Training Community Health Workers for Large-Scale Community-Based Health Care Programs

By: Dr. Paul Freeman

This is the ninth chapter of the CHW Reference Guide produced under the Maternal and Child Health Integrated Program, the United States Agency for International Development Bureau for Global Health’s flagship maternal, neonatal and child health project. 

To be effective workers, CHWs need specific competencies and skills. This chapter focuses on how these competencies can be best acquired and ways in which this training can be most effectively organized. The author, Ian Aitken, provides an excellent overview of the key elements of CHW training. As the author notes, this training is not fixed on the basis of an unchangeable blueprint, but rather one that needs to be adapted to:

• the job of the CHW
• the tasks each CHW is expected to perform
• the context in which the CHW is working
• the needs of the trainers

The chapter content is well organized and an extensive range of examples of training programs around the world is presented. This chapter needs to be thought of in the context of all other chapters in Section 2, as well as the planning and scaling-up chapters in the CHW Reference Guide that address the training and management skills needed to train CHWs.

The chapter content is organized in terms of four key questions for planners and trainers. Key content will be highlighted here under these questions.

What sort of CHW training program is being planned?

The typical characteristics of training programs are presented in terms of the two types of CHWs presented in the Reference Guide and summarized in Table 1. These are Level 1, community health volunteers – ongoing and intermittent – and Level 2, auxiliary health workers and health extension workers.

How should the training program be organized?

Under this question, the differences between the training programs for the above two types of CHWs are reviewed. The key point made is that if there is already a CHW cadre established in a community, it is usually best to build on the scope of practice and previous training that CHWs have received and the rapport that they have already established with their communities rather than establishing a whole new cadre of workers. However, this point needs to be viewed in relation to each local context. Overburdening a few CHWs with many tasks can be counterproductive. With adequate local community-level organization, depending on local roles and contexts, it may be better to add volunteers with limited roles working in coordination with CHWs with more demanding roles rather than overburdening a few CHWs with multiple roles.

While at least a primary school educational level is usually desirable, the point is well made that in some roles and contexts illiterate CHWs have shown they can work as well as literate ones. Likewise, experience has shown that CHWs of a higher educational level than the communities they serve may not work well. The issues of how long training should be, where should it occur, and how it should be scheduled are discussed and illustrated by an extensive tabulation of training programs from different countries for different types of workers.

Good preparation and ongoing development of the trainers of CHWs are presented as essential. Many trainers of CHWs at the health facility, provincial, and district levels have been trained through traditional rote approaches. Therefore, adequate training in competency-based approaches with ongoing mentoring from a cadre of master trainers is an important part of CHW training programs. Standards-based approaches, including accreditation of training institutions, are needed to maintain the quality of teaching.

Who should be responsible for the governance and management of the training program?

It is important to clarify which organization is responsible for the governance and management of CHW training. For new programs it is recommended that both a steering committee and an ad hoc or formal technical advisory committee be established. Key characteristics of these committees are presented through examples.

How can optimal performance be achieved through training?

This section discusses the different types of training that CHWs need to perform their tasks properly. While the quality of training and the regularity of refresher trainings are important for effective performance, other factors influencing CHW performance also need to be addressed. The Chapter presents factors that effective programs need to address as appropriate to each local context. Tasks that each CHW need to perform are presented in the Guide’s Chapter 7: CHW Roles and Tasks. Once a thorough analysis of each task has been undertaken, the combination of skills that make up each task – whether psychomotor, communication, or decision-making – can be identified, performance protocols and training curricula developed, and the particular learning needed for any or all of these three skill areas provided. Since CHWs need to perform specific tasks well, competency training based on a combination of skills from all three areas, rather than traditional knowledge-based curricula, should be used for most CHW training.

While the three types of skills require different types of learning, all require active participation of the trainee in the learning experience if competency is to be achieved. The different types of learning required for each of these skills are presented in some detail with good practical examples for each from programs in several countries. Of particular note is that when dealing with community beliefs and norms, community-oriented rather than individual-oriented communication approaches are needed. The use of appropriate teaching aides – such as pictures, photographs or videos, depending on different local circumstances – is also well presented. Appropriate attitudes towards patients are a key part of CHW learning; supporting CHWs to adopt supportive attitudes is well covered.

The focus of CHW training is achieving competency in performing particular tasks. Therefore, only evaluation of student competency by observation of their performance of these tasks is a valid assessment of CHW performance. Usually this assessment is taken using a checklist of the essential components of that task. Mastery of skills is a gradual process that requires ongoing practice and assessment. Maintenance of skills at a particular standard of competency requires regular refresher training and assessment. Therefore, follow-up monitoring and refresher training are essential to maintain the competency of CHWs. Remembering most CHWs are adults, I would have liked to see more emphasis on ongoing CHW input into course content and peer evaluation.

The different components of CHW training are brought together in the final section of this chapter. This section focuses on fitting the training to the situation in which the CHW will work. Training is a necessary but not sufficient basis for successful CHW programs. Key factors which need to be considered in adopting a particular type of CHW training are discussed and the characteristics of an effective training program for CHWs are summarized.

 

 

 

 

 

 

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Dr Paul Freeman, DR PH (Hopkins), MBBS, MHP(Ed), MPH (TropH) is a physician with advanced training in tropical disease control and general public health, health personnel education, and health program management and evaluation. He has over three decades of experience in capacity building and the design, planning, implementation, monitoring and evaluation of primary health care, child survival and malaria control programs in developing countries and for deprived rural indigenous populations in developed countries. His research and report publications cover the evidence-base for community based primary health care, operational aspects and curricula covering the gamut of  community-based primary health care, malaria, tuberculosis and tobacco control and problem-based, scenario-based, elearning and traditional curricula. He has liaised at the national level with the Secretaries of Health in Papua New Guinea (PNG) and Fiji, a vice-minister in Vietnam and senior Health officials in Uganda, Nepal and Madagascar.  In 2010, he was appointed as a Clinical Assistant Professor at the University of Washington in the Department of Global Health and was elected Chair of the International Health Section of the American Public Health Association in 2012. He is also a long-standing Associate Member of the CORE Group

 

 

 

 

 

 

 

 

 

Photo Credit: AusAID/Creative Commons