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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 28, No 3, May/June 2017
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AFRICA
>
180 mmHg were deemed clinically urgent cases and were given
an urgent referral letter for immediate evaluation by a health
professional at the closest health facility. They were ineligible for
the CVD risk-assessment arm of the trial but were eligible for
the referral arm.
ACVD risk score was calculated for all remaining participants
using the risk-scoring tool (Fig. 1). Those whose risk score was
>
20% were provided with non-urgent referral letters to see a
health professional within two weeks of screening.
To validate the scores, a professional nurse who was a
field coordinator calculated a second CVD risk score using
de-identified data and was blinded to the CHWs’ risk scores and
BMI calculations. Each CHW was expected to screen at least 100
people over a four- to six-week period at community screenings
or in members’ homes. Table 2 provides information on the
number screened and referred for treatment.
Discussion
The process described in this article indicates that CHWs
can be effectively trained in screening for CVD risk using a
non-invasive screening tool. From the training process of the
CHWs, three important points regarding the training were
noted: (1) pre-training knowledge on NCDs; (2) language used
during the training and in the written tests; and (3) knowledge
retention over the longer term.
From the pre-training test in which no CHW scored more
than 60%, it is clear that although they were working with NCDs,
their knowledge of NCDs was limited. This raises concern about
the appropriateness of current training received by CHWs in this
area, given that the CHWs selected for this study were typical of
those employed in the community by the largest NGO, so it is
not clear what messages they were imparting to the community
members during delivery of health services. It also raises
questions as to who should be responsible for training the CHWs
and how often they should be trained.
This is supported by a 2014 study by Tsolekile
et al.
,
15
which
found that in the absence of organised training for CHWs, most
newly employed CHWs obtain their knowledge from their peers,
who themselves do not always have or share correct information.
In order for CHWs not to be viewed as providers of cheap or
inferior-quality healthcare, they need to be properly trained.
If properly trained they can provide an affordable first-contact
level of care within the PHC system. Calculation of BMI was a
new concept for the CHWs, even though obesity is a major risk
factor for NCDs and a major public health problem in the South
African population, especially among black women.
16
Similarly, in 2011, Parker
et al.
,
17
who examined knowledge
about practical issues related to the prevention and control of
non-communicable diseases, found that less than 10% of health
professionals at primary-health facilities in the Western Cape
attained a score of 80% and above. There is therefore a need for
continuing training of health workers to keep them updated.
Although the CHWs were keen to be trained in English, it
became clear that it was necessary to explain some of the difficult
concepts in the local language commonly used by community
members, including CHWs. This implies that training teams
for CHWs should include trainers who are fluent in the local
language of trainees, to ensure effective training. Furthermore,
the burden of the requirement that all training materials must
be produced and delivered in English is a potential barrier to
effective training. Given that CHWs are trained to enable them
to impart knowledge and skills to their communities using a local
language, the training should be given in their local language.
A study that examined the challenges of facilitation in adult
education found that facilitators are often not familiar with
the language of the learners, which creates a barrier to proper
learning, as some learners cannot check their understanding
of the subject by communicating in their local language.
18
Consideration should be given with regard to the purpose of
using English to train this cadre of health professionals to
accommodate trainers or learners.
Eighty-seven per cent of CHWs scored better in the second
post-training test at the end of the second week of training
than in the first post-training test administered at the end of
the first week of training. This improvement is an indication
that the challenges for CHWs in understanding new concepts
were appropriately identified and addressed by the training team
following exploration of the CHWs’ understanding of why the
first week of training had failed.
The finding that 70% of the CHWs passed the post-field-work
test demonstrates that effective training can facilitate long-term
retention of new knowledge, and may also prove to be instructive
when considering the need for retraining and the appropriate
retraining intervals in future research. This is also an indication
that people will remember activities that they perform on a daily
basis. The decline in the percentage of CHWs who had retained
the knowledge at the post-field-work test is similar to the findings
of several studies that reported declining knowledge.
19,20
From the training evaluation, it was clear that the training
period was too short to cover all the new information. The
CHWs reported that they experienced great difficulty in
understanding the written examination tests in English rather
than in their native isi-Xhosa, which was the language used
to address conceptual challenges during the training itself. A
retraining session including an extensive familiarisation of basic
terminology in English correlating with the concepts under study
was therefore necessary in order to get better scores. Further
written tests should be administered in the CHWs’ first language
or in English once proficiency has been demonstrated.
Study limitations
While the ability to generalise the findings of this research is
limited by its selection of CHWs working for a particular NGO
Table 2. Field-work activities of the community health workers
CHWs trained
15
CHWs selected for field-work
10
Community members screened
1 217
Community members with CVD risk
>
20%
(high risk)
7% of all screened
persons
Persons provided with urgent referrals
1
32.5% of all high-risk
persons
Persons provided with non-urgent referrals
2
67.5% of all high-risk
persons
1
Urgent referrals: screened persons advised to attend a health clinic on
the day of screening.
2
Non-urgent referrals: screened persons advised to attend a health
clinic within two weeks of screening.