Non-Randomized Pre-Post Testing to Evaluate Knowledge of Community Health Workers on Chronic Diseases After Asynchronous Online Training

Abstract

Background:

Community Health Worker (CHW) training started to be conducted mostly virtually during the 2020 COVID-19 pandemic when there was increased need for CHWs and a restriction on in-person gathering. Synchronous virtual training has become the norm for initial training with a need for continuous training to further improve capabilities found in the literature. In this paper we explore conducting online continuing education on chronic diseases asynchronously for CHWs.

Methods:

CHWs in Maryland were sent information on availability of online training for chronic diseases through the network of Area Health Education Centers (AHEC) in the state. It was a convenient sample. Pre-post testing was used to evaluate a CHW online training module for 3 chronic diseases delivered asynchronously. The training used slides developed for virtual synchronous training which had been delivered earlier, and the online training opened to CHWs in Maryland from March 31st to June 20th 2025. The trainees were given a pre-test before each module and a post-training test.

Results:

The pre-test score average were 78.8%, 80%, and 82% for the hypertension, cholesterol, and diabetes modules respectively and the post-test score average was 89.9%. The post-training average test score was statistically significantly higher than the pre-test scores for each of the modules. Each of the training module pre-test scores were not statistically significantly different from each other.

Discussion:

Virtual training of CHWs is becoming the norm, starting during the COVID-19 pandemic to train CHWs under the pervading no contact limitations in place, without analysis for whether such mode of delivery improved knowledge and skills. Studies have started to indicate that virtual training adequately improves knowledge of CHWs, and in this study we delivered an asynchronous continuing education training on chronic diseases that CHWs in the field could take on their own time. We found improved post-training knowledge on chronic diseases. Having access to online asynchronous learning means CHWs can continue to have further training that they can take at their own pace to improve their ability to serve their clients effectively, without having to travel out of their communities for such training.

Introduction

Community Health Workers (CHWs) have become cornerstone in improving health outcomes in low-income communities around the world. As health workers trained on health issues of their local area and community context, they are especially valuable for improving health outcomes in their communities. ¹ CHWs are at the frontline of locally focused health improvement and enhancing their education is essential to their ability to assist community members improve their health status. CHWs have been found to be particularly effective in managing chronic diseases such as diabetes, hypertension, and cardiovascular disease.^2-7 McAtee et al, ⁸ assigned hypertension, high cholesterol, and diabetes, patients to CHWs, and found that they helped improve patients’ blood pressure readings and cholesterol levels and HBA_1c and that the patients also reported more confidence in managing their disease conditions with CHW intervention. In addition, engaging Community Health Workers in cardiovascular disease prevention and type 2 diabetes management is cost effective. ⁹ Smith and Washburn ¹⁰ found that CHWs assigned to chronic disease patients effectively helped them reduce weight, HbA1c, and blood pressure, significantly over a 3-year period.

The training duration, content and scope of work of CHWs varies around the world but is usually 2 to 6 months. ¹¹ Given the short duration of most trainings, continuing education for CHWs has been recognized to be a way to assist in providing additional knowledge and professionalization.^11-14 CHWs can be trained to take on more roles in health care and public health using continuing education to increase knowledge and skills. A survey by Dunn et al ¹³ of CHW employers found that the order of diseases employers had CHWs work on was Diabetes and Hypertension as number 1 and 2 and heart disease was number 5, after Mental/Behavioral Health and Obesity. A survey of CHWs in Florida found that chronic diseases was the number 1 topic CHWs noted that they wanted training on, ¹⁵ and in a survey of CHWs at a national conference, the CHWs ranked getting additional training as the top factor they valued most on their career path. ¹⁶ When training has been provided it has been found to be effective in improving knowledge of CHWs.^17-22 A literature review paper published before the COVID-19 pandemic, discussed that digital technology can be used for training of CHWs and would improve their health literacy especially on chronic diseases such as diabetes and hypertension, which can be combined because of the similarity in risk factors. ²³ Pre-post testing is classically used in education to measure improved knowledge after an educational intervention and has been used to evaluate CHW knowledge after trainings with several studies indicating increased knowledge post training.^24-32 There are limitations to the pre-post design in that it does not take into account other sources of bias which could affect how individuals perform in the tests but it is widely used as a means of evaluating the effectiveness of an educational intervention. Porterfield et al, ³³ found increases in post-training knowledge for a foundational course for CHW delivered virtually but did not report statistical evaluation and they recommended further evaluation of continuing education training focused on chronic diseases for CHWs. A virtual training on diabetes prevention and management using 3D and animation, found an increase in knowledge in the pre-post analyses and the participants in the virtual training were as satisfied with the training as were people that did in-person training. ³⁴ In this study we evaluated pre-post knowledge on chronic non-communicable diseases (coronary artery disease, diabetes, and hypertension) after online asynchronous training modules taken by CHWs in the state of Maryland, USA.

Materials and Methods

The PowerPoint slides from synchronous trainings carried out in 2024 were turned into online self-directed asynchronous trainings with voice over provided by the trainer from the notes and scripts she used for the live synchronous training. The synchronous training were 3-h long and were on 3 chronic diseases, namely hypertension, cholesterol/coronary heart disease, and diabetes with each training carried out on 3 different days. The 2024/2025 synchronous and asynchronous modules included content from earlier modules on CHW continuing education approved by the Maryland Department of Health, with contributions from the training staff and MPH student interns of the training organization. All content was based on American Heart Association guidelines. The final slides were reviewed and approved by the training organization’s Medical Director and the Maryland Department of Health.

The online modules were opened on March 31, 2025, and closed on June 20, 2025, for CHWs in Maryland. The training organization, the Central Maryland Area Health Educaton Center reached out to everyone in its database who had gone through CHW training with the organization over the past 6 years and to other Health Education Area Centers across the state to inform CHWs about the availability of the online training. This was a convenient sampling of CHWs across the state. There was no a priori sample size calculation, and the approximately 3 months availability of the training online was based on the timeline to report findings to the funding agency. There were 3 modules for online training to align with the synchronous training of hypertension, cholesterol and heart disease, and diabetes and the trainings were ordered as listed when opened by trainees. The trainees would read the slides and listen to the voice overs and move to the next slide at their own pace or could move back to return to previous slides. After entering registration information for the asynchronous online training, each participant could start with the pretest for hypertension and then move to the training slides, then take the post-test, then move on to the pretest for cholesterol and heart disease and then the to the slides and then do the post-test, then move to the pretest for diabetes and so on. Because the topics are inter-related, the post-training test was the same for each module. Individuals could choose to skip a module and move to another module without taking the pretest for the skipped module. There were 72 slides for hypertension including a slide with a link to how to accurately measure blood pressure and 2 citation slides. For cholesterol and heart disease, there were 68 slides including 1 with a link to the American Heart Association website on managing cholesterol levels and 2 citation slides. There were 66 diabetes slides and 4 slides of citations. No test was compulsory and CHWs could decide whether to take or not take a pre-test or post-test and the post-training test was done anonymously so an individual’s test score could not be identified to them or their pretest score. While this created anonymity and allowed trainees to be comfortable taking the post-test, we could not carry out paired analyses of the results because of this design. The answer to each question for the pretests and post-tests was captured in an excel spreadsheet which was then graded by the first author. Our hypothesis was that training of CHWs on chronic diseases virtually and asynchronously will increase their post training knowledge of chronic diseases. We used the pre-post testing design as this is the standard for evaluating the immediate impact of educational interventions, but we also note that external factors we did not control in our analyses may influence pre-post testing results. We carried out one-tailed t-test for equal variances to determine if the post-training test scores were statistically significantly higher than the pre-training test scores for each chronic disease module. Statistical analysis was carried out in Excel.

Results

Table 1 shows the summary registration information entered by people taking the online training, including the number of people who took each pre training module test. Figure 1 is a bar chart of the pre-test average score per module and the post-test average was 89.9% with 39 people taking the post-test. The post-test score was significantly higher than each of the module pre-test training scores (P = .01 for hypertension; P = .02 for cholesterol; and P = .04 for diabetes) using a 1-tailed t-test for each comparison. Each pretest score was not significantly different from the other (hypertension vs cholesterol P = .41; hypertension vs diabetes P = .27; and cholesterol vs diabetes P = .34).

Table 1.

Information on Online Training Modules.

Trainee information	Hypertension	Cholesterol and heart disease	Diabetes
Number of pretest evaluations	35	23	25
Average age	47.4	41.0	42.9
Race
White	3	2	1
Black/African American	29	16	21
Hispanic/Asian	3	5	3
Gender
Male	5	2	2
Female	25	21	23
Work setting
Rural	12	6	9
Primary care	10	8	10
Number certified in MD as CHW	21	9	14
Pretest score average	78.8%	80.0%	82.0%

Figure 1.

Bar chart showing pre-training score for each module and the score for the post-training test.

Discussion

Virtual training of CHWs started during COVID-19 as a necessity under the pervading limited contact situation of the pandemic, without formal evaluation of their effectiveness, but studies have now begun to show that such training improve knowledge. Our result show concordance with other research that indicate CHW knowledge on chronic diseases can be improved by online training, and we carried out our training asynchronously allowing CHWs to pace themselves and manage their time in taking the training. The improved pretest scoring mean observed with each module, follows how the training was ordered online, indicating that most people probably took the training in the order it was listed and improved their knowledge based on the information they got from the previous module although comparison between the module scores was not statistically significant. Given the wide disease focus areas CHWs work in and the variety of work situations they are deployed in, it can be assumed that CHWs have varying degrees of knowledge about the chronic diseases that would affect their test scores. We were not able to control for these varying knowledge levels given the implementation design to make post-testing scores anonymous.

While CHW certification standards vary by state in the US, there may be a need for national continuing education standards and training, that helps upskill CHWs for different disease focus areas or for specific skills. This will help CHWs improve their skillset and knowledge while remaining in their local area, especially for CHWs who do not want to go back to school for degrees. A global CHW continuing education training module for low- and middle-income countries offered for download to smartphones and tablets was found to be effective in helping CHWs improve on the services they deliver to the communities they serve and such a training that is downloadable nationally for CHWs to learn on their own time should be evaluated in the US. ³⁵ As CHW roles expand to fill out the gaps in the trained health workforce available, additional training will make it easy for individuals to contribute more to supporting healthcare and public health.

Limitations

A major limitation of this study was the fact that the post-training evaluations were anonymous to make CHWs comfortable taking it, but this led to the inability to carry out paired t-test which is statistically the best approach for pre-post testing because it takes into account the individual knowledge level that preceded taking the test. We could not identify who the 39 individuals who took the post-test were, and after which module they took the post-test, but the low number of people who took the post-test is probably because after taking the post-test after the first module, many individuals chose not to take the post-test after the other modules. The short deployment period of the modules for less than 3 months also limited the number of CHWs who accessed the training. The short deployment period of less than 3 months was due to end of the funding cycle and the need to report results to the funder, but it could have limited the generalizability of our results.

Conclusions

Given the expanding accessibility to digital tools worldwide, online training of CHWs globally is feasible and can help improve and standardize CHW knowledge especially for those working in remote areas, and areas with limited accessibility to formal healthcare personnel. There is a need for nationally standardized training for CHWs, and global standardization of CHW knowledge and skills, to ensure service quality across the world, and such standardized training can feasibly be delivered digitally. Lack of adequate number of formally trained health professionals is a global problem, and using CHWs to support healthcare delivery is essential for reaching universal health access. The current emphasis on higher level trained health professionals only increases the health access gap and does not improve it, while training CHWs online remotely as we have demonstrated, will keep CHWs in their local areas where they can continue to provide service to those underserved with healthcare, while also improving their skills and knowledge. The COVID-19 pandemic resulted in wider use of online resources for teaching and training, and the pandemic also resulted in more deployment of CHWs and there is an opportunity to keep the momentum on both going.^36,37 The use of online training for CHWs should not be lost post-pandemic, but be further enhanced as a way to prepare for the next pandemic and to manage chronic diseases, and other localized health challenges. Further studies carried out under real world conditions are needed to evaluate the practicalities of deploying CHW training at scale, nationally and globally, for improved health access for marginalized communities.