Design, setting and sample
To assess awareness and the value of the Community Health Worker, a post-intervention design was used. Using a post-intervention design to assess awareness was warranted as the findings of a previous study conducted in the same setting (Maree et al. 2011a) served as pre-intervention baseline data.
The setting was a resource poor area 45 km north of Pretoria. This well-demarcated area is a new extension to an established township and houses a multilingual and ethnically diverse population. In a community assessment conducted by Maree and Wright in 2008 (Maree & Ferns 2008), the community comprised 703 households and a population of approximately 2533 people of which 1320 were 20 years and older. Women were in the majority (51% vs. 49%) of which 221 were aged between 20 and 29 while 452 were 30 years and older. Slightly more than a quarter of the adult population (27%) was functionally illiterate as they either had no formal education (6.6%) or had education of 7 years and less (20.4%). Housing consisted primarily of informal dwellings with only 2.2% having a tap in the house; the rest had either a tap in the yard (57.5%) or used one of the communal taps (40.3%). Poverty as well as unemployment was rife as 65% of the adult population was unemployed with 11.5% households having no income and a further 23.4% living on an income of approximately $400 per month.
Purposive sampling was used and all women reporting at the Cancer Nursing Community of Practice during the first 4 months after initiating the service were recruited for the study. Inclusion criteria were 18 years and older and willing to participate. There seems not to be an exact rule for the sample size of a pilot study and according to Thabane et al. (2010) ‘a pilot study should be large enough to provide useful information about the aspects that are being assessed for feasibility’. A total of 22 women reported for screening during the first 4 months after establishing the Cancer Nursing Community of Practice and all (100%) were willing to participate in the study. The sample therefore totalled 22 (n= 22) and was considered to be large enough to provide useful information as to whether the intervention would work (Burns & Grove 2010). Furthermore, a 4-month period was considered to be sufficient to serve as indicator of the success of the intervention.
Delivering the nursing intervention
The intervention consisted of training five community members to become Community Health Workers, and to train one of the five to specifically work in the field of cancer prevention 3 days a week and to assist in the clinic 2 days a week. The specifics are described below.
The community leaders were approached and after informing them of the need for Community Health Workers, what would be expected of them, their work hours and remuneration, the community leaders were asked to select five members suitable to be trained as Community Health Workers. The following selection criteria were agreed on: older than 18 years; able to understand, speak, read and write simple English; born and residing in the specific community; and completed secondary school (12 years of schooling). The five community members were trained by the lead researcher, a baccalaureate-prepared nurse for a period of 3 months.
Teaching and learning took place in an allocated classroom at the Adelaide Tambo School of Nursing Science. The learners travelled from the township to the university to attend contact sessions. At the beginning of each week, learners received transport money to prevent transport-related absenteeism and also tea and lunch to encourage regular attendance. The learning programme was offered in an accessible level of English. The macro-curriculum was also written in simple English language with practical examples, illustrations and summaries of the important points in every chapter, which made it easier both for teaching and learning. Training of the selected Community Health Workers commenced in May 2010 and was completed in July 2010.
Teaching and learning took place from Mondays to Wednesdays from 0800 h to 1600 h. The curriculum consisted of existing South African guidelines (Clarke et al. 2003). Two modules were presented to the learners, namely ‘How to become a Community Health Worker’ and ‘The essentials of health’. Each week, two to three learning units were offered, depending on the content of the learning unit and the learners' ease at comprehending the work. Assignments were given daily. Learning was assessed by means of a written test every Thursday. The test would only consist of the content covered during the specific week. After the test was written, learners would receive the study material for the following week and encouraged to prepare accordingly. Tests were discussed in class after scripts were handed back to the learners and correct answers provided. To facilitate better understanding, the researcher repeated certain learning units the following week, if the learners performed poorly in the tests or voiced they had difficulty with understanding some of the work. Group discussions, brainstorming and class assignments were used to foster better understanding. Learners with better comprehension were asked to assist, as much as possible, those who were struggling, sometimes by translating the learning content in vernacular to their counterparts. Learners, who did not pass a test with at least 50%, were given a rewrite opportunity. The researcher changed the questions of the specific test slightly to promote a culture of hard work. When marking assignments and tests, the researcher did not take grammatical and spelling errors into account because learners struggled with writing English.
The summative assessment consisted of a test covering the total curriculum content. The test comprised questions that were meticulously selected from previous weekly tests. The learners were given a study and revision a week prior to the final test, during which they were assisted with queries. All the learners passed the test. Following the successful completion of the learning programme, the researcher explained the specific activities of each of the Nursing Communities of Practice where each of the five Community Health Workers was going to work. The five Community Health Workers were asked who among them would be interested in cancer prevention and one volunteered.
The researcher introduced cervical and breast cancer to the volunteering Community Health Worker in terms of: definitions; risk factors; prevention; signs and symptoms; screening; importance of early screening and diagnosis; disadvantages/dangers of late screening and diagnosis; importance of health education of women; and the role of the Community Health Worker in terms of cancer prevention. Thereafter the Community Health Worker specifically trained for cancer prevention was coached by the registered nurse in charge of the Cancer Nursing Community of Practice. Coaching included a repetition of the various aspects of cervical and breast cancer as well as her tasks during the screening procedures for a duration of 1 week. During the screening procedure the Community Health Worker was tasked to assist the women with undressing and dressing, ensuring that the women were suitably covered, supporting the woman during the screening procedure, assisting the registered nurse when performing the procedure and cleaning the instruments used for screening.
One month before data gathering commenced, all five Community Health Workers were sent into the community to inform them about the launching of the greater Nursing Community of Practice in their community. They were also mandated to tell the community about the services that would be rendered. During this time, the Community Health Worker specifically trained for cancer prevention was tasked to teach the community, especially the women, on what cancer is and what cervical and breast cancer are, the signs of cervical cancer breast cancer, the risk factors, prevention and early detection and the treatment of these diseases. The venue and times of screening services were also provided as well as information about undressing for the procedures. After the Community Health Worker commenced with her tasks in the community, the lead researcher and Community Health Worker met biweekly to discuss the challenges the Community Health Worker experienced and possible resolutions for the challenge.
Measuring the outcomes
Screening uptake was assessed using the statistics of the Cancer Nursing Community of Practice for the first 4 months after initiating the screening service and available statistics. To evaluate the secondary outcomes, self-report data were gathered by means of a structured interview. A self-designed questionnaire, based on the literature and expert opinion was used. The questionnaire consisted of both open- and closed-ended questions and contained three sections. In Section A, demographic information was gathered, Section B contained questions to assess the value of the Community Health Worker as perceived by the participants and Section C was devoted to questions to assess the level of knowledge of cervical and breast cancer. Possible responses were listed for the closed-ended questions, but an added ‘other’ option was provided to allow participants to add options not included in the possible responses. The questionnaire was pre-tested on the first participant and no changes were necessary. The data gathered by means of the pre-test are included in the findings of the study. A field worker was used to assist with language issues.
Secondary analysis was used to analyse statistics for screening uptake and descriptive statistics was used to analyse the numerical data which was entered on an Excel spread sheet and presented as descriptive statistics. Data gathered by means of open-ended questions were coded during the examination of the data using content analysis, a descriptive coding strategy, where after it was entered onto the Excel spread sheet. The findings are presented using tables.