Improving the health literacy of Lay Community Health Workers (LCHWs) in Southern Africa to improve the health of women and children

This research project ultimately aims to improve the health literacy of Lay Community Health Workers (LCHWs) in rural Southern Africa to enable women to make better choices about their own and their children's health.

Lay Community Health Workers (LCHWs) complement primary healthcare clinics by providing health advice and care in family homes in rural Southern Africa. LCHWs provide antenatal and postnatal care, general health advice and also support management of chronic conditions such as HIV. However, their role is currently limited by their basic, insufficient and poor training and a lack of understanding and use of information to promote and maintain good health, known as health literacy. Health Literacy is very poor among rural black Southern African women and therefore, choices that women make about their own and their children's health are often poorly informed. In turn, this contributes to increased pressure on already overburdened primary health services in Southern Africa and poor health outcomes, in particular malnutrition and underweight children. Health Literacy and empowerment are essential to enable women to make informed decisions to improve their own and their children's health, for example relating to contraception and infant feeding and nutrition.

We are targeting rural black Southern African women and their children as health literacy is poor amongst this population. We are working with Sizabantu, a training provider in Southern Africa, to develop, implement and evaluate a training intervention for LCHWs in four communities. In order to develop the training intervention, we first need to identify the facilitators and barriers to change before starting an educational programme. This is because improving health literacy in this population is particularly challenging, since health information may conflict with women's prior beliefs (including stigma and myths) making it less likely to be adapted. Therefore, the training intervention needs to consider more than educational content in order to help LCHWs draw women's beliefs out into the open and provide a safe environment in which women can be equipped with the knowledge and skills to understand and make sense of their options.

Once the training intervention has been developed and evaluated for effectiveness in four communities in South Africa, it will be rolled out to communities in Lesotho and Mozambique. The educational programme will include training for LCHWs on sexual and reproductive health, antenatal health and early childhood health and development. Once LCHWs have taken part in the educational training programme they will then use their newly-acquired knowledge and skills to improve the health literacy of black African women during weekly household visits.

The ultimate outcome of the intervention is for black African women to be able to make the necessary positive decisions to improve their own and their children's health. The type of positive health decisions that are most likely to arise as a result of this study include uptake of (more effective) contraception methods to reduce sexually transmitted diseases and increased breast feeding rates.

Lay Community Health Workers (LCHWs) complement primary healthcare clinics by providing health advice and care in family homes in rural Southern Africa. LCHWs support hypertension management and HIV but also provide antenatal and postnatal care and general healthcare advice. Their role is however currently limited by their basic, insufficient and poor standard training, and lack of Health Literacy (HL). HL, defined by the WHO as "the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health", has a positive effect on health outcomes. Working in partnership with Sizabantu, the training provider, the proposed research is based on the development, implementation and evaluation of a "training the trainer" HL intervention for LCHWs. The aims are to: (1) enhance the role and effectiveness of LCHWs, (2) improve women's own HL, (3) empower women to make decisions regarding their own and their children's health and (4) improve women's and their children's health. The early stage study includes the initial development and formative evaluation of the intervention in four communities in South Africa. The objectives of this stage of the project are to: (1) develop the intervention through contemporaneous study of the process of educating and motivating LCHWs, (2) undertake a formative evaluation of intervention using qualitative methods to enable refinement prior to piloting, rollout and evaluation using a cluster randomised stepped wedge design and (3) test quantitative outcome measures and collect quantitative data to calculate sample size requirements for the main study.