Community health workers in educational activities: potentials and weaknesses


Elaine Franco dos Santos AraujoI; Elisabete Pimenta Araújo PazII; Liane Gack GhelmanIII; Maria Yvone Chaves MauroIV; Marilurde DonatoV; Sheila Nascimento Pereira de FariasVI

IPhD in Public Health. Professor, Federal University of Rio de Janeiro. Brazil. E-mail: elainefsaraujo@gmail.com
IIPhD in Nursing. Professor, Federal University of Rio de Janeiro. Brazil. E-mail: bete.paz@gmail.com
III PhD in Nursing. Professor, Federal University of Rio de Janeiro. Brazil. E-mail: lgghelman@gmail.com
IVPhD in Nursing. Professor, Federal University of Rio de Janeiro. Brazil. E-mail: mycmauro@uol.com.br
V PhD in Nursing. Professor, Federal University of Rio de Janeiro. Brazil. E-mail: marilurdedonato@superest.ufrj.br
VIPhD in Nursing. Professor, Federal University of Rio de Janeiro. Brazil. E-mail: sheilaguadagnini@yahoo.com.br

DOI: http://dx.doi.org/10.12957/reuerj.2017.18425




Objective: to examine community health workers’ (CHWs) self-assessment of their facilitation / moderation of health education practices and actions. Method: this qualitative study of 36 CHWs in two family health units in Rio de Janeiro City was conducted in 2013. The study was approved by the research and ethics committee. Data were obtained by scripted, semi-structured interview and analyzed using content analysis. Results: two categories were obtained, one highlighting the greater security resulting from training and satisfaction, and the other, the weaknesses, such as work overload and lack of time to plan educational activities. Conclusion: CHWs feel fulfilled, although still insecure, in taking on and appropriating health education activities in the community. Accordingly, there is a need for greater investment in continued professional development and education for CHWs.

Descriptors: Community health agents; health education; self-evaluation; health promotion.




Primary care has its priority strategy based on family health and the principles of the Unified Health System, observing the local and regional needs, considering the person and their uniqueness. It is characterized by delimitation, that is, the population present in the territory, in order to stimulate the link between professionals and community. The delimitation allows the continuity of care, the accountability for health by professionals and users over time and permanently. We must establish practitioners' performance, in the work process, based on the community's health needs, being indispensable the exchange of knowledge between professionals and users through permanent and health education. Educational actions must be systematized in order to interfere in the health-disease process of the population, in the search for individual and collective autonomy and in the promotion of quality of life1.

One of the main elements of the community health worker (CHW) is mediation. It is common, in documents and speeches of technicians and managers of health institutions, for them to be identified as the link between the service and the community, which denotes the overvaluation of the mediating and, therefore, educational role of this worker. They carry out an important work with the community, helping the individuals to recognize responsibility with their own history and the process of building citizenship2. However, the practice has shown that the participation of the CHW in educational actions has been little explored by the teams and the local community, which has reduced their role in social change for better health conditions of the population.

The National Health Policy, focused on primary care, advocates an active participation of the CHWs based on strategies encompassing learning through active methodologies, in order to enable a better understanding of health education by the population1.

Based on this premise, the present study aimed to analyze the self-assessment of CHWs in relation to their actions in health education practices and actions, in which they were the facilitators/moderators.



With the implementation of the Family Health Strategy (FHS), the functions of the CHWs were expanded, requiring new skills in the fields, mainly in health promotion, for example, through educational activities with the community3.

For health work, especially that carried out by the CHWs, it is crucial that the worker realize how important it is to develop argumentation before individuals so that they understand the health of all also depends on them and on the bonds of solidarity they draw with their neighbors4.

There is the need for professionals to discuss on health practices, seeking a joint solution with strategic health actors to promote the health of the population, thus highlighting the factors that hinder the implementation of the activity and overcome them for the promotion of health in the FHS5.

This is the movement to be made by the health workers who understand their actions as a practice focused on the present and future transformation.

One cannot assume that educational work does not require critical reflection. Rather, it must contribute to the population's recognition of the health risk situations. Professionals must promote popular mobilization to guarantee rights to improve the living conditions of the population6.



This is a qualitative study, developed with 36 participants about their self-assessment in relation to their performance in health education practices, in which they acted as facilitators/moderators. It was developed from April to November 2013 in two family health units of coverage area 5.2 of the city of Rio de Janeiro. In the first unit, 17 participated and in the second, 19.

Data collection was done through interviews at the units on scheduled days and times, with the application of a semistructured script of questions about the self-assessment of the CHWs regarding the educational activities they had conducted at the units. The interviews were recorded in magnetic media and transcribed in full to facilitate the analytical process.

The selection of participants was random, based on a single criterion: having been a volunteer as a facilitator of educational activity, after having attended the workshops on permanent education with active learning methodologies, performed at the family health unit (FHU). In these workshops, they were able to exchange experiences and receive guidance on the main methods of group work and the role of the learning facilitator.

Participants signed the Informed Consent Form (ICF) in compliance with Resolution No. 466/2012 of the National Health Council. The study was submitted to normative procedures and approved by the Research Ethics Committee of the Nursing School Anna Nery, Opinion no. 095/2010.

In order to guarantee the confidentiality of their identities, the 36 participants were identified by alphanumeric codes, in which the two letters represented the initials of the names of the units where they worked (IG - Ilha de Guaratiba and FM - Fazenda Modelo) and the numbers represented the order of performance of the interview (1, 2, 3, ...).

For data treatment, we used the content analysis, based on the interviewees' statements. The following steps were followed: pre-analysis - initial organization of data to systematize ideas; exploration of the material - systematical management of the guidelines and decisions taken in the pre-analysis; and treatment of the results - inference and interpretation work7. At the end of the data analysis, two categories emerged, which will be presented in the next section.



After the workshops on permanent education, the community workers started to conduct some groups of health education in the units. Based on their experiences, they made the self-evaluation in relation to their role as facilitators of the educational groups. For them, there were potentialities and weaknesses in this performance, as can be seen in the following two categories.

Category 1 – Potentialities of the changes in the actions of the CHWs

The potentialities identified were greater trust and confidence; relationship of knowledge exchange; increased creativity to change group approach strategies; feeling of usefulness and importance; more rewarding and fruitful work related to greater motivation and job satisfaction.

Greater safety and confidence were associated with continuing education activities carried out by the nurses with the CHWs before they began community education activities, which further improved the trust between the community agent and the families he or she accompanied8.

Because we [...] get prepared; it feels good to know what we are doing. (IG1)

[...] So, it was cool, rewarding; it was really cool, I liked it. (IG10)

Sometimes, the CHWs are not prepared to guide on a certain subject because they lack knowledge, which evidences the need for greater investment in the education of these members of the health team9.

I think after the training [course], we got more confident. (FM11)

I feel good. Preparation has greatly helped me developing community work [...]. (FM15)

The community worker is known as a bridge, a communicator between the health system and the community10.

What we learn here goes to the community. (IG15)

Because we talk about prevention in dentistry [...]. (FM14)

The change in group approach strategies certainly makes educational activities rich and creative moments.

And our target audience who, in this case, is the teenager [...]. We make a circle and chat. Because teenager distracts often gets distracted [...]. Lectures do not work properly; it is easier to sit and have a meeting, in a circle [...]. (IG12)

Many felt important and useful, as they were responsible for improving the quality of life and health of community users through the educational activities.

I felt useful before the community because they always expect something from you and you feel valued. (IG8)

They were so happy, [...] So that made us feel a little important. (FM7)

The working process model made the activity more satisfying. Health teams need to be encouraged and prepared to assume new standards of responsibility11.

Oh, I was happy. [...] when you look at that lot of seniors looking at you, having more confidence in what you are talking about, teaching. [...] It's satisfying [...] (FM5)

[...] when you are participating, is one thing, when you promote is another. This is all very satisfying. (FM12)

The CHW has a different identity from other health professionals because he/she is a popular educator. Their proximity to the community reproduces a multiplier effect with specific and welcoming characteristics12.

Category 2 - Weaknesses of the changes in the actions of the CHWs

Among the weaknesses pointed out, the following stand out: Individual limitations (nervousness, shyness, lack of confidence); lack of preparation; lack of time for the preparation of educational activities with the community; lack of time and organization to carry out permanent education activities; and lack of time and interest by the community to participate in educational actions.

Feelings such as nervousness, lack of confidence and shyness can be observed in the speeches of some workers. However, in order to combat fear, one must know the subject, practice it, acquire experience and develop self-knowledge13.

I do it very well when I do it [educational activity] within my micro-area, but now, when I do it in a group, I get a bit shy. (IG5)

And the feeling of nervousness is due to the anxiety of passing on the right information within what they expect. (FM16)

According to the opinion of other CHWs about their performance in education, there was a lack of preparation.

Being prepared, one hundred percent prepared, I can say that I am not, because there are questions, so we get afraid to talk. (FM14)

I do not feel able to say anything; I did not say anything. (FM6)

Studies have identified the day-to-day work of CHWs and the results show that they find it difficult to fulfill their duties both due to the requirements and for the limited socioeconomic conditions of the families14,15.

In addition to the lack of time for the preparation of educational activities, there is also the lack of time and organization to carry out continuing education activities.

[...] There should be a training in advance [...]. We have to rush a lot to get it; we have to research a lot. We have to leave something aside from our activities. (IG7)

[...] nowadays, with the increase of the attributions [...], we see that the time to dedicate to this training has been smaller. However, we are interested in it, but the time and the availability of professionals are lacking [...]. (IG11)

Some challenges should be overcome, such as work overload. This overload is characterized by the lack of a delimitation of the attributions of the CHWs, which leads to a distortion of their work16.

Another weakness refers to the lack of interest of the community to participate in the activities, as they resist accepting the CHW as capable of promoting an improvement in the quality of life, as seen in the following speech.

We even talk to people, it's okay, but the acceptance is a bit complicated. [...] They are not so open to listen to us and accept what we have to teach them. (FM13)

[...] the patients, they do not see us, the community worker, as an educator, do you understand? They think we have to be in that white gown, you know? They see us and think we have nothing to teach. [...] With the gowns, professionals can talk about anything and they accept it; but, for us, they do not give much importance. (FM13)

The training courses must be based on the development of skills, using innovative, reflexive and student-centered teaching methods, whose central objectives must be to turn them into proactive subjects16,17.

Society needs to understand that prevention is necessary, and with this, the change from the curative to the preventive model through the appreciation of preventive health practices and education18,19.

This occurs with the cognition and behavioral change of the population, through the understanding that they must exercise control of their own lives and their determinants of health, acquiring habits that promote health, and not disease20,21.

Efforts should be made to ensure that educational practices are no longer fragmented and mechanistic in order to effectively achieve the long-awaited social transformation in health, thus valuing the involvement and awareness of social actors22. For this purpose, there should be a pedagogical practice committed to the learning of the community23.



When conducting educational groups, CHWs involve the community and seek their health guidance needs. Among the potentialities of educational activities carried out by community workers, we can mention the community's trust in them, which, over time, makes them receive the due recognition of the population, which also makes their work even more rewarding.

Among the weaknesses identified by community workers, attention is drawn to the work overload.

In the proposal to reorganize the assistance practices that guide the FHS, new and old instruments of work can be incorporated to better execute the activities, facilitating the achievement of health promotion objectives together with families. The training and permanent education of the multiprofessional team and the community workers are crucial so that they can meet the needs of the families, directing the look and health actions beyond the curative practices.

The steadiness of the teams is crucial to ensure continuity of work. The permanent education of the CHWs enables them to engage in participatory, reflective and transformative community work.



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