BackgroundCommunity health workers (CHWs) are a component of the health system in many countries, providing effective community-based services to mothers and infants. However, implementation of CHW programmes at scale has been challenging in many settings.AimTo explore the acceptability of CHWs conducting household visits to mothers and infants during pregnancy and after delivery, from the perspective of community members, professional nurses and CHWs themselves.SettingPrimary health care clinics in five rural districts in KwaZulu-Natal, South Africa.MethodsA qualitative exploratory study was conducted where participants were purposively selected to participate in 19 focus group discussions based on their experience with CHWs or child rearing.ResultsPoor confidentiality and trust emerged as key barriers to CHW acceptability in delivering maternal and child health services in the home. Most community members felt that CHWs could not be trusted because of their lack of professionalism and inability to maintain confidentiality. Familiarity and the complex relationships between household members and CHWs caused difficulties in developing and maintaining a relationship of trust, particularly in high HIV prevalence settings. Professional staff at the clinic were crucial in supporting the CHW’s role; if they appeared to question the CHW’s competency or trustworthiness, this seriously undermined CHW credibility in the eyes of the community.ConclusionUnderstanding the complex contextual challenges faced by CHWs and community members can strengthen community-based interventions. CHWs require training, support and supervision to develop competencies navigating complex relationships within the community and the health system to provide effective care in communities.

BackgroundCommunity health workers (CHWs) play key roles in delivering health programmes in many countries worldwide. CHW programmes can improve coverage of maternal and child health services for the most disadvantaged and remote communities, leading to substantial benefits for mothers and children. However, there is limited evidence of effective mentoring and supervision approaches for CHWs.MethodsThis is a cluster randomised controlled trial to investigate the effectiveness of a continuous quality improvement (CQI) intervention amongst CHWs providing home-based education and support to pregnant women and mothers. Thirty CHW supervisors were randomly allocated to intervention (n = 15) and control (n = 15) arms. Four CHWs were randomly selected from those routinely supported by each supervisor (n = 60 per arm). In the intervention arm, these four CHWs and their supervisor formed a quality improvement team. Intervention CHWs received a 2-week training in WHO Community Case Management followed by CQI mentoring for 12 months (preceded by 3 months lead-in to establish QI processes). Baseline and follow-up surveys were conducted with mothers of infants <12 months old living in households served by participating CHWs.ResultsInterviews were conducted with 736 and 606 mothers at baseline and follow-up respectively; socio-demographic characteristics were similar in both study arms and at each time point.At follow-up, compared to mothers served by control CHWs, mothers served by intervention CHWs were more likely to have received a CHW visit during pregnancy (75.7 vs 29.0%, p < 0.0001) and the postnatal period (72.6 vs 30.3%, p < 0.0001). Intervention mothers had higher maternal and child health knowledge scores (49 vs 43%, p = 0.02) and reported higher exclusive breastfeeding rates to 6 weeks (76.7 vs 65.1%, p = 0.02). HIV-positive mothers served by intervention CHWs were more likely to have disclosed their HIV status to the CHW (78.7 vs 50.0%, p = 0.007). Uptake of facility-based interventions were not significantly different.ConclusionsImproved training and CQI-based mentoring of CHWs can improve quantity and quality of CHW-mother interactions at household level, leading to improvements in mothers’ knowledge and infant feeding practices.Trial registrationClinicalTrials.Gov NCT01774136

Close to 14% of the global burden of disease can be attributed to neuropsychiatric disorders primarily related to the disabling nature of common mental disorders (CMDs), [1,2] which typically include depression, anxiety and psychoactive substance use or alcohol use disorder. A review and meta-analysis of studies between 1980 and 2013 established that 29.2% of individuals globally experienced CMDs at some point in their lifetime. [3] CMDs have been shown to contribute to the burden of disease in low-and middle-income countries, [4-6] and can variously compromise adherence to treatment, health behaviour change and self-management efforts. [7-9] In South Africa (SA), almost a third (30.3%) of the population has experienced a CMD in their lifetime, [10] with a 12-month prevalence estimate of 16.5% for CMDs (anxiety, mood and substance use disorders). [11] Although effective treatment for mental disorders is available [12,13] and can be delivered in routine primary healthcare (PHC), [14] only about half of patients with a depressive disorder in high-income settings are detected [15,16] and only 16.5% of all individuals with a 12-month major depressive disorder receive minimally adequate treatment. [17] In SA this gap is far greater, with only one in four people with a CMD reporting receiving treatment of any kind. [18] While integrating mental healthcare into existing health systems may be the most effective and cost-efficient approach to improve access to mental health services in SA, it requires addressing major knowledge gaps, inter alia the development and assessment of interventions that integrate mental health screening and treatment into existing health systems [8,19] as well as training lay counsellors in the identification of mental disorders. [20] However, screening that is integrated into routine care must use measures that can be administered by nonspecialist health staff, are brief and easy to administer, and promote high specificity given the meagre resources available to treat false positives. [21] Objectives This validation study was a substudy of the Southern African Mental Health Integration project on evaluating the scale-up of evidencebased packages for integration of mental healthcare in PHC settings for depression and alcohol use disorders into routine care that is part of the Mental Health Integration Programme (MhINT). Continuous This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

In the context of the ANRS 12249 Treatment as Prevention (TasP) trial, we investigated perceptions of regular and repeat HIV-testing in rural KwaZulu-Natal (South Africa), an area of very high HIV prevalence and incidence. We conducted two qualitative studies, before (2010) and during the early implementation stages of the trial (2013-2014), to appreciate the evolution in community perceptions of repeat HIV-testing over this period of rapid changes in HIV-testing and treatment approaches. Repeated focus group discussions were organized with young adults, older adults and mixed groups. Repeat and regular HIV-testing was overall well perceived before, and well received during, trial implementation. Yet community members were not able to articulate reasons why people might want to test regularly or repeatedly, apart from individual sexual risk-taking. Repeat home-based HIV-testing was considered as feasible and convenient, and described as more acceptable than clinic-based HIV-testing, mostly because of privacy and confidentiality. However, socially regulated discourses around appropriate sexual behaviour and perceptions of stigma and prejudice regarding HIV and sexual risk-taking were consistently reported. This study suggests several avenues to improve HIV-testing acceptability, including implementing diverse and personalised approaches to HIV-testing and care, and providing opportunities for antiretroviral therapy initiation and care at home.

BackgroundSouth African infant and child mortality remains high, with many deaths occurring outside the formal health services. Delayed health care seeking represents a large proportion of these deaths.AimTo generate knowledge about the role of, and influences on, caregivers with regard to decision-making about when and where to seek care for sick children.SettingTwo communities in KwaZulu-Natal.MethodsA qualitative, exploratory design employing participatory research techniques was used to undertake focus group discussions with community members.ResultsHealth care seeking for a sick child was described as a complex process influenced by multiple carers using multiple providers. Decision-making about seeking health care for a sick child was not an individual effort, but was shared with others in the household and guided by how the symptoms were perceived, either a Western illness or African illness. A sick child could either be treated at home or be taken to a variety of places including clinics, private doctors, traditional healers, faith healers and hospitals. Traditional healers were associated with the treatment of illnesses perceived to be traditional. Few participants said that they would take their child back to the original health provider if the child remained ill, but would move from one provider to another until the child’s health improved.ConclusionThe formal health system needs to ensure that sick children are identified and managed appropriately to reduce child deaths. Knowledge and understanding of health care seeking behaviour for sick children by carers is an important aspect. Interventions need to be designed with these contextual issues in mind.