The training and fieldwork experiences of community health workers conducting population-based, noninvasive screening for CVD in LMIC.

BACKGROUND: Cardiovascular disease (CVD) is on the rise in low- and middle-income countries and is proving difficult to combat due to the emphasis on improving outcomes in maternal and child health and infectious diseases against a backdrop of severe human resource and infrastructure constraints. Effective task-sharing from physicians or nurses to community health workers (CHW) to conduct population-based screening for persons at risk has the potential to mitigate the impact of CVD on vulnerable populations. CHW in Bangladesh, Guatemala, Mexico, and South Africa were trained to conduct noninvasive population-based screening for persons at high risk for CVD. OBJECTIVES: This study sought to quantitatively assess the performance of CHW during training and to qualitatively capture their training and fieldwork experiences while conducting noninvasive screening for CVD risk in their communities. METHODS: Written tests were used to assess CHW's acquisition of content knowledge during training, and focus group discussions were conducted to capture their training and fieldwork experiences. RESULTS: Training was effective at increasing the CHW's content knowledge of CVD, and this knowledge was largely retained up to 6 months after the completion of fieldwork. Common themes that need to be addressed when designing task-sharing with CHW in chronic diseases are identified, including language, respect, and compensation. The importance of having intimate knowledge of the community receiving services from design to implementation is underscored. CONCLUSIONS: Effective training for screening for CVD in community settings should have a strong didactic core that is supplemented with culture-specific adaptations in the delivery of instruction. The incorporation of expert and intimate knowledge of the communities themselves is critical, from the design to implementation phases of training. Challenges such as role definition, defining career paths, and providing adequate remuneration must be addressed.

Training and supervision of community health workers conducting population-based, noninvasive screening for CVD in LMIC: implications for scaling up.

BACKGROUND: Community health workers (CHW) can screen for cardiovascular disease risk as well as health professionals using a noninvasive screening tool. However, this demonstrated success does not guarantee effective scaling of the intervention to a population level. OBJECTIVES: This study sought to report lessons learned from supervisors' experiences monitoring CHW and perceptions of other stakeholders regarding features for successful scaling of interventions that incorporate task-sharing with CHW. METHODS: We conducted a qualitative analysis of in-depth interviews to explore stakeholder perceptions. Data was collected through interviews of 36 supervisors and administrators at nongovernmental organizations contracted to deliver and manage primary care services using CHW, directors, and staff at the government health care clinics, and officials from the departments of health responsible for the implementation of health policy. RESULTS: CHW are recognized for their value in offsetting severe human resource shortages and for their expert community knowledge. There is a lack of clear definitions for roles, expectations, and career paths for CHW. Formal evaluation and supervisory systems are highly desirable but nonexistent or poorly implemented, creating a critical deficit for effective implementation of programs using task-sharing. There is acknowledgment of environmental challenges (e.g., safety) and systemic challenges (e.g., respect from trained health professionals) that hamper the effectiveness of CHW. The government-community relationships presumed to form the basis of redesigned health care services have to be supported more explicitly and consistently on both sides in order to increase the acceptability of CHW and their effectiveness. CONCLUSIONS: The criteria critical for successful scaling of CHW-led screening are consistent with evidence for scaling-up communicable disease programs. Policy makers have to commit appropriate levels of resources and political will to ensure successful scaling of this intervention.