'Empowerment' as a proximal implementation outcome for task shifting with informal cadres: findings from a qualitative study with traditional healers in rural Uganda

Task shifting and task sharing (TSS) are widely used implementation strategies to expand HIV service delivery in low-resource settings. Informal lay health workers, such as traditional healers (THs), have been proposed as critical partners in bridging service delivery gaps. However, the mechanisms that support their successful integration into formal health systems remain underexplored. This qualitative sub-study aimed characterizes a novel proximal implementation outcome - empowerment - based on lived experiences of THs participating in a TSS intervention in rural Uganda.

Between July and August 2023, we conducted 22 in-depth interviews with THs in rural Uganda who completed a three day training to become lay HIV supporters. The curriculum included HIV transmission, ART adherence, stigma reduction, and HIV self-testing. Interviews were conducted in the local language, transcribed, translated into English, and analyzed using a thematic approach. Our analysis was guided by Lee and Koh's empowerment framework, which links role transformation to domains of empowerment.

THs reported experiencing empowerment across four domains: meaningfulness, competence, self-determination, and impact. Participants described strong alignment between their traditional caregiving roles and new responsibilities in HIV support. They reported increased HIV-related knowledge, confidence in client care, autonomy in decision-making, and a sense of contributing meaningfully to improved health outcomes. Notably, we identified a fifth domain - external validation - defined as recognition and legitimacy conferred by representatives of the biomedical health system. This domain was central to participants' perceived integration, motivation, and potential sustainability of their involvement in these types of programs.

We propose empowerment as a novel proximal implementation outcome that reflects the internal and external transformations necessary for successful implementation with informal providers. Our findings support expanding Lee and Koh's empowerment framework to include external validation, particularly for cadres operating outside the formal system. Positioning empowerment as a proximal outcome offers a valuable lens for evaluating early success of broad implementation strategies that involve role transformation, such as training trainers, or engaging community champions.

ClinicalTrials.gov, NCT05943548. Registered 2023-07-13, https://clinicaltrials.gov/study/NCT05943548 .