Community health workers' efforts to build health system trust in marginalised communities: a qualitative study from South Africa.
Community health workers' efforts to build health system trust in marginalised communities: a qualitative study from South Africa.
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DOI：
10.1136/bmjopen-2020-044065
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发表时间：
2021-05-19
期刊：
影响因子：
2.9
通讯作者：
Goudge J
中科院分区：
文献类型：
--
作者：
Anstey Watkins J;Griffiths F;Goudge J
社区卫生工作者（CHW）使边缘化社区，往往经历结构性贫困，获得医疗保健。信任在所有医患关系中都很重要，但在这些社区很难建立信任，特别是当与艾滋病毒/艾滋病、结核病以及现在的COVID-19相关的耻辱感普遍存在时。负责将人们重新纳入护理的CHW必须修复信任。在南非，一项全国性的社区卫生工作方案正在推出，边缘化社区的失业率、家庭暴力和伤害率很高。在这个复杂的社会环境中，我们探讨了CHW的工作场所信任，患者和CHW之间的人际信任，以及患者对卫生系统的机构信任。在为期3年的干预研究的观察阶段，我们进行了访谈，焦点小组和观察病人，CHW，他们的主管和，设施经理在Sedibeng。CHW的工作场所信任度较低。他们最近举行了罢工，要求提高工资、改善就业条件和承认他们的工作。他们没有安全开展工作的设备，一些同事不信任或不重视他们的贡献。社区卫生工作者与患者之间存在相当大的人际信任，然而，社区卫生工作者的努力受到结构性贫困、酗酒和长期移民中没有身份证件的阻碍。那些了解贫困程度的主管支持CHW帮助社区的努力。当病人退出护理时，通常是由于护士的不敏感行为，CHW试图修复病人的机构信任，但由于社区的脆弱性和缺乏卫生系统的支持，往往失败。需要制定战略，建立工作场所的信任，包括对社区卫生工作者的支持性监督和更好的工作条件，并通过确保对社会不平等和医疗保健提供者结构性贫困影响的敏感性，建立人际和机构信任。社会需要照顾每一个人。
Community health workers (CHWs) enable marginalised communities, often experiencing structural poverty, to access healthcare. Trust, important in all patient–provider relationships, is difficult to build in such communities, particularly when stigma associated with HIV/AIDS, tuberculosis and now COVID-19, is widespread. CHWs, responsible for bringing people back into care, must repair trust. In South Africa, where a national CHW programme is being rolled out, marginalised communities have high levels of unemployment, domestic violence and injury. In this complex social environment, we explored CHW workplace trust, interpersonal trust between the patient and CHW, and the institutional trust patients place in the health system. Within the observation phase of a 3-year intervention study, we conducted interviews, focus groups and observations with patients, CHWs, their supervisors and, facility managers in Sedibeng. CHWs had low levels of workplace trust. They had recently been on strike demanding better pay, employment conditions and recognition of their work. They did not have the equipment to perform their work safely, and some colleagues did not trust, or value, their contribution. There was considerable interpersonal trust between CHWs and patients, however, CHWs’ efforts were hampered by structural poverty, alcohol abuse and no identification documents among long-term migrants. Those supervisors who understood the extent of the poverty supported CHW efforts to help the community. When patients had withdrawn from care, often due to nurses’ insensitive behaviour, the CHWs’ attempts to repair patients’ institutional trust often failed due to the vulnerabilities of the community, and lack of support from the health system. Strategies are needed to build workplace trust including supportive supervision for CHWs and better working conditions, and to build interpersonal and institutional trust by ensuring sensitivity to social inequalities and the effects of structural poverty among healthcare providers. Societies need to care for everyone.
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