“Because Even the Person Living With HIV/AIDS Might Need to Make Babies” – Perspectives on the Drivers of Feasibility and Acceptability of an Integrated Community Health Worker Model in Iringa, Tanzania

Document Type : Original Article


1 Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

2 Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania

3 Department of Epidemiology and Biostatistics, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania

4 Christian Social Services Commission, Dar es Salaam, Tanzania

5 School of Public Health, University of the Western Cape, Cape Town, South Africa


Countries with health workforce shortages are increasingly turning to multipurpose community health workers (CHWs) to extend integrated services to the community-level. However, there may be tradeoffs with the number of tasks a CHW can effectively perform before quality and/or productivity decline. This qualitative study was conducted within an existing program in Iringa, Tanzania where HIV-focused CHWs working as volunteers received additional training on maternal, newborn, and child health (MNCH) promotion, thereby establishing a dual role CHW model.
To evaluate the feasibility and acceptability of the combined HIV/MNCH CHW model, qualitative in-depth interviews (IDIs) with 36 CHWs, 21 supervisors, and 10 program managers were conducted following integration of HIV and MNCH responsibilities (n = 67). Thematic analysis explored perspectives on task planning, prioritization and integration, workload, and the feasibility and acceptability of the dual role model. Interview data and field observations were also used to describe implementation differences between HIV and MNCH roles as a basis for further contextualizing the qualitative findings.
Perspectives from a diverse set of stakeholders suggested provision of both HIV and MNCH health promotion by CHWs was feasible. Most CHWs attempted to balance HIV/MNCH responsibilities, although some prioritized MNCH tasks. An increased workload from MNCH did not appear to interfere with HIV responsibilities but drew time away from other income-generating activities on which volunteer CHWs rely. Satisfaction with the dual role model hinged on increased community respect, gaining new knowledge/skills, and improving community health, while the remuneration-level caused dissatisfaction, a complaint that could challenge sustainability.
Despite extensive literature on integration, little research at the community level exists. This study demonstrated CHWs can feasibly balance HIV and MNCH roles, but not without some challenges related to the heavier workload. Further research is necessary to determine the quality of health promotion in both HIV and MNCH domains, and whether the dual role model can be maintained over time among these volunteers.


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  1. Hope R, Kendall T, Langer A, Bärnighausen T. Health Systems Integration of Sexual and Reproductive Health and HIV Services in Sub-Saharan Africa. JAIDS J Acquir Immune Defic Syndr. 2014;67:S259-S270.
  2. Rabkin M, El-Sadr WM, De Cock KM. The impact of HIV scale-up on health systems: A priority research agenda. J Acquir Immune Defic Syndr. 2009;52 Suppl 1:S6-11.
  3. Lindegren ML, Kennedy CE, Bain-Brickley D, et al. Integration of HIV/AIDS services with maternal, neonatal and child health, nutrition, and family planning services. Cochrane Database Syst Rev. 2012;9:1-134.
  4. Shigayeva A, Atun R, McKee M, Coker R. Health systems, communicable diseases and integration. Health Policy Plan. 2010;25(1 suppl):i4-i20. doi:10.1093/heapol/czq060
  5. Topp SM, Abimbola S, Joshi R, Negin J. How to assess and prepare health systems in low- and middle-income countries for integration of services - A systematic review. Health Policy Plan. 2018;33(2):298-312. doi:10.1093/heapol/czx169
  6. Dudley L, Garner P. Strategies for integrating primary health services in low- and middle-income countries at the point of delivery. Cochrane Database Syst Rev. 2011;(7):CD003318. Doi:10.1002/14651858.CD003318.pub3
  7. Chin-Quee D, Mugeni C, Nkunda D, Uwizeye MR, Stockton LL, Wesson J. Balancing workload, motivation and job satisfaction in Rwanda: assessing the effect of adding family planning service provision to community health worker duties. Reprod Health. 2016;13:1-7.
  8. Puett C, Coates J, Alderman H, Sadruddin S, Sadler K. Does greater workload lead to reduced quality of preventive and curative care among community health workers in Bangladesh? Food Nutr Bull. 2012;33(4):273-287. doi:10.1177/156482651203300408
  9. Smith S, Deveridge A, Berman J, et al. Task-shifting and prioritization: a situational analysis examining the role and experiences of community health workers in Malawi. Hum Resour Health. 2014;12:1-13.
  10. MUHAS, JHSPH. CHW Learning Agenda Project: Mapping Tanzania’s Community Health Worker Programs. Dar es Salaam, Tanzania; 2015.
  11. Woldie M, Feyissa GT, Admasu B, et al. Community health volunteers could help improve access to and use of essential health services by communities in LMICs: an umbrella review. Health Policy Plan. 2018:1-16. doi:10.1093/heapol/czy094
  12. Tanzania MoHSW. National Community Based Health Program Policy Guidelines: Towards a sustainable cadre of Community Health Workers’ Extending Primary Health Care to people; 2014.
  13. FHI 360, Deloitte. TUNAJALI HIV Care and Treatment Project: 2006-2011 Technical Close-out Report; 2012.
  14. Tanzania NBS, Zanzibar Office of Chief Government Statistician. 2012 Population and Housing Census: Population Distribution by Administrative Areas. Dar es Salaam, Tanzania; 2013.
  15. Tanzania Commission for AIDS, Zanzibar AIDS Commission, Tanzania National Bureau of Statistics, Zanzibar Office of Chief Government Statistician, ICF International.  Tanzania HIV/AIDS and Malaria Indicator Survey 2011-2012. Dar es Salaam, Tanzania; 2013.
  16. Tanzania NBS, ICF Macro. Tanzania Demographic and Health Survey 2010. Dar es Salaam, Tanzania: NBS & ICF Macro; 2011.
  17. Tanzania MoHCDGEC, Zanzibar MoH, Tanzania National Bureau of Statistics, Zanzibar Office of Chief Government Statistician, ICF. Tanzania Demographic and Health Survey and Malaria Indicator Survey 2015-2016. Dar es Salaam, Tanzania & Rockville, Maryland, USA: MoHCDGEC, MoH, NBS, OCGS, & ICF; 2016.
  18. Tanzania Commission for AIDS, Zanzibar AIDS Commission, Tanzania National Bureau of Statistics, Zanzibar Office of Chief Government Statistician, ICF International. Tanzania HIV/AIDS and Malaria Indicator Survey 2011-12. Dar es Salaam, Tanzania; 2013.
  19. Tanzania Commission for AIDS. Home Based Care Services in Tanzania. http://www.tacaids.go.tz/index.php?option=com_content&view=article&id=121:home-based-care-hbc&catid=46:care-and-treatment&Itemid=243.  Accessed August 15, 2015.
  20. Tanzania MoHSW. National Integrated Community Maternal Newborn and Child Health Guidelines. Baltimore, MD: Jhpiego; 2012.
  21. QGIS Development Team. QGIS Geographic Information System; 2017.
  22. Tanzania National Bureau of Statistics. Tanzania Population and Housing Census Geographic Shapefiles. http://nbs.go.tz/nbstz/index.php/english/statistics-by-subject/population-and-housing-census/258-2012-phc-shapefiles-level-one-and-two.  Published 2013. Accessed January 27, 2017.
  23. Tanzania MoHSW. Health Facility Registry. http://hfr-portal.ucchosting.co.tz/index.php?r=facilities/homeAdvancedSearch.  Published 2015. Accessed February 10, 2017.
  24. SocioCultural Research Consultants. Dedoose, Version 2016.
  25. Zhang Y, Wildermuth BM. Qualitative Analysis of Content. Analysis. 2005;1(2):1-12.
  26. Peters DH, Tran NT, Adam T. Implementation Research in Health: A Practical Guide. Geneva: WHO; Alliance for Health Policy and Systems Research; 2013.
  27. The World Bank. Tanzania GNI Per Capita. World DataBank. http://data.worldbank.org/country/tanzania.  Published 2016. Accessed September 18, 2016.
  28. Glenton C, Colvin C, Carlsen B, et al. Barriers and facilitators to the implementation of lay health worker programmes to improve access to maternal and child health: Qualitative evidence synthesis. Cochrane Database Syst Rev. 2013;(10):1-72.
  29. Shelley KD, Frumence G, Mpembeni R, et al. Can volunteer community health workers manage multiple roles ? An interrupted time-series analysis of combined HIV and maternal and child health promotion in Iringa, Tanzania. Health Policy Plan. 2018;33(10):1096-1106. doi:10.1093/heapol/czy104
  30. LeFevre AE, Mpembeni R, Chitama D, et al. Profile, knowledge, and work patterns of a cadre of maternal, newborn, and child health CHWs focusing on preventive and promotive services in Morogoro Region, Tanzania. Hum Resour Health. 2015;13:1-14.
  31. Schneider H, Okello D, Lehmann U. The global pendulum swing towards community health workers in low- and middle-income countries: a scoping review of trends, geographical distribution and programmatic orientations, 2005 to 2014. Hum Resour Health. 2016;14:1-12.
  32. Castellani J, Mihaylova B, Ajayi IO, et al. Quantifying and Valuing Community Health Worker Time in Improving Access to Malaria Diagnosis and Treatment. Clin Infect Dis. 2016;63(suppl 5):S298-S305.
  33. Maes K. Examining health-care volunteerism in a food- and financially-insecure world. Bull World Health Organ. 2010;88(11):867-869.
  34. Swidler A, Watkins SC. “Teach a Man to Fish”: The Sustainability Doctrine and Its Social Consequences. World Dev. 2009;37(7):1182-1196.
  35. Glenton C, Scheel IB, Pradhan S, Lewin S, Hodgins S, Shrestha V. The female community health volunteer programme in Nepal: Decision makers’ perceptions of volunteerism, payment and other incentives. Soc Sci Med. 2010;70(12):1920-1927.
  36. Gilson L, Hanson K, Sheikh K, Agyepong IA, Ssengooba F, Bennett S. Building the field of health policy and systems research: social science matters. PLoS Med. 2011;8(8):e1001079. 10.1371/journal.pmed.1001079
  37. Creswell JW. Standards of Validation and Evaluation. In: Qualitative Inquiry and Research Design: Choosing among Five Approaches. 2nd ed. Thousand Oaks, CA: SAGE Publications; 2006:201-221.
  38. Houghton C, Casey D, Shaw D, Murphy K. Rigour in qualitative case-study Research. Nurse Res. 2013;20(4):12-17. doi:10.4135/9781473914230
Volume 8, Issue 9
September 2019
Pages 538-549
  • Receive Date: 04 October 2018
  • Revise Date: 19 May 2019
  • Accept Date: 20 May 2019
  • First Publish Date: 01 September 2019