An examination of the ability of community health workers to effectively conduct community-based screening for cardiovascular disease in South Africa, Guatemala, and Mexico
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BACKGROUND: This study explored training effectiveness for community health workers (CHWs) in a successful intervention in which they conducted primary screening for cardiovascular disease (CVD) in low resource settings. Implementation challenges related to scaling were explored with key informants. METHODS: A multiple methods assessment was conducted to: (1) quantitatively assess training effectiveness; (2) qualitatively capture the CHWs’ experience of training; (3) gather feedback from key stakeholders about factors anticipated to impact scaling the intervention to the population level. Change in knowledge levels at three different time points was determined through comparison of group means (ANOVA). The Consolidated Framework for Implementation Research (CFIR) guided the qualitative data collection and analyses, using nVIVO® and Atlas.ti® software, combined with manual coding. RESULTS: Training was effective at increasing content knowledge of CVD and the effect persisted for 3-6 months after completion of field work. CHWs felt empowered by the training and the acquisition of new skills but some expressed their reservations about written tests being used to accurately capture their capabilities. Some supervisors (nurses) perceived CHW training as a threat to their own professional standing while also acknowledging the value CHWs added to health services through their expert community knowledge and connections. CHWs remained frustrated by inadequate and irregular compensation, disrespect from formally trained health professionals, lack of career development pathways, and failure to account for the influence environmental factors – safety, extreme weather, and infrastructure – in workload planning. Key informants raised additional concerns about the negative impact of ineffective government communication regarding CHW programs and policies to communities and key actors in the health care system, including failure to consult key stakeholders, lack of clear role definitions, setting standards for training and performance evaluation, and lack of supervisory mechanisms. The issue of financing for CHW programs was not raised by key informants. CONCLUSIONS: Scaling strategies for successful interventions using CHWs need to be guided by well-designed implementation plans that include proactive, multi-level engagement with communities and health systems, and appropriate evaluation measures tied to health outcomes. Training effectiveness should be evaluated and linked to well-defined outcome measures in CHW’s programs that involve task-shifting.