"Because Even the Person Living With HIV/AIDS Might Need to Make Babies" - Perspectives on the Drivers of Feasibility and Acceptability of an Integrated Community Health Worker Model in Iringa, Tanzania.

Katharine D Shelley,Asha S George,Juliana Joachim,Abdullah H Baqui,Gasto Frumence,George Mwinnyaa,David H Peters,Hawa Kadria Kisusi,Japhet Killewo,Rose Mpembeni

doi:10.15171/ijhpm.2019.38

Abstract

Background: Countries with health workforce shortages are increasingly turning to multipurpose community health workers (CHWs) to extend integrated services to the community-level. However, there may be tradeoffs with the number of tasks a CHW can effectively perform before quality and/or productivity decline. This qualitative study was conducted within an existing program in Iringa, Tanzania where HIV-focused CHWs working as volunteers received additional training on maternal, newborn, and child health (MNCH) promotion, thereby establishing a dual role CHW model. Methods: To evaluate the feasibility and acceptability of the combined HIV/MNCH CHW model, qualitative in-depth interviews (IDIs) with 36 CHWs, 21 supervisors, and 10 program managers were conducted following integration of HIV and MNCH responsibilities (n=67). Thematic analysis explored perspectives on task planning, prioritization and integration, workload, and the feasibility and acceptability of the dual role model. Interview data and field observations were also used to describe implementation differences between HIV and MNCH roles as a basis for further contextualizing the qualitative findings. Results: Perspectives from a diverse set of stakeholders suggested provision of both HIV and MNCH health promotion by CHWs was feasible. Most CHWs attempted to balance HIV/MNCH responsibilities, although some prioritized MNCH tasks. An increased workload from MNCH did not appear to interfere with HIV responsibilities but drew time away from other income-generating activities on which volunteer CHWs rely. Satisfaction with the dual role model hinged on increased community respect, gaining new knowledge/skills, and improving community health, while the remuneration-level caused dissatisfaction, a complaint that could challenge sustainability. Conclusions: Despite extensive literature on integration, little research at the community level exists. This study demonstrated CHWs can feasibly balance HIV and MNCH roles, but not without some challenges related to the heavier workload. Further research is necessary to determine the quality of health promotion in both HIV and MNCH domains, and whether the dual role model can be maintained over time among these volunteers.

Highlights

HIV programs are often organized and delivered as stand-alone services (“vertical”) in sub-Saharan Africa.[1,2] integration of maternal, newborn, and child health (MNCH), family planning, and HIV services is recognized as an important strategy for reducing maternal and child mortality, and the Global Plan for Elimination of Mother-toChild-Transmission of HIV calls for “leveraging synergies, linkages, and integration for improved sustainability.”[3]
A total of 67 in-depth interview (IDI) were conducted with 6 respondent types: 21 dual role community health worker (CHW), 15 single role CHWs, HIV supervisors, MNCH supervisors, 7 program management staff from civil society organization (CSO), and 3 technical staff from the prime partner (Table 1)
Workload balance sometimes shifted toward MNCH responsibilities, partially due to lengthier household visits and the urgency of MNCH conditions, in contrast to the perceived stabilization of HIV needs in the community and overall long-term experience of CHWs in providing home-based HIV care

Summary

Introduction

HIV programs are often organized and delivered as stand-alone services (“vertical”) in sub-Saharan Africa.[1,2] integration of maternal, newborn, and child health (MNCH), family planning, and HIV services is recognized as an important strategy for reducing maternal and child mortality, and the Global Plan for Elimination of Mother-toChild-Transmission of HIV calls for “leveraging synergies, linkages, and integration for improved sustainability.”[3]. Building “people-centered” primary healthcare systems will require consideration of service integration opportunities by CHWs, where the potential benefits to both providers and clients may include increased satisfaction, improved care outcomes, reduced fragmentation of services, and cost and human resource efficiencies. Carefully consider opportunities for integration and evaluate realistic CHW workloads and compensation packages (monetary and nonmonetary) during policy and planning stages—a relevant concern in countries expanding national multi-tasked CHW cadres, such as Tanzania

Methods

Results

Discussion

Conclusion