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PN-ABE-445 Bestavailablecopy-- pages 70 and 76 - 77 missing
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1-W Ll CL
ALTERNATIVETRAININGSTRATEGIES FORBARANGAYHEALTHWORKERS
IN PRIMARYHEALTHCARE
Leticia S.M.Lantican ThelmaF.Corcega
AResearch Project ofthe University of thePhilippinesCollege of Nursing,U.P. Manila,withthe support ofCENTERFORHUMANSERVICES-PRIMARYHEALTHCAREOPERATIONSRESEARCH (CHS-PRICOR)under SubordinateAgreement #83/17/3600
December 1,1983 - February 28, 1986
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TABLEOFCONTENTS Page
ACKNOWLEDGEMENT LISTOFACRONYMSUSEDINTHEREPORT EXECUTIVESUMMARY
Chapter I BACKGROUND
The HealthProblemandTarget Population ..................... 1
Primary HealthCareas an InterventionStrategy ........... 2
BarangayHealthWorkers inPHC .... 5
A-ProblemAnalysis andSlution
Description ofData-gathering
TrainingofResearchAssistants/
BHWTraining: Reviewof Literature 9 The ThirdWorldView ........... 9 The PhilippineSituation ........ 14
II STUDY PURPOSE: OPERATIONALPROBLEM 22 III METHODOLOGY.............................. 27
Devr. .................. 27
Instruments .......................... 29
DataCollectors ............. 31 Descriptionof StudySites ...... 33 SamplingFrame .........................40
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Chapter Page Results ofProblem Analysis ..... 41
Training ProgramManuals ..... 42 Trainors ....................' 44 BHWs ......................... 46 Assessment of DHWTraining Programs fromBHWs and
Assessment of BHWTrainingUsing Trainors' Viewpoints ....... 49
Community Indices .......... 52 SolutionDevelopment ........... 55 SolutionValidation: Field Testing of the AlternativeBHWTraining Program ...................... 69 Data Collection Methods ......... 71 Development ofaTool for Rating the Performance ofBHWs in Primary
HealthCare .................. 73 IV RESULTS (SolutionValidationOutcome) 79
Part I. Case Studies: 80 A. Bairangay Matimbo ........... 80 B. Barangay Dalupirip ........... 113 C. Barangay BagongSilangan ...... 134 Part II. Quantitative Data ...... 155
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Chapter Page
V SUMMARY, CONCLUSIONS ANDRECOMMENDATIONS 178REFERENCES ................... 185APPENDICES
Appendix I- Administrative 187Appendix II - Research Dissemination
SeminarAppendix A- Training ProgramAssessment FormAppendix B- BHW Trainor Questionnaire
191
200201
Appendix C- BHWTrainee Questionnaire 210Appendix D- Community RespondentQuestionnaire 215Appendix
Table
E- Results of ProblemAnalysis1- Course Syllabi in Study
Sites
222
223Table 2- GSE of Trainors 227Table
Table
3- PersonalityProfile ofTrainors
4- Trainor "PUP" Results228229
Table 5- GSE of BHWs 230Table 6- BHW "PUP"Results 230Table 7- Assessment of BHWPerformance by Trainors 231
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ChapterTables'8a- 8c
Tables 9a- 9c
Table 10
Tableslla-llc
Table 12
Appendix F
Appendix G
- Assessment of Training Prograz by Trainors (Dalupirip, Bagong Silangan,Matimbo)- Rankingcf Courses by Trainors and Trainees According to Importance (BagongSilangan, Dalupirip,Matimbo)- Trainee Responses on Adequacy of Training- Problems Encounteredby Trainors DuringTraining (BagongSilangan, Dalupirip,Matimbo)- Person Consultedby Community for Health Needs and Problems- Group Dynamics (GD)
Exercises- Modules
Primary HealthCareMaternalHealthCareChild CareTuberculosis ControlDiarrhea
Page
232
235
238
239
246
249 252 253 262 276 287 293
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Page
Appendix H PracticumActivities andWorksheets 307
HouseholdInformation
Performance Rating
SupervisedFieldActi-
Appendix I - FamilyMonthlyMonitoring
Appendix K - BHW Performance Rating
Appendix L - BHW "Incentive" Certi-
Appendix M - Research-Dissemination
PHC and BHW: 308
Sheet 309 RecordingaMeeting 311
Scale 312 MaternalHealthCare 313
vities in Child Care 315 Well Baby Record 316 TBPrevention 319 SlidePreparation 320 Diarrhea 321
Sheet (FMMS) 323 Appendix J - Post-Tests 326
Scale 333
ficate 334
SeminarProgram 335
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LISTOFTABLES
Page SampleSize forthe ThreeStudySites 41 Comparative Characteristicsof the TrainingPrograms in the ThreeStudy Sites ......... ........................42 BHW Profile ...................... 47 Socio-Demographic Characteristics of CommunityRespondents ............ 53 Community AwarenessofBHWExistence 53 UtilizationofBHWServices Through Consultation.............................54 SolutionDevelcpment ............. 60 Summary ofTrainingCharacteristics in Three StudySites ............. 70 Weights Assigned by Expert-Trainor andBHWGroups to Items in the BHW RatingScale ........ .................. 75BHW PerformanceRatingScale ...... 77 Socio-Demographic Characteristics of BHWTrainees (Matimbo) ........... 84 WeightsAssignedbythe BHWs to Items inthe PerformanceRatingScale (Matimbo) ....... .................... 107 BHWAssignedWeights to Items inthe
128erformance RatingScale .........Socio-Demographic Characteristics of BHWs (BagongSilangan) ........... 138 WeightsAssignedbythe BHWs (BagongSilangan)tothe Itemsinthe PerformanceRatingScale ............ 150
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Table Page
16 KnowledgeScores ofBHWs ......... 15517 NumberofBHWsWho ObtainedMinimum
Pass PerformanceScores ........... 15618
19
BHWResponses ConcerningAdequacy ofthe BHWTrainingProgram ...........Topics Rankedby the BHWsAccordingto Importance ...................
159
16020 Criteria for BHW Selection ....... 16121 RankingofTopics by Trainors
Accordingto Importance .......... 16222
23
Socio-DemographicCharacteristics ofCommunity Respondentsin the ThreeStudy Sites ......................EnvironmentalFeatures ofthe ThreeStudy Sites .......................
164
16624 CommunityAwarenessofBHWExistence 16725 Awareness ofPHC in Community 16826 PerceivedFunctions ofBHWs byCom
munityRespondents ............... 16827 PercentageofCommunityRespondentswhoConsultedBHWs ............... 16928 Community'sInclinationtoShare
HealthNeeds and ProblemswithBHs 17029 Community'sPerception ConcerningBHWs'
CapabilitiestoHelp Them ........ 17030 CommunityResponse ConcerningBHWIncentives ...................... 17331 Criteriafor BHWSelectionas Per
ceivedby CommunityRespondents 17432 PerceivedPersonalityCharacteristics
ofBHWsby theCommunity .......... 176
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LISTOFFIGURES
Figure Page
1 ConceptualModel ofthe Study ..... 23
2 ProblemAnalysisandSolutionDevelopment ......... .........................27
3 ConceptualModel ................. 59 (GuidingSolutionDevelopment)
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EXECUTIVE SUMMARY This reportdocuments theexperiences of the U.P.CollegeofNursingResearch Programin atwo-yearoperationsresearchprojectunderthesponsorshipofCHS-PRICOR. The studyprimarily aimedtodevelopsolutions to problemsinthe designanddeliveryof trainingof BHWs inPrimary healthcareservicedelivery. Itwas undertakenin cooperationwiththe agencies inchargeof thestudy sites utilized,such as the MOH-Provincial HealthOffice inBulacan,QuezonCityHealthDepartment,and St.LouisUniversityCollege of NursingMobileNursingClinicin BaguioCity. The study'sspecificobjectiveswere to: examine ongoingtrainingprograms for BHWs in PHC, focusingon factorsinvolvedin theselection,trainingandsupervisionof BHWs in the field,as wellasproblemsand difficultiesencounteredin training; developand fieldtest alternativetrainingstrategies inBHW training; and finally,evaluatethe outcomesof thesealternativetrainingstrategies. Attainmentof these objectivesweresoughtutilizingthreephasesin thestudy. PHASE Iassessedthe qualityof trainingprogramsin three studysites in theLuzon region. Of these study sites,twowere academicallyinitiated; one,representedby an urbandepressedarea inBagongSilangAn,QuezonCity,and theother,aruraldepressedarea inDalupirip,Itogon,Benguetprovincein theNorth. The hirdsite wasanotherrural area in Matimbo,Malolos,Bulacan inCentralLuzon,underthe jurisdictionof theMOH-Provincial HealthOffice. At the timethestudywas initiated,thesethreeareaswereconsideredmodelsinprimaryhealthcaze servicedelivery. Thefollowingindiceswereutilizedin assessingthequalityof trainingin thesethreeareas,namely, :rainingprogramdesign,trainor,trainee,andcommunity. Dataweregathered throughexaminationof thetrainingprogrammanualsusedin BHWtrainingas well asformalinterviewsthroughtheuse of structuredquestionnaires ofBHWs,Trainors andcommunityrespondents. Psychological instrumentswereadministered too,tobothBHWsandTrainors to obtainadditionalpersonalitycharacteristics. The followingwere theresultsofPhaseIanalysis:
1. TrainingProgramDesign:Thetrainingprogrammanualscoveredtheessentialcontents thatBHWsshouldlearn. Theywerealsotrainedtodevelopskills in takingbloodpressure, temperature andstool examination. Thedurationof trainingwastwoweeks fortheBulacan andBenguetareas andeightweeks forthe QuezonCitysite.
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2. Trainor: The trainors for theQuezon Citysite werethreefacultymembers fromaUniversity-basedCollegeof Nursing,while that in Bulacan,had the RHUstaffcomposedof thePhysician,NurseandMidwife, with invitedresourcespeakerson certain topics. InBenguet area,the trainingstaff consisted of three staffnurses,one facultymemberand amedicaltechnologist. In general, the trainors in thethree studysitesbelong to theyoung adultand earlymiddle-aged group, females,andmarried. Their length of service in cormnunityhealthrangedfrom 3to 15 years. Theirpersonality characteristics as revealed by thepersonalityinventorieswerethose ofmature,well-adjustedgroups interested in thewelfareof humanbeings.Theyalsoexhibitedpersonalitytraits suchas self-esteem,self-regard, self-acceptance,patience,ambition, creativityandsenseof responsibility, whichwere generally ofahighlevel. Thesepositivequalities were further supportedby theBHWs' satisfactoryratingsof theirtrainors withregardstocharacteristics suchas punctuality,knowledgeof subjectmatter,clinicalskills, interestin teachingandlearningofothers,ability tomotivate andgive constructivecriticismsas well.Thesetrainors characteristics,traits and attitudeswere alsoperceivedbybothtrainors andBHWs as facilitatingTrainee learning. 3. BHWTrainee: TheBHWs in thethree study sitesgenerally.belongto the earlymiddle-agedgroup,mostly females, married,self-employed and elementarygraduates. Theirmean lengthofstayin their :espective barangays ranged from10 to 32years.heirpersonalitycharacteristicspresentedagenerallymatureandcongenial groupwithmediumlevelof self-esteem,achievementorientation,and capacity forwarminterpersonalrelationship. Theyalso yieldedin thepersonality inventories,traitsofhighquality, specifically,on ambition,endurance,patience,fortitude,sense ofresponsibilityandrespect. Withinthisgenerallypositive self-imagehowever,were interpersedsomefeelings ofinferiority,anxietyanddeprivation. Nonetheless,thepositive image oftheBHWs, generallyprevailedandbutressedbythe favorable assessmentof theirperformanceby thetrainors duringdifferentperiodsof theirtrainingandposttraining, specificallypertaining to servicesrendered.
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The comparativeanalysis of both BHWsand Trainorspertaining to adequacyof trainingprograms,specificallyoncontentcoverage, duration, teachingmethods andpracticum,yielded further the followingresults: a. Both groups,in general,agreedon the adequacyof the content coverage of the training programs. They differed however in judging the practicumaspectswith regards to adequacyas well as in ranking thetopicstaken in theorder of importance. b. Some problems encountered in training concernedtrainingschedules,poor ventilation in trainingvenues, boringlectures, useof English asmediumof instruction and lackof teachingmaterials.
4. Community: Thecommunity indices,especiallypertainingto awarenessand utilizationof BHWserviceswere generallyinadequatein two outof the three study sites. Itwas onlyin the Benguet regionwhere therewas ahighpercentageof responseson communityawareness as well as utilization of BHW services. Basedon thepertinent findingsof PhaseI,it wasconcluded that whilethe trainingprograms covered theessential contentsneeded by theBHWs and ratedadequateaswellbyboth trainorsandBHWs, the negativefindings on the community awareness and utilizationof BHW servicespointed to somedeficienciesof the trainingprograms. Thesedeficiencies were related toinadequate supervisionandmonitoring of BHW performance after training,ambiguous perception byBHWs oftheirrolesand functions,particularlythe conceptof household coveragein their catchment areas,wide contentcoveragewhich weremorecurative-orientedthanpreventive,and inadequate informationdisseminationor recruitment campaignin the community concerningthe BHW trainingProgram. Against the foregoingbackdrop,plans for implementingalternative training strategieswere made with thetrainors in thethree study sites. PHASE II of theproject involved the planning andimplementationof thealternative training strategies forBHWsinprimaryhealthcare, using the samestudy sites. Thus,eachstudysitebecame itsown control, in this field testing phase.
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Thenewtraining scheme had the following features: 1. Intensification of the recruitmentprocess through conductionofan informationcampaign concerningthe new
trainingprogram. Thiswas done throughholding of communityassemblies two weeks prior to actual training. 2. Course Syllabusfocused on fivemain topicswhichwere morepreventiveoriented,using the Five ImpactProgram of the MOHas standard trainingcontent. 3. Useof module as mainteaching tool. 4. Standardization ofdurationof trainingto five (5)weeks,withone day devoted to didacticsand four days to practicum per week. This schedulehad to be varied however ineach study site to suit the timeavailabilityand preference of the participants. 5. Alldidactic sessionswere preceded byGroupDynamicsexperience as "warm-ups", aside from servingitspurposeof relatingthe valueof the group experience to the topics to be learned for the dayand to the entire training program as well. 6. Monitoring of practicumactivities through theuse of worksheetsthatweresubmitted everyweek aftereach lesson. 7. Tseof pre- andpost-teststo assess level and acquisition ofknowledge. 8. EmphasisonBHWHouseholdassignment ataratio of 1:20. 9. Monitoring of BHWactivitiesandperformanceafter training through regularmnnthlymeetingsand use ofhousehold recordformswhichdocument BHWactivities foronewhole year.
10. ConstructionofBHWPerformanceRating Scale withequalparticipationfrom BHWs, Trainorsand aPanelof Experts inCommunityHealth
11. DisseminationtoBHWs oftheresults of the communitysurveyconductedbefore andafter theimplementation of thealternative training program. PHASE III of thestudy evaluated the resultsof the above alternativetraining schemes. Qualitativeanalysis utilized case studyanalysisofeach studysite to assess programeffectiveness. Quantitative
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analysisfocused ondata obtainedthrough structured interviewsof the BHWs, Trainorsand Community respondentsaswasdone inPhase I.
The resultsof Phase IIIwereas follows: 1. CommunityIndices: Some positive findingswere obtainedon the variables concerningawarenessof BH4existence, awarenessof
PHC, perceived functions of the BHWs and utilization of BHW services. In general,therewas an increase in percentage of responses,especiallyin the two studysites of Bulacanand QuezonCity, fromthe baseline period to post-trainingimplementation,concerningawareness of BMWand PHCin the community. The oppositehowever,happened in Benguet regionwhere there was adecrease in contrast to the highpercentage of responseson thesevariables in the baseline period. This thereforeproved to be astartling finding whichmaybe attributed to the inactive status of some BHWs in this area. Anotherpositivefinding consistent in all threeareas however, concerned the perceived functions of BHWswhere the prevailingpicture in the postimplementationperiod wasmorepreventive-orientedrather than curative as found during the baseline priod. Further, anappreciable increase inutilizationof BHWservice,,, fromba3eline topost-implementationperiods,thoughnotveryhigh,was alsonoted inBulacanandQugzonCitysites. The situation did notchange verymuchhow4ever, in the Benguet site,where previously, therewasalreadyan30% utilizationrate of BHW services. Other encouragingfindings showed increasedinclinationon thepart of the communityto sharewiththe BHWs their healthneedsand problems,such as those related to environmental sanitation,malnutrition,illnesses,inadequate healthfacilitiesand lackofmedicines. Likewise,agreat majorityof the respondentsstated that theBHWs wereaccessible and availablewhenneeded. Therewas alsoanappreciable increase in their perceptionofthe BHWs' capabilities to help them. Further, therewasalsoamarkedincrease in percentageof responses,frombaseline to post-implumentation periods,affirmingtheir belief that the BHWs shouldbe given someremunerationorincentivesfor their services. Majority oftherespondentsopined too that this incentive should be morein theformof cashrather than inkind. They also cited someselectioncriteriathatmaybe used for BHWtraineesas follows: young adult,eithermaleor female, singleormarried, andhigh schoolgraduate. Amongthe personalitytraits thata BHWmustpossess as yieldedby the communityrespondentswere willingnessto help thepeople,dedicationto service,possessionofknowledgeandskills, goodmoralcharacterandgood interpersonal relationship.
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2. BHWTrainee: TheBHWs who finished thenewtraining program generally belong to middle-agedgroup,married, self-employed and elementary graduates. The BHWswho finished the training course inBulacanwere all newrecruitswhilethose in Quezon Cityand Benguet were old BHWs, thus, thenewtraining served more as arefresher course. AllBHWs in Bulacan were females and out of 30 whocompleted training,only 22 were in active status during the post-implementation survey tenmonthsafter training. In Quezon City, 17 BHWs, onemale and 16 females, were in active status out of 20who underwentthe re-training course,while inBenguet,only 16 out of 19 who took the retrainingcourse were likewisein active status. The personality traits of theseBHWs as revealedby the personality testswere industry, fortitude,ambition, self-assurance, dedication,and sense ofresponsibility. They alsopossessed mediumlevel of self-esteem and as awhole,presentedaprofile of amatureandwell-adjusted group.
More than 80%of these BHWs claimedthat thenewtraining programprovided themwithknowledgeand skillswhich theywere able to applyin their work. Further,agreatmajority replied, especiallythe veryactiveones, that whatmotivated them to continueproviding servicesdespite absence ofmonetary compensationwas their desire to help thepeople and loveof theirneighbors. Some problems they sharedin connectionwiththe trainingthey underwentdealtwithinadequatepracticum. Otherproblemscited in the course of theirpractice as BHWs,werethe presence of co-workerswho seemed uninterestedin theirwork,lackof medicinesto give to clientswho consult them, lackof bloodpressureapparatus,inabilityto attend regularly the monthlymonitoringmeetingsaswell as submission of themonitoring sheets. Further,whiletheyrecognized the valueof preventiveservicesmorethan curativeones, it was still the latterthat theywereable to rendermore,citing lackof time to go out in the field to makehomevisitsandpromote health educationservices asreasons. Regarding the training content,theBHWs also cited the following topics asneedingmoreemphasis: namely,MCwithactualdemonstrationand practiceinhomedeliveries,community
organization,TB case finding andfollow-up, andassessment ofmalnutrition.
The BHWsalso suggested the following selectioncriteria for thosewhowillundergoBHWtrainingprograms,suchas youngadult, female, single, high school graduate and aresident of the community to be served. Further,somepersonality
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traits citedthat agood BHW mustpossess are willingnessto serve the people,dedication,possessionof knowledgeandskills, good interpersonalrelationship, goodmoralcharacter, kindness, senseof responsibility,endurance andhumility 3. Trainor: The trainor in the Bulacan sitewas the RHU Midwife,while in Quezon Cityand Benguet, the trainorswere nurses.They wereall females; two were single and two were married.The psychological tests revealedagenerallymature,welladjusted group, withhigh levelof self-esteem,selfacceptanceand self regard. Theyalsoobtained high scoresin the personalitytests, on traits of ambition,patiente,creativity,inquisitiveness,sense of responsibilityand respect.
In general, the trainors rated the newBHWTrainingprograms adequate. Theyclaimed the program provided theBHWswithbasicknowledgeand skills theyneeded in their work. Theyited also the use of themodules asavery helpful and valuable teaching tool. Some problems cited during trainingand post-training wereHWtardiness andabsences especiallyduring regularmonthlymeetingsafter the trainingperiod. The trainors also citedlackof audiovisualaids that can supplement the lecture discussionmethodused indidacticsessions,suchas slidesandfilm strips. Further, lackof incentivesto BHWswasalsorelated to the waninginterest of BHWs in theirwork after formal training. The trainors alsoidentified some trainee characteristicswhichbest facilitatedlearning, such asmotivation, interest,commitmentandinquisitiveness. Further,educationalbackgroundof at leastpost-elementarywasalso citedas enablingthe BHWs to understand the subjectmatters easily. In turn, trainorcharacteristics identified bytheBHWss facilitatinglearningwereapproachability,patience, goodsense of humor,good interpersonalrelatinns,facilitywithlanguageexpression,interestin teaching,and abilitytootivatelearners. The trainor characteristicscitedas hinderinglearningwereimpatienceand lackof interestin teaching.
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Summary,Conclusions and Recommendations In general, the resultsof the field-testingof thealternativ BHW training strategies,using the trainor, trainee, and community variables asmeasuresof programeffectivenesswe-,'e positiveand favorable. The dataon the Communityindexwhichshowed ageneral increase in percentageof responses, though,not very high, specifically onaspectsof communityawarenessofBHWs and PHC, as well as utilization of BHW services,can still be consideredencouraging. This minimalincrease can still be appreciatedespeciallywhenviewedin the context ofaten-monthperiod withinwhichthe programhas been in implementation,and thus too short atime to fully evaluate its impact or effectiveness. The followingconclusions derivedfromthis study.are:
1. The alternative training strategieswithits distinctive featuresofutilizingmodules,activelyinvolvingBHWs in evaluatingtheirperformance,and disseminatingto BHWsa communityfeedbackreflectingtheirperformanceasBHWs, were generallyadequateand provided theBHWswithbasic knowledgeand skills theyneeded in renderinghealth services to the community. The data on trainor, traineeand communityindices buttress this conclusion. 2. The use ofmodules wasan effectivesupplementarytool in BHW trainingprogramand servedas handyreference for
reviewpurposes as well. 3. PeriodicconsultationswithBHWs, andactively soliciting their cooperationinmattersrelatedto theirperformance, suchas theconstructionof aBHWperformance rating scale,numberofhouseholdassignments,aswell asdissemination of cesultsof the communitysurvey reflectingtheir own performances,served to re-kindleand sustaintheir continuing interestandmotivation to performtheir functionsas BHWs. 4. Group Dynamicsserved notonlyaspre-didacticcatalyzers butprovidedvaluableinsightsaswell,inrelation to self growthandteambuilding among the BHWs. 5. Grantingof concrete incentives in anyform,is necessary to sustainBHWinterestandmotivationin theirwork.
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6. There is stillaneedto improve onthe supervision and monitoring aspects of BHWtraining programs relatedspecifically to sustaining theirinterest andmotivationto continue functioningas BHWs.
7. There aredistinctivepersonality traits andcharacteristics of BHWsassociated withefficient performance. 8. Thereare distinctive trainorpersonality traits and charac
teristicsthat facilitateas wellas hinderBHWlearning. 9. BHWperformance reflectsthekindof training theyunderwent.
10. There isaneed for the community to bemore involvedin the recruitment process.
The results of this studydefinitelyraise important implications in BHWtraining programs, especially pertaining to the aspectsof Content,Practicum, BHW tasks, and SupervisionandMonitoring of. BHW performanceaftertraining.
In the lightof the aboveconclusions,the followingsuggestionsand recommendationsaremade:
1. Make thecommunitymoreaware of their participation in BHW training by selecting ornominatingarepresentativefrom their communityto undergo.BHW Training.
2. Implement aset of criteria forBHW selectionespecially onpersonalitytraits and educationalbackground,oncethe number of applicantsto BHW trainingprograms increase.
3. Evolveamore effectivemonitoring scheme inmonitoringBHW performance,one thattheywouldappreciate and towhich theycandevote time toattend and accomplish.
4. Continually involve theBHWs inevaluating their ownperformaice. Apeerevaluationisalso suggested.
5. Continually involve theBHWs inactively participating in planning thecontentas well as skills to be taughtby getting theiropinionson theseaspectsof the training program.
6. Sustain theinterestandmotivationof the BHWsin their work throughsomekindof incentives (asidefromthepackage of healthbenefitsrecentlyprovidedbythegovernment)as wellas throughdemonstration bytrainorsofinterest in their work.
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X
7. For thetrainors,tocontinually seekways of improving their training strategies inBHWtrainingprogramsas wellas in supervising BHWs aftertraining. 8. Conduct another operationsresearch study onvarious trainingmixesalong thevariables of content, trainor and selection criteriapertaining to trainees'age, sex, civil status andoccupation. Porinstance,on traineevariable, it wouldbeworthwhile to compare the effects ofatrainingmix usinghousewivesonlyvs.aheterogenousgroup,or an all-maleor an all-female group; youngadults vs.middle-aged groups;and thosewithprimaryor elementaryeducation vs. thosewith some high school education. Fortrainors, thr aseof a midwife, vs.anurse, orahealth educator, or evenanexperienced BHW,mayalso be tested. For training content, acompetency-basedcurriculummay be compared against theongoing standard BHW training programs. For trainingmethod, an on thejob training which ismore skills-oriented,maybecompared with thestandard teachingmethodof didactics followed by practicum. Includealso cost-effectiveanalysisindataanalysis. Anotheroperationsresearchmaybe proposedto focus moreon the operationalproblemof supervisionof BHWsespecially aftertraining. 9. For endusers of this study, such as theadministrators and PHC implementors,to continuallyextend thenecessaryadministrative and logistical support to BHWtrainingprogramsthroughoutthe country, specificallythe provision ofmore indigenous traiing programmaterials. Also, for the socialsciefitiststo explore deeper the concept of "voluntarism"in the local healthdelivery system against Filipinovalues andculture,as wellas theconcept of "incentives"for services,supposedlyrendered onavoluntarybasis. Are the two conceptscomplementary,or in conflict, in thePhilippinesetting?
10. For thefundingagencies, to continually sponsor studiesof thiskind,untilwe comeup withwhatcould really bean effective BHWtrainingprogram,especially in relationtocrucial indicesof communityawarenessand utilization of BHWservices,in this country.
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ACKNOWLEDGMENT
This studywas madepossible through the invaluable assistance and support by anumber of agencies and individuals. To the following,we express our deepgratitude and profound appreciation:
- the PrimaryHealth Care OperationsResearch (PRICOR),whose sponsorshipmadethis study possible,especially to PRICORSenior Scientist,Dr. Stewart Blumenfeld;
We also acknowledge the administrative assistanceextendedbyMs. BeverleyGraham and LaraineDanes;
- Dr. TrinidadOsteria,whowas instrumental in introducingthe researchers to PRICOR,and hurdling the first screeningof the concept paper; also for her sustainedinterestand unselfish sharingofher expertise in dataanalysisandother aspects of the project;
- MissVirginiaOrais, for sharinghervaluable time andexpertise despiteherperennialbusy schedule asMOHTraining Specialist;
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2
hundredprograms and projects currently operating,all aiming to deliver apackage of health services to various areas of the Philippines. Carifto and Associates (1982) provide adetailed compendiumfor about thirty of thesein abook concerningeffects of five rural health delivery mechanisms.
On the part of the government, the Ministryof Health (MOH) , in response to the pressing healthneedsandproblems existing in rural communities, had identifiedandcurrently givingattentionto five priority/impact healthprograms, namely,Maternal and Child Health (MCH)which embraces FamilyPlanning (FP)and Nutrition; Control of Tuberculosis;Preventionand Control of Diarrheal diseases;
and Prevention andPrevention and Control ofMalaria;Control of Schistosomiasis.
2. PrimaryHealthCare as an Intervention Strategy: In 1978, duringthe International Conference on
Primary HealthCare at Alma-Ata, Soviet Union,primary health care, as an approach towards achieving "Healthfor All by the Year 2000" was adopted. In this conference, primaryhealthcarewas defined as "... essentialhealth care basedon practical, scientifically soundand socially acceptablemethodsandtechnology madeuniversallyaccessible to individualsand families in the communitythrough their full participationand at acost thatthe community
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andcountrycanafford...". PrimaryHealth Careaddresses the mainhealth problems in the community, providing promotive,preventive, curativeandrehabilitative services accordingly ... it includes at least: educationconcerning prevailinghealth problems and the methods of preventing and controlling them; promotionof food supply and proper nutrition; an adequate supply of safewaterand basic sanitation,maternaland child health care, including family planning; immunizationagainstmajorinfectious diseases; preventionand control of locallyendemic diseases; appropriatetreatment of common diseases and injuries; and provisionof essential drugs". (Declaration ofAlma-Ata, 1978). Thus, the philosophyof primaryhealth care revolves around the development ofmaximumcommunity
and individual self-reliance throughfull communityparticipation in theplanning, organization andmanagementof the health services. This envisages that the community will define its ownhealthproblems andneeds, devise and carryout programs oractivities to solve them inpartnershipwiththe government and the private sector (MOH, 1980). TheMOHunderscoresthis conceptof communityparticipation and theneed to involvepeople in the communities inhealthrelatedactivities. Thus, as astrategy to health development, the MOH launched its primaryhealthcareprogram nationwidein September,1981. As of January,1985 atotal
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of 38,005 barangayswereinitiated to PHC. Further, to facilitate community involvement and active participation, BarangayPrimary HealthCare Committees (BPHCC)wereorganized as part of the initiation to PHC. At present,there are 39,000 PHC committees in the country. Data gathered from fieldreports and technical workinggroup assessment reports indicated that PHC implementation is movingtoward its goal of providinghealth for all Filipinos. However, the status of its implementationvaries fromregion to region and fromprovince to province due to the presenceof factors which may eitherboost orretard its progress. An investigation of areas where PHC hasbeen successfully implementedrevealedthat the following factorswere evident: adequate social preparationof the community, collaborating agencies and MOHpersonnel in PHC; strong intersectoral and intrasectoralcollaboration; adequate training ofmidwives and BHWs, active communityparticipation,strong leadership qualities, dynamism,and enthusiasmof themidwives involvedinPHC; andclosemonitoring of projects andactivities byPHC coordinators. (MOH,1984. Likewise, the areas of concernwhichneededlooking into because of someproblems theypresent to the field implementors,werethe following: inadequate social preparation ofasubstantial numberof barangays on the concept and strategies of PHC, needto adequately trainmidwives and BHWs to enable them to performboththeir health-related
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5and community-relatedjobs, lack of instructionalmaterials, logistic support, and need to comeup withincentives which will sustain the commitment and motivationof BHWs. At present, the MOHhas 42,000 functional PHC barangays (Dr. Florendo, personal communication). Basedon the set indicators for levels of PHC implementation ,most of these barangays are alreadyon the second level (organizational level). Further, having beenorganized, these barangays are expected to proceedwith implementation and project
(3rdand 4th levels of healthdevelopmaintenance levelsment).
3. Barangay HealthWorkers in PHC: One of the key components of Primary Health Care is
the utilizationof indigenous healthresources and health manpowerdevelopment. Withinmanynational strategies among developing nations, theuse of volunteerhealthworkers among communitymembersis seen as oneof themajorways to implement primaryhealthcare. Communityhealthworkers are viewed as the keyto attaining the acceptability, affordability, and accessibilityofprimaryhealthcare.
1985, p.7). This type ofhealth(Schaefer~andReynolsids,workerwho arecalledbyalot ofnames aside fromthe term "Communityhealthworker",such as BarangayHealthWorker (BHW), BarangayHealthTechnicians (BHT),Volunteer Community HealthWorker (VCHW), Village HealthWorker (VHW), Health Visitor (HV), or Barefoot Doctors (BDs) act as links to the
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6community in the provision of basic health services. What is common to these terms inmost developing countries is that they refer to workers who are: 1)"indigenous to the settlement or the soc-alclass of those to be served; 2) trained to function at the auxiliary level of healthcare; 3)based in rural, and in some cases urban communities; 4)trained to workcloselywith the communities they serve so as to involve communities in the process of improving their own health; 5)prepared to facilitate access to other health services formore complexandunusual diseases and ailments; and 6)charged withtasks such 6.1),as education concerningprevailing healthproblems and the methods of identifying,preventing and controlling them; 6 .2),promotionof food supplyand propernutrition and adequate supply of safewater, andbasic sanitation; 6.3), maternaland child care, including familyplanning; 6.4), immunization against major infectious diseases; 6.5), preventionand control of locally endemic diseases; 6.6), appropriate treatment ofcommon diseases and injuries; 6.7), promotion ofmentalhealth; and 6.8), provisionof essential drugs. In some national PHC strategies, this type ofhealthworker also functions as part ofamultisectoralor intersectoral schemeofrural socioeconomicagricultural and rural development agents, andwatersupply-sanitationworkers.
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7
The justification for theuseof community health workers is basedon the assumptionthat: 1)coveragewith minimumservices can be achieved relativelyrapidly because
canbe trained faster and manycommunityhealthworkershighly trained healthpersonnelless expensivelythanmore
and can be distributedmore easily tounderservedareas, especially if they are recruited fromthe settlements where theyare to serve; 2)acceptability of services is enhanced
clients or, atwhenoffered by persons who are known toI'least, are "the same kind of people as we are"; 3)commnu
can encourage community participationnity healthworkersinprimaryhealthcare and facilitate the delivery of other related services to the population; and 4)communityhealth workers, in contrast to specialists in various diseases and
can facilitateprovision of integrated healthdisciplines,care, can help linkpreventive and curative services, and cancollaboratewithagents and activities of other sectors. (Schaeferand Reynolds, 1985, p.8). In this particular study, the termBHW (BarangayHealthWorker)is usedto
this type ofhealthworker. One of the strategiesrefertoutilizedby the Ministryof Health (MOH), in implementing
to involve andutilizeBarangayPHC throughout the countryisfacilitate participationof theHealthWorkers (BHWs) to
To date, the MOHwhose goal is to achieve aratiocommunity.of one BHWto 20 households (1:20), has intensifiedefforts in the recruitment, trainingand employment ofBHWs in
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8
primaryhealthcare service. Likewise,anumber of private voluntaryorganization in the different regions of the country,as well as University-based projects, utilized various schemes andmechanisms inwhichlocal health care projects could operate, mainlythrough the utilizationof the BHWs, who function eitheronavoluntarybasis orthrough some forms ofremuneration. In providing basic PHC services such as immunization,oral rehydration therapy, environmental sanitation,nutrition,maternal andchild health services, the recipients will bemainlyinfants and preschoolers who arevulnerable to respiratory, gastro-intestinal and communicable diseases in childhood, as well as pregnant womenand lactatingmothers, thereby stressing primarypreventiveservices. Thus, it is envisioned that through effectiveutilizationofBHWs in PHC, there will be reduced rates of mortalityandmorbidity,especially among infant andpre-school age groups; reductionin theprevalenceof total third and second-degreemalnutritionamong preschoolers (0-6 years old) and school aged (7-14years old); reduceprevalenceof anemiaamong pregnant women,nursing mothers and affected children; reduce healthdisabilities and improve environmental sanitation. This positive picture is illustratedbycertainregions under the MOH. MOHreports for the past three years claimed that all barangays with trained indigenous healthworkerswere involved in lay reportingof events suchas deaths, births, and illnesses
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9
by symptoms. Further, foremostamong services providedby this type of healthworkerwas thewide use oforal rehydrationdistributed to thousands of families in the regions. In brief, the reports emphasize-d noticeableand substantial improvement in the health of its constituency.
4. BHWTraining: Reviewof Literature: The preceding sections underscore the importance
of the BH-s in the PHC deliverysystem. With the increased utilizationand dependenceon this trained indigenoushealth worker,the trai-ing6f BHWs is considered the mostvital component of PHC delivery' Moreover, the successes or failures of PHC can be associatedwith the kindof training provided.
Apropos, areviewof related literatureon training ofcommunityhealthworkers is in order at this point. This will serve as background too for the operational problemin the succeeding section.
4.1 The ThirdWorldView: In ruralGhana, Lampteyet al. (1980)reported
on thecriteria for selectionof traineesusedin trainingvillagehealthworkers,such as beingavolunteer,aresident of the villagewith no intentionof moving, literate,between 20 and 50 years of age, and acceptable to the community. The use of trainingmanual
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10
was also emphasized. Similarly,F.S. Soong's article (1982) on theAboriginalHealth Workers in Australia enumerated certaintraining piinciples considered particularly relevant, including training procedure and content. On the whole, it emphasized the favorable results of eight years' experience in training and using aboriginalhealthworkers. The approachdemonstrated its efficacy in meetingprimary healthneeds and reduceddependence on services providedby outside authorities and professionals,through the involvement of the people in their own care. The trainingprogram preparedthe aboriginal health workers to function as primaryhealth care workers in their own communities.
In Nicaragua, Heiby (1982) discussed some lesson.s learned fromthe training of traditional birth attendants ("parteras"). The trainingwas given by a single teamofnurses hired specifically for the training program. The five-daytrainingcoursewas taskorientedand focusedon the appropriateuse of the contents of the "parteras" healthkit, and asmall numberofhealtheducationconcepts. Amajorproblem identifiedhowever,was theinabilityof the trained traditional birthattendantsto introduce theirnew services to the community. It was reported that less than onehalf of the adultwomenknew of theprogram's
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This study also underscoredthe usefulnessexistence.of identifying the characteristics ofvolunteers that
For instance,areassociatedwithsuperior-performance.the "parteras" performance in health servicedelivery, was closely related to her activity as abirthattendant before training.
Withregards to training, Smith (1982) stressed the needto examinevarying approaches to training in
determinewhichwas most appropriate foraorder toHeeven opined that perhaps acomparticularsetting.,
petency based edcational trainingmay be the most On the aspectsappropriateapproach to training in PHC.
of supervisionof communityhealthworkers, inastudy done inMexico and in Indonesia, Smith (1982) further
discussed the supervision of community healthworkers as well as numerous fundingbymid-level healthworkers,
He cited the villagepossibilities for the former.support on afee-for-servicebasis inMexico, and district authoritysupport in Indonesia. In his treatise on "PrimaryHealthCare-Rhetoric or Reality" (WHF,1982),
failures of Smith furtherattributedthe collapse orPHC demonstrationprojects inmanydevelopmentcountries
problemswithsupervision,management, supportdue toand training.
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12
In Burma,UThan SeinandMick Bennet (1982) presentedavivid picture of the training program includingthe selection ofcommunityhealthworkers, training content and procedure. Theseresearchersalso cited problems and difficulties encountered in training. Further, theypointed out certainfeatures of the training program which posed particular challenges, such as the following: 1) Heterogeneityof trainees in age and education,hence, the training programhas either to adapt to this heterogeneityor utilizeit. Theauthors disclosedthat young, bettereducatedtrainees are seen as ideal, although,those trainors who were able to make' the training practical and field oriented fotnd that theycouldmake use of the different skills and experiences offeredby aheterogenous group. The use of peer teaching also provided extra experienceto the faster learning trainees related to their educative role of CHTs. 2) Ladk of reward system for trainees. The authors underscoredthe fact that the CHWs are expected to provide aservice whilstcontinuingwith theirnormal life in thevillage. While voluntary servicewas seenby some trainors and trainees as being unrealistic,UThan Sein and Bennet (1983), however, found thatmajorityof CHWs still tried to carryout their duties conscientiously,hence, cannot beviewedas being motivatedonly by externalrewards suchas money or goods. 3) Short durationof trainingand lack of certification requirements.
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134) Supervisiondifficulties of CHW: The authors claimed that the general situationregarding supervisionandsupport whichmight be expected
with this level ofworkers do notexist. The CHW (in contrast to afactoryworker receiving close supervision) tends to have irregular supervision. Hence, arecommendationwasmade that the supervisorsneedto be sensitive to the difficulties encountered by CHWs, who have to satisfybothcommunityand the Ministryof Health's expectations. Further, the trainors must alsocommunicate sufficient enthusiasmso as to attain the objectives of the training and obtain as well the positive cooperation of the trainees. The authors also cited that experience indicates that this effort takes anonauthoritariansupportive training stylewhich is oftendifferent from that e::periancedby the trainorsintheir student days. These problems pertaining to remunerationand supervisionof BHWs w~re also underscoredby Lamptey et al. in their report on "Trainingof Village H-eal-th Workers in Rural Ghana" (WHF, 1980). These authors stressed that the VT--lage Health Workerswillneed special support andunderstandingduring the first fewdifficultmonths followingtraining. Ifmotivation and training are not reinforced during this period, theywill becomediscouraged and abandon thework. In a nuiber ofprojects studied,drop-outs during training and years after training,have been encounteredas problems. Theauthors also suggested that other healthpersonnelin thedistrict be madeaware of the valueof the VHWto the district health's effort. Withregards to remunerations, whilemanyVHWs seemednotconcerned withthis, and are content to enjoy the prestige of serving as "villagedoctor", theprogramme's long term success will be better ensuredby making certain that anyremunerationis actually given. The authors stressed this point in connectionwithpromised financial support from the village for the VHWs but forgotten in the end. Still on the concept ofremuneration,Dr. Khandker (1982), reporting on the Bangladeshexperience, claimedthat the conceptof "voluntary"workers wanedgraduallyandwas replacedby the paid workers.
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3.2 The PhilippineSituation: Regarding BKW training,Caragay (1982) presented
some promisingand educational results of the training providedsome traditionalhealers to improve their skills. In aUniversity-basedcommunityhealth care
the UP-CCHP, an action-researchproject, knownasproject was launchedon the trainingof "herbolarios" (traditionalhealers) in Cuenca,atown in the province of Batangas, 100 kms. south ofManila,where 27 "herbolarios" underwentathree-monthcourse inmodern primaryhealthcare in the years 1978-1979. Caragay also reportedsome problems encounteredin the "herbolarios" after training, such .isabsences from the monthlypost-trainingmeetings, profit-making,failure to referpatients,beingboastful about theirnew status, and prescribing other than over-the-counter
Heended hisreport byraising pertinentmedicines.implications on the criteria for selection of trainees: "notjust on interestandwillingness,equally important are their attitudes,values, aspirations, commit
ments and acceptabilityto thevillagers. If these characteristicshadbeenconsideredin their selection, problems couldhave beenminimized". (Caragay,WHF, 1982, p.163).
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15
Additional local datawas contributed by Alfiler (1981) who studied six communitybased projects in health and familyplanning. Asection of her report compared the training programand procedure provided the Barangay or Community healthworkers specifically pertaining to the durationof training, and found to vary fromutilizingweek-ends versus weekdays, and total training days which ranged from3weeks to 3 months or 9months, with the longest duration being 1yearand 3months. On the other hand, content coverage on basic health services, nutrition, environmental sanitation,first aid intervention, were similar for the six communities studied. However, aslightvariation on teachingmethodologies were noted,with some, focusingon experientialrather than didactics. On the whole, the trainingprograms comprised both didactics and practicum.
Amoredetailedreport especiallyon performance oftrained Barangayhealthworkers,referred to as BHT (BarangayHealthTechnician)was reported in adoctoral dissertationof Maayo (1983). The study focused on the importanceofcitizenparticipation in health care delivery through astudy of two communities in Nueva Ecija, identified as model training areas in health service delivery. Maayo (1983) reported the favorable reaction of the communitytowards the BHT, as well as utilization
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16
of the latter in seeking health services, thereby portraying avery positive picture of training for this type of health worker. On the aspect of remuneration, Carifo et al. (1982) reportedthat there exists agreat variationin incentives provided the community health workers. W4hile many do purelyvoluntarywork, like the participants in residentworkers' trainingprograms, mothers' classes, "hilot" trainingprograms, and youth volunteers groups, others are providedwith small allowances or honoraria. The latter are specifically offered in most government programs, such as the Barangay NutritionScholarof the Nutrition Council of the Philippines whichprovide sixty pesos (around $3.00) whileafew others are being funded fromincome-generating projects undertaken by communityorganizations such as the ICAproject and theBarangay HealthAides Project. The latter is the financing schemeadopted in the BHTprogramin BarangayCabucbucan,Rizal, Nueva Ecija,which yieldedpositiveresults as foundby Maayo (1983) in her study. Maayo (1983) also recommended that if funds are available, andwhencircumstances make it necessary, the government could pay the entire salaries ofcommunityworkers. Apropos, noteworthyto mention that in the Bicol region, the BHAs (Barangay HealthAides) trainedunder theUS-AID sponsoredBicol Integrated Health,Nutrition andPopulationProject,
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17 receivedamonthlystipend for their services (G.Cook, PersonalCommunication). Specifically, the project report stated:"TheBA will be afull timeworker of the local government, and paid aproposedmonthly stipend of P306.75 ($30.67) through the municipal treasurer" (US-AID,Bicol IntegratedHealth, Nutritionand Population, 1979)
An intervention study on Primary Health Care which employed Trainingof Community Health Volunteers was conducted by the St. Louis College of Nursing-Mobile Nursing Clinic (SLU-WIC) based in Baguio City, from1983 to 1984, under astudy grant from International Development and Research Centre (IDRC) of Canada. The study utilized three depressed study sites in the mountainous region of Benguet. The unique features of the sixweek BHiW training programwere inclusion of Human Relations Training for the trainees prior to exposing them to formal didactic sessions, training in use of "DecisionTrees", and practicumwhichincluded learning how to do simple laboratory tests. Each formal session was immediatelyfollowedby apracticumon the topics/ systems to be learned. Tomeasureknowledgeacquisition, pre-testsand post-tests on all topics covered were also administered. The trainors comprised three nurses and onemedical technologist. Currently, after almost two years of programimplementation,the IDRC,
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is
is funding anewan impact evaluation study, bv the same institution, of this intervention strategy in primarv health care. It is appropriate to mention that the St. Louis College of Nursing is also involved in ongoing training and performance monitoringof nurses employed by the TUCP (TradeUnion Congress of the Philippines), the umbrella organizationof severalmajor laborunions in the Philippines, for primaryhealth care service deliveryinthe different regions of the country. These nurses in turn, trainBHsin their respective field of assignment, forprimary health care services.
Anothermajorresearch, "The Impact of Panay Unified Service for Health (PUSH)project of Economic and Social Import Analysis/Womenin Development (ESIA/WID) (citedby Maayo, 1983) sought to provide unifiedhealth services to 600 depressedbarangays through the training of 600barangayhealth workers who were to be supervised by the Rural HealthUnits in the area. TheseBarangay healthworkersservedas extenderof RHU health services. Thesehealthworkersthoughdiffered fromvolunteerworkers in otherprograms, in that the Barangay HealthWorker of the PUSH project is paid by the local government (Maayo, 1983. The BHWencourages participation in need/problem identification,prioritysettingand plan formulation to improve communitylife. One of the major conclusions of the studywas that thekeyvariables in the success
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of the PUSHproject initiatedactivities are the BHWs' mobilizing effortsand relationshipwithpeople in the community, community support, inter-agency coordination and timelydeliveryofproject inputs andoutputs. The study pointedout likewise, that acompetent,resourceful, dedicatedand likeableBHWwhohas influential relatives and friends bothwithin andoutside the community has greaterchances of elicitingsupport for projects andeffectingchanges in the barangay (Maayo, p. 44).
The Philippine NursesAssociation (PNA)undertook alsoaproject in PrimaryHealthCare. In areport "ThePNA'sPrimaryHealthCare Project-TwoYearsAfter", Quesada, the projectDirector, described andassessed the PNAProject in Parang, Marikina, after two years of implementation. As acommunity-based healthoriented program, it wasinspiredby abelief that aprofessional organization couldundertakeaprogramwithameaningful impact in peopleand the community. Among the activities aroundwhich the program revolved were training andfollow-up supervisionofBarangayHealthWorkers including theirorganization andmobilization. The projectwas implemented stressing its philosophyof self-reliance, thus the proponentsmade use of the strategyof transferringsome of theirtechnologyas nurses to enablethe community to developtheir skills and
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20
confidence in attending to primaryhealth care needs. (cited byMaayo, 1983). The study concluded that two years after the project, the PNA could L-1.ase out from
enable the local people to plan, implementthe area toand evaluatewhateverprojects theywouldconsider to be their priority concerns. Further, it expressed the hope that all the association's chapters in the country, wouldattempt to undertake asimilar project thus making the organizationan important partner in the development ofunderserved and depressed communities.
As afitting conclusion to this section, it is pertinent to state the MOH's own training program forBWs. The MOH is providingboth basic and continuingeducationfor Bh'Ws as first level workers in the provision of updated basic health services particularlyon the five (5)impact/ priorityprogramsof the Ministry,namely,MCH,Nutrition, Family Planning, Control of Tuberculosis, Diarrhea and Endemic Diseases, includinghousehold teaching. (MOHGuidelines for Implementationof PriorityHealth Programs in PHC, 1984). It also has producedanumber of trainingpamphlets for Bh-W trainingprograms. The latestmaterialproducedby the Ministry's PHCTrainingDepartmentis theTraining Module on the FiveImpact Programs for theTraining of Barangay HealthWorkers. This material is valuable in assisting the BHWs acquirebasic knowledge anddevelopskills and attitudes, especiallyon the impact programs of the
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Ministry. Appropos to mentionlikewise, that during the presidential campaign, in late December, 1985, concrete incentive in the form of free consultation, hospitalization, medicines,and other health benefits and privileges was granted to BHls. To date, certificates attesting to these benefits bearing the signature of the former president of the Philippines (please see AppendixL ,p.*34) are being distributed to BHWs in active service throughout the country. Significantly,this move proved to be an attractive incentive, mobilizingmanypeople from the community at present to volunteerand undergo BHW trainingfor primary health care services.
Summarizing, the studies and eventsreviewed both foreign and local, presented various aspects and issues related to.BHW,trainin-, nanely, selection of trainees, content,methods, duration of training,trainors, supervision,and BHWincentives.
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STUDY PURPOSE: OPERATIONALPROBLEM
The preceding chapterhas emphasized the importance of trainingof communityhealthworkers as akeycomponent of primaryhealthcare service delivery. There are anumber of operational issues that the countries, like the Philippines, implementingPHC programs need to resolve to ensure the effectivedevelopment of their BHW trainingprograms. Someof these issues deal with BHWtaskspecification, selection criteria,trailing strategies,supervision, and trainors. It is for this'reason that operations research canmake an important contribution to the solutionofproblems thathave hindered the development or implementation of effectivestrategies for usingbarangay healthworkers in primaryhealthcare.
In December,1983, the PrimaryHealth CareOperations Research (PRICOR)awarded aresearchgrant to the U.P. College ofNursing Research Program,to conduct a two-year operationsresearchon thearea ofTrainingof Community HealthWorkers in PrimaryHealth Care.
Against the foregoingbackdrop then, this operations researchattempted to develop solutions to anticipated problems in thedesignanddeliveryof trainingof BHWs in primaryhealth care.
The followingconceptualmodelguided the conductof this study.
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FIGURE I CONCEPTUAL MODEL OFTHESTUDY
Health Problems HealthServices Target Population
ExistingBHWTrainingProgramsTrainor relatedTrainee factors
Constraints Human
Fiscal Legal
Administrative
BHW Task Specifi-cationTrainingProgram FactorsSelection Criteria
tTraineeCharacter-istics
Trainor chanacteristi Training Outcome -T
. BUW CompetencPerfor- Accepta
mance bilityTraining Utiliza-Knowledge'- tionstrategiesSkills_Attitudes Retention
' by communit
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24As illustrated in the model, Boxes 1,2and 3cor
respond to ProblemAnalysis; boxes 4,5and 6to Solution Development; and boxes 7,8and 9to solutionvalidation, the main steps in Operations research. This model illustrates the interaction among the variables as they affect BHWTraining program, as well as the outcome of such training. The latter in terms of the BH-s performance, as well as acceptance and utilizationby the community is especiallyconsidered the crucial index ofwhat maybe consideredan effective BHWTrainingProgram.
Henceforth,t~e objectives formulated were to: 1. examineongoing training programs for BHWs in
selected three study sites, 2. identify the complex interplay of factors in
volved in the selection, training and supervisionwhichcontributed to the level of functioningof BHWs in the field, including trainor and trainee related factors which facilitated or hindered BHW learningas well as problems anddifficulties encounteredin providing BHW trainingprograms,
3. develop and implement alternative strategies in BHW trainingbased on results of problem analysis, and
4. evaluateeffects of alternative training strategies for BHW training.
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This study comprised three phases. Phase Ifocused on the attainment of objectives 1and 2. Utilizing four indices, namely, training program, trainor-related factors, trainee-relatedfactors, and communityhousehold responses, answers to the following questionswere sought:
1. Training Programs: 1.1 What did the BHW trainingprogram consistof? 1.2 Howwere BHW trainees recruitedand selected?
2. Trainors: 2.1 What werei the qualifications of trainors? 2.2 What: approacheswere utilized in BHW training? 2.3 What problems were encountered during training? 2.4 Whatwere the trainor's assessmentof BHW
training and performance in PHC? 2.5 What trainor qualities, attitudes, and traits
facilitated or hinderedBHW learning and performance?
3. Trainees: 3.1 What were the qualificationsof trainees? 3.2 Whatproblemswere encountered by the trainees
in their trainingand practice in PHC? 3.3 Whatwere the trainees' assessmentof their
training and performance in PHC service? 3.4 What trainee qualities, attitudes, and traits
facilitated/hinderedtheir learning and performance in PHC?
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26
4. Community/ServiceRecipients: 4.1 Was the communityaware of the BH14 existence
as providers of basic health services? 4.2 What types of BHW serviceswere utilized
most? 4.3 Was the community satisfiedwith BHWs' per
formanceas providers of basic health services?
In Phase II of the project, solutions to problems analyzed in BHW trainingwere developedand field-tested, the effectsofwhichwere assessed in Phase III. Hence, attainment of objectives 3'and 4of the studywere sought through answers to the followingquestions:
1. What were the outcomes of the alternative training strategies on BHWperformance in PrimaryHealth Care as perceivedbyboth trainees and trainor as well as by the communityin terms of their awareness and utilizationof BHW services?
2. Has therebeen achange in performance of BHWs trainedwithalternativetraining strategies comparedto theirprevious training?
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III
METHODOLOGY
A. ProblemAnalysis and SolutionDevelopment The steps takenin ProblemAnalysis and Solution
Development in this operationsresearch project are further schematicallyillustrated in Figure 2below:
FIGURE 2 PROBLEMANALYSISAND SOLUTION DEVELOPMENT
AssessmentofBHWTraining ProgramstUsing Training Content,Trainor, Trainee and Communityrespondent indices in 1. Bo. Matimbo (MOH) 2. Bagong Silangan (UPCN) Bo. Dalupirip (SLUCN)
Results ofProblemAnalysis
SolutionDevelopmentIAlternativeBHWTraining Programt tPhase I Decision results variables
Field Testingof Solutions Developed
Barangay Baran~ay BarangayMatimbo Silangan Dalupirip
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28
ProblemAnalysis involved the following activities: 1. Examination of BHW training programmanuals
focusing on content andduration of training, trainingmethods, and recruitment and selection procedure. Aform for this purpose was developed. (See AppendixA,p.200).
2. Data on .rainor-related factors and traineerelated factors such as socio-demographiccharacteristics and personal assessment of BHWtraining programs were obtained through theuse of structured interviewquestionnaires(See Appendices B&C,pp.201-214 ). In addition, personality traits and attitudes of bothtrainors and traineeswere assessed throughthe use of psychological personalityinstruments consistingof two structured paper and pencil personality inventories and adevised projectivetest.
3. Data onCommunity indiceswere obtained through the use of asurveystructuredquestionnaire (SeeAppendixD,pp.215-221).
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00
Description of Data-gathering Instruments: 1. Questionnaire Design:
The draft of the questionnaire for the three tvpes of respondentswhichhave beenpreviously sub
mitted to PRICOR followingapprovalof the proposalwas subjected to furthermodificationand refinement during the month of December, 1983 forpre-testing in January 1984 after two meetings with the consultantof the project.
The questionnaireswere translated into the vernacular, withthe helpof the hired research assistants, andpre-tested for the first time in an urban PHC-site in CaloocanCity.Metro Manila,during the secondweekof January,1984. The subjects comprised two trainors, 6BHWs, and 7householdrespondents. The resultsofpre-testing were discussedwith the consultant, and somequestions wereeitherrephrased,modified, deleted from,oradded to the first pre-testing draft. Adecisionto subject the revisedthirddraft to second pre-testingwas arrived at after furtherreviewofthe questionnaires for BHWs andhousehold respondents. Thus, on the firstweekofFebruary, 1984, additional 11 BHWs and 18 communityhouseholdrespondents constituted the subjects for the secondpre-testing. Based on the results of the secondpre-test, the final set ofquestionnaires for BHWs, trainorsandhousehold
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respondents evolved afterminor revisions on the third draft. The questionnaires, constructed in the formof interviewmanual to aid the research assistants in interviewing, were finalized and prepared for actual data collectionon the secondweek of February, 1984.
The Psychological instruments (administered only to BHWs and Trainors) comprised two self-administered structuredpersonality inventories, the PUP ("Panukat ng Ugali at Pagkatao"), alocally developed structured personality inventory, which taps 26 traits/Icharacteristics,and the GSE (Global Self-Esteem Scale). For purposes of this study, only8traits were tapped however, in the PUP. The other personality inventory, the GSE consisting of ten items, tapped the individual's feelings of self worth. The projective test consisted of adevised ten-item sentence completion test (SCT). Both the SCT and GSEhave bothEnglishand Tagalog items onone sheet, and the respondents had the option to answer theversion theypreferred. For the "PUP" however, the Tagalogversionwas the one administered to
both trainors and trainees. An additional personality inventorywas alsoadministered to the trainors in its Englishoriginalversion. This was the Personality OrientationInvntory (POI), the development ofwhich was guided byMaslow's Self-Actualizationtheory. This
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inventoryhas 2major and 12 minor sub-scales, measuring several personality traits some ofwhich are selfactualizing value, self-regard, self-acceptance, time orientation, view ofman andothers. 2. Training of Research Assistant (R.A.'s)/Data
Collectors: The four ResearchAssistants were College
Graduates. The one appointed as Senior R.A.was a graduate in CommunityDevelopment, at the College of Social Workand Community Development at the University of the Philippines and presently aMasteral degree candidate withprevious experiencesinfieldresearch. The other three (two ofwhich were hired later during the first weekof February)were all graduates of Bachelors'degreein Nursing, also fromthe University of the Philippines. The two fielddata-collectors hired on acontractualbasis only for the study site in Mt. Provincewere also nursinggraduates and have just been involved in fieldresearchon asimilar project prior to their employme~t in the project. These personnelwere all given training in data-collection. Theywere all involved in the construction of the revised questionnaires especiallyin the preparationof the translated versions (in tlocano or Tagalog) in order to familiarize themwiththe instrument inasmuchas theywere the ones
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32
to administer them. Theywere also involved in the pretesting andmodification/refinementof the final sets for actual data-collection. Further, aseries of role plays among data collectors guided by the two coprincipal investigatorswas held, before and after each pre-testingsession. The problems which arose during the role playing sessions and experiences during pretesting sessions served as bases formodifyingthe statement of some questions. For instance, some questions were dividedinto.a series of more specific questions. Likewise, rating scales were reduced to dichotomous choices instead of the' Likert type. Notations were also added in the interviewmanual as further guide in the process of questioning. Finally, to instill asense of commitment to the project by the personnel, initial meetings prior to training harped on the importance of eachmember in the research teamandcordial working relationshipwas also maintained. Regular staffmeetings were conductedweeklyor monthly to discuss problems as well as to maintain acordial workingrelationship.
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33
3. Description of StudySites study sites consistedof threecommunitiesThe
considered recipients ofPrimaryHealth Care Services.
Two sites were academicallyinitiatedand directed,one in anurban depressedarea in QuezonCity, MetroManila under the aegis of the Universityof the Philippines College of Nursing, and the other, arural setting in Benguet Province, amountainous region in Northern Luzonunder the directionof St. Louis UniversityCollege ofNursing. The third sitewas an MOH-directedarea in
Thus, representativeBulacan province in CentralLuzon.geograDhical samples frombothgovernment andnon
fromthe former,governmental agencieswereobtained, tworepresenting the MinistryofHealthand State University
TheMOH-Health Service, andone fromthe latter.directedbarangayprojects in the provinceofBulacan, at the timeofits choice as astudy site, have steadfastlygainedrecognition as primaryhealthcaremodel
The Universityof the Philippines Collegeofareas.Nursing project in BagongSilangan,while considered a
angovernmentinstitution, is also identifiedmoreasthat this siteacademic institution aside from the fact
contrasttorepresents anurbandepressedcommunity, inthe rural community in Bulacanprovince. On the other
Louis MobileNursing Clinic (SLU-MNC)hand, the St.project,whilealso consideredanacademicinstitution,
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represents the private and religious sector, St. Louis Universitybeingunder the administration of the Belgian fathers, aprominent religious order. The SLU-MNC renders health services to the "Ibaloi"-"Kangkanaen" cultural minoritygroups in the Northern Benguet.
These three study sites are further described below:
3.1 The St. Louis UniversityMobile Nursing Clinic(SLU-MNC)Themobilenursing clinic is an extensionof
the Out-Patient Ddpartment of the St. Louis University Hospital of the Sacred Heartproviding primary health care services to depressed, deprived and far flung areas of the Province of Benguet. The mainthrust of the clinic is to reduce the incidence of illness through health promotion,maintenanceand disease prevention programs, in an effort to alleviate the criticalhealth situation in these areas, especially preventable diseases (MNCAnnual Report, 1982). The clinic is manned by afull time professional nursewho at the same time is theProject director, assistedby two full time staff nurses, amedical technologist, and Senior students of the College of Nursing on practicum,andadriver.
The clinic is equippedwithamodernvan to service the clinic's transport requirements. It also
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contains basic supplies and equipment like thermometers, weighing scale, BP apparatus, stethoscope, syringes, a
minor surgical set, apocket diagnostic set, obstetric bags, disinfectants and laboratory facilities such as
It also has an amplemicroscope,slides, reagents, etc.supply of primarymedicineswhich are mostlyover the counter drugs. It also has two tents used for outdoorclinics.
Operationally,the teamvisits rural areas fourtimes aweek,covering preventive, promotive and curativeI
For the past four years, the clinic has seraspects.viced selected barangay8 of the 13 municipalitiesof Benguet Province. The total number of barangays served was 63 or 45.9% of the total 137 barangays of Benguet EachBarangay has an approximate population of 1,000. The areas servedwere chosen based on the suggestion of the Provincial Health Officer and the following criteria: a)must be adepressedarea and apopulationof not less thanone thousand; b)not serviced centrally by any health agency; c)mustbe centrally located so
serthat other barangaysmay also be reached and thatvicemaybe eventuallyexpanded; d)the people especially the barrio leaders must be enthusiastic about this project; and e)area shouldbe accessible to transportation.
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Initially, the clinic's activities centeredon curative health care services, as thiswas the determinedneed. Towards the Latter half of 1930 however, MNC efforts focused on scouting for potential community leaders who can be trained as volunteer community healthworkers (VCHWs). More specifically, formal trainingof VCHUs was initiated in January 1983 in selected service sites,
The selected study site for this projectwas barangay Dalupirip in themunicipalityof Itogon. There are presentlynine barangays of Itogon ofwhichDalupirip is identified to be the second largest barangay andmost depressed, hence, chosen to be the starting point for MNC services andVCHW training. Dalupirip, has atotal area of 12,715 hectares and atotal population of 1,599, and is divided into thirty sitios. The main crop or these sitios is rice. The other source of income isgold panningwhichis not stable as asource of income.
Since 1980, the MNC staff has been serving BarangayDalupirip, Itogonand has coverednine sitios.
Of these, only two arereachable by avehicle,while the rest are reachable by foot trail and horsebackride. A Seminar Workshopon PrimaryHealth Care was heldin October, 1982, followedby formal training of VCHWs in January, 1983, whichlasted till April, 1983. Of the 23 who registered as trainees, only 15 completed the program and continue to function as VCHWs at present.
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Data gathering in this site commenced oLn the first weekof March,1984.
3.2 Bagong SilanganNursing Clinic Project (BSNCP) Barangay Bagon Silangan is located in Quezon Citv,
apart of MetropolitanManila andone of the leading cities in the countrywheremost government offices are located. The maincampus of the University of the Philippines is situated in this City.
Quezon CityHealthDepartment suggested that BarangayBagong Silanganbe the site for thenursing clinic project of the 1.P. College of Nursing which started in 1978. The basic criterion for the selection was the absence of health services within the community. The termnursing clinicmeans ahub for the developmentofthe community toward self-direction, selfreliance and self-support inhealth. It served as the core frcmwhichactivities supportiveof the goals of primaryhealthcare shall emanate.
The Bagong SilanganNursing Clinic Project(BSNCP) initiated in 1978, was afive year communitybased projectwithtwo goals: It aimed to develop the capabilities of thecommunity such that its memberswill be able to establish basicmechanisms to direct, support and maintainhealth andhealthrelated activities and services. It also aimed to provide relevant andmeaningfullearning
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experiences for the student, both at the graduate and undergraduate levels.
The main strategies utilized to atzain the objectives were training of community health workers, development of indigenous resources i.e., herbal medicine,communityorganization,leadership training, multisectoral linkages, and development ofwork groups in addition to provision of direct curative and preventive services. Atotal of twentyone (21) health volunteers were trained in two batches. The first batch composed of eleven memberswere trained from April 2to May 27, 1979; however, only nine finished the course. The secondbatchcomposed of twelve members were trained from June 13 to October 5,1979. Today, these trainedvolunteers form the core of health care workers in the community.
Themanagementof the project by the U.P. College of Nursing (UPCN)ended in November, 1983 however. The Quezon CityHealthDepartment took over and has adopted the model developed in Barangay BagongSilangan in implementingprimary healthcare in other parts of Quezon City. Data gathering in this site commencedon the secondweekof March,1984.
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3.3 BarangavMatimbc - Servicedby Rural Health Unit (RHU)IV in Malolos, Bulacan. The province of Bulacanwas recently gaining
reputation as an MOH-PHC demonstration area in Region 3,Central Luzon, alongwith the province ofNueva Ecija. Bulacan is bounded by Valenzuela and Rizal in the National Capital Region and Pampanga and Nueva Ecija in Central Luzon, and consists of 24 Municipalities. The Municipalityof Malolos is the Capital of Bulacan province. This is where theProvincial HealthOffice under the MOH Vs located. The town proper is grossly urbanizedand industrialized. Among the town's health facilities are the provincial hospital, four private hospitals,four Rural Health Units (RHUs), and ten BarangayHealth Stations (BHS). EachRural Health Unit services different groups of barangays, some ofwhich are situated in the town proper,with largemajority situated in predominantlyrural districts, especially those serviced by the BarangayHealth Stations.
All four RHUs started incorporating thePrimary HealthCare Concept in their services including training of BHWs in late 1982. Specifically,RHU IVwhichhas jurisdictionoverMatimbo started PHC activities in May, 1982. Its staff include aphysician, anurse, and a midwife. From acommitteeorganization as astarting point, it gradually expandedto include trainingof BHWs in May, 1983, establishmentof "Botika sa Barangay", and
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"Hilot" training. It serves the healthneedsof nine barangays. Of these, Barangay Matimbo,under RHU IV, was chosen as the study site mainlyon the basis of the date of training of its first batch of BiWs inthis area. They completed their training in May, 1983 compared to the other three unitswhichhad amuch later date of BHV Training implementation.
Datacollection in this site commenced in February16, 1984.
4. Sampling Framel All trainors arid trained BHWs (activeand
inactive) in the three study siteswere included in the study. For the community respondents,the household wasmadethe frame ofreference in determining the populationsample. Apurposive sampling, comprising 50% of the total population of the barangaywas used. The sampling scheme called for interviewingevery other house in each study site.
Therespondents to the surveywere preferably mothersorwhoeverwas consideredrepresenting the households. The total sample size for each categoryof respondents is presented in Table Ibelow.
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TABLE I SAKPLE SIZE FOR THE THREE STUDY SITES
Matimbo, DalupiripB.Silangan, Respondent Category 'Bulacan!Benguet Quezon Civ Total
Trainors 3 5 3 11BH1s 12 15 21 48 Communityhouseholds 308 103 315 726
B. Results of ProblemAnalysis: This section presents the data on problem analysis
on BHW training programs utilizing the four indices previouslymentioned,namely, examination of trainingprogram manuals utilizedin BHW training and results of interviews of BHW trainors and BHWs themselves as well as community household respondents.
The three study sites were comparedalong each indicator.
1. TrainingProgramManuals: The following table summarizes the results of
content analysis on this variableusing the tool developed for this purpose.
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TABLE 2 COMPARATIVECHARACTERISTICS OFTRAINING PROGRAMS IN THE
THREE STUDYSITES
TrainingProgramDate of Implemen-
tationProject Site
DurationofTrainingNumber ofRecruits
Number of Drop-outs During TrainingNumber ofDrop-outs AfterMonths/YearsNumber of Retained/ Functioning BHWs
Bo.Matimbo'Bo.DalupiripBulacan Benguet
May, 1983 Jan.-July ,1983
Malolos, Itogon,Bulacan Benguet 2weeks 15 days19 volun- 23 volun-
teers teersNone 8drop-outs
5drop-outs2drop-outs
14 BHJs 13 BHWs
B.Silangan Quezon City April-May.
1982 Quezon City
8weeks 20 volun
teers None
4drop-outs
16 BHWs
seen n the above table, Bagong Silanganhada. Asthe longestduration of trainingof the three studysites and had two years of implementation priorto this research. Thetraining in Bo. Dalupiripwas givenona staggeredbasis from January to July, 1983, for atotal of 15 days,while the one in Bo. Matimbo, Bulacanwas offeredonacontinuousbasis, like Bagong Silangan,but for onlytwo weeks.
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b. Regarding criteria for selection of trainees, Bagong Silagan formulated acriteria for selection, as stated in its Training .Ianual, especially Dertaining to age, civil status, residency, literacy, and some desirable personality characteristics, while the other two study sites did not specify such in thei.r training manuals. However, it was understood that residency in the communities served, and literacywere assumed criteria for selection of volunteers in these study sites.
c. The mannerof training, in the three sites consisted of bothdidactics andpracticum. The one inDalupirip, had 12 days devoted to didactics and three days to practicumsuch as doing communitysurvey and spot mapping, health assessment andmanagement of common ailments in the community. The one in Matimbo had both didactics and practicumtoo, with the latter consistingmainlyof blood pressure andTPR taking, communityrecord taking as well as administeringfirst aid. The hours for practicum were notreflected in the Training Manual of Bagong Silangan. However, through interview of trainors, it was learned that the trainees' practicum,consistedmainlyof administering
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first aid, training in familyplanningandMCH services. Further, didactic sessions emphasized participatorygroup discussions, instead ofmere lectures
d. Withregards to content coverage, Bagong Silanganhad themost extensivecoverage, consisting of 25 unit topics, compared to the 17 unit topics ofMatimbo and 7main Unit topicsin Dalupirip (Pleasesee AppendixE, Table1-.41)
e. Withregards to CourseSyllabi, BagongSilangan and Dalupiripbothhadobjectives formulated for training. -The latter also hadindicators for evaluatingprogress of participantsonmain topics covered.
f. Themain teachingtools utilizedin all three areas, consistedofaudio-visual aids in the formof film,slides andchart presentations, while demonstrationand returndemonstrations were themain techniquesutilized in practicum.
2. Trainors: The trainors forBagong Silanganconsistedof
three Nursing*facultymembers from the U.P. College ofNursing,while theone in Matimbohad the staffof
*One of the trainorshas leftfor the U.S.prior to this research,hence,wasnot interviewed.
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the Rural Health Unit composed ofadoctor, nurse and midwife,with invited resource speakers on certain topics. In Dalupirip, the Draining staff consisted of four staff nurses, one of whomwas afacultymember of St. Louis College ofNursing and aMedicalTechnologist.
in general, the trainees in the three study sites belong to the young adult and earlymiddle-aged group,mostly females and married. Their length of service in community health ranged from 3to 15 years. Their mean monthly family income was slightlyabove P3,000.00
In addition,the personalitycharacteristics of these trainors as revealedby the PersonalityInventories, presentedagenerallymature, independent, and achieving group interested in the welfare of human beings. The GSE Scale yielded ahigh level of selfesteem for the trainors in Dalupirip and Bagong Silangan areas, and mediumlevel for the Matimbo site. (Please see AppendixE,Table 2p.227 ) The PersonalityOrientation Inventory (POI) yieldeddesirablepersonality characteristicssuch as time competence, self-regard, self-acceptance,self-actualizing value, capacityfor warm interpersonalrelationships, and constructive view ofman, whichwere withinnorms and even above the norms on certain traits. (Please seeAppendixE,Table 3,228)
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p. 228). Further, as revealed by the PUP, alocally developedpersonalitv inventory, the trainors yieldedtraits of high qualitv in ambition, patience, fortitude, being resDectful, creativity, being helpful,inquisitiveness, and sense of responsibility. (Pleasesee AppendixE,Table 4,p.L29). The projective instrument also yieldedneeds and traits reflectingcapacity for warminterpersonal relationships, senseofachievement, nurturingqualities, as well as anxiety, and some amount of deprivation.
These positive qualities were supported by the BHWs' satisfactoryratings of their trainors with regards to characte-ristics'such as punctuality,knowledge of subject matter, clinical skills, interest in teaching and learning of others, ability to motivate, ability to give constructive criticisms, and others. Further, these trainor characteristics, traits and attitudes were alsoperceived by both trainors and trainees as facilitatingtrainee learning.
3. BHWs: The BHW Profile in the three study sites is pre
sented in the following table.
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TABLE 3 BHWPROFILE
Socio-Demographic ........___ .Characteristics (n=14) (n=!3) (n= 16)Meanage 39.57 37.38 42.31 Modal sex Female Male Female Modal civil status Married Married Married Mean number ofchildren 4 3 4 Modal occupation Self- Farmer SelfemployedMlean monthly employedfamily income
?1,578.57 P355.54 P 731.25 Mean years ofschooling 7.79 8.08 12.875 Educational attainment ElementaryHSunder- HSundergraduate graduateModal religion Catholic Catholic Catholic
Mean length of stay in barangay (years) 30 32.15 10.69Modal spouse'soccupation Farmer/ Farmer Blue collar selfemployed
In addition to the above socio-demographiccharacteristics the BHWs'personality characteristics as yieldedby the personalityinventories, presenteda generallymature andcongenial group exhibitingmedium level of self-esteem,(pleasesee AppendixE,Table 5, p.-230 ),achievement orientation,andcapacity for warm, interpersonal relationship. The "PUP"yielded traits of ahigh level especiallyonambition,patience, fortitude beingrespectful,being helpful, inquisitiveness and sense ofresponsibility. (Pleasesee AppendixE,Table 6, p.230 ). Within this generallypositive image
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however, were interpersed feelings of abasement/ inferiority, anxiety, and some amount of deprivation, as yielded by the SCT.
Nonetheless, the positive image of the BHWs, generally prevailedand further buttressed by the favorable assessment of their performance during different periods of their trainingby the trainors, specifically pertaining to services rendered. (Please see AppendixE,Table 7,p.231). However, the general trend of performance,in relation to some services performed such as Family Planning, Nutritionand others, was downward, with peak performance level during and immediately after training, and gradually declining six months after and ayear after. This trend was reversednonetheless,withregards to services such as Maternal-ChildHealthand Immunization,which showed further improvement in performan
