Trust of community health workers influences the acceptance of community-based maternal and child health services

BACKGROUND: Community health workers (CHWs) are a component of the health system in many countries, providing effective community-based services to mothers and infants. However, implementation of CHW programmes at scale has been challenging in many settings. AIM: To explore the acceptability of CHWs conducting household visits to mothers and infants during pregnancy and after delivery, from the perspective of community members, professional nurses and CHWs themselves. SETTING: Primary health care clinics in five rural districts in KwaZulu-Natal, South Africa. METHODS: A qualitative exploratory study was conducted where participants were purposively selected to participate in 19 focus group discussions based on their experience with CHWs or child rearing. RESULTS: Poor confidentiality and trust emerged as key barriers to CHW acceptability in delivering maternal and child health services in the home. Most community members felt that CHWs could not be trusted because of their lack of professionalism and inability to maintain confidentiality. Familiarity and the complex relationships between household members and CHWs caused difficulties in developing and maintaining a relationship of trust, particularly in high HIV prevalence settings. Professional staff at the clinic were crucial in supporting the CHW’s role; if they appeared to question the CHW’s competency or trustworthiness, this seriously undermined CHW credibility in the eyes of the community. CONCLUSION: Understanding the complex contextual challenges faced by CHWs and community members can strengthen community-based interventions. CHWs require training, support and supervision to develop competencies navigating complex relationships within the community and the health system to provide effective care in communities.