Community health workers (CHWs) remain a critical component towards ensuring efficient delivery of healthcare services in low- and middle-income countries (LMICs). They are integral in the prevention, treatment and care of individuals living with various disease conditions, such as human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS), childhood illnesses and tuberculosis (TB), as well as provision of palliative care services through home-based care.^1,2,3 The provision of these services by CHWs has been especially vital in remote areas, where inaccessibility to health facilities is a challenge.

In South Africa, the services offered by CHWs are included within a primary health care (PHC) ward-based outreach team. This team consists of a professional nurse, environmental health practitioner, health promotion practitioner and four to five CHWs.⁴ These teams have since been experiencing varying degrees of success throughout the country.^{5,6,7,8,9,10,11,12,13,14} It could be argued that potentially there could be a risk of overwhelming the CHWs with health interventions at community level. However, the CHWs have been instrumental in combating TB infection in South Africa and other countries of similar contexts through the directly observed treatment and therapy programme,^{3,15,16,17,18,19} apart from their other responsibilities. Evidently, TB shares similarities in terms of signs and symptoms with lung cancer, hence poor treatment response by their patients misclassified as TB patients.^20,21

The authors’ project, as part of a larger study of lung cancer in sub-Saharan Africa, introduced the training of CHWs on lung cancer community awareness intervention, as a contribution to promoting early lung cancer screening, detection and care. In South Africa, lung cancer is among the top four ranking cancers in terms of morbidity and mortality after breast, prostate and cervical cancers.²² Among men, lung cancer is the leading cause of cancer deaths in the country, while it ranked third among women.²³ However, the trends of lung cancer mortality in Africa are based on scanty epidemiological evidence,²⁴ and the burden of disease may be underestimated.^25,26 Poor health outcomes have been documented for lung cancer patients, including death while undergoing treatment.²⁷ More than 80% of lung cancer cases are linked to cigarette smoking and other tobacco products,²⁸ therefore making a case for expanded prevention efforts at the community level. Community health workers are better placed to carry out this function at this level. To the authors’ knowledge, there are limited published studies on lung cancer health interventions by CHWs at the community level. In addition, it has been established that currently, the CHW curriculum does not include lung cancer awareness.^29,30 Hence, the opportunity to work with CHWs in raising awareness on lung cancer at community level was considered an important contribution to potentially ensuring early disease detection, diagnosis and treatment, as CHWs often serve as linkages between health facilities and patients. Therefore, the integration of lung cancer awareness interventions on the training of CHWs should be explored. This article explored the CHW experiences of the lung cancer awareness intervention training in a South African province.

A final total of 23 CHWs participated in the training, after two potential CHWs retracted from the 25 initial selected. Ten participants (six women and four men) volunteered to participate in the FGD. Their ages ranged from 20 to 52 years. The majority were women who resided in the communities identified by the project (Table 1). The majority of the CHWs did not have postmatric qualifications. A few possessed postmatric training (e.g. a certificate-level training).

Figure 1 provides a descriptive summary of the emergent themes that emanated from the FGD data of the CHWs’ experiences of the lung cancer awareness training.

This study showed that CHWs had, on the whole, positive experiences of training, and this seemed to have encouraged CHWs to be a positive change in their communities. The training facilitator’s approach to the training was embraced positively. This fostered positive interactions and a positive learning environment. Consequently, this environment could increase the likelihood of the CHWs performing their tasks more competently in their communities. A study conducted in Bangladesh, Mexico, Guatemala and South Africa assessing the CHWs’ ability to screen for cardiovascular disease revealed the CHWs were able to conduct their tasks at levels comparable to the formally trained health professionals.³⁷

Although most of the CHWs highly appreciated the knowledge gained during training, some of the CHWs suggested using alternate modes of learning as reinforcement. A study mapping the evidence from various CHW trainings demonstrated an increasing trend on the use of mobile technologies to support training in LMIC contexts.³⁸ However, this trend was not widely adopted for broad training, service delivery interventions and supervision at the community level involving CHWs. In settings where Internet connectivity and mobile data availability are not a challenge, these mobile technologies could be a viable platform for providing training and support to the CHWs. However, South Africa may not be able to provide such platforms and service, especially in the rural areas where CHWs services are most valuable.^39,40,41 For these technologies to be implemented in South Africa, the Internet infrastructure needs to be made widely accessible and be stable for use in the rural areas of the country.

The CHWs were encouraged to be active participants in their own learning, thus enforcing a positive learning environment. A study conducted on the training of CHWs regarding oral health intervention indicated that the CHWs performed well on their knowledge scores after training.⁴² When questioned about the presenters leading the training, the CHWs also communicated a positive opinion. Similarly, they felt that the level of the training together with its duration were ideal. These results seem to align with the findings of the present study. However, a study conducted among CHWs in Cape Town on noncommunicable diseases and training concluded that the knowledge on the subject matter was poor while their training was unstandardised and haphazard.⁴³

Although culture seems to have played a role in the group dynamics, it is not clear whether a male training facilitator would be preferred in the future trainings among this group of individuals. Future studies could explore this phenomenon and inform the successful training of CHWs. Studies have investigated how culturally adapted interventions implemented by CHWs affect service provision.^{44,45,46,47,48}

The dynamics of power between the group and the researcher were perceived positively, which seem to have contributed to the learning environment. These findings affirm that if there is a relationship of trust and collegiality, it fosters a good learning and working environment. VeneKlasen and Miller⁴⁹ offer that power relationships do not have to be one-dimensional; they are viewed as toxic and unchanging. These relationships can also be collaborative and transformative (i.e. power with). The efforts of sharing of power were noted by participants. A study conducted in South Africa regarding interpersonal trust among CHWs and their supervisors indicated the importance of this concept.^50,51 Because the CHWs’ supervisors were perceived negatively in terms of their relationship with the CHWs, this seemed to affect the CHWs’ performance at work. By extension, this performance could even spill over to their training and learning environment. Nonetheless, the acknowledgement of the brokenness of these by those in power usually leads to the willingness to work together in resolving them and moving forward.⁵⁰

The feeling of empowerment through the knowledge gained from the training was seen as a confidence booster to engage with the community regarding lung cancer. A study conducted in rural Cape Town on self-management training among CHWs indicated that the CHWs expressed confidence about what they learnt and motivated them to change or modify certain behaviours detrimental to their own health.⁵² Although CHWs participating in the present study hardly viewed the newly acquired knowledge in relation to their own health, they still considered that information would help them better perform their tasks as CHWs. Some suggested that their motivation to engage in training was their desire to assist others. Similar sentiments were also conveyed in a study that evaluated CHW training outcomes in two districts of KwaZulu-Natal, which revealed that the CHWs had marked improvements on their knowledge scores.⁵³ They also reported high levels of contentment with their training and discernible increases in their confidence in advising clients. However, increases in the level of knowledge after training does not always translate to confidence providing services that they are trained for. A Brazilian study on the training of CHWs regarding cervical cancer screening alluded to this phenomenon.⁵⁴ It has also been demonstrated that poor training and supervision often results in poor knowledge retention and job performance.⁴³ Invariably, this could also affect feelings of being empowered and motivated to perform on the job.

The CHWs’ roles of being advocates and agents of change were not necessarily motivated by politics or progressivism, as has been reported in other studies,^55,56 although it could be suggested that visiting companies where employees are deemed to be at risk of lung cancer, doing uniform inspections and assessing whether the safety protocols are observed is a form of activism. In this case, it seems to be the desire to assist their community members and those deemed at risk of lung cancer in avoiding the dire consequences of not attending to the disease early, suggesting an altruistic motivation.^55,57,58 Being the agent of change in this case means effecting behaviour change or being part of the process of achieving desired outcomes at the community level.⁵⁹

Some of the CHWs had strong feelings about going to the places of entertainment to raise awareness about risk factors of lung cancer. The South African government has put restrictions and prohibitions in the advertisement of tobacco products in public spaces, including clubs.⁶⁰ Therefore, these actions would be responding to the government’s prerogative of reinforcing the regulations. It is not clear, however, how this could be accomplished in the clubs, as the club owners have a right to restrict what happens in their places of business. This kind of awareness could possibly be done outside the club as the patrons are waiting to go inside the club.

L.M. English and colleagues investigated the trends of cigarette use among the youth in South Africa and Botswana using the Global Youth Tobacco Survey (GYTS) data.⁶¹ They demonstrated a significant decreasing trend of tobacco use over time in South Africa. However, this trend was no longer significant when factoring the parental use of cigarettes. In Botswana, the trend was the opposite of the South Africans’, where there was an observed upward trend over time. This highlights the importance of intervening early, as mentioned by the participant above.

Studies conducted in LMICs regarding assessments of training outcomes of CHWs have varying success of knowledge retention among CHWs.⁶² Half of the studies used pre- and post-training assessments and the other half added a follow-up test 6–8 months after training. In our study, pre- and post-training assessments were done. These assessments were used as a measure to gauge the CHWs’ knowledge increase because of the training, not in the traditional sense where students write a test and are graded. However, the results are not part of the scope of this article. The current study gives important insights on the approach and content of a lung cancer awareness training programme for CHWs and the integration of such training to existing training curricula. Nonetheless, the results are from the experiences of a limited number of CHWs. Finally, researchers’ experiences in qualitative research, establishment of rapport between the lead researcher and the research participants, training of the FGD facilitator, use of debriefing sessions between the FGD facilitator and lead researcher, use of verbatim quotes in the presentation of the results, as well as clear audit trail of the research process all contributed to the trustworthiness of the study findings.

Overall, the CHWs’ training experiences seemed to be positive. The group session afforded acknowledgment of the gains in knowledge and closing of the existing gaps among CHWs. They offered definitive thoughts on improvements and identified strategies that could be utilised in the process. The training seemed to have succeeded in empowering CHWs to perceive themselves as agents of change in the communities. The advocacy role was pivotal in sustaining learning. Although gender and age differences were acknowledged between the training facilitator and the participants, it positively influenced the interactional nature of learning. This component warrants further investigation.

Some studies have reported on the importance of follow-up training to reinforce learning.^43,63,64,65 Future trainings of this group of health workers should consider other modes of training and reinforcing learning, such as the use of technology.

The CHWs recognise the significance of their training in facilitating their engagement and knowledge awareness of lung cancer in the communities. Evidently, they affirmed that early detection through awareness was a vital component of training in reducing the number of lung cancer cases. Their expressed commitment to such awareness was notable. The various sections of their 1-week training proved extensive and adequate in preparing them for further engagement with their communities of service. Hence, it would be prudent to consider integrating this modality of training and learning in the CHW TB training curriculum, because of the overlap in symptomatology between the two diseases and the misdiagnosis of lung cancer for TB. However, large-scale intervention studies are required to arrive at conclusive evidence on the effectiveness of such interventions and wide-scale adoption of such.

This article provides insight into the training of community health workers on lung cancer awareness and future research on the integration of the intervention into already existing programmes