Community health worker training to reduce mental health and substance use stigma towards patients who have disengaged from HIV/TB care in South Africa: protocol for a stepped wedge hybrid type II pilot implementation trial

Abstract

Background South Africa has deployed community health workers (CHWs) to support individuals to enter and stay in HIV/TB care. Although CHWs routinely encounter patients with mental health (particularly depression) and substance use (SU) conditions that impact their engagement in HIV/TB care, CHWs are rarely trained in how to work with these patients. This contributes to mental health and SU stigma among CHWs, a known barrier to patient engagement in care. Mental health and SU training interventions could reduce CHW stigma and potentially improve patient engagement in care, but evidence of the feasibility, acceptability, and preliminary effectiveness of these interventions is scarce. Therefore, we designed a hybrid type 2 effectiveness-implementation pilot trial to evaluate the implementation and preliminary effectiveness of a CHW training intervention for reducing depression and SU stigma in the Western Cape, South Africa. Methods This stepped wedge pilot trial will engage CHWs from six primary care clinics offering HIV/TB care. Clinics will be block randomized into three-step cohorts that receive the intervention at varying time points. The Siyakhana intervention involves 3 days of training in depression and SU focused on psychoeducation, evidence-based skills for working with patients, and self-care strategies for promoting CHW wellness. The implementation strategy involves social contact with people with lived experience of depression/SU during training (via patient videos and a peer trainer) and clinical supervision to support CHWs to practice new skills. Both implementation outcomes (acceptability, feasibility, fidelity) and preliminary effectiveness of the intervention on CHW stigma will be assessed using mixed methods at 3- and 6-month follow-up assessments. Discussion This trial will advance knowledge of the feasibility, acceptability, and preliminary effectiveness of a CHW training for reducing depression and SU stigma towards patients with HIV and/or TB. Study findings will inform a larger implementation trial to evaluate the longer-term implementation and effectiveness of this intervention for reducing CHW stigma towards patients with depression and SU and improving patient engagement in HIV/TB care. Trial registration ClinicalTrials.gov NCT05282173. Registered on 7 March 2022.

“Early in the morning, there’s tolerance and later in the day it disappears” – The intersection of resource scarcity, stress and stigma in mental health and substance use care in South Africa

“…For multiple reasons, while they may reduce stigma, interventions to reduce non-specialist stress are unlikely to eliminate non-specialist stigma toward patients with MH/SU concerns, highlighting the need for MH/SU stigma reduction interventions targeting non-specialists in this setting. Initially, stigma reduction interventions in low- and middle-income countries focused on HIV-related stigma (Rao et al, 2019 ); however, trainings intended to reduce stigma toward MH/SU have also been developed and shown to be effective (Kaiser et al, 2022 ; Kohrt et al, 2022 ; Myers et al, 2024 ; Regenauer et al, in Press ). These trainings tend to challenge stigmatizing attitudes and beliefs toward patients with SU/MH, addressing judgmental communication styles and providing the opportunity for non-specialists to have direct and indirect contact with people who have lived experience of MH and/or SU concerns.…”

“…Semi-structured, individual interviews ( N = 30) were conducted between February and June 2021 with patients ( n = 15) and non-specialist health workers ( n = 15) from HIV/TB and SU treatment clinics in low-income areas with high HIV/TB and SU burdens in Cape Town, South Africa. The primary aim of the parent study was to inform the development of an intervention to help reduce MH/SU stigma among providers and improve engagement in HIV care for PWH with co-occurring MH or SU problems (Myers et al, 2024 ). The interview guide focused on stigma (primarily enacted stigma) and strategies for stigma reduction among non-specialists (Rose et al, 2023 ; Regenauer et al, in Press ).…”