Training, supervision and performance of Community Health Workers in the delivery of ear and hearing care to 321 community members in rural Uganda.

OBJECTIVES: Community Health Workers are one way to address the shortage of ear and hearing care specialists in low-resource settings. However, there are few reports evaluating training and service delivery by Community Health Workers. DESIGN, SETTING AND PARTICIPANTS: We trained 13 Community Health Workers in primary ear and hearing care in Mukono District, Uganda. Community Health Workers attended a two-day training workshop and received remote supervision thereafter during service delivery in the community. An ear camp was held at the local health centre every two months, where a local ENT specialist could assess referred cases. MAIN OUTCOME MEASURES: Clinical and diagnostic skills and decision-making were assessed using an Objective Structured Clinical Examination, with scores recorded at baseline and six months. Service delivery was evaluated by analysing the following: (i) number of individuals evaluated; (ii) treatments delivered; (iii) cases referred for specialist opinion; (iv) proportion of appropriately referred cases; and (v) agreement between Community Health Worker and specialist diagnosis. RESULTS: Observed Structured Clinical Examination scores were high and stable for six months. 312 individuals were screened in the community by the Community Health Workers, with 298 classified as having an abnormality. Care was delivered in the community to 167 of these, and the remaining 131 referred to the ear camp. Diagnostic agreement was 39%, but 98% of referrals were deemed "appropriate" by the ENT specialist. 27 individuals self-presented to the ear camp without prior assessment by a Community Health Worker, and 97% of these were deemed appropriate. CONCLUSION: Trained Community Health Workers can play an important role in delivering ear and hearing services. Future work should look to explore this model in other contexts and/or compare it to other models of service delivery.

Exploring perceptions, barriers, and enablers for delivery of primary ear and hearing care by community health workers: a photovoice study in Mukono District, Uganda.

BACKGROUND: Hearing loss is a prevalent but neglected disease, especially in low- or middle-income countries. The role of Community Health Workers (CHWs) to deliver primary ear and hearing care has been explored in several studies from a technical standpoint, but understanding perceptions, barriers, and enablers of such an approach from the perspective of CHWs themselves through a health equity lens has been less well documented. METHODS: This qualitative study used photovoice to explore the views and experiences of CHWs in the Seeta Nazigo Parish of Mukono District in the delivery of ear and hearing care in the community. CHWs were trained in ear and hearing care, and provided with digital cameras to capture photographs related to their work in the community over the following 3 months. Individual interviews regarding the photographs were held at the end of each month, in addition to one focus group discussion. A community workshop was convened at the end of the study to display the photos. Thematic analysis of photographs was conducted using Braune and Clarkes six-step framework. We also used the data to explore potential roles for key stakeholders in primary ear and hearing care, and how photovoice may facilitate their engagement. RESULTS: 13 CHWs participated in the study. Several themes were generated from analysis. CHWs perceived a high burden of ear and hearing disorders in their community and recognised the role they could play in tackling that burden. Potential barriers identified included a lack of equipment, training, and supervision of CHWs; logistical, financial, or psychological barriers to community participation; and the widespread use of traditional medicine. CHWs identified roles for the government and NGO bodies to enable and support delivery of ear and hearing care in the community. The community workshop was a useful method to engage key stakeholders in this topic. CONCLUSIONS: Photovoice is a powerful method to capture issues affecting CHWs. Here it was used to identify a number of perceptions, barriers and enablers to the delivery of ear and hearing care. Our results may inform future strategy in the field of ear and hearing care, and the potential use of photovoice to enact sociocultural change.