title: Training and supervision of community health workers conducting population-based, noninvasive screening for CVD in LMIC: implications for scaling up.
abstract: BACKGROUND
  Community health workers (CHW) can screen for cardiovascular disease risk as well as health professionals using a noninvasive screening tool. However, this demonstrated success does not guarantee effective scaling of the intervention to a population level.
  
  
  OBJECTIVE
  This study sought to report lessons learned from supervisors' experiences monitoring CHW and perceptions of other stakeholders regarding features for successful scaling of interventions that incorporate task-sharing with CHW.
  
  
  METHODS
  We conducted a qualitative analysis of in-depth interviews to explore stakeholder perceptions. Data was collected through interviews of 36 supervisors and administrators at nongovernmental organizations contracted to deliver and manage primary care services using CHW, directors, and staff at the government health care clinics, and officials from the departments of health responsible for the implementation of health policy.
  
  
  RESULTS
  CHW are recognized for their value in offsetting severe human resource shortages and for their expert community knowledge. There is a lack of clear definitions for roles, expectations, and career paths for CHW. Formal evaluation and supervisory systems are highly desirable but nonexistent or poorly implemented, creating a critical deficit for effective implementation of programs using task-sharing. There is acknowledgment of environmental challenges (e.g., safety) and systemic challenges (e.g., respect from trained health professionals) that hamper the effectiveness of CHW. The government-community relationships presumed to form the basis of redesigned health care services have to be supported more explicitly and consistently on both sides in order to increase the acceptability of CHW and their effectiveness.
  
  
  CONCLUSIONS
  The criteria critical for successful scaling of CHW-led screening are consistent with evidence for scaling-up communicable disease programs. Policy makers have to commit appropriate levels of resources and political will to ensure successful scaling of this intervention.
authors.affiliation: Center for Health Decision Science, Harvard School of Public Health, Boston, MA, USA. Electronic address: Shafika_Abrahams-Gessel@Harvard.Edu.
authors.forename: Shafika
authors.initials: S
authors.lastname: Abrahams-Gessel
authors.affiliation: Centro de Estudios en Salud y Sociedad, El Colegio de Sonora, Colonia Centro, Hermosillo, Sonora, México.
authors.forename: Catalina A
authors.initials: CA
authors.lastname: Denman
authors.affiliation: Institute of Nutrition of Central America and Panama, Ciudad de Guatemala, Guatemala.
authors.forename: Carlos Mendoza
authors.initials: CM
authors.lastname: Montano
authors.affiliation: Center for Health Decision Science, Harvard School of Public Health, Boston, MA, USA; Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA.
authors.forename: Thomas A
authors.initials: TA
authors.lastname: Gaziano
authors.affiliation: Chronic Diseases Initiative for Africa, Groote Schuur Hospital, Cape Town, South Africa; Division of Endocrinology and Diabetes, Department of Medicine, University of Cape Town, Cape Town, South Africa.
authors.forename: Naomi
authors.initials: N
authors.lastname: Levitt
authors.affiliation: Institute of Nutrition of Central America and Panama, Ciudad de Guatemala, Guatemala.
authors.forename: Alvaro
authors.initials: A
authors.lastname: Rivera-Andrade
authors.affiliation: Centro de Estudios en Salud y Sociedad, El Colegio de Sonora, Colonia Centro, Hermosillo, Sonora, México.
authors.forename: Diana Munguía
authors.initials: DM
authors.lastname: Carrasco
authors.affiliation: School of Public Health, University of the Western Cape, Bellville, Republic of South Africa.
authors.forename: Jabu
authors.initials: J
authors.lastname: Zulu
authors.affiliation: International Centre for Diarrhoeal Disease Research, Bangladesh, ICDDRB, Mohakali, Bangladesh; Centre for Clinical Epidemiology and Biostatistics, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, New South Wales, Australia.
authors.forename: Masuma Akter
authors.initials: MA
authors.lastname: Khanam
authors.affiliation: School of Public Health, University of the Western Cape, Bellville, Republic of South Africa.
authors.forename: Thandi
authors.initials: T
authors.lastname: Puoane
mesh_terms: D002318:Cardiovascular Diseases / Q000517:prevention & control*; D003150:Community Health Workers / Q000193:education; D003906:Developing Countries; D006801:Humans; D007398:Interpersonal Relations; D008403:Mass Screening / Q000458:organization & administration*; D011203:Poverty; D058257:Surgical Attire