Community health workers and the need for training in communication skills.

If the CHW wishes to extend his role to prevention and promotion he will need to possess considerable skills in communicating effectively. In fact, his effectiveness as a CHW will largely depend on whether or not he possesses them. In most countries governments tend to encourage local communities to select CHWs from among their members. He is then more likely to have the confidence of the people in his neighbourhood and he should also know how to communicate with his neighbours. However, he may well be a prisoner of the situation. The confidence of his neighbourhood in him may only extend to his role as a curer of ills. It may not cover the more sensitive political and social issues which are at the heart of promotional and preventive health care. Only a foolish CHW would interfere with issues which in his neighbour's eyes have nothing to do with a CHW. The alternative is to appoint someone from outside, either from a nearby community or from further afield. This is likely to lead to more difficulties because the CHW is an outsider. The community is, therefore, more likely to restrict his role to cure and to prevent the CHW playing any part outside this role. There may be other difficulties. The CHW may be too young or too old to give advice to others. As a man he may find it impossible to talk about "women's matters" and vice versa. Such considerations will tend to restrict him to treating sick people. But if PHC is to succeed the CHW must be able to break out of these bonds. First, he must demonstrate his skills in diagnosing and treating sick people. His success will determine the degree of trust and confidence the community will have in him. Once he has proved himself he is in a position to extend his role. If he attempts this too soon he may well strike opposition or, worse, indifference. How is he to extend his role to prevention and promotion? He is likely to have had the same opinions and values as the rest of his community. These are often in conflict with many of the concepts fundamental to PHC. If the CHW is to change the ideas of his neighbours he will have had to change his own ideas first. So the first step is the training of the CHW, and many PHC programmes have been successful in converting the CHW to new K. R. Cripwell University of London Institute of Education, London. England