS cadres by 28%. Regression test formula Y = −97.080 + 0.738X1 + 1.944X2. CONCLUSION: The results showed that the four types of nurse social support may be interrelated and are generally still low in the process of empowering HIV/AIDS cadres. There is an effect of nurse support and empowerment of HIV/AIDS cadres on the ability of cadres to assist women with HIV/AIDS.

Community-based health workers implementing universal access to HIV testing and treatment: lessons from South Africa and Zambia-HPTN 071 (PopART)

The global expansion of HIV testing, prevention and treatment services is necessary to achieve HIV epidemic control and promote individual and population health benefits for people living with HIV (PLHIV) in sub-Saharan Africa. Community-based health workers (CHWs) could play a key role in supporting implementation at scale. In the HPTN 071 (PopART) trial in Zambia and South Africa, a cadre of 737 study-specific CHWs, working closely with government-employed CHW, were deployed to deliver a ‘universal’ door-to-door HIV prevention package, including an annual offer of HIV testing and referral services for all households in 14 study communities. We conducted a process evaluation using qualitative and quantitative data collected during the trial (2013–2018) to document the implementation of the CHW intervention in practice. We focused on the recruitment, retention, training and support of CHWs, as they delivered study-specific services. We then used these descriptions to: (i) analyse the fidelity to design of the delivery of the intervention package, and (ii) suggest key insights for the transferability of the intervention to other settings. The data included baseline quantitative data collected with the study-specific CHWs (2014–2018); and qualitative data from key informant interviews with study management (n = 91), observations of CHW training events (n = 12) and annual observations of and group discussions (GD) with intervention staff (n = 68). We show that it was feasible for newly recruited CHWs to implement the PopART intervention with good fidelity, supporting the interpretation of the trial outcome findings. This was despite some challenges in managing service quality and CHW retention in the early years of the programme. We suggest that by prioritizing the adoption of key elements of the in-home HIV services delivery intervention model—including training, emotional support to workers, monitoring and appropriate remuneration for CHWs—these services could be successfully transferred to new settings.

Categorization of Factors Influencing Community Health Workers from a Socio-Technical Systems Perspective

In low-and-middle-income countries (LMICs), community health workers (CHWs) are often seen as a connecting bridge between two dynamic and overlapping systems- the community and formal health systems. Although the importance of CHWs is acknowledged, there is minimal aggregated evidence contributing towards understanding their position, technological capabilities, barriers and facilitators of their effectiveness in the South African context. Despite the widespread enthusiasm around the potential that mobile health (mHealth) technology holds in extending healthcare through CHW to underserved communities, an understanding of mHealth’s various implications in a developing world context is imperative to appreciate both the community and health systems context. The CHWs within this context need to assume multiple roles as they work and live amongst and in the community. The study argues that by examining their multiple roles as part of the healthcare continuum and from within the community setting, appropriating technological solutions can be conceptualized to facilitate and enhance their impact and visibility. This research article then aims to articulate the key conceptual factors which should be considered when implementing technological solutions for CHWs within the South African context. The aim is operationalized by means of the best-fit framework synthesis method to explore the body of knowledge towards presenting a conceptual understanding through a categorization of Factors Influencing Community Health Workers from a Socio-Technical Systems Perspective.

The role of community health workers in improving HIV treatment outcomes in children: lessons learned from the ZENITH trial in Zimbabwe

Reliance on community health workers (CHWs) for HIV care continues to increase, particularly in resource-limited settings. CHWs can improve HIV service use and adherence to treatment, but effectiveness of these programmes relies on providing an enabling work environment for CHWs, including reasonable workload, supportive supervision and adequate training and supplies. Although criteria for effective CHW programmes have been identified, these have rarely been prospectively applied to design and evaluation of new interventions. For the Zimbabwe study for Enhancing Testing and Improving Treatment of HIV in Children (ZENITH) randomized controlled trial, we based our intervention on an existing evidence-based framework for successful CHW programmes. To assess CHWs’ experiences delivering the intervention, we conducted longitudinal, qualitative semi-structured interviews with all 19 CHWs at three times during implementation. The study aimed to explore CHWs’ perceptions of how the intervention’s structure and management affected their performance, and consider implications for the programme’s future scale-up and adoption in other settings. CHWs expressed strong motivation, commitment and job satisfaction. They considered the intervention acceptable and feasible to deliver, and levels of satisfaction rose over interview rounds. Intensive supervision and mentoring emerged as critical to ensuring CHWs’ long-term satisfaction. Provision of job aids, standardized manuals and refresher training were also important, as were formalized links between clinics and CHWs. Concerns raised by CHWs included poor remuneration, their reluctance to stop providing support to individual families following the requisite number of home visits, and disappointment at the lack of programme sustainability following completion of the trial. Furthermore, intensive supervision and integration with clinical services may be difficult to replicate outside a trial setting. This study shows that existing criteria for designing successful CHW programmes are useful for maximizing effectiveness, but challenges remain for ensuring long-term sustainability of ‘task shifting’ strategies.

Harmonization of community health worker programs for HIV: A four-country qualitative study in Southern Africa

BACKGROUND

Community health worker (CHW) programs are believed to be poorly coordinated, poorly integrated into national health systems, and lacking long-term support. Duplication of services, fragmentation, and resource limitations may have impeded the potential impact of CHWs for achieving HIV goals. This study assesses mediators of a more harmonized approach to implementing large-scale CHW programs for HIV in the context of complex health systems and multiple donors.

METHODS AND FINDINGS

We undertook four country case studies in Lesotho, Mozambique, South Africa, and Swaziland between August 2015 and May 2016. We conducted 60 semistructured interviews with donors, government officials, and expert observers involved in CHW programs delivering HIV services. Interviews were triangulated with published literature, country reports, national health plans, and policies. Data were analyzed based on 3 priority areas of harmonization (coordination, integration, and sustainability) and 5 components of a conceptual framework (the health issue, intervention, stakeholders, health system, and context) to assess facilitators and barriers to harmonization of CHW programs. CHWs supporting HIV programs were found to be highly fragmented and poorly integrated into national health systems. Stakeholders generally supported increasing harmonization, although they recognized several challenges and disadvantages to harmonization. Key facilitators to harmonization included (i) a large existing national CHW program and recognition of nongovernmental CHW programs, (ii) use of common incentives and training processes for CHWs, (iii) existence of an organizational structure dedicated to community health initiatives, and (iv) involvement of community leaders in decision-making. Key barriers included a wide range of stakeholders and lack of ownership and accountability of non-governmental CHW programs. Limitations of our study include subjectively selected case studies, our focus on decision-makers, and limited generalizability beyond the countries analyzed.

CONCLUSION

CHW programs for HIV in Southern Africa are fragmented, poorly integrated, and lack long-term support. We provide 5 policy recommendations to harmonize CHW programs in order to strengthen and sustain the role of CHWs in HIV service delivery.