Performance Based Education

for Community Health Workers


What's wrong with this picture? (A True Life Story):


Scene: A three-day training session for health workers who do street outreach, counseling and partner notification in sexually transmitted diseases in a major city. A series of doctors lecture to the health workers, showing slides of patients with STDs, and presenting on diagnosis and treatment. They reel off facts and figures which the health workers are supposed to memorize for their pre- and post-tests. The doctors drone on and by the end of each day the health workers' eyes are glazed over and they are completely frustrated.


What's wrong?


1. The doctors are teaching what they were taught, not what the health workers need to know how to do. The content of the training is determined by "experts," not by people who really do the work on the ground in the community. The people who are teaching have never done what the health workers need to know how to do.


2. Learning is evaluated by regurgitation of facts, not by the mastery of skills in a real-life situation. This kind of pencil-and-paper evaluation favors people with more formal education, not necessarily people with knowledge of the community who are most effective in the field.


3. The health workers get an informal certificate of completion, but not college credits that contribute to raises, career mobility or educational advancement. No matter how much they know, how high their skill level, or how much responsibility they take, they are too often ghettoized in a dead-end job.


4. Every topical specialty--for example, sexually transmitted disease, or nutrition, or perinatal--designs its own training program. None of these programs recognize the trainings put on by other programs, so that health workers find it hard to advance no matter how many trainings they attend. However when our project compared job descriptions across specialties, we found that many process skills -- for example client interviewing or health advising -- are common to CHWs no matter what their topical focus.


To address these problems, the Community Health Works of San Franciso, a joint project of San Francisco State University and City College of San Francisco, established a Community Health Worker Certificate, the first such college-sponsored certificate in the US. Our approach is called Competency Based Education. The foundation of the curriculum is a job task analysis. In a two-day workshop facilitated by the DACUM Center ("Develop a Curriculum") of Spokane Community College, twelve veteran community health workers pinpointed key competencies based on their first-hand knowledge of what they do each day. The seven competencies are client interviewing/intake; client orientation; care coordination or case management; documenting and reporting; providing referrals; providing health information; and community health education or outreach/organizing. With the input of veteran CHWs and supervisors, each competency is broken down into subcompetencies, and each one is described in detail: What does it look like when this competency is done well or poorly? In this way each person in the program knows she is learning what is critical, and that she has mastered the competency well enough for use in a real life situation. On the first day a learner comes to class, she or he receives this roadmap of what they are to learn and what criteria will be used to evaluate mastery. The curriculum addresses the knowledge, skills, and attitudes that a health worker needs to be successful. Potential employers know that graduates of the Certificate program are capable of consistent performance.


Together with partners, we are now developing the full listing of competencies and proficiency criteria into a Standards of Practice Manual for CHWs (to be available in 1997). We also carried out statewide and regional surveys of employers to analyze the job market and skill sets that are in greatest demand in a rapidly-changing health system.


In Competency Based Education, evaluation is done not mainly by pen-and-paper exams, but by performance in scenarios based on typical real life situations. We adapted the Objective Structured Practical Exam format first used by the World Health Organization (Abbatt 1993). Health Workers and supervisors scripted typical scenes from the workplace. Then we set up stations where each class member enacts the role play with an actor and is observed by an examiner (a veteran community health worker or supervisor). The examiner uses the competency checklist to determine if the skill was carried out at a level of proficiency required by someone entering the field. Because the criteria are clear and spelled out in advance, exams can be used for learning and feedback, not as an exercise in memorization.


Our program has a strong belief that health workers need a strong orientation to "the big picture" of the urban health crisis. Poor communities are embattled by cutbacks against people on welfare, immigrants, and those caught up in the criminal justice system. CHWs need to master not only technical information, but also be able to serve as a voice of the community in the political process that has such a big effect on community health. One learning activity we use is a simulation called "the Single Room Occupancy Game," in which the classroom is turned into something that resembles a giant Monopoly game board. The simulation, distributed by the Bay Area Homelessness Project at San Francisco State, allows the players to see and analyze the social, political and economic dynamics that lead to homelessness. Our educational process also stays close to real life by having many class sessions led by CHWs and supervisors.


City College of San Francisco has an open admissions policy, and costs only $13 a unit, so it is truly accessible to grassroots community people. Because our Center is one of the rare partnerships between a community college and four-year university, we are well-positioned to make sure our program is not a dead-end, but part of an educational ladder. We have an excellent agreement in which people who complete our Certificate can apply credits to an associate's degree and then transfer 12 college units to San Francisco State University toward a bachelor's degree in Community Health Education.


In 1995 our program was recognized as one of the 15 most "innovative and promising" health training programs in the US (Seedco/Annie E. Casey Foundation). We were also one of the top three percent of programs funded by the U.S. Department of Education (Fund for the Improvement of Postsecondary Education, FIPSE). For further information, send for our brochure and publications list: Community Health Works of San Franciso, Department of Health Education, 1600 Holloway Avenue, San Francisco CA 94132-4161, e-mail:, fax (415) 338-7948.


This article was published in the Healthy Mothers/Healthy Babies POWER Newsletter, 1997.



SFSU/CCSF Community Health Works of San Franciso, 1997.

For more information contact: CHTDC, Department of Health Education, 1600 Holloway Ave., San Francisco, CA 94132.

Phone: 415/338-3034 Fax: 415/338-7948 Email:

fn: competencybasededpower/pr 9.9.97