Village Health Worker Program

I have spent the last week helping out with a once every 3 month training session for the Village Health Workers, (VHW). The VHW program is focusing on the Kisoro sub-district of Muramba. The way I understand it is that there are dozens of small villages of 100-150 houses within each village. Using Village Health Workers is an attempt to use trusted members of a village to make rounds to each house in their village. Each VHW is paid a stipend to visit a certain number of houses each week. Once there, they assess the sick people, provide health education, and refer people to the clinics or hospital when needed. It is not uncommon for villagers to avoid seeking medical attention until it is much too late in their disease or injury state, and the VHW’s are being trained to catch many illnesses early on. One becomes a VHW through being nominated by their community, and then selected by a Village Leader and the KDH Clinic Officers, (Physician Assistants) which help run the program.

The 3 day training session consisted of approximately 45 experienced VHW’s who have attended 2 years of regular training sessions, (1 day training monthly and 3 day training quarterly) and 25 new VHW’s who have no previous training in health care. Some are professionals, most have completed secondary school, and about 50% only speak the local language of Rufimbira. The experienced VHW’s, were tested for the first half of each day so that the program organizers could assess where the learning gaps are. The new VHW’s attended classes in the morning, some of which I taught. All 65 met back together in the afternoon to learn about physical examination of infants, children, and children with disabilities.

On Wednesday morning I, along with Morgen presented a lesson on Family Planning. The Hesperian books, Where There Is No Doctor and Where Women Have No Doctor, were invaluable resources, when I planned my lessons. I taught a 2 hour class for two groups of about 12 VHW’s, using a translator. It was a challenge to remain culturally sensitive, since I had only arrived in Uganda a few days prior. I figured the best way was to ask them questions about their thoughts on family planning. This is where I learned a lot. First, I learned that the average family in each village has 8-12 children in their family. This provided a great opportunity to find out if the VHW’s thought that this number was too high. They agreed that having too many children can negatively impact mother and child health, if not spaced properly. They also understood that if there were too many children, there often would not be enough food for each child and not enough land for each son. According to the VHW’s the perfect number of children was six. I realized that I might be imposing my western views, if I stated that having more than 4 children increases the mother’s risk of death during childbirth. Here I learned that family planning is defined as, “having the number of children you want, when you want them.”

The second part of the family planning lesson, is where I explained the 6 different family planning methods available for free at Kisoro District Hospital. The VHW’s explained to me that the preferred method was the hormone injection that prevents pregnancy for 3 months. I learned that often husbands don’t want their wives to use family planning and the injection was the most discreet. The concern with the injection was that the shot in the arm may affect a woman’s ability to shovel. Condoms were the most unpopular option in the group, because there were questions about weather or not it would work if used improperly, (for example if the man was drunk) and if used, one partner would think it was being implied that the other had multiple sex partners. The Intra Uterine Device (IUD) was somewhat lost on them, even though we showed them the device, and explained how it works, they were concerned it would harm the man. The biggest concerns overall is that family planning might cause harmful side effects and that a woman may not be able to get pregnant when she wants, once she stopped using the birth control method. Overall, I think the presentation cleared up a lot of myths for some of the VHW’s and helped me understand how to be more culturally sensitive in the future on this subject. After giving a lesson for almost 4 hours straight I have a whole new appreciation for what teachers do!

The next day I gave a presentation on Health History Taking. Here I learned that medical translation from English to Rufimbira can sometimes be confusing. I instructed the VHW’s on the value of developing a positive rapport with each villager, since it requires asking so many personal questions, taking someone’s health history can feel invasive. After explaining what types of questions to ask, it was fun to watch the VHW’s begin to see how all of body systems work together. This initial introduction really helped them in the upcoming classes where they were taught how to do a head to toe examination and take vital signs. When I taught a small group how to measure heart rate, respiratory rate, and take blood pressures, the VHW’s were so interested, and when it really cliqued with them, it was very exciting to see their eyes light up.

The last lesson I taught was, in a way, the most challenging. At this point the VHW’s had learned the developmental milestones of infants and children, they learned about how to do a physical exam on infants and children, and they were able to practice doing an exam on a healthy infant. The final physical exam practicum was on a disabled child. A mother brought her 4 year old child that was developmentally delayed and could not talk. Signa and I, along with about 9 VHW’s examined the child. The mother brought in medical papers that stated he had Downs Syndrome, but Signa and I agreed that he did not have the typical markers of someone with Downs Syndrome. The VHW’s began by taking the baby’s health history from the mother. The mother stated that she was very sick during pregnancy and did not eat much, but did drink a lot of alcohol. She assured us that she no longer drank alcohol This raised a red flag for Signa and I because we immediately thought that the baby may have Fetal Alcohol Syndrome. More questions were asked about her alcohol intake and the mother stated that she began to feel judged. The mother did not seem to make the connection that her drinking may have caused her son’s developmental delay, yet it seemed insensitive to reiterate this to the mother, given that she was already feeling attacked. We made sure to tell her she had been doing a great job with her son, because he was physically very healthy, and although he was unable to talk he was walking, interacting with other children, and had the ability to communicate his needs without words. We explained to the mother that for him, reaching his developmental milestones would take longer. We had a debriefing with the VHW’s, after the examination, and explained that this was the perfect example of building trusting relationships with families. If the villagers distrust or feel condemned by health care workers in any way, it is unlikely that they will seek care in the future.

I have learned so much this week and look forward to next week, when I will follow Sister Maria Kagame, the Public Health Nurse around the community. My third week here I will begin to be oriented to the female ward, where I will work as a nurse. I just wanted to let you know that it has been difficult to remain in regular contact, because the power has been out during the day all week and the internet café is too far to walk to in the dark. Love you and miss you! Please keep in touch.