Enabling Community Health Worker Recognition and Referral of Surgical Diseases: Pilot Study Results of a Pictorial Guide

  • Sebastian Gualy
  • Christopher Herrera
  • Clara Warden
  • Tyron Valle
  • Jeanie Barnum
  • Bessy Colman
  • Armando Siu
  • Jordan W. SwansonEmail author
Surgery in Low and Middle Income Countries



Access to surgical care is a pressing challenge, particularly for vulnerable populations. Informal and formal community health workers (CHWs), including lay people, increasingly function in pivotal roles in primary care, however, remain disconnected from surgical care in most environments. This study examined the degree to which CHW understanding of surgical conditions could be improved through the use of a pictorially based manual.


A manual and associated situational problem-solving questionnaire instrument were developed and contextualized through focus groups in Central America. A baseline assessment was obtained. In the program implementation, cohorts of formal and informal CHWs were introduced and trained to use the manual through a short curriculum. Assessment was repeated in program implementation, first with access to relevant manual content only, and then after the teaching session. Participants were also surveyed about manual scheme, usability, and utility.


A total of 100 subjects (67% female) participated in baseline assessment, and 403 subjects (68% female) were assessed through the program implementation. Baseline problem-solving averaged 11.8 (SD 2.46) out of a possible 20 points. Mean score increased to 15.4 (SD 3.10) when participants had access to relevant surgical manual content and again to 15.9 (SD 3.09, p < 0.0001) following participation with an instructive curriculum. Participant score while utilizing the manual correlated with amount of education completed (r = 0.26), but baseline score did not. High readability 389 (96%) and high self-reported willingness for use 398 (96%) were noted.


Baseline familiarity with surgically treatable conditions appears modest among rural Central American populations, and improves with access to a contextualized, pictorial manual focused on recognizing and appropriately referring surgical conditions.



We thank our colleagues in Honduras, Julissa Colman from the Department of Education and Alex Guerrero from Operation Smile, for assistance with recruitment of participants and administration of the curriculum and assessment tool. We thank Dr. Marco Swanson for overseeing initial stakeholder meetings and design of the manual.


Dr. Jordan Swanson is funded in part by the UBS Optimus Foundation. Chris Herrera and Sebastian Gualy were supported in part by the Agnew Surgical Society and the Center for Global Health at the Perelman School of Medicine. Clara Warden was supported by the National Heart, Lung and Blood Institute, National Institutes of Health, through Grant R25-HL084665. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. Operation Smile International, Agnew Surgical Society.

Compliance with ethical standards

Conflict of interest

The author declares that they have no conflict of interest, real or potential.


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Copyright information

© Société Internationale de Chirurgie 2019

Authors and Affiliations

  • Sebastian Gualy
    • 1
    • 3
    • 4
  • Christopher Herrera
    • 1
    • 3
    • 4
  • Clara Warden
    • 1
  • Tyron Valle
    • 5
  • Jeanie Barnum
    • 3
    • 4
  • Bessy Colman
    • 3
    • 4
  • Armando Siu
    • 3
    • 4
  • Jordan W. Swanson
    • 1
    • 2
    • 3
    • 4
    Email author
  1. 1.Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaUSA
  2. 2.Division of Plastic SurgeryChildren’s Hospital of PhiladelphiaPhiladelphiaUSA
  3. 3.Operation SmileTegucigalpaHonduras
  4. 4.Operation SmileManaguaNicaragua
  5. 5.General SurgeryHospital Carlos CentenoSiunaNicaragua

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