<p>This research investigates the nature and extent of community participation and involvement in the recruitment and selection processes for Community Health Workers (CHWs), primarily through detailed case studies of three CHW programmes, one in the Western Cape, another in KwaZulu-Natal, and a third which operates in the Western Cape and KwaZulu-Natal. The first utilizes CHWs in health education and home-based care in Khayelitsha and Nyanga. The second specializes in the training, management and supervision of home-based care CHWs in the rural areas of KwaZulu-Natal. The third utilizes CHWs in addressing maternal and child health issues in targeted peri-urban and rural areas in the three provinces. The mini-thesis is organized into five chapters: the first chapter provides the introduction and background as well as the methodological design of the mini-thesis / the second chapter focuses on providing a detailed literature review of relevant materials that cover the subject matter / the third chapter provides the descriptive background of the history of CHWs, CHW policies and community participation in South Africa, as well as a description of the three case study organizations / the fourth chapter describes and discusses the findings and the last and fifth chapter provides a summary of the findings as well as recommendations and conclusions.</p>

Magister Administrationis - MAdmin / This research investigates the nature and extent of community participation and involvement in the recruitment and selection processes for Community Health Workers (CHWs), primarily through detailed case studies of three CHW programmes, one in the Western Cape, another in KwaZulu-Natal, and a third which operates in the Western Cape and KwaZulu-Natal. The first utilizes CHWs in health education and home-based care in Khayelitsha and Nyanga. The second specializes in the training, management and supervision of home-based care CHWs in the rural areas of KwaZulu-Natal. The third utilizes CHWs in addressing maternal and child health issues in targeted peri-urban and rural areas in the three provinces. The mini-thesis is organized into five chapters: the first chapter provides the introduction and background as well as the methodological design of the mini-thesis; the second chapter focuses on providing a detailed literature review of relevant materials that cover the subject matter; the third chapter provides the descriptive background of the history of CHWs, CHW policies and community participation in South Africa, as well as a description of the three case study organizations; the fourth chapter describes and discusses the findings and the last and fifth chapter provides a summary of the findings as well as recommendations and conclusions. / South Africa

Objective: To expand the access to culturally relevant hearing health services in a rural U.S. border community with already limited healthcare resources, community health workers (Promotoras de Salud) were trained to provide peer-facilitated hearing education classes. Design: A specialized three-phase training process for community health workers was developed, implemented, and evaluated. The training process included: 1) Focus groups with community health workers and residents from the community to raise awareness of hearing loss among community health workers and the community; 2) A 3-hour workshop training to introduce basic topics to prepare community health workers to identify signs of hearing loss among community members and utilize effective communication strategies; and 3) A 24-hour multi-session, interactive training over 6 weeks for community health workers who would become facilitators of educational and peer-support groups for individuals with hearing loss and family members. Study Sample: Twelve Spanish-speaking local community health workers employed by a federally qualified health center participated in a focus group, 12 received the general training, and four individuals with prior experience as health educators received further in-person training as facilitators of peer-education groups on hearing loss and communication. Results: Community health workers increased their knowledge base and confidence in effective communication strategies and developed skills in facilitating hearing education and peer support groups. Through case study practice, community health workers demonstrated competencies and applied their learning to specific situations related to effective communication with hearing loss, family support, assistive technology, use of hearing protection, and making referrals for hearing health care. Needs were identified for ongoing training in the area of assistive technology and addressing situations of more severe hearing loss. Conclusions: It is feasible to train community health workers to begin to address hearing loss and facilitate peer health education and support groups for individuals with hearing loss and their family members. In efforts to increase access to audiologic services in rural or hard-to-reach areas, application of the community health worker model with a partnership of audiologists deserves further consideration as a viable approach.

Use of skilled care during antenatal visits and delivery is recommended to address the burden of maternal mortality. However there are few facility deliveries and insufficient knowledge of danger signs, especially in rural Tanzania.  The aim of this thesis was to explore the perceptions and challenges that the community faces while preparing for childbirth and to evaluate an intervention of the Home Based Life Saving Skills education programme on knowledge of danger signs, facility delivery and male involvement when delivered by rural community health workers in Tanzania. In Paper I, Focus Group Discussions explored the perceptions and challenges that the community encounters while preparing for childbirth. Structured questionnaires assessed men’s knowledge of danger signs and birth preparedness and complication readiness in Paper II. The effect of the Home Based Life Saving Skills education programme in the community was assessed with a before-and-after evaluation in two districts; one intervention and one comparison. Paper III assessed the effect of the programme on knowledge of danger signs and birth preparedness and facility delivery among women, while Paper IV evaluated its effect on male involvement. The community perceived that all births must be prepared for and that obstetric complication demands hospital care; hence skilled care was favoured. Men’s knowledge of danger signs was limited; only 12% were prepared for childbirth and complications. Preparedness was associated with knowledge of obstetric complications (AOR=1.4 95% CI 1.8 – 2.6). The intervention showed women utilizing antenatal care (four visits) significantly more (43.4 vs 67.8%) with a net effect of 25.3% (95% CI: 16.9 – 33.2; p &lt; .0001). The use of facility delivery improved in the intervention area (75.6 vs 90.2%; p = 0.0002), but with no significant net effect 11.5% (95% CI: -5.1 – 39.6; p = 0.123) when comparing the two districts. Male involvement improved (39.2% vs 80.9%) with a net intervention effect of 41.1% (CI: 28.5 – 53.8; p &lt; .0001). Improvements were demonstrated in men’s knowledge level, in escorting partners for antenatal care and delivery, making birth preparations, and shared decision-making. The intervention, in educating this rural community, is effective in improving knowledge, birth preparedness, male involvement and use of skilled care.

In South Africa, which has the largest HIV infected population world-wide, more than 5 million individuals presently live with HIV and AIDS (Evian, 2002:20; LINAIDS, 2004:19). These HIV-infected patients in turn affect the family structure within which they find themselves in a specific community. According to Saleeby (1992:54) and Barnett and Blaikie (1992:34), several families in South Africa are affected by the challenges posed by AIDS. This research forms part of the group research project, Tswaragano, which deals with an investigation into the competencies, abilities and strengths of the family of the HIV-positive patient while supporting the patient at home (Wessels, 2003:54). Problems such as unemployment, poverty, crime and changed demands in the community where these families live and increased challenges place a tremendous amount of stress on the families (Saleeby, 1992:54; Barnett & Blaikie, 1992:34). A vicious circle of AIDS and poverty is clearly confirmed and it has been found that people who live with HIV and AIDS need more support than health care alone (Booysen et al,. 2004:817-826). It is evident from the literature that, although information regarding HIV and AIDS is conveyed during pre- and post-HIV and AIDS test counselling, the transmission of information is not necessarily successful (Parker et al., 1998:18). A question which hence arises is whether the HIV positive patient and his family who support him at home fully grasp the necessary information. Greeff and Du Plessis (2001:2) confirm that health workers in the North-West Province do not convey the information effectively. Several factors probably contribute to defective information transfer between the health worker and the patient. One factor is that if the environment within which information is conveyed is not comfortable and mutual respect and trust between the health worker and the HIV positive patient is limited, the interpretation of information on HIV and AIDS is impaired (Allender & Spratley, 2001:163). A further aspect that should be taken into consideration is that HIV and AIDS-related information can be understood and internalised by the HIV positive patient in different ways, since several interpretation possibilities exist for information that is conveyed (Parker et al., 1998:20). Health workers who convey the information to the patient does however not always determine whether the HIV positive patient understands and internalises the information correctly (Parker et al., 1998:21). The facts mentioned above not only limit the HIV positive patient's understanding but also eventually the understanding of the family who have to support the HIV positive patient at home, regarding HIV and AIDS. The family can be seen as a primary core support resource for the HIV positive patient (Uys, 1999:2), and limited understanding impairs support at home (Hartman, 1981:10). With this is meant that the family is the "social service agency in meeting the social, educational and health care needs" of its members. The aim of this research was to investigate and describe the understanding of the HIV positive patient and the family regarding HIV and AIDS-related information. Guidelines were formulated to promote the understanding of the family of the HIV positive patient regarding HIV and AIDS-related information with the view to empower the family of the HIV positive patient in order to be able to support the patient at home. The research design was quantitative and descriptive by nature. It entails a pilot study in the Kagiso district, Vryburg area (Bophirima) of the North-West Province. The actual research study was performed in the Primary Health Clinics in the Potchefstroom district of the southern area of the North-West Province. Purposive sampling was performed (Burns & Grove, 2001:376; Brink, 1996:141; Abramson & Abramson, 1999:70; Bainbridge, 1989:46). Selected health workers acted voluntarily as go-betweens to identify HIV positive patients and their families who are prepared to participate in the research and who answer to the criteria, and to assist in filling out the questionnaires. The questionnaires were analysed by means of the frequency method with the assistance of the Statistical Consultation Services of the North-West University, Potchefstroom Campus and reported on by means of tables and graphs (Brink, 1996:499; Burns & Grove, 1997:430). From the research it was found that, although information transfer regarding HIV and AIDS does take place, there still are many voids in respect of the understanding of this information and this pertains to HIV positive patient as well as the families. The researcher has come to the conclusion that the proposed guidelines in order to empower families of the HIV-positive patients to support these patients at home therefore is obvious and important. Furthermore, the researcher is of opinion that families midst the difficult circumstances will realise their own strengths if they could acquire the necessary knowledge and skills. Recommendations were made for nursing education, for the practice of the community nurse as well as for nursing research. Guidelines were formulated to empower the family of the HIV positive patient to be able to support the patient at home. / Thesis (M.Cur.)--North-West University, Potchefstroom Campus, 2008.

Philosophiae Doctor - PhD / Non-communicable diseases (NCD) continue to be a public health concern globally and contribute to the burden of disease. The formal health system in developing countries lacks the capacity to deal with these NCD as it is overburdened by communicable diseases. Thus, community health workers (CHWs) have been suggested as a solution for alleviating the burden for primary health facilities, by extending NCD care to the community. This thesis aims to develop an integrated model of care for CHWs working with patients with non-communicable diseases by describing and exploring current CHW roles, knowledge and practices in relation to community-based NCD care. The specific objectives for this study included 1) the exploration of the NCD roles of generalist CHWs in the context of a limited resource urban setting; 2) determining the NCD-related knowledge of CHWs, and factors influencing this in a limited resource urban setting and 3) a comparison of actual and envisaged roles in the management and prevention of NCD using the integrated chronic diseases management model (ICDM) as a benchmark, and propose key competencies and systems support for NCD functions of CHWs in South Africa Mixed methods were used to achieve the objectives of this study. First, a qualitative enquiry was conducted using observations to respond to the first objective. A quantitative cross-sectional design was then used to achieve the second objective, and a questionnaire was used to interview CHWs. A comparison of findings from both the quantitative and qualitative studies with policy guidelines was undertaken to address the third objective.

Violent and traumatic events are a regular occurrence in many South Africans’ lives. The term 'continuous traumatic stress’ was coined by South African anti-apartheid health professionals in the 1980’s to explain the continuous nature of violence and trauma happening within the country. Although the political agenda may have shifted, many South Africans are still living within a context in which violent and traumatic events regularly occur. However, little is known about how health workers respond to continuous trauma within the South African setting. The Community Health Workers - within this study - are part of the South African health model called ‘Primary Health Care Re-engineering’ that is currently being piloted. The research was exploratory in nature and used a mixed methods design. Twenty three Community Health Workers who participated in the study were from two sub-districts within the Ekurhuleni district, Gauteng, Johannesburg. The research included two face to face semi-structured individual interviews. The first included qualitative questions and completion of the quantitative Stressful Life Events Screening Questionnaire (1998) to explore past trauma experiences. Over a seven month period, the participants were asked to document traumatic event exposure and responses through the adapted Life Events Checklist (1995) and personal journaling. At the end of this period, participants were interviewed again to explore their current traumatic experiences. Qualitative data were analysed through thematic content analysis and quantitative data were used to substantiate information from the interviews and checklists. Results show that Community Health Workers – within this study - have a high prevalence of exposure to traumatic events (directly experiencing, witnessing and hearing about). Prominent events included physical and sexual assault, transport accidents, fires and explosions. Media played a powerful role in exposure to events. Traumatic and unexpected losses were key experiences that need to be considered when working with trauma in the South African context. Acknowledgement of experiences (peer and external) is an essential element in developing support structures. These findings – from the context of Ekurhuleni, South Africa - contribute to exploring and understanding the experience of ‘continuous traumatic stress’ for Community Health Workers.

Today's society places greater demands on how preventative and promotional efforts should be based on evidence for optimal results. Public health workers have a great responsibility to act and support the population ahead in a positive healthy direction where evidence-based methods are to form the basis of their actions, but simultaneously they perceive high demands, lack of resources and difficulties in controlling their work situation. This leads to the purpose; how this group of workers relate to and are affected by evidence-based practices in relation to the three themes of this thesis; demands, resources and control. Eleven participants went through semi-structured interviews and a content analysis was conducted by the author on the transcribed material. Results are presented in line with the content of the three themes where demands are represented by categories named time limits, workload and responsibility; resources are represented by cooperation, adequate guidance and budget; and control is represented by context adjustments and loneliness. Public health workers are affected by evidence-based methods where perceived demands lower their ability to function efficiently, where resources are vital and where control is threatened by perceived obstacles but is longed for. Together, public health workers are pillars for raising the well-being of residents and they need attention because their actions affect us all.

A detecção de casos de tuberculose é uma das prioridades do Plano Nacional de Controle da Tuberculose, sendo que a Busca de Sintomáticos Respiratórios (BSR) precisa ser uma atitude permanente e incorporada à rotina de atividades dos membros das equipes de saúde, principalmente dos Agentes Comunitários de Saúde (ACS). Este estudo teve como objetivo analisar a BSR na percepção do ACS, em dois municípios prioritários para o controle da tuberculose. Trata-se de um estudo descritivo e exploratório, do tipo inquérito realizado em 2009 através de dados secundários, roteiro observacional e formulário estruturado aplicado a 210 ACS (105 do município de Natal - RN e 105 de Ribeirão Preto - SP). Criou-se indicadores de estrutura, processo e resultado a partir das proporções dos itens observados e colhidos através de fontes secundárias, e dos escores médios das respostas dos entrevistados aos itens do formulário que continham escala Likert de resposta, sendo avaliados como insatisfatório (valores próximos de 1 e 2), regular (próximos de 3) e satisfatório (próximos 4 e 5). De acordo com a observação, os municípios apresentaram algumas fragilidades em relação à estrutura dos serviços de saúde para a BSR: ausência de pote de escarro (21%), ausência de geladeira para acondicionamento das baciloscopia (63,2%) e a falta de laboratórios responsáveis pelo recolhimento das baciloscopias (31,6%) nas unidades de saúde de Natal. Em Ribeirão Preto, verificou-se ausência de livro de registro de sintomáticos respiratórios (42,6%), de profissionais responsáveis pelo cuidado do paciente com tuberculose (30,7%) e de rotina sistematizada para o atendimento do suspeito de tuberculose (38,5%). No julgamento dos ACS, identificaram-se escores satisfatórios relacionados ao treinamento e ao preparo dos mesmos para o controle da tuberculose. Observou-se fragilidades na ação de investigação da tosse nas visitas domiciliares e na oferta de pote de escarro, embora escores satisfatórios tenham sido encontrados na identificação de sintomáticos respiratórios na comunidade e nos serviços de saúde, bem como na investigação de casos suspeitos a partir dos casos índice. Identificou-se fragilidades no estabelecimento de parcerias com a comunidade para a BSR e para discussões sobre tuberculose, contudo verificou-se escore razoável em relação à educação em saúde sobre a doença na comunidade. Verificaram-se ainda escores satisfatórios em relação à participação dos ACS em discussões sobre a tuberculose no serviço e ao apoio institucional ofertado frente a uma situação de suspeita da doença. Dos sintomáticos respiratórios estimados no território circunscrito às unidades dos ACS de Natal e Ribeirão Preto, observou-se que, respectivamente, apenas 11,2% e 6,2% desta população foi examinada com baciloscopia de escarro. O processo de trabalho do ACS no território possibilita refletir sobre seu protagonismo como parceiro no controle da tuberculose. Fragilidades foram encontradas na estrutura dos serviços de saúde em ambos os municípios, as quais podem ter resultado no desempenho deficiente dos ACS para a BSR. O trabalho ressaltou ainda a necessidade de um novo processo de trabalho capaz de intervir sobre os reais problemas de saúde da comunidade, com avanços na educação permanente e na articulação intersetorial visando o incremento na detecção de casos da doença. / Detection of tuberculosis is one of the National Tuberculosis Control Policy priorities, which consider active case finding (ACF) as a permanent action, incorporated into the routine activities of all health teams members, especially for Community Health Workers (CHW). This study aimed to analyze the ACF according to CHW perspective in two priority cities for tuberculosis control. Descriptive study conducted in 2009 using secondary data and an observational and structured questionnaire applied to 210 CHW (105 in Natal - RN and 105 in Ribeirão Preto - SP). Indicators of structure, process and result were developed from the proportions of the items observed and collected from secondary sources and from the mean scores of respondents\' answers to items which contained Likert scale response - assessed as insatisfactory (values close to 1 and 2), regular (near 3) and satisfactory (near 4 and 5). According to observation forms, some weaknesses in structure of health services for the RS\' search were identified: lack of sputum pot (21%), lack of refrigerator for storing the smear (63.2%) and lack of laboratories responsible for collecting the sputum (31.6%) in health facilities in Natal. In Ribeirão Preto, there was no form register of TB suspects (42.6%), neither professionals for tuberculosis patients care (30.7%) and for systematic search and routine assistance for suspected tuberculosis cases (38 5%). In the CHW inquiry, satisfactory scores have been identified related to training and self-prepare for tuberculosis control. There are weaknesses in detection of cough during home visits and the provision of sputum pot in the territory, although scores have been found satisfactory in the ACF in the community and health services, as well as in the investigation of suspected cases from the index cases. We identified weaknesses in partnerships with the community to the ACF and to discussions on tuberculosis, but there was a reasonable score for health education about the disease in the community. There were also satisfactory scores for participation of CHW in discussions about TB inside the health services and institutional support offered when a suspected case was identified by CHW. The analysis of estimated RS in the CHW area in Natal and Ribeirão Preto, showed that, respectively, only 11.2% and 6.2% of this population was examined with sputum smear microscopy. The CHW work process bring out a reflection on their role as partners in tuberculosis control. Weaknesses were found in the structure of health services in both cities, which may have resulted in poor performance of the CHW for the ACF. The work also highlighted the need for a new work process capable of intervention on the real health problems of the community, improving permanent education actions and intersectoral coordination to increase case detection.

A pesquisa tem como objetivo caracterizar o perfil dos Agentes Comunitários de Saúde (ACS), identificando as ações realizadas e analisando-as à luz do paradigma da Promoção da saúde. Para isso optou-se por uma pesquisa exploratória do tipo quanti-qualitativa, realizada com todos os ACS das 15 equipes de PACS, num total de 241 ACS, do município de São Bernardo do Campo (SP). A coleta de dados foi pela aplicação de um questionário para a caracterização dos ACS e um formulário baseado nas competências preconizadas pelo Ministério da Saúde (MS), que buscou identificar as ações que este profissional realiza, bem como a freqüência com a qual executa essas ações. O conteúdo dos instrumentos de coleta foi organizado e analisado no programa computacional SPSS. Como resultado da análise evidenciou-se que a maioria dos ACS é constituída de mulheres, com idade média de 33 anos, com união conjugal, de raça branca e parda, nascidas na região Sudeste, zona urbana, com ensino médio completo e curso profissionalizante, com participação em um trabalho formal antes de ser ACS e que vivem com média de 3 salários mínimos. Em média, moram há 15 anos no bairro onde trabalham, sendo que há 4 anos trabalham como ACS. A forma de participação comunitária na vida pessoal que mais se destaca é a ligada a grupos religiosos. As competências preconizadas pelo MS: \"Integração da equipe com a população local\"; \"Prevenção e monitoramento de risco ambiental e sanitário\" e \"Prevenção e monitoramento a grupos específicos e morbidades\" são em sua maioria realizadas pelos ACS, enquanto que as de \"Planejamento e avaliação das ações de saúde\" e \"Promoção da saúde\" são realizadas de forma heterogênea pelo Município. Partindo-se do princípio que as estratégias de Promoção da saúde necessitam, entre outros fatores, das políticas públicas para concretizar suas ações, concluiu-se pela necessidade de se realizar um planejamento das ações do ACS que seja comum a todo o Município, pela importância de se fortalecer a competência do ACS para a Promoção da saúde, de forma que esta possa encaminhar para o empowerment da comunidade e para a intersetorialidade. / The research has as objective to characterize the profile of the Communitarian Agents of Heath (CAH), identifying the carried through actions and analyzing them in the way of the paradigm of the Health Promotion. For this it was opted to an exploring research of the quanti-qualitative kind, carried through with 241 CAH of the city of São Bernardo do Campo (SP). Collection of data was made through application of questionnaire for characterization of CAH and form based in abilities praised for Ministry of Health (MH), that it searched to identify the actions that this professional carries through, as well as the frequency which executes these actions with. The content of the collection instruments was organized and analyzed in the computational program SPSS. As result of the analysis, it was evidenced that the majority is constituted of women, with average age of 33 years, conjugal union, of white and medium brown race, born in the southeastern region, urban zone, with complete high school education and professionalizing course, with participation in a formal job before being CAH and that they live with average of 3 minimum wages. In average, they live has 15 years in the neighborhood where they work, and it has 4 years they work as CAH. The form of communitarian participation that is more distinguished is bound to religious groups. The abilities praised for the MH: Integration of the team with the local population; Prevention and monitoring of ambiental risk and sanitary; Prevention and monitoring the specific groups and morbidities are in its majority carried through by the CAH while that of planning and the evaluation of the actions of health and promotion of the health they are carried through of heterogeneous form in the city. Considering the strategies of health promotion need, among others factors, of the public politics to materialize its action, it\'s concluded for the necessity to carry through a planning of the actions of the CAH to the health promotion, such that it\'s able to direct to the empowerment of the community and to the action between sectors.