This article aimed to describe Bukhali HHs’ perspectives and experiences, and adds to recent LMIC literature that provides a voice to CHW’s perspectives and experiences (12, 22, 29, 31, 41–44). Key findings include the complex workload of HHs, how they manage the mental health demands of their work in the context of Soweto (in relation to participants, the positive impact of this work on their own learning and development, and their own wellbeing). Bukhali HHs’ workload includes what could be classified as more traditional CHW roles, but there appears to be added complexity due to working across phases of the life course, as well as, the perceived need to provide counselling, even though this is beyond the scope of what is expected of HHs. The dynamic of misalignment between HH's expectations and the reality of the job further contributes to this complexity.
The context of this trial in Soweto contributes to a greater than anticipated burden of mental health challenges amongst participants, which has been documented (25, 32), and highlights the need for a more trauma-informed approach (33) not only for the Bukhali study but more generally for CHWs in primary care. Added to this are the HHs own similar experiences, since they are from the same context and may have faced or currently face many similar mental health challenges and experiences, and the emotional toll of their work. Although this can be triggering and difficult to manage, the HHs’ geographic (and social) proximity to participants seems to significantly contribute to the successful relationships that they are able to develop with participants, which could also be positively impacted by their similarity in age, as would be expected (28).
Specifically, the trust built between HHs and participants appears to be a powerful mechanism to attain intervention impact; the value of trust has been emphasised in work with CHWs in South Africa (21, 23) and India (45, 46). Trust has also been highlighted from the perspective of Bukhali participants in previous qualitative work, along with the potentially stabilising role that HHs can play in the lives of participants which are often characterised by instability in various fronts (36). This adds to the argument that CHWs have the potential to be “powerful social actors”, and not “just another pair of hands” in the health system (47). However, in Bukhali, it seems that the critical role of relationship building to establish trust and fully maximise the HHs potential impact is not without its cost in terms of the emotional toll that relationship building can take. Also, the issue of renumeration as it relates to recognition for HHs’ contribution has been raised in previous research (21, 22, 48–51)
and is indeed a challenge we have noted as a critical factor in CHW’s motivation, performance and retention. Any future scale-up of CHW-delivered interventions needs to consider this issue of remuneration (and workload) of CHWs to optimise morale and motivation and hence implementation, although the challenges of doing this in resource-constrained settings are recognised, along with the need for political and economic support (52).
Given the importance of considering contextual factors that influence the implementation of CHW programmes and performance of CHWs (49, 53), these findings provide valuable understanding of how the Soweto context impacts on the Bukhali trial and HHs, but CHWs more generally. Firstly, as in many LMIC contexts, the complexity of multiple roles can impact on the delivery of the intervention as HHs/CHWs are required to flexibly switch between roles, depending on what may be a priority for a participant, what is urgent within a particular phase of a trial, or specific demands with a certain socioeconomic context. To some degree, this relates to the task-shifting associated with CHWs, and just as the ethics of task-shifting need to be considered in terms of the toll this takes on CHWs (43), the toll of this role switching also warrants attention. Potentially, as CHWs become more mainstream within health services, task differentiation and specialisation maybe be useful strategies to counter overburdening CHWs and providing a career development path.
Secondly, the emotional toll of this type of ‘front line’ work in a context such as Soweto can negatively impact on implementation if HHs/CHWs burn out or do not have the emotional and mental capacity to engage in meaningful interactions with participants mentioned above. While the resilience of HHs/CHWs is admirable, a dependence on this resilience in the context of the intergenerational trauma so prevalent in SA is unhealthy. Continuing to provide training and support on skills such as healthy boundaries and coping mechanisms, including peer support, is critical, along with mental health support for these types of workers. The switching mentioned above would also benefit from supportive supervision. The importance of support for CHWs in challenging settings, like Soweto, has been highlighted (48, 54), along with supportive supervision for CHWs (23, 49, 55–58). Thirdly, HHs’ accounts of their own learning and development as a result of their involvement in Bukhali indicate that the positive gains of this type of work could be amplified to help counter some of the emotional toll of this work. This could include highlighting the interpersonal skills obtained, the ability to work effectively in multilingual environments, and increased self-awareness. A sense of self-efficacy and enactive mastery, and an increase in self-esteem have previously been identified as mechanisms for improving CHW performance in LMICs (59).
While the focus on CHWs from one intervention could be perceived as a limitation of this study, this has allowed for consideration of unique features of these HHs’ experiences in a specific context. As discussed above, these findings have implications for other settings not just in terms of how contextual factors can influence implementation of CHW-delivered interventions, but also, considerations to build into CHW health service programmes. The exploratory nature of the study may be seen as a limitation, but given the importance of highlighting CHWs perceptions and experiences, the study has helped to elucidate relevant issues. The small number of focus groups could also be viewed as a limitation, but all 13 CHWs employed at the time of the data collection were included, and we were able to explore their perspectives in depth.