Reducing community health worker stigma toward depression and substance use to improve human immunodeficiency virus and tuberculosis care engagement in South Africa: Results from a randomized, stepped-wedge hybrid effectiveness-implementation trial
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
Epidemiology and Biostatistics, University of Maryland, College Park, College Park, MD, United States
5
Psychiatry, Massachusetts General Hospital, Boston, MA, United States
6
Psychology, University of Maryland, College Park, College Park, MD, 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 impact patient engagement in Human Immunodeficiency Virus (HIV) and tuberculosis (TB) care. Community health workers (CHWs) play a central role in supporting HIV/TB care engagement in South Africa, despite having limited-to-no training in addressing depression and substance use challenges. Some CHWs may also hold negative attitudes toward these conditions. Strengthening CHWs’ ability to address depression and substance use may reduce CHW-level stigma and support improved patient engagement in HIV and TB care.
METHODS:
We conducted a cluster-randomized, stepped-wedge hybrid type 2 effectiveness-implementation trial (N = 82 CHWs) to evaluate a CHW training (“Siyakhana”) designed to reduce stigma toward depression and substance use in HIV/TB care. Siyakhana was implemented across six primary care clinics in a low-resource area of Cape Town, South Africa. CHWs completed pre-training and 3- and 6-month post-training assessments of stigma toward depression and substance use using the Social Distance Scale. HIV/TB visit dates within 3-months before and after the Siyakhana training were extracted from routine health department records for patients. Paired t-tests examined differences in overall, HIV, and TB visit counts. Based on these findings, linear regression models examined whether changes in CHW stigma were associated with post-training TB visits, adjusting for pre-training TB visit counts and time to re-engagement.
RESULTS:
Paired t-tests showed no significant pre–post differences in overall or HIV visits. TB visits increased significantly following training (t(36) = 3.12, p = 0.004). In adjusted models, reduction in CHW stigma toward depression at 3-months was significantly associated with more TB visits (β = 0.32, SE = 0.13, p = 0.023).
CONCLUSIONS:
Findings suggest that changes in CHW attitudes toward mental health may represent an important mechanism through which workforce-focused interventions influence engagement in HIV and TB services in high-burden settings.
Mental health and substance use problems impact patient engagement in Human Immunodeficiency Virus (HIV) and tuberculosis (TB) care. Community health workers (CHWs) play a central role in supporting HIV/TB care engagement in South Africa, despite having limited-to-no training in addressing depression and substance use challenges. Some CHWs may also hold negative attitudes toward these conditions. Strengthening CHWs’ ability to address depression and substance use may reduce CHW-level stigma and support improved patient engagement in HIV and TB care.
METHODS:
We conducted a cluster-randomized, stepped-wedge hybrid type 2 effectiveness-implementation trial (N = 82 CHWs) to evaluate a CHW training (“Siyakhana”) designed to reduce stigma toward depression and substance use in HIV/TB care. Siyakhana was implemented across six primary care clinics in a low-resource area of Cape Town, South Africa. CHWs completed pre-training and 3- and 6-month post-training assessments of stigma toward depression and substance use using the Social Distance Scale. HIV/TB visit dates within 3-months before and after the Siyakhana training were extracted from routine health department records for patients. Paired t-tests examined differences in overall, HIV, and TB visit counts. Based on these findings, linear regression models examined whether changes in CHW stigma were associated with post-training TB visits, adjusting for pre-training TB visit counts and time to re-engagement.
RESULTS:
Paired t-tests showed no significant pre–post differences in overall or HIV visits. TB visits increased significantly following training (t(36) = 3.12, p = 0.004). In adjusted models, reduction in CHW stigma toward depression at 3-months was significantly associated with more TB visits (β = 0.32, SE = 0.13, p = 0.023).
CONCLUSIONS:
Findings suggest that changes in CHW attitudes toward mental health may represent an important mechanism through which workforce-focused interventions influence engagement in HIV and TB services in high-burden settings.
| eISSN: | 2654-1459 |
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