Factors Associated With Workplace and Interpersonal Trust in the Supervisory System of a Community Health Worker Programme in a Rural South African District

Document Type : Original Article


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

2 South African Medical Research Council Health Services to Systems Unit, University of the Western Cape, Cape Town, South Africa


Key to effective supportive supervision, and ultimately performance of community health workers (CHWs), is the nature of relationships in the formal health system at the coal face of programmes. The central character and defining feature of effective relationships, in turn, is the ability to engender trust. This study describes factors associated with workplace and interpersonal trust, the relationship between the two sets of trust factors and how this shaped perceived performance of CHWs in ward-based outreach teams (WBOTs) in a rural South African district.
In the context of a wider study of supportive supervision of CHWs, factors recognised to be associated with trust in the literature were studied qualitatively in Ngaka Modiri Molema district, North West Province. Focus group discussions (FGDs) and individual interviews were conducted by the first author with CHWs (23), team leaders (12), facility managers (10) and middle managers (5). Interviews were recorded, translated and transcribed. Perceptions of trust factors associated with workplace and interpersonal trust were analysed thematically.
The interviews revealed a climate of considerable workplace mistrust due to the perceived abandonment of the WBOTs programme by managers at all levels, and this affected support and supervision of WBOTs. However, there was a degree of variability and discretion in expressions of interpersonal trust at the coal face, leading to different perceptions of the competence and functionality of the WBOTs. Mistrust in the workplace and poor interpersonal relationships translated into low confidence in the ability of CHWs, which in turn compromised the performance of these teams.
The study contributes empirical evidence on how workplace trust factors impact on interpersonal trust factors and the possible implications of both sets of trust factors on perceived performance of CHWs. Wider trust in the health system have a significant bearing on interpersonal trust between CHWs and other players in the primary healthcare (PHC) system.



"Watch the Video Summary"


  Check the full list of "CHS-Connect" special issue here

  1. World Health Organization (WHO). WHO Guideline on Health Policy and System Support to Optimize Community Health Worker Programmes. Geneva, Switzerland: WHO; 2018.
  2. Ludwick T, Turyakira E, Kyomuhangi T, Manalili K, Robinson S, Brenner JL. Supportive supervision and constructive relationships with healthcare workers support CHW performance: use of a qualitative framework to evaluate CHW programming in Uganda. Hum Resour Health. 2018;16(1):11. doi:10.1186/s12960-018-0272-1
  3. Hill Z, Dumbaugh M, Benton L, et al. Supervising community health workers in low-income countries--a review of impact and implementation issues. Glob Health Action. 2014;7:24085. doi:10.3402/gha.v7.24085
  4. Kok MC, Dieleman M, Taegtmeyer M, et al. Which intervention design factors influence performance of community health workers in low- and middle-income countries? a systematic review. Health Policy Plan. 2015;30(9):1207-1227. doi:10.1093/heapol/czu126
  5. Kok MC, Kea AZ, Datiko DG, et al. A qualitative assessment of health extension workers' relationships with the community and health sector in Ethiopia: opportunities for enhancing maternal health performance. Hum Resour Health. 2015;13:80. doi:10.1186/s12960-015-0077-4
  6. Gilson L. Trust and the development of health care as a social institution. Soc Sci Med. 2003;56(7):1453-1468. doi:10.1016/s0277-9536(02)00142-9
  7. Kok MC, Ormel H, Broerse JEW, et al. Optimising the benefits of community health workers' unique position between communities and the health sector: a comparative analysis of factors shaping relationships in four countries. Glob Public Health. 2017;12(11):1404-1432. doi:10.1080/17441692.2016.1174722
  8. Nyhan RC. Changing the paradigm: trust and its role in public sector organizations. Am Rev Public Adm. 2000;30(1):87-109. doi:10.1177/02750740022064560
  9. Gilson L. Trust in health care: theoretical perspectives and research needs. J Health Organ Manag. 2006;20(5):359-375. doi:10.1108/14777260610701768
  10. McDonald J, Jayasuriya R, Harris MF. The influence of power dynamics and trust on multidisciplinary collaboration: a qualitative case study of type 2 diabetes mellitus. BMC Health Serv Res. 2012;12:63. doi:10.1186/1472-6963-12-63
  11. Dynes MM, Stephenson R, Hadley C, Sibley LM. Factors shaping interactions among community health workers in rural Ethiopia: rethinking workplace trust and teamwork. J Midwifery Womens Health. 2014;59 Suppl 1:S32-43. doi:10.1111/jmwh.12135
  12. Hall MA, Dugan E, Zheng B, Mishra AK. Trust in physicians and medical institutions: what is it, can it be measured, and does it matter? Milbank Q. 2001;79(4):613-639. doi:10.1111/1468-0009.00223
  13. Topp SM, Chipukuma JM. A qualitative study of the role of workplace and interpersonal trust in shaping service quality and responsiveness in Zambian primary health centres. Health Policy Plan. 2016;31(2):192-204. doi:10.1093/heapol/czv041
  14. Topp SM, Chipukuma JM. How did rapid scale-up of HIV services impact on workplace and interpersonal trust in Zambian primary health centres: a case-based health systems analysis. BMJ Glob Health. 2016;1(4):e000179. doi:10.1136/bmjgh-2016-000179
  15. Gilson L, Palmer N, Schneider H. Trust and health worker performance: exploring a conceptual framework using South African evidence. Soc Sci Med. 2005;61(7):1418-1429. doi:10.1016/j.socscimed.2004.11.062
  16. Albrecht S, Travaglione A. Trust in public-sector senior management. Int J Hum Resour Manag. 2003;14(1):76-92. doi:10.1080/09585190210158529
  17. Okello DRO, Gilson L. Exploring the influence of trust relationships on motivation in the health sector: a systematic review. Hum Resour Health. 2015;13(1):16. doi:10.1186/s12960-015-0007-5
  18. Grant M, Wilford A, Haskins L, Phakathi S, Mntambo N, Horwood CM. Trust of community health workers influences the acceptance of community-based maternal and child health services. Afr J Prim Health Care Fam Med. 2017;9(1):e1-e8. doi:10.4102/phcfm.v9i1.1281
  19. Kok MC, Namakhoma I, Nyirenda L, et al. Health surveillance assistants as intermediates between the community and health sector in Malawi: exploring how relationships influence performance. BMC Health Serv Res. 2016;16:164. doi:10.1186/s12913-016-1402-x
  20. Nxumalo N, Goudge J, Manderson L. Community health workers, recipients' experiences and constraints to care in South Africa-a pathway to trust. AIDS Care. 2016;28 Suppl 4:61-71. doi:10.1080/09540121.2016.1195484
  21. Mishra A. 'Trust and teamwork matter': community health workers' experiences in integrated service delivery in India. Glob Public Health. 2014;9(8):960-974. doi:10.1080/17441692.2014.934877
  22. Assegaai T, Schneider H. National guidance and district-level practices in the supervision of community health workers in South Africa: a qualitative study. Hum Resour Health. 2019;17(1):25. doi:10.1186/s12960-019-0360-x
  23. Assegaai T, Schneider H. The supervisory relationships of community health workers in primary health care: social network analysis of ward-based outreach teams in Ngaka Modiri Molema District, South Africa. BMJ Glob Health. 2019;4(6):e001839. doi:10.1136/bmjgh-2019-001839
  24. Tseng YH, Griffiths F, de Kadt J, et al. Integrating community health workers into the formal health system to improve performance: a qualitative study on the role of on-site supervision in the South African programme. BMJ Open. 2019;9(2):e022186. doi:10.1136/bmjopen-2018-022186
  25. Marcus TS, Hugo J, Jinabhai CC. Which primary care model? A qualitative analysis of ward-based outreach teams in South Africa. Afr J Prim Health Care Fam Med. 2017;9(1):e1-e8. doi:10.4102/phcfm.v9i1.1252
  26. Naidoo N, Railton J, Jobson G, et al. Making ward-based outreach teams an effective component of human immunodeficiency virus programmes in South Africa. South Afr J HIV Med. 2018;19(1):778. doi:10.4102/sajhivmed.v19i1.778
  27. Austin-Evelyn K, Rabkin M, Macheka T, et al. Community health worker perspectives on a new primary health care initiative in the Eastern Cape of South Africa. PLoS One. 2017;12(3):e0173863. doi:10.1371/journal.pone.0173863
  28. Schneider H, English R, Tabana H, Padayachee T, Orgill M. Whole-system change: case study of factors facilitating early implementation of a primary health care reform in a South African province. BMC Health Serv Res. 2014;14:609. doi:10.1186/s12913-014-0609-y
  29. Padayachee T, Chetty N, Matse M, Mampe T, Schneider H. Progress in the establishment of ward-based outreach teams: experiences in the North West Province. In: South African Health Review 2013-2014. Durban: Health Systems Trust; 2014.
  30. Mampe T, Schneider H, Reagon H. Effectiveness of Ward Based Outreach Teams in the North West Province: An Evaluation. Cape Town: University of the Western Cape; 2016.
  31. National Department of Health. Handbook for District Clinical Specialist Teams (DCST). Pretoria: Department of Health; 2014.
  32. Krumpal I. Determinants of social desirability bias in sensitive surveys: a literature review. Qual Quant. 2013;47(4):2025-2047. doi:10.1007/s11135-011-9640-9
  33. Vaismoradi M, Turunen H, Bondas T. Content analysis and thematic analysis: implications for conducting a qualitative descriptive study. Nurs Health Sci. 2013;15(3):398-405. doi:10.1111/nhs.12048
  34. Schneider H, Nxumalo N. Leadership and governance of community health worker programmes at scale: a cross case analysis of provincial implementation in South Africa. Int J Equity Health. 2017;16(1):72. doi:10.1186/s12939-017-0565-3
  35. Hernández AR, Hurtig AK, Dahlblom K, San Sebastián M. More than a checklist: a realist evaluation of supervision of mid-level health workers in rural Guatemala. BMC Health Serv Res. 2014;14:112. doi:10.1186/1472-6963-14-112
  36. Sheikh K, Ranson MK, Gilson L. Explorations on people centredness in health systems. Health Policy Plan. 2014;29 Suppl 2:ii1-5. doi:10.1093/heapol/czu082
  37. Adam MB, Minyenya-Njuguna J, Karuri Kamiru W, Mbugua S, Makobu NW, Donelson AJ. Implementation research and human-centred design: how theory driven human-centred design can sustain trust in complex health systems, support measurement and drive sustained community health volunteer engagement. Health Policy Plan. 2020;35(Suppl_2):ii150-ii162. doi:10.1093/heapol/czaa129
  38. Schneider H. The governance of national community health worker programmes in low- and middle-income countries: an empirically based framework of governance principles, purposes and tasks. Int J Health Policy Manag. 2019;8(1):18-27. doi:10.15171/ijhpm.2018.92
  • Receive Date: 06 July 2020
  • Revise Date: 10 January 2021
  • Accept Date: 11 January 2021
  • First Publish Date: 24 January 2021