Identifying implementation determinants for mental health and substance use stigma-reduction training in human immunodeficiency virus and tuberculosis care in South Africa
1
Behavioral and Community Health, University of Maryland, College Park, College Park, MD, United States
2
Center for Substance Use, Addiction & Health Research, University of Maryland, College Park, College Park, MD, United States
3
Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Cape Town, South Africa
4
Psychiatry & Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, United States
5
Psychology, University of Maryland, College Park, College Park, MD, United States
6
Psychiatry, Massachusetts General Hospital, Boston, MA, United States
7
Curtin enAble Institute, Curtin University, Perth, Australia
Popul. Med. 2026;8(Supplement Supplement 1):
ABSTRACT
BACKGROUND:
Mental health and substance use problems contribute to poor engagement in human immunodeficiency virus (HIV) and tuberculosis (TB) care. Community health workers (CHWs) play a central role in re-engaging patients in care in South Africa; however, they often receive limited training in addressing mental health and substance use problems and may hold stigmatizing views toward these conditions. Training CHWs to address mental health and substance use may therefore improve patient engagement in HIV/TB care. Optimizing the outcomes of training requires understanding and addressing contextual determinants.
METHODS:
We conducted semi-structured individual interviews with patients (n = 15) and CHWs (n = 15) in Cape Town, South Africa. Interviews explored barriers and facilitators to care engagement, stigma, cultural beliefs about mental health and substance use, and provider training needs. Transcripts were coded using thematic analysis, and themes were subsequently mapped to Consolidated Framework for Implementation Research (CFIR) domains to characterize implementation determinants.
RESULTS:
Outer-setting determinants that limited patient engagement in HIV/TB care included social determinants of health such as poverty, food insecurity, and limited access to transportation. Cultural beliefs around mental health and substance use also impacted patient engagement. Inner-setting determinants included fragmented referral pathways and limited mental health and substance use services. At the individual level, CHW stigma toward HIV, TB, depression, and substance use emerged as key barriers to engagement. CHWs also expressed burnout and noted the challenges of managing large caseloads. Despite this, CHWs were viewed as trusted community figures and expressed strong interest in receiving training and regular supervision to better engage with patients with substance use and mental health problems.
CONCLUSIONS:
Pre-implementation findings identified multilevel determinants that shape the implementation outcomes of CHW training. Addressing structural barriers, stigma, and workforce skills and capacity may enhance the acceptability, appropriateness, and feasibility of CHW–focused trainings in high-burden settings.
Mental health and substance use problems contribute to poor engagement in human immunodeficiency virus (HIV) and tuberculosis (TB) care. Community health workers (CHWs) play a central role in re-engaging patients in care in South Africa; however, they often receive limited training in addressing mental health and substance use problems and may hold stigmatizing views toward these conditions. Training CHWs to address mental health and substance use may therefore improve patient engagement in HIV/TB care. Optimizing the outcomes of training requires understanding and addressing contextual determinants.
METHODS:
We conducted semi-structured individual interviews with patients (n = 15) and CHWs (n = 15) in Cape Town, South Africa. Interviews explored barriers and facilitators to care engagement, stigma, cultural beliefs about mental health and substance use, and provider training needs. Transcripts were coded using thematic analysis, and themes were subsequently mapped to Consolidated Framework for Implementation Research (CFIR) domains to characterize implementation determinants.
RESULTS:
Outer-setting determinants that limited patient engagement in HIV/TB care included social determinants of health such as poverty, food insecurity, and limited access to transportation. Cultural beliefs around mental health and substance use also impacted patient engagement. Inner-setting determinants included fragmented referral pathways and limited mental health and substance use services. At the individual level, CHW stigma toward HIV, TB, depression, and substance use emerged as key barriers to engagement. CHWs also expressed burnout and noted the challenges of managing large caseloads. Despite this, CHWs were viewed as trusted community figures and expressed strong interest in receiving training and regular supervision to better engage with patients with substance use and mental health problems.
CONCLUSIONS:
Pre-implementation findings identified multilevel determinants that shape the implementation outcomes of CHW training. Addressing structural barriers, stigma, and workforce skills and capacity may enhance the acceptability, appropriateness, and feasibility of CHW–focused trainings in high-burden settings.
| eISSN: | 2654-1459 |
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