Table 3 Thematic analysis on ‘Authority’: clarity in roles and responsibilities
Pre-intervention | Post intervention | ||
|---|---|---|---|
Sub-themes | Quotes (barriers) | Sub-themes | Quotes (enablers, impacts) |
Barriers • Hierarchical organisational culture punitive and disrespectful towards CHWs • Initial concerns that training intervention punitive and designed to ‘expose weaknesses’ | “What I learnt about the clinic system and at the clinic is that there is a lot of discrimination, especially for CHWs like us who have not been trained by WBPHCOT.” Participant, clinic 1 | Enablers • Engaging in respectful dialogue • Stable platform • Peer modality • Process framed for respect and development of shared mindsets • Enjoyable process of co-learning and action | “The training was challenging in the beginning, maybe it was my attitude towards it but is the training continued I started enjoying it. I had a lot of fun engaging with others, especially the clinic managers, on days that they attended, it felt like the managers are paying attention and are suddenly interested in what CHWs do. I learnt a lot from the training.” Participant, clinic 3 |
“…the training also helped us to engage better with the nurses and to realise our relevance in both the community and the health facilities.” Participant, clinic 3 | |||
“… we don’t feel welcome at the clinics because of how we are treated”. Participant, clinic 3 | “At first I was shy to facilitate or to even raise my opinion, but I later adapted because while you were training us you made us feel equal and you always showed us respect.” Participant, clinic 1 | ||
“We do have support from the clinic although there are some nurses who still have bad attitude toward us such that they either don’t have time to assist when we need help, or they are not patient with us.” Participant, clinic 3 | “The VAPAR training addressed a lot of things that I didn’t know for example, as CHWs we are expected to conduct health talks, but it was challenging for me because I am a shy person but after attending the training, I learnt a lot about public speaking and ways of engaging with other people.” Participant, clinic 1 | ||
“I would say, generally, we get enough support at the clinic … however I wish all the nurses at the clinics could recognise us as their colleagues. Sometimes we don’t feel welcome at the clinics because of how we are treated” Participant, clinic 3 | Impacts • Communication skills built to engage supervisors • Negotiation skills built • Trust relationships strengthened, and quality relationships built • New collaborations to work towards shared goals | “My experience with the training was good. At the beginning I thought that you wanted to expose when you asked us to facilitate the workshops but as time goes on, I realised that you were training us to be better CHWs because now I can speak confidently and my report writing have improved” Participant, clinic 1 | |
Barriers • Knowledge on CHW roles mixed | “The roles are not clear because we are stationed at different working stations, there is no rotation and there are no clear criteria as to why certain people are stationed at certain stations.” Participant clinic 1 | Enablers • Dialogue and awareness raising regarding challenges owing to lack of role clarity | “VAPAR training addressed a lot of things that I didn’t know for example, as CHWs we are expected to conduct health talks, but it was challenging for me because I am a shy person but after attending the training I learnt a lot about public speaking and way of engaging with other people.” Participant, clinic 1 |
“My roles and responsibilities were clear… I know what I need to do at the community, and I also know what I need to do at the clinic.” Participant, clinic 2 | “The training highlighted some of our responsibilities as CHWs, but I am still not certain about what is expected of me at the clinic.” Participant clinic 1 | ||
“I will not say everyone in the community understands what we do because there is still a lot of confusion… people still don’t believe that we are trained to support them with getting their chronic medication which is why we have a lot of defaulters.” Participant, clinic 3 | Impacts • Role clarity improved • Competencies built in community mobilisation • Competencies built in public speaking • Competencies built in peer relationships | “…the VAPAR training helped us understand some of our responsibilities. It made me understand my role as a CHW because as we met with other CHWs from other clinics, we got to learn exactly what is expected of us” Participant, clinic 1 | |
Barriers • Workloads high, pay and conditions insufficient • ‘Double burden’ of clinic and community roles | “…lately targets don’t matter because we neglect some of our responsibilities to assist the clinic whenever they need us.” Participant, clinic 3 | Enablers • Resilience and commitment of CHWs to community health deep and enduring • Forum to broker dialogue on workloads with OMs/higher systems actors | “…now I have a better understanding of the role of different stakeholders at the clinic and how effective us as CHW can benefit from working with them.” Participant clinic 1 |
“I go to outreach and come back to work at the clinic, sometimes I spend the whole night compiling reports, the other time I had 50 people that I needed to capture, and they expected me to submit the report the following day.” Participant, clinic 3 |