A qualitative analysis of community health worker perspectives on the implementation of the preconception and pregnancy phases of theBukhalirandomised controlled trial

Abstract

AbstractCommunity health workers (CHWs) play an important role in health systems in low– and middle-income countries, including South Africa.Bukhaliis a CHW-delivered intervention as part of a randomised controlled trial, to improve the health trajectories of young women in Soweto, South Africa. This study aimed to qualitatively explore factors influencing implementation of the preconception and pregnancy phases ofBukhali, from the perspective of the CHWs (Health Helpers, HHs) delivering the intervention. As part of theBukhalitrial process evaluation, three focus group discussions were conducted with the 13 HHs employed by the trial. A thematic approach was used to analyse the data, drawing on elements of a reflexive thematic and codebook approach. The following six themes were developed, representing factors impacting implementation of the HH roles: interaction with the existing public healthcare sector; participant perceptions of health; health literacy and language barriers; participants’ socioeconomic constraints; family, partner, and community views of trial components; and the HH-participant relationship. HHs reported uses of several trial-based tools to overcome implementation challenges, increasing their ability to implement their roles as planned. The relationship of trust between the HH and participants seemed to function as one important mechanism for impact. The findings supported a number of adaptations to the implementation ofBukhali, such as intensified trial-based follow-up of referrals that do not receive management at clinics, continued HH training and community engagement parallel to trial implementation, with an increased emphasis on health-related stigma and education.HH perspectives on intervention implementation highlighted adaptations relevant to theBukhaliintervention, other CHW-delivered preconception and pregnancy trials, and ‘real-world’ CHW roles, across three broad strategic areas: navigating and bridging healthcare systems, adaptability to individual participant needs, and navigating stigma around disease.