Electronic Thesis and Dissertation Repository

Thesis Format

Integrated Article


Doctor of Philosophy


Health and Rehabilitation Sciences


Lloy Wylie


Achieving global health-care goals hinges on a health workforce that is available, competent, and productive. Chronic health worker shortages impede the abilities of health systems to provide equitable services, especially in low-resource settings.

Global consensus on bridging health workforce gaps calls for alternatives such as using community health workers (CHWs) to achieve health-care aims. CHWs are laypeople who are closely connected with communities and provide frontline health services. Although CHWs are an integral part of workforces in many countries, with potential to inform global health systems, CHW programs continue to operate on the fringe and are fraught with challenges.

This dissertation applies a critical pedagogical lens to study CHW education and practices in Rwanda. Identifying CHWs and trainers as key stakeholders, this work brings their perspectives to the fore. The dissertation a) unpacks CHWs’ and trainers’ experiences with CHW education and practices, b) discusses preferred pedagogical approaches for optimized CHW education, and c) highlights drivers, enablers, and challenges of community maternal and child health work.

This work comprises three integrated manuscripts along with introduction, methodology, and discussion chapters. The first manuscript contributes to broad health-care systems discussions on addressing worker shortages with a focus on CHW programs and calls for critical systems thinking to be applied to CHWs’ engagement. The second examines CHW education from the perspectives of CHWs and trainers. The third discusses enablers, drivers, and challenges of community health work, highlighting inherent assumptions and ethical issues. It also unpacks burdens and support needs identified by CHWs.

Qualitative case study methodology was used to investigate the perspectives of 16 CHWs and 10 trainers on CHW education and practices. Data was analyzed using thematic analysis, mind mapping, and NVivo software. The data reveals gaps in CHW education and practices, and highlights contextual factors shaping their work.

This thesis contributes to knowledge about CHWs within health systems, approaches to optimize CHW programs, and CHW education. The results suggest holistic systems-thinking approaches situating CHWs within varying sociocultural, educational, and practice-specific contexts should be adopted in designing CHW educational programs. Furthermore, it demonstrates the benefits of engaging CHWs and trainers as key stakeholders.

Summary for Lay Audience

Health systems are struggling to meet the needs of people across the world. One of the difficulties is a shortage in the number of health-care workers needed to provide services. Governments and health-care leaders in Rwanda agreed that women known as “community health workers” (CHWs) should be recruited to take care of the health-care needs of pregnant women in their communities. CHWs are local women without professional education who are trained to carry out health work. Although many organizations are training CHWs, there is a lack of research where the workers and their trainers are asked what they have to say about their education and the work they do in communities. This information is especially important because there are many CHWs providing health-care services in countries around the world.

This research undertook a case study of community health work in maternal health in Rwanda. Sixteen community health workers and ten trainers were asked about their education, teaching preferences, and working conditions. Four approaches to facilitate CHW education were identified: 1) the power of storytelling using pictures and real-life scenarios, 2) effective educational design for learning, repetition of learning materials, learning from peers and doing role plays, 3) using their own experiences, knowledge, and relationships, and 4) paying attention to the workers’ practical needs. Three approaches to facilitate CHWs capacity to work in their communities were also identified: 1) more educational support, 2) wages – their present work is unpaid, and 3) essential health-care equipment.

The research findings show there is a need to change the way CHWs are being educated. Methods that are more participative, interactive and build on the knowledge CHWs already have are recommended. Also, there is a need to change the way CHWs work, to compensate them for their work, and provide them the support they need to be effective.

CHWs are very important to health systems, but there are ways to improve the way they are educated and supported within the system. Addressing these issues using information from the workers themselves and their trainers will help people design better educational and work packages for CHWs.