Community health workers’ non-technical skills for delivering primary healthcare in low-income areas

1 Introduction

Many countries comprise Community Health Workers (CHWs) in their health systems as frontline primary carers entitled to promoting health, disease prevention, and maintaining patient health. Although their profiles vary, in most countries, especially the ones with universal health systems like Canada, United Kingdom, and Brazil, CHWs usually work very close to communities, visiting patients’ residences, carrying initial health procedures, and bridging the gap between the population and the health services [1, 2].

In developing countries like Brazil, CHWs’ work is significantly challenging due to diverse social, cultural, economic, and medical conditions. Moreover, in Brazil most CHWs are based in low-income communities usually inflicted by urban violence, poor infrastructure, low-quality housing and sanitation, among other issues that make residents difficult to care for. In addition, the only requirement for becoming a CHW in Brazil is to be a resident in the community where they are going to work, thus most CHWs start their work either poorly recruited, minimally trained, or in some cases without any training at all [3–5].

Previous studies have shown that patient engagement relies on deep understanding of the community and its rules [6, 7]. Such cultural and interpersonal nuances can only be learned by staying in the territories and bonding with their residents through social means. This highlights the importance of non-technical skills (NTS) in the CHW’s work.

NTSs are the cognitive and social skills that complement technical skills to enhance efficiency and safety [8, 9]. They relate to specific behaviors employed to accomplish a task. Therefore, non-technical skills do not characterize a specific person, but rather her/his behavior. In healthcare, non-technical skills are additional to clinical and procedural knowledge. They form the gamut of cognitive, social, and interpersonal skills that facilitate the effective delivery of safe care [10, 11].

Despite the wide recognition on the importance of NTS in health care, very little is known about how CHWs develop and adopt them in their regular performance. Significant literature is found on the work of physicians and nurses [12–14], while the use of NTS by CHWs remain almost unexplored.

Thus, this study aims at identifying the major NTS developed by CHWs to deliver healthcare in diverse, low-income, and poorly developed communities. Recent occurrences like the COVID-19 pandemic illustrate the increasing importance of CHWs in the frontline healthcare workforce in vulnerable communities. This study then contributes to better recruitment and earlier development of NTS in novice CHWs, in a scenario of scarce literature in this topic.

2 Methods

This study follows an qualitative exploratory design, underpinned by the Grounded Theory [15]. Data collection procedures were based on in-depth interviews with CHWs based on two primary care clinics, while the data analysis followed the Analytical Hierarchy Process (AHP) [16].

Observing the relationship between workers and the context in which they perform their regular activities is paramount to describe the strategies to cope with extraordinary events and explicit the tacit knowledge they employ. Thus, a qualitative approach showed to be useful in this exploratory study. Moreover, given the qualitative nature of this study, a large sample of participants would bring repetitive data and not necessarily present new information regarding the structure of the object observed [17].

It is also important to highlight that the grounded theory relies on adequate representations of the object of analysis, its culture, and symbols, rather than frequencies – encompassing its subjectivity and complexity, which cannot be quantified [15, 18].

The study was carried out with according to Brazilian regulations regarding research with human participants. Prior to its beginning, the present study underwent review and obtained clearance by the Institutional Review Board.

3 Results

Given the NTSs mapped, Table 1 summarizes the results of the pairwise comparisons carried out to calculate the relative importance of each NTS. Thus, Table 2 shows the scores given by each interviewed CHW, as well as the final score resulting of the aggregation of the opinions of CHWs. Finally, Table 3 presents the NTSs in order of importance, from the most to the least important one.

Recent literature suggests that the most critical abilities for coping with local contexts are the ones related to understanding symbols and meanings of the shared space, and being able to generate knowledge from such information [25–27]. Such symbols and meanings of the space are formed in what Santos [27] defines as “banal space” – the space and time directly linked to people’s everyday life.

In the banal space, the daily coexistence allows to identify and analyze neighborhood relations, conflicts, and differences, as well as the construction of specific rules of coexistence that must be respected by everyone, otherwise they would be subject to punishments for violating local rules [27]. As such rules are usually defined by a “local authority” – which in many locations in which CHWs are based consists of criminals, for example – adequate performance relies on making knowledge of such rules and how to cope with them as explicit as possible.

Enforcing the formal education background of CHWs has been a recurring topic in academia, not only in Brazil [26, 28–30], but also in Australia, the USA, and other countries, disregarding the model in which their health systems are based on [31–35].

Research on other healthcare professions have shown that especially physicians and nurses are more likely to explicit knowledge on their work, which entails the increasing description of their NTSs [12, 37]. Moreover, the results of this research show that work-based skills involving collaborative performance were an essential point of focus, with four of the seven work-based skills being related to group cohesion (i.e., disagreeing with the group, coping with bullying within the group, supporting other members of the group, negotiation). The importance of enforcing collaborative competencies in CHWs is confirmed by recent literature and has shown that collaboration with other CHWs, and with the rest of the healthcare team, is essential for improving health outcomes [38–40].

This study shows that, among the ten highest scored NTS, two are related to communication (Participating in conversations; Sustaining conversation), and one is related to advocacy (offering help). This corroborates with recent literature highlighting the importance of such skills for CHWs [41–43]. Other skills, namely ‘Introducing themselves’ and ‘Speaking in public’, were also highly ranked and relied heavily on the CHWs’ ability to communicate.

Regarding civility, a CHW’s ability to introduce themselves to other people was deemed to be of very high importance as introductions are typically the first action taken by CHWs while approaching communities or entering patients’ homes. Poor abilities in civility may hinder the consent a patient provides to access their home, thus delaying or even denying care. Previous studies have also highlighted the difficulties by CHWs in obtaining patients’ permissions to perform house calls. This is especially true in low-income and violent areas, where gaining the trust of people takes time, patience, and requires acute communication abilities [44–46].

The work of CHWs is essential to improving health outcomes, but their efficiency is tied to the understanding of local context, culture, and traditions. This is especially true when communities may present cultural or infrastructure barriers that hamper communication, logistics or technology use [47, 48].

5 Conclusions

One contribution of this study is the identification of major NTSs to deliver primary care in low-income areas. With accurate identification of NTSs provided by the participatory methods adopted in this article, recruitment, and training of novice CHWs can encompass the challenges that expose workers to harmful situations or affect the quality of health outcomes.

Furthermore, the results present a categorized set of socially applied skills commonly used to reinforce relationships in the workplace and prioritize the skills according to the weighted opinion of specialists following interviews of CHWs.

Regarding the limitations of the research, the results of this study contribute primarily to the improvement of community-based primary care programs as it helps to identify major skills required for community action. Moreover, managers and policymakers could take advantage of the results of our study by incorporating the selected skills into their training regimes for CHWs. Future research may expand our results by employing the methods we use in this study for other community-based primary healthcare scenarios, thus providing new empirical evidence on essential requirements for CHWs.

The second limitation of this study regards the broad scope of CHWs’ work, and the different configurations these professionals have worldwide. This study is based on Brazilian CHWs, as they operate mostly outside primary care clinics, visiting residences, and performing non-clinic procedures, differently from some other countries.

Conflict of interest

The authors have no conflicts of interest to declare.