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Opportunities to sustain community engagement by Community Health Workers

Reflection on Cycles 1 to 3

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Two CHW representatives from local areas presented their reflection of the process. They shared that the VAPAR process has been very helpful to them as they have gained confidence that they were previously lacking, to the point of being able to stand in front of their managers and speak with confidence as their public speaking skills have also improved. They furthermore indicated that they are able to apply the knowledge gained from VAPAR, including the PAR tools, to reduce the number of HIV and TB clients who are lost to follow-up. In addition, the CHWs shared that they use the problem tree tool to help them solve any problem in their line of work. Lastly, the CHWs reported that the VAPAR programme improved the relationship between CHWs and their outreach team leaders (OTLs).

At individual level, the CHWs shared their personal growth that has been facilitated through the program. This included an increase in their self-confidence and believing in their own abilities to perform the duties expected of them. The newly acquired confidence enabled CHWs to reach out to and collaborate with other stakeholders, including traditional leaders and local authorities. The CHWs also reported on how they are applying PAR tools, including problem tress and Venn diagrams, to identify and address problems at facility and individual level. The CHWs shared their learning with other CHWs from their organisations and also shared the learning and application of PAR tools with their managers; enabling them to collectively approach problem identification and solving in a systematic, collaborative and action-orientated way. Health managers confirmed that the CHWs are doing a great job to curb HIV / TB loss to follow-up, but that the rate of loss to follow-up fluctuates due to several factors including community uprises, changes of address and contact numbers and administrative errors.

At a broader health-system level, VAPAR was reported to have facilitated role clarification, specifically with regards to the roles and responsibilities of CHWs as a fairly new cadre of health workers. In the past, the role of CHWs were not clear to other health workers, including their outreach team leaders (who are delegated to this now role from a position of employment within a health facility) and clinic operational managers. CHWs were also not clear on what their duties are, coming from a history of providing home based care services.

Role clarification was reported to facilitate the uptake of CHW services, including their acceptance by community members, who previously would at times refuse to be visited by CHWs or even chase them away from their households due to the stigma associated with home based care services from the era of providing care to terminally ill AIDS patients. A clear understanding of the role of CHWs also assisted with better health service delivery, as their role as the first line of contact between the health system and the community was clear, including how CHWs could advocate for uptake of services at clinic level.

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Two community representatives shared their reflection on the process. Highlights included that everyone’s opinion was being valued and all were treated equally during programme activities. They also reported to have learned to identify and solve a problem and that they shared the knowledge gained from VAPAR with other stakeholders. The community representatives also shared their learning on using different methods to vote e.g., using beans and that they were happy to have been part of the radio dissemination process as it was a great experience, their skills improved, and they learned about perseverance as well.

Reflection on Cycles 4 and 5

CHWs from Cycle 4 reported that they have been enabled to do more in the clinic than they were able to before. Furthermore, their public speaking skills have improved along with their confidence. The CHWs reported that they have acquired facilitation skills and that they are now well received and accepted in the communities where they work.

Trainers’ reflection

The CHWs who participated in Cycle 5 in the training-of-trainers approached expressed appreciation for the opportunity to have been made leaders. Facilitating the training motivated them to research before every workshop, hence they gained a lot of knowledge and experience through the process.

Overall reflections

Health programme managers encouraged the CHWs to build up others as they are now regarded as leaders. Even if the formal VAPAR programme comes to an end, the CHWs are requested to continue doing the great work that they are doing to sustain and further expand the learning and service improvement. VAPAR was regarded to have left a great legacy in the sub-district and contributed to recognition and appreciation of the work that the CHWs are doing. The CHWs confidence, presentation skills and knowledge were acknowledged by the health managers, with appreciation for the learning from the VAPAR programme. The potential to impact on health outcomes, through a skilled and empowered CHW base, was acknowledged. The support by OTLs and OPMs was stressed as a key component towards ensuring that CHWs are able to perform their roles and duties as per policy prescripts.

Representatives from districts expressed the need for further sharing of the learning from the VAPAR program in their respective districts. It was proposed that this further dissemination could be initiated to all districts, to share an overview of the VAPAR program, the learning and the impact on CHWs and their services, as well as at operational level. Should funding in future allow for further roll-out of the VAPAR process, it would be well received in all districts.

 Members of the Mpumalanga Provincial Health Research and Ethics Committee also commended the VAPAR researchers on their approach towards integration with service delivery, along with continued engagement and dissemination of activities at operational, district and provincial level. This learning would be taken forward as a requirement for other research projects in the province.

In conclusion, the programme managers expressed a request for further roll-out of the CHW training, should further funding become available. In closing, it was agreed that further opportunities to disseminate the VAPAR learning will be investigated and pursued by all stakeholders.

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