Community health workers (CHWs) play a vital role in the referral network of the primary healthcare system, enhancing patient outcomes in underserved rural areas by bridging the gap between the community and healthcare facilities, particularly in middle- and low-income regions with a shortage of healthcare professionals.¹ Some of the primary responsibilities of CHWs include conducting health screenings, promoting health through education, making home visits to support patients with chronic illnesses, such as diabetes mellitus (DM), and providing referrals to primary healthcare nurses in the community clinic.¹ Additionally, CHWs enhance community capacity, collect data and convey important information, such as patient progress reports, to healthcare professionals at the primary healthcare level.² The contributions of CHWs are essential for promoting healthy household behaviours.³ Globally, CHWs are referred to by various titles, such as ‘village health workers’ in China, ‘lady health workers’ in Pakistan and ‘health extension workers’ in Ethiopia and the United States of America (USA).^4,5,6,7

Unlike healthcare professionals (HCPs), CHWs have lower educational qualifications.⁸ In response to the shortage of HCPs, many countries initiated a task shifting approach, supported by the World Health Organization (WHO), which is the delegation of the HCPs’ responsibilities to either existing personnel with less training and credentials, such as CHWs.⁹ The workforce of CHWs within the healthcare system varies significantly across different countries. In 2023, the USA employed approximately 63 400 CHWs.¹⁰ In comparison, China reported having 582 000 CHWs in 2018.¹¹ There were about 490 000 CHWs in Africa, with Kenya having the highest workforce (86 490) in 2021, a decline from 91 653 as of 2020.^12,13 In 2019, South Africa employed over 54 180 CHWs nationwide.¹⁴

South Africa (SA) is experiencing a significant shortage of HCPs, particularly doctors and nurses.¹⁵ The country has an estimated ratio of 2.87 HCPs for every 1000 people. In contrast, the WHO recommends a ratio of 4.45 HCPs per 1000 population.⁹ The National Department of Health (SA) has formulated a policy document on the establishment of ward-based outreach teams comprising various HCPs and CHWs, aimed at re-engineering primary healthcare services.¹⁶ Community health workers are meant to be a foundational component of the primary healthcare system, bringing essential health services directly into communities and households. As with communicable diseases, where CHWs refer patients for testing for HIV or tuberculosis (TB), they should also be aware of the complications of non-communicable diseases, such as DM, and refer patients for appropriate screening of these complications, such as DR.

Diabetic retinopathy (DR) is one of the microvascular complications of DM that leads to impaired vision and blindness if untreated.¹⁷ Patients diagnosed with type II DM should be referred for DR screening immediately after diagnosis, and those with type I DM can be referred after 6 months of a DM diagnosis.¹⁸ The prevalence of DR varies globally, with an estimated 25.2% of diabetic patients affected worldwide.¹⁹ In 2019, the prevalence of DR in SA was estimated to be 12.7%.²⁰ A study in Limpopo found inadequate referral of patients for DR screenings, with more than a third of diabetic patients having DR.²¹

Community health workers can play a crucial role in DR screening programmes, especially in resource-limited settings. Additionally, CHWs can help to raise community awareness about DR and provide culturally sensitive education to encourage individuals with DM to adhere to treatment, attend regular DR screening to minimise the risks associated with DR.²² There is a paucity of research on this topic among CHWs, particularly in the African context. The knowledge, attitudes and practices (KAP) model explains how an individual’s knowledge and beliefs affect their health-related behaviours.²³ In the context of CHWs, their understanding and beliefs about health conditions, and in this context, DR, are likely to affect their actions in terms of providing relevant health education to patients and referring them for appropriate health services.²⁴

We therefore aimed to assess the KAPs regarding DR among CHWs in the Maruleng sub-district in Limpopo, South Africa.

This is the first research to assess the KAPs of DR screening among CHWs in South Africa. The majority of CHWs in this study were female, in keeping with previous research conducted among CHWs across all five municipal districts of the Limpopo Province, where a higher proportion of female participants was also reported.²⁵ In a study conducted in Gauteng Province in South Africa, 95% of CHWs were females.²⁶ Research from various regions consistently shows a high percentage of female CHWs, with some indicating that 87.7% and 80% of participants are women.²⁷ In some low and middle-income countries, such as Pakistan and India, CHWs are referred to as ‘lady health workers’ because of the predominance of women in this field.^5,28

Most CHWs (61.8%) had completed secondary school, a trend consistent with studies from other provinces in South Africa.^25,29,30 The minimum qualifications for employment as a CHW in South Africa vary depending on whether the CHW is permanently employed, on a short-term contract, or is working voluntarily.^8,29,31 Permanently employed CHWs are required to have completed secondary education, as their responsibilities include reading patients’ clinical records and writing progress reports for the chronic patients they visit.^8,27,30 There are no standardised employment requirements across all health programmes.³² Some programmes, like the one initiated by the Hospice Palliative Care Association of South Africa, require formal training of CHWs.^32,33 The variation in qualification of CHWs in South Africa differs from countries such as Ethiopia and Pakistan, where CHWs are required to have completed a specific certification programme.^5,7 Community health workers’ programmes in South Sudan,³⁴ Afghanistan³⁵ and Nepal³⁶ used illiterate and poorly trained women to record healthcare services. The findings of the current study highlight inconsistencies in the employment status of CHWs, with the majority employed on short-term contracts by non-governmental organisations (NGOs). In South Africa, there is no standardised employment policy for CHWs.^31,32

There was a high median knowledge score, indicating that most CHWs possess a basic understanding of DR and the importance of referring diabetic patients for eye examinations. However, this finding did not translate into practice. The majority of CHWs recognised that diabetic patients who do not report any ocular problems should still be referred for an eye examination. This practice is crucial, as DR frequently presents asymptomatically in its early stages and may not reveal any symptoms until it has advanced to more severe levels. Timely detection facilitates appropriate treatment, which can mitigate the progression of the disease and avert permanent vision loss.³⁷ The association between years of work experience and knowledge is likely a result of the frequent encounters CHWs have with diabetic patients who report visual-related problems. Community health workers often have limited knowledge of DR screening and referral guidelines, possibly because of their level of education attained before employment, as supported by findings from previous research in Fiji, where CHWs’ understanding of basic screening procedures for DR and referral guidelines significantly improved after in-service training.³⁸ Increased knowledge can empower CHWs to effectively educate patients and the community about the importance of regular DR screening and management.^38,39,40

We found that CHWs with good knowledge were more likely to have positive attitudes and refer patients for DR screening, in keeping with KAP theory.⁴¹ While we found no significant associations between sociodemographic variables and attitudes, a study in Northeast China reported that CHWs’ attitudes were influenced by their employment status in China by reimbursement for transport in Pakistan.^5,40 A previous study conducted among CHWs in the Fetakgomo-Tubatse sub-district in Limpopo, South Africa, aimed at investigating the importance of utilising a non-communicable diseases screening tool, which found a positive impact on both CHWs and community members, where they were open and expressed their feelings freely, inconsistent with a study from Pakistan, where CHWs’ positive attitudes were associated with employment status.⁴² We assessed the type of employment only and not other aspects of financial incentives. Some CHWs reported the lack of an ophthalmologist in the district as a barrier to referring patients for DR screening. In South Africa, ophthalmology services are available at regional or provincial hospitals.⁴³ However, screening for DR can be done by optometrists at district hospitals. This highlights a lack of understanding of what DR screening entails among CHWs. A small proportion of CHWs also cited long waiting times and travel distances as reasons not to refer patients for DR screening. Earlier research shows that while CHWs often have good knowledge and positive attitudes, actual screening remains a key challenge because of systematic barriers.⁴⁴ Unfortunately, as with many other healthcare services in South Africa, these issues are ongoing and require strengthening the health system, including the employment of more optometrists and ophthalmologists. The rural nature of the sub-district can make travel to the district hospital a challenge for some patients, and there are no mobile optometry services available. Community health workers’ attitudes towards DR can influence their willingness to advocate for DR screening and treatment, where negative attitudes can lead to low referral rates.^39,40 In this study, some CHWs perceived diabetic eye complications as less significant or lower priority than other health issues, such as managing overall blood glucose control or other systemic complications, consistent with earlier research from Fiji.³⁸ This viewpoint may stem from a lack of awareness regarding the potential for irreversible damage to the ocular vasculature.

Timely referrals and regular eye check-ups for DR screening are essential practices that can mitigate the risk of having diabetic patients with vision impairment or loss resulting from diabetes-related complications in various regions across the globe.^37,45,46 In Limpopo, there is no standardised home support visit schedule for CHWs.^16,43 Their schedules are tailor-made at the local clinic level, depending on the community needs of the individual health programme. Moreover, over half of the CHWs in the current study did not receive any in-service training for referring diabetic patients for an eye examination. Training has the potential to significantly improve the confidence of CHWs in raising community awareness on diabetes and DR, particularly in low-resource settings, to increase referrals for screening.^37,47,48 We found a significant association between knowledge and practice, aligned with a previous study on undesirable behaviour and associated knowledge of DR screening and management among CHWs in South India.⁴⁹ A 2018 systematic review on the delivery of public healthcare services by the CHWs in the primary healthcare settings in China found that effective practices of DR among CHWs were linked to ongoing training, community involvement, financial incentives or compensation for the CHWs.²

The important strength of this study is that it is the first documented research conducted among CHWs and has revealed important gaps that can be easily addressed within the current context in which CHW work. Eye care is often overlooked as an aspect that CHWs can be involved in, yet referral of patients for DR screening is a simple task that can be included in the duties expected of CHWs. This study does have some limitations. Firstly, the cross-sectional design limits the ability to establish a causal relationship between KAPs, and we were unable to report on trends or changes in the KAP. Secondly, practice was assessed through self-reporting, which may not reflect the actual practice of the CHWs. The participants were self-selected, introducing selection bias. Thirdly, the research was conducted in a single sub-district in Limpopo Province, which limits the generalisability of the findings to other districts in South Africa, particularly those that are more urban.

The findings of this study can inform the development of a training programme on DR for CHWs, covering risk factors, screening guidelines and referral pathways. The use of appropriate health screening tools that include referral for DR screening should also be considered, as previous research has indicated that patient screening tools facilitate the fieldwork of CHWs.⁴² Future research should focus on intervention studies to evaluate the effectiveness of training programmes on DR screening. Qualitative studies can yield better insight into facilitators and barriers faced by CHWs with regard to eye health promotion. Permanent recognition of CHWs within the public health sector, including offering them financial incentives, would improve their morale and effectiveness, as previously reported from a study that assessed CHW policy implementation across six provinces in SA.²⁷

Community health workers have good knowledge and attitudes towards DR, but there are important gaps that warrant an intervention. The study highlighted the need for in-service training on DR for CHWs. Addressing knowledge gaps, promoting positive attitudes and ensuring access to necessary tools can empower CHWs to effectively identify and refer patients for DR screening, ultimately reducing the burden of vision loss as a result of advanced DR.