Symposium Report—Lay Health Workers (Health Promoters) Project: Community Mobilization to Improve Cardiovascular Health in the Americas

(Santiago, Chile, 17–18 October 2005)

Report (36 pp, PDF, 169 Kb)
Background
Executive Summary (text to right)
Presentation of Experiences: Module I
- The Growing Field of Health Promotion
- Pastoral da Criança (Children's Ministry)
- The Way of the Heart: The Promotora Institute in Nogales, Arizona
- Community Health Program: Managing Child Health Services
- Citizenship-Building and the Reforms
Summary of Comments and Questions on Module I
Presentation of Experiences: Module II
- The NHLBI Experience with Lay Health Workers
Summary of Comments and Questions on Module II
- Evaluation
- Political context
- Accountability
- Roles and Limitations of Health Promoters
Facilitated Discussion on How to Apply the Health-Promoter Model: Module III

Viewpoint of Health Promoters
- Your Heart, Your Life: Outlook on Health Promoter Training from the Standpoint of Health
- The Politics of Citizen Participation in Health
Summary of Comments and Questions on Module III
Group Activity: Building a Common Vision of Cardiovascular Health
- Southern Cone (Argentina, Brazil, Chile, Paraguay, and Uruguay)
Andean Region (Bolivia, Colombia, Peru, and Venezuela)
- Central America and the Latin Caribbean (Costa Rica, Cuba, El Salvador, Mexico, Nicaragua, Panama, and Puerto Rico)
- English-Speaking and Francophone Caribbean (Anguilla, Bahamas, Canada, Haiti, and Trinidad and Tobago)
Closing Remarks
- List of Participants

- PAHO CARMEN Page
- PAHO Noncommunicable Disease Unit
- NHBLI

Co-sponsored by the National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), USA, and the PAHO CARMEN Initiative.

Executive Summary

General Objective: To exchange information on emerging models for programs that rely on health promoters to carry out community interventions and to take any lessons learned into account in the planning of future programs.

Specific Objectives

• Explore and identify the extent to which health promoters are currently used to address health issues in the Americas.
• Build consensus on the concept and potential of health promoters and the difficulties inherent in promoting, preventing, and controlling the risks of developing CVD in the Americas.
• Analyze the strategies, best practices and emerging criteria, with the purpose of implementing and evaluating projects led by health promoters.
• Offer recommendations for the development of conceptual models for pilot programs to carry out and evaluate the interventions of health promoters in the Americas.

Framework of the Symposium

The definition ultimately arrived at for the concept of "health promoter" and the conclusions as to the usefulness and feasibility of incorporating this concept in cardiovascular health programs should be considered in the context of the title of this symposium: Community Mobilization to Improve Cardiovascular Health in the Americas. The primary goal, therefore, is to support the prevention and control of CVD by tapping community know-how to disseminate knowledge and change harmful behaviors and habits (areas where traditional health interventions have a poor track record). Secondarily, the goal is to use the strength of the organized community to improve health service coverage and the early detection of people at risk. Beyond facilitating changes in the behaviors of individuals, the strength of a community led and organized by health promoters can also bring about changes in social and environmental determinants to the benefit of cardiovascular health.

All of this notwithstanding, experience demonstrates that the community's contribution-either through the health promoter model or community organizations that take part in health activities and decisions-has been used in different ways and for different purposes depending on the individual needs and reality of each country. Accordingly, several visions have emerged with respect to the role of health promoters, the scope of their work, and the characteristics required of people who assume that role. In this regard three important, but not necessarily exclusive, groups can be identified:

• Those who view the health promoter as a member of the community with training in health issues who helps to extend the coverage of the health sector: considered as a way to make up for personnel shortages and as an additional source of labor.
• Those who view the health promoter as a member of the community whose personal characteristics and additional training make him/her more effective at reaching people and the community and bringing about the desired behavioral changes: the promoter complements the work of the health team with actions and interventions in which he/she is a stakeholder and possesses better skills to that end.
• Those who attribute an additional value to the health promoter as a more active community stakeholder, recognizing that he/she is an effective representative of the community who, in addition to assuming health tasks and supporting changes, serves as a channel for communication between the community and the health sector, and represents community interests in dealings with local authorities.

With respect to these models, the consensus was that health promoters can be especially valuable to the success of cardiovascular health programs at any stage of an intervention in a given country.

This assertion is rooted in the fact that CVD can remain asymptomatic for a long period of time; are common and high-risk; are associated with behaviors and lifestyles; and, in most cases, are preventable or controllable. Therefore, information, education, and the development of know-how and skills for changing behavior are key to managing this health problem.

Changing behavior is not achieved through information alone or the instructions of health workers. On the contrary, it is achieved through a combination of factors, which, in addition to the two mentioned above, include many others, such as motivation and attitude about the change of behavior, the feasibility of the change, personal capacity to cope with adverse conditions, positive reinforcement, peer support, and the availability of models to follow (the promoter may serve as one such model), favorable settings, etc.

In this context, health promoters are regarded as important participants, given their capacity to reach people and communities with information and skills; health promoters appear to have greater potential for eliciting changes in behavior than classical health interventions, because they operate within the peoples' daily reality, gain their trust, and serve as a recognizable model within reach.

The presentations of experiences involving health promoters were varied and described the general features of programs covering health problems other than cardiovascular disease. However, these presentations made it clear that health promoters perform their work under similar basic conditions, and that it appears both feasible and practical to employ these conditions in cardiovascular health programs. Moreover, there was also consensus that health promoters serve as a mechanism for delivering relevant information from the communities they serve to the health sector, which makes it possible to better match interventions to people's real needs.

The group agreed on the following core elements for achieving successful results in cardiovascular health projects involving health promoters:

• ensuring the structural, technical, and financial sustainability of programs;
• adequate promoter selection and training;
• the availability of a core set of systematized support materials;
• ongoing monitoring and positive reinforcement of promoters;
• evaluation of promoters and the results of their interventions;
• the insertion of promoters' activities within the broader context of health and extrasectoral strategies; and
• encouraging a cultural change among health professionals toward embracing and supporting these programs.

Additionally, there appears to be no significant difference between paid and volunteer health promoters (this will depend on each case) or in the number of health programs that each promoter works on at the same time.

Special consideration was given to the idea that health promoters should be part of the community served and should work "from the inside." In some cases, health promoters from outside of the community are used, but the work they do is considered more as "health education" and not characteristic of health promoter activities, which are more comprehensive in nature.

Likewise, emphasis was placed on the idea that the health promoter should be respected and considered another member of the health team, but by the same token, should not be integrated to the point where he/she is no longer perceived as representing the community but instead as a staff member of the system.

One presentation emphasized the decision not to use health promoters, opting instead to formally incorporate organized community groups into the work of health facilities and the health system. This was achieved through "health committees" that participate on the boards of clinics offices, hospitals, and area health bureaus. Community representatives serving on these committees act as a bridge between the two parties; they participate in decision-making and work to help change beliefs and behavior in their communities.

Toward the end of the Symposium, the participants worked to define baseline conditions and assess the Region's strengths and weaknesses in terms of implementing cardiovascular health programs involving the use of promoters. Among these conclusions, the following elements were considered positive, necessary, and, in large measure, present in most of the participating countries:

• the availability of information;
• the political will to address the problem of cardiovascular disease;
• the existence of basic structures in terms of health services and health programs that make it easier to implement programs involving the use of health promoters;
• the development of community health programs;
• prior experience with health promoters (albeit in other areas of health);
• a reserve of trained health promoters in many countries;
• the existence of regional networks to support the sharing of information/experiences and to ensure the sustainability of interventions, thanks to regional commitments that extend beyond the term of the government of the moment; and
• a growing awareness on the part of the community and the health authorities of the health threat posed by CVD.

Forums such as this Symposium are seen as opportunities for countries to come together and share experiences to improve health interventions and the sustainability of such programs.

The following common challenges and objectives were emphasized:

• the need to integrate cardiovascular health interventions in actions aimed at preventing and controlling the risk factors for noncommunicable diseases;
• how to coexist with the high priority placed on maternal and child programs in the Region;
• how to ensure financing, technical, and programmatic support for sustainable projects;
• the need to develop suitable evaluation mechanisms (still under development);
• the dissemination and use of work materials for health promoters and their adaptation and/or validation for use in the local culture.

Inasmuch as this Symposium is part of a larger project still in development, which will continue to be improved in future forums and workshops, it is important to summarize those areas that generated group consensus and those that resulted in only general conclusions. This could be the starting point for future activities.

Areas of Consensus

• Effective cardiovascular health interventions should combine several strategies; one of the pertinent strategies—which is difficult to achieve through traditional health sector actions—involves changing unhealthy habits and behaviors.
• Information (knowledge) and enabling environments (i.e. creating environments that make it easier and more feasible for people to make healthy choices) need to be complemented with direct interventions designed to motivate people and strengthen their resolve to change their behavior, as well as support and follow-up activities to cement the new behavior.
• With respect to cardiovascular health programs, health promoters make their most useful and effective contribution to the educational component and boosting people's capacity to change their behavior.
• In some cases, promoters can also serve as liaisons for community empowerment and advocacy with local authorities, working to establish enabling environments in their communities that promote healthy habits and behaviors aimed for the prevention and control of CVD.

Areas under Discussion

• Should health promoters work exclusively in general health interventions or health promotion activities?
• Should health promoters work exclusively in health education activities or should they also be trained to carry out specific health actions (i.e., take blood pressure, administer injections, and attend births)?
• Should promoters be certified?
• Should health promoters work exclusively at the health center, or should they make house visits?
• Should promoters be paid?
• Should promoters focus exclusively on cardiovascular health, or should cardiovascular health be included in promoters' interventions for other health problems?
• Should health promoters belong to and live in the communities they serve, or can outsiders perform these functions?
• Should health promoters be considered mere instruments of the health promotion strategy or are they, in fact, something more?
• With respect to the health promoter's relationship to the community… Is it a core and defining element of that relationship? Does that element change if the relationship is lost?
• With respect to organized community groups … Can they replace the role of the health promoter? Can they take over complementary areas of health promotion, or is it possible for them to perform both roles?
• Are health promoters effective only in poverty-stricken or remote areas, or can they perform effectively in other social settings?

At the close of the Symposium, the participants recognized and validated the work of health promoters in the various contexts described and considered health promoters a resource with vast potential in terms of cardiovascular disease, as agents of change, educators, and a means to perform limited health research and control interventions.