Volunteer community health workers (CHWs) are a major strategy for increasing access to and coverage of basic health interventions. Our village health worker training course reviews the process of training and continuing education of CHWs as an important component of involving communities in their own health service delivery. Participants will be guided through the steps of planning training and continuing education activities for village volunteers. The course draws on real-life examples from community-directed onchocerciasis control, village health worker programs, community case management efforts, peer educators programs and patent medicine vendor training programs, to name a few.
Lecture 3C: Observation of Performance
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From the course by Johns Hopkins University
Training and Learning Programs for Volunteer Community Health Workers
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From the lesson
Diagnosing Needs and Identifying Objectives
In this module, we will focus on what information we will need to begin training and planning, as well as cover content, objectives, and SMART objectives. There will be a quiz covering lectures 3-4 after completing the lectures in this module. You will also begin to create your rough draft of your plan in the Course Project.
Meet the Instructors
William Brieger, DrPHProfessor, Health Systems Program of the Department of International Health
Bloomberg School of Public Health
In our previous sections,
we've talked about two of the three methods for diagnosing training needs.
Reviewing existing documents, and interviewing
various people involved in work performance.
That may contribute to our understanding of training needs.
In this section we're reviewing a little more detail using
observation to understand how health workers are
performing their job and identifying training needs.
Observation is probably the best way to judge a trainee's skill and
the relationships that they have with
other people, their interactions with the clients.
The best way is to look at how they carry out these things.
On the job in real life.
This can be done in a formal structured way.
We can
have check lists listing the various skills and activities
whether we're talking about counseling a client and we
look for whether the health worker greets the client,
whether the health worker sets the client at ease.
Through a friendly conversation, whether the health worker, I asked the
client to explain problems in his or her own words, etc.
We can observe, hear, these things being done and check them off.
We can also do informal observation that can be integrated into normal supervision.
Looking at supervisory reports asking supervisors to see
how he or she is performing the job.
Observation can look for specific things such as, again how employee performs a
task, all the steps involved in the task. As you'll recall earlier
in this lecture, we talked about task analysis,
so we have a list of steps in order.
We can see if these are carried out.
We can observe how services are generally flowing in a clinic,
all the way from registration, the waiting time, what happens in
the waiting room, how people are seen, where they're seen, how
people people find the consulting room that they may go to,
after they leave that, do they know where to go
in terms of collecting medicine, paying for their services, etc?
We can see how all this moves smoothly if people find their way or they get lost.
We can observe the interaction between employees.
And clients among employees themselves.
We can see how well, as we mentioned before,
the human relations, the quality of information and communication
that goes along.
We can observe employees interacting with each other.
And things they say, whether they joke about
their job, whether they take it seriously, whether
they share information, whether certain employees intimidate each
other, whether they encourage certain values and beliefs.
Remember listening to health workers discussing at a clinic in rural Kenya and
they were talking about one of the big problems they have getting home
in time before the afternoon rains And one said yes
we really have difficulty we have to fight the queue.
We wondered what that meant, and of course the queue the line of clients.
This showed that their attitude was such that
they had depersonalized the consumers of their service, they
had turned them into this thing called a
queue and they were talking about different ways of.
Fighting or getting rid of this queue not how they were helping people.
So listening and observing and watching people interact
is an important way to learn about training needs.
And again as we said, we can look for,
observe whether the needed supplies and equipment are there
so that the health worker can actually perform the
task that he or she is trained to do.
We've been talking about observing different
things in the clinics and the community.
We've been
talking about of course observing our health workers performing their job.
And we have to look at this dynamic
between those who're observing and those were being observed.
Observations may have limitations in the sense that the
person being observed may feel uncomfortable, may not behave normally.
We may not get a clear indication of the task
they're performing, if they feel
uncomfortable or feel they're being judged,
therefore the observer must establish trust
and try to blend into the background.
We've done a number of studies observing pet
medicine shops and again, this is even more difficult
than observing health workers, because the medicine vendors
Have a strong distrust of people from the outside.
They're not sure if you're the police or you're from health inspector
and are trying to criticize them or shut them down, so it's
important to let them know who you are, work through
their association, so that they know someone is coming around.
And then sit quietly, and make several observations.
Once they get used to your presence there, they will
not think much about it, and go about their normal work.
And we found, in shops, that many times, the medecine sellers.
Their cousin or a friend comes in and sits.
And it becomes a social occasion.
And so
when the customers come in, they don't think
anything much of someone else in the shop.
So it's important to become inobstrusive.
But to do so in a way that.
The people trust you, and then ultimately ignore you.
So, again, in review, we've talked about three
broad methods of diagnosing training needs, gathering information.
We've talked about reviewing documents.
We've talked about interviewing the people concerned.
And we've talked
about observing the process of providing health
services, observing the health workers perform their job.
And it's important to bring all these methods
together in a process of what we call triangulation.
If you recall how people determine where a
earthquake is actually centered and where help is needed.
They use a process of triangulation.
The shock waves move through the earth, and various sensing centers
pick them up.
You can remember from way back from geometry.
If you have two points, you have a line.
It takes three points to create a plane.
And those three points, if you draw, when they pick
up the timing and the intensity, when they pick up the
shock from the earthquake, if you draw circles around them,
where the three circles intersect should be the point at which.
The earthquake actually happened.
And the same thing, if we have three different
methods of collecting information, they can validate each other.
We can determine, in fact, what is the
core issue that training may be needed for.
Let's look at the example of polio eradication.
We see that records may show increasing number of children receiving
the immunization during state-wide campaigns
but reports from sentinel servailance sites.
Throughout the country show that there are new cases of wild polio virus popping up.
This is a serious problem in Nigeria as we can see from the map.
All those red dots are, and blue dots
are where wild polio virus has been found recently.
And they seem to be clustered in the north central part of the country.
So, even though people are.
Giving feedback
that oh, yes, we're immunizing, so, so many children, something must be wrong,
because we are seeing that the virus still persists.
Again, we look at our reports, and these reports sometimes show that the
number of children being vaccinated during
these house-to-house campaigns are approaching the targets.
But the projected census from the state indicates that these targets may only
represent about 80% of the likely population.
Our census data may be off or the targets may not have been calculated properly.
We find that the issue of calculating population
growth based on census may not be done properly.
The growth rates may have been different in urban versus world districts and so.
You know, even though it looks like we're approaching
targets, we may have been using the wrong denominator.
The wrong baseline.
Also, one thing, in terms of documents that
we've seen in a number of newspaper articles.
in that part of the country, is that the people are
complaining that the government is trying to sterilize our children with vaccines.
So something is not right.
We look like, by the reports of the staff who
are going out doing the vaccination, that we are doing fine.
But based on our recalculation of the census we are not meeting that and
secondly the community members are complaining
that the program is damaging their children.
What is really going on?
It is necessary to use. Interview to check these documents.
Discussions may be held with village elders.
People talk about the fear of sterilization.
They were worried the vaccinators, some of them are male and the women and
children are in the house and the men should not enter into the compound.
These, these strangers who are bringing the vaccine and one elder in the
village discussion said look, here behind those
bushes in the entrance to the village.
Look at all these discarded vials of vaccine.
They haven't even been used.
And then you start to wonder, well, what's going on?
So, you've observed the vaccine being thrown away behind the bush.
You hear the villagers complain about the performance of the health workers, their.
Fears about the vaccine. Then you talk
to the, the health workers.
And again, this is a sensitive issue, so you might have
informal discussions with them, so they don't feel pressured by you.
But then they point out that, yes, there is political pressure.
The President's wife is leading the immunization effort.
If you don't give good reports, then you may be queried in your job.
So, even though the villagers don't want the thing, we still
fill in information that makes it look like we're achieving our targets.
They believe that the village police and customs are an impediment to health.
They have a negative attitude toward the villagers.
And they don't even think it's their job
to question the accuracy and the appropriateness of the
target goals, figuring out the number of eligible children,
doing house census, giving feedback and readjusting their targets.
They just do what they're told to do
because the President's wife wants to see good results.
Finally, it's possible
for some of the trainers or supervisors to
follow the vaccinators into the field to see
what goes on, when they approached the village,
people often ran and hid in their huts.
The vaccinators were ordered to select guides from the local area
to take them around, but they treated these guys like servants
Instead of like partners, and when they got to the village
they didn't even go to the house of the chief to do
appropriate introductions according to custom.
So all of these things we had a clue from our sentinel report.
That the virus was still there.
It contradicted the official submissions in terms of coverage.
We talked to people who are involved with the
community, the health workers who had to deliver this.
We observed them and found that there were a number of
implications for training to try to improve the results of this
polio program.
Clearly, there was need for training
in human relations skills And cultural respect.
Health workers need better skills at estimating
their village populations in conducting a local census.
Clearly, communication skills were needed to explain vaccines
and their purposes to the community, that vaccines aren't.
Designed to sterilize your children, they are designed to prevent
them from having diseases like polio so that they can actually be
more productive citizens and have families of their own in the future.
Again, that training needs to focus on how
to get information from the sentinel surveillance process.
Used by local health workers, integrated into the process so that timely decisions
could be made and so that health
workers themselves understand what this data means.
We will be using this information
that we gather from our observations, our interviews.
And our documents to try to formulate training
objectives and training content in our next lecture.
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