A conversation with: Prof Rohina Joshi and Dr Azeb G Tesema, School of Population Health, University of New South Wales, Australia
Fiji faces a growing burden of diseases, especially non-communicable diseases (NCDs), compounded by a significant out-migration of nurses, which has impacted community health. These challenges have added pressure on community health workers (CHWs) who live in communities and are the key link between the community and the health system. Effective training is important for CHWs to strengthen their capacity to provide quality healthcare. While training policies are well-established in Fiji, there is lack of implementation and no training related to NCDs which are the leading causes of premature mortality in Fiji.
In 2023, we (University of New South Wales [UNSW] and The George Institute for Global Health, Australia) undertook a research study with the Fiji Ministry of Health and Medical Services to understand the role of CHWs in the prevention and control of NCDs (See Figure 1). The study, using the CHW-AIM toolkit, helped us understand the challenges faced by CHWs in delivering care to the communities. It also helped us to use human-centred design thinking to revise training for CHWs, aiming to address these challenges and strengthen primary health care.
Figure 1: Discussion about the role of CHWs in community health
Why use a human-centred design thinking process?
A human-centered design allows focusing on the people you’re designing for. It listens to their voices and ideas and allows participants to arrive at optimal solutions that meet the needs. Using design theory, such as IDEO’s 3 I’s model, is an innovative, human-centered approach that is context and need-specific to address current problems in both health education and health care. IDEO’s 3 I’s model involves three steps: inspiration, ideation, and implementation (Figure 2). We used this framework to design the CHW training program with CHWs, their supervisors and key stakeholders from various Ministries and agencies involved in the CHW program.
Figure 2: IDEO’s 3 I design framework (Source: https://designthinking.ideo.com/)
Inspiration: The CHW training and population health needs were the inspiration for the design phase. This phase included reviewing the burden of disease and health policies, conducting focus group discussions with CHWs, and interviewing CHW supervisors. This process helped us understand the context in which CHWs work, their role, key facilitating factors, and barriers in their functioning. CHWs voiced their concerns and aspirations which were collated and presented to the Ministry representatives.
Ideation: The ideation phase included discussions, a workshop, survey, and meetings with the key nursing and CHW divisional heads at the Ministry of Health and all the agencies involved with the CHW program. A draft WHO CHW training curricula was used as a framework to generate discussion about the capabilities, role, and responsibilities of CHWs. The workshop enabled various ideas to be shared, discussed, and built upon. Some ideas were dropped as being too ambitious while others required policy change. Staying focussed on the collaborative agenda helped the participants to converge their ideas to a common ground. Remembering the context in which CHWs work, what they can do in the community, and their capacity and ability to focus on prevention, helped us to stay focussed. Listening to one voice and one idea at a time helped the conversation to stay focussed and allowed us to listen to each other.
Figure 3: Workshop participants used sticky notes to bundle ideas into themes
IDEO’s 3 I’s model was key in framing the co-design of CHW training. The co-design workshop helped identify gaps in training content and implementation, along with recommendations shared by CHWs and their supervisors. The participants discussed their vision of a CHW’s role, listed competencies, and identified areas of alignment with the current CHW policy. While there were diverging ideas initially, discussions and use of context-specific examples helped in the convergence of ideas.
The interaction was facilitated based on six domains of competency: people-centeredness, decision-making, communication, collaboration, evidence, and personal conduct which was adapted to the local context. During the workshops and discussions, participants discussed and highlighted the need for CHW policy reform. All the stakeholders agreed to the competency framework and training content. The Ministry of Health accepted, appreciated and embraced the co-design process. . Including CHWs and their supervisors in identifying needs and devising implementation strategies helped define the problem and plan suitable interventions.
Implementation: Based on the feedback received, we are developing the training modules which will be reviewed by various Ministries integral to the CHW program. The training will be implemented in the second half of 2024. The training program will be implemented by the division of nursing through a train-the-trainer model. The entire implementation process will be evaluated through the consolidated framework for implementation research to understand the context of the implementation, what worked, what didn’t and why. We look forward to reporting the implementation of the CHW training in the future.