El Manual Para el Pueblo (The Manual for the People): a pictorial aid for community health workers to identify surgical conditions

Background: Access to safe, effective, and affordable surgical care is a pressing contemporary public health issue. Deaths from surgically treated conditions exceed those from HIV, tuberculosis, and malaria combined. Community outreach is a potential driver of access to surgical treatment, yet education among community health workers (CHWs) about such conditions is insufficient. Here, we describe the development and testing of a picture-based curriculum—El Manual Para el Pueblo (The Manual for the People)—to help CHWs to identify and refer surgical conditions in a largely illiterate population. Methods: Central American rural multi-ethnic indigenous groups and surgical providers provided context-specific expertise and advice for the development of El Manual Para el Pueblo, established in 2017. During a pilot implementation in July, 2018, the Ministry of Education and a local community leader recruited groups of CHWs, parents in the communities, and groups of students from the Olancho department of Honduras. We assessed participants before and after the teaching programme for situational problem-solving. Participants completed quantitative surveys to measure the efficacy of an accompanying curriculum on the scheme and iconography of the manual; we also collected qualitative data from participants about the utility of the programme for their practice patterns. Findings: The surgical manual includes 13 chapters with 133 different medical and surgical conditions represented. For the surveys, participants used three sample pages of the manual to answer the questions. We included 403 participants; 68% were women and mean age was 26 years. Overall, 245 participants (61%) had scores of 75% or more on the pre-intervention survey and 170 (42%) had scores of 85% or more. Manual understanding and utilisation abilities improved from pre-intervention mean score of 15·37 (SD 3·10) to 15·91 (3·09) post-intervention out of a maximum score of 20 (p