Community Health Workers and Primary Health Care in Honduras

Community Health Workers and Primary Health Care in Honduras

Janet Parkinson Quillian DrPH, FNP, CPNP Director,

Family Nurse Practitioner Program, Department of Nursing,

University of Nevada, Las Vegas

Community participation and utilization of community health workers (CHWs) are essential components of the primary health care model. The success of CHWs is dependent on their training and subsequent community support. Community-prepared nurses are ideal CHW educators. A training program for CHWs was implemented in Honduras emphasizing the principles of adult learning and problem-based learning. Following a 4-month program of training a primary health care clinic was opened and managed by CHWs for a population over 10,000. Approximately 80% of local health problems were managed by the CHWs proving that well-trained CHWs can have a significant impact on the delivery of health care.

In 1978 the World Health Organization (WHO) introduced the following concept of primary health care.

Essential health care is made universally accessible to individuals and families in the community by means acceptable to them through their full participation and at a cost that the cornmunity and country can afford. Primary health care forms an integral part both of the country’s health system of which it is the nucleus and the overall social and economic development of the community. (Bennett, 1979, p. 505)

Primary health care focuses on a preventive model of care that places health within the domain of the community and stresses the importance of environmental and social factors. The primary health care model emphasizes community participation, utilization of community health workers (CHWs), and intersec-

Address correspondence toJanet Parkinson Quillian, DrPH, FNP, CPNP, Director, Family Nurse Practitioner Program, Department of Nursing, IJniversity of NtTddd-hS Vrgas, 4505 S. Maryland Pkwy., Box 4.55018, Las Vegas, NV 89154-9018.

toral collaboration (i.e., coordination and collaboration between sectors such as education, agriculture, and environment). In this model the CHWs are the foundation of primary health care because they serve as the common link between their community and the health sector (Bender & Pitkin, 1987).

CHWs are a new group of health personnel. They are trained to provide both curative and preventive care. Selection criteria differs from one country to another and sex preference generally is guided by culture. Their training programs are shorter than programs for professional health workers. CHWs play a vital role in the implementation of primary health care because they not only provide health services but also are key to the promotion of community participation and intersecto- rial collaboration.

Nurses also play vital roles in the domain of primary health care practice and in the training of CHWs. Nursing’s value of the CHW concept is reflected in a statement by Manfredi, regional nursing director of the Pan American Health Organization: “Nurses more than any other health personnel have the potential to

VOLUME 5, NUMBER 5, SEPTEMBERIOCTOBER, 1993 219

FIGURE 1 , San Pedro Sula, Honduras, site of the primary health care clinic run by community health workers

form auxiliary nursing personnel and community-based workers into an efficient primary health care team” (Manfredi, 1983, p .107).

The education and training of CHWs ideally can be carried out by nurses who have a background in community-based education because they view the community, not the individual, as the patient. Commu- nity health nurses recognize the social, cultural, and environmental factors that influence the health of a community and they are able to synthesize the knowledge of public health sciences, the nursing process, interpersonal skills, and leadership principles. A community health nurse’s role in primary health care can be demonstrated by personal experience in Honduras teaching CHWs and forming a primary health care clinic.

For 3 years (1986-1989) this author served as a Catholic lay missioner with the Maryknoll Catholic Foreign Mission Society of America. The city of San Pedro Sula in the country of Honduras was selected as a site for ministry because of the considerable health care needs both displayed and expressed by the local Honduran people during an earlier visit in 1985.

SAN PEDRO SULA. HONDURAS

San Pedro Sula, in Northern Honduras, is an indus- trial city of approximately 400,000 people (Howard, 1992). Many indigent rural people come to San Pedro Sula seeking employment. Unfortunately, when em-

ployment cannot be found, people are forced to move to the outskirts of town into semiurban areas called colonias, land areas that represent more econoniic development, and invasion areas. Invasion areas are sections of land which groups of‘ people have moved onto without owning the land or paying rent. They literally have reclaimed the land and live in makeshift shacks without benefit of‘ adequate sanitation or water. Outside the city of San Pedro Sula exist several invasion areas and colonias. One colonia was called SanJose.

The colonia of San Jose originally had been an invasion area. In 1986 it was categorized as a colonia because of the economic growth that had occurred. For example, most homes were constructed of either cinder block or wood. Indoor toilets and unsanitized piped running water were available in a few areas and electric- ity had been installed. This author’s one room home had water, lights, and a bathroom.

HEALTH IN HONDURAS

The small country of Honduras in Central America borders the republics of El Salvador, Guatemala, and Nicaragua (Figure 1). The population base is approximately 4.6 million of which 63% reside in rural areas (Kendall, 1988). Almost half‘ the population (48%) are <15 years of age and 20% are <5 years of age (Kendall, 1988). The annual growth rate in Honduras is 3.5%, and the annual per capita income is $560 (The World Factbook, 1988). However, it is estimated that approximately 40% of the population have an annual per capita income of <$50 (Honduran Ministry of Public Health [HMPH] , 1989) and life expectancy here is calculated to be 59 years (The World Fuctbook, 1988). Despite substantial foreign aid for many years, Honduras still remains one of the poorest nations in Central America (Howard, 1992).

The health system in Honduras follows the concept of primary health care as adopted by WHO in 19’78 at Alma Ata (HMPH, 1989). The health care system structure is based on two subsystems: one institutionally based and the other community based. The institutionally based system is composed of five tiers as depicted in Figure 2. Major health services and resources such as hospitals are centralized in urban areas with a focus on curative care. In rural and periurban areas primary health care is provided through health centers staffed by doctors, nurses, or health promoters (Janowitz, Bailey, Ochoa, & Suazo, 1987).

The second subsystem is community based and is composed of health volunteers who provide basic health care services including maternal and newborn care, sanitation, and malaria control. Although 70% of

220 JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS

the Honduran population have access to health care (HMPH, 1989) basic health care facilities and personnel still are lacking in regions, medical care can range from minimal to nonexistent, and there is a predomi- nance of curative rather than preventative care.

Major reported health problems include enteritis, gastritis, tuberculosis (Encycloprrlia of the Third World, 1987), diarrhea, malnutrition (HMPH, 1989), and ac- quired immunodeficiency syndrome (AIDS) (Fox et al., 1990). Diarrhea kills one third of Honduran children below 5 years of age (Staff Pacafic News Service, 1990). Almost one half of children under 5 years (45.1%) are chronically malnourished and approximately two thirds (63%) of individual Honduran family members con- sume less than 1900 Kcal daily (HMPH, 1989). Diarrhea coupled with malnutrition may account for the infant mortality rate of 76 in 1,000 ( U N Z W Centrul Amm'can Report, 1988) which is considered high in relation to worldwide levels.

In 1987, one third of reported AIDS cases in Central America were in Honduras. By 1988 Honduras alone had 237 cases (Fox et al., 1990) which prompted Zelaya, director of the Epidemiology Division ofthe Honduran Ministry of Health (personal communication, April 1988) to declare that Honduras has the highest inci- dence of AIDS in Central America. According to the Pan American Health Organization, health conditions in Honduras were among the worst in Latin America (Enryrlopediu ofthe Third World, 1987).

VALIDATION OF COMMUNITY NEEDS

The most successful training programs developed by health professionals are those in which the health professionals are familiar with local problems (Watkins et al., 1990; Werner & Bower, 1983). One recognized method for becoming familiar with a community and its problems is through community assessment. In the colonias and invasion areas surrounding San Jose there was only one small public government health clinic. Although it was evident that this clinic could not meet the needs of a population base greater than 10,000 people, validation was required to confirm the health needs of the local colonias and invasion areas.

The first step in community assessment was to visit the surrounding colonias that had health committees and to learn about the health care needs of their communities. Although there were 14 colonias in vary- ing stages of development, only three had health committees.

The second step was to conduct teaching sessions on common community health problems in the homes of several local women. After the teaching sessions there

VOLUME 5, NUMBER 5, SEPTEMBER/OCTOBER, 1993

National

Regional

CESAMOs (Centro de Salud con Medico) b CESARs (Centro de Salud Rural)

FIGURE 2. A diagrammatical representation of the Honduran National Health Service System.

Note. Adapted from information contained in Epidemiology and family Health Survey-Honduras, 1987 Final Report, the Honduran Ministry of Public Health, Association for Family Planning in Hondu- ras, Management Sciences for Health, and Family Health Interna- tional, 1989.

would be informal discussions about health problems and local community news.

The last step was to offer a weekly mobile health clinic. This mobile health clinic was conducted from the back of a Volkswagen car. The car was loaded with medicines and supplies and driven into a designated colonia or invasion area. Mothers, children, and men would come to be examined and to receive medicines and health advice. Local women who were community leaders assisted with these clinics.

The community assessment revealed three major health problems affecting all of the communities (Table 1) : malnutrition, upper respiratory infections, and infestation with parasites. Other findings from the assessment revealed that poor economic conditions, lack of education, illiteracy, hot tropical climate, and inadequate sanitation were contributing factors to the residents' health problems.

Above all, the community assessment revealed that the primary health need of the people was to have a health clinic that would be respectful of their health needs and accessible to all, even those who were unable to pay.

This need was stated by patients and residents at both the weekly health visits to the colonias and the teaching sessions. Mothers would tell of their frustration in trying to obtain health services at either the local government

221

TABLE 1. COMMUNITY ASSESSMENT DATA

Population Approximate

population Age distribution

Number of children per family

Education Level

Economic Level

Environment Climate Housing

Sanitation

Health Facilities

Major Problems

5,000- 1 5,000

Approximately 55% below 15 years of

Average of 6 per family age

Majority below 8th grade

Males earn an average of 5 lempiras ($2.50) daily. Local women selling tortillas, vegetables, and fruit earn an average of 2 to 3 lempiras daily.

Tropical, humid Houses consist of tar paper, tin, wood,

cement blocks Lack of clean water, lack of indoor

toilets, lack of waste disposal facilities

No hospital, one government clinic, one

Malnutrition, parasitic infections, respiratory infections, skin problems, lack of health education

private medical doctor's office

clinic or the hospital clinic located in San Pedro Sula. Frustrations listed were long waiting lines, refused entry into the hospital c h i c unless there was an emergency, rudeness on the part of health personnel, and lack of money to pay for prescribed medicines.

Following the community assessment evaluation, this author, the local priest, and key community people decided to open a primary health care clinic that would be staffed and managed by local CHWs.

RECRUITMENT OF CHWS

One of the first steps in establishing a primary health care clinic was to recruit applicants to be CHWs. Only women were considered as applicants.

This women-only decision was based on the following rationale. First, many of the women living in the colonias and invasion areas either had been abandoned by their spouses or their spouses were without work. Conse- quen tly, they needed employment. Second, poor women in Honduras have a low societal status. Therefore, the CHMr training program was seen as a means of raising the status of women and providing empowerment.

In most primary care programs, i t is the commitment and penonal characteristics of the health workers that

are important in creating and maintaining successful programs. Hence, five factors were considered in the selection process. The applicants were women who: 0 were able to read;

were living in the colonias or invasion areas; had the support of their community; were in need of employment; and

0 were motivated and dedicated. I n January 1987 three women representing two

communities asked to become CHWs. For 4 months, daily classes lasting 4 to 5 hours were held in a local church and in the author's home. The author was the sole educator and trainer.

The curriculum of the training program was based on the health curriculum developed for village health workers by Werner (1985). Basic content was divided into the following instructional modules: common illnesses, communicable diseases, first aid, ear and eye problems, maternal and child health, medicines, nutrition, sanitation, and skin problems.

EDUCATING CHWS

The training and education received by CHWs are important in determining and directing their perform- ance in the community. It is important that educators and trainers of CHWs receive specific training that allows them to choose appropriate methods for teaching, to prepare relevant curricula, and thus supervise students in a positive supportive manner (Amaah- Ofosu, 1983; WHO in Action, 1987).

This author felt qualified as an educator as a conse- quence of prior experience in educational planning and teaching and from having provided health care to indigenous people in rural Mexico. Also, a workshop on adult-based learning methodologies in addition to having access to experienced health educators who were working in health promoter programs in Guatemala and Nicaragua helped. These educators willingly shared curricula and ideas.

The teaching methodologies used in the San Jose project were chosen because they were student cen- tered, would build student self-confidence, and, most importantly, would empower the students to view them- selves as capable of fulfilling the role of CHWs. These methodologies were a combination of popular, adult, and problem-based learning theories (WHO, 1987).

Popular educational theory can be defined as education that stresses equality between student and teacher. The student's life experiences, values, and knowledge are valued and are included daily as essential conipo- nents of the learning process (Freire, 1970).

Adult learning implies that the adult learner should


TABLE 2. FUNCTIONS OF COMMUNITY HEALTH WORKERS

Provision of curative care Provision of preventative care Health education Management of health services Participation in health team work Training other members of the health team Collaboration with other sectors involved in health and community

Self-assessment and continuous development of personal development

professional skills

be involved in the entire learning process from planning to evaluation. Additionally, motivation ensues through using material and content that has a direct application to the learner’s life (Hope & Timel, 1985).

Problem-based learning theory (Berman, Gwarkin, & Burger, 1987; Werner & Bowen, 1983; WHO, 1987) is structured around solving specific primary health care problems and community situations that influence health. A primary health care problem is introduced, and instead of the teacher providing the answer, the students try to solve it or come to some conclusion as to how the health problem should be managed. A second component of problem-based learning is hands-on experience. Following most classes, all students had clinical sessions related to the health material being taught (Werner 8c Bower, 1983).

IMPLEMENTING A PRIMARY HEALTH CARE PROGRAM

In May 1987 the clinic of San Jose opened with two small rooms. By September 1987 a nutrition program was added for malnourished children under 5 years when a clinic survey of children’s weight and heights indicated that over 25% of the children under 5 years were severely malnourished. By early 1988 a pharmacy was added and in January 1989, a formal laboratory. Also in 1989 a second class of CHWs was graduated.

It has been recognized by many primary health care programs that CHWs must work in teams to be effective (Boerma, 1987; Nichter, 1986). The concept of utilizing primary health care teams is an integral part of the overall primary health care strategy (Berman et al., 1987).

The value of adding a health care team is manifested by San Jose clinic’s philosophy and guidelines: 0 team members must be willing to interchange job positions according to the needs of the clinic; 0 management decisions are mutually decided; 0 team members are unique and valuable; and

TABLE 3. MAJOR HEALTH PROBLEMS SEEN AT THE CLINIC OF SAN JOSE

Parasitic infection Gastrointestinal problems Diarrhea Otitis media Acute respiratory infections Anemia Malnutrition Skin infections Urinary tract infections Vaginitis Burns Hypertension Family problems Mental health problems Musculoskeletal problems Birth defects

0 patients are to be treated with respect and courtesy. The functions of the CHWs also enabled them to

build the necessary foundations for forming a successful health care team within the clinic setting (Table 2).

By May 1989 the clinic was financially self-sustaining, totally managed by the CHWs, and administered by a church committee composed of members from a local colonia and invasion area.

The clinic of San Jose fulfilled the first tenet of primary health as defined byWH0 (Lee, essential health care was made accessible to individuals and families of all the colonias and invasion areas). The CHWs saw 20 to 60 patients daily and were able to manage approximately 80% of local health problems (Table 3).

The second tenet fulfilled by the San Jose clinic was manifested through community participation in clinic services. These services were at costs the community could afford. For example, the cost of a consultation was 2 lempiras ($1) which included all prescribed medicines but not laboratory charges. Clients who could not pay for a consultation or for laboratory tests were treated gratis.

Collaboration was achieved by mutual referrals between the clinic of San Jose and the local public government clinic. Additionally, referrals were made to a local physician in San Pedro Sula and to the San Pedro Sula government hospital.

Unfortunately, the promotion of a disease prevention model of care was not implemented. The CHWs’ attempts to group teach about either health promotion or disease prevention topics were not successful. Pa- tients did not attend health teaching sessions. Perhaps it is not possible to implement a disease prevention model of care when a population or community suffers

VOLUME 5. NUMBER 5, SEPTEMBER/OCTOBER, 1993 223

from profound poverty. Until the basic needs of life are fulfilled (i.e., adequate food, water, housing, employment, and education) people are less apt to accept health promotion and disease prevention strategies.

FACTORS RELATED TO WORKING WITH CHWS

Several observations were made during the 3-year experience with regard to factors that enhanced success in the education of CHWs.

Answers and solutions to problems coming from the CHWs and members of the community, rather than from the educator and trainer, strengthened the knowledge and skill of all participants. This required development of good listening skills on the part of the educator and trainer.

Modeling of interdependence in problem solving and daily working activities fostered teamwork.

Facilitating an atmosphere in which mistakes were accepted and used for positive learning opportunities fostered openness and trust.

Sharing functions and leadership tasks with the CHWs became a way of giving power that encouraged participants to behave in powerful ways.

The presence of the educator and trainer on a daily basis fostered trust in the community at large. The visibility of the nurse through providing care and instruction was a critical factor in developing this trust.

CONCLUSION

The major reason for the success of the San Jose clinic was the commitment and dedication of the

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CHWs. They were successful because of the trust and competency they manifested daily to the people they served. Part of the CHWs’ success also was due to the education, training, and support they received. The education and training probably would not have been as effective without a teacher with a background in community health nursing. Together, as a health care team, they were able to implement primary health care with the aid and support of the people.

Implementation of a primary health care model with CHWs could be adopted with modification in meeting the health needs of some populations in the United States. Various studies have examined the role of lay health advisers in the United States in mediating the effects of barriers to health care (Mahon, McFarlane, & Golden, 1991; Watkins et al., 1990) and reactions have been favorable. The bene- fits gained from using a community lay support network include increased availability and viability of health services, better communication between professionals and consumers, and increased community participation.

Today, the United States health care system is in crisis due to increasing costs of health care resulting in little or no access to health care, plus consumer dissatisfaction with the lack of concern and human- ness in the delivery of health care. The adoption of a community-oriented primary health care model could be an essential component in alleviating current health problems.

Health for all by the year 2000 is a universal goal. In order to achieve this goal, communities worldwide must take responsibility for their health and become empowered through community primary health care and the introduction of CHWs.

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Janowitz, B., Bailey, P., Ochoa, J., & Suazo, M. (1987). Contracep- tive use and fertility in Honduras, 1981-84. Studies in Family Planning, 78, 291-301.

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CALL FOR ABSTRACTS I 1 Fourth International Primary Health Care Confer-

ence. Kensington Town Hall, London, England. June 1-3, 1994. Sponsored by Nursing Times and Community Outlook. Abstract deadline is November 30, 1993. For further information write to Fourth International Primary Health Care Conference, Con- ference Office, 4 Little Essex St., London, WC2R 3LF, England.

First Primary Health Care Conference Celebrating 20 Years of Primary Health Care in Nursing Educa-

1 1

tion. Sheraton-Tara Hotel, Parsippany, NJ. June 3-4, 1994. Sponsored by Seton Hall University College of Nursing. Completed or in-progress research or professional papers concerning all aspects of primary health care are invited. Abstract deadline is October 15, 1993. Submit four copies of abstract, indicate whether it is for poster or oral presentation, with CV to Dr. Margo Griffin, Seton Hall University, College of Nursing, South Orange Ave., South Orange, NJ 07079.

VOLUME 5, NUMBER 5, SEPTEMBER/OCTOBER, 1993 225

Community Health Workers and Primary Health Care in Honduras

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