BUILDING GETTING STARTED - COMMUNITY HEALTH WORKERS TRAINING - UNICEF
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
COMMUNITIES CARE: TRANSFORMING LIVES AND PREVENTING VIOLENCE
PART 3
STRENGTHENING COMMUNITY-BASED CARE
CAPACITY
SECTION 2
BUILDING
TRAINING SESSIONS AND MATERIALS
COMMUNITY HEALTH WORKERS TRAINING
GETTING STARTEDPART 3 Strengthening Community-Based Care
all survivors need
good quality care and
support to help them
heal and recover
bCAPACITY BUILDING
Community health workers
Getting started
STRENGTHENING COMMUNITY-BASED CARE
CAPACITY BUILDING
10 DAYS • 8 MODULES
GETTING STARTED
Key considerations for capacity
building of Community Health Workers
The purpose of this document is to help Communities Care:
Transforming Lives and Preventing Violence (CC) Programme staff plan
for building capacity of Community Health Workers to provide good
quality community-based care for survivors of sexual violence.
Accompanying materials include a Facilitator’s Guide and
a Participant’s Packet.
1PART 3 Strengthening Community-Based Care
Part I of this guide provides a justification for community-based approaches to
managing survivors of sexual violence.
Part II contains a step by step guide for planning for strengthening community-
based medical care for survivors of sexual violence. The steps address:
1. Selecting sites for piloting community-based medical care for survivors
of sexual violence
2. Examining site specific policies, protocols and treatment
3. Mapping available services to determine the scope of referrals
4. Selecting participating community health workers
5. Considerations for piloting community-based care for survivors
of sexual violence
6. Supporting a communications strategy
7. Working with facility-based health providers receiving referrals
from community health workers (CHWs)
8. Troubleshooting
9. Data collection
Part III includes information on preparing to train community health workers.
Annex I offers an additional decision-making tool on what care and tasks community
health workers can implement in specific settings.
Annex II summarizes the evidence around community-based care for survivors
of sexual violence.
2CAPACITY BUILDING
Community health workers
Getting started
Part I: Why use community-based approaches to managing
survivors of sexual violence?
Community-based medical care for survivors of sexual violence
Medical care for those who have survived sexual violence is frequently limited in humanitarian settings.
Service providers are often ill-equipped to treat survivors and facilities may lack supplies and trained
providers at the height of insecurity. Barriers for survivors to access care can also include the distance to
a health facility and stigma associated with sexual violence. Given these challenges, a community-based
approach may increase access to and uptake of health services by survivors of sexual violence.
The community-based model to providing medical care for survivors of sexual violence translates the
World Health Organization’s (WHO) 2004 Clinical Management of Rape Survivors: Developing protocols
for use with refugees and internally displaced persons for community health workers (CHWs) to provide
post-rape care where facility-based health services are not available or inaccessible. The model builds on
the work undertaken by the Women’s Refugee Commission (WRC) and partners working with internally
displaced persons in Burma. This work explores the safety and feasibility of this alternative service
delivery method in humanitarian settings. The findings are documented in “Piloting community-based
medical care for survivors of sexual assault in conflict-affected Karen State of eastern Burma,” from the
May 2013 issue of Conflict and Health.1
To further the evidence base, UNICEF’s Child Protection, Health, and HIV/AIDS Sections have been
working with the WRC to develop a broader training package for community-based management of
survivors of sexual violence and to address the critical role that CHWs can play in managing survivors
of sexual violence in varied conflict settings. The effort supports the inter-agency Joint Statement on
Scaling Up the Community-Based Health Workforce for Emergencies that emphasizes the role of the
community health workforce. Elements of the model include capacity-building and linking CHWs with
other community-based response systems as well as the broader work of UNICEF and other partners in
order to bolster the protective environment for children, women and their families. Such efforts promote
a continuum of prevention and care across formal and less-formal response systems.
Community-based approaches to care for survivors of sexual violence are expected to contribute to
global commitments to provide medical and psychosocial support to survivors in conflicts. The urgency
of this need has been recognized in UN Security Council Resolutions.2 As the global community focuses
on monitoring and reporting of sexual violence perpetrated in conflict, the need to ensure services is
paramount. An alternative approach to facility-based care may offer solutions in settings where traditional
methods of medical care are not practical for the women and girls that need it most.
1 Mihoko Tanabe et al, “Piloting community-based medical care for survivors of sexual assault in conflict-affected Karen State of eastern Burma,”
Conflict and Health 7(12) (2013).
2 1325, 1820, 1888, 1889, and 1960 on Women, Peace and Security.
3PART 3 Strengthening Community-Based Care
Community-based approaches to prevention and response to sexual violence
Community-level prevention and response strategies have the potential to reduce levels of sexual
violence during and following conflict. They may also, over the long-term, succeed in building social
norms that undermine notions of sexual violence as an inevitable and acceptable part of war. Response
activities – especially the provision of services – are critical. As community norms around sexual violence
are challenged, a greater awareness is built around sexual violence as a crime/human rights violation. At
the same time, and communities are encouraged to understand the importance of services and survivors
may increasingly seek care. It is essential that care and support services are accessible to survivors,
including through community-based options.
The positive outcomes of CC Programme community discussions and deliberations will be further
reinforced as services improve and/or are made available through CHWs and as other service providers
and survivors begin to access quality services. As trust and faith are built around confidential and quality
services, health seeking behaviour can be encouraged among survivors.
Part II: Planning for strengthening community-based medical
care for survivors of sexual violence
The following sections detail key considerations for laying the groundwork prior to pilot site selection,
engagement with and training of CHWs, and among other key components. The full support
of implementing partners is critical for the required preparatory work. Key components include:
• Meeting with critical stakeholders, including relevant government ministries
• Supporting IPs for systems mapping in target sites
• Identifying referral points for participants of any focus group discussions and key
informant interviews
• Providing ongoing support for research, monitoring and evaluation (M&E) and
capacity development
• Supporting the identification and training of CHWs and other service providers
• Implementing workshops to launch the project at various levels to secure district
level leadership and community buy-in
4CAPACITY BUILDING
Community health workers
Getting started
1. Selecting sites for piloting community-based care for survivors of sexual violence
The first step in piloting the community-based model is to select appropriate intervention sites where
CHWs will be trained to provide health care for survivors of sexual violence. In order to pilot community-
based care, the following criteria should be applied to selecting locations that are optimal for assessing
the safety and feasibility of this approach. The ideal setting for the pilot meets all required criteria. The
recommended criteria are not mandatory, although desired.
Criteria Yes No
Required Access to medical care for survivors of sexual violence is
unavailable or inaccessible due to distance to facility-based
services, stigma associated with reporting, or lack of an enabling
environment for survivors to seek care.
No known policy barriers for CHW provision of medical care
to survivors or known policy barriers that cannot be overcome.
No requirement to report incidents of sexual violence to
traditional or formal judicial systems.
Limited population movement for CHWs to provide care
and follow-up services and the possibility to implement
monitoring activities.
Possibility to:
• Protect any documentation by CHWs.
• Supply chain management.
• Begin community conversations around sexual violence.
Village/community leader and other stakeholder understanding
of pilot objectives.
Recommended Relative accessibility in terms of logistics.
Reasonable CHW to population ratio (2 CHWs per 1,000
population).
Community confidence and trust of CHWs, or capacity to
build such faith exists.
No known CHW connections with fighting forces.
2. Examining site specific policies
Once the pilot locations are selected, it is essential to gather national and local health protocols, agency
protocols and legal guidelines to understand the context and align pilot implementation.3 It will also be
helpful to know what services CHWs are currently providing, what they have been trained in (such as
community case management for childhood illnesses), and how the skills to provide post-rape care build
on their existing training and scope of work. This information will maximize the related learning of the
CHWs and allow them to apply already learned skills.
3 IRC, Clinical Care for Survivors of Sexual Assault: A Multi-Media Training Tool, 2008.
5PART 3 Strengthening Community-Based Care
To determine protocols and legal guidelines, the following information is needed:
• National, local and agency protocols for clinical care for survivors of sexual violence:
HIV post exposure prophylaxis
STI prophylaxis and treatment
Emergency contraception
Hepatitis B
• Local legal guidelines regarding:
Status of minors (age of majority, age of consent and laws regarding consent for
medical treatment of minors)
Existing legal systems to try perpetrators of sexual violence
Definitions of sexual crimes
Mandatory reporting of sexual violence/abuse (for what type of survivor or perpetrator,
and reporting to whom)
Standards for medical documentation and testimony (what constitutes valid evidence,
and from whom? Can only doctors sign medical certificates?)
Pregnancy termination
Local treatment protocols should be followed in order to minimize drug resistance. Treatment protocols
(job aids) in the participants’ packet should be adapted as necessary for this purpose. Please see the
table in Part IV to assist with this process.
In some instances, active laws or policies may exist to prevent CHWs from providing certain services,
such as dispensing antibiotics or offering emergency contraception to unmarried persons. In other
instances, records provided by CHWs may not suffice as legitimate evidence of services rendered,
although they can still serve as documentation that a CHW-client interaction took place.
When health providers care for survivors, a medical certificate is often issued that summarizes the
survivor’s history and findings. This certificate is issued specifically for use in court if the survivor
chooses to go to court and legal justice is available. The intake form which providers – including CHWs
– complete, is a medical track record that serves to remind the provider about the history and care
provided. While a medical certificate can serve as important evidence for future pursuance of legal
justice, this is beyond the scope of services that CHWs can provide. Protocol can instead be established
in the pilot sites for CHWs to develop a duplicate copy of the intake form should the survivor request
written information and providing that the survivor understands any potential security risks associated
with the possession of such documentation. Original records of the medical care provided can then be
kept with the CHWs in a locked cabinet.
In further instances, where no formal law or policy exists, health workers and others may incorrectly
assume that health providers should not provide health care to survivors for various reasons including
the need for a survivor to present a marriage certificate, obtain her husband’s permission, or file a police
report that has “verified” the rape. It is extremely important to distinguish policy from myth in the pilot
setting, to be able to reinforce that CHWs should be providing care to all who seek it for any type of
forced sex. It is not up to the CHW or any health provider to determine or verify “rape”.
6CAPACITY BUILDING
Community health workers
Getting started
Programs should assess mandatory reporting requirements and develop a plan on how to handle cases.
In some cases, such requirements and the local situation may lead programs to not collect certain types
of information or have health staff refrain from asking certain types of questions because of the potential
risks to survivors and/or themselves. Where mandatory reporting exists by law (not perceived), it is likely
best for CHWs to report the incident to a program staff member who will decide on the course of action.
Module 3 discusses these issues and programs should develop strategies and protocols before CHW
training begins.
In further instances, no protocols or policies may be available to guide the CHW provision of health care
for survivors. If this is the case, it may be possible to work with the appropriate ministries to garner their
support for the piloting process in order to influence emerging policies and protocols. Such advocacy can
also offer opportunities to revise any hindering protocols and create a more enabling environment for
survivors to seek care.
3. Mapping available services to determine the scope of referrals
With CHWs playing a role in a larger health system, it is important to map the services that are available
to refer survivors prior to the training of CHWs. The mapping is part of the groundwork to be completed
by program staff and used to support CHWs in their work. The table below can help programs map
available referral services for survivors in the pilot setting, and segments can be shared with CHWs
when discussing referrals in Module 4.4
4 Médecins Sans Frontières. “Sexual & Gender Based Violence: A handbook for implementing a response in health services towards Sexual
Violence”, Operational Centre Barcelona, 2011.
7PART 3 Strengthening Community-Based Care
Mapping available referral services
Who provides this service,
Linkages to services Yes No and what specifically?
Community mapping of all referral points
conducted.
Organization(s) and individual(s) are in place
to facilitate gender-based violence (GBV)
coordination meetings.
GBV coordination meetings take place and are
attended for coordination and communication.
System(s) developed to track referral services.
Referral by CHW 1 to CHWs 2 and 3.
Referral to a mid/low level facility that can
treat shock, wounds, and pelvic inflammatory
disease; provide intrauterine devices, etc.
Referral to a mid/high level facility that has
surgical capacity for fistula or rectal sphincter
muscle tears, broken bones, etc.
Referral for HIV prevention services (HIV
testing, antenatal care, and prevention of
mother-to-child transmission of HIV).
Referral for HIV treatment services
(antiretroviral treatment, pediatric treatment,
etc.).
Referral for abortion services where legal.
Referral for psychosocial support.
Referral for specialized mental health services.
Referral for shelter and protection, including
community protection for survivors.
Referral to police.
Referral for legal assistance.
Referral for social support (rehabilitation,
reintegration, income-generation, education,
support groups, etc.).
*Only those services/organizations that have been assessed for their quality (especially the ability to maintain confidentiality)
per existing applicable standards should be engaged as part of the pilot’s referral network.
8CAPACITY BUILDING
Community health workers
Getting started
Where is this referral Does this service meet When are they
located? quality standards?* (Y/N) open? (24/7) Contact
N/A N/A N/A
N/A N/A N/A
N/A N/A N/A
N/A N/A N/A
9PART 3 Strengthening Community-Based Care
4. Selecting participating community health workers
The role of the CHW may differ in the pilot sites depending on national policies, local health infrastructure
and existing skill sets of CHWs. In circumstances where higher level health care providers—such as
nurses, midwives and doctors—are available, CHWs may only be involved in referring survivors of sexual
violence for appropriate services. However, in settings where higher level providers are lacking or health
facilities inaccessible, CHWs may play a larger role in managing survivors of sexual violence within the
overall health system. Three categories of CHWs that can be engaged in the pilot project are noted
below. Categories 1 and 2 are relevant for this pilot.
CHW Category 1: CHWs only conduct health education as part of daily activities and refer survivors
(Modules 2-4). Non-literate CHWs will fall into this category. Eligibility criteria are:
• No literacy or numeracy required.
• Limited experience serving as a CHW which could be as a volunteer or health promotion staff.
• Compassion/empathy and willingness to care for survivors of sexual violence.
CHW Category 2: CHWs involved in the provision of basic treatment and follow-up care to survivors
(Modules 2-6). Many CHWs in this project will fall into this category (as well as category 1). Eligibility
criteria are:
• Some level of reading and written literacy (not non-literate) to read instructions and complete client
records/forms.
• Basic numeracy to count days, hours and measure dosages.
• Basic training in primary health care based on national policies.
• Understands the importance and is capable of maintaining confidentiality of survivors and any
data collected.
• Demonstrates compassion/empathy and willingness to care for survivors of sexual violence.
• Capacity to provide minimal documentation if the survivor wants a record for herself or himself.
CHW Category 3: CHWs involved in higher-level care (Modules 2-Advance Module 8). This category
is applicable only in settings where CHWs have evolved advanced roles5 with clinical experience
and skills. This category will not be relevant in the pilot settings of Somalia and South Sudan.
Eligibility criteria include:
• Basic literacy and numeracy.
• Advanced training and experience providing clinical care based on national or international policies.
• Understands the importance and is capable of maintaining confidentiality of survivors and any
data collected (through previous experience with HIV testing, for example).
• Demonstrates compassion/empathy and willingness to care for survivors of sexual violence.
• Capacity to provide minimal documentation upon request.
5 Such as, “maternal health workers” in LC Mullany et al, “The MOM project: delivering maternal health services among internally displaced
populations in eastern Burma” Reprod Health Matters (2008) 16: 44-56.
10CAPACITY BUILDING
Community health workers
Getting started
5. Considerations for piloting community-based care for survivors of sexual violence
As CHWs will only be offering certain elements of health care for survivors of sexual violence, there will
be limitations to the care provided. A decision-making tool on the care and tasks CHWs can be expected
to implement in the setting is provided in Annex I. In summary, the scope of work as determined by
capacity (NOT by nuances in the setting) is as follows:
✔ = Yes
Blank = No
★ = Only if capacity exists and the intervention warranted
Intervention CHW 1 CHW 2 CHW 3
Conduct health education around sexual violence and the benefits of
seeking care
✔ ✔ ✔
Recognize survivors of sexual violence when they come forward
(passive identification)
✔ ✔ ✔
Actively screen for survivors of sexual violence ✔ ✔ ★
Provide some basic first aid to stabilize survivors for referrals ✔ ✔ ✔
Refer survivors to higher level health staff or the health facility for
health care
✔ ✔ ✔
Take a health history ✔ ✔
Collect forensic evidence
Conduct a minimum medical exam (physical) ★
Conduct a minimum medical exam (pelvic) ★
Complete simplified intake form ✔ ✔
Generate a medical certificate (duplicate intake form) ✔ ✔
Provide some basic first aid to treat minor injuries ✔ ✔
Provide other wound care as feasible ★
Provide presumptive treatment for sexually transmitted infections
(STIs), emergency contraception (EC) for pregnancy prevention and
supportive counseling (including psychological first aid and basic
✔ ✔
emotional support)
Conduct HIV counseling and testing ✔
Provide Postexposure Prophylaxis (PEP) ✔ ✔
Provide tetanus toxoid and/or Hepatitis B vaccine ✔
Provide follow-up care to survivors ✔ ✔
Manage STIs (syndromic management) ★
Additionally, to minimize error in providing treatment, it would be helpful for the program to consider
prepackaging standard treatment packages. Treatment packages can be color-coded and prepared for
adult female survivors of vaginal assault that come within three days, five days and 30 days of the
violence. This way, the CHW will not need to dose drugs for each survivor, but can merely give the
appropriate colored packet and simple instructions on patient messaging. A client form is available in
the participants’ packet where CHWs can note the medicines provided, as well as other information.
For children, pregnant women and adult female survivors of other sexual violence (anal or oral assault),
CHWs can work from the pre-packaged treatment packets to remove or add medicines as relevant.
11PART 3 Strengthening Community-Based Care
6. Supporting a communications strategy
An important component of the pilot project is to raise awareness among the different actors in the
community, and to learn who among them needs to be informed about sexual violence, the benefits of
seeking care, and how to facilitate survivors’ access to care. Messages include:
• What is sexual violence
• Who can experience sexual violence
• Why does sexual violence happen
• What should survivors do after experiencing sexual violence
• What should others do if they know someone has experienced sexual violence
• What are the benefits of survivors seeking health care immediately (preventing pregnancy,
preventing STI/HIV, receiving basic emotional support)
• Where can survivors go for services
• What will survivors of sexual violence expect if they seek health care
• What are the terms of receiving care (health services are free, private, voluntary and safe,
and available 24 hours a day, 7 days a week)6
Some options to reach different groups are:
• Face-to-face trainings or awareness-raising sessions. CHWs or peer educators can conduct these
sessions in schools, youth clubs, religious facilities, and other locations where people congregate.
• Print material, such as brochures, leaflets, posters, etc.
• Theater or drama
• Radio or television
• Cell phone messaging
The following table may be helpful for the program to identify potential audiences and determine how
to reach them. The table is important given that CHWs will only be responsible for health education as
part of their day-to-day activities yet the entire community can influence whether or not an enabling
environment exists for survivors.
6 WHO, Clinical Management of Rape Survivors: Developing protocols for use with refugees and internally displaced persons, 2005.
12CAPACITY BUILDING
Community health workers
Getting started
How might What are the
How can they hinder key messages
messages be or facilitate to convey to
communicated? survivors’ facilitate survivors’
Audience Where are they? (methods) access to care? access to care?
Women
Men
Adults with disabilities
Elderly
Adolescent girls
Adolescent boys
Adolescents with
disabilities
Children (girls)
Children (boys)
Children with
disabilities
Community leaders,
including women’s
groups or wives of
powerful men
Local community-based
organizations (CBOs),
services and charities
Local Ministry of Health
(MoH) officials
Traditional health care
providers
Police departments and
other law enforcement
officers
Teachers/social workers
Religious groups
13PART 3 Strengthening Community-Based Care
7. W
orking with facility-based health providers receiving referrals from community
health workers
While CHWs 2 and 3 will be trained to provide basic health care for survivors of sexual violence, they
will also be trained on when to facilitate referrals to higher level health care as available. Some instances
will require immediate referrals from all levels of CHWs (especially CHWs 1 and 2) while others will be
conducted primarily by CHW 2s as part of their routine work to provide initial or follow-up care to survivors.
Referrals to facility-based health care made by CHWs
Immediate referral:* Referral upon history taking: Referral upon follow-up care:
• Swelling and hardness • If the survivor is an infant • Severe side effects
of the abdomen (belly) • Severe bleeding of medicines
• Pain in abdomen (belly) • Infected wounds • Signs of STIs that
• Severe pain in back, chest, • Open wounds where skin may be a result of
arms, legs or head does not come together treatment failure or
• Vomiting blood by itself recurrent STI infection
• Heavy bleeding from • Leaking urine or feces • Partner testing for
vagina/anus • Object in vagina/anus HIV
• Heavy bleeding from • Bleeding from vagina/anus • Pregnancy termination
other parts of the body if available
• Severe pain
• Possible object lodged • Other cases that
• Any abdominal or
in vagina/anus CHWs cannot treat
belly pain
• Altered mental state • Vaginal bleeding
or confusion • Vaginal discharge
• Pale, blue, or gray-skinned • HIV testing
• In a small child, fast • Tetanus vaccine
or difficulty breathing
• Hepatitis B vaccine
• Unconsciousness
*CHWs will not complete an intake form if immediate referral is made to a health facility and no
treatment is provided.
The means of referral will differ in each setting and will need to be arranged by the program and the
receiving health facility. Depending on the survivor’s condition, an ambulance may be necessary if a
vehicle is available at the health facility. Program staff should brief providers from receiving referral facilities
about the CHWs’ role in providing care to survivors of sexual violence. Reviewing the one-page caring
for survivors flowchart (Module 5 handout for CHWs) as well as the table of CHW interventions (see
page 8 of this document) may be good ways to review CHW roles and expectations. More specifically,
CHWs will be trained to provide the following treatment for different types of sexual violence:
Activity Sexual assault Anal assault Oral assault
Antibiotics to prevent or treat Yes Yes Yes for Gonorrhoea,
sexually transmitted infections chlamydia and syphilis
No for trichomoniasis
Emergency contraception (pills) Yes Yes No
to prevent unwanted pregnancy
Post-exposure prophylaxis Yes Yes No
to prevent HIV
Tetanus vaccine Yes Yes No
Hepatitis B vaccine Yes Yes Yes
14CAPACITY BUILDING
Community health workers
Getting started
• While EC is typically not necessary for anal assault, given that CHWs will not be asking detailed
questions about the assault to determine the risk of sperm leaking into the vagina, the position of the
assault, or location of ejaculation; and survivors may not be familiar with their reproductive anatomy,
CHWs will be trained to provide care in cases of anal assault in the pilot project.
• For oral assault, CHWs will be taught that they do not need to provide presumptive treatment for
trichomoniasis. Further, as the risk of HIV transmission is low, PEP is not indicated. The tetanus
vaccine will only need to be provided if there are wounds in or around the mouth, or if the survivor has
not been vaccinated in 10 years.
• While survivors are typically asked whether or not they are using a method of family planning, CHWs
will not be asking this question due to the added challenges to determine if EC is warranted, or if any
risk of pregnancy exists. As such, in this pilot, EC will be provided to all survivors of reproductive age
who have experienced vaginal or anal assault, even if they were using a method of family planning at
the time of the assault.
During pilot start-up, the most important form to review with health providers serving as referral points
is the intake form. CHWs 2 and 3 will be trained to complete the intake form for every survivor from
whom they take a health history, even if the survivor comes after five days of the assault. If the survivor
consents to receiving additional services from a health facility, she or he will be provided with a duplicate
intake form to take with her or him to see the referral staff. Providers need to trust the information that
has been noted on the intake form, so that they do not re-question the survivor for issues that have
already been discussed. These include:
• The type of assault that the survivor has sustained (vaginal, anal, and/or oral assault)
• Whether the survivor has been vaccinated against tetanus
• Whether the survivor has been vaccinated against hepatitis B
• What treatment the survivor has received from the CHW (EC, PEP, antibiotics for STIs,
basic wound care, basic counseling)
• What type of health referral the survivor is seeking (HIV testing, vaccinations,
advanced wound care, etc.)
• What other referrals the survivor has consented to receive
Health providers receiving referrals should ensure they understand the intake form, and know how to
contact the CHW for any questions. Further, if appropriate and valid in the setting for legal purposes,
the provider can sign the intake form to certify it has been reviewed by an accredited health provider.
Health facilities should make sure to keep their own records of any care they give to a survivor at the
facility level, similar to protocol for all patients that come to the health facility.
An additional point that can be helpful for health providers is to capitalize on the CHWs’ capacity to offer
community-based follow-up to survivors two weeks after the first visit, although preferably after one
week. While health facilities should follow existing protocol on providing their own follow-up to survivors
if they have been referred to their care, if a provider judges that the survivor’s condition can be best
managed by a CHW, the provider can counsel the survivor on issues that s/he can discuss with the
CHW as s/he begins the healing process. Providers should take the initiative to work with CHWs to
ensure that the survivor receives optimal care as the environment allows, and that she or he does not
fall through the cracks.
If the program feels that health providers should attend segments of the CHW training, the most relevant
sections are Module 4, Session 4.2, on referring survivors for health care and other services and Module
5 on providing community-based care for survivors of sexual violence.
15PART 3 Strengthening Community-Based Care
8. Troubleshooting
In addition to determining the CHWs’ scope of work in the setting, it is important for the pilot to
troubleshoot any potentially negative consequences of community-based care, especially if CHWs
are the primary providers of care (CHWs 2 and 3).
Sample troubleshooting matrix:
Potential Negative Consequences
The survivor presents with significant trauma that is beyond the CHW’s capability to treat.
The survivor is at risk of further physical harm or retaliation by the perpetrator(s).
A survivor experiences unrelated physical attacks while seeking care from a CHW that she
or he would not have otherwise sought had the pilot not been implemented.
CHW refuses to provide post-rape care due to fear of retaliation, beliefs including, for example,
the inappropriateness of emergency contraception to prevent pregnancy.
CHW breaches confidentiality.
A case becomes public and the community tries to seek official or traditional means of redress, against the
wishes of the survivor.
A survivor requests a medical certificate but a family member or third party finds the document.
Documentation kept hidden by the CHW is found or looted.
Perpetrators discover the role of the CHW in providing post-rape care and the physical safety of the CHW
becomes a concern.
The community becomes suspicious of the CHW suddenly coming into close contact with a survivor that
may not have had any reason for an encounter.
A CHW refuses to continue providing care, having discovered potential risks to her or his family’s safety.
Demand for post-rape care has been created, however, and a survivor has come forth.
16CAPACITY BUILDING
Community health workers
Getting started
Example solutions to prevent the consequences Possible action plans for the project
before they arise should they occur
Agree upon first aid measures and referral protocol via Follow agreed upon protocol for referral to a higher
existing and available means within the community. level facility. CHWs should document any referrals on
their intake forms.
If a breach of confidentiality by CHWs is the issue, Discuss and take active protection measures. If breach
ensure CHWs are aware of the consequences of not of confidentiality is the issue, program staff should
maintaining confidentiality. Agree upon and establish discuss the issue with the CHW.
communication channels to address protection concerns,
including for relocation of survivors if requested and feasible.
Select a setting with moderate stability to minimize Provide care and protection as feasible.
known risks.
Raise awareness among and train CHWs on gender issues Re-evaluate the inclusion of the CHW in this pilot by
and the benefits of providing care to survivors, etc., first. discussing the reasons for which care was refused.
Train CHWs to also debrief with a supervisor (program staff) Ensure that care is provided to the survivor in a timely
and to let the supervisor know about any concerns she or he manner regardless of the CHW’s refusal to provide care.
has about providing this care.
Only allow CHWs that demonstrate pre-established Re-evaluate the inclusion of the CHW in the project
competencies to play a role in managing survivors. by discussing the circumstances under which
Emphasize the importance of maintaining confidentiality confidentiality was breached.
during CHW trainings. Identify and address any incentives
for the CHWs that may lead to breaches in confidentiality.
Predetermine how best to meet the best interests of Assist the survivor to respect her or his wishes and
the survivor in the context of official and traditional ensure her or his protection. Involve respected figures –
means of redress. as relevant and appropriate – to conduct damage
control in the community.
Review the intake form and predetermine what will be Identify and minimize any immediate risks for the
documented for the survivor. Inform the survivor of potential survivor and take action within the limits of the setting.
risks to her or his safety if the document is discovered.
Keep documentation and records minimal with no identifying Identify and minimize any immediate risks for survivors.
information of the name, age, sex and village of the survivor. Re-evaluate storage of records to minimize
reoccurrence.
Agree upon and establish communication channels to Assist CHWs to address this situation by possibly
address protection concerns. Reinforce the overall role relocating the CHW for a period of time.
of CHWs in the community.
Predetermine means of follow-up care to monitor and Increase community understanding of the role of
address unintended consequences. CHWs in providing services for primary health care
issues. For a particular situation, ensure the safety
of the CHW while the issue is resolved.
Discuss potential risks with the CHW before enabling Ensure that remaining CHWs continue providing care
her or him to assume responsibilities and identify by addressing motivation, etc.
responsible ways to relinquish duties. Address any
incentive issues for the CHW to maintain motivation.
Train multiple CHWs in each site. 17PART 3 Strengthening Community-Based Care
9. Data Collection
Both qualitative and quantitative tools have been developed to assess changes in the extent of
reported sexual violence and other forms of GBV. These tools have also been developed to identify
bottlenecks in systems strengthening and service accessibility, and to “break the silence” around
sexual violence and GBV. Baseline efforts will include identification of the extent to which different
community groups identify sexual violence. Changes will be assessed at midline and endline intervals.
Tools will also be developed for ongoing collection and review of service access, quality and utilization.
Support will be provided to research and monitoring and evaluation staff for the collection of service
data in order to measure potential increases in the number of survivors reporting for services and CHW
adherence to various treatment protocols. There will be a focus on documentation to ensure adequate
collection of data.
Because of the nature of the project as a pilot project, the following questions will be monitored and
evaluated at key intervals over the course of project implementation (for more information, please refer
to the technical note for the overall project):
• Was the provision of services by CHWs safe (per medical protocol, etc.) and feasible (in terms
of CHWs’ ability to maintain confidentiality, ability to garner trust among the community, etc.)?
• To what extent did disclosure and uptake of multi-sectoral services for GBV increase in
intervention areas?
• What are the levels of survivors/participants’ satisfaction with the interventions?
• What changes have occurred in related knowledge, attitudes and behaviours among service
providers, including CHWs, as a result of the training and intervention?
Suggested indicators to track CHW competencies include: (see following pages)
18CAPACITY BUILDING
Community health workers
Getting started
Suggested indicators to track CHW competencies
Indicator Numerator Denominator Sources Type Target
% of sexual violence # of sexual Total # of sexual CHW Outcome 100%
survivors seeking care at violence survivors violence survivors monitoring
a pilot project site who who receive who seek health care form
receive package of care for treatment and for sexual violence
sexual violence per pilot care in a timely* from CHWs at the
protocol manner (1) sites (A) **
# of sexual violence CHW
survivors who seek health monitoring Process
-- -- --
care for sexual violence form
from CHWs at the sites (A)
# of sexual violence CHW
survivors who seek health monitoring Process
care for sexual violence from -- -- form --
CHWs at the sites in < 72
hours (to receive PEP) (B)
# of sexual violence CHW Process
survivors who seek health monitoring
care for sexual violence from -- -- form --
CHWs at the sites in < 120
hours (to receive EC) (C)
% of sexual violence # of sexual Total # of sexual CHW Process 100%
survivors from whom violence survivors violence survivors monitoring
informed consent is sought from whom who seek health care form
from CHWs informed consent for sexual violence
is sought from from CHWs at the
CHWs (2) sites (A)
% of sexual violence # of sexual Total # of sexual CHW Process 100%
survivors who receive STI violence survivors violence survivors monitoring
presumptive treatment who receive STI who seek health care form
from CHWs per local presumptive for sexual violence
protocol treatment from from CHWs at the
CHWs per local sites (A)
protocol (3)
% of sexual violence # of sexual Total # of sexual CHW Process 100%
survivors who receive violence survivors violence survivors who monitoring
EC < 120 hours from who receive EC seek health care for form
CHWsPART 3 Strengthening Community-Based Care
Suggested indicators to track CHW competencies (continued)
Indicator Numerator Denominator Sources Type Target
% of sexual violence # of sexual Total # of sexual CHW Process 100%
survivors who receive basic violence survivors violence survivors monitoring
emotional support from who receive basic who seek health care form
CHWs emotional support for sexual violence
from CHWs (7) from CHWs at the
sites (A)
% of sexual violence # of sexual Total # of sexual CHW Process
survivors referred by violence survivors violence survivors monitoring
CHWs for other medical, for whom a who seek health care form
--
psychosocial, protection, referral was made for sexual violence
etc. services (where by CHWs (8) from CHWs at the
available) sites (A)
% of sexual violence # of sexual Total # of sexual CHW 100%
survivors seen by a violence survivors violence survivors monitoring Process
CHW with whom issues seen by a CHW who seek health care form
of personal safety and who receive for sexual violence
security are discussed counseling on from CHWs at the
personal safety sites (A)
and security (9)
% of sexual violence # of sexual Total # of sexual CHW Process
survivors who request violence survivors violence survivors monitoring
a copy of their medical who request who seek health care form
--
records using a medical records for sexual violence
standardized, minimal form (10) from CHWs at the
sites (A)
% of sexual violence # of sexual Total # of sexual CHW Process 100%
survivors seeking care who violence survivors violence survivors monitoring
receive two week follow-up who receive two who seek health care form
visit from CHWs week follow-up for sexual violence
visit from CHWs from CHWs at the
(11) sites (A)
% of changes in Baseline, Process
knowledge of benefits to midline,
seeking care after sexual endline
-- -- --
violence and attitudes population-
towards health-seeking based survey
behaviour
# of CHWs per 1,000 # of CHWs # of women ages Training Process 2 per 1,000
women ages 15-49 in 15-49 in target roster, local population
program target population population organization
trained specifically for this population
pilot project information
% of CHWs who attend # of CHWs who Total # of CHWs who Training Process 100%
training that pass the pass attend training roster, post-
post-test to start the pilot test scores
project
*Timely care refers to medical treatment appropriate at the time the survivor has sought care. If the
survivor reports too late for (3) per local STI presumptive treatment protocol (if restrictions apply); (4) for
EC, or (5) for PEP, then “timely” care (1) does not include (3), (4) or (5).
**(A) is the total number of survivors that seek any type of health care from a health care worker for
sexual violence.
20CAPACITY BUILDING
Community health workers
Getting started
Part III: Preparing for the training
Careful planning is important and should start several weeks before the training.
1. Initial planning:
• Establish objectives for the training.
• Determine the participants/trainees and establish criteria for participation.
• Know the training needs of the participants, especially their literacy levels and expected role
in managing survivors of sexual violence in the community.
• Develop a budget for the training.
2. Logistics:
• Decide the training date and venue that will work for participants, facilitators and other
stakeholders.
• Determine the cost per participant with regard to food, lodging, transportation and materials.
• Reserve the training venue and make it as conducive to learning (i.e. well-lit, good ventilation,
limited external noise) as possible.
3. Identification of participants and resource persons:
• Ensure attendance of participants by contacting them directly or through letters of invitation.
• Follow up with participants to confirm their attendance.
• Determine if there is a need for resource persons to handle or facilitate any topics and if so,
make a list of possible persons to invite.
• Email or send letters to the selected resource persons. Be sure to inform them about the goals
and objectives of the training as well as the specifics of what will be expected of them.
4. Preparation and review of the training tool:
• Determine the relevant modules and sessions to use in the training.
• Review and adapt the methodologies and activities of the sessions as necessary.
• Select documents to use based on the training needs of the participants.
• Adapt as necessary, photocopy and otherwise obtain any handouts, notebooks, demonstration
models or other reference materials for training use and distribution.
• Prepare flipchart, markers, pencils, pens and anything else you may need. Prepare materials
that are applicable and most suited to the training venue.
• Consider and prepare for each module:
Module 1
■■ Develop workshop timetable from the schedule on pages 9-13.
■■ If registration forms will be used, have copies ready for participants to fill in as they enter
the training.
■■ Have a sign-in sheet and pen on the table at least 30 minutes before the workshop begins.
■■ Arrange participants’ materials on the registration table so participants can easily be given
one of each as they register.
■■ Prepare copies of the literate and non-literate pre-tests.
21PART 3 Strengthening Community-Based Care
Module 2
■■ Print and cut HIV cards annexed to the facilitator’s guide.
Module 3
■■ Know the legal, policy and social barriers for survivors to access health care, especially any or
perceived need for mandatory reporting such as a marriage certificate, husband’s permission,
a police report, etc.
■■ Know the program’s care for survivors’ protocols to address or overcome the barriers and
challenges.
Module 4
■■ Map who is doing work to respond to sexual violence, including referral mechanisms
(complete above table on service mapping), and where.
■■ Identify private and safe locations for client interactions.
■■ Know how much basic first aid participants have learned to stabilize persons in life-
threatening conditions for referrals (to determine the handouts used).
Module 5
■■ Know participants’ experiences giving medicines accurately and safely (to determine scope
of relevant sections).
■■ Learn about standard precaution and infection prevention measures used in the program and
adapt handout as necessary.
■■ Understand information storage and handling procedures, including where forms will be
stored, who has access, and how information can be sent safely and confidentially to any
centralized location as appropriate.
■■ Know and adapt treatment protocol handouts for STI prevention, EC and PEP, as well as the
table of weight-based treatment for antibiotics based on the local context. ** (see next page)
■■ Know if and where intrauterine devices are available (to determine whether IUDs will be
discussed).
■■ Know if and where referrals are available for tetanus and Hepatitis B vaccines.
■■ Know if pregnancy tests are available and how soon they can detect pregnancies.
■■ Know the legal indications for safe abortion care.
Module 7
■■ Prepare copies of the literate and non-literate post-tests.
■■ Develop clinical assessment schedule for CHWs 2 and 3.
Advanced Module 8
■■ Learn whether a cold chain, tetanus and Hepatitis B injections are available, and whether
CHWs can administer injections.
■■ Adapt intake, health history and monitoring forms to note the provision of additional services.
■■ Know and adapt protocol handouts for STI treatment based on the local context.**
■■ Adapt the infection prevention handout according to the program’s protocol.
22CAPACITY BUILDING
Community health workers
Getting started
5. Follow-up
• Ensure mentoring of CHWs, supervision and follow-up.
• Convene CHWs to meet routinely to discuss challenges and emerging issues.
• Follow up with survivors as necessary.
• Report information on monitoring and evaluation plans and conduct data analysis.
Additional resources:
1) CHW Training Tool: Facilitators Guide
2) CHW Training Tool: Participants’ Packet
**Determining available drugs in the pilot setting (all tables from Inter-agency Field Manual
on Reproductive Health in Humanitarian Settings)
Review the following protocols for STI presumptive treatment, emergency contraception and HIV PEP.
Compare with local protocol and available drugs and regimens by circling any drugs that will be used in
the pilot setting, and then complete the last column. Always follow local treatment protocols for STIs and
use drugs and dosages that are appropriate for children, adolescents and pregnant women.
23PART 3 Strengthening Community-Based Care
STI presumptive treatment in ADULTS
Local drugs
and dosage if
different from
WHO Protocol7 WHO to be used
STI Circle drug used in pilot setting Notes in pilot setting
Gonorrhoea cefixime 400 mg orally, single dose
or
ceftriaxone 125 mg intramuscularly,
single dose
Chlamydial azithromycin 1 g orally, in a single dose
infection (This antibiotic is also active against incubating
syphilis (within 30 days of exposure)
or
doxycycline 100 mg orally, twice daily for
7 days
(contraindicated in pregnancy) If the survivor presents
Chlamydia azithromycin 1 g orally, in a single dose within 30 days of the
infection in (This antibiotic is also active against incubating incident, benzathine
pregnant women syphilis (within 30 days of exposure) benzylpenicillin can be
or omitted if the treatment
erythromycin 500 mg orally, 4 times daily regimen includes
for 7 days azithromycin 1 g as
or a single dose, which
amoxicillin 500 mg orally, 3 times daily is effective against
for 7 days incubating syphilis
Syphilis benzathine as well as chlamydial
benzylpenicillin* .4 million IU,
2 infection. If the survivor
intramuscularly, once only presents more than 30
(give as two injections in days after the incident,
separate sites) azithromycin 2 g as a
or single dose is sufficient
azithromycin 2 g orally as a single dose presumptive treatment
(for treatment of primary, for primary, secondary
secondary and early latent and early latent syphilis
syphilis of < 2 years duration) of < 2 years duration and
(This antibiotic is also active against chlamydial also covers chlamydial
infections) infections.
Syphilis, patient azithromycin 2 g orally as a single dose
allergic to (for treatment of primary,
penicillin secondary and early latent
syphilis of < 2 years duration)
or
doxycycline 100 mg orally, twice daily for
7 days
(contraindicated in pregnancy)
Both azithromycin and doxycycline are active
against chlamydial infections
7 IAWG on Reproductive Health in Crises, Inter-agency Field Manual on Reproductive Health in Humanitarian Settings (2010): 28-33.
24CAPACITY BUILDING
Community health workers
Getting started
STI presumptive treatment in ADULTS
Local drugs
and dosage if
different from
WHO Protocol7 WHO to be used
STI Circle drug used in pilot setting Notes in pilot setting
Syphilis in azithromycin 2 g orally as a single dose
pregnant women (for treatment of primary,
allergic to secondary and early latent
penicillin syphilis of < 2 years duration)
or
erythromycin 500 mg orally, 4 times daily
for 14 days
Both azithromycin and erythromycin are also
active against chlamydial infections
Trichomoniasis metronidazole 2 g orally as a single dose
or
tinidazole 2 g orally as a single dose
or
metronidazole 400 or 500 mg orally,
2 times daily for 7 days
Avoid metronidazole and tinidazole in the first
trimester of pregnancy
7 IAWG on Reproductive Health in Crises, Inter-agency Field Manual on Reproductive Health in Humanitarian Settings (2010): 28-33.
25PART 3 Strengthening Community-Based Care
STI presumptive treatment in CHILDREN and ADOLESCENTS
Local drugs
and dosage if
different from
WHO to be
Weight WHO Protocol used in pilot
STI or age Circle drug used in pilot setting Notes setting
Gonorrhoea 6 months)
cefixime 8mg/kg of body weight orally,
single dose
If the survivor
>45 kg Treat according to adult protocol presents within
Chlamydial 12 Treat according to adult protocol syphilis can
years be omitted if
the treatment
>45 kg erythromycin 500 mg orally, 4 times daily
regimen includes
butCAPACITY BUILDING
Community health workers
Getting started
Emergency contraception
Protocol8 Local drugs and
Circle drug used in pilot setting dosage if different,
Amount per dose Prescribe Notes to be used in pilot
Levonorgestrel 1,500 µg 1 tablet as first dose, Escapelle, Plan B
only 0 tablets 12 hours later One-Step, NorLevo 1.5,
Vikela, Postinor 1
750 mg 2 tablets as first dose, Levonelle, NorLevo,
0 tablets 12 hours later Plan B, Postinor-2, Vikela
30 µg 50 tablets, 0 tablets Microlut, Microval,
12 hours later Norgeston
37.5 µg 40 tablets, 0 tablets Ovrette
12 hours later
Combined EE 100 µg First dose as soon as possible, Yuspe method
plus LNG 500 µg same dose 12 hours later
EE 50 µg 2 tablets, 2 tablets Eugynon 50, Fertilan,
plus LNG 250 µg 12 hours later Neogynon, Noral, Nordiol,
or Ovidon, Ovral, Ovran,
EE 50 µg Tetragynon/PC-4, Preven,
plus NG 500 µg E-Gen-C, Neo-Primovlar 4
EE 30 µg 4 tablets, 4 tablets Lo-Femenal,
plus LNG 150 µg 12 hours later Microgynon, Nordete,
or Ovral L, Rigevidon
EE 30 µg
plus NG 300 µg
Recommended two-drug combination therapies for HIV-PEP
Local drugs and
Weight WHO Protocol9 dosage if different,
or age Circle drug used in pilot setting Prescribe Notes to be used in pilot
Adult Combines tablet containing
Zidovudine (300 mg) and
Lamivudine (150 mg) 1 tablet twice/day 60 tablets (28 days)
or or or
Zidovudine (ZDV/AZT) 1 tablet twice/day 60 tablets (28 days)
300 mg tablet
plus plus plus
Lamivudine (3TC) 150 mg tablet 1 tablet twice/day 60 tablets (28 days)
Children Zidovudine (ZDV/AZT) syrup* 7.5 ml twice/day = 420 ml (28 days)PART 3 Strengthening Community-Based Care
ANNEX 1
Decision-making tool on care and tasks
to be undertaken by CHWs
Interventions and considerations
Health education on sexual violence and benefits of seeking care Yes No
A. Is health care for survivors of sexual violence available in the setting (through the pilot or otherwise)?
If “yes,” intervention A can be offered by CHWs 1, 2 and 3. (See Module 2, Session 2.3)
Recognize survivors of sexual violence when they come forward
(passive identification)
A. Is health care for survivors of sexual violence available in the setting?
If “yes,” intervention A can be offered by CHWs 1, 2 and 3. CHW 1 should refer for health services.
(See Module 4)
Actively screen for survivors of sexual violence
A. Is there a system to respond to survivors of sexual violence?
B. Do CHWs have prior experience and skills in working with survivors?
If the answers are “no” to even one, this intervention should not be implemented and CHWs should
rely on self-reporting by survivors in the provision of care. This activity should be reserved for skilled and
experienced providers.
Provide some basic first aid to stabilize survivors for referrals
A. Do CHWs have the capacity to be taught basic first aid?
If “yes,” basic first aid can be taught to stabilize survivors until they can reach higher level services. For
CHW 1s, this should be at a minimum. (See optional handouts in Module 4, Session 4.2, Section 1.3)
Refer survivors to higher level health staff or the health facility
for health care
A. Is there a referral system available?
If “yes,” this intervention can be undertaken by CHWs 1, 2 and 3. (See Module 4, Session 4.2)
Take a health history
A. Will CHWs provide care after taking a history?
If “yes,” CHWs 2 and 3 can take a survivor’s history. CHW 1 should not be involved in providing any part of
the care from here below. (See Module 5, Session 5.2, Section 2)
28You can also read
