Nurses and CHWs Working Together: An expert panel hosted this week June 25-29

By Maggie Sullivan Moderator | 23 Jun, 2012

Expert Panel: Nurses and CHWs Working Together

Nurses and community health workers (CHWs) provide the vast majority of health care services around the world. However, training/education, scope of practice, compensation (to name only a few points) vary widely amongst and between both nurses and CHWs. There is also very little formally known about their working relationships, best practices or effects on patient outcomes. In November 2011, GHDonline members in the nursing community expressed a significant amount of interest in the topic. We hope that with your participation, this week-long expert panel broadens, informs and continues this important conversation. Please join in, ask questions, make comments, share resources and post some of your own responses to the questions.

Jessica Aguilera-Steinert, LICSW, Director of Training and Technical Assistance at the PACT Project
Heidi Behforouz, MD, Founder, Executive Director and Medical Director of the PACT Project
Albany Chavarria, Health Promoter and Program Assistant for Teach for Health
Sarah Nunn, RN, MSN, Teach for Health co-founder, Director of Nicaragua Programs
Carolina Lopez Ochoa, Health Promoter and Program Coordinator for Teach for Health

During this Expert Panel, panelists will address the following questions:

* What successes and challenges have you seen in collaborations between nurses and CHWs?
* From your experience, how can CHWs and nurses improve their partnerships and work better together?
* How can nurses help support/empower CHWs to improve patient outcomes?
* What qualities/skills make CHWs successful in their work? And how does this complement (or not) the roles of nurses?

Please share your own thoughts on these important topics and feel free to ask additional questions of our panelists - we look forward to a rich discussion!



Sheila Davis Moderator Emeritus Replied at 2:58 PM, 24 Jun 2012

This is such an important topic. I am so fortunate to be in Malawi right now and have seen the impact of community health workers and nurses working together to provide health care in this very rural Neno district.

Marie Connelly Replied at 5:13 PM, 25 Jun 2012

Thank you all for joining us for this important discussion! Please allow me to introduce a few of our panelists in the following posts.

We invite our panelists and all members of the GHDonline nursing community to share their thoughts on the following questions:

* What successes and challenges have you seen in collaborations between nurses and CHWs?
* From your experience, how can CHWs and nurses improve their partnerships and work better together?
* How can nurses help support/empower CHWs to improve patient outcomes?
* What qualities/skills make CHWs successful in their work? And how does this complement (or not) the roles of nurses?

Marie Connelly Replied at 5:14 PM, 25 Jun 2012

HEIDI L. BEHFOROUZ, M.D. is an attending physician at the Brigham and Women’s Hospital, an Assistant Professor at Harvard Medical School, and a graduate of the Open Society Institute’s Medicine as a Profession physician advocacy fellowship. A graduate of Harvard Medical School , Dr. Behforouz has focused her career on the health issues of the urban indigent and practices primary care in the Jen Center at Brigham and Women’s Hospital.

She is currently Founder and Executive Director of the Prevention and Access to Care and Treatment (PACT) project in Boston, Massachusetts. Sponsored by Partners In Health and the Division of Global Health Equity at the Brigham and Women’s Hospital, this program employs community health workers to advocate for the health and wellbeing of inner city residents infected with or at risk for HIV and other chronic diseases.

Dr. Behforouz is committed to the transformation of primary care to better serve the needs of the most vulnerable patients in our system and is hopeful that the integration of community health workers into patient-centered medical homes can help reduce disparities and improve outcomes among this population.

Marie Connelly Replied at 5:15 PM, 25 Jun 2012

JESSICA AGUILERA-STEINERT began her work in community health in Honduras as a Peace Corps volunteer. After Social Work school, she worked at the Brigham and Southern JP health Center as a clinical social worker and a domestic violence specialist. She has worked in public health since then and landed at PACT in 2003. Jessica's initial role at PACT was the Program Manager and Clinical Supervisor of the HIV Health Promotion and DOT Programs and two years ago she moved over to a leading the training and technical assistance institute. Jessica's charge is to help health centers and health systems enhance their care management programs by incorporating skilled community health workers and providing training to the CHWs and their team members to make their programs successful.

Jessica has trained and supported over 600 CHWs, their managers and clinicians in the PACT model.

Marie Connelly Replied at 5:16 PM, 25 Jun 2012

SARAH NUNN, RN, MSN is a co-founder of Teach for Health and the Director of Nicaragua Programs. She completed her MSN at the University of California – San Francisco in 2010, specializing in Advanced Community Health and International Nursing. Sarah works as a clinical nurse at Santa Monica UCLA Medical Center and Orthopaedic Hospital when stateside. She has done a variety of volunteer work in global and community health, including participating in outreach programs within Milwaukee’s Hmong, African American and Latino communities, organizing cultural programming within the UW-Milwalukee College of Nursing, and acting as a spokesperson and presenter at a city-wide Health Fair for the Racine Latino community. Sarah is particularly interested in community-driven public health work and highly values collaboration, open-mindedness and mutual learning in public health. She was recently awarded a Fulbright fellowship to expand the TFH Nicaragua program and has moved to San Ramon Nicaragua to supervise all Teach for Health field activities.

Heidi Behforouz, MD Replied at 5:22 PM, 25 Jun 2012

Hi everyone!
We at PACT have had a great deal of experience helping integrate CHWs into high risk care management teams in the US. Making sure that nurses (who are often the existing care managers) feel confident/comfortable with task sharing with newly minted CHWs is critical. In addition, the nurses are often placed into managerial positions and need to be given the training/support and time to accomodate and supervise the CHWs. As such, in addition to developing training for CHWs to do high risk care management, we train their managers (often nurses) how to work with CHWs and provide both programmatic and clinical supervision. We also work with the leadership to make sure that the nurses have protected time to manage/teach.

Issues that have come up for the nurses via-a-vis working with CHWs include:
(Please note...these are actual things that have come up...we don't endorse them as generalizable sentiments)
1. Nurses feeling somewhat threatened by the CHWs and unsure of how to share tasks with them most effectively without obviating their personal roles/responsibilities
2. Nurses feeling unsure about what tasks they should relegate to CHWs and what tasks they should retain for themselves
3. Nurses feeling that their licenses may be on the line if they delegate certain monitoring or education functions to the unlicensed CHWs
4. Nurses feeling unsure as to how to support CHWs to be professional employees when CHWs have their own life challenges and struggles that can make it difficult for them to perform effectively
5. Nurses feeling unsure about how to engage with the more psychosocial aspects of patient care in concert with the CHWs and social workers when they are more heavily trained in the biomedical approach
6. Nurses feeling that they need training in providing supervision and training to CHWs as well as protected time to do this work well

Issues that have come up with the CHWs with whom we have worked vis-a vis nurses (in addition to being reciprocally affected as above):
1. CHWs feeling that nurses only give them the "undesirable tasks" that no one else would want to do
2. CHWs feeling not included in formal care plan design or delivery
3. CHWs feeling restrained in terms of what they are allowed to do given concern for liability (if they are working under nurse direction)
4. CHWs feeling generally underappreciated and unlegitimized when working in traditional care teams

Happy to engage in further conversation on this important topic.
Heidi Behforouz

Sarah Nunn Replied at 7:55 PM, 25 Jun 2012

JOSE ALBANY CHAVARRIA PICADO is one of two Teach for Health program coordinators for the 2011-2012 year. Albany is in his second year of university studies at the Universidad Popular de Nicaragua. His field of study is business administration. He also volunteers with World Vision, a community development organization that works in 10 of the departments of Matagalpa, As a promoter, he wants to learn more and share what he learns with others from his community. He is interested in first aid, family planning, venereal diseases and respiratory illness, and would like to use what he learns as a health promoter to improve the health of his community.

Sarah Nunn Replied at 8:00 PM, 25 Jun 2012

RUTH CAROLINA LOPEZ OCHOA is one of two Teach for Health program coordinators for the 2011-2012 year. Carolina is a very active and dedicated health promoter, both in her community and during workshops with promoters from other communities. She is one of six promoters who volunteered to be part of the recruitment committee in 2011. This group developed the strategy used by the program to recruit 40 new promoters, including promoters from 5 vulnerable communities not previously involved in the program. Almost all of these new promoters were elected by their communities during recruitment visits which were arranged and facilitated by the recruitment team. As program coordinator, she is excited to help strengthen and develop the promoter network and to take an active role in the development and facilitation of our July workshops with the health promoters.

Bistra Zheleva Replied at 10:41 PM, 25 Jun 2012

I am not sure if this is open for discussion but I have couple of questions specifically related to CHW.
1) This is a very basic question, so forgive my ignorance on the topic - How does one become a CHW? They seem to be pretty important in many low-resource countries but how do they get this role?
2) I work for an NGO that focuses on building capacity in pediatric cardiac care. One of the issues we face is the huge number of children with undiagnosed heart disease, congenital or acquired (rheumatic heart disease). We have begun working with pediatricians to provide basic training on early detection, as well as with nurses to ensure follow up, but is there a role for CHW in that chain? How helpful can they be with more complex clinical diagnoses as often they are the primary care provider?
Would love to hear different perspectives on this!

Maggie Sullivan Moderator Replied at 11:09 PM, 25 Jun 2012

Yes, this is very much open for discussion among all of us. The panelists will be addressing a few opening questions, but the goal of the panel is to generate a large number of questions, responses and comments from everyone. And what might seem like a very basic question (for example, how one becomes a CHW) is often more complicated than one would think. So thank you for asking what, I'm sure, many are wondering. I will let the experts respond to both of your great questions. Thank you for asking!

Elna Osso, RN MPH Replied at 11:12 PM, 25 Jun 2012

Thank you for the opportunity to write to this expert panel on topics related to the work of CHW. I would like to ask the panel their opinions regarding compensation for CHW. I believe CHWs work has great value, often determines the sucess of proyects, yet I have encountered, both working in rural and urban settings that monetary compensation ignites much disagreement among local leadership and program administration.

Local oficials claim they can not allow to start something that can not be generalized to other workers or that it is no sutainable, others say that CHW is a service that had to be done on volunteer bases for their community. When I have poised the question directly to CHW , usually women in the countries where I have worked, most often I hear they would like, as most of us do, to receive payement for their work. Some have said food vouchers are welcomed and at times preferable to cash because they fear their husbands would not have the same priorities they do (almost always their children) .

Most resently, while volunteering with a small Canadian NGO in the high Andes villages in Peru where Quechua speaking women, selected by their own villages had worked with a nurse practitioner and peruvian nurses to provide health aid in their community and serve a liason with the health center and support the weekly primary care visit from the nurses. The local authorities made it very clear monetary compensation was not to be permitted. Much agony went into deciding what to do. Our short time solution was to provide vouchers to three types of stores, food, clothing and construction materials (3 priorities of the women) and the CHW could choose each month where they wanted their voucher. Afterall we could not afford to stop the work until reaching an agreement nor loose the funding from the grant. But we have not lost sight of the main goal, to advocate at all levels for fair policies to more just conditions.

Sarah Nunn Replied at 11:56 PM, 25 Jun 2012

Question #1: What successes and challenges have you seen in collaborations between nurses and CHWs?

Nicaragua is a prime example of a country that relies heavily on CHWs to provide care to its rural populations. However, Nicaragua’s use of CHWs is different from what I have seen in other countries. The Ministry of Health does appoint CHWs who report directly to Ministry of Health doctors, nurses, and other staff. However, there is also an expansive and diversified network of volunteer health promoters working in rural settings throughout the country. This network is made up of men and women from rural communities who receive trainings from a variety of national and international NGOs, many of which target specific public health issues such as prevention of sexually transmitted disease, family planning, and gender based violence. Promoters from these various networks collaborate with government appointed doctors and nurses, as well as with a variety of other public health and community development organizations.

Teach for Health provides capacity building and community health related trainings to an expanding network of roughly 65 active community health promoters from 21 different communities within the municipalities of San Ramon and Matagalpa. Activities performed by these promoters include first aid response, referrals to the health center and/or activation of the emergency response system when necessary, home visits for targeted health education or data collection, and health education presentations in schools and community centers. Beyond these basic CHW skills, health promoters also learn how to facilitate community diagnoses activities during which pertinent community health issues are identified and prioritized, as well as how to use this information to develop community projects and seek out appropriate support from both governmental and non-governmental sources.

The somewhat overwhelming variety of CHWs and health promotion organizations/activities in Nicaragua can be challenging. It can be difficult for communities, governmental health workers, CHWs and NGOs to fully understand the resources that are available to them and maintain effective communication and working relationships. However, this variety can also lead to interesting and fruitful collaborations when appropriate emphasis is placed on resource mapping, linkages and community empowerment. Roughly 85% of the promoters who participate in Teach for Health trainings have forged links with other organizations, either to support the project/s of those organizations or to request support for their own projects. Roughly 20% of promoters participating in Teach for Health are also government appointed CHWs, known here as ‘brigadistas de salud’. Approximately 75% have supported Ministry of Health doctors and nurses in activities such as canine vaccination campaigns, vaccination campaigns for young children and the general public, the treating of drinking wells, and collection of data for the government census and community diagnoses. As most health promoters are volunteers who live in the same rural communities they support, they are an excellent resource in determining and addressing community specific health issues. Their presence provides much needed support to rural communities who are not adequately reached by the Ministry of Health due to funding constraints, access and other issues. They are also a link the Ministry of Health can use to gather data, secure support for health outreach activities, and implement a variety of interventions in communities that, otherwise, would not be as accessible or supported.

Carolina Lopez Ochoa Replied at 11:58 PM, 25 Jun 2012

Pregunta #1: ¿Cuales son los éxitos y las dificultades que han notado el la colaboración entre los enfermeros y los promotores de salud?

Los promotores de salud han sido mejor capacitado, tienen mayor conocimiento acerca de temas de salud, los promotores han identificado problemas de salud en la comunidad y han buscado la manera de solucionarlos, tenemos promotores en las comunidades mas vulnerables estas comunidades han mejorado mucho con los consejos y charlas de los promotores de salud, también se ha hecho jornadas de limpieza en las comunidades y hemos logrado obtener una comunidad un poco mas limpia. Hemos trabajado en colaboración con enfermeros y hemos obtenido dichos avances.
Question 1: What successes and challenges have you seen in collaborations between nurses and CHWs?

Health promoters are better trained and have more knowledge about health topics. Promoters identify community health problems and search for ways to solve them. We have promoters in the most vulnerable communities and these communities have made many improvements based on the suggestions and health presentations provided by the health promoters. Community clean-ups have also been organized in many communities and we’ve managed to create cleaner communities. We work in collaboration with nurses and have made significant improvements.

Jose Albany Chavarria Picado Replied at 12:00 AM, 26 Jun 2012

Pregunta #1: ¿Cuales son los éxitos y las dificultades que han notado el la colaboración entre los enfermeros y los promotores de salud?

Unos de los éxitos que se ha logrado es que los promotores es que han podido encontrar los problemas de salud que hay en sus comunidades y de esta forma poder ayudar a las personas de la comunidad de diferentes maneras y tratar de resolverlos en sus comunidades y compartirlos con los promotores de otras comunidades para que ellos también sepan como ayudar en sus comunidades. Una de las dificultades es que los promotores de salud viven en comunidades donde no cuentan con una vía de comunicación donde nosotros podamos contactarlos para ver en que necesitan apoyo ya que algunas comunidades son muy lejanas y lo que podemos hacer es visitarlos una ves cada tres meces para apoyarles en su trabajo.
Question #1: What successes and challenges have you seen in collaborations between nurses and CHWs?

One of the successes we have achieved is that the promoters have been able to identify health problems present in the communities and in this way have been able to help community members in different ways. We try to solve community problems and share what we learn with promoters from other communities so that they also know how to help their communities. One of the difficulties is that the health promoters live in communities that do not have adequate communication systems. This makes it difficult for us to contact them to see if they need support, since some of the communities are very far away. In this case, we end up needing to visit the communities every 3 months to support them in their work.

Jose Albany Chavarria Picado Replied at 3:33 PM, 26 Jun 2012

¿Como se convierte uno en chw?

En Nicaragua, uno se convierte en un voluntario de salud comunitaria cuando
siente interés por ese rol y cuando hay una organización dispuesta a
trabajar en tu comunidad y proveer la capacticación. Muchas veces, es
necesario ser elegido por la comunidad ya es en la comunidad donde vas a
ejercer tu labor como trabajador de la salud comunitaria y es la misma
comunidad quien te va apoyar en las actividades que vas a ejecutar para el
bienestar de la comunidad. Siempre recordando que un trabajo voluntario.
Muchas organizaciones en Nicaragua que trabajan en el tema de la salud y no
todas se enfocan en la misma meta ya que trabajan de distintas formas. Por
ejemplo yo como promotor de salud de TEACH FOR HEALTH puedo ayudar en la
salud de mi comunidad mas en prevenir las enfermedades brindando charlas,
jornadas de limpiezas, apoyando en las jornadas de vacunación entre otras
actividades y brindar primeros auxilios en casos de emergencias. Y no
podemos recetar o dar medicamentos por que no estamos capacitados para eso
y podemos hacer mas daño dando medicamentos a las personas por que no somos
médicos. Al contrario de los brigadistas de salud que son de parte del
ministerio de salud que si pueden dar algunos medicamentos por ejemplo el
medicamento para la malaria y el dengue entre otras.

Además, los brigadistas de salud son elegidos de una forma donde la
comunidad no los elige, sino que es algo voluntario de ellos. Además, no
son capacitados en todos los temas de salud ya que el MINSA no cuenta con
muchos recursos para capacitar a estas brigadistas. Esto puede traer
problemas al momento de tratar alguna emergencia o algún caso de enfermedad
en la comunidad.



How does one become a CHW?

In Nicaragua, a person can become a community health volunteer if he or she
is interested in the role and has access to an organization willing to work
with the community and provide the training. Often, the person must then be
elected by their community members since it is in their same community that
they will be working as a community health volunteers and it is that same
community that will support the volunteer in their activities for the good
of the community. It is important to remember that this is a volunteer
position. There are many public health organizations in Nicaragua and not
all of them focus on the same goals, rather they work in different areas.
For example, as a health promoter with Teach for Health, I can help my
community in preventing certain illnesses by providing health education,
community cleanliness campaigns, helping with vaccination campaigns and
other activities, and providing first aid in case of an emergency. We
cannot, however, prescribe medications because we are not trained in this
and may end up doing more harm than good by giving people medications since
we are not doctors. On the other hand, ‘brigadistas de salud’ who are part
of the Ministry of Health can give some medications such as those to
prevent/treat malaria and dengue, among others.

‘Brigadistas de Salud’ are usually not elected by the community. Rather
they volunteer themselves for the position. They do not receive thorough
training before beginning work as brigadistas because the Ministry of
Health does not have the resources to adequately train these ‘brigadistas.’
This can cause problems when they are needed to respond to an emergency or
illness in the community.

Heidi Behforouz, MD Replied at 6:38 PM, 26 Jun 2012

1. From your experience, how can CHWs and nurses improve their partnerships and work better together?
A few ideas:
a. Clear understanding of each other's roles/responsibilites
b. Clear understanding of each other's capacities through cross training and group case discussions
c. Good management from above that fosters mutual respect and team-based work as well as good working conditions/fair pay/time for quality improvement initiatives that involve all members of the team/ and active problem solving if team dynamics or function deteriorates

2. How can nurses help support/empower CHWs to improve patient outcomes?
Nurses can participate in training/supervision of CHWs...
At PACT we've developed training syllabi for supervisors and trainers
Nurses can also involve CHWs in building and delivering care plans for patients
Nurses can involve CHWs in QI initiatives

3. What compensation strategies have you found successful when working with CHWs (or, how have you advocated for CHW compensation, since that seems to be part of the challenge Elna's organization is facing at the moment)
At PACT, we believe that CHWs are critical health care professionals that should be recompensed just like any other member of the health care team. Their work is hard and requires a great deal of skill and sacrifice...and paying them a living wage is important to validating their work, enabling them to dedicate themselves to their work and take care of their families. In addition, by investing in CHWs, you are investing in the community. CHWs are often community leaders who already give of themselves to their friends/neighbors. By financing them, you empower the community.

We also believe that CHWs are more cost effective than other more highly paid/more highly licensed providers. A nurse who might only be able to manage 50 complex patients may be able to manage 100 complex patients with the addition of a CHW...and do so in a more effective way that is more satisfying to both providers and patients.

4. Perhaps you could share some thoughts today about how PACT identifies members of the community to become CHWs?
We post job descriptions in the community at local clinics, service organizations, churches, barber shops, etc. We also post jobs in local newspapers and advertise at job fairs. We also utilize existing CHWs and patients to spread the word among their network. We have learned that some of our best CHWs don't necessarily have the longest resumes. Through a process of 3 interviews (that include role plays, presentation of case scenarios, and group discussion) we find people who have the inherent qualities we seek: compassion, passion, intelligence, common sense, communication and relational prowess etc. The rest we can teach!

Jose Albany Chavarria Picado Replied at 6:39 PM, 26 Jun 2012

Pregunta #2:

A partir de su experiencia, ¿cómo pueden los CHW y enfermeras a mejorar sus
alianzas y trabajar mejor juntos?

Una de las sugerencias que yo haría para trabajar mejor juntos seria la
comunicación entre las enfermaras y los CHW para poder saber lo que están
haciendo cada uno, en sus campos de trabajos para coordinar las actividades
en las cuales están involucrados ambas partes y de esta forma llegar a
cumplir las metas que se han propuesto ejecutar. Cuando tu coordinas con
tus contraparte puedes llevar una organización de tu tiempo principalmente
y de las actividades. Porqué a través de esto puedes lograr que ambos se
pongan de acuerdo y de esta forma evitarse malos ratos y contratiempos con
tus colaboradores y poder realizar los labores propuestos por las
enfermeras y los CHW.

También es bueno determinar los objetivos en los cuales están enfocados en
cumplir ya sea como ASC o como enfermero ya que estos se pueden relacionar
con el trabajo de ambos. Esto nos va a proporcionar un buen ambiente de
trabajo que viene ayudar con nuestro propio bienestar tomando en cuenta el
respeto mutuo y el compañerismo para incentivar y cumplir conde objetivos y
metas propuestas.


translation for question 2:

>From your experience, how can CHWs and nurses improve their partnerships
and work better together?

One thing I would suggest in order to work better together would be
improving communication between nurses and CHWs so that each knows what the
others are doing/working on. This will allow better coordination of
activities that involve both parties and in this way we will be better able
to achieve the goals we set for our work. When you coordinate with your
counterparts you are better able to organize your own schedule as well as
joint activities, because by doing this you can make sure that both parties
are in agreement and avoid misunderstandings and scheduling conflicts. In
this way, you will be able to carry out activities proposed by both CHWs
and Ministry of Health nurses.

It is also good to identify outcomes desired by both CHWs and nurses since
many are related to the work of both groups. This allows us a working
environment that can help us [community members] improve our own
well-being, taking mutual respect and teamwork into account in order to
achieve proposed goals.

Carolina Lopez Ochoa Replied at 7:44 PM, 26 Jun 2012

Para responder a la preguntar de Elna Osso acerca de que si los
trabajadores de salud comunitaria deberían recibir pago/In response to the
question by Elna Osso about whether or not CHWs should be paid:

Pienso que si deberían recibir una ayuda, ya que el trabajo que ellos
ejercen beneficia mucho a las personas de dichas comunidades, ya que ellos
son personas que se interesan por el bienestar de las comunidades. Quizás
ellos deberían pedir la ayuda ala organización ala cual pertenecen y la
organización debería ser justo con los que están trabajando verdaderamente,
ya que algunas personas no tienen recursos económicos para mantener a su
familia y tienen el amor por servir a la comunidad pienso que si la
organización no lo va a permitir tendrían que seguir intentando hasta
llegar a un acuerdo, porque es de gran valor y no se puede dejar caer el
trabajo, a lo mejor esto traería problemas pero no se debe perder el
objetivo. Creo que de esta manera un brigadista de salud y un promotor se
sentirían mas comprometidos con su trabajo comunitario.

Algunos problemas que he visto en mi país es que algunos brigadistas de
salud y promotores de salud han fracasado con su comunidad debido a que no
reciben un salario, quizás en el momento que ellos fueron propuestos para
ejercer dichos cargos estaban animados, pero con el transcurso del tiempo
se fueron dando cuenta que el trabajo es bastante recargado y se

Otro problema es que algunos promotores se sienten bastante frustrados
porque las personas ni siquiera agradecen el trabajo que ellos hacen, otras
personas de las mismas comunidades no colaboran mas bien critican a los
promotores, quizás ellos trabajan por amor a su comunidad, pero algunas
personas no le toman importancia a su trabajo, entonces ellos se desaniman



In response to the question by Elna Osso about whether or not CHWs should
be paid:

Yes, I think CHWs should receive some financial support, because their work
benefits the community members they support and because they are people who
take an interest in the well-being of their communities. Perhaps the CHWs
should ask for this support from the organizations they belong to and these
organizations should be fair to those who really are working, because some
people do not have the resources to support their families and are
dedicated to serving their communities. I think that if the organization
does not want to allow it, the CHWs should continue advocating until an
agreement is reached, because the work they do is very valuable and it
would not be good to let the work disintegrate. Maybe this might cause
problems, but we must always think of our goals. In this way ‘brigadistas
de salud’ and health promoters would feel more accountable for their work.

Some problems I have seen in my country are that ‘brigadistas de salud’ and
health promoters sometimes fail their communities because they don’t
receive a salary. Maybe when they were elected to fill the role they were
enthusiastic, but with time they realized that the job is quite involved
and they lost motivation.

Another problem is that some of the promoters feel frustrated because
people in their communities do not appreciate the job they do. Some people
from their same communities don’t collaborate with promoters. Rather, they
criticize them. For a promoter who is working out of love for their
community, it discourages them to know that some people don’t think their
work is important.

Carolina Lopez Ochoa Replied at 7:46 PM, 26 Jun 2012

¿Como pueden los CHWs y los enfermeros mejorar sus alianzas y trabajar
mejor juntos?/ From your experience, how can CHWs and nurses improve their
partnerships and work better together?

Se puede trabajar junto teniendo en cuenta la comunicación entre ambos
grupos. Quizás podemos trabajar mejor tomando en cuenta las opiniones de
ambos grupos sus comentarios, ideas, sugerencias etc. y así se puede
organizar un buen trabajo entre ambos grupos. Tendremos mejor coordinación.

Ayudándonos. Si un grupo tiene problemas y son muy difíciles de
resolverlos, se pueden ayudar entre ambos para buscarle una solución, y así
no fracasar. No dejar que los obstáculos entre ambos grupos nos
perjudiquen, si no que los podamos vencer.



>From your experience, how can CHWs and nurses improve their partnerships
and work better together?

By working together and taking appropriate communication between both
groups into account. We could also work better by taking the opinions,
ideas and comments of both groups into account so that we can develop
better work. We should coordinate better.

By helping each other. If one group has problems they are having trouble
solving, the two groups [CHWs and Ministry of Health nurses/doctors] can
work together to find a solution and in this way avoid failure. We also
must not let challenges and obstacles between CHWs and nurses/Ministry of
Health workers stop us in our work. We can resolve our differences

Sarah Nunn Replied at 9:28 PM, 26 Jun 2012

In response to the question by Elna Osso about whether or not CHWs should
be paid:

I agree with PACT that when integrated appropriately, CHWs can be an
invaluable part of the healthcare team and should be compensated for their
work like any other health worker. Unfortunately, that is largely not the
case in Nicaragua. Government appointed CHWs (or ‘brigadistas de salud’)
are completely voluntary and their training is nowhere near standardized.
Although brigadistas do receive reimbursement for transportation to and
from trainings and activities such as vaccination campaigns, they do not
receive a salary. Community educators employed through the Ministry of
Health, who are responsible for training the ‘brigadistas de salud’ do
receive payment when possible, but even this position is often assumed by a
nurse on top of his/her other responsibilities and with no extra financial

Many of the issues mentioned by Carolina stem from the inability of both
the Nicaraguan government and the majority of national and international
NGOs providing training and oversight to CHWs to provide financial
compensation for the work they do. If government appointed CHWs were paid,
I believe there would be much less need for volunteer community health
promoters here. For the most part, community health promoters are also
completely voluntary though they also receive reimbursement for
transportation to and from trainings. These are people living in rural
communities with poor access to health services who want to learn more
about health in order to support their communities in the form of first
aid, health education and community projects.

Teach for Health (TFH) is, at this point, a very young organization and a
completely voluntary one. TFH staff and volunteers do not receive payment
and in most cases, are responsible for seeking outside grants and
scholarships to help fund their involvement. It is our belief that the
majority of our funds should go directly toward promoter trainings and
community projects. Our current funding does not allow us to provide
financial compensation to the health promoters. The only TFH staff members
receiving a salary at this point are 2 of the promoters who act as local
program coordinators. This is a rotating 14 month administrative and
supervisory position which provides a part-time stipend most often used to
help pay for university studies. This allows for internal program
management and decision-making and provides financial compensation to those
promoters who are willing to take on extra responsibilities within the

When TFH first began work in Nicaragua, we made a 5 year commitment to
support and help develop the community health promoter network. One aspect
of this development relates to the group’s ability to seek out and secure
its own funding. Providing financial compensation directly to the health
promoters only for the 5 year period of our proposed involvement would most
likely ensure that the program does not survive beyond our departure.
Instead, we are working with the promoter network to develop their ability
to seek out and secure funding from a variety of the many NGOs (both
domestic and international) active in Nicaragua. Our trainings with the
promoters focus mainly on community and individual empowerment (taking
ownership and leadership for community decision-making related to health
and community projects and for the promoter network itself). Participating
communities gain organizational and leadership skills, learn how to
complete community diagnoses and develop/manage community projects, and
learn the methods and importance of seeking out and maintaining
relationships with others. This leads to participating communities becoming
more active players in their own health and well-being. It helps
communities to navigate the complicated web of public health and community
development resources available to them, know how and when to make
adjustments when necessary, and to put their community and personal health
in their own hands. The presence of such individuals allows remote
communities to collaborate and communicate more effectively with NGOs as
well as with Ministry of Health staff. It also improves the Ministry of
Health’s access to said communities and opens up opportunities for
collaboration and development that would not have existed otherwise.

Sarah Nunn, RN, MSN

Nicaragua Program Director, Teach for Health
Directora del Programa - Nicaragua
Enseña por Salud

Jason Villarreal Replied at 10:19 PM, 26 Jun 2012

Hello everyone!

this is a topic which is, I believe, absolutely pivotal in effective and quality healthcare delivery, and is unfortunately simultaneously under-discussed. I have a unique position in my approach to this question: I had the privilege of being formed as a CHW with Heidi and Jess at PACT, where I worked for 3 years. After that, I went to get my MSN, which I just finished a month ago, so I have feet in what seems to be "both" worlds.

The word "both" is in quotations, because as both a CHW and an RN, I believe that RNs (and MDs/PAs/NPs/etc) are at their best when they are CHWs at their core. The essential question, then, becomes, "what exactly is a CHW"? As we see in this discussion, this question is vexing. The strength and the challenge with CHWs is that, of all the providers in a healthcare enterprise, they are the most adept at assessing and adapting to the needs of those we serve in real time. When an RN despondently hangs up the phone leaving a message for the 4th time hoping to discuss the latest A1C or VL, the CHW can actually go to the house. In other settings, the RN is stuck in a clinic with a line of people needing assistance, and cannot even hope to reach those who live further afield who cannot reach the clinic. In these situations, the relationship and role understanding (as Heidi discussed earlier) is strongest when there is respect from all parties in word and in reality...

It is very true that one great frustration of CHWs is that we do not have licensure, and at least in the US biomedical culture of the primacy of the quantitative data, "unlicensed" persons can be viewed as being (at best) outsiders looking in. However, if the institutions (eg MDs, RNs, etc) respect the CHWs, all will find previously unexpected dividends. I remember one of my first rounds at a prominent Boston hospital, with the attending, all the fellows, and the social work team in the room. At one point, discussing a particularly vexing person, the attending turned to me and asked me "Jason, what do you think we should do?" I never forgot that moment. Here was an attending at one of the most renowned hospitals in the world asking for my input. After being shocked for about a second, I realized I had a lot to contribute. This particular "patient" was considered "lost to care" but I saw him semiweekly, in his home. I knew many things that the RNs and MDs and SWs could not possibly know. 2 years later, this person was undetectable, owing in no small part to a great team that knew its roles, respected each other, and relied on A-game input at all times.

So I would begin by saying that RNs and others are best served when we find ways to put egos aside and realize that we as RNs do great work, every bit as much as CHWs do, not unlike an enzyme allowing for exponentially greater growth. Indeed, I strongly feel that working as a CHW should be a prerequisite for nursing or medical school. I will soon be taking my NP boards, and am often reminded by professors and other RNs that even as an NP, I am an RN first. I add a corollary to that statement: I am a CHW first, who happens to be an RN, soon to be an NP. There is so much to say here, but I think that good outcomes begin with a sense of mutual respect leading to working together for common goals (of people served and advocacy for RNs and CHWs), doing what we do best as CHWs trained in challenging situations and RNs trained at the bedside: put aside the facts, figures, the "patient" of the books for a moment, and accept the privilege another human has just given in letting you into their life. Ask. Then listen to the human sitting next to you. I look forward to a great discussion here!

Jason G. Villarreal, RN, MSN

Sarah Nunn Replied at 11:10 PM, 26 Jun 2012

1. Question: From your experience, how can CHWs and nurses improve
their partnerships and work better together?

I agree with Carolina and Albany that communication and collaboration are
key. CHWs, especially those who live in the same communities in which they
work, are a crucial link between doctors/nurses and remote communities.
CHWs working in their own communities have the most up-to-date and in depth
knowledge of the health of those communities and individuals and this is a
wealth of knowledge that should not be ignored or under-utilized. The
provider Jason Villarreal mentioned in his response is a wonderful example
of how recognizing and appreciating all members of the health care team for
what they can bring to the table can lead to improved outcomes.

Here in Nicaragua, many community-level interventions proposed either by
NGOs or the Ministry of Health doctors/nurses fail because those proposing
the intervention fail to seek the support and expertise of CHWs and other
community leaders before and during. Afterwards as well, come to that,
since the CHWs are the most accessible for follow-up and sustainability of

CHWs should also take advantage of the knowledge and expertise of
nurses/doctors and maximize collaboration with them, both by providing
support for Ministry of Health doctors/nurses in their community work and
in seeking support for their own goals and activities in their communities.

Sarah Nunn, RN, MSN

Nicaragua Program Director, Teach for Health
Directora del Programa - Nicaragua
Enseña por Salud

Maggie Sullivan Moderator Replied at 12:07 AM, 27 Jun 2012

Sarah, Albany and Carolina - do politics influence the MOH appointments of CHWs? I understand that CHWs volunteer themselves for the positions, but especially as compared to the other (non-MOH) volunteer health promoters, I'm wondering how it affects community perception of them.
Es posible que la politica influye como se logra una posicion de promotor de salud con el ministerio de salud? Entiendo que uno tiene que voluntar a su mismo, pero en comparasion a los otros promoteres (los que no tienen que ver con el ministerio de salud), me imagino que se puede afectar la perspectiva de la comunidad.

Anatole Manzi Replied at 5:47 AM, 27 Jun 2012

Thank you so much for raising this important point.
Rwanda has is one of African countries with a structured community health system. The remarkable role of CHWs has been noticed in health promotion/disease prevention, case detection and treatment.

Particularly, CHWs are doing an incredible work in TB and HIV prevention, care and treatment.
We talk of MIRACLES when seeing Partners In Health/Inshuti Mu Buzima (PIH/IMB)’s work in Rwanda. Working with community health workers made health care much easier and cost-effective.
I have mentioned some points to respond to key questions of the discussion:
What successes and challenges have you seen in collaborations between nurses and CHWs?

- CHWs enable nurses and other clinicians to reach the community which normally is critical especially in rural area. With CHWs, a health center nurse can reach thousands of patients very easily.
- Accessibility: CHWs alleviated the burden of some special care. Example: TB patients are no longer visiting clinics everyday for DOT. This solved issues around adherence to anti TB drugs which was very difficult since patients had to walk for a long distance(15-30miles).
- Using CHWs to accompany patients constitute Partners In Health’s success in HIV care and treatment in Rwanda and other supported countries.
- A similar experience in Uganda, “CHWs carry out a household assessment of every patient using standard questionnaires before enrollment to determine their socio-economic (S-E) needs. Patients found eligible for S-E support at enrollment are referred to social workers, who carry out additional assessments using standard questionnaires, semi-structured interviews, or validated tools to confirm eligibility. S-E support is provided on a “needs-most gets-first” basis. Reassessments for continued support are done annually using the same standard questionnaires, and patients whose S-E situations have stabilized are phased-out using a predetermined phase-out plan.” (see the attached paper)

How can CHWs and nurses improve their partnerships and work better together? How can nurses help support/empower CHWs to improve patient outcomes?

I totally agree with what Heidi Behforouz mentioned earlier (Clear understanding of each other's roles/responsibilities, understanding of each other's capacities, mutual respect and team-based work).
In addition to that, it is very important to build/strengthen CH program/structure.
Nurses at Partners In Health supported sites helped to build/strengthen their structure including the CHWs leader who coordinate CHWs’ activities and keep track on challenges faced during their regular work.
Also, having joint monthly/quarterly meetings have been great opportunities to both learn(capacity building) and troubleshoot.
Recognize the role of CHWs is key. Establishing a system that helps them to have a formal or ad hoc communication and recognition with nurses constitute an important consideration.
Rwanda Ministry of Health has revealed a great recognition to CHWs and distributed a cell phone to each CHW across the country and supported creation of cooperative and appointed a nurse in-charge of community health department at each health center and district hospital.
The department of CH at Partners In Health-Rwanda works with National Community Health Desk to strengthen this system.
Thanks again for posting this important discussion. I believe that Nurses and CHWs working together make a strong team of WINNERS.

All the best,


Attached resource:

LLeni Pach Miller Replied at 6:01 AM, 27 Jun 2012

I would appreciate receiving a training Curriculum for Health Workers,
since I want to develop
a program for the indigenous communities in Cusco, Peru,
Agradeciendoles de antemano,
LLeni Pach

Jessica Aguilera-Steinert Replied at 8:13 AM, 27 Jun 2012

Re: CHW curriculum: check out the website for CHW curricula as well as program manager curricula.
Jessica Aguilera-Steinert
PACT Project/PIH

Jessica Aguilera-Steinert Replied at 8:32 AM, 27 Jun 2012

Re: politics and CHWs
This is an issue that impacts the role and perception of the CHWs in the US as well. I the western part of the US the role of a promotora de salud or health promotora often is a volunteer position whereas the CHW role is a paid position. At the Rural Health Conference in Portland, Oregon there was a presentation that discussed this issue that included pros and cons of paying staff. For more details you can reference it on line. One of the issues that they raised was credibility felt by the promotoras and perceived by clinicians of this role. My impression was that the people hired have very similar backgrounds and that the promotora role is a helpful stepping stone to a CHW position at later point. In the field of HIV in the US there is a blurring of the HIV case manager and Peer roles and having recently done trainings for both, I see there are very similar skills and responsibilities for these staff.

The issue that this brings up that is relevant to the RN/CHW relationship is the support that RNs can give staff in both of these positions.
First, the CHW or peer has unique skills and experiences that other clinicians often do not have and these skills include the ability to identify with their patients (and vis-a-versa) and build trust and safety quickly.

In addition, I have heard significant concerns from different types of clinicians about the professional boundaries of peers/CHWs (of any kind- illness, ethnicity, economic, etc.). These professional boundary concerns are legitimate but are concerns for all of us working with patients. Trainings addressing this issue, including organization policy expectations are helpful for ALL professionals working with patients. All of us are in this work for personal reasons and they are reflected in some of our choices when a patient requests $5.00 or asks us to attend a graduation or a baby shower or even when we struggle with revealing personal information that we may feel could help the patient.
A training on professional boundaries could be extremely clarifying for all types of health care workers.

Cathy Franklin Replied at 8:45 AM, 27 Jun 2012

The issue raised is a good one and not surprising. As new roles are introduced in health care, role confusion and tension is a predictable outcome. I witnessed this first hand as acute care NP’s were introduced into a primary nursing care setting. Many excellent ideas have been presented already and I would like to direct my comments to what is likely at the heart of the problem. By virtue of their position and licensure, RN’s hold perceived power over the CHW and the first step in healing relationships is the need first to recognize this phenomenon. Once recognized, RN’s must exercise leadership in the CHW-RN-patient triad with a commitment to excellent communication. RN’s can exercise this leadership by demonstrating respect for the CHW position by both use of words and action: placing value on CHW’s input to patient care by recognizing their bonds with their patients, including them in the care planning based on their “knowing” of the patient, and acknowledging the contributions to achieved outcomes publicly within the organization and to patients directly. If this can occur with support from administration, my prediction is that relationships will improve, collaboration between the two role groups will grow, and all of the rest of the issues raised will seem achievable and ultimately resolve because the trust, mutual respect, and communication to solve problems together will exist. ~Cathy Franklin

Tess Panizales, DNP, MSN, RN Replied at 3:12 PM, 27 Jun 2012

Historically, CHW's have been the best partner extender in healthcare
delivery. During the Health for All Alma ATA era, CHW's have been
recognized for what they can do and make a difference. The challenge
remains that we need to be able to create a simple consistent outcome
measure so as to quantify CHW's role and use the same in
building their capacity in the community.

* What successes and challenges have you seen in collaborations between
> nurses and CHWs? * From your experience, how can CHWs and nurses improve
> their partnerships and work better together?

Per my experience, successes and challenges so much so depends on the
initial engagement of both profession. If nursing is coming from another
location/country, it is very important to be familiar with the pre-existing
culture and current practices. Knowledge of what exist from another
country or location on CHW roles does not mean the same exist in another
location. It is best to gather information and observe the dynamics during
the initial engagement. As with anything else TRUST must be built, and
help from within the context of assessed needs and validation.

Most often, we see organizations or individual volunteers defining their
personal right to knowledge and skills, and with excitement ready to
download all at once -under estimating human cultural and learning
dynamics. At times, CHWs may not hold the health care leadership and power
in the community hence our effort may not merit any impact towards

Another challenge is the duplicated efforts between NGO CHW and GO CHW in
the same locale. This usually happens when there is poorly organized GO
and NGO collaboration.

As nurses we are in a position to be the power broker to help redefine and
re-understand the roles and significance of the CHW from the NGO to the GO
governance. Nursing and CHW partnership is a very important role to be

Seeing how Nyaya Health in Bayalpata Hospital in Nepal empowers their CHW
is quite impressive. As an outsider walking besides a Nepali CHW for the
first time, only means I have to observe quietly, and be a step back as the
role she plays unfolds before my eyes. My next visit may not still mean a
full engagement, but a long and gradual process of understanding where I
fit to be able to share and be trusted as a mentor/mentee.

> * How can nurses help support/empower CHWs to improve patient outcomes?
> * What qualities/skills make CHWs successful in their work? And how does
> this complement (or not) the roles of nurses?"

What is important is not just health knowledge and skills but building
CHW's leadership and management skills. Nursing had the opportunity to
learn these and thus in a position to be able to strengthen the identified
needs of the CHW. Helping CHW understand simple quality measures and
develop simple visual graphics are just as important for them to witness
their successes and challenges.

CHW that has evolved from within the community are in
an advantageous position to help nursing understand the silent pulse of the
community. This is very important especially in identifying ways to
implement needed health interventions, etc. Various CHW's apply various
strategies in care delivery - this is important to learn as well.

Having developed CHW training programs, trained and worked with them side
by side in various capacities has allowed me to build an alliance that will
help sustain health care programs. If nothing else, I owe much for what I
have learned from them. I call them my silent heroes and I believe
someday, with nurses help, we can give them their bigger voice.


Tess Panizales, DNP, MSN, RN Replied at 3:21 PM, 27 Jun 2012

Another great CHW and Nursing partnership is being done by Dorothy Granada
in Matagalpa, Nicaragua. She has done wonderful jobs - will try to invite
her to join GHD online.

Maggie Sullivan Moderator Replied at 10:11 PM, 27 Jun 2012

Lleni, here are a few additional examples of CHW training manuals. I'm sure there are many more out there. Please let us know if you need more suggestions or resources!

Center for Disease Control and Prevention: CHW manual for cardiovascular health

Health Initiatives of the Americas: CHW manuals on a variety of health topics

Migrant Clinicans Network: Family Violence Training Manual for CHWs

Rural Assistance Center: Health and Human Services Information for Rural America

Jessica Aguilera-Steinert Replied at 10:22 PM, 27 Jun 2012

Response to question #3- How can nurses help support/empower CHWs to improve patient outcomes?

1. Nurses can expect CHWs to do many of the interventions that they have been doing assuming that the CHWs are trained and supervised effectively. It may be challenging to "give up" some of those tasks but the tasks may not need to be completed by a nurse of other licensed clinician. When clinicians can recognize the technical support that CHW can give the patient (and indirectly the clinicians), then these clinicians can be more freed up to work to their highest capacity.

2. A healthy, supported and knowledgeable CHW is a productive and effective CHW. Clinical supervision can also be a significant support for CHWs. In the Social Work and Mental Health worlds, Clinical supervision is defined as the support and teaching done by a mental health clinician to address the mental health and substance use issues of patients through supervision discussions with a provider- in this case a CHW . These case based discussions increase the learning and skill of CHWs to assess, screen, support and refer patients exhibiting mental health symptoms. The second goal of clinical supervision is to support the provider or CHW in developing his/her own self awareness as a tool to provide improved interventions with patients. Because our perceptions, judgments, and life experiences can influence our interactions with patients, it is extremely helpful to have a safe forum (group or individual) to analyze our interactions and reactions and to learn therapeutic skills. The National Association of Social Workers says "Clinical supervision is also concerned with increasing job performance by decreasing job related stress that interferes with job performance."

Training and supervision are some of the building blocks to be able to capacitate CHWs to improve patient outcomes.

Jessica Aguilera-Steinert, MSW, LICSW
Director of Training and Technical Assistance

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LLeni Pach Miller Replied at 10:52 PM, 27 Jun 2012

*Gracias Jessica y Maggie,*

Jose Albany Chavarria Picado Replied at 10:59 PM, 27 Jun 2012

Pregunta #3: ¿Cuales son unas maneras en como las enfermeras pueden apoyar
a los promotores para que los pacientes siguen adelante?

Una de las maneras de como un enfermero puede ayudar a un promotor es
explicándoles de una manera mas fácil como ayudar a un paciente en su
comunidad ya que hay personas en las comunidades que no saben leer y las
recetas muchas veces no son muy clara la escritura y esto viene a confundir
el procedimiento de como se debe tomar los medicamentos además hay ciertas
indicaciones en que las enfermeras nos pueden dar para mejorar la atención
en la comunidad.

Otras de las maneras en que las enfermeras nos pueden ayudar a los
promotores de salud es manteniendo un procedimiento estándar de como hacer
para estabilizar a un paciente en caso de que no haya una persona indicada
para tratarla.

Los enfermeros manejan un índice de las personas más vulnerables en las
comunidades a través de las consultas médicas en los centros de salud y los
promotores podemos ayudar más cuando también se nos comparte esto. Porque
nosotros somos quienes vivimos en la comunidad y podemos ayudar estando al
tanto de la salud de esa persona. Por ejemplo aquí en Nicaragua y en el
municipio de san ramón donde actualmente está Teach for Health podemos
trabajar con las embarazadas que están en riesgo en las comunidades y que
han llegado al centro de salud a chequearse para ver el estado en que se
encuentre y decirles que salgan a tiempo a la casa materna.



Question #3: How can nurses help support/empower CHWs to improve patient

One way in which nurses can help promoters is by explaining to them in the
clearest way possible how they can help a patient in their community. This
is important because there are people in the communities who don’t know how
to read and many times prescriptions are not written very clearly. This can
lead to mix-ups with regards to how the medications should be taken. Also,
there are certain instructions that nurses can give to improve the
attention given in the communities.

Another way that nurses can help health promoters is by maintaining
standard procedures with regards to stabilizing patients when there is no
one available to treat them.

Ministry of Health nurses maintain a registry of the most vulnerable
members of the population who are identified as such during medical
appointments at the health center. Promoters could help more if this
registry were shared with them, because promoters are the ones who live in
the communities and we can help if we know what is going on with these
people’s health. For example, here in Nicaragua and particularly in the
municipality of San Ramón where Teach for Health works, we could work more
with high-risk pregnant women who perhaps have come to the health center
for a check-up. We could follow-up with these women and tell them when they
should go to the ‘casa materna’ [*this is a center where women from remote
communities within the municipality of San Ramón can come when they are
nearing full-term to ensure they deliver in a health center when the time
comes*] so that they get there in time.

Carolina Lopez Ochoa Replied at 11:05 PM, 27 Jun 2012

Para responder a la pregunta: ¿Es posible que la política influya como se
logra una posición de promotor de salud con el ministerio de salud?

No creo, aunque las políticas de cada gobierno son diferentes, porque los
trabajadores de salud comunitaria son personas voluntarias que prestan
servicios a la comunidad y pienso que no les afectaría, o quizás si, pero
ellos tendrán que regirse por dichas políticas. Con respecto a los otros
promotores pienso que quizás afectaría a la comunidad porque se trabajaría
de diferentes maneras pero ellos tendrán que organizarse con la comunidad,
porque lo que se quiere es que la comunidad salga adelante aunque sea con
políticas diferentes.



In response to the question: Is it possible that politics influences who
becomes a health promoter with the Ministry of Health?

[In the case of Ministry of Health CHWs] I don’t think so, because even
though the politics of each party are different, the CHWs are volunteers
who provide a service to their communities and I think that it wouldn’t
really affect them. Maybe it might, but only if they allowed themselves to
be controlled by said politics.

With regards to health promoters [who are not official Ministry of Health
CHWs], I think that it might affect the community because they would work
in different ways but the promoters would just have to organize and unify
themselves with the community because the goal is for the community to move
forward despite political differences.

Carolina Lopez Ochoa Replied at 11:16 PM, 27 Jun 2012

Pregunta #3: ¿Como pueden las enfermeras apoyar a los promotores para que
los pacientes aprovechen de los mejores servicios de salud?

Las enfermeras pueden apoyar a los promotores de salud explicándoles los
temas que tienen que relacionarse con los casos mas comunes en las
comunidades, además pienso que pueden apoyarlos explicándoles los temas de
una manera mas sencilla o mas cómoda, para que los promotores de salud
comunitaria puedan enfocarse mejor en las comunidades ya que ellos son los
que van a tratar directamente con las comunidades.

Apoyarían dándoles suficiente información como pequeños folletos para que
ellos puedan compartir con la comunidad y así adquirir conocimientos.



Question #3: How can nurses help support/empower CHWs to improve patient

Nurses can support health promoters by explaining the health topics that
are most common in our communities. I also think that they can support us
by explaining topics in a simple or more comfortable way so that community
health promoters can be of more assistance to their communities since they
are the ones who will work most directly with the communities.

It would be helpful for promoters to be provided with appropriate
information such as pamphlets so that they can share these with the
community and gain more knowledge.

Sarah Nunn Replied at 12:07 AM, 28 Jun 2012

Question 3: How can nurses help support/empower CHWs to improve patient

Health promoters working with Teach for Health in Nicaragua have recently
completed a joint training provided by the Ministry of Health and Teach for
Health in the administration of IM injections. This training was requested
by the health promoters to address two public health problems. The first is
that injectable medications are very commonly prescribed here, but patients
are expected to fill the prescriptions themselves at local pharmacies and
find someone who can administer the injection. They are not provided with
teaching either at the hospital/health center or through the pharmacy (as
pharmacy staff are not trained for this). It is often difficult if not
impossible to find someone from their own communities who has been trained
in giving IM injections. This leads to medication errors, infections at the
injection site, and at the community level, a fear and distrust of allowing
oneself to be given an injection.

The second public health issue is that depo provera and similar injectable
birth control are the most commonly available and sometimes most culturally
appropriate options here. However, many women who would like to take birth
control feel that they cannot because they do not have access to anyone who
could administer it for them.

The injection training was carried out with the goal of addressing these
two problems in participating communities. However, we’ve since seen that
the training itself is not necessarily enough. Last month, the Ministry of
Health carried out a municipality-wide vaccination campaign, and the health
promoters who had attended the injection training supported the Ministry of
Health doctors and nurses in this endeavor. However, in some of the
communities people did not want to allow the health promoters to administer
the vaccines even though they had been trained by the Ministry of Health. I
believe this is partly due to the lack of consistent and formal recognition
of the health promoters by the Ministry of Health. Providing such
recognition would go a long way to improving both the community members’
and the health promoters’ perceptions and understanding of the role and
abilities of a promoter. Strengthening the relationship between volunteer
community health promoters and the Ministry of Health, and
formalizing/standardizing the role of health promoters in certain
activities would clarify and support the important role promoters can play
in many such activities. This in turn would lead to improved efficacy of
the health promoters and better patient outcomes.

Jose Albany Chavarria Picado Replied at 12:10 AM, 28 Jun 2012

Para responder a la pregunta: ¿Es posible que la política influya en como
se pueda lograr una posición de promotor de salud con el ministerio de

En algunas veces si porque la mayoría de las veces estas personas son
elegidas para que puedan trabajar con el modelo implantado por el gobierno.
Por ejemplo en Nicaragua cuando estaba en el poder los liberales la forma
de trabajar de l ministerio de salud era distinta ala de ahora que esta en
el poder los sandinista y por ese motivo se eligen personas que estén de
acuerdo con las políticas de gobierno.

es posible que el ministerio de salud tenga una política diferente para la
capacitación de las brigadista de salud y ellos son mas reconocidos en la
comunidad ya que son departe del gobierno y tienen otros beneficios por que
ellos en la mayoría son lideres reconocidos en la comunidad y tienen un
botiquín con ciertos medicamentos y los promotores de salud solo tenemos un
botiquín con que solo podemos brindar primeros auxilios alas personas pero
ahora cierta cantidad de brigadistas se están uniendo al programa para
trabajar unidos ya ese debería de ser el objetivo que nos unamos para el
bien de todos sin distinción de nadie.



In response to the question: Is it possible that politics influences who
becomes a health promoter with the Ministry of Health?

In some cases, yes, because most often people are elected to work within
the model employed by the government. In Nicaragua for example, when the
liberal party was in power the Ministry of Health worked differently than
it does now that the Sandinista party is in power. Because of this, people
who support the politics of the current government might be elected.

It is possible that the Ministry of Health has a different policy with
regards to training of the ‘brigadistas de salud’ [government appointed
CHWs]. These CHWs are more recognized by the community since they are
appointed by the government and have some benefits due to this. Most are
leaders recognized by their communities. They have a first-aid kit which is
supplemented with certain medications whereas the health promoters have a
basic first-aid kit solely for the purpose of treating injuries. However,
some of the ‘brigadistas de salud’ are also being trained as health
promoters to work together. It should be our goal to unite for the good of
all, without giving preferential treatment to anyone.

Maggie Sullivan Moderator Replied at 5:42 PM, 28 Jun 2012

Pregunata #4 por Carolina Lopez Ochoa: ¿Cuales son las habilidades/capacitaciones que da un promotor éxito en su trabajo, y como es diferente o no diferente que el papel de un enfermero?

Un promotor de salud logra éxito al amar ala comunidad, al ser responsable y respetuoso, al ser organizado, comunicativo, al llevarse bien en todo los aspectos con las personas, al ser un ejemplo de bien en la comunidad, al ser solidario, comprensible, animador, al estar dispuesto a trabajar por la comunidad, al ser honrada, al dirigir y tener visión para sacar a la comunidad adelante.

Un promotor de salud en mi país esta capacitado para dar consejos y así iniciar cambios de actitud en las personas, dan charlas de salud, brindar información ala comunidad, pueden ayudar a prevenir algunas enfermedades, están capacitados para proveer Primeros Auxilios, colaboran con miembros de las comunidades para gestionar proyectos para resolver problemas, se reúnen con la comunidad para planificar, buscan a personas que estén interesadas en prevenir enfermedades o mantener la salud.

Es diferente al papel de un enfermero, porque ellos están directa mente con las personas delas comunidades, y son personas que se entienden perfectamente con su gente, son personas que son propuestas por las mismas comunidades y ellas saben a quien van a elegir, alas personas que son responsables y capaces y se entienden perfectamente con las personas que eligen. En cuanto al papel de los enfermeros es un poco diferente porque ellos atienden a personas de diferentes lugares y las personas ni si quiera saben como es su manera de portarse con el paciente y pienso que ellos están súper mas capacitados en todos los aspectos que el promotor. Porque un promotor solo promueve la salud.

A health promoter achieves success by loving his or her community, being responsible and respectful, organizad, communicative, getting along well with others, being a good example to the community, being in solidarity, comprehensive, encouraging, being available, being honorable, and by leading and having a vision to help advance the community.

A health promoter in my country is trained to give advice and similarly to initiate behavior/attitudinal changes in people, to give health talks and offer information to the community. They can help prevent certain illnesses, they’re trained to provide first aid, collaborate with community members to manage solution-oriented projects, they meet with the community to plan, and look for others who are interested in disease prevention or health maintenance.

The role of a nurse is different, because promoters are directly connected with the community members, and they are people who perfectly understand their community. Promoters are people elected by their own communities, who will elect someone responsable, capable and perfectly understanding of those who elect them. On the other hand, the role of nurses is a little different because they take care of people who come from many different places and may not even know how their customs are different. I think nurses have much more training in all aspects in which the health promoter is trained, because a health promoter only promotes health.

Maggie Sullivan Moderator Replied at 6:25 PM, 28 Jun 2012

On behalf of several of our members, I am please to release this first survey to the GHDonline nursing community. Given the richness of discussion and questions regarding CHWs in this community, a short survey was developed to poll our members' knowledge and experience. It is for all nurses to take whether or not you have much experience with CHWs. This survey was initiated by GHDonline members Tess Panizales, Monica Onyango and Greta Martin. It could not have been done without their help. It should not take longer than 10 minutes to complete. Please consider participating and we will post the results for all to see!

Attached resource:

Sarah Nunn Replied at 11:11 PM, 28 Jun 2012

Question #4: What qualities/skills make CHWs successful in their work? And
how does this complement (or not) the roles of nurses?

· - Flexibility

· -Curiosity

· -Creativity

· -Motivated/self-starter

· -Takes responsibility for their own learning

· -Passion for the work they do

· -Ability/tendency to ask ‘why?’ in the context of community health
problems and throughout the process of addressing them

· -Ability to build and maintain relationships with community
members/patients, nurses and doctors

· -Ability to work well with others/collaborate

· -Strong conflict resolution and communication skills

These are also good qualities in nurses working in public/community health,
particularly in settings where the role of the CHW and the relationship
between CHW and nurse have not been thoroughly explored or clearly defined.

Maggie Sullivan Moderator Replied at 1:34 AM, 29 Jun 2012

Respuesta a la pregunta #4 por Jose Albany Chavarria Picado: ¿Cuales calidades/habilidades se hace lograr éxito un promotor de salud? Y como son similares or diferentes del papel de una enfermera?

Una de las cualidades que un promotor debe de tener para tener éxito es que sea respetuoso con las personas de la comunidad y con todas las personas que lo rodean, siempre y cuando teniendo en cuenta ser amistoso y tener amor por lo que haces. Por ejemplo cuando uno como promotor de salud eres solidario y servicial con las personas que te rodean siempre te van a tener la confianza de pedirte ayuda pero si eres timado y poco amistoso con las personas entonces no te van apoyar ni te buscaran para pedirte ayuda y mucho menos tenerte confianza.

Las habilidades que en un promotor para que tenga éxito seria poder trabajar en equipo ya que esto viene a permitir que realicen actividades en conjunto para el beneficio de todos, motivación es una de las habilidades mas importantes por que bien a formar un buen ambiente entres el grupo de trabajo como con las personas de la comunidades. Otras de las habilidades seria el poder resolver conflicto ya en los grupos siempre van a ver conflictos que nos van afectar pero si lo sabemos manejar podremos salir de todos los obstáculos.

La mayoría de estas cualidades y habilidades son similares en una enfermera por que las enfermeras son las que mas contacto tienen con los pacientes por lo cual tienen que poder manejar a los diferentes tipo de pacientes que se le presenten y también para trabajar de la mano con sus compañeros de labores y con los promotores de salud.


Response to question #4 by Jose Albany Chavarria Picado: What qualities/skills make CHWs successful in their work? And how does this complement (or not) the roles of nurses?

One of the qualities a promoter should have in order to succeed is that he be respectful of community members and of others around him, taking into account to be friendly and to have love for what he does. For example, when a health promototer works in solidarity and is helpful to those arround him, the community will always trust him to help. But if he is timid and not very friendly with people, then the community will neither support him nor seek him out for help, much less trust him.

A skill that a health promoter should have to succeed is to be able to work as a team, so that projects can be accomplished which benefit everyone. Motivation is one of the most important skills because it creates a good group environment. Additional skills should be the ability to resolve conflict, as within a group there will always be conflict that will affect us, but if we know how to manage it, we can overcome the challenges.

The majority of these qualities and skills are similar to that of a nurse because nurses are the ones who have the most contact with patients, therefore they have to be able to work with all different types of patients, in addition to working hand in hand with their fellow workers and other health promoters.

Alison Hernandez Replied at 7:33 AM, 29 Jun 2012

I am looking at strategies to support the performance of auxiliary nurses in health care in rural Guatemala in my PhD research (Epidemiology and Global Health, Umea University, Sweden). And the issues brought up in this discussion have a lot of similarities to the Guatemalan system.

Auxiliary nurses have a 1 year accredited training and are front-line health care providers in primary care services. Their work depends on collaboration with a team of CHWs and traditional birth attendants from the communities they serve, and the auxiliary nurses' responsibility to coordinate this is specified in institutional guidelines of public health services. In the cases I have observed in the department of Alta Verapaz, the relationship between the auxilary nurse and the CHWs (and community in general) is facilitated by the fact that they are from a similar rural indigenous background and feel connected to the communities they are serving. This is not so often the case with the professional nurses who usually don't speak the local language very well. So the auxiliary nurse role is an important bridge between the professional nurse and CHW in this setting.

Primary care is provided through 2 different mechanisms in rural areas - health posts (and health centers) and contracted NGOs who deliver a defined package of services via mobile health teams to the most remote areas. These 2 mechanisms work with CHWs in similar ways, but the NGOs' budget includes incentives while the public services' budget does not. But even when incentives are available, the more important factor seems to be the level of organization and activeness of the community leadership in pursuing their own "development goals". When the auxiliary nurses have good relationships with community leaders and have a shared vision of promoting health for the community, then they are more successful in overcoming challenges and organizing support.

I have been looking more closely at the relationship between the auxiliary nurse and nurse supervisor, but I think it can also be relevant. In many cases, the supervisors take a managerial control approach to their role - ensuring that institutional coverage goals are met, paperwork is filled out correctly, etc. However, I have also seen several examples of relationships built on "humanized support", where the supervisor approaches her role more through her identity as a nurse, treating the auxiliary nurses almost as patients themselves, seeking to understand their needs as they perceive them and then seeing what they can do to help. These nurse supervisors also convey that the desired outcome of their work is to improve care for patients, which is a goal they share with the auxiliary nurses. In the cases of humanized support, auxilary nurses felt their work is valued by their supervisor, while in managerial control, the auxiliary nurses expressed that the supervisor helps them improve, but does not really value or understand his work. Based on this, it seems the nurse supervisor - auxiliary nurse (or perhaps CHW) relationship is strengthened by a holistic approach to understanding auxiliary nurse's needs in order to support them to carry out valuable work. However, the managerial control of completion of tasks is what is operationalized in the job description and institutional expectations. I think an important question for nursing in this issue of relating to support cadres is how to hold onto to the NURSE in nurse supervisor, because the our own caring profession holds all of the important bases for the kinds of supportive human relationships needed at all levels.

Alison Hernandez, RN, MPH

Heidi Behforouz, MD Replied at 2:21 PM, 29 Jun 2012

What qualities/skills make CHWs successful in their work? And how does this complement (or not) the roles of nurses?
Passion, compassion, channeled outrage against social injustice, dedication, strong inner core, trustworthy, reliable, creative, good common sense, love of people, love of self, patience, perseverance, ability to tell truth from fiction, ability to accompany people to sometimes scary or uncomfortable places, nonjudmental, teacher, advocate, teller of truth.

Jessica Aguilera-Steinert Replied at 3:02 PM, 29 Jun 2012

Reply contents:
"Question #4: What qualities/skills make CHWs successful in their work? And
how does this complement (or not) the roles of nurses?

I appreciate all of the comments so far on important qualities of CHWs and wanted to add a few more:

Empathy- the ability to be able to put yourself in the shoes of your patient, or even of a provider to appreciate their perspective as valid and important

Self-awareness and self-reflection- a developed sense awareness of our values and judgments and how we bring them to relationships with clients or team members. In addition, the ability and motivation to explore what we have in common with or what is different from our clients' experience and how those things can be triggered when talking with our clients.

The ability to live in both the patient's world and provider's world- speak both languages, understand the perspectives and be credible in both.

Reliability and autonomy- Much of the work is done outside in the community and a CHW needs to be an ambassador of the organization/health center. They need to make commitments they can keep rather than saying yes to something they can not achieve.

Professional Boundaries- work hard with the organization around understanding and maintaining the policies but also being willing to discuss the questions or concerns about a boundary issue as it comes up even when a mistake is made. We are all in this to help so usually boundary crossing is done with good intention.

Of course these qualities/skills are essential for nurses too!!

Jessica Aguilera-Steinert
Partners in Health / PACT Project

Maggie Sullivan Moderator Replied at 11:15 PM, 29 Jun 2012

Respuesta a la pregunta por Carolina Lopez Ochoa sobre el tema de pagamiento a los promotores, como unos dicen que deben ser voluntarios, otros dicen que les deben pagar, y como afectaría el trabajo?

Los trabajadores de salud comunitaria en mi país son personas voluntarias, pero yo también pienso que seria justo que a ellos se les pagara quizás no un salario completo, pero si una ayuda para que ellos puedan mantener a su familia, ya que algunos de ellos son personas que no tienen recursos económicos, pero tienen el amor por servir a la comunidad. Esta bien que ellos han sido voluntarios, pero seria justo que se les pagara porque su trabajo es de mucho beneficio para las personas.

Pienso que su trabajo no les afectaría, porque quizás ellos así se sentirían más incentivados y más comprometidos con su trabajo y orgullosos de ser trabajadores de salud comunitaria.


Response by Carolina Lopez Ochoa regarding the issue of payment/compensation of CHWs and how it might affect their work.

Community health workers in my country are volunteers, but I think it would be fair to pay them, perhaps not a full salary, but some type of asistance to help support their family, especiallly as some of them don’t have financial resources, but they do have a love of serving their community. It’s been fine that they have been volunteers, but it would be fair that they get paid because their work benefits many people.

I don’t think getting paid would affect their work negatively, because they might feel even more encouraged, committed and proud to be a community health worker.

Maggie Sullivan Moderator Replied at 11:38 PM, 29 Jun 2012

Respuesta por Jose Albany Chavarria Picado sobre el tema de pagamiento a los promotores, como unos dicen que deben ser voluntarios, otros dicen que les deben pagar, y como afectaría el trabajo?

Cada quien tiene sus puntos de vista y ambos son buenos pero hay ventajas y desventajas en cuanto a lo de pagar o no pagar a los promotores de salud por que si es algo voluntario es por que realmente te gusta lo que haces y por qué tienes amor por la comunidad.

Al contrario cuando se les paga por ser promotores de salud por el trabajo lo harían por que les van a pagar y esto no seria voluntario pero también tiene sus beneficios por los promotores de salud trabajaran mas en la comunidad por que se sentirían mas responsables con su trabajo comopromotor.

Esto vendría afectar al trabajo por que hay diferentes tipo propuesta de las organizaciones que trabajan en ámbito de salud por reciben algunos beneficios económicos y en otras organizaciones es totalmente voluntario. También creo que es bueno incentivar un poco a los promotores con un pequeño reconocimiento por su trabajo y de esta manera mantener la motivación en el grupo.


Each person has their own perspective and both are good, but there are advantages and disadvantages regarding paying or not paying CHWs. If it’s work done voluntarily then it’s because you really like what you’re doing and because you have love for the community.

On the contrary, when you pay someone to be a CHW, they would do it for the money and it wouldn’t be voluntary, but this would also have its benefits. The CHWs would work more in the community because they would feel more responsible in their role.

Payment would affect their work as there are different approaches by different health care organizations, some would receive an economic benefit while other organizations support a voluntary method. I also think it’s good to incentivise the CHWs a little with a small acknowledgment for their work and in this way to sustain the motivation of the group.

Maggie Sullivan Moderator Replied at 12:16 AM, 30 Jun 2012

Alison, your work sounds very interesting and important. I'm currently in Guatemala and working with two auxilary nurses doing VIA/cryotherapy. Auxiliary nurses and CHWs do seem to be the front line of health care service provision here, though not to exclude individuals who set up local pharmacy shops. I think looking in to the relationship between auxiliary nurses/CHWs and professional nurses (graduada) is constructive. I was told today by some nurses that the normas (national guidelines) might change here in Guatemala and that the scope of practice for auxiliary nurses may be truncated. From my understanding, this is something that has been known to fluctuate with politics and with new appointments to the Ministry of Health. I also learned that while there is a national organization for auxiliary nurses, one does not exist for professional nurses. I would think that having a national professional organization in Guatemala would stabilize some of these fluctuations resulting from political change. Speaking in regards to CHWs, there definitely seems to be a hierarchy between CHWs and auxiliary nurses. I think this is reflective of the field of medicine. A strategy of humanized support (as you mention) would go a long way to iron out differences not only between CHWs, auxiliary nurses and professional nurses, but doctors as well.

Maggie Sullivan Moderator Replied at 11:41 PM, 2 Jul 2012

Thank you to all of our panelists and members for participating in last week's expert panel on nurses working with CHWs! It was wonderful to read your thoughts, ideas and different perspectives on this important topic. While the panelists may no longer be able to respond directly to questions now that the panel has ended, we do hope members will continue sharing their experiences and asking questions about the relationship between nurses and CHWs. Also, fellow nurses please don't forget to complete the related short survey at: Even if you're a nurse who has not worked with CHWs (your survey time will take 1-2 minutes) it would be helpful to hear from you. The results are something that we will share with the community.

Fay Guled Replied at 3:26 PM, 8 Jul 2012

I had the opportunity to meet and interview CHW in Ethiopia last year, they are such a great link between the health care facility to the community level ( household level).

Ron Ribitzky, M.D. Replied at 3:45 PM, 15 Jul 2012

We may want to expand the discussion on the impact of ICT, eHealth, and mHealth on Nurse-CHW dynamics and task shifting: what are the opportunities, what are the barriers, key learnings, and case studies.

Thank you Maggie and Sarah for posting the PDF “Task shifting - the answer to the human resources crisis in Africa”. A couple of other interesting reports are linked here.

National framework for eHealth that is founded on village-based CHW mHealth platform to enable task shifting is inevitable strategy for health sector strengthening in developing countries. While challenges and opportunities differ fundamentally from developed countries, models and key learnings from the latter may be relevant.

Cross-cutting collaboration from the national leadership to individuals carrying on the day to day disease burden is required to make task shifting successful. Health, education, ICT, legal, social, and economic development are front and center. The impact on village social dynamics is not trivial: transforming the role of traditional healers, rising micro-entrepreneurships, and privacy are just a few noteworthy considerations. Governance is another serious issue.

Rwanda appears to be rising as a national-scale prototype and potentially an intriguing incubator for developing countries seeking to overcome legacy and geo-physical barriers by accelerating innovation and adoption of eHealth and mHealth.

Disclosure: this subject is part of the modules ‘Introduction to Strategic Planning for National eHealth’ and ‘Social-cultural, Legal and Economic impact of Health Informatics’ I teach at KIST/KHI in Rwanda; Dr. Aimable Mbituyumuremyi, M.D., of the Ministry of Health RBC/IHDPC/HIV Division/STIs Unit provided material insights on the subject.

Attached resources:

Bistra Zheleva Replied at 10:45 PM, 18 Jul 2012

I had posted part of this at the beginning of the discussion but on Maggie's suggestion, thought I'd repost it again.
I work for an NGO that focuses on building capacity in pediatric cardiac care. One of the issues we face is the huge number of children with undiagnosed heart disease, congenital or acquired (rheumatic heart disease). We have begun working with pediatricians to provide basic training on early detection, as well as with nurses to ensure follow up, but have started wondering if there is a role for CHW in that chain as well. Based on experiences of this group, how helpful can they be with more complex clinical diagnoses as often they are the primary care provider?

Also, does interested in hearing about any experiences of working with CHWs is in India.
thank you!

Maggie Sullivan Moderator Replied at 6:22 PM, 30 Dec 2012

I wanted to share a new resource with everyone. It came to me by way of the ever-useful HIFA2015. It is highly relevant to our previous conversation about community health workers and speaks to retention/incentives:

December 2012 by Wanda Jaskiewicz, Rachel Deussom, Laura Wurts, and George Mgomella
Rapid Retention Survey Toolkit
The Rapid Retention Survey Toolkit is intended to allow human resources managers to determine health professionals’ motivational preferences for accepting and remaining in posts. The toolkit builds on the WHO global policy recommendations for rural retention and is based on the discrete choice experiment (DCE), a powerful research method that identifies the trade-offs health professionals (or other types of workers) are willing to make between specific job characteristics and determines their preferences for various incentive packages, including the probability of accepting a post in a rural health facility. Employing a simplified but reliable version of the DCE methodology, the toolkit guides human resources managers through the survey process to rapidly assess health professional students’ and health workers’ motivational preferences to accept a position and continue working in underserved facilities. It allows for rapid data-gathering and analysis, and the results can be used to create evidence-based incentive packages.

The toolkit includes step-by-step instructions, sample formats, and examples that can easily be adapted to a specific country context, including:

Survey planning
Survey design
Survey instrument development using a specialized software program
Survey administration
Data analysis and interpretation
Presentation of results to stakeholders.

Attached resources:

Cheralyn McKee Replied at 11:22 PM, 30 Dec 2012

Thank you SO much, Dr. Sullivan. This was such a timely post. I was looking for a bonafide retention survey to take with me on an upcoming medical mission trip to rural Benin (leaving January 6th). I am just delighted by how ideal this one is! So, thanks.


Maggie Sullivan Moderator Replied at 12:33 PM, 5 Feb 2013

For those of you not familiar with Frontline Health Workers Coalition, I thought I'd share this recent post titled "Preparing health workers for the growing burden of non-communicable diseases" by Jeff Meer, Public Health Institute. I thought the comment about preferring to be diagnosed with HIV versus diabetes in Africa to be provocative. This is an example of the shift in global health from infectious to chronic/non-communicable diseases. Feel free to read and share your perspectives...

"Frontline health workers face enormous challenges and must be prepared to adapt to changing circumstances. One of the largest changes occurring in global health is increasing urgency for health workers to prevent, diagnose and treat non-communicable diseases (NCDs). Unfortunately, few frontline health workers in developing countries have the training and expertise to do this.

I recently attended a conference where an African deputy health minister privately lamented that in his country, it would be better to be diagnosed with HIV/AIDS than with diabetes. “We finally have the means to treat HIV/AIDS now, but to be diabetic in my country is a death sentence,” he said.

For the past several decades, global health programs have focused on infectious diseases including HIV/AIDS, malaria and tuberculosis. This was rational, based on the burden these diseases placed upon all countries. And, although there has been progress against some of these illnesses, there remains much more to be done.

It also has become clear in the last several years that other diseases including cancer, diabetes, chronic heart disease and chronic lung disease are overwhelming health systems in a many countries. The World Health Organization (WHO) estimates that in 2008, these four diseases accounted for more than six out of every 10 deaths. Just as astounding, NCDs are occurring with greater ferocity among the poorest of the poor, and among younger populations, perhaps because of rising global urbanization and changing lifestyles. In fact, the World Economic Forum now estimates that by 2030, if present trends continue, NCDs (including mental health) will have sapped a cumulative total of $47 trillion from the global economy.

Solid research in the United States and other developed countries provide a host of strategies that can help prevent NCDs, a great deal of which can be done at the local level. Prevention strategies, such as support for tobacco cessation and decreased alcohol consumption, and reducing barriers to physical activity and healthier eating can stop people from getting sick in the first place. Paying attention to social determinants including poverty, education and shelter also can help. There are also relatively inexpensive ways to diagnose these illnesses and treat most NCDs when they are caught early.

The United States has an opportunity to lend its extensive technical expertise to help developing countries to equip frontline health workers, through formal education and in-service training, to face both today’s global health challenges and those of tomorrow. We can do this through more comprehensive training that incorporates NCDs into existing programs focused on infectious diseases and other health issues. In this way, we give these vital individuals more tools to keep community members healthy and productive."

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