Performance Based Education
for Community Health Workers
What's wrong
with this picture? (A True Life Story):
Scene: A three-day training session for
health workers who do street outreach, counseling and partner notification in
sexually transmitted diseases in a major city. A series of doctors lecture to
the health workers, showing slides of patients with STDs, and presenting on
diagnosis and treatment. They reel off facts and figures which the health
workers are supposed to memorize for their pre- and post-tests. The doctors
drone on and by the end of each day the health workers' eyes are glazed over
and they are completely frustrated.
What's wrong?
1. The doctors
are teaching what they were taught, not what the health workers need to know
how to do. The content of the training is determined by "experts,"
not by people who really do the work on the ground in the community. The people
who are teaching have never done what the health workers need to know how to
do.
2. Learning is
evaluated by regurgitation of facts, not by the mastery of skills in a
real-life situation. This kind of pencil-and-paper evaluation favors people
with more formal education, not necessarily people with knowledge of the
community who are most effective in the field.
3. The health
workers get an informal certificate of completion, but not college credits that
contribute to raises, career mobility or educational advancement. No matter how
much they know, how high their skill level, or how much responsibility they
take, they are too often ghettoized in a dead-end job.
4. Every topical
specialty--for example, sexually transmitted disease, or nutrition, or
perinatal--designs its own training program. None of these programs recognize
the trainings put on by other programs, so that health workers find it hard to
advance no matter how many trainings they attend. However when our project
compared job descriptions across specialties, we found that many process skills
-- for example client interviewing or health advising -- are common to CHWs no
matter what their topical focus.
To address these
problems, the Community Health Works of San Franciso, a joint project of San
Francisco State University and City College of San Francisco, established a
Community Health Worker Certificate, the first such college-sponsored
certificate in the US. Our approach is called Competency Based Education. The
foundation of the curriculum is a job task analysis. In a two-day workshop
facilitated by the DACUM Center ("Develop a Curriculum") of Spokane Community
College, twelve veteran community health workers pinpointed key competencies
based on their first-hand knowledge of what they do each day. The seven
competencies are client interviewing/intake; client orientation; care
coordination or case management; documenting and reporting; providing
referrals; providing health information; and community health education or
outreach/organizing. With the input of veteran CHWs and supervisors, each
competency is broken down into subcompetencies, and each one is described in detail:
What does it look like when this competency is done well or poorly? In this way
each person in the program knows she is learning what is critical, and that she
has mastered the competency well enough for use in a real life situation. On
the first day a learner comes to class, she or he receives this roadmap of what
they are to learn and what criteria will be used to evaluate mastery. The
curriculum addresses the knowledge, skills, and attitudes that a health worker
needs to be successful. Potential employers know that graduates of the
Certificate program are capable of consistent performance.
Together with
partners, we are now developing the full listing of competencies and
proficiency criteria into a Standards of Practice Manual for CHWs (to be available
in 1997). We also carried out statewide and regional surveys of employers to
analyze the job market and skill sets that are in greatest demand in a
rapidly-changing health system.
In Competency
Based Education, evaluation is done not mainly by pen-and-paper exams, but by
performance in scenarios based on typical real life situations. We adapted the
Objective Structured Practical Exam format first used by the World Health
Organization (Abbatt 1993). Health Workers and supervisors scripted typical scenes
from the workplace. Then we set up stations where each class member enacts the
role play with an actor and is observed by an examiner (a veteran community
health worker or supervisor). The examiner uses the competency checklist to
determine if the skill was carried out at a level of proficiency required by
someone entering the field. Because the criteria are clear and spelled out in
advance, exams can be used for learning and feedback, not as an exercise in
memorization.
Our program has
a strong belief that health workers need a strong orientation to "the big
picture" of the urban health crisis. Poor communities are embattled by
cutbacks against people on welfare, immigrants, and those caught up in the
criminal justice system. CHWs need to master not only technical information,
but also be able to serve as a voice of the community in the political process
that has such a big effect on community health. One learning activity we use is
a simulation called "the Single Room Occupancy Game," in which the
classroom is turned into something that resembles a giant Monopoly game board.
The simulation, distributed by the Bay Area Homelessness Project at San
Francisco State, allows the players to see and analyze the social, political
and economic dynamics that lead to homelessness. Our educational process also
stays close to real life by having many class sessions led by CHWs and
supervisors.
City College of
San Francisco has an open admissions policy, and costs only $13 a unit, so it
is truly accessible to grassroots community people. Because our Center is one
of the rare partnerships between a community college and four-year university,
we are well-positioned to make sure our program is not a dead-end, but part of
an educational ladder. We have an excellent agreement in which people who
complete our Certificate can apply credits to an associate's degree and then
transfer 12 college units to San Francisco State University toward a bachelor's
degree in Community Health Education.
In 1995 our
program was recognized as one of the 15 most "innovative and
promising" health training programs in the US (Seedco/Annie E. Casey
Foundation). We were also one of the top three percent of programs funded by
the U.S. Department of Education (Fund for the Improvement of Postsecondary
Education, FIPSE). For further information, send for our brochure and
publications list: Community Health Works of San Franciso, Department of Health
Education, 1600 Holloway Avenue, San Francisco CA 94132-4161, e-mail:
chw@sfsu.edu, fax (415) 338-7948.
This article was published in the Healthy
Mothers/Healthy Babies POWER Newsletter, 1997.
© SFSU/CCSF Community Health Works of San
Franciso, 1997.
For more information contact: CHTDC, Department
of Health Education, 1600 Holloway Ave., San Francisco, CA 94132.
Phone: 415/338-3034 Fax: 415/338-7948 Email:
chw@sfsu.edu
fn: competencybasededpower/pr 9.9.97
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