COMMUNITIES CARE: TRANSFORMING LIVES AND PREVENTING VIOLENCE

PART 3 STRENGTHENING COMMUNITY-BASED CARE

SECTION 2 CAPACITY

TRAININGBUILDING SESSIONS AND MATERIALS

COMMUNITY HEALTH WORKERS TRAINING GETTING STARTED PART 3 Strengthening Community-Based Care

all survivors need good quality care and support to help them heal and recover

b CAPACITY BUILDING

Community health workers Getting started

STRENGTHENING COMMUNITY-BASED CARE CAPACITY BUILDING 10 DAYS • 8 MODULES GETTING STARTED Key considerations for capacity building of Community Health Workers

The purpose of this document is to help Communities Care: Transforming Lives and Preventing Violence (CC) Programme staff plan for building capacity of Community Health Workers to provide good quality community-based care for survivors of sexual violence.

Accompanying materials include a Facilitator’s Guide and a Participant’s Packet.

1 PART 3 Strengthening Community-Based Care

Part I of this guide provides a justification for community-based approaches to managing survivors of sexual violence.

Part II contains a step by step guide for planning for strengthening community- based medical care for survivors of sexual violence. The steps address: 1. Selecting sites for piloting community-based medical care for survivors of sexual violence 2. Examining site specific policies, protocols and treatment 3. Mapping available services to determine the scope of referrals 4. Selecting participating community health workers 5. Considerations for piloting community-based care for survivors of sexual violence 6. Supporting a communications strategy 7. Working with facility-based health providers receiving referrals from community health workers (CHWs) 8. Troubleshooting 9. Data collection

Part III includes information on preparing to train community health workers.

Annex I offers an additional decision-making tool on what care and tasks community health workers can implement in specific settings.

Annex II summarizes the evidence around community-based care for survivors of sexual violence.

2 CAPACITY BUILDING

Community health workers Getting started

Part I: Why use community-based approaches to managing survivors of sexual violence?

Community-based medical care for survivors of sexual violence

Medical care for those who have survived sexual violence is frequently limited in humanitarian settings. Service providers are often ill-equipped to treat survivors and facilities may lack supplies and trained providers at the height of insecurity. Barriers for survivors to access care can also include the distance to a health facility and stigma associated with sexual violence. Given these challenges, a community-based approach may increase access to and uptake of health services by survivors of sexual violence.

The community-based model to providing medical care for survivors of sexual violence translates the World Health Organization’s (WHO) 2004 Clinical Management of Rape Survivors: Developing protocols for use with refugees and internally displaced persons for community health workers (CHWs) to provide post-rape care where facility-based health services are not available or inaccessible. The model builds on the work undertaken by the Women’s Refugee Commission (WRC) and partners working with internally displaced persons in Burma. This work explores the safety and feasibility of this alternative service delivery method in humanitarian settings. The findings are documented in “Piloting community-based medical care for survivors of sexual assault in conflict-affected Karen State of eastern Burma,” from the May 2013 issue of Conflict and Health.1

To further the evidence base, UNICEF’s Child Protection, Health, and HIV/AIDS Sections have been working with the WRC to develop a broader training package for community-based management of survivors of sexual violence and to address the critical role that CHWs can play in managing survivors of sexual violence in varied conflict settings. The effort supports the inter-agency Joint Statement on Scaling Up the Community-Based Health Workforce for Emergencies that emphasizes the role of the community health workforce. Elements of the model include capacity-building and linking CHWs with other community-based response systems as well as the broader work of UNICEF and other partners in order to bolster the protective environment for children, women and their families. Such efforts promote a continuum of prevention and care across formal and less-formal response systems.

Community-based approaches to care for survivors of sexual violence are expected to contribute to global commitments to provide medical and psychosocial support to survivors in conflicts. The urgency of this need has been recognized in UN Security Council Resolutions.2 As the global community focuses on monitoring and reporting of sexual violence perpetrated in conflict, the need to ensure services is paramount. An alternative approach to facility-based care may offer solutions in settings where traditional methods of medical care are not practical for the women and girls that need it most.

1 Mihoko Tanabe et al, “Piloting community-based medical care for survivors of sexual assault in conflict-affected Karen State of eastern Burma,” Conflict and Health 7(12) (2013). 2 1325, 1820, 1888, 1889, and 1960 on Women, Peace and Security.

3 PART 3 Strengthening Community-Based Care

Community-based approaches to prevention and response to sexual violence

Community-level prevention and response strategies have the potential to reduce levels of sexual violence during and following conflict. They may also, over the long-term, succeed in building social norms that undermine notions of sexual violence as an inevitable and acceptable part of war. Response activities – especially the provision of services – are critical. As community norms around sexual violence are challenged, a greater awareness is built around sexual violence as a crime/human rights violation. At the same time, and communities are encouraged to understand the importance of services and survivors may increasingly seek care. It is essential that care and support services are accessible to survivors, including through community-based options.

The positive outcomes of CC Programme community discussions and deliberations will be further reinforced as services improve and/or are made available through CHWs and as other service providers and survivors begin to access quality services. As trust and faith are built around confidential and quality services, health seeking behaviour can be encouraged among survivors.

Part II: Planning for strengthening community-based medical care for survivors of sexual violence

The following sections detail key considerations for laying the groundwork prior to pilot site selection, engagement with and training of CHWs, and among other key components. The full support of implementing partners is critical for the required preparatory work. Key components include: • Meeting with critical stakeholders, including relevant government ministries • Supporting IPs for systems mapping in target sites • Identifying referral points for participants of any focus group discussions and key informant interviews • Providing ongoing support for research, monitoring and evaluation (M&E) and capacity development • Supporting the identification and training of CHWs and other service providers • Implementing workshops to launch the project at various levels to secure district level leadership and community buy-in

4 CAPACITY BUILDING

Community health workers Getting started

1. Selecting sites for piloting community-based care for survivors of sexual violence

The first step in piloting the community-based model is to select appropriate intervention sites where CHWs will be trained to provide health care for survivors of sexual violence. In order to pilot community- based care, the following criteria should be applied to selecting locations that are optimal for assessing the safety and feasibility of this approach. The ideal setting for the pilot meets all required criteria. The recommended criteria are not mandatory, although desired.

Criteria Yes No Required Access to medical care for survivors of sexual violence is unavailable or inaccessible due to distance to facility-based services, stigma associated with reporting, or lack of an enabling environment for survivors to seek care. No known policy barriers for CHW provision of medical care to survivors or known policy barriers that cannot be overcome. No requirement to report incidents of sexual violence to traditional or formal judicial systems. Limited population movement for CHWs to provide care and follow-up services and the possibility to implement monitoring activities. Possibility to: • Protect any documentation by CHWs. • Supply chain management. • Begin community conversations around sexual violence. Village/community leader and other stakeholder understanding of pilot objectives.

Recommended Relative accessibility in terms of logistics.

Reasonable CHW to population ratio (2 CHWs per 1,000 population). Community confidence and trust of CHWs, or capacity to build such faith exists. No known CHW connections with fighting forces.

2. Examining site specific policies

Once the pilot locations are selected, it is essential to gather national and local health protocols, agency protocols and legal guidelines to understand the context and align pilot implementation.3 It will also be helpful to know what services CHWs are currently providing, what they have been trained in (such as community case management for childhood illnesses), and how the skills to provide post-rape care build on their existing training and scope of work. This information will maximize the related learning of the CHWs and allow them to apply already learned skills.

3 IRC, Clinical Care for Survivors of Sexual Assault: A Multi-Media Training Tool, 2008.

5 PART 3 Strengthening Community-Based Care

To determine protocols and legal guidelines, the following information is needed: • National, local and agency protocols for clinical care for survivors of sexual violence: HIV post exposure prophylaxis STI prophylaxis and treatment Emergency contraception Hepatitis B • Local legal guidelines regarding: Status of minors (age of majority, age of consent and laws regarding consent for medical treatment of minors) Existing legal systems to try perpetrators of sexual violence Definitions of sexual crimes Mandatory reporting of sexual violence/abuse (for what type of survivor or perpetrator, and reporting to whom) Standards for medical documentation and testimony (what constitutes valid evidence, and from whom? Can only doctors sign medical certificates?) Pregnancy termination

Local treatment protocols should be followed in order to minimize drug resistance. Treatment protocols (job aids) in the participants’ packet should be adapted as necessary for this purpose. Please see the table in Part IV to assist with this process.

In some instances, active laws or policies may exist to prevent CHWs from providing certain services, such as dispensing antibiotics or offering emergency contraception to unmarried persons. In other instances, records provided by CHWs may not suffice as legitimate evidence of services rendered, although they can still serve as documentation that a CHW-client interaction took place.

When health providers care for survivors, a medical certificate is often issued that summarizes the survivor’s history and findings. This certificate is issued specifically for use in court if the survivor chooses to go to court and legal justice is available. The intake form which providers – including CHWs – complete, is a medical track record that serves to remind the provider about the history and care provided. While a medical certificate can serve as important evidence for future pursuance of legal justice, this is beyond the scope of services that CHWs can provide. Protocol can instead be established in the pilot sites for CHWs to develop a duplicate copy of the intake form should the survivor request written information and providing that the survivor understands any potential security risks associated with the possession of such documentation. Original records of the medical care provided can then be kept with the CHWs in a locked cabinet.

In further instances, where no formal law or policy exists, health workers and others may incorrectly assume that health providers should not provide health care to survivors for various reasons including the need for a survivor to present a marriage certificate, obtain her husband’s permission, or file a police report that has “verified” the rape. It is extremely important to distinguish policy from myth in the pilot setting, to be able to reinforce that CHWs should be providing care to all who seek it for any type of forced sex. It is not up to the CHW or any health provider to determine or verify “rape”.

6 CAPACITY BUILDING

Community health workers Getting started

Programs should assess mandatory reporting requirements and develop a plan on how to handle cases. In some cases, such requirements and the local situation may lead programs to not collect certain types of information or have health staff refrain from asking certain types of questions because of the potential risks to survivors and/or themselves. Where mandatory reporting exists by law (not perceived), it is likely best for CHWs to report the incident to a program staff member who will decide on the course of action. Module 3 discusses these issues and programs should develop strategies and protocols before CHW training begins.

In further instances, no protocols or policies may be available to guide the CHW provision of health care for survivors. If this is the case, it may be possible to work with the appropriate ministries to garner their support for the piloting process in order to influence emerging policies and protocols. Such advocacy can also offer opportunities to revise any hindering protocols and create a more enabling environment for survivors to seek care.

3. Mapping available services to determine the scope of referrals

With CHWs playing a role in a larger health system, it is important to map the services that are available to refer survivors prior to the training of CHWs. The mapping is part of the groundwork to be completed by program staff and used to support CHWs in their work. The table below can help programs map available referral services for survivors in the pilot setting, and segments can be shared with CHWs when discussing referrals in Module 4.4

4 Médecins Sans Frontières. “Sexual & Gender Based Violence: A handbook for implementing a response in health services towards Sexual Violence”, Operational Centre Barcelona, 2011.

7 PART 3 Strengthening Community-Based Care

Mapping available referral services

Who provides this service, Where is this referral Does this service meet When are they Linkages to services Yes No and what specifically? located? quality standards?* (Y/N) open? (24/7) Contact Community mapping of all referral points N/A N/A N/A conducted. Organization(s) and individual(s) are in place to facilitate gender-based violence (GBV) N/A N/A N/A coordination meetings. GBV coordination meetings take place and are N/A N/A N/A attended for coordination and communication.

System(s) developed to track referral services. N/A N/A N/A

Referral by CHW 1 to CHWs 2 and 3.

Referral to a mid/low level facility that can treat shock, wounds, and pelvic inflammatory disease; provide intrauterine devices, etc. Referral to a mid/high level facility that has surgical capacity for fistula or rectal sphincter muscle tears, broken bones, etc. Referral for HIV prevention services (HIV testing, antenatal care, and prevention of mother-to-child transmission of HIV). Referral for HIV treatment services (antiretroviral treatment, pediatric treatment, etc.). Referral for abortion services where legal.

Referral for psychosocial support.

Referral for specialized mental health services.

Referral for shelter and protection, including community protection for survivors. Referral to police.

Referral for legal assistance.

Referral for social support (rehabilitation, reintegration, income-generation, education, support groups, etc.).

*Only those services/organizations that have been assessed for their quality (especially the ability to maintain confidentiality) per existing applicable standards should be engaged as part of the pilot’s referral network.

8 CAPACITY BUILDING

Community health workers Getting started

Who provides this service, Where is this referral Does this service meet When are they Linkages to services Yes No and what specifically? located? quality standards?* (Y/N) open? (24/7) Contact Community mapping of all referral points N/A N/A N/A conducted. Organization(s) and individual(s) are in place to facilitate gender-based violence (GBV) N/A N/A N/A coordination meetings. GBV coordination meetings take place and are N/A N/A N/A attended for coordination and communication.

System(s) developed to track referral services. N/A N/A N/A

Referral by CHW 1 to CHWs 2 and 3.

Referral to a mid/low level facility that can treat shock, wounds, and pelvic inflammatory disease; provide intrauterine devices, etc. Referral to a mid/high level facility that has surgical capacity for fistula or rectal sphincter muscle tears, broken bones, etc. Referral for HIV prevention services (HIV testing, antenatal care, and prevention of mother-to-child transmission of HIV). Referral for HIV treatment services (antiretroviral treatment, pediatric treatment, etc.). Referral for abortion services where legal.

Referral for psychosocial support.

Referral for specialized mental health services.

Referral for shelter and protection, including community protection for survivors. Referral to police.

Referral for legal assistance.

Referral for social support (rehabilitation, reintegration, income-generation, education, support groups, etc.).

*Only those services/organizations that have been assessed for their quality (especially the ability to maintain confidentiality) per existing applicable standards should be engaged as part of the pilot’s referral network.

9 PART 3 Strengthening Community-Based Care

4. Selecting participating community health workers

The role of the CHW may differ in the pilot sites depending on national policies, local health infrastructure and existing skill sets of CHWs. In circumstances where higher level health care providers—such as nurses, midwives and doctors—are available, CHWs may only be involved in referring survivors of sexual violence for appropriate services. However, in settings where higher level providers are lacking or health facilities inaccessible, CHWs may play a larger role in managing survivors of sexual violence within the overall health system. Three categories of CHWs that can be engaged in the pilot project are noted below. Categories 1 and 2 are relevant for this pilot.

CHW Category 1: CHWs only conduct health education as part of daily activities and refer survivors (Modules 2-4). Non-literate CHWs will fall into this category. Eligibility criteria are: • No literacy or numeracy required. • Limited experience serving as a CHW which could be as a volunteer or health promotion staff. • Compassion/empathy and willingness to care for survivors of sexual violence.

CHW Category 2: CHWs involved in the provision of basic treatment and follow-up care to survivors (Modules 2-6). Many CHWs in this project will fall into this category (as well as category 1). Eligibility criteria are: • Some level of reading and written literacy (not non-literate) to read instructions and complete client records/forms. • Basic numeracy to count days, hours and measure dosages. • Basic training in primary health care based on national policies. • Understands the importance and is capable of maintaining confidentiality of survivors and any data collected. • Demonstrates compassion/empathy and willingness to care for survivors of sexual violence. • Capacity to provide minimal documentation if the survivor wants a record for herself or himself.

CHW Category 3: CHWs involved in higher-level care (Modules 2-Advance Module 8). This category is applicable only in settings where CHWs have evolved advanced roles5 with clinical experience and skills. This category will not be relevant in the pilot settings of Somalia and South Sudan. Eligibility criteria include: • Basic literacy and numeracy. • Advanced training and experience providing clinical care based on national or international policies. • Understands the importance and is capable of maintaining confidentiality of survivors and any data collected (through previous experience with HIV testing, for example). • Demonstrates compassion/empathy and willingness to care for survivors of sexual violence. • Capacity to provide minimal documentation upon request.

5 Such as, “maternal health workers” in LC Mullany et al, “The MOM project: delivering maternal health services among internally displaced populations in eastern Burma” Reprod Health Matters (2008) 16: 44-56.

10 CAPACITY BUILDING

Community health workers Getting started

5. Considerations for piloting community-based care for survivors of sexual violence

As CHWs will only be offering certain elements of health care for survivors of sexual violence, there will be limitations to the care provided. A decision-making tool on the care and tasks CHWs can be expected to implement in the setting is provided in Annex I. In summary, the scope of work as determined by capacity (NOT by nuances in the setting) is as follows: ✔ = Yes Blank = No ★ = Only if capacity exists and the intervention warranted

Intervention CHW 1 CHW 2 CHW 3 Conduct health education around sexual violence and the benefits of ✔ ✔ ✔ seeking care Recognize survivors of sexual violence when they come forward ✔ ✔ ✔ (passive identification) Actively screen for survivors of sexual violence ✔ ✔ ★ Provide some basic first aid to stabilize survivors for referrals ✔ ✔ ✔ Refer survivors to higher level health staff or the health facility for ✔ ✔ ✔ health care Take a health history ✔ ✔ Collect forensic evidence Conduct a minimum medical exam (physical) ★ Conduct a minimum medical exam (pelvic) ★ Complete simplified intake form ✔ ✔ Generate a medical certificate (duplicate intake form) ✔ ✔ Provide some basic first aid to treat minor injuries ✔ ✔ Provide other wound care as feasible ★ Provide presumptive treatment for sexually transmitted infections (STIs), emergency contraception (EC) for pregnancy prevention and ✔ ✔ supportive counseling (including psychological first aid and basic emotional support) Conduct HIV counseling and testing ✔ Provide Postexposure Prophylaxis (PEP) ✔ ✔ Provide tetanus toxoid and/or Hepatitis B vaccine ✔ Provide follow-up care to survivors ✔ ✔ Manage STIs (syndromic management) ★

Additionally, to minimize error in providing treatment, it would be helpful for the program to consider prepackaging standard treatment packages. Treatment packages can be color-coded and prepared for adult female survivors of vaginal assault that come within three days, five days and 30 days of the violence. This way, the CHW will not need to dose drugs for each survivor, but can merely give the appropriate colored packet and simple instructions on patient messaging. A client form is available in the participants’ packet where CHWs can note the medicines provided, as well as other information. For children, pregnant women and adult female survivors of other sexual violence (anal or oral assault), CHWs can work from the pre-packaged treatment packets to remove or add medicines as relevant.

11 PART 3 Strengthening Community-Based Care

6. Supporting a communications strategy

An important component of the pilot project is to raise awareness among the different actors in the community, and to learn who among them needs to be informed about sexual violence, the benefits of seeking care, and how to facilitate survivors’ access to care. Messages include: • What is sexual violence • Who can experience sexual violence • Why does sexual violence happen • What should survivors do after experiencing sexual violence • What should others do if they know someone has experienced sexual violence • What are the benefits of survivors seeking health care immediately (preventing pregnancy, preventing STI/HIV, receiving basic emotional support) • Where can survivors go for services • What will survivors of sexual violence expect if they seek health care • What are the terms of receiving care (health services are free, private, voluntary and safe, and available 24 hours a day, 7 days a week)6

Some options to reach different groups are: • Face-to-face trainings or awareness-raising sessions. CHWs or peer educators can conduct these sessions in schools, youth clubs, religious facilities, and other locations where people congregate. • Print material, such as brochures, leaflets, posters, etc. • Theater or drama • Radio or television • Cell phone messaging

The following table may be helpful for the program to identify potential audiences and determine how to reach them. The table is important given that CHWs will only be responsible for health education as part of their day-to-day activities yet the entire community can influence whether or not an enabling environment exists for survivors.

6 WHO, Clinical Management of Rape Survivors: Developing protocols for use with refugees and internally displaced persons, 2005.

12 CAPACITY BUILDING

Community health workers Getting started

How might What are the How can they hinder key messages messages be or facilitate to convey to communicated? survivors’ facilitate survivors’ Audience Where are they? (methods) access to care? access to care? Women

Men

Adults with disabilities

Elderly

Adolescent girls

Adolescent boys

Adolescents with disabilities Children (girls)

Children (boys)

Children with disabilities Community leaders, including women’s groups or wives of powerful men Local community-based organizations (CBOs), services and charities Local Ministry of Health (MoH) officials Traditional health care providers Police departments and other law enforcement officers Teachers/social workers

Religious groups

13 PART 3 Strengthening Community-Based Care

7. Working with facility-based health providers receiving referrals from community health workers

While CHWs 2 and 3 will be trained to provide basic health care for survivors of sexual violence, they will also be trained on when to facilitate referrals to higher level health care as available. Some instances will require immediate referrals from all levels of CHWs (especially CHWs 1 and 2) while others will be conducted primarily by CHW 2s as part of their routine work to provide initial or follow-up care to survivors.

Referrals to facility-based health care made by CHWs

Immediate referral:* Referral upon history taking: Referral upon follow-up care: • Swelling and hardness • If the survivor is an infant • Severe side effects of the abdomen (belly) • Severe bleeding of medicines • Pain in abdomen (belly) • Infected wounds • Signs of STIs that • Severe pain in back, chest, • Open wounds where skin may be a result of arms, legs or head does not come together treatment failure or • Vomiting blood by itself recurrent STI infection • Heavy bleeding from • Leaking urine or feces • Partner testing for vagina/anus • Object in vagina/anus HIV • Heavy bleeding from • Bleeding from vagina/anus • Pregnancy termination if available other parts of the body • Severe pain • Other cases that • Possible object lodged • Any abdominal or CHWs cannot treat in vagina/anus belly pain • Altered mental state • Vaginal bleeding or confusion • Vaginal discharge • Pale, blue, or gray-skinned • HIV testing • In a small child, fast • Tetanus vaccine or difficulty breathing • Hepatitis B vaccine • Unconsciousness

*CHWs will not complete an intake form if immediate referral is made to a health facility and no treatment is provided. The means of referral will differ in each setting and will need to be arranged by the program and the receiving health facility. Depending on the survivor’s condition, an ambulance may be necessary if a vehicle is available at the health facility. Program staff should brief providers from receiving referral facilities about the CHWs’ role in providing care to survivors of sexual violence. Reviewing the one-page caring for survivors flowchart (Module 5 handout for CHWs) as well as the table of CHW interventions (see page 8 of this document) may be good ways to review CHW roles and expectations. More specifically, CHWs will be trained to provide the following treatment for different types of sexual violence:

Activity Sexual assault Anal assault Oral assault Antibiotics to prevent or treat Yes Yes Yes for Gonorrhoea, sexually transmitted infections chlamydia and syphilis No for trichomoniasis Emergency contraception (pills) Yes Yes No to prevent unwanted pregnancy Post-exposure prophylaxis Yes Yes No to prevent HIV Tetanus vaccine Yes Yes No Hepatitis B vaccine Yes Yes Yes 14 CAPACITY BUILDING

Community health workers Getting started

• While EC is typically not necessary for anal assault, given that CHWs will not be asking detailed questions about the assault to determine the risk of sperm leaking into the vagina, the position of the assault, or location of ejaculation; and survivors may not be familiar with their reproductive anatomy, CHWs will be trained to provide care in cases of anal assault in the pilot project. • For oral assault, CHWs will be taught that they do not need to provide presumptive treatment for trichomoniasis. Further, as the risk of HIV transmission is low, PEP is not indicated. The tetanus vaccine will only need to be provided if there are wounds in or around the mouth, or if the survivor has not been vaccinated in 10 years. • While survivors are typically asked whether or not they are using a method of family planning, CHWs will not be asking this question due to the added challenges to determine if EC is warranted, or if any risk of pregnancy exists. As such, in this pilot, EC will be provided to all survivors of reproductive age who have experienced vaginal or anal assault, even if they were using a method of family planning at the time of the assault.

During pilot start-up, the most important form to review with health providers serving as referral points is the intake form. CHWs 2 and 3 will be trained to complete the intake form for every survivor from whom they take a health history, even if the survivor comes after five days of the assault. If the survivor consents to receiving additional services from a health facility, she or he will be provided with a duplicate intake form to take with her or him to see the referral staff. Providers need to trust the information that has been noted on the intake form, so that they do not re-question the survivor for issues that have already been discussed. These include: • The type of assault that the survivor has sustained (vaginal, anal, and/or oral assault) • Whether the survivor has been vaccinated against tetanus • Whether the survivor has been vaccinated against hepatitis B • What treatment the survivor has received from the CHW (EC, PEP, antibiotics for STIs, basic wound care, basic counseling) • What type of health referral the survivor is seeking (HIV testing, vaccinations, advanced wound care, etc.) • What other referrals the survivor has consented to receive

Health providers receiving referrals should ensure they understand the intake form, and know how to contact the CHW for any questions. Further, if appropriate and valid in the setting for legal purposes, the provider can sign the intake form to certify it has been reviewed by an accredited health provider. Health facilities should make sure to keep their own records of any care they give to a survivor at the facility level, similar to protocol for all patients that come to the health facility.

An additional point that can be helpful for health providers is to capitalize on the CHWs’ capacity to offer community-based follow-up to survivors two weeks after the first visit, although preferably after one week. While health facilities should follow existing protocol on providing their own follow-up to survivors if they have been referred to their care, if a provider judges that the survivor’s condition can be best managed by a CHW, the provider can counsel the survivor on issues that s/he can discuss with the CHW as s/he begins the healing process. Providers should take the initiative to work with CHWs to ensure that the survivor receives optimal care as the environment allows, and that she or he does not fall through the cracks.

If the program feels that health providers should attend segments of the CHW training, the most relevant sections are Module 4, Session 4.2, on referring survivors for health care and other services and Module 5 on providing community-based care for survivors of sexual violence.

15 PART 3 Strengthening Community-Based Care

8. Troubleshooting In addition to determining the CHWs’ scope of work in the setting, it is important for the pilot to troubleshoot any potentially negative consequences of community-based care, especially if CHWs are the primary providers of care (CHWs 2 and 3).

Sample troubleshooting matrix:

Example solutions to prevent the consequences Possible action plans for the project Potential Negative Consequences before they arise should they occur The survivor presents with significant trauma that is beyond the CHW’s capability to treat. Agree upon first aid measures and referral protocol via Follow agreed upon protocol for referral to a higher existing and available means within the community. level facility. CHWs should document any referrals on their intake forms. The survivor is at risk of further physical harm or retaliation by the perpetrator(s). If a breach of confidentiality by CHWs is the issue, Discuss and take active protection measures. If breach ensure CHWs are aware of the consequences of not of confidentiality is the issue, program staff should maintaining confidentiality. Agree upon and establish discuss the issue with the CHW. communication channels to address protection concerns, including for relocation of survivors if requested and feasible. A survivor experiences unrelated physical attacks while seeking care from a CHW that she Select a setting with moderate stability to minimize Provide care and protection as feasible. or he would not have otherwise sought had the pilot not been implemented. known risks. CHW refuses to provide post-rape care due to fear of retaliation, beliefs including, for example, Raise awareness among and train CHWs on gender issues Re-evaluate the inclusion of the CHW in this pilot by the inappropriateness of emergency contraception to prevent pregnancy. and the benefits of providing care to survivors, etc., first. discussing the reasons for which care was refused. Train CHWs to also debrief with a supervisor (program staff) Ensure that care is provided to the survivor in a timely and to let the supervisor know about any concerns she or he manner regardless of the CHW’s refusal to provide care. has about providing this care. CHW breaches confidentiality. Only allow CHWs that demonstrate pre-established Re-evaluate the inclusion of the CHW in the project competencies to play a role in managing survivors. by discussing the circumstances under which Emphasize the importance of maintaining confidentiality confidentiality was breached. during CHW trainings. Identify and address any incentives for the CHWs that may lead to breaches in confidentiality. A case becomes public and the community tries to seek official or traditional means of redress, against the Predetermine how best to meet the best interests of Assist the survivor to respect her or his wishes and wishes of the survivor. the survivor in the context of official and traditional ensure her or his protection. Involve respected figures – means of redress. as relevant and appropriate – to conduct damage control in the community.

A survivor requests a medical certificate but a family member or third party finds the document. Review the intake form and predetermine what will be Identify and minimize any immediate risks for the documented for the survivor. Inform the survivor of potential survivor and take action within the limits of the setting. risks to her or his safety if the document is discovered. Documentation kept hidden by the CHW is found or looted. Keep documentation and records minimal with no identifying Identify and minimize any immediate risks for survivors. information of the name, age, sex and village of the survivor. Re-evaluate storage of records to minimize reoccurrence. Perpetrators discover the role of the CHW in providing post-rape care and the physical safety of the CHW Agree upon and establish communication channels to Assist CHWs to address this situation by possibly becomes a concern. address protection concerns. Reinforce the overall role relocating the CHW for a period of time. of CHWs in the community. The community becomes suspicious of the CHW suddenly coming into close contact with a survivor that Predetermine means of follow-up care to monitor and Increase community understanding of the role of may not have had any reason for an encounter. address unintended consequences. CHWs in providing services for primary health care issues. For a particular situation, ensure the safety of the CHW while the issue is resolved. A CHW refuses to continue providing care, having discovered potential risks to her or his family’s safety. Discuss potential risks with the CHW before enabling Ensure that remaining CHWs continue providing care Demand for post-rape care has been created, however, and a survivor has come forth. her or him to assume responsibilities and identify by addressing motivation, etc. responsible ways to relinquish duties. Address any incentive issues for the CHW to maintain motivation. 16 Train multiple CHWs in each site. CAPACITY BUILDING

Community health workers Getting started

8. Troubleshooting In addition to determining the CHWs’ scope of work in the setting, it is important for the pilot to troubleshoot any potentially negative consequences of community-based care, especially if CHWs are the primary providers of care (CHWs 2 and 3).

Sample troubleshooting matrix:

Example solutions to prevent the consequences Possible action plans for the project Potential Negative Consequences before they arise should they occur The survivor presents with significant trauma that is beyond the CHW’s capability to treat. Agree upon first aid measures and referral protocol via Follow agreed upon protocol for referral to a higher existing and available means within the community. level facility. CHWs should document any referrals on their intake forms. The survivor is at risk of further physical harm or retaliation by the perpetrator(s). If a breach of confidentiality by CHWs is the issue, Discuss and take active protection measures. If breach ensure CHWs are aware of the consequences of not of confidentiality is the issue, program staff should maintaining confidentiality. Agree upon and establish discuss the issue with the CHW. communication channels to address protection concerns, including for relocation of survivors if requested and feasible. A survivor experiences unrelated physical attacks while seeking care from a CHW that she Select a setting with moderate stability to minimize Provide care and protection as feasible. or he would not have otherwise sought had the pilot not been implemented. known risks. CHW refuses to provide post-rape care due to fear of retaliation, beliefs including, for example, Raise awareness among and train CHWs on gender issues Re-evaluate the inclusion of the CHW in this pilot by the inappropriateness of emergency contraception to prevent pregnancy. and the benefits of providing care to survivors, etc., first. discussing the reasons for which care was refused. Train CHWs to also debrief with a supervisor (program staff) Ensure that care is provided to the survivor in a timely and to let the supervisor know about any concerns she or he manner regardless of the CHW’s refusal to provide care. has about providing this care. CHW breaches confidentiality. Only allow CHWs that demonstrate pre-established Re-evaluate the inclusion of the CHW in the project competencies to play a role in managing survivors. by discussing the circumstances under which Emphasize the importance of maintaining confidentiality confidentiality was breached. during CHW trainings. Identify and address any incentives for the CHWs that may lead to breaches in confidentiality. A case becomes public and the community tries to seek official or traditional means of redress, against the Predetermine how best to meet the best interests of Assist the survivor to respect her or his wishes and wishes of the survivor. the survivor in the context of official and traditional ensure her or his protection. Involve respected figures – means of redress. as relevant and appropriate – to conduct damage control in the community.

A survivor requests a medical certificate but a family member or third party finds the document. Review the intake form and predetermine what will be Identify and minimize any immediate risks for the documented for the survivor. Inform the survivor of potential survivor and take action within the limits of the setting. risks to her or his safety if the document is discovered. Documentation kept hidden by the CHW is found or looted. Keep documentation and records minimal with no identifying Identify and minimize any immediate risks for survivors. information of the name, age, sex and village of the survivor. Re-evaluate storage of records to minimize reoccurrence. Perpetrators discover the role of the CHW in providing post-rape care and the physical safety of the CHW Agree upon and establish communication channels to Assist CHWs to address this situation by possibly becomes a concern. address protection concerns. Reinforce the overall role relocating the CHW for a period of time. of CHWs in the community. The community becomes suspicious of the CHW suddenly coming into close contact with a survivor that Predetermine means of follow-up care to monitor and Increase community understanding of the role of may not have had any reason for an encounter. address unintended consequences. CHWs in providing services for primary health care issues. For a particular situation, ensure the safety of the CHW while the issue is resolved. A CHW refuses to continue providing care, having discovered potential risks to her or his family’s safety. Discuss potential risks with the CHW before enabling Ensure that remaining CHWs continue providing care Demand for post-rape care has been created, however, and a survivor has come forth. her or him to assume responsibilities and identify by addressing motivation, etc. responsible ways to relinquish duties. Address any incentive issues for the CHW to maintain motivation. Train multiple CHWs in each site. 17 PART 3 Strengthening Community-Based Care

9. Data Collection

Both qualitative and quantitative tools have been developed to assess changes in the extent of reported sexual violence and other forms of GBV. These tools have also been developed to identify bottlenecks in systems strengthening and service accessibility, and to “break the silence” around sexual violence and GBV. Baseline efforts will include identification of the extent to which different community groups identify sexual violence. Changes will be assessed at midline and endline intervals. Tools will also be developed for ongoing collection and review of service access, quality and utilization.

Support will be provided to research and monitoring and evaluation staff for the collection of service data in order to measure potential increases in the number of survivors reporting for services and CHW adherence to various treatment protocols. There will be a focus on documentation to ensure adequate collection of data.

Because of the nature of the project as a pilot project, the following questions will be monitored and evaluated at key intervals over the course of project implementation (for more information, please refer to the technical note for the overall project): • Was the provision of services by CHWs safe (per medical protocol, etc.) and feasible (in terms of CHWs’ ability to maintain confidentiality, ability to garner trust among the community, etc.)? • To what extent did disclosure and uptake of multi-sectoral services for GBV increase in intervention areas? • What are the levels of survivors/participants’ satisfaction with the interventions? • What changes have occurred in related knowledge, attitudes and behaviours among service providers, including CHWs, as a result of the training and intervention?

Suggested indicators to track CHW competencies include: (see following pages)

18 CAPACITY BUILDING

Community health workers Getting started Suggested indicators to track CHW competencies

Indicator Numerator Denominator Sources Type Target % of sexual violence # of sexual Total # of sexual CHW Outcome 100% survivors seeking care at violence survivors violence survivors monitoring a pilot project site who who receive who seek health care form receive package of care for treatment and for sexual violence sexual violence per pilot care in a timely* from CHWs at the protocol manner (1) sites (A) ** # of sexual violence CHW survivors who seek health monitoring Process ------care for sexual violence form from CHWs at the sites (A) # of sexual violence CHW survivors who seek health monitoring Process care for sexual violence from -- -- form -- CHWs at the sites in < 72 hours (to receive PEP) (B) # of sexual violence CHW Process survivors who seek health monitoring care for sexual violence from -- -- form -- CHWs at the sites in < 120 hours (to receive EC) (C) % of sexual violence # of sexual Total # of sexual CHW Process 100% survivors from whom violence survivors violence survivors monitoring informed consent is sought from whom who seek health care form from CHWs informed consent for sexual violence is sought from from CHWs at the CHWs (2) sites (A) % of sexual violence # of sexual Total # of sexual CHW Process 100% survivors who receive STI violence survivors violence survivors monitoring presumptive treatment who receive STI who seek health care form from CHWs per local presumptive for sexual violence protocol treatment from from CHWs at the CHWs per local sites (A) protocol (3) % of sexual violence # of sexual Total # of sexual CHW Process 100% survivors who receive violence survivors violence survivors who monitoring EC < 120 hours from who receive EC seek health care for form CHWs <120 hours from sexual violence from CHWs (4) CHWs at the sites in < 120 hours (C) % of sexual violence # of sexual Total # of sexual CHW Process 100% survivors who receive PEP violence survivors violence survivors monitoring < 72 hours from CHWs who receive PEP who seek health care form <72 hours from for sexual violence CHWs (5) from CHWs at the sites in < 72 hours (B) % of sexual violence # of sexual Total # of sexual CHW Process survivors who receive basic violence survivors violence survivors monitoring wound care (first aid) from who receive basic who seek health care form -- CHWs wound care from for sexual violence CHWs (6) from CHWs at the sites (A)

19 PART 3 Strengthening Community-Based Care

Suggested indicators to track CHW competencies (continued)

Indicator Numerator Denominator Sources Type Target % of sexual violence # of sexual Total # of sexual CHW Process 100% survivors who receive basic violence survivors violence survivors monitoring emotional support from who receive basic who seek health care form CHWs emotional support for sexual violence from CHWs (7) from CHWs at the sites (A) % of sexual violence # of sexual Total # of sexual CHW Process survivors referred by violence survivors violence survivors monitoring CHWs for other medical, for whom a who seek health care form -- psychosocial, protection, referral was made for sexual violence etc. services (where by CHWs (8) from CHWs at the available) sites (A) % of sexual violence # of sexual Total # of sexual CHW 100% survivors seen by a violence survivors violence survivors monitoring Process CHW with whom issues seen by a CHW who seek health care form of personal safety and who receive for sexual violence security are discussed counseling on from CHWs at the personal safety sites (A) and security (9) % of sexual violence # of sexual Total # of sexual CHW Process survivors who request violence survivors violence survivors monitoring a copy of their medical who request who seek health care form -- records using a medical records for sexual violence standardized, minimal form (10) from CHWs at the sites (A) % of sexual violence # of sexual Total # of sexual CHW Process 100% survivors seeking care who violence survivors violence survivors monitoring receive two week follow-up who receive two who seek health care form visit from CHWs week follow-up for sexual violence visit from CHWs from CHWs at the (11) sites (A) % of changes in Baseline, Process knowledge of benefits to midline, seeking care after sexual endline ------violence and attitudes population- towards health-seeking based survey behaviour # of CHWs per 1,000 # of CHWs # of women ages Training Process 2 per 1,000 women ages 15-49 in 15-49 in target roster, local population program target population population organization trained specifically for this population pilot project information % of CHWs who attend # of CHWs who Total # of CHWs who Training Process 100% training that pass the pass attend training roster, post- post-test to start the pilot test scores project

*Timely care refers to medical treatment appropriate at the time the survivor has sought care. If the survivor reports too late for (3) per local STI presumptive treatment protocol (if restrictions apply); (4) for EC, or (5) for PEP, then “timely” care (1) does not include (3), (4) or (5).

**(A) is the total number of survivors that seek any type of health care from a health care worker for sexual violence.

20 CAPACITY BUILDING

Community health workers Getting started

Part III: Preparing for the training

Careful planning is important and should start several weeks before the training.

1. Initial planning: • Establish objectives for the training. • Determine the participants/trainees and establish criteria for participation. • Know the training needs of the participants, especially their literacy levels and expected role in managing survivors of sexual violence in the community. • Develop a budget for the training.

2. Logistics: • Decide the training date and venue that will work for participants, facilitators and other stakeholders. • Determine the cost per participant with regard to food, lodging, transportation and materials. • Reserve the training venue and make it as conducive to learning (i.e. well-lit, good ventilation, limited external noise) as possible.

3. Identification of participants and resource persons: • Ensure attendance of participants by contacting them directly or through letters of invitation. • Follow up with participants to confirm their attendance. • Determine if there is a need for resource persons to handle or facilitate any topics and if so, make a list of possible persons to invite. • Email or send letters to the selected resource persons. Be sure to inform them about the goals and objectives of the training as well as the specifics of what will be expected of them.

4. Preparation and review of the training tool: • Determine the relevant modules and sessions to use in the training. • Review and adapt the methodologies and activities of the sessions as necessary. • Select documents to use based on the training needs of the participants. • Adapt as necessary, photocopy and otherwise obtain any handouts, notebooks, demonstration models or other reference materials for training use and distribution. • Prepare flipchart, markers, pencils, pens and anything else you may need. Prepare materials that are applicable and most suited to the training venue. • Consider and prepare for each module: Module 1

■■ Develop workshop timetable from the schedule on pages 9-13.

■■ If registration forms will be used, have copies ready for participants to fill in as they enter the training.

■■ Have a sign-in sheet and pen on the table at least 30 minutes before the workshop begins.

■■ Arrange participants’ materials on the registration table so participants can easily be given one of each as they register.

■■ Prepare copies of the literate and non-literate pre-tests.

21 PART 3 Strengthening Community-Based Care

Module 2

■■ Print and cut HIV cards annexed to the facilitator’s guide.

Module 3

■■ Know the legal, policy and social barriers for survivors to access health care, especially any or perceived need for mandatory reporting such as a marriage certificate, husband’s permission, a police report, etc.

■■ Know the program’s care for survivors’ protocols to address or overcome the barriers and challenges.

Module 4

■■ Map who is doing work to respond to sexual violence, including referral mechanisms (complete above table on service mapping), and where.

■■ Identify private and safe locations for client interactions.

■■ Know how much basic first aid participants have learned to stabilize persons in life- threatening conditions for referrals (to determine the handouts used).

Module 5

■■ Know participants’ experiences giving medicines accurately and safely (to determine scope of relevant sections).

■■ Learn about standard precaution and infection prevention measures used in the program and adapt handout as necessary.

■■ Understand information storage and handling procedures, including where forms will be stored, who has access, and how information can be sent safely and confidentially to any centralized location as appropriate.

■■ Know and adapt treatment protocol handouts for STI prevention, EC and PEP, as well as the table of weight-based treatment for antibiotics based on the local context. ** (see next page)

■■ Know if and where intrauterine devices are available (to determine whether IUDs will be discussed).

■■ Know if and where referrals are available for tetanus and Hepatitis B vaccines.

■■ Know if pregnancy tests are available and how soon they can detect pregnancies.

■■ Know the legal indications for safe abortion care.

Module 7

■■ Prepare copies of the literate and non-literate post-tests.

■■ Develop clinical assessment schedule for CHWs 2 and 3.

Advanced Module 8

■■ Learn whether a cold chain, tetanus and Hepatitis B injections are available, and whether CHWs can administer injections.

■■ Adapt intake, health history and monitoring forms to note the provision of additional services.

■■ Know and adapt protocol handouts for STI treatment based on the local context.**

■■ Adapt the infection prevention handout according to the program’s protocol.

22 CAPACITY BUILDING

Community health workers Getting started

5. Follow-up • Ensure mentoring of CHWs, supervision and follow-up. • Convene CHWs to meet routinely to discuss challenges and emerging issues. • Follow up with survivors as necessary. • Report information on monitoring and evaluation plans and conduct data analysis.

Additional resources:

1) CHW Training Tool: Facilitators Guide

2) CHW Training Tool: Participants’ Packet

**Determining available drugs in the pilot setting (all tables from Inter-agency Field Manual on Reproductive Health in Humanitarian Settings)

Review the following protocols for STI presumptive treatment, emergency contraception and HIV PEP. Compare with local protocol and available drugs and regimens by circling any drugs that will be used in the pilot setting, and then complete the last column. Always follow local treatment protocols for STIs and use drugs and dosages that are appropriate for children, adolescents and pregnant women.

23 PART 3 Strengthening Community-Based Care

STI presumptive treatment in ADULTS

Local drugs and dosage if different from WHO Protocol7 WHO to be used STI Circle drug used in pilot setting Notes in pilot setting Gonorrhoea cefixime 400 mg orally, single dose or ceftriaxone 125 mg intramuscularly, single dose Chlamydial azithromycin 1 g orally, in a single dose infection (This antibiotic is also active against incubating syphilis (within 30 days of exposure) or doxycycline 100 mg orally, twice daily for 7 days (contraindicated in pregnancy) If the survivor presents Chlamydia azithromycin 1 g orally, in a single dose within 30 days of the infection in (This antibiotic is also active against incubating incident, benzathine pregnant women syphilis (within 30 days of exposure) benzylpenicillin can be or omitted if the treatment erythromycin 500 mg orally, 4 times daily regimen includes for 7 days azithromycin 1 g as or a single dose, which amoxicillin 500 mg orally, 3 times daily is effective against for 7 days incubating syphilis Syphilis benzathine as well as chlamydial benzylpenicillin* 2.4 million IU, infection. If the survivor intramuscularly, once only presents more than 30 (give as two injections in days after the incident, separate sites) azithromycin 2 g as a or single dose is sufficient azithromycin 2 g orally as a single dose presumptive treatment (for treatment of primary, for primary, secondary secondary and early latent and early latent syphilis syphilis of < 2 years duration) of < 2 years duration and (This antibiotic is also active against chlamydial also covers chlamydial infections) infections. Syphilis, patient azithromycin 2 g orally as a single dose allergic to (for treatment of primary, penicillin secondary and early latent syphilis of < 2 years duration) or doxycycline 100 mg orally, twice daily for 7 days (contraindicated in pregnancy) Both azithromycin and doxycycline are active against chlamydial infections

7 IAWG on Reproductive Health in Crises, Inter-agency Field Manual on Reproductive Health in Humanitarian Settings (2010): 28-33.

24 CAPACITY BUILDING

Community health workers Getting started

STI presumptive treatment in ADULTS

Local drugs and dosage if different from WHO Protocol7 WHO to be used STI Circle drug used in pilot setting Notes in pilot setting Syphilis in azithromycin 2 g orally as a single dose pregnant women (for treatment of primary, allergic to secondary and early latent penicillin syphilis of < 2 years duration) or erythromycin 500 mg orally, 4 times daily for 14 days Both azithromycin and erythromycin are also active against chlamydial infections Trichomoniasis metronidazole 2 g orally as a single dose or tinidazole 2 g orally as a single dose or metronidazole 400 or 500 mg orally, 2 times daily for 7 days Avoid metronidazole and tinidazole in the first trimester of pregnancy

7 IAWG on Reproductive Health in Crises, Inter-agency Field Manual on Reproductive Health in Humanitarian Settings (2010): 28-33.

25 PART 3 Strengthening Community-Based Care

STI presumptive treatment in CHILDREN and ADOLESCENTS

Local drugs and dosage if different from WHO to be Weight WHO Protocol used in pilot STI or age Circle drug used in pilot setting Notes setting Gonorrhoea <45 kg ceftriaxone 125 mg intramuscularly, single dose or spectinomycin 40 mg/kg of body weight, intramuscularly (up to a maximum of 2 g), single dose or (if > 6 months) cefixime 8mg/kg of body weight orally, single dose If the survivor >45 kg Treat according to adult protocol presents within Chlamydial <45 kg azithromycin 20 mg/kg orally, single dose 30 days of infection or the incident, erythromycin 50 mg/kg of body weight benzathine daily, orally (up to a maximum penicillin of 2 g), divided into 4 doses, presumptive for 7 days treatment for >12 Treat according to adult protocol syphilis can years be omitted if the treatment >45 kg erythromycin 500 mg orally, 4 times daily regimen includes but <12 for 7 days azithromycin, years or which is effective azithromycin 1 g orally, single dose against incubating Syphilis benzathine syphilis as well penicillin* 50,000 IU/kg IM (up to a as chlamydial maximum of 2.4 million IU), infection. single dose Syphilis, patient erythromycin 50 mg/kg of body weight allergic to daily, orally (up to a maximum penicillin of 2 g), divided into 4 doses, for 14 days Trichomoniasis <12 metronidazole 5 mg/kg of body weight, years orally, 3 times daily for 7 days >12 Treat according to adult protocol years

26 CAPACITY BUILDING

Community health workers Getting started

Emergency contraception

8 Protocol Local drugs and Circle drug used in pilot setting dosage if different, Amount per dose Prescribe Notes to be used in pilot Levonorgestrel 1,500 µg 1 tablet as first dose, Escapelle, Plan B only 0 tablets 12 hours later One-Step, NorLevo 1.5, Vikela, Postinor 1 750 mg 2 tablets as first dose, Levonelle, NorLevo, 0 tablets 12 hours later Plan B, Postinor-2, Vikela 30 µg 50 tablets, 0 tablets Microlut, Microval, 12 hours later Norgeston 37.5 µg 40 tablets, 0 tablets Ovrette 12 hours later Combined EE 100 µg First dose as soon as possible, Yuspe method plus LNG 500 µg same dose 12 hours later EE 50 µg 2 tablets, 2 tablets Eugynon 50, Fertilan, plus LNG 250 µg 12 hours later Neogynon, Noral, Nordiol, or Ovidon, Ovral, Ovran, EE 50 µg Tetragynon/PC-4, Preven, plus NG 500 µg E-Gen-C, Neo-Primovlar 4 EE 30 µg 4 tablets, 4 tablets Lo-Femenal, plus LNG 150 µg 12 hours later Microgynon, Nordete, or Ovral L, Rigevidon EE 30 µg plus NG 300 µg

Recommended two-drug combination therapies for HIV-PEP

Local drugs and Weight WHO Protocol9 dosage if different, or age Circle drug used in pilot setting Prescribe Notes to be used in pilot Adult Combines tablet containing Zidovudine (300 mg) and Lamivudine (150 mg) 1 tablet twice/day 60 tablets (28 days) or or or Zidovudine (ZDV/AZT) 1 tablet twice/day 60 tablets (28 days) 300 mg tablet plus plus plus Lamivudine (3TC) 150 mg tablet 1 tablet twice/day 60 tablets (28 days) Children Zidovudine (ZDV/AZT) syrup* 7.5 ml twice/day = 420 ml (28 days) <2 years 10 mg/ml *Discard a bottle of or 5-9 kg plus syrup 15 days after Lamivudine (3 TC) syrup plus opening 10 mg/ml 2.5 ml twice/day = 120 ml (28 days) Children Zidovudine (ZDV/AZT) 1 capsule 90 capsules 10-19 kg 100 mg capsule three times/day (28 days) plus plus plus Lamivudine (3 TC) 150 mg tablet ½ tablet twice/day 30 tablets (28 days) Children Zidovudine (ZDV/AZT) 2 capsule 120 capsules and 100 mg capsule three times/day (28 days) adolescents plus plus plus 20-39 kg Lamivudine (3 TC) 150 mg tablet 1 tablet twice/day 60 tablets (28 days)

8 IAWG on Reproductive Health in Crises, Inter-agency Field Manual on Reproductive Health in Humanitarian Settings (2010): 28-33. 9 Reproduced and adapted from IAWG, Inter-agency Field Manual on Reproductive Health in Humanitarian Settings (2010): 34. 27 PART 3 Strengthening Community-Based Care

ANNEX 1

Decision-making tool on care and tasks to be undertaken by CHWs

Interventions and considerations

Health education on sexual violence and benefits of seeking care Yes No A. Is health care for survivors of sexual violence available in the setting (through the pilot or otherwise)? If “yes,” intervention A can be offered by CHWs 1, 2 and 3. (See Module 2, Session 2.3)

Recognize survivors of sexual violence when they come forward (passive identification) A. Is health care for survivors of sexual violence available in the setting? If “yes,” intervention A can be offered by CHWs 1, 2 and 3. CHW 1 should refer for health services. (See Module 4)

Actively screen for survivors of sexual violence A. Is there a system to respond to survivors of sexual violence? B. Do CHWs have prior experience and skills in working with survivors? If the answers are “no” to even one, this intervention should not be implemented and CHWs should rely on self-reporting by survivors in the provision of care. This activity should be reserved for skilled and experienced providers.

Provide some basic first aid to stabilize survivors for referrals A. Do CHWs have the capacity to be taught basic first aid? If “yes,” basic first aid can be taught to stabilize survivors until they can reach higher level services. For CHW 1s, this should be at a minimum. (See optional handouts in Module 4, Session 4.2, Section 1.3)

Refer survivors to higher level health staff or the health facility for health care A. Is there a referral system available? If “yes,” this intervention can be undertaken by CHWs 1, 2 and 3. (See Module 4, Session 4.2)

Take a health history A. Will CHWs provide care after taking a history? If “yes,” CHWs 2 and 3 can take a survivor’s history. CHW 1 should not be involved in providing any part of the care from here below. (See Module 5, Session 5.2, Section 2)

28 CAPACITY BUILDING

Community health workers Getting started: Annex 1 – Care and tasks decision-making tool

ANNEX 1 DECISION-MAKING TOOL ON CARE AND TASKS TO BE UNDERTAKEN BY CHWs (continued)

Collect forensic evidence Yes No A. Does capacity exist in the setting for forensic evidence collection (laboratory capacity or chain of evidence capacity)? B. Does capacity exist to use the information collected (ability to use evidence in court)? CHWs 1, 2 and 3 should NOT be collecting forensic evidence even if “yes” to A and B, given the scope of their work and priorities of ensuring health care. However, CHWs 2 and 3 can briefly document general observations on the intake form. (See Module 5, Session 5.1, Section 3 and Session 5.2, Section 2)

Conduct a minimum medical exam (physical and pelvic) A. Are the CHWs providers of last resort in the setting (i.e., no referral to higher level health care is available)? If “no,” CHWs should NOT be conducting the physical or genital exams. CHWs 2 and 3 should be limiting any exam to basic observation and presumptive treatment. Any condition requiring further examination or care should be referred to a higher level facility. If “yes,” CHW 3 (with advanced skills) should only be conducting a physical examination if they cannot provide the particular care otherwise, and only with the survivor’s consent. Any invasive activity should be avoided to the extent possible.

Complete simplified intake form A. Are CHWs literate? B. Can the intake forms be stored securely? If “no” to both, then CHWs should not complete intake forms. If “yes” to both, CHWs 2 and 3 can complete intake forms. However, if “yes” to A but not B, the pilot can possibly have CHWs 2 and 3 complete one monitoring form where all collected information is aggregated. (See Module 5, Session 5.1, Section 3) Note that the intake form does not collect perpetrator information or identifying information about the survivor. This is to minimize security risks for the survivor and CHW, however, it also limits the ability for survivors to pursue legal justice at a later date.

Generate a medical certificate A. Can safety of the documentation be ensured? B. Is there use for this information in the setting? If “yes” to both, CHWs 2 and 3 can provide a copy of the intake form (if used), but only upon request and after discussing any possible security risks with the survivor. (See Module 5, Session 5.2, Section 9.8)

29 PART 3 Strengthening Community-Based Care

ANNEX 1 DECISION-MAKING TOOL ON CARE AND TASKS TO BE UNDERTAKEN BY CHWs (continued)

Provide some basic first aid to treat minor injuries Yes No A. Can the observed wound or condition be treated with basic first aid? If “yes” to A, CHWs 2 and 3 can provide basic first aid. (See Module 5, Session 5.2, Section 6)

Provide other wound care as feasible A. Does the wound require suturing and is higher level care available in the setting (referral)? B. Does the wound require suturing and is higher level care not available in the setting? If “yes” to A, CHWs 2 and 3 should refer to higher level care. If “yes” to B, only CHW 3 should attend to this if they are the provider of last resort, and only if capacity exists for this type of care.

Provide presumptive treatment for STIs, EC for pregnancy prevention and supportive counseling (including psychological first aid and basic emotional support) A. Will supportive supervision for CHWs be available? B. Can the setting adequately procure commodities for treatment? If “yes,” CHWs 2 and 3 can be engaged in this effort. (See Module 5, Session 5.2)

Conduct HIV counseling and testing A. Does the setting have the capacity for HIV testing? If “no,” then this intervention should not be implemented. If “yes,” CHWs 2 and 3 can be engaged in this effort.

Provide PEP A. Will there be higher level health care workers or staff that can monitor CHW initiation of PEP? B. Is HIV prevalence relatively high or are there other reasons to warrant provision of PEP? (A good indicator is to see whether any health facilities in the area routinely provide PEP, or only on a case-by-case basis.) C. Can the setting procure PEP adequately (i.e., will there be problematic supply chain gaps)? If “no” to any of the three, then this intervention should not be implemented. If “yes” to all three, CHW 2 and 3 can be engaged in this effort. (See Module 5, Session 5.2, Section 5)

30 CAPACITY BUILDING

Community health workers Getting started: Annex I – Care and tasks decision-making tool

ANNEX 1 DECISION-MAKING TOOL ON CARE AND TASKS TO BE UNDERTAKEN BY CHWs (continued)

Provide tetanus toxoid and/or Hepatitis B vaccine? Yes No A. Is a cold chain available? B. Can infection prevention standards be met? C. Can CHWs provide injections in the setting (policy or existing experience)? If “no” to any of the three, then this intervention should not be implemented and CHWs 2 and 3 should refer survivors to a health facility. (See Module 5, Session 5.2, Section 8) If “yes” to all of the three, then CHW 3 (with advanced skills) can be engaged in this effort. (See Advanced Module 8, Session 1 and 2)

Provide follow-up care to survivors (2 weeks, 1 week preferable if taking PEP) A. Setting provides enough stability for CHWs to be able to follow-up. B. Referrals to higher level health services and other support services (protection, social support, psychosocial care, etc.) are available to address survivor needs. If “yes” to both, CHWs 2 and 3 can be engaged in this effort. (See Module 5, Session 5.3)

Treat recurring STIs A. Are the CHWs providers of last resort in the setting (i.e., no referral to higher level health care is available). B. Can the setting adequately procure commodities for treatment? If “yes” to both, CHW 3 (with advanced skills) can be engaged in this effort. (See Advanced Module 8, Session 3)

31 PART 3 Strengthening Community-Based Care

Annex II: Reviewing the evidence

Community-based care for survivors of sexual violence is based on task-shifting and task-sharing concepts to empower community health workers to play a critical role in managing survivors of sexual violence. The facility-based response in the 2004 WHO protocol encompasses: • Collecting minimum forensic evidence with the survivor’s consent if capacity exists for its use • Conducting a minimum medical examination with the survivor’s consent • Providing compassionate and confidential treatment that includes: Treatment and referral for life-threatening complications Presumptive treatment for sexually transmitted infections (STIs) Emergency contraception to reduce the risk of pregnancy Care of wounds Supportive counseling Referral to social support and psychosocial counseling services

In addition, comprehensive treatment of sexual violence also includes the provision of: Post-exposure prophylaxis (PEP) to reduce the risk of HIV transmission Tetanus toxoid/Tetanus immunoglobin to prevent tetanus Vaccines to prevent Hepatitis B

While a pilot project undertaken by the Women’s Refugee Commission and partners in Karen State, Burma, managed to examine the feasibility of the community-based model, the model’s safety needs to be further explored. Feasibility was assessed through examining CHW’s ability to comprehend compassionate clinical care and understand confidentiality, including confidentiality during data handling processes. Excess security risks, as well as maintenance of sustainable logistics systems were also examined. However, given the lack of survivor reporting, the safety of CHWs administering the package of post-rape care needs to be further assessed, especially if the model is to include the initiation of PEP for HIV prevention. Additional pilot projects would be useful in this regard.

The following table (beginning on page 34) examines the evidence-base of task-shifting and task-sharing guidance on the interventions pertaining to medical care for sexual violence survivors.

The key to understanding the table is on page 33:

32 CAPACITY BUILDING

Community health workers Getting started: Annex II – Reviewing the evidence

Key10, 11, 12 Level Explanation Referral This level of delivery of interventions refers to hospitals in general. These can be either Level of care where intervention can district hospitals or referral be provided hospitals. Primary Primary care facilities equipped to provide clinical care. Community Community services, through CHWs and outreach workers. Type of health worker Additional job titles Physician clinicians • Specialist medical doctors • Non-specialist medical doctors Non-physician clinicians • Advanced level associate clinicians • Associate clinicians • Medical assistant Type of health workers who can • Nurse practitioners implement intervention Midwives Nurses Auxiliary nurse midwives Auxiliary nurses Lay health workers • Community health workers • Village health worker Pharmacy workers

10 WHO, Essential Interventions, Commodities and Guidelines for Reproductive, Maternal, Newborn and Child Health: A global review of the key interventions related to reproductive, maternal, newborn and child Health (2011). http://www.who.int/pmnch/topics/part_publications/essential_interventions_14_12_2011_reproductive_maternalhealthinterventions.pdf 11 WHO Recommendations: Optimizing Health Worker Roles to Improve Access to Key Maternal and Newborn Health Interventions Through Task Shifting (2012). http://apps.who.int/iris/bitstream/10665/77764/1/9789241504843_eng.pdf 12 IPPF Medical Bulletin: IMAP Statement on Task Sharing in Sexual and Reproductive Health (2013). http://www.ippf.org/system/files/imap_statement_task_sharing.pdf

33 PART 3 Strengthening Community-Based Care

Sexual Violence Interventions

Type of health Level of care where workers who intervention can be can implement Intervention provided intervention Key commodities Practice guidelines, training manuals and evidence Notes pertaining to CHWs Health education on sexual All levels All • IEC materials WHO Recommendations: Optimizing Health Worker Roles to Improve Access to WHO guidance applicable to violence and benefits of Key Maternal and Newborn Health Interventions Through Task Shifting, 2012. reproductive health interventions. seeking care http://apps.who.int/iris/bitstream/10665/77764/1/9789241504843_eng.pdf IASC, Guidelines for Gender-Based Violence Interventions in Humanitarian Settings: Focusing on Prevention of and Response to Sexual Violence in Emergencies, 2005. http://www.humanitarianinfo.org/iasc/pageloader.aspx?page=content-subsidi- tf_gender-gbv Recognition of survivors All levels All None IPPF Medical Bulletin: IMAP Statement on Task Sharing in Sexual and Only if systems are available to (passive identification) Reproductive Health, 2013. http://ippf.org/sites/default/files/imap_statement_task_ respond to identified survivors. sharing.pdf Active screening Not specified in Not specified in None None available. While guidance does not specify, guidance guidance presumably only skilled and experienced providers should be actively screening for survivors, and only if systems are in place for response. Provision of supportive All levels All None IASC, IASC Guidelines on Mental Health and Psychosocial Support in Emergency counseling (including basic Settings, 2007. http://www.who.int/hac/network/interagency/news/iasc_ psychological first aid) guidelines_mental_health_psychososial.pdf Referrals to protection, legal All levels All None IPPF Medical Bulletin: IMAP Statement on Task Sharing in Sexual and support, shelters, psychosocial, Reproductive Health, 2013. http://ippf.org/sites/default/files/imap_statement_task_ mental health and other sharing.pdf services Collection of minimum forensic Not specified in Non-specific, although • Speculum WHO, Guidelines for medico-legal care of victims of sexual violence, 2003. No guidance exists on CHW collection evidence guidance existing guidelines • Set of replacement clothes http://whqlibdoc.who.int/publications/2004/924154628X.pdf of minimum forensic evidence. Utility note “clinicians and • Tape measure for measuring of this intervention is questionable for nurses” (presumably bruises, lacerations, etc. CHWs, given priorities, CHW capacity physician clinicians, and use of information. non-physician clinicians and nurses) Conducting a minimum medical Not specified in Non-specific, although • Speculum WHO, Guidelines for medico-legal care of victims of sexual violence, 2003. No guidance exists on CHWs exam guidance existing guidelines • Gown, cloth or sheet to cover http://whqlibdoc.who.int/publications/2004/924154628X.pdf conducting a minimum medical exam. (Physical and genital exam) note “clinicians and survivor during examination nurses” (presumably physician clinicians, non-physician clinicians and nurses) Provision of basic first aid to All levels All • First aid kit or equivalent International Federation of Red Cross and Red Crescent Societies, IFRC guidance is for laypersons and treat minor injuries • Paracetamol, etc. for pain relief International first aid and resuscitation guidelines 2011, 2011. http://www. volunteers. (burns, bleeding, head and ifrc.org/PageFiles/53459/IFRC%20-International%20first%20aid%20and%20 spinal injury, chest and resuscitation%20guideline%202011.pdf abdomen injuries, injured extremities, wounds and abrasions, dental injuries, eye injuries.)

34 CAPACITY BUILDING

Community health workers Getting started: Annex II – Reviewing the evidence

Type of health Level of care where workers who intervention can be can implement Intervention provided intervention Key commodities Practice guidelines, training manuals and evidence Notes pertaining to CHWs Health education on sexual All levels All • IEC materials WHO Recommendations: Optimizing Health Worker Roles to Improve Access to WHO guidance applicable to violence and benefits of Key Maternal and Newborn Health Interventions Through Task Shifting, 2012. reproductive health interventions. seeking care http://apps.who.int/iris/bitstream/10665/77764/1/9789241504843_eng.pdf IASC, Guidelines for Gender-Based Violence Interventions in Humanitarian Settings: Focusing on Prevention of and Response to Sexual Violence in Emergencies, 2005. http://www.humanitarianinfo.org/iasc/pageloader.aspx?page=content-subsidi- tf_gender-gbv Recognition of survivors All levels All None IPPF Medical Bulletin: IMAP Statement on Task Sharing in Sexual and Only if systems are available to (passive identification) Reproductive Health, 2013. http://ippf.org/sites/default/files/imap_statement_task_ respond to identified survivors. sharing.pdf Active screening Not specified in Not specified in None None available. While guidance does not specify, guidance guidance presumably only skilled and experienced providers should be actively screening for survivors, and only if systems are in place for response. Provision of supportive All levels All None IASC, IASC Guidelines on Mental Health and Psychosocial Support in Emergency counseling (including basic Settings, 2007. http://www.who.int/hac/network/interagency/news/iasc_ psychological first aid) guidelines_mental_health_psychososial.pdf Referrals to protection, legal All levels All None IPPF Medical Bulletin: IMAP Statement on Task Sharing in Sexual and support, shelters, psychosocial, Reproductive Health, 2013. http://ippf.org/sites/default/files/imap_statement_task_ mental health and other sharing.pdf services Collection of minimum forensic Not specified in Non-specific, although • Speculum WHO, Guidelines for medico-legal care of victims of sexual violence, 2003. No guidance exists on CHW collection evidence guidance existing guidelines • Set of replacement clothes http://whqlibdoc.who.int/publications/2004/924154628X.pdf of minimum forensic evidence. Utility note “clinicians and • Tape measure for measuring of this intervention is questionable for nurses” (presumably bruises, lacerations, etc. CHWs, given priorities, CHW capacity physician clinicians, and use of information. non-physician clinicians and nurses) Conducting a minimum medical Not specified in Non-specific, although • Speculum WHO, Guidelines for medico-legal care of victims of sexual violence, 2003. No guidance exists on CHWs exam guidance existing guidelines • Gown, cloth or sheet to cover http://whqlibdoc.who.int/publications/2004/924154628X.pdf conducting a minimum medical exam. (Physical and genital exam) note “clinicians and survivor during examination nurses” (presumably physician clinicians, non-physician clinicians and nurses) Provision of basic first aid to All levels All • First aid kit or equivalent International Federation of Red Cross and Red Crescent Societies, IFRC guidance is for laypersons and treat minor injuries • Paracetamol, etc. for pain relief International first aid and resuscitation guidelines 2011, 2011. http://www. volunteers. (burns, bleeding, head and ifrc.org/PageFiles/53459/IFRC%20-International%20first%20aid%20and%20 spinal injury, chest and resuscitation%20guideline%202011.pdf abdomen injuries, injured extremities, wounds and abrasions, dental injuries, eye injuries.)

35 PART 3 Strengthening Community-Based Care

SEXUAL VIOLENCE INTERVENTIONS (continued)

Type of health Level of care where workers who intervention can be can implement Intervention provided intervention Key commodities Practice guidelines, training manuals and evidence Notes pertaining to CHWs Provision of wound care • Primary Non-specialist medical • Sterile medical instruments for WHO Recommendations: Optimizing Health Worker Roles to Improve Access WHO 2012 recommendations requiring suturing • Referral doctors, advanced repair of tears and suture material to Key Maternal and Newborn Health Interventions Through Task Shifting, 2012. conclude that this task is outside (of minor perineal/genital level associate • Local anesthesia http://apps.who.int/iris/bitstream/10665/77764/1/9789241504843_eng.pdf the competency of this health worker lacerations) clinicians, midwives, • Antibiotics for wound care category. nurses, auxiliary nurse midwives, auxiliary nurse Presumptive treatment for and All levels All • Materials for counseling WHO, Essential Interventions, Commodities and Guidelines for Reproductive, management of • Condoms (male and female) Maternal, Newborn and Child Health: A global review of the key interventions sexually transmitted • Antibiotics in line with essential related to reproductive, maternal, newborn and child health, 2011. http://www. infections (STIs) medicine guidelines who.int/pmnch/topics/part_publications/essential_interventions_14_12_2011_ reproductive_maternalhealthinterventions.pdf WHO, Sexually transmitted and other reproductive tract infections: a guide to essential practice, 2005. http://whqlibdoc.who.int/ publications/2005/9241592656.pdf Provision of emergency All levels All • Emergency contraceptive pills WHO, Essential Interventions, Commodities and Guidelines for Reproductive, contraception • Oral contraceptives (progestin Maternal, Newborn and Child Health: A global review of the key interventions only and combined) related to reproductive, maternal, newborn and child health, 2011. http://www. who.int/pmnch/topics/part_publications/essential_interventions_14_12_2011_ reproductive_maternalhealthinterventions.pdf WHO, Medical eligibility criteria for contraceptive use, 2009. http://whqlibdoc.who.int/publications/2010/9789241563888_eng.pdf WHO, Family Planning: a global handbook for providers, 2011. http://whqlibdoc.who.int/publications/2011/9780978856373_eng.pdf HIV pre-/post-test counseling All levels All • Materials for counseling IPPF Medical Bulletin: IMAP Statement on Task Sharing in Sexual and Reproductive Health, 2013. http://www.ippf.org/resources/publications/IPPF- Medical-Bulletin-January-2013 WHO, Task Shifting: Global Recommendations and Guidelines, 2008. http://www. who.int/healthsystems/TTR-TaskShifting.pdf HIV testing All levels All • HIV test kits IPPF Medical Bulletin: IMAP Statement on Task Sharing in Sexual and CHWs are not advised to request Reproductive Health, 2013. http://ippf.org/sites/default/files/imap_statement_task_ CD4 testing or to take and prepare sharing.pdf blood for a CD4 test. WHO, Task Shifting: Global Recommendations and Guidelines, 2008. http://www. who.int/healthsystems/TTR-TaskShifting.pdf Recommendation of two or • Primary Physician clinicians, None WHO, Task Shifting: Global Recommendations and Guidelines, 2008. http://www. more ARV drug PEP regimens • Referral non-physician who.int/healthsystems/TTR-TaskShifting.pdf clinicians, midwives, nurses

36 CAPACITY BUILDING

Community health workers Getting started: Annex II – Reviewing the evidence

Type of health Level of care where workers who intervention can be can implement Intervention provided intervention Key commodities Practice guidelines, training manuals and evidence Notes pertaining to CHWs Provision of wound care • Primary Non-specialist medical • Sterile medical instruments for WHO Recommendations: Optimizing Health Worker Roles to Improve Access WHO 2012 recommendations requiring suturing • Referral doctors, advanced repair of tears and suture material to Key Maternal and Newborn Health Interventions Through Task Shifting, 2012. conclude that this task is outside (of minor perineal/genital level associate • Local anesthesia http://apps.who.int/iris/bitstream/10665/77764/1/9789241504843_eng.pdf the competency of this health worker lacerations) clinicians, midwives, • Antibiotics for wound care category. nurses, auxiliary nurse midwives, auxiliary nurse Presumptive treatment for and All levels All • Materials for counseling WHO, Essential Interventions, Commodities and Guidelines for Reproductive, management of • Condoms (male and female) Maternal, Newborn and Child Health: A global review of the key interventions sexually transmitted • Antibiotics in line with essential related to reproductive, maternal, newborn and child health, 2011. http://www. infections (STIs) medicine guidelines who.int/pmnch/topics/part_publications/essential_interventions_14_12_2011_ reproductive_maternalhealthinterventions.pdf WHO, Sexually transmitted and other reproductive tract infections: a guide to essential practice, 2005. http://whqlibdoc.who.int/ publications/2005/9241592656.pdf Provision of emergency All levels All • Emergency contraceptive pills WHO, Essential Interventions, Commodities and Guidelines for Reproductive, contraception • Oral contraceptives (progestin Maternal, Newborn and Child Health: A global review of the key interventions only and combined) related to reproductive, maternal, newborn and child health, 2011. http://www. who.int/pmnch/topics/part_publications/essential_interventions_14_12_2011_ reproductive_maternalhealthinterventions.pdf WHO, Medical eligibility criteria for contraceptive use, 2009. http://whqlibdoc.who.int/publications/2010/9789241563888_eng.pdf WHO, Family Planning: a global handbook for providers, 2011. http://whqlibdoc.who.int/publications/2011/9780978856373_eng.pdf HIV pre-/post-test counseling All levels All • Materials for counseling IPPF Medical Bulletin: IMAP Statement on Task Sharing in Sexual and Reproductive Health, 2013. http://www.ippf.org/resources/publications/IPPF- Medical-Bulletin-January-2013 WHO, Task Shifting: Global Recommendations and Guidelines, 2008. http://www. who.int/healthsystems/TTR-TaskShifting.pdf HIV testing All levels All • HIV test kits IPPF Medical Bulletin: IMAP Statement on Task Sharing in Sexual and CHWs are not advised to request Reproductive Health, 2013. http://ippf.org/sites/default/files/imap_statement_task_ CD4 testing or to take and prepare sharing.pdf blood for a CD4 test. WHO, Task Shifting: Global Recommendations and Guidelines, 2008. http://www. who.int/healthsystems/TTR-TaskShifting.pdf Recommendation of two or • Primary Physician clinicians, None WHO, Task Shifting: Global Recommendations and Guidelines, 2008. http://www. more ARV drug PEP regimens • Referral non-physician who.int/healthsystems/TTR-TaskShifting.pdf clinicians, midwives, nurses

37 PART 3 Strengthening Community-Based Care

SEXUAL VIOLENCE INTERVENTIONS (continued)

Type of health Level of care where workers who intervention can be can implement Intervention provided intervention Key commodities Practice guidelines, training manuals and evidence Notes pertaining to CHWs Initiation of two or more ARV • Primary Physician clinicians, • PEP WHO, Essential Interventions, Commodities and Guidelines for Reproductive, While CHWs can provide ARVs, drug PEP regimens • Referral non-physician Maternal, Newborn and Child Health: A global review of the key interventions they are not permitted to initiate clinicians, midwives, related to reproductive, maternal, newborn and child health, 2011. http://www. PEP under current WHO guidance. nurses who.int/pmnch/topics/part_publications/essential_interventions_14_12_2011_ reproductive_maternalhealthinterventions.pdf WHO, Pregnancy, Childbirth, Postpartum and Newborn Care: a guide to essential practice, 2005. http://whqlibdoc.who.int/publications/2006/924159084X_eng.pdf WHO, Rapid advice: use of antiretroviral drugs for treating pregnant women and preventing HIV infection in infants, 2010. www.who.int/hiv/pub/mtct/advice/en/ index.html WHO, Task Shifting: Global Recommendations and Guidelines, 2008. http://www. who.int/healthsystems/TTR-TaskShifting.pdf Provision of counseling and All levels All None WHO, Task Shifting: Global Recommendations and Guidelines, 2008. support for PEP http://www.who.int/healthsystems/TTR-TaskShifting.pdf Provision of Tetanus Toxoid All levels All • Vaccine (TT vaccine) WHO, Essential Interventions, Commodities and Guidelines for Reproductive, Research is available from Maternal, Newborn and Child Health: A global review of the key interventions development contexts on the related to reproductive, maternal, newborn and child health, 2011. http://www. delivery of tetanus toxoid through who.int/pmnch/topics/part_publications/essential_interventions_14_12_2011_ the safe and proper use of the reproductive_maternalhealthinterventions.pdf Uniject device, which has received WHO, Pregnancy, Childbirth, Postpartum and Newborn Care: a guide to essential WHO prequalification. practice, 2005. http://whqlibdoc.who.int/publications/2006/924159084X_eng.pdf Rosaria Quiroga et al, “A prefilled injection device for outreach tetanus immunization by Bolivian traditional birth attendants”, Pan Am J Public Health 4 (1998): 20-25. A. Sutanto et al, “Home delivery of heat-stable vaccines in Indonesia: outreach immunization with a prefilled, single-use injection device”,Bulletin of the World Health Organization, 77 (2) (1999): 119-126. Provision of Hepatitis B vaccine All levels All • Vaccine B.F. Otto et al, “At-birth immunisation against hepatitis B using a novel pre-filled Research is available from immunisation device stored outside the cold chain”, Vaccine 18 (1999): 498-502. development contexts on Hepatitis B vaccines through the safe and proper use of the Uniject device, which has received WHO prequalification. Management of self-limiting All levels All None WHO, Task Shifting: Global Recommendations and Guidelines, 2008. side-effects of ARV drugs in http://www.who.int/healthsystems/TTR-TaskShifting.pdf PEP regimens (follow-up care) Management of severe Not specified in Physician clinicians, None WHO, Task Shifting: Global Recommendations and Guidelines, 2008. toxicities of ARV drugs in guidance, although non-physician http://www.who.int/healthsystems/TTR-TaskShifting.pdf PEP regimens presumably referral. clinicians (follow-up care) Execution and interpretation All levels All • HIV test WHO, Task Shifting: Global Recommendations and Guidelines, 2008. of post-exposure HIV test http://www.who.int/healthsystems/TTR-TaskShifting.pdf (follow-up care)

38 CAPACITY BUILDING

Community health workers Getting started: Annex II – Reviewing the evidence

Type of health Level of care where workers who intervention can be can implement Intervention provided intervention Key commodities Practice guidelines, training manuals and evidence Notes pertaining to CHWs Initiation of two or more ARV • Primary Physician clinicians, • PEP WHO, Essential Interventions, Commodities and Guidelines for Reproductive, While CHWs can provide ARVs, drug PEP regimens • Referral non-physician Maternal, Newborn and Child Health: A global review of the key interventions they are not permitted to initiate clinicians, midwives, related to reproductive, maternal, newborn and child health, 2011. http://www. PEP under current WHO guidance. nurses who.int/pmnch/topics/part_publications/essential_interventions_14_12_2011_ reproductive_maternalhealthinterventions.pdf WHO, Pregnancy, Childbirth, Postpartum and Newborn Care: a guide to essential practice, 2005. http://whqlibdoc.who.int/publications/2006/924159084X_eng.pdf WHO, Rapid advice: use of antiretroviral drugs for treating pregnant women and preventing HIV infection in infants, 2010. www.who.int/hiv/pub/mtct/advice/en/ index.html WHO, Task Shifting: Global Recommendations and Guidelines, 2008. http://www. who.int/healthsystems/TTR-TaskShifting.pdf Provision of counseling and All levels All None WHO, Task Shifting: Global Recommendations and Guidelines, 2008. support for PEP http://www.who.int/healthsystems/TTR-TaskShifting.pdf Provision of Tetanus Toxoid All levels All • Vaccine (TT vaccine) WHO, Essential Interventions, Commodities and Guidelines for Reproductive, Research is available from Maternal, Newborn and Child Health: A global review of the key interventions development contexts on the related to reproductive, maternal, newborn and child health, 2011. http://www. delivery of tetanus toxoid through who.int/pmnch/topics/part_publications/essential_interventions_14_12_2011_ the safe and proper use of the reproductive_maternalhealthinterventions.pdf Uniject device, which has received WHO, Pregnancy, Childbirth, Postpartum and Newborn Care: a guide to essential WHO prequalification. practice, 2005. http://whqlibdoc.who.int/publications/2006/924159084X_eng.pdf Rosaria Quiroga et al, “A prefilled injection device for outreach tetanus immunization by Bolivian traditional birth attendants”, Pan Am J Public Health 4 (1998): 20-25. A. Sutanto et al, “Home delivery of heat-stable vaccines in Indonesia: outreach immunization with a prefilled, single-use injection device”,Bulletin of the World Health Organization, 77 (2) (1999): 119-126. Provision of Hepatitis B vaccine All levels All • Vaccine B.F. Otto et al, “At-birth immunisation against hepatitis B using a novel pre-filled Research is available from immunisation device stored outside the cold chain”, Vaccine 18 (1999): 498-502. development contexts on Hepatitis B vaccines through the safe and proper use of the Uniject device, which has received WHO prequalification. Management of self-limiting All levels All None WHO, Task Shifting: Global Recommendations and Guidelines, 2008. side-effects of ARV drugs in http://www.who.int/healthsystems/TTR-TaskShifting.pdf PEP regimens (follow-up care) Management of severe Not specified in Physician clinicians, None WHO, Task Shifting: Global Recommendations and Guidelines, 2008. toxicities of ARV drugs in guidance, although non-physician http://www.who.int/healthsystems/TTR-TaskShifting.pdf PEP regimens presumably referral. clinicians (follow-up care) Execution and interpretation All levels All • HIV test WHO, Task Shifting: Global Recommendations and Guidelines, 2008. of post-exposure HIV test http://www.who.int/healthsystems/TTR-TaskShifting.pdf (follow-up care)

39 PART 3 Strengthening Community-Based Care

40

PART 3 Strengthening Community-Based Care

Communities Care: Transforming Lives and Preventing Violence © UNICEF, 2014 All rights reserved

ISBN: (pending)

United Nations Children’s Fund Women’s Refugee Commission Programme Division, Child Protection in Emergencies 122 East 42nd Street 3 United Nations Plaza New York, NY 10168-1289 New York, NY 10017 +1.212.551.3115 Email: [email protected] Email: [email protected] Website: www.unicef.org Website: womensrefugeecommission.org

42