Module 3: Training Community Health Workers

Based on a literature review of 44 articles concerning community health worker (CHW) selection and training in the US, CHW training can last from 5 hours to 6 months, depending on the health issue(s) and the complexity of the CHW’s role.  In this training, the teaching methods used include role playing, didactic sessions, and mentored one-on-one learning.  The three broad areas covered in the sessions are skills-based knowledge, relevant health knowledge, and research implementation knowledge. A majority of the time is spent on skills-based training, including clinical skills, interpersonal skills, and managerial skills.  While the training of healthcare professionals is largely regulated and homogenized, CHW training varies from program to program.  Due to this heterogeneity, the quality of training programs and the effectiveness of CHWs differ.  Only a few states, including Texas and Ohio, have mandatory certification programs for CHWs.  O’Brien et al. (2009) state that the lack of standardization inhibits the expansion and development of the CHW workforce.(1)

Case Study: The Mobilization of Community Health Workers in Unite For Sight's Global Health Delivery Programs

To further build its local outreach capacity, Unite For Sight sponsors and trains local community health workers who enable Unite For Sight to reach the poorest, most vulnerable patients – many of whom may not respond to larger publicity announcements about eye care services. While Unite For Sight's current outreach teams provide eye care to approximately 150 patients in each community per outreach day, the most vulnerable patients may not attend the monthly eye care services. Many barriers continue to exist, including lack of education and awareness, and fear. Community eye health workers help to eliminate these patient barriers.

Community Eye Health Worker Training Model

Objectives of community health workers: Community health workers have logistical, administrative, and eye health duties. Logistical tasks include coordinating screening schedules, home visitations, and keeping patients informed of subsequent visits. Health workers will also arrange screening sites for the outreach team before arrival, inform community members about the time and location, and arrange transportation for surgeries and post-operative care. Administrative duties include keeping basic records of which communities were visited, and which patients were seen on what dates.  Community health workers must be able to identify eye conditions such as cataracts so that those with eye conditions can be examined and diagnosed by the outreach team's ophthalmic nurses. The community health workers also give appropriate basic hygiene education. Further, they can assist the eye clinic’s outreach team during their monthly visits to the village.

Eye anatomy, physiology, diseases and treatments: Unite For Sight’s Medical Director in Ghana, Dr. James Clarke, begins his training of CHWs by teaching the health worker about the basic anatomy of the eye, using the camera analogy to illustrate the function of the eye. Health workers then learn to recognize common eye diseases, including conjunctivitis, cataracts, and pterygium. Dr. Clarke also discusses refractive error, as well as other afflictions that can affect the eye such as diabetes, hypertension, anemia, sickle cell disease and trauma. Possible treatments for all conditions are explained, though it is emphasized that not all blindness is curable, and only the eye doctors can recommend or prescribe treatment. After receiving this basic health education, CHWs observe Dr. Clarke perform surgery; this provides the community eye health workers with the experience to inform other community members about cataract surgery and its procedures.

Ethics and professionalism: Before they can begin to work in their local communities, health workers learn about best practices in public health and ethical volunteerism.

Case Study: CHW Program in Senegal

In a study conducted in Senegal on the effectiveness of a CHW training program, it was determined that while CHWs retain most of the material learned during training, several CHWs expressed problems with the training program.  The training program included the following components: selection of appropriate individuals, communication techniques for health education, basic nursing concepts (person, health, and environment), examination of a sick person, treatment of endemic diseases (including malaria and Acute Respiratory Infections), basic life support skills, hygiene (clean water sources), and maternity and pediatric health (menstruation, labor and birth, neonatal care, vaccinations, common pediatric diseases).  The training occurred in 2.5 hour sessions for five days per week for four weeks.  At the end, the CHWs were tested in clinical situations.(2)

In order to improve the results of the CHW training, the study determined that a CHW should be able to work at an operating healthcare center near the community, should participate in an intensive internship with a nurse to learn about healthcare delivery, should be issued a certificate after successfully completing the training to verify the skills learned, and should participate in public events with other medical personnel to advertise their role.  Although the training program is valid and adequate on paper, in practice, several components are needed to make it successful. For example, the study determined that training program barriers included “the lack of instructors, the lack of healthcare structures in which to carry out internships, the lack of mobility of those designated to be CHWs due to the poor transport system, poverty, the fact that most of them have to run families, and the absence of a national economic plan for the training of the CHWs.”  As stated in the “Quality Program Implementation” Module, CHWs need support from local healthcare professionals, as well as a system that enables patient referrals.  The practical internship is also of utmost importance since it puts theoretical medical training into practice under the supervision of an instructor, and it gives the CHW more confidence in performing medical practices.  In addition, interviews with the villagers revealed that they needed to have more input in the design and implementation of the training program.  The village members perceived the training to benefit primarily the CHW and his or her family rather than the village. This conception was mostly due to the fact that the villagers do not have much confidence in Western medicine.  Thus, the village members, whom the CHWs are supposed to help, must be involved in the training process.  Meetings with the community can not only improve the delivery of care, but can also serve as a means to publicize the role of the CHW. Training sessions must be evaluated and adapted based on the needs of the community and the CHWs in order for the programs to affect positive outcomes for the target community.(3)

Case Study: CHW Training in the United States

A 2007 survey of CHW training and certification programs in the United States revealed that program requirements and training standards varied widely among states.  Some states offered state-run certification programs, while others provided training through community colleges or other agencies.  CHW certification was state-legislated or required by the state in Alaska, Indiana, Ohio, and Texas; training was required in North Carolina and Nevada and was supported by the state, financially or otherwise, in Arizona, California, Connecticut, Kentucky, Massachusetts, New Mexico, Virginia, Florida, and West Virginia.  CHW training programs received no state support in Oregon or Mississippi.  States also differed in the types of certification programs offered.  For instance, Alaska and Indiana certified highly skilled CHW workers, while Texas and Ohio only offered “generalist” CHW certification programs.(4)  Many public health scholars recommend standardization of training and certification policies within and across states in order to legitimize the CHW profession, and improve quality of care.(5) 

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(1) O’Brien, Matthew, Allison P. Squires, Rebecca A. Bixby, Steven C. Larson. “Role Development of Community Health Workers: An Examination of Selection and Training Processes in the Intervention Literature.”  American Journal of Preventive Medicine 37(2009): 262-269.

(2) Sarli, Leopoldo, Emile Enongene, Ketty Bulgarelli, Annavittoria Sarli, Alessandra Renda, Giuliano Sansebastiano, Moustapha Diouff. “Training program for community health workers in remote areas in Senegal. First Experience.” Acta Biomed 81(2010): 54-62.

(3) Ibid.

(4) Kash, B.A., May, M.L., Tai-Seale, M. (2007). Community health worker training and certification programs in the United States: findings from a national survey. Health Policy, 80(1): 32-42.

(5) Balcazar, H., Rosenthal, E. L., Brownstein, J.N., Rush, C.H., Matos, S., Hernandez, L. (2011).  Community health workers can be a public health force for change in the United States: three actions for a new paradigm.  American Journal of Public Health, 101(12): 2199-203.