Home Visitation by Community Health Workers

Abstract

Community health workers are faced with challenges in the community during home visits. The re-engineering of primary health care services in South Africa brought a new cadre of community health workers that relieved the extra workload of primary health care nurses of conducting home visits as one of the activities. The findings of the study conducted in the Tshwane District culminated in the challenges of community, logistical, occupational, human resource, and managerial in nature. The CHWs stated the need for respect and acceptance by the community during home visits, improved planning related to delegation of households by Outreach Leaders and provision of material resources, and the support by managers for career development through training and education for various disease prevention. This indicated that the training of community health workers needs to be formalized and in-service education related to home visits should be planned, structured, and supported by the Department of Health.

1. Introduction

This chapter defines home visits, community health worker and primary health care, the overview of home visits, the purpose of home visits, the historical perspective of home visits, the process of home visits, the advantages and disadvantages of home visits, challenges encountered by community health workers (CHWs) during home visits from a South African perspective, and report from the study done in 2020 by CHWs in the Tshwane district.

2. Definition of home visits

A home visit is a formal interaction between a nurse and an individual’s place of residence designed to provide nursing care related to the identified need.

3. Definition of community health worker

Community health worker means an individual with an in-depth understanding of the community culture and language, who has received standardized job-related training, which is of shorter duration than health professionals, and whose the primary goal is to provide culturally appropriate health services to the community. CHW is an individual employed by the state, allocated at a PHC facility by a nongovernmental entity, and receives a stipend for the services rendered in the community.

4. Primary health care

Primary health care is health care based on scientifically evidence-based care by socially acceptable standards, which is universally accessible to individuals and their families at a cost the community and the country can afford by being self-reliant and by self-determination. PHC is rendered to individuals and families who are residents of the area surrounding the community clinic by health workers.

5. Overview of home visits

Families and individuals visit the primary health care (PHC) clinic daily and/or monthly to be assessed for acute and chronic ailments as well as monitor compliance. Noncompliance to treatment will warrant that the community health worker (CHW) visits the individual more frequently to establish the reasons for clinic nonattendance and noncompliance to treatment regimens [1]. CHW programs are designed to target hard-to-reach communities that are more than 5 km from a health facility or in the lowest socioeconomic areas [2]. The PHC clinics provide preventive, promotive, curative, and rehabilitative services to the community within a 5-km radius. Currently, the clinics consult with the ward-based outreach teams to allocate CHWs to do home visits to individuals who default on treatment and are noncompliant with treatment. CHWs are responsible for home visits to make sure that vulnerable groups are getting adequate care and are not missed in the health system. CHWs are currently paid stipends by the Department of Health and through nongovernmental organizations [3].

Currently, an estimated 5482 PHC outreach teams are caring for the uninsured population of South Africa, and the teams are required to reach 84% of the total population who are based in rural areas, informal urban settlements, and townships [4]. In the financial year 2014/2015, it was estimated that there were 86 teams in Tshwane covering 46 wards, with 39 trained team leaders and 217 CHWs [5]. The services are available, accessible, and affordable [6], and are provided at homes, schools, and other public and private institutions because health care is a right for all citizens. The role of the CHWs among others is to do home visits [7]. Home visit services originated in Great Britain, dating back to the 1850s, and focused on improving health and hygiene in families with young children. The families were visited for the continuation of nursing care and support. According to the study [8], home visits offer a viable strategy to avoid challenges associated with obtaining health from clinics, which include difficulty in scheduling clinic appointments, long waiting lines, and expensive transport.

The evaluation of the effectiveness of the home-visit program for high-risk pregnant women [9] found that at least one visitation during pregnancy was effective in preventing preterm births. Participating in the home-visit program reduced the risk of adverse outcomes in a disadvantaged population [10]. It was found that home visits are part of larger programs that might have positive effects on individuals, including exercise programs, improved assessment methods by medical professionals, or fall prevention [11]. Skilled health workers do home visits, but in areas where there is a lack of health providers, trained community members, called CHWs, are used instead. These workers are trained to perform basic preventative and curative care and to assist families in seeking necessary care at a healthcare facility.

The role of CHWs in Lesotho dates to 1979 when the country embraced primary health care (PHC) and improved the efforts to reach underserved and remote areas [12]. The CHWs’ scope ranges from core roles of disease prevention, early detection of ill-health, community advocacy, outreach services, and assisting in accessing services through referrals and home visits. The CHWs understand their roles and responsibilities regarding health promotion. However, the changes in disease burden have resulted in a shift in roles and this is affecting their health promotion practice and experience. You et el. [13] reported that the outcomes of health workers doing home visits for at-risk mothers in the United States are less effective compared to nurses, who are better suited to enhance and determine physical and psychological health, and decrease the use of emergency medical services. Bheekie and Bradley [14] reported that home visiting has been demonstrated as being effective when mounted by professionals, but low and middle-income countries (LMICs), such as South Africa, cannot afford nurses and will not be able to train the personnel necessary to render such support until at least by the year 2050.

In 2010, the South African National Department of Health (NDoH) launched a national PHC initiative to strengthen health promotion, disease prevention, and early disease detection called reengineering of primary health care (rPHC) to provide preventive and health-promoting community-based PHC model [15]. A key component of rPHC is the use of ward-based outreach teams (WBOTS) staffed by generalist CHWs to do home visits and provide care to families and communities [16, 17]. CHWs are a core in the community-based PHC model and the complex contextual challenges they face during home visits and the development of skills in community care need specific attention [18]. Health facilities are challenged by limited staffing, resources, infrastructure, and access to PHC clinics is affected by distance, financial constraints, and transport availability.

6. The purpose of home visits

The purpose of the home visit is to have face-to-face contact at an individual’s home, with a healthcare professional. The home visit allows an assessment of the home environment and family situation to provide for healthcare-related activities. It is done to reduce the defaulter rate and to enhance compliance with treatment [7]. Home visits provide opportunities for professional development, as well as improve the life orientation skills of healthcare students [19].

7. Historical perspective

Globally, home visits were intended to improve health and hygiene in families with young children [7]. A home visit is vital to reducing maternal and infant morbidity and mortality [20]. A healthcare project in Egypt recommended four home visits to women and their infants during the postnatal period within 24 h of delivery, on day 4 after birth, on day 7 after birth, and a clinical visit on day 40 [21]. American Indian and Alaska Native people have used informal home visits as a traditional cultural practice to take care of and address the needs of young children and families and improved outcomes in these areas [22].

Salami and Brieger [23] stated that the benefits of home visits by trained community health workers can change newborn practices. Rotheram-Borus et al. [8] confirmed that at least one visitation during pregnancy would reduce the risk of preterm births. Health workers during their home visits were able to keep track of non-facility-based births, which were not recorded officially and affected the calculations of infant mortality [24]. Trainees in medicine can gain experience and confidence in making house calls by doing structured home visits [25]. The focus of home visits expanded to other areas such as care of the elderly. The authors further reported that home visits are proposed to be an essential component of general practice care in the provision of comprehensive person-centered care for the elderly.

Home visits are an integral part of primary care provided by family physicians and medical assistants to homebound elderly individuals living in private households, and not by communities [26]. Preventative home visits may have a positive effect on healthcare costs by decreasing nursing home admission, hospitalizations, and the length of stay in hospitals [27]. Home visiting services are part of the national health systems in most countries in Western Europe, where services are voluntary and free to all families [7].

The role of professional nurses’ in home visits as stated by Grant et al. [17] reported that health facilities faced the challenge of limited staffing and resources. The shortage of nurses at PHC clinics made their role to conduct home visits compromised. Wells et al. [28] agreed that, to prevent diseases and promote health, the role of community nurses was to conduct home visits irrespective of work overload. However, it is important to recognize that the clinical proficiency of the nurse performing the home visits had a heavy influence on visits due to their experience, which assists them to diagnose challenges and refer to relevant healthcare providers [29].

In the study by Bheekie and Bradley [14], the establishment of district management teams (DMT) to improve the primary health system increases life expectancy, decreases child and maternal mortality, combats HIV and AIDS, and decreases the tuberculosis burden. The effective use of CHWs is by allocating them to 250 families each, to address health problems. The PHC outreach team consists of a professional nurse, an environmental officer, a health promoter, and six CHWs in a municipal ward who work together with the designated nurses at the clinic to provide comprehensive care to this population, from health promotion to the treatment of minor ailments [30]. According to Kane et al. [31], more than five million CHWs are active globally and are known for their effectiveness and importance in providing services to communities [32]. CHWs are trained government workers allocated at facilities and the community recognizes them as health professionals and an extension of the formal health system.

Kok et al. [33] stated that CHWs had their origins in China in the 1920s and were precursors to the “barefoot doctors” movement in the 1950s, they indicated that CHWs’ are groups of health workers who work outside health facilities directly with people in their homes, neighborhoods, communities, and other nonclinical spaces where health and diseases are produced. Zulliger et al. [34] regarded CHWs as health workers conducting functions related to health care delivery; trained in some way in the context of the intervention and having no formal professional or paraprofessional certificate or degree in tertiary education. The role of CHWs is to conduct household profiling, screening, and health education through supervision by the professional nurse team leader [29]. In South Africa, CHWs are expected to assess health needs; facilitate service access; provide community-based information, education, and psychosocial support; deliver basic health care; and support community campaigns [35]. PHC training package identifies 12 roles that are to be performed by the CHWs working in PHC, which are home-based care, counseling, support and stress relief, health promotion and education at a household level, referral to relevant departments, initiative and support home-based projects, liaison between NDoH and the community, mobilization against diseases and poor health through campaigns, Directly Supervised Treatment Support (DOTS), screening of health-related clinic cards for compliance or default, assessment of health status for all family members and giving advice, weighing infants and babies and recording in “Road to Health” card, and providing prevention of mother-to-child transmission of HIV/AIDS [4].

Kelly et al. [36] reported that the NDoH was developing a policy framework to regulate the role of CHWs and their working conditions and further asserts that shifting tasks and care responsibilities from professionals is necessary to meet the needs of the health care service. CHWs are trained to accompany HIV individuals on ART and do routine home visits to monitor side effects and appointment reminders [37]. The role of CHWs is to collaborate with community leaders in providing basic health and environmental service in rural areas, create a link between the facility and the community, and are paid salaries by the Ministry of Health [38]. In the paper by Ref [39], the role of CHWs in countries has contributed to better outcomes; however, in South Africa, the health outcomes are suboptimal in areas of maternal and child health. Home visits by CHWs during pregnancy can play a role in improving thermal care, early and exclusive breastfeeding, and hygienic cord care practices in different settings [22].

At the international conference on primary health care at Alma-Ata in 1978 where a declaration of “Health for All” by the year 2000 was made by the representatives, CHWs’ role in providing PHC was highlighted [32]. The World Health Organization (WHO) has identified five key elements to achieving this goal: reducing exclusion and social disparities in health (universal coverage reforms); principles of equity, access, empowerment, community self-determination, and inter-sectoral collaboration. Universal health coverage (UHC) is aspired by most countries in terms of rights to health care, financial protection, and utilization of healthcare services on an equitable basis. UHC indicates equity of access and financial risk protection [40] and community care is a crucial contribution that is affordable with running costs of less than one dollar per capita per year [41]. The recent Astana Declaration (2018) has emphasized the critical role of PHC in advancing UHC. The potential contribution of CHWs to supporting UHC is commendable [42].

UHC, broadly, means that all people receive the health services they need, including health initiatives designed to promote better health, prevent illness, and provide treatment, rehabilitation, and palliative care of sufficient quality to be effective while at the same time ensuring that the use of these services does not expose the individual to financial hardship. The District Health System (DHS) in South Africa provides an equitable, efficient, and effective health system based on the principles of the PHC approach. The National Health Insurance (NHI) systems and the DHS model are key elements of UHC in South Africa. The DHS depicts a set of activities such as community involvement, integrated and holistic healthcare delivery, intersectoral collaboration, and a strong “bottom-up” approach to planning, policy development, and management. NHI aims to provide funds that will improve access to health services for all South Africans [43] and to rectify the public-private funding inequality. NHI includes rPHC, which focuses on the prevention of diseases, including three streams of municipal ward-based PHC outreach teams, school health teams, and district-based clinical specialist teams [29]. In terms of cost, a preliminary policy paper issued by the government estimated that NHI will cost R255 billion per year by 2025 if implemented as planned over 15 years [44]. To achieve the principles of PHC, together with inclusion in the NHI and UHC, the employment of CHWs commenced.

The health services in which CHWs work often present preconditions or limitations to function [33]. The challenges found in the study of CHWs in Lesotho are demotivation because of inconsistent incentives, lack of supplies, community attitude, increased workload, gaps in training, and lack of standardized reporting tools [11]. CHWs work in an environment where trust and confidentiality play a cornerstone in social relationships. CHWs interact with other family members during home visits and discussing confidential information seemed to be challenging if family members were present and could lead to unwanted disclosure of sensitive information [17]. Families failed to obtain medications due to transportation and financial problems [29]. Transport is identified as a challenge in the study of workers in Malawi [38]. Management apathy around allowances for CHWs in Kenya is a source of feelings of devaluation and of not having control over one’s work sphere [31].

Other barriers included the lack of career prospects for CHWs, lack of formal recognition as government employees of the health system (even though the stipend is paid through the government pay system), low incentives, and delayed payments [45]. CHWs preferred better financial recognition for their work, an increase in stipend, and proof of their work for prospects, raincoats, Christmas hampers, and tokens to help mitigate financial constraints [46]. The CHWs mentioned their role in solving social issues in the community, but the stipend did not match the extra work they did on top of health issues. Working in the community allows opportunities to channel their values and beliefs into concrete actions with opportunities for self-actualization [31]. A perceived lack of personal safety was found to affect motivation to work at locations and into people resigning. Young female health workers felt unsafe, scared of substance abuse among young men, violent assaults, verbal abuse, accusations, and were afraid of contracting infections [22].

Climate, environmental challenges, and the need to cover large distances hampered CHWs’ performance of their duties. It was reported that the CHWs’ had difficulties in reaching communities because of flooding [33]. A study done in Uganda for the visitation of mothers during prenatal and postnatal by Village Health Teams proved that the teams could not navigate large geographical areas in some cases and had low incentives for Village Health Teams to travel long distances [47]. Traditionally in Jordan, women are not supposed to leave the house for 40 days post-delivery, mothers preferred that the home visit should be conducted by a female CHW in the presence of a family member to enhance a sense of security [19].

8. Advantages of home visits

The advantages of home visits are ranging from and not conclusive to the following:

• It provides an assessment window into the household characteristics.

• The nurse obtains the full picture of the home environment the individuals reside in.

• Identification of the influence of the environment on the individual’s health.

• It allows the CHW to view the individuals’ relationship with family members and the community.

• It is an opportunity for a CHW to view the individual’s performance of activities of daily living.

• It gives the CHW a perspective to plan and evaluate interventions in a natural setting.

• It allows a CHW to recognize unidentified health and social needs.

9. Disadvantages of home visits

There are a few disadvantages of home visits as stated below:

• A stigma attached to the family’s self-perspective of incompetence.

• It is not cost-effective for a health worker to travel to one individual and see them at home unlike seeing them at the clinic and achieving the goal of consulting twenty individuals in a day.

10. The process of home visits, a home visitation program

The home visitation program in South Africa is structured by the outreach team leaders who allocate different individuals to a specific CHW to visit the homes in a particular month. The nursing process approach of assessment, diagnosing, planning, implementation, evaluation documentation, and termination is utilized by following the outlined steps to explain the program [48].

10.1 Step 1

Initiation of the home visit whereby the CHW introduces themself to establish rapport.

10.2 Step 2

Conduct a preliminary assessment by reviewing the individual’s history and documentation to determine the health care needs related to biological, psychological, environmental, sociocultural, behavioral, and health system determinants of health.

10.3 Step 3

Formulate a diagnosis based on the assessment.

10.4 Step 4

Plan to review the previous interventions made and their results. Prioritize the needs and identify those that need immediate attention. Develop goals and objectives for the visit and determine the levels of care involved. Consider the individual’s circumstances and consent related to the visit and time of visits. Identify appropriate interventions to address problems. Mobilize resources, supplies, and equipment. Plan for evaluation of the home visit.

10.5 Step 5

Implementation of the plans made by priority and dealing with any distractions.

10.6 Step 6

Evaluate the response to the interventions, short-term and long-term outcomes, the quality of planning and implementation of the home visit, and the quality of care.

10.7 Step 7

Document the individuals’ assessment, interventions, individuals’ responses to care, outcomes of interventions, plans of care, and the individual’s health status at discharge.

10.8 Step 8

Plan for termination on the first visit, inform the individual about the number of visits and their duration, review the goals and objectives, and make referrals where necessary.

11. Challenges encountered by community health workers

Below are narrative perspectives of community health workers from the study done by the author.

11.1 Community challenges

Community challenges emerged as the first perceived challenge by the CHWs. Various challenges from the community posed a problem in accessing the community members during home visits. This included community access, animosity, mistrust, noncompliance to treatment, nonrecognition, acceptance, and public environmental health.

11.1.1 Community access

The CHWs were faced with difficulty in accessing members of the community during the day and the attitude they received from community members hampered access. CHWs reported that when going to visit individuals at homes, they meet people in the street calling them names and swearing at them and when they reach the designated homes individuals will chase them away or send dogs after them. The CHWs are required to map 250 household registrations as part of the workload for the area that is allocated to them. All the households should be captured and followed up to reach all members of the designated community linked to the PHC clinic.

11.1.2 Community animosity and mistrust

CHWs mentioned that data capturing included registration of the water meter reading, which led to the community members asking questions about the relation of meter checking to health and illness. CHWs were faced with mistrust and resentment from the community due to the belief that their roles were not in support of community needs. The lack of respect from the community has been seen to demotivate CHWs [45].

Several factors undermining the work of CHWs, as stated in the study by Mhlongo and Lutge [32], were different perceptions of the CHW roles, lack of knowledge and skills, and lack of stakeholders and community support.

11.1.3 Community noncompliance with treatment

Individuals with chronic conditions, TB, and HIV default to treatment and are not compliant with taking the medication. Follow-up is done to monitor compliance with treatment. Home visits are conducted to follow up with defaulters of treatment and to encourage compliance with treatment. The individuals are traced back to their addresses to keep them on track with and to comply with the treatment prescribed.

11.1.4 Nonrecognition and acceptance by the community

The CHWs reported that the clinic does not provide uniforms but only name tags. The uniform that they wear was provided by the NGO before being transferred to the clinics. The lack of uniform and name tags make the community not recognize and accept the workers as professionals and they are given a bad attitude. In the study about the role of CHWs [46], it was reported that the workers asked for “branded” goods, such as t-shirts, hats, or ID cards, to identify them as part of the health team. The provision of branded goods would prevent them from being viewed with suspicion by the community.

11.1.5 Public environmental health

The CHWs assist with the cleaning of the home, such as dirty windows, and open windows for fresh air before commencing with procedures. The unsafe and unkempt environment in the community leads to CHWs to extend their scope of work by cleaning the household and referring the challenges to the social development ministry.

11.2 Logistical challenges

The government should devise a means of providing the CHW programs with transport and absorb them to be permanent employees with all benefits. CHW programs tend to be unsustainable at scale when there is poor planning, vague and/or extensive CHW scopes of work, lack of community and health system buy-in, resource scarcity, inadequate training, low incentives to the CHWs, and poor supervision [45].

11.2.1 Ineffective planning and delegation

The concept of walking the distance from house to house and to and from the clinic to report and clock out poses a challenge even though it is structured daily. The CHW program should be planned so that CHWs report weekly to the OTLs at a designated area in the clinic. The CHW should draw a monthly schedule and submit it to the manager for approval.

11.2.2 Lack of transport

The CHWs walk distances to individuals’ homes after they have reported at the clinic and at the end of the home visit go back to the clinic to clock out. The clinic does not provide transport for CHWs. They are not allowed in government vehicles as they do not have indemnity. Weather conditions and the fact that the CHWs are contract workers also mitigate the challenge of transport. CHWs in other areas did not access formal modes of transport and instead walked to and from their allocated area of work.

11.3 Occupational challenges

The scope of practice of CHWs does not include aspects of mental health and domestic abuse and cannot intervene when faced with situations. The CHWs refer the matters beyond their control to the police and social workers because it is not covered in their training.

11.3.1 Exposure to ethical-legal risks

The CHWs gave information about this insufficient training, which causes distress when dealing with individuals. Other health topics were not covered in their training, which made them frustrated. The insufficient training given to CHWs will lead them to be involved in legal cases and can be found to have violated ethical issues.

11.3.2 Exposure to psychological risks

The CHWs have trouble dealing with emotions and would be brave in front of individuals not to expose their sadness in seeing children with terminal conditions. They cry privately when they reach their homes. They pray daily not to meet dangerous individuals in the community. The CHWs experience emotional stress of coping with difficult circumstances of being scared to venture into the community. Exposure to sick individuals causes emotional distress and frustration.

11.3.3 Exposure to safety risks in the community

The CHWs mentioned that the nurses at the clinic will give referrals to trace individuals who defaulted treatment of TB, others are XDR or MDR individuals, and end up being exposed to health risks of contracting diseases because of insufficient information given to them about the individual status.

The lack of face masks when visiting homes can lead to workers contracting airborne diseases. There were concerns about CHW’s safety, identification, debriefing, and risk of contracting diseases [29].

11.3.4 Insufficient equipment and resources

The CHWs reported challenges of limited resources of having to carry blood pressure machines to different homes on certain days. Lack of data on cell phones to call the OTLs or to summon the ambulance when faced with emergencies during home visits. The cell phones issued had a short lifespan. The lack of material resources creates a challenge and financial burden for community workers, which can lead to feelings of frustration and spending their own money to counter the limited resources [47].

11.3.5 Working relationship problems with clinic staff

The lack of medical aid to consult when ill poses a challenge to CHWs and this is seen by the clinic staff, making CHWs queue like any other individual visiting the facility.

The lack of support from clinic staff leads to stress and frustration [29]. Managers reported that the CHW’s workload was very heavy and their working conditions are difficult and mentioned the lack of space, stationery, and equipment.

11.4 Human resources challenges

The human resource department in the clinics does not include CHWs in the skill professional development plan. The CHWs reported no opportunities to improve their skills and see growth in their chosen job and the reluctance of the clinic to include them during in-service training.

11.4.1 Inadequate opportunities for personal development and promotion

The CHWs have no opportunities for promotion from one level to the other, they remain in one category. There should be a growth pathway for CHWs to ensure that the persons with experience can achieve higher levels of employment and mentor the newer applicants in the program [4]. In South Africa, the Human Resource for Health Strategy estimated that the critical need gap persists with a shortage of over three thousand formally qualified CHWs and over two thousand qualified home-based caregivers [45].

11.4.2 Inadequate training and education

The CHWs reported that there is inadequate training when they observed that other CHWs were performing the same skill differently. Peer training is encouraged in areas that were not covered in the CHW course. Conducting more in-service education will make sure that the acquired skills and knowledge are not lost forever [37]. Formalization of CHWs’ training about procedures done during home visits will bring job satisfaction. It was recommended that the training of the CHWs should be incorporated into the Expanded Public Works Programme (EPWP) training strategy, which will enable the CHWs to obtain a formal qualification that is aligned with national standards [4]. The general training of CHWs as generalist health workers is ideal, but program-specific training is effective and ensures that core knowledge and skills are effectively relayed [49].

11.4.3 Unconducive conditions of service

The CHWS sign a contract every year and they have been in the temporary position for more than five years. The CHWs expressed anger and frustration when narrating the aspect of stipends and signing contracts of employment every year. The gifts received from employers helped mitigate financial requests [46]. CHWs reflected negatively on the fact that they earned a meager stipend whilst they needed to cover their transport to and from their allocated area of work and that they worked a normal workday of 8 hours duration [4] and asserted to the review of the remuneration package to be aligned with labor law in the country.

11.5 Management challenges

The CHWs mentioned that managers are not supporting them in terms of training, shortage of resources, and engaging with the department to transfer their posts to permanent employees.

11.5.1 Inconsistent training

Training of CHWs is not the same; some CHWs have done 10-day courses, and others 59- or 69-day courses, which included HIV counseling and irregular one-off training sessions without opportunities to refresh knowledge which has been reported to demotivate and reduce CHW performance in other LMICs [50]. CHWs refused to conduct certain tasks when they had not been invited to be trained because the training was given to those who were favored and was attached to financial gain [33].

11.5.2 Lack of managerial support and recognition

It was perceived that the challenges of being contract workers and not having enough resources are ongoing. There is an indication that managers are not supporting in terms of the shortage of resources and engaging with the department to transfer their posts to permanent employees. Managers questioned CHW’s role perceived by the community as professionals, because of limited training. The managers wanted a planned strategy for CHWs, including career progression and professional regulation, and were concerned about security risk, space, and logistical support. The managers think that CHWs need to be selected based on some criteria, such as education more than matriculation [29].

12. Conclusion

The chapter focused on the definitions of home visits, community health workers and primary health care, overview, the purpose of home visits, historical perspective, advantages and disadvantages, the process of home visits, the challenges perceived by CHWs regarding home visits in the Tshwane district, which were that of community, logistical, occupational, human resource, and managerial.

Acknowledgments

I want to thank the community health workers in the Tshwane District, SG Lourens Nursing College management, supervisors Prof MM Moagi and Prof MD Peu for their guidance and support, and the Department of Health Region C, supervisors of Community Health Workers, Outreach Team Leaders, and Facility managers of the sub-district clinics.

Conflict of interest

The author declares no conflict of interest.

Additional information

Parts of this book chapter are taken from the dissertation titled “Challenges Community Health Workers Perceived Regarding Home Visits in the Tshwane District,” authored by Hilda Kawaya, which is available on the University of Pretoria repository platform, dated December 2020. The dissertation has not been peer-reviewed and has not been published.