Globally, Africa reported the highest number of infectious disease outbreaks in 2018, with 96 new outbreaks.¹ This high number of infectious disease outbreaks is partly because of climate change, which contributes to the climatic suitability of vector-borne diseases² and increased travel.^3,4 In South Africa, major infectious disease outbreaks, including the listeriosis outbreak from 2017 to 2018,⁵ and coronavirus disease 2019 (COVID-19)⁶ have been reported, posing severe public health threats. During outbreaks, such as the COVID-19 pandemic, community health workers are often assigned community-level duties to prevent and manage them.⁷ In addition, other health workers, such as nurses and environmental health officers, perform health promotion activities and collaborate with health promotion practitioners – professionals who focus on the practical socio-environmental determinants of health.^8,9 Health promotion activities in South Africa are delivered at the primary healthcare level^9,10 and broadly encompass training, providing health education, research, policy coordination and community development.⁹ Given that different health workers perform health promotion activities in contexts where infectious disease outbreaks frequently occur, it is necessary to clarify the roles of health promotion practitioners to reduce role ambiguity and foster efficient team effort. Therefore, the purpose of this study was to describe the role of health promotion practitioners in infectious disease outbreaks in the OR Tambo District.

The Ottawa Charter of 1986¹¹ facilitated the inclusion of the health promotion agenda in health policies across several countries.¹² Since then, health promotion has grown as a discipline in some countries,^8,12 with advocacy^13,14,15 for active inclusion of health promotion during major disease outbreaks, such as the COVID-19 pandemic, becoming increasingly prominent. During outbreaks, health promotion practitioners can assume tasks such as improving preventive behaviour through health education.¹⁵ This need for health promotion during outbreaks is essential to inform individual behaviour change, develop interventions to promote health and inform health promotion policies during outbreaks.¹³

Several studies^16,17,18 have examined the impact of health promotion in infectious disease control, noting how health promotion practitioners work with communities through mobilisation, health education programmes and empowerment initiatives.¹⁶ For example, in Iraq, health promotion was acknowledged as instrumental in strengthening COVID-19 vaccination through engaging the community by delivering health education to encourage vaccine uptake.¹⁷ Although health promotion is acknowledged as instrumental in the Iraq study, notably, the teams responsible for the success of the vaccination campaign comprised vaccinators, community mobilisers, among other team members, such as data entry clerks and registrars.¹⁷ Similarly, in Singapore and Malaysia, migrant communities who lived in overcrowded dormitory facilities benefited from health promotion activities during the COVID-19 pandemic. In this regard, health promoters encouraged the implementation of hygiene measures in the dormitories to reduce the spread of COVID-19, while the government quarantined the dormitories, thus also illustrating how government policy can support health promotion initiatives.¹⁸ These studies from Iraq, Singapore and Malaysia, although highlight the importance of health promotion during outbreaks, also underscore the multidisciplinary nature of health promotion and raise the question: Do we need trained and professional dedicated health promotion practitioners during outbreaks?

In South Africa,¹⁹ like in other low-income to middle-income countries,¹² the role of health promotion practitioners remains poorly defined and often dominated by health professions with curative roles.¹⁹ Despite this, there are South African studies^10,19 that acknowledge the work implemented by dedicated health promotion practitioners. Boboko et al.,¹⁰ in their study in the Dr. Kenneth Kaunda District in the North West province of South Africa, note that the work of health promotion practitioners in South Africa is often marred by insufficient resources, inadequate managerial monitoring and supervision and inadequate health promotion structures.¹⁰ The poorly defined role of health promotion practitioners in South Africa also occurs in a context marked by several infectious disease outbreaks. For example, between 2013 and 2017, 327 foodborne disease outbreaks were reported in South Africa, resulting in 8680 hospital visits.²⁰ Given the high burden of infectious disease outbreaks, the importance of health promotion in outbreak mitigation and the poorly defined role of professional health promotion practitioners in South Africa, this study sought to describe the role of health promotion practitioners in disease outbreaks in the OR Tambo District in South Africa. This description will clarify the roles of health promotion practitioners, facilitating effective health promotion during infectious disease outbreaks.

To describe the role of health promotion practitioners, the study was framed in accordance with the National Health Promotion Policy and Strategy 2015–2019, which was the national framework in use at the time.⁹ This framework was selected as it guides the activities of health promoters. The National Health Promotion Policy and Strategy 2015–2019 outlines six areas of action for health promotion at three different levels in South Africa. The levels include national, provincial and district or sub-district levels. The areas of action are categorised into six broad areas: (1) advocacy and communication; (2) policy and regulatory framework; (3) leadership; (4) implementation; (5) research, monitoring and evaluation and (6) skills development and capacity building.⁹

The study used a qualitative research approach and a descriptive-phenomenological design. The researchers selected this design to ensure a complete description of the roles that health promotion officers play during outbreaks. The study was conducted in the OR Tambo District located in the Eastern Cape province of South Africa. In 2022, the district had a population of 1 501 702 and was the fourth largest in South Africa.²¹ The OR Tambo District comprises five local municipalities, is predominantly rural, and most (83.27%) people live below the poverty line.²¹

The study population comprised health promotion practitioners working in the district at the time of data collection. The study included only health promotion practitioners who had completed a tertiary qualification in health promotion and were working in the OR Tambo District for at least 1 year and had a role in an outbreak. The study excluded health promotion practitioners who were unwilling to participate, those without a role in prior infectious disease outbreaks and those with fewer than 1 year of work experience. Snowball sampling was employed to select study participants because of the scarcity of information on the population size and the difficulty in locating health promotion practitioners across various community settings. The researcher began by locating health promotion practitioners whom they knew and were closest to the researcher. Thereafter, the identified health promotion practitioners referred other practitioners in the district. The sample size was determined by data saturation.

Data were collected using individual interviews with a semi-structured interview guide by the researcher Mzwanele Toni. At the time of data collection, the researcher, Mzwanele Toni, had also been trained as a health promotion practitioner, worked in quality assurance at a tertiary educational institution and had no personal or professional relationship with the participants. A pilot study was first conducted in April 2021. After the pilot study, the researchers included a screening question about whether the health promotion practitioners had worked during an infectious disease outbreak. Data collection was then conducted in May and June 2021. All interviews were conducted in isiXhosa, as preferred by the participants, and each lasted approximately 40 min. One interview was conducted by telephone, and the remaining interviews were conducted face to face in various community settings where health promotion practitioners worked. These included private rooms in primary healthcare facilities and schools. The interview questions were designed to elicit the tasks performed during outbreaks, the outbreaks in which they worked and the training they received during these outbreaks. Interview questions also included the health promotion practitioners’ experiences with the tasks they carried out during outbreaks, their work experiences during outbreaks, their perceptions of their capacity to manage outbreaks, with whom they collaborated and how and their perceptions of the impact of their tasks during outbreaks.

Data were analysed using Braun and Clark’s six steps of thematic analysis.²² The researcher Nongiwe L. Mhlanga analysed data with the assistance of a co-coder, Mzwanele Toni. NVivo version 9 was used to analyse data, using an inductive approach. This entailed transcribing and translating the collected data, then using NVivo to generate the codebook, which was based on four transcripts selected by the researchers. Themes were then searched across the remaining dataset and reviewed. The generated themes were named, and a report was produced. While collecting and analysing data, the researchers reflected on their roles as researchers. To ensure trustworthiness, Lincoln and Guba’s framework²³ was used, with member checking conducted to ensure credibility and dependability. This was achieved by presenting transcripts to seven participants, who confirmed that the findings accurately reflected the discussions during the interviews. After this, no further changes were made. Direct quotes from participants were also included in the findings to ensure credibility. Credibility was further ensured by analysing data with a co-coder (Mzwanele Toni), who also assisted in developing a codebook. Dependability and confirmability were also guaranteed by detailing how the study was conducted. The researchers also described the study setting in detail to guarantee transferability and confirmability.

The sample consisted of 14 health promotion practitioners working in the OR Tambo District. Most (57.1%, n = 8) participants were female, while males comprised 42.9% of the sample. Participants’ ages ranged from 26 years to 54 years, with an average age of 36.1 years (standard deviation [s.d.] ± 7.8). The majority (64.3%, n = 9) of participants worked in rural settlements, while 35.7% worked in urban settlements. Participants’ work experience ranged from 1 year to 15 years. Table 1, which follows, shows the sample demographic characteristics.

The study found that during infectious disease outbreaks in the OR Tambo District, health promotion practitioners’ tasks include health education, planning and organising, advocacy and communication, monitoring and evaluation and conducting surveillance and assessments. These tasks were mostly performed within teams with other health workers.

The study included 14 participants, all of whom had a minimum qualification of a bachelor’s degree; two participants held a postgraduate qualification. The qualification levels among participants reflect the professional nature of health promotion as a discipline, as evidenced by the high proportion of participants holding university qualifications.⁸ However, the inclusion of participants with only a university degree or higher may limit the applicability of these findings to health promotion practitioners with similar qualifications. This contrasts with other studies in South Africa, which did not include health promotion practitioners with tertiary qualifications.^10,19 In addition, the study comprised participants who worked primarily in rural areas, reflecting the predominantly rural nature of the OR Tambo District in the Eastern Cape.²¹

Notably, the study found that health promotion practitioners conducted activities during outbreaks that aligned with the activities outlined in the National Health Promotion Policy and Strategy: 2015–2019 at the district level.⁹ These health promotion activities, indicated in the strategy, aligned with three of the six categories of roles and responsibilities.⁹ The activities carried out by the health promotion practitioners are also stated in the Health Promotion Strategy for the African Region, which prioritises the use of a multisectoral approach to ensuring community awareness of preventable diseases.²⁴ The study observed how health promotion practitioners in the OR Tambo District worked collaboratively to provide health education with other health disciplines, such as nursing, community health workers and environmental health practitioners. This collaboration with other health workers was not unexpected and affirms the general multidisciplinary nature of health promotion activities.^8,9 Although their work was collaborative, health education is an inherent function in the discipline of health promotion.¹⁴ Reviews by Woodall et al.²⁵ and Laverack²⁶ acknowledge the critical role of health promotion practitioners in providing a reliable source of information during outbreaks, particularly during the COVID-19 pandemic, which was characterised by extensive misinformation.²⁵ In this regard, participants such as P1 explained how they planned awareness campaigns and provided reliable information during outbreaks. ‘I am responsible for conducting community awareness’. This collaborative role in providing health education during outbreaks also aligns with a Tanzanian study, which found that during Cholera outbreaks in a rural setting, health promoters are key to delivering health education.²⁷ In addition, the prominence of the collaborative role in providing health education may be attributed to the focus of the study only at the district level, where the National Health Promotion Policy and Strategy: 2015–2019⁹ stipulates the formation of epidemic response teams and a multisectoral approach to health promotion, which is reflected in this study. Future studies may also explore the additional role of health promotion practitioners at all levels of service provision, including national and provincial, during outbreaks, to achieve a comprehensive and conclusive understanding of their collaborative role in health education.

Although health promoters provided health education during outbreaks, it was also observed that this collaborative role is constrained by limited inclusion in training, as other health workers with whom they collaborated were trained. Notably, the participants had similar exclusion in planning during outbreaks. This exclusion of health promotion practitioners in training and planning during outbreaks may also reflect the obscurity of health promotion practitioners in South Africa in the broader pool of health professions described by Rwafa-Ponela et al.¹⁹ and Boboko et al.¹⁰ However, it is essential to consider that during outbreaks, health promotion plays a crucial role and should be incorporated into outbreak planning.

This study also found that the health promotion officers’ research role encompassed surveillance and assessment, as well as monitoring and evaluation. In case studies presented by Corbin et al.,²⁸ the authors note that although health education plays a critical role in disease prevention, it is often insufficient, and other interventions, such as research and monitoring, as well as advocacy, are critical. In the case of the Ebola outbreak in Sierra Leone, one of the critical success factors was the continuous analysis of community-level conditions and the adaptation of health education messaging based on data collected.²⁸ Additionally, advocacy played a critical role in ensuring community entry for health promotion interventions in Kenya during the COVID-19 pandemic.²⁸ Similarly, in this study, participants reported investigating and documenting the causes of outbreaks and using research to inform their health education. Although health promotion practitioners conduct research in South Africa, there remains a paucity of published literature and institutional reports from a health promotion perspective on outbreak mitigation. Therefore, it is recommended that the Health Promotion Directorate foster this research role by establishing a research repository where case reports on outbreaks can be made available to the broader scientific community.

The study aimed to describe the role of health promotion practitioners during outbreaks in the OR Tambo District, South Africa. The roles of health promotion practitioners included collaborative health education, planning and organising, advocacy, monitoring, evaluation, surveillance and assessment. These functions of health promotion practitioners align with existing policies, such as the National Health Promotion and Policy Strategy in South Africa at the district level and the Health Promotion Strategy for the African Region. As such, policymakers may use these findings to update existing policies in South Africa and across Africa. Based on these study findings, it is recommended that future studies include health promotion practitioners working at provincial and national levels during outbreaks. It is also recommended that, in the development of outbreak response plans, health promotion officers be included in all aspects of service provision, such as planning to optimise their role in outbreak mitigation, as stated in existing national and regional policies on health promotion. In addition, the study recommends establishing a research repository for health promotion, utilising case reports during outbreaks, to highlight the research role.

The study’s main strengths were a sample that provided adequate information to enable thematic saturation. This was supported by rich narratives that provided adequate insight into the activities of health promotion officers during outbreaks. Another strength was the analytic approach used, which was informed by Lincoln and Guba’s framework. This study, however, had some limitations, including the lack of health promotion practitioners in managerial positions and/or management structures where health promotion practitioners worked, as some responses referred to management structures. The study was also limited by the inclusion of health promotion practitioners who had a minimum of a degree in health promotion, which may exclude the application of these findings to health promotion practitioners with lower-level qualifications. However, this could have been increased by utilising telephonic interviewing and snowball sampling, as applied in the study design, which would have enabled the recruitment of participants with various tertiary-level qualifications and those outside the OR Tambo District. Snowball sampling may also have introduced selection bias, as participants with similar networks may share similar perspectives.