Effectiveness of a large-scale, sustained and comprehensive community health worker program in improving population health: the experience of an urban health district in South Africa

Abstract

Introduction South Africa is an upper middle-income country with wide wealth inequality. It faces a quadruple burden of disease and poor health outcomes, with access to appropriate and adequate health care a challenge for millions of South Africans. The introduction of large-scale, comprehensive community health worker (CHW) programs in the country, within the context of implementing universal health coverage, was anticipated to improve population health outcomes. However, there is inadequate local (or global) evidence on whether such programs are effective, especially in urban settings. Methods This study is part of a multi-method, quasi-experimental intervention study measuring effectiveness of a large-scale CHW program in a health district in an urban province of South Africa, where CHWs now support approximately one million people in 280,000 households. Using interviewer administered questionnaires, a 2019 cross-sectional survey of 417 vulnerable households with long-term CHW support (intervention households) are compared to 417 households with no CHW support (control households). Households were selected from similar vulnerable areas from all sub-levels of the Ekurhuleni health district. Results The 417 intervention and control households each had good health knowledge. Compared to controls, intervention households with long-term comprehensive CHW support were more likely to access early care, get diagnosed for a chronic condition, be put on treatment and be well controlled on chronic treatment. They were also more likely to receive a social grant, and have a birth certificate or identity document. The differences were statistically significant for social support, health seeking behavior, and health outcomes for maternal, child health and chronic care. Conclusion A large-scale and sustained comprehensive CHW program in an urban setting improved access to social support, chronic and minor acute health services at household and population level through better health-seeking behavior and adherence to treatment. Direct evidence from households illustrated that such community health worker programs are therefore effective and should be part of health systems in low- and middle-income countries.

Validation of a brief screener for broad-spectrum mental and substance-use disorders in South Africa

“…In order to capture sufficient numbers of individuals with SMD, additional data were collected from one tertiary care facility in BCM District in May 2022. Eastern Cape Province has a particularly high HIV prevalence (25.2%; 95% CI: 19.8%-31.5%), high TB incidence (1236 per 100,000 persons; 95% CI: 945-1526), and poor HIV, TB, mental health, maternal-child health, and health service delivery indicators National Department of Health, 2018;Massyn et al, 2019;Microbiologically Confirmed Pulmonary TB -Centre for Tuberculosis, 2019;Simbayi et al, 2019;Massyn et al, 2020)…”

Community perceptions of community health worker effectiveness: Contributions to health behaviour change in an urban health district in South Africa

“…Nearly all were indigent South Africans earning <USD150 per month and had lived in the area for ≥5 years. [3] As can be seen from household head interviews, as shown in Table 1, the CHWs visited 72% of sampled households for >2 years. Visits were regular, either weekly or monthly.…”

“…This improved diagnosis and management of maternal and child health outcomes as well as chronic disease control. [3] This is primarily because of the long-term relationship built between the CHW and the household; 72% of households had been supported by CHWs for 2 years or longer. Notably, 85% of household members cherished the friendship and good individual traits of CHWs.…”

“…[2] CHW programmes can contribute to improvements in population health. [3] Arvey et al [4] argue that while the potential of CHW programmes to improve health outcomes is evident, the details on how they make a difference is not well described in studies. This could be part of the 'core elements' determining effectiveness of CHW programmes, one of which is changing health behaviour of communities through consistent and sustained interactions at individual, household and community levels.…”

“…[10] The care included early screening and detection of health problems, referrals to higher levels of care and ensuring clients accessed care and control of diseases timeously, and over time were found to have improved population health outcomes in areas supported by the CHWs in Ekurhuleni. [3]…”