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Training community health workers: an evaluation of effectiveness,

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Article  in  International Journal of Health Promotion and Education · February 2017

DOI: 10.1080/14635240.2017.1284014

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 International Journal of Health Promotion and Education

ISSN: 1463-5240 (Print) 2164-9545 (Online) Journal homepage: http://www.tandfonline.com/loi/rhpe20

Training community health workers: an evaluation

of effectiveness, sustainable continuity, and
cultural humility in an educational program in
rural Haiti

Brandon A. Knettel, Shay E. Slifko, Arpana G. Inman & Iveta Silova

To cite this article: Brandon A. Knettel, Shay E. Slifko, Arpana G. Inman & Iveta Silova (2017):
Training community health workers: an evaluation of effectiveness, sustainable continuity, and
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International Journal of Health Promotion and Education, 2017
http://dx.doi.org/10.1080/14635240.2017.1284014

Training community health workers: an evaluation of

effectiveness, sustainable continuity, and cultural humility in
an educational program in rural Haiti
Brandon A. Knettela,b, Shay E. Slifkob,c, Arpana G. Inmanb and Iveta Silovab,d
a
Duke Global Health Institute, Duke University, Durham, NC, USA; bDepartment of Education and Human
Services, College of Education, Lehigh University, Bethlehem, PA, USA; cOffice of International Activities,
The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA; dMary Lou Fulton
Teachers College, Arizona State University, Tempe, AZ, USA

ABSTRACT ARTICLE HISTORY

Community health worker (CHW) programs, which provide health- Received 28 November 2015
related training to members of the general public, have emerged as a Accepted 16 January 2017
key tool in addressing the health needs of the world’s poorest citizens. KEYWORDS
The Caribbean nation of Haiti is widely considered the least developed Community-based
in the Western hemisphere with health indicators near the bottom of participatory action; health
all countries worldwide. In response to the vast healthcare needs of education; short-term
the country, attempts have been made to extend sustainable rural volunteerism; task-shifting;
health services with a small number of CHW programs formed through task-sharing
international and community partnerships. The purpose of the current
mixed methods research was to evaluate the efficacy, sustainability, and
cultural compatibility of an annual volunteer-led training program for
CHWs in rural southeast Haiti. The course aimed to expand the health
literacy of 126 Haitian CHWs with a specific focus on maternal and
child health. Results showed significant improvement in participants’
knowledge of course content and participants overwhelmingly
endorsed the course as valuable. However, trainees cited logistical,
material, and financial barriers impeding them from carrying out their
roles as CHWs. Additionally, although the partnership responsible
for the ongoing training is taking a long-term stance to their work
in Haiti, training provided by non-Haitian, short-term volunteers
creates concerns about a lack of sustainable continuity and cultural
compatibility. In response, the authors provide recommendations
for building effective, volunteer-led training programs that uphold
principles of participatory action and cultural humility.

The training and implementation of community health workers (CHWs), local residents
who provide health consultations and basic treatment in the communities where they reside,
has been among the greatest trends in public health over the last ten years (Lehmann and
Sanders 2007; Gates et al. 2015). These workers ‘are integrated as an essential link in the
chain of access to care in a variety of settings,’ (Knettel and Slifko forthcoming) and provide
a variety of services, including health interventions such as administering vaccinations

CONTACT  Brandon A. Knettel  Brandon.Knettel@duke.edu

© 2017 Institute of Health Promotion and Education
2   B. A. KNETTEL ET AL.

and monitoring chronic conditions, health education, facilitating communication among

services, and referral to higher levels of care. A report by the World Health Organization
states that CHWs, when provided adequate ongoing support, represent the foundation of
health systems and become invaluable in combatting ‘the human resource crisis affecting
many countries’ (Bhutta et al. 2010, 8). However, CHW program practices, roles, training,
and levels of support from sponsoring organizations vary widely, as does the definition of
what constitutes a sustainable program model in international aid.
The lack of clear guidelines in key areas creates confusion about how to effectively imple-
ment CHW programs and maximize long-term improvement in health outcomes (Bhutta
et al. 2010; Perry, Zulliger, and Rogers 2014; Gates et al. 2015). The current study aims to
evaluate and improve the efforts of one CHW training initiative with specific attention to
the long-term sustainability of the program. Evaluating sustainability in health promotion
includes a critical examination of (a) the extent to which a community currently has access
to the desired skills, knowledge, and resources needed to conduct effective health promotion,
and (b) the extent to which a program or intervention is advancing these areas (Shediac-
Rizkallah and Bone 1998). Evaluating sustainability also requires assessment of the cost
effectiveness of a project in delivering its services in a way that upholds the participation
of the community, utilizes local resources, and seeks to reinforce lasting, long-term impact
(Bamberger and Cheema 1990; Jason et al. 2004). In response to calls for increased atten-
tion to project sustainability, aid organizations are also being encouraged to take a more
active role in formalizing, documenting, and evaluating the effectiveness of CHW training
programs (Lehmann and Sanders 2007).
In addition to questions about the sustainability of their work, non-governmental organ-
izations (NGOs), aid agencies, and governments also face questions about the cultural
appropriateness of their work in foreign nations (Barnett and Weiss 2008; Biquet 2013).
Attention and criticism in this area were perhaps most evident in the context of the earth-
quake that struck the nation of Haiti in 2010, killing more than 200,000 people, leaving
approximately 1 million displaced, and causing an estimated $7.8 billion USD in damages.
The quake made an immense impact on a nation that was already the least developed in
the Western Hemisphere with a per capita income of about $2 USD per day and approxi-
mately 85% of the population living below the global poverty line (CIA (Central Intelligence
Agency) 2013). However, it was the humanitarian response to the disaster that may have
received the most adverse attention. The aid provided in the aftermath of the earthquake
was perceived by many to be inadequate, inefficient, transient, and grossly disorganized
(Schwartz 2008; Farmer 2011; Katz 2013).
In Haiti, the legacies of the earthquake and the failed aid response continue to be visible
on the streets today, as do the attempts to remedy these mistakes with more sustainable,
ground-up approaches. CHW programs appear to be an integral component of these solu-
tions. A WHO country case study in Haiti observed inverse relationships between the
number of health workers and mortality for pregnant women and children under five. In
the same study, areas of the country with fewer trained health practitioners saw lower rates
of attended births, lower childhood vaccination rates, less effective treatment of tuberculosis
and malaria, and reduced likelihood of sick people seeking necessary medical attention
(Bhutta et al. 2010).
 INTERNATIONAL JOURNAL OF HEALTH PROMOTION AND EDUCATION   3

Collaborative models of research and community programs

Within the context of Haiti, it is vital for CHW programs to learn from the past by
taking a more measured approach based on modern principles of participatory action.
For instance, examples of successful CHW programs demonstrate that in order to
adequately address the overwhelming burden of disease through the local workforce,
programs must effectively recruit and train CHWs, pay them a living wage, provide
necessary supplies, offer ongoing supervision and oversight, monitor and evaluate effec-
tiveness, provide incentives as needed, and support opportunities for the professional
advancement of CHWs (Bhutta et al. 2010; Perry 2013; Gates et al. 2015). The com-
munity-based participatory action (CBPA) model assists in these goals by encouraging
the minimization of power differentials between those providing instruction and those
receiving it, including participation and input from stakeholders at every level of the
process (Jason et al. 2004). CBPA principles have been implemented successfully with
exemplary health care and CHW programs. The founders of one such program in
Jamkhed, India outlined a replicable model for collaborative community health pro-
grams, including (1) community empowerment, (2) the prevention as well as treatment
of health concerns, and (3) applying appropriate tools and technology according to
cultural context (Gates et al. 2015).
Finally, while sustainable health promotion and CBPA models encourage stakeholder
involvement, they rarely provide clear guidelines for the manner in which interactions
should be carried out. However, this information is readily available in the multicultural lit-
erature, where providers often advocate for the advancement of cultural humility (Tervalon
and Murray-García 1998), an attitude aimed at capturing perspectives with a ‘radical open-
ness to them that can lead to a fusion of horizons – a melding of outlooks that transforms
participants’ (Christopher et al. 2014, 653). Interventions that foster cultural humility take
steps to create equal footing in interactions between the historical ‘providers’ and ‘recipients’
of aid and care, whether they be in the form of instruction, service, research, or the direct
contribution of funds or supplies. Cultural humility also includes the examination of one’s
own privilege and biases, as well as appreciation and respect for the cultural context, impact,
and messages of the work being done (Christopher et al. 2014). Just as attention to sustain-
ability involves developing long-term effectiveness and local capacity building in programs,
a stance based on cultural humility seeks to promote dignity, autonomy, and social justice.
The cultural humility of programs conducted in Haiti has come under question in recent
years. Due in part to its social needs, proximity to the United States, and high profile nat-
ural disasters, thousands of foreigner citizens travel to Haiti each year for brief volunteer
trips (Lasker 2016). These volunteers have varying degrees of experience in Haiti or pro-
ficiency in Creole, necessitating the assistance of local staff, interpreters, and community
liaisons to carry out their goals. Historically within the public health field, volunteerism of
this sort was viewed as an effective model for sharing knowledge and resources; however,
more recently, critics have expressed concerns about potential drawbacks of such programs
(Richter and Norman 2010; Curci 2012). Specifically, critiques point to the material costs
of hosting volunteers, productivity costs that are a natural result of working in unfamiliar
cultural settings, and social costs of relying on workers from foreign nations at the expense
of building domestic capacity (Lasker 2016). In response to these concerns, programs in
4   B. A. KNETTEL ET AL.

Haiti are increasingly conducting formal program evaluations as a means of examining the
costs and benefits of their programs to the host nation.

A community health worker training example in Haiti

The present research consisted of a mixed-methods evaluation of a CHW training program
in rural southern Haiti aimed at measuring the program’s effectiveness, sustainability, and
cultural compatibility. The yearly CHW training course was established shortly after the
earthquake in 2010 through the partnership between a US-based humanitarian assistance
organization and the Haitian Ministry of Public Health and Population (MSPP). Participants
in the training were originally selected with input from local ‘federations,’ or grassroots
community organizations from the host region, who identified leaders in the community
who would complete the training and earn the title of CHW. Some participants had previous
health training, with a small number formally trained in the clinical sector, but most were
simply community members identified for their leadership, literacy, and the belief that they
were well-equipped to learn and disseminate health information.
Past trainings held by this collaborative consisted of one week of daylong education
sessions offered once per year, providing information on the importance of seeking regular
primary health care, prevention of common infectious diseases and infections, identifying
more complicated and often fatal health concerns requiring immediate intervention, and
ways of maintaining good sanitation and hygiene in the home. The courses were taught by
US-based volunteers with expertise in public health and varying levels of experience work-
ing in Haiti or other developing countries. After three years of courses focused on general
health knowledge, the participants requested more specialized content on topics such as
maternal and child health, which was the focus of the three weeklong trainings held in 2013
and the subject of the current research. The instructors for the maternal and child health
course were four volunteers formally trained in the health sciences – two originating from
the United States, one from Canada, and one from Guyana. Two of the instructors were
employed as registered nurses, one as a public health specialist, and one as a laboratory
scientist. The instructors used informal feedback from the previous year’s training to identify
areas of focus and developed the curriculum and course textbook (Knettel and Slifko 2013;
Slifko 2014) using guidelines and materials published by the MSPP. The goal of the training
was to equip the CHWs with information aimed at reducing illness and mortality among
pregnant women, postpartum mothers, and children under five years old. Course content
directly reflected these goals and included methods for preventing health complications (e.g.
nutrition, hygiene, prenatal care), recognition of problems, and recommendations for when
to seek professional help. The course content was presented in a lecture format but included
various visual aids and demonstrations involving trainee participation. Course instructors
also frequently paused to take questions. The course was taught in English and immediately
translated to Creole by Haitian interpreters hired by the sponsoring organization.

Methods
Evaluation of the CHW training program was conducted by a doctoral student and a
Master’s student in education from Lehigh University, who accompanied the instruction
team to Haiti. The evaluators were not previously affiliated with the sponsoring organizations
 INTERNATIONAL JOURNAL OF HEALTH PROMOTION AND EDUCATION   5

and were encouraged throughout the process to provide open and objective feedback. All
procedures were approved by Lehigh University’s ethical review board.

Participants
The participants in the evaluation were local volunteer CHWs, all of whom were Haitians
residing in the rural southern region of the country. In previous years, participants were
recruited by a general invitation and were required to pass a literacy test to participate.
However, the initial screening standards were not maintained and additional participants of
varying levels of education and literacy were allowed to participate in the training. A total
of 126 participants took part in one of three consecutive week-long CHW courses and all
of these participants agreed to take part in the evaluation; however, 13 participants were
absent on either the first or last day of their assigned course and therefore completed only
half of the evaluation tasks.
A total of 119 participants completed the demographic questions with 64.3% identifying
as male (n = 81) and 30.2% identifying as female (n = 38) with a mean age of 38 years (range
18–75). On average, participants had completed nine years of formal education. All partic-
ipants identified as African Origin, Black, or Haitian with the exception of one participant
identifying as Mixed Race/Multiracial. All participants (n = 119) indicated that they were
Haitian Creole speakers while 51 (42.9%) indicated that they had additional proficiency
in French. Participants travelled an average distance of 15.98 km to attend the class, with a
majority traveling exclusively by foot (n = 59, 50.9%).

Procedure
The evaluation of the course included quantitative pre- and post-course tests of knowledge
administered to the participants in the curriculum areas, a brief satisfaction survey, and
two semi-structured focus groups for each participant. These were administered on the
morning of the first day of the course, prior to the start of instruction, and the afternoon
of the last day, once all instruction had been completed. All evaluations were adminis-
tered solely by the research team and were conducted independent of the training course.
The consent form and all instruments were translated from English to Creole by native
Haitians prior to the course and read aloud prior to participants signing their informed
consent. Participation was entirely voluntary and a decision not to participate had no
impact on a CHW’s standing in the course. Throughout the test administration and focus
groups, Haitian interpreters read aloud each item and participants were encouraged to
ask questions.

Measures
Pre- and post-course focus group interviews
Focus groups were conducted with all participants on the first and last day of each course
with participants of each week’s course randomly split into two focus groups. The goal of
these groups was to examine participants’ expectations, goals, and reactions related to the
training. Pre-course interviews included questions such as ‘What motivated you to attend
this course?’ and ‘What do you hope to accomplish from taking this course?’ and post-course
6   B. A. KNETTEL ET AL.

interviews included questions about the most and least helpful aspects of the course as well
as potential implications for participants’ role in the community.

Post-course satisfaction survey

On the final day of the course, participants completed four multiple-choice questions eval-
uating the effectiveness and applicability of the course. Specifically, participants were asked:
(1) How helpful was this course for your work in the community?, (2) If a similar course
were made available next year, would you like to participate?, (3) Would you recommend
this course to a friend or neighbor?, and (4) Was the length of the course appropriate, too
long, or too short?

Pre- and post-course knowledge tests

At the beginning and end of each course, participants were asked to complete 35 multiple
choice and true-false questions aimed at testing their knowledge of the course content.
These questions were written by the course instructors and included items such as, ‘How
can you tell if a child or adult has cholera?’ and ‘What can we do to help when a child has
diarrhea?’

In-depth interviews with course instructors and administrators

Data from the structured evaluation were supplemented by in-depths interviews with the
course instructors and two key administrators: the sponsoring organization’s executive
director and their director of programs in Haiti. These interviews included content about
the circumstances leading to the establishment of the program, changes in the program
over time, rationale for several decisions related to format and structure, and plans and
goals for the future.

Data analysis
To interpret the data, we utilized repeated measures analysis of variance (ANOVA) to exam-
ine potential improvement in course knowledge and analysis of covariance (ANCOVA) to
compare participants who had attended previous trainings with new participants. Power
analyses were completed using G*Power software (Faul, Erdfelder, and Lang 2007) to con-
firm adequate power for the sample. A priori power analysis for the ANCOVA yielded a
suggested sample size of 128. The final number of participants was slightly below this total;
however, a post hoc power analysis yielded a 1–β value of .795, indicating adequate statistical
power (Cohen 1988).
Qualitative items, focus group data, and interview notes were analyzed using discov-
ery-oriented exploratory analysis (Mahrer and Boulet 1999). All responses were reviewed
independently by three graduate student coders familiar with the work. The coders first
created independent, preliminary lists of dominant themes in the responses for each
question, then consolidated these initial lists into one master list. Discrepancies and dis-
agreements in the themes were discussed until consensus was achieved. This analytical
process resulted in final structures ranging from three to six themes for each qualitative
item. Next, each of the 126 qualitative surveys was analyzed by the three coders to deter-
mine which themes were present in each response and all disagreements were once again
discussed to consensus.
 INTERNATIONAL JOURNAL OF HEALTH PROMOTION AND EDUCATION   7

Table 1. Pre- and post-test knowledge scores for the three study groups.
Mean years Frequency of
education of return Improvement
Group participants participants Pre-test mean Post-test mean F (p)
Group 1 (n = 34) 8.50 91.2% 23.3 27.4 8.576 (.006)
Group 2 (n = 27) 9.29 3.7% 28.6 28.9 .189 (.668)
Group 3 (n = 52) 9.53 61.1% 28.1 29.7 13.331 (.001)
Total (n = 113) 9.09 54.8% 26.8 28.8 14.653 (<.001)
Note: Test scores out of a total of 35 questions/points.

Results
Effectiveness of the course
The effectiveness of the course was examined via the post-course satisfaction survey, pre-
and post-course tests of knowledge, and focus group responses. On the satisfaction survey,
participants overall reported that the course was ‘very helpful’ for their work in the com-
munity (n = 116, 92.1%), they would participate again if possible (n = 120, 95.2%), and
they would recommend the course to a friend or neighbor (n = 119, 94.4%). Participants
also progressed in their understanding of the course materials. Repeated measures ANOVA
with 113 participants who were present for both the pre-test and post-test showed sig-
nificant improvement in knowledge scores over time (Wilks’ lambda = .882, F(1, 110) =
14.653, p < .001) as can be observed in Table 1 above. It should be noted that Box’s M test
of the homogeneity of covariance matrices for these data yielded a significant result (Box’s
M = 59.782, F(6, 99,811) = 9.678, p < .001), indicating the assumption of homogeneity was
not met and results should be interpreted with caution (Leech, Barrett, and Morgan 2008).
In addition to significant improvement in scored from pre-test to post-test, a significant
interaction effect was observed between time point and course grouping (F(2, 110) = 3.947,
p = .022), indicating that differences from pre-test to post-test were not consistent among
the three groups who took the course. Using post hoc simple contrasts with a Bonferroni
correction, we determined that the level of improvement was significantly greater for par-
ticipants in the first week’s group than either the second (p = .003) or third week (p < .001).
Participants in Group 1 had substantially lower levels of formal education and lower pre-test
scores than other participants, which indicates that the course content may have been more
novel for these participants and thus more likely to improve their knowledge.
Interestingly, an ANCOVA comparing the baseline knowledge of return participants
against first-time participants (with education level included as a covariate) showed that
attendance at the previous year’s training did not significantly predict a difference in pre-
test score (F(2, 104) = .416, p = .661), indicating potential concerns about the retention of
course content between trainings. However, this lack of significance may be at least partially
explained by the change in focus of this year’s course (maternal and child health) from prior
years’ content on more general health knowledge.
The course’s effectiveness was also addressed in the focus groups. The qualitative analysis
revealed a common theme that participants valued the course and that it provided longer,
more detailed, and more helpful training than other health education they had access to,
particularly in this rural area where such opportunities for learning were rare. There was
also a distinct emphasis on the practical application of the knowledge to improve the over-
all health of the community. For example, when asked about motivations for attending
8   B. A. KNETTEL ET AL.

the course, one participant expressed, ‘My neighbors were suffering from cholera and I
heard about this program. I decided to come here to learn more and be able to help them.’
Others placed this desire in direct relation to the lack of other local health resources: ‘I am
learning more health knowledge to help my community that has limited access to a clinic
or hospital in an emergency.’

Difficulties in sustainable implementation of health knowledge

Several focus group questions were aimed at the broader implementation and impact of the
course. Participants frequently shared that they felt that improving their knowledge and
sharing it with others would prevent unnecessary death and illness in the community and
improve health overall. As one participant shared, ‘We must have knowledge first. Tools
are much more powerful and long-lasting if they are paired with strong knowledge.’ When
asked how they dispensed health knowledge to others, the most common methods were
visits to individual homes or meetings in public places (e.g. churches and markets).
Participants were reluctant to provide criticism of the training program, but did fre-
quently refer to barriers in both their access to and dissemination of health knowledge.
For example, participants cited the long distances they travelled to attend the training.
Several participants requested that future trainings be held in more central locations and
that transportation, lodging, childcare, and more food be provided or subsidized.
Additionally, several CHWs requested materials to implement the goals of the train-
ing (e.g. educational materials, medications, water sanitation tabs, building materials for
latrines), which would better enable them to perform their roles. Those who assisted in
childbirth often expressed a desire for birthing kits so that they could have clean bandages
and a sharp instrument for cutting the umbilical cord. One participant in a post-course
focus group shared, ‘I feel excited because I work with many pregnant women and now I
can be more helpful, but I need the tools!’
One counterargument to the desire for tools or materials arose when some participants
expressed concern that CHWs were using their training to illegally practice medicine in
the community. This included accounts of CHWs diagnosing and treating, charging for
services, and even performing minor medical procedures under the auspices of their train-
ing and title. In light of these concerns, course administrators expressed varying levels of
openness to providing material assistance to CHWs, agreeing that materials reflecting the
goal of preventing disease (i.e. building materials for latrines, sanitation tabs) would be
more appropriate than materials for providing treatment (i.e. medical supplies, medication).
In addition to conversations about materials, multiple CHWs suggested that being paid
for their roles as CHWs would allow them to put more time and energy into their work.
More than half (52.3%) listed their unpaid CHW role as their primary profession, an indica-
tion of the overall lack of formal employment opportunities in the region. Participants also
indicated there was no ongoing training between the yearly courses, little formal supervi-
sion by the sponsoring organization, and minimal opportunities for regular collaboration
among the CHWs. Several suggested that adding these components would enable them
to solidify their past learning, discuss their work to obtain feedback, and build on their
health knowledge.
 INTERNATIONAL JOURNAL OF HEALTH PROMOTION AND EDUCATION   9

Cultural humility
In addition to recommendations for improved sustainability, we identified culturally
nuanced challenges in this short-term program that require closer examination. Upon
arriving in Haiti, the cultural distance between the CHW instructors and their Haitian hosts
was apparent. Volunteer instructors wore different clothing, spoke different languages, and
held different views about health concerns and treatment. It is therefore unsurprising that
several areas of the curriculum did not reflect the social and economic realities of the Haitian
participants. Some of the training content suggested unfamiliar, expensive, or hard-to-find
treatments such as a three-part series of immunizations for the Human Papillomavirus and
expensive sterile supplies for labor and delivery.
The course instructors frequently stated their desire to improve health knowledge and
outcomes in Haiti. Several also demonstrated a stance reflecting cultural humility: keeping
an open mind about cultural differences, seeking to learn first and teach second, and adapt-
ing their content to the local context. However, the challenges of making these adaptations
with little or no prior experience in Haiti were readily apparent. Despite clear improvement
in their cultural understanding as the courses progressed, the instructors’ lack of famili-
arity with the daily circumstances of the participants’ lives clearly impacted the cultural
compatibility of the course.

Discussion
International partnerships between developed and underdeveloped nations are imperative to
the improvement of global health. However, grassroots, collaborative, and community-based
approaches are increasingly emerging as vital alternatives to top-down ‘provider and recip-
ient’ relationships (Murphy et al. 2013). Mutually beneficial partnerships strengthen health
systems and create a two-way conduit of knowledge-sharing for both the international
partners (often from high income countries) and the hosting region (often low and middle
income countries). Such partnerships foster the understanding of health and education as
truly global areas of inquiry without sacrificing the importance of cultural context.
While the goal of partnerships is to work together in order to reduce the burden of
preventable disease and ongoing health disparities, partnerships come with their share of
challenges. Without an international partner for the CHW training evaluated in the current
research, the program would most certainly not exist due to a deficit in resources. However,
our findings indicate that the participation and support being offered have also come with
disparities in power and voice.
The findings of the current evaluation indicate that the CHW course is effective at
improving health-related knowledge among participants in the short term. However, the
evaluation also revealed a lack of sustainable continuity to support the logistical needs of
CHWs during and between trainings, including a lack of needed resources, ongoing train-
ing, oversight, and financial support. Finally, the results showed a considerable gap in the
cultural understanding between the sponsoring organization and the program participants.
The following recommendations outline methods for improving the current program, as
well as implications for similar CHW and community health partnerships.
10   B. A. KNETTEL ET AL.

Effectiveness of instruction and sustainable continuity

The lack of significant differences in knowledge between first time participants and return
participants indicates a need for greater attention to the retention of knowledge between
the yearly courses. Although there are opportunities to reshape didactics to improve reten-
tion (instruction encouraging critical thinking, problem solving, and greater emphasis on
interactive education), these are unlikely to fully address the issue of retention. We believe
that the most effective method for improving retention of knowledge between courses will
be to increase the frequency of contact among the CHWs and between the CHWs and
the sponsoring organization. More frequent trainings may also allow the trainers to shift
the focus of the training to more practical skills (e.g. techniques for disseminating course
knowledge) and allow the sponsoring organization to better maintain the vital relational
component of successful training programs.
Further, CHWs have a clear understanding of the resources necessary to improve train-
ing programs, including financial and logistical support and more frequent trainings to
improve their health literacy. Exemplar CHW programs have chosen to make CHWs sal-
aried employees, have hired dedicated staff who engage consistently with CHWs to pro-
mote their work in the field, take steps to formally integrate CHWs into the larger health
and emergency response systems, and provide the possibility of upward mobility through
professional development training. Such efforts not only improve the effectiveness and
impact of programs, but also foster a sense of investment and create opportunities for local
leadership in the future (Farmer 2011; Gates et al. 2015).

Advancing cultural humility and participatory action

Successful partnerships must create bidirectional exchanges of knowledge and feedback
at various levels of the organization, including program leadership. This may be especially
true when utilizing a short-term volunteer model, where the steep learning curve of vol-
unteers must be an acknowledged limitation. The knowledge and skills necessary to work
effectively in new cultural environments are complex and continue to develop across one’s
career (Arredondo and Tovar-Blank 2013). Professionals with little international expe-
rience working in unfamiliar settings are unlikely to espouse these ideals in their work.
Additionally, it has been argued that the import of international volunteers to ‘provide’ a
service may unintentionally widen power differentials and expose participants to ideals
that run counter to cultural models of coping and resilience (Schwartz 2008; Curci 2012).
We believe that the use of short-term volunteers must be balanced by consistency in pro-
gram leadership and organizational understanding of how best to serve the host community.
This may include steps to empower members of the host community through opportunities
in leadership and the exchange of information. We believe that it will be valuable to explore
these factors in future evaluations of the CHW program examined here. For all CHW part-
nerships working with short-term volunteers, we recommend implementing a thorough
cultural orientation aimed at building knowledge, awareness, skills, and humility in work-
ing across cultures. This should include knowledge specific to the host community and a
distinct emphasis on challenging personal biases, misconceptions, or deficits in knowledge.
Although mastery in these areas is developed over years, not hours, more comprehensive
training will engage volunteers in self-exploration and learning about the host culture in
ways that will advance the goals of the program and the autonomy of its participants.
 INTERNATIONAL JOURNAL OF HEALTH PROMOTION AND EDUCATION   11

Finally, a core concept of cultural humility is that participants should be able to collab-
orate with, see images of, and learn from people who share their linguistic, racial, ethnic
and cultural identities. Therefore, we believe that Haitian instructors must be involved in
ongoing training programs held in this country and that Haitian contributors should receive
substantial, continuous support in the implementation of programs in their communities.
This will aid in addressing the shortcomings of the short-term volunteer model by fostering
cultural compatibility, strengthening community ownership, and advancing sponsoring
organizations’ mission of sustainability.

Limitations of the study

Limitations to the current study include challenges in the affinity of the knowledge tests to
the course content, participants’ lack of familiarity with research and testing procedures,
and the potential for perceived demand characteristics. The evaluation knowledge test was
developed several weeks prior to the course, but the instructors continued to shape their
content up to the day of instruction. Therefore, the knowledge tests did not always neatly
reflect the course content. It was also apparent in the administration of the tests that many
of the participants had little prior experience with research, including components such as
Likert-type items, multiple choice question formats, and true/false formats. The evaluators
made every effort to clarify these concepts in the instructions for these materials, but these
issues may have influenced the results by favoring participants with more research expe-
rience. Finally, as noted previously, participants were hesitant to provide critical feedback
of the program, which may have been the result of social desirability or perceived demand
characteristics of the evaluation. While the evaluators clearly explained that our roles were
independent of the instruction and that confidentiality would be strictly maintained, these
perceptions did likely influence participants’ willingness to share some critical feedback.

Disclosure statement
No potential conflict of interest was reported by the authors.

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