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Training the indigenous nonprofessional: The screening technician
SPECIAL
ARTICLE
Training the indigenous nonprofessional:The screening technician The ever increasing shortage o[ professional health manpower and the skyrocketing costs of medical care necessitate a better utilization of available manpower. This paper presents steps which must be taken to develop new careers. The new career of screening technician is utilized to illustrate each of the steps.
William K. Frankenburg, M.D., "x" Arnold Goldstein, Ph.D., Andr6 Chabot, M.D., M.P.H., Bonnie M. Camp, M.D., Ph.D., and Michael Fitch, Ed.D. DENVER,
QOLO.
B E c A u s ~ of the strain put upon existing health services by rising costs and increasing demands, the development of different means of utilizing available medical care and new ways of providing care has become imperative. T h e poor is one group for whom there is both a need and a national demand for better health care. In the past, medical From the Department of Pediatrics, University oJ Colorado Medical Center, and the Neighborhood Health Program, Denver Department of Health and Hospitals. Supported in part by United States Public Health Service Grant No. CH 00425, the United States Office o[ Economic Opportunity Grant Nos. CG 8720 and CG 8810, and Health, Education and WeI]are--Child and Youth Project No. 624. This paper was presented in part before the Maternal and Child Health "Section of the Ninety-Seventh Annual Meeting of the American Public Health Association in Philadelphia, November 10, 1969. ~Address: Department o[ Pediatrics, University of Colorado Medical Center, 4200 E. Ninth Ave., Denver, Colorado 80220.
Vol, 77, No. 4, pp. 564-570
care for the poor has often been inadequate, intermittent, and limited to times of crisis in spite of the fact that there is a greater incidence of health problems among them. Provision of funds alone wilt not improve heahh services. T h e wide social gulf between the professional suppliers of health care and the hesitancy of the poor to avail themselves of existing facilities make the improvement of such care for the poor very difficult. T h e indigenous nonprofessional health worker, recruited from the poverty neighborhood in which he will serve, is ideally suited to bridge the gap between the skilled professional and the poor, and to help the poor make better use of the existing medical services?, 2 Tile indigenous worker who shares a common ethnic origin, language, religion, and group interest, and is also poor, may be in the best position to ward off the suspicion,
Volume 77 Number 4
distrust, and obsequiousness which too often characterize the attitude of the poor toward professionals of dissimilar background. The indigenous worker, trained to be aware of the health needs and the resources available to the poor, can serve as an educator, interpret needs of the poor to the professionals, and expedite improvement of health services. In addition, the indigenous worker can be trained to carry out some of the jobs that usually are the responsibility of the professionals, who are then freed for other more skilled work. In this way professional costs can be diminished. Moreover, the indigenous worker improves his own position, often becoming an independent contributing member of the community rather than remaining on the welfare rolls. With proper organization of the job and appropriate training, the indigenous worker can be employed to a far greater degree than is presently recognized, as was demonstrated during World War II, when the unemployment rate of the civilian population was reduced to one per cent? The marked successes of the teacher aide, social work aide, family planning worker, and nurse's aide programs, which have relied largely upon the nonprofessionals serving in their own neighborhoods, have demonstrated the feasibility of training nonprofessionals for new careers. I n describing a new career, it is important to make the distinction between a job and a career. Whereas a job is a specific duty or role, the term career is generally considered to be a graded group of jobs within which one can rise in responsibility, prestige, and remuneration. A career also implies permanence; if one working situation is terminated, another will be available. One method of developing a new career is to reallocate work which has been performed by existing categories of workers. The purpose of this paper is to describe one method of selecting, training, and evaluating the performance of indigenous workers as screening technicians. The problems met and the methods used should be applicable to all training programs for indigenous workers.
Training indigenous nonprofessional
5 65
METHOD Selection of the n e w career and the career ladder.
General principles. New careers for the indigenous worker should be in fields which are not likely to be automated out of existence and should provide an opportunity for upward mobility in rank and salary. The h u m a n service fields (such as health, education, and welfare), which presently have manpower shortages of about five million people, are estimated to employ 25 to 35 per cent of the entire labor force. 4 Therefore, the area of health offers an ideal opportunity for new careers. I n developing the new career it is essential to describe the work and to analyze it carefully into its individual components. T h e work description is particularly important in explaining the career to other professionals and nonprofessional personnel who may come into contact with the new careerist. A general awareness of the work description helps to avoid duplication and omissions of health services and thus facilitates coordination of the work with that of other health workers. Evaluation of the various components of the work is essential to the selection of trainees who will be able to acquire the knowledge and skills required. In addition, the work description facilitates the evaluation of performance on the job, both for the trainee and the supervisor. Finally, work descriptions must be written for the various job levels as well as opportunities for advancement in title, responsibility, and pay. Failure to provide opportunities for advancement frequently results in resignation from the program. All t o o often trainees go from one training program to another without advancement. Such movement is not only discouraging to the trainee but also is very costly in terms of time and money spent in training. Application Of principles. Our project was designed to develop a new career in screening preschool youngsters for handicapping conditions involving development, hearing, articulation, and eye function. The shortage of nurses and physicians to carry out these
566
Frankenburg et al.
services pointed to screening as an appropriate new career area. Furthermore, it was anticipated that the indigenously poor would be ideally suited to screen in the homes of the poor who might not take advantage of the screening programs in the clinics. The age span of children screened was from 1 month to 6 years of age. General development was assessed with the Denver Developmental Screening Test. 5 Hearing in children below 2 ~ years of age was assessed with calibrated noise makers by modifying the technique of Hardy and associates, s An audiometer (Ambco Audiometer, Model No. 601D) was utilized to assess the hearing of children from 2 89 to 6 years. Articulation was assessed in children 3 years of age and above with our modification of the Templin Non-Diagnostic Articulation Test. 7 Eye screening was based upon a history of eye problems, general inspection of the eyes, and the following tests: fixation, pupillary reaction to light, cover test, Allen Illiterate Picture Test, s and the Illiterate E Test2 The technicians were selected to work in the health facilities of Denver's Neighborhood Health Program, which is funded from local sources and four major federal grants-Maternal and Infant Care Project, Children and Youth Project, an Office of Economic Opportunity grant, and a Public Health Service grant--and administered by the Denvet Department of Health and Hospitals. The Neighborhood Health Program delivers health care to the needy families of Denver in two health centers and eight satellite health stations. At the present time, approximately 25,000 children are enrolled in the program. Each screening technician is assigned an office in one of the above-mentioned health facilities; some spend part of their time screening in homes located in the poverty target area (frequently their own neighborhoods). The job description for the screening technicians required an ability.to read the manuals, which were written at the seventh grade level; to administer tests to standards of proficiency; to calculate the age of children (which required an ability to perform arith-
The Journal of Pediatrics October 1970
metic at the fourth grade level); to write the results legibly; and to have good rapport with the poor and the fellow health workers. In addition, dependability was essential since many of the children would be scheduled for the screening procedures. A career ladder is being established for the screening technicians. The job gradations vary in title, education, screening experience, responsibility, and pay. The entrance level, which is as a screening aide, has no educational prerequisites. The level of screening technician I is attained upon the successful completion of the training program. Screening technician II is attained after one year's experience as a screening technician I; it also requires a high school diploma or its equivalent. To qualify as a screening technician I I I (supervisor), the technician must have one year's experience as a screening technician II, in addition to satisfactory completion of 9 college credit hours in subjects related to the work. Funds and endorsement. General principles. Prior to the selection and training for new careers, it is essential to have adequate funds and sufficient job openings to assure an opportunity for the new careerist to apply her new skills. All too often a person completing a new training program finds that no job openings exist. The pay scale should be well above the welfare payment levels to minimize the employee's regression to welfare status. If the new job is part of one formerly performed by a professional specialist, it is important to obtain the endorsement of the training program by the organizations representing the specialist prior to the program's initiation. Application of principles. The screening technicians initially were paid from funds of the Neighborhood Health Program. Those screening technicians performing satisfactorily 6 months after entry into the training program are eligible to transfer to Career Service status, which assures them of longterm job security. An advisory committee with respresentatives from the various specialty groups such as speech and hearing societies, medical groups, nursing groups,
Volume 77 Number 4
and the Department of Health was established for the program. This committee has offered an avenue for explaining the program and exchanging ideas with the various groups for further improvement in the training program. Endorsement of the new career and additional employment opportunities have also been requested of the groups through the Advisory Group. Selection procedure. General principles. An ideal selection procedure would make it possible to select only those individuals who can master the knowledge and skills required for the work and who will fulfill all of the facets of the job for an indefinite period of time. Selection of candidates solely on the basis of financial need without regard for abilities is certain to result in failure of some of the trainees to master the skills and knowledge required. Failure of trainees to master the work is not only demoralizing to the trainees but is also uneconomical. The ideal selection process should also thoroughly acquaint work applicants with the career for which they are applying; thorough familiarity reduces the loss of personnel due to misunderstanding of what is entailed in the work. The use of reliable measures of the candidate's skills and knowledge in terms of leal~ing the career can greatly minimize dropouts secondary to lack of ability. Additional selection criteria such as financial need, racioethnic origin, bilingualism, area of residence, age, and sex may be equally important selection factors. One error frequently made by persons selecting career applicants, among the indigenously poor is the selection of those with middle class outlook rather than those with firm roots in their community; the latter may be more effective in working with the poor. Application of principles. Potential applicants for the screening technician positions were selected from nonprofessional persons living in the area serviced by the neighborhood health program and seeking employment at the neighborhood health center. Prior to evaluating the applicants, the work of the technicians was explained and
Training indigenous nonpro[essional
56 7
demonstrated. Candidates were selected on the basis of evaluations made by interviews and tests. The individual interview was designed to evaluate each applicant Oil the basis of financial need, the number of preschool dependents, availability of babysitters, health of candidate and family members, emotional stability, motivation, and maturity. The ability to relate to others was evaluated through group discussions. Each applicant was further evaluated in intelligence (the Shipley Hartford Intelligence Scale), arithmetic skills (simple addition and subtraction calculations similar to those required of the technician), and reading ability (the reading scale of the Wide Range Achievement Test). Of the fifteen people considered for the training program, two were excluded from further consideration because they could not read at the seventh grade level. Training procedure. General principles. The learning skills of the trainees, the number of individuals to be trained at one time, and the frequency of training periods must be considered in planning a sound training program. If one or two persons are to be trained, the training may best consist of tutoring by a professional person. If more than ten people are to be trained, it may be best to utilize written materials and films to minimize the personnel time required to teach and to insure uniformity of standards. The teachers' use of daily lesson plans with specified goals assures continuity, completeness, and efficiency. Periodic evaluations of the trainees' progress in the acquisition of the knowledge and skills make it possible to continue the training at maximum efficiency, to identify the trainee requiring extra help, and to determine when the training program should be terminated. Periodic evaluations are also helpful in letting the trainees know how they are progressing. Prolonged training periods without an opportunity to provide some meaningful service or application of new skills frequently lead to discouragement and withdrawal from the program; it is important to provide the new careerist with opportunities to
5 68
Frankenburg et al.
apply some aspect of his new skills within the first week of training. Application of principles. Since it was anticipated that there would be a large demand for screening technicians locally and nationally, the selection procedure and all of the factual information required by the screening technicians were presented in manuals which were designed and written specifically for the project. The screening manuals were written at the seventh grade reading level; attempts were made to include only information which was relevant to the actual screening procedures. Video tapes were developed to demonstrate the administration and interpretation of the screening procedures; some of the tapes also demonstrated various types of abnormalities that would be encountered during screening. Initially, three screening technicians were trained by professional personnel; thereafter, these three were given the sole responsibility for training five new technicians. One screening procedure was taught at a time. Of the four screening procedures, articulation screening was considered to be the easiest to master and was taught first. Developmental screening, which includes the greatest number of subtests and was considered to be the most difficult to master, was taught last. To become thoroughly :familiar with administering the screening procedure, the trainees first tested each other; when they had achieved proficiency, they evaluated preschool-aged children. Instructors utilized the television camera to film the students screening the children; thus it was possible for the students to observe themselves screening and to enter into critiques of their performances. From the first day the trainees spent the afternoons in pediatric clinics testing actual patients under the direction of one of the screening instructors. All five trainees mastered the four screening procedures in four weeks (articulation in two days, hearing in two d@s, eye in six days, and development in ten days) and spent the fifth week in clinics testing children with the combined four screening procedures. Three days of the sixth week were utilized by professional personnel (pediatrician, audi-
The Journal o[ Pediatrics October 1970
ologist, speech pathologist, psychologist 1 to evaluate the screening proficiency of the trainees. All five trainees met screening proficiency requirements without further training. They obtained interobserver reliability of 90 to 100 per cent with their professional counterparts on ten consecutive children tested with each of the screening procedures. The project staff anticipates that with minor revisions of the training procedure and the use of skilled screening technicians to evaluate screening proficiency, it will be possible for the present screening technicians to fully train twice their number of new trainees in a total of four weeks. T h e cost of personnel for training the screening technicians is therefore nominal. Performance on the job. General principles. Once the new careerist is placed in his new job, it is important to make frequent evaluations of his general working habits and performance. Such evaluations are of utmost importance for the trainees' reassurance and awareness of areas requiring improvement, and also make it possible to identify without undue delay a careerist who is unable to work satisfactorily on the job despite being made aware of substandard performance. In addition, periodic evaluations of working skills are necessary to assure a continued high standard of work.
Application of principles. After the new screening technicians were placed on the job, they were evaluated upon their general working habits in the assigned clinics by professional personnel associated with them. Although the initial adjustment of the new technicians to the work was good, in a few instances counseling regarding attitudes and work habits was necessary. All of the technicians were eager to discuss their evaluations and to improve their performances. Evaluations of screening skill were scheduled three months after the initial training and every six months thereafter and have proven necessary to assure a continued high level of performance. Group meetings. General principles. Placement of persons into new careers is certain to arouse anxieties.
Volume 77 Number 4
The long-term degradation and spiritual depression of poverty make it particularly difficult for the indigenous to assume a career with all of its responsibilities. The purpose of the group meetings is to help the new careerist to effectively adapt to his new role through achieving greater insight into his own feelings and those of others. In addition, these sessions can play a vital role in encouraging the indigenous to effectively adapt to the job requirements rather than giving up and leaving the program. A frequently encountered problem is that of overidentification with professional persons and the professional role. This tendency causes the new careerist to emulate the manner and the approach o f the professional, decreases the effectiveness of the indigenous worker in working with the poor, and may lead to conflict with the professionals and inappropriate service to the clients. As the new careerist adapts in greater degree to habits of punctuality, dependability, and neatness, he may begin to look down upon his poor clients. Awareness of these attitudes and their consequences can greatly aid indigenous workers in adapting to and maintaining effectiveness in their new career. Application of principles. Weekly group meetings with a psychologist have had a significant impact on the technicians' performance. For instance, when the experienced technicians were asked to teach the screening skills to the new technicians, they readily agreed to do so. However, during one of the group meetings it became apparent that they inwardly rejected the assignment. Some of their reluctance was based on the fear that their prestige would be diminished if there were many other screening technicians performing the same duties. Others felt overwhelmed by the responsibility of teaching. Throug h discussions the group members became aware of their added importance if they served as teachers. Through role playing and mutual help as well as staff-sponsored teaching workshops, the technicians had no difficulty with teaching assignments. During t h e past year numerous other topics such as attitudes toward peers and supervisors, personal and family problems, problems of iden-
Training indigenous nonpro[essional
569
tity (feeling themselves to be neither members of the poverty class nor yet of the middle class), and many others relevant to their present lives have been discussed. It is the conviction of the professional staff that these discussions have had a significant impact upon the private lives and careers of the technicians. Furthermore, these sessions have decreased absenteeism and withdrawals from the program and have helped the new careerist to develop new methods of dealing more effectively with difficult situations encountered in everyday life. Success of the program. The technicians. The technicians were asked to express their reactions to the program and the impact of the program upon themselves. Most of them mentioned that the program gave them more responsibility, offered them prestige, and made them more aware of the effect of health problems upon the behavior of children. They also believed that their work was rewarding because they were helping children. Most expressed greater interest in furthering their education and training, as well as advancement in the job. While working as screening aides, one has received her General Education diploma (high school certificate); the other two are actively pursuing studies to obtain the diploma. Some technicians have also expressed an interest in taking necessary college courses to advance up the career ladder. Unfortunately, none have been in a position to save enough money to guard against a loss of income through prolonged illness. Two technicians have sought and obtained educational scholarships for three of their children. To date one technician has been in the program for two years, three for twelve months, and five for six months.
Physicians and nurses working with the technicians. In general, the physicians and nurses working in the neighborhood health program are very positive in their appraisal of the work of the technicians. In fact, several physicians have asked for additional screening technicians. The physicians believe that the technicians are liked and accepted by the parents, although at times there have been minor communication difficulties.
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T h e poor. Perhaps, the greatest success of the program has been that while screening over 3,000 children the technicians have uncovered numerous, previously unsuspected health problems, confirmed by follow-up diagnostic evaluations by professional personnel. Though it is widely recognized that the poor generally fail to take advantage of preventive health care, many parents have requested the technicians to screen their other children and the children of relatives. Such requests demonstrate better than any other that the technicians have reached the "unreachable." CONCLUSION The indigenously poor offer a vast pool of insufficiently used manpower and talent. The challenge is to successfully train these people for careers in which manpower shortages exist now and in the future. Random selection, lack of supervision, and lack of opportunities for advancement all too frequently result in failure and migration to another training program. Often failures on the part of the trainees are the failures of the training programs to meet the needs of the trainees rather than a failure of the trainees themselves. Careful career planning in terms of work selection and description, selection of applicants, training procedures, and personal advancement can make possible a successful training program. The authors have presented an application of the above principles in the training of screening technicians. Through the use of previously trained tech-
The ]ournal o[ Pediatrics October 1970
nicians, it has been possible to keep the personnel training cost down to a nominal sum. Use of similar training programs will help alleviate manpower shortages, provide services previously not possible, and offer opportunities for self-improvement to the indigenous poverty residents. REFERENCES 1. Reiff, R., and Riessman, F.: The indigenous nonprofessional: A strategy of change in community action and community mental health programs, Monograph of the National Institute of Labor Education Mental Health Program. 2. Irelan, L. M.: Low-income life styles, U. S. Dept. of Health, Education, and Welfare Administration, Division of Research, Washington, D. C., 1967, U. S. Government Printing Office, p. 51. 3. Riessman, F.: Two anti-poverty strategies: New careers versus the guaranteed annual income, paper distributed by New Careers Development Center, New York University, January, 1967. 4. Rosen, S. M.: An introduction to new careers, paper presented to Adult Education Summer Conference, University of Wisconsin, Madison, Wisconsin, July 1, 1968. 5. Frankenburg, W. K., and Dodds, J. B.: The Denver Developmental Screening Test, J. PRDIAT. 71: 181, 1967. 6. Hardy, W. G., Brinker, C. H., Frazier, T. M., and Dougherty, A.: Auditory screening of infants, Ann. Otol. 71: 759, 1962. 7. Templin, M. C.: Norms on a screening test of articulation for ages three through eight, J. Speech Hearing Dis. 18: 323, 1953. 8. Allen, H. F.: A new picture series for preschool vision testing, Amer. J. Ophthal. 44: 38, 1957. 9. Preschool vision screening, publication P-253, New York, 1965, National Society for Pre;r of Blindness.
ARTICLE
Training the indigenous nonprofessional:The screening technician The ever increasing shortage o[ professional health manpower and the skyrocketing costs of medical care necessitate a better utilization of available manpower. This paper presents steps which must be taken to develop new careers. The new career of screening technician is utilized to illustrate each of the steps.
William K. Frankenburg, M.D., "x" Arnold Goldstein, Ph.D., Andr6 Chabot, M.D., M.P.H., Bonnie M. Camp, M.D., Ph.D., and Michael Fitch, Ed.D. DENVER,
QOLO.
B E c A u s ~ of the strain put upon existing health services by rising costs and increasing demands, the development of different means of utilizing available medical care and new ways of providing care has become imperative. T h e poor is one group for whom there is both a need and a national demand for better health care. In the past, medical From the Department of Pediatrics, University oJ Colorado Medical Center, and the Neighborhood Health Program, Denver Department of Health and Hospitals. Supported in part by United States Public Health Service Grant No. CH 00425, the United States Office o[ Economic Opportunity Grant Nos. CG 8720 and CG 8810, and Health, Education and WeI]are--Child and Youth Project No. 624. This paper was presented in part before the Maternal and Child Health "Section of the Ninety-Seventh Annual Meeting of the American Public Health Association in Philadelphia, November 10, 1969. ~Address: Department o[ Pediatrics, University of Colorado Medical Center, 4200 E. Ninth Ave., Denver, Colorado 80220.
Vol, 77, No. 4, pp. 564-570
care for the poor has often been inadequate, intermittent, and limited to times of crisis in spite of the fact that there is a greater incidence of health problems among them. Provision of funds alone wilt not improve heahh services. T h e wide social gulf between the professional suppliers of health care and the hesitancy of the poor to avail themselves of existing facilities make the improvement of such care for the poor very difficult. T h e indigenous nonprofessional health worker, recruited from the poverty neighborhood in which he will serve, is ideally suited to bridge the gap between the skilled professional and the poor, and to help the poor make better use of the existing medical services?, 2 Tile indigenous worker who shares a common ethnic origin, language, religion, and group interest, and is also poor, may be in the best position to ward off the suspicion,
Volume 77 Number 4
distrust, and obsequiousness which too often characterize the attitude of the poor toward professionals of dissimilar background. The indigenous worker, trained to be aware of the health needs and the resources available to the poor, can serve as an educator, interpret needs of the poor to the professionals, and expedite improvement of health services. In addition, the indigenous worker can be trained to carry out some of the jobs that usually are the responsibility of the professionals, who are then freed for other more skilled work. In this way professional costs can be diminished. Moreover, the indigenous worker improves his own position, often becoming an independent contributing member of the community rather than remaining on the welfare rolls. With proper organization of the job and appropriate training, the indigenous worker can be employed to a far greater degree than is presently recognized, as was demonstrated during World War II, when the unemployment rate of the civilian population was reduced to one per cent? The marked successes of the teacher aide, social work aide, family planning worker, and nurse's aide programs, which have relied largely upon the nonprofessionals serving in their own neighborhoods, have demonstrated the feasibility of training nonprofessionals for new careers. I n describing a new career, it is important to make the distinction between a job and a career. Whereas a job is a specific duty or role, the term career is generally considered to be a graded group of jobs within which one can rise in responsibility, prestige, and remuneration. A career also implies permanence; if one working situation is terminated, another will be available. One method of developing a new career is to reallocate work which has been performed by existing categories of workers. The purpose of this paper is to describe one method of selecting, training, and evaluating the performance of indigenous workers as screening technicians. The problems met and the methods used should be applicable to all training programs for indigenous workers.
Training indigenous nonprofessional
5 65
METHOD Selection of the n e w career and the career ladder.
General principles. New careers for the indigenous worker should be in fields which are not likely to be automated out of existence and should provide an opportunity for upward mobility in rank and salary. The h u m a n service fields (such as health, education, and welfare), which presently have manpower shortages of about five million people, are estimated to employ 25 to 35 per cent of the entire labor force. 4 Therefore, the area of health offers an ideal opportunity for new careers. I n developing the new career it is essential to describe the work and to analyze it carefully into its individual components. T h e work description is particularly important in explaining the career to other professionals and nonprofessional personnel who may come into contact with the new careerist. A general awareness of the work description helps to avoid duplication and omissions of health services and thus facilitates coordination of the work with that of other health workers. Evaluation of the various components of the work is essential to the selection of trainees who will be able to acquire the knowledge and skills required. In addition, the work description facilitates the evaluation of performance on the job, both for the trainee and the supervisor. Finally, work descriptions must be written for the various job levels as well as opportunities for advancement in title, responsibility, and pay. Failure to provide opportunities for advancement frequently results in resignation from the program. All t o o often trainees go from one training program to another without advancement. Such movement is not only discouraging to the trainee but also is very costly in terms of time and money spent in training. Application Of principles. Our project was designed to develop a new career in screening preschool youngsters for handicapping conditions involving development, hearing, articulation, and eye function. The shortage of nurses and physicians to carry out these
566
Frankenburg et al.
services pointed to screening as an appropriate new career area. Furthermore, it was anticipated that the indigenously poor would be ideally suited to screen in the homes of the poor who might not take advantage of the screening programs in the clinics. The age span of children screened was from 1 month to 6 years of age. General development was assessed with the Denver Developmental Screening Test. 5 Hearing in children below 2 ~ years of age was assessed with calibrated noise makers by modifying the technique of Hardy and associates, s An audiometer (Ambco Audiometer, Model No. 601D) was utilized to assess the hearing of children from 2 89 to 6 years. Articulation was assessed in children 3 years of age and above with our modification of the Templin Non-Diagnostic Articulation Test. 7 Eye screening was based upon a history of eye problems, general inspection of the eyes, and the following tests: fixation, pupillary reaction to light, cover test, Allen Illiterate Picture Test, s and the Illiterate E Test2 The technicians were selected to work in the health facilities of Denver's Neighborhood Health Program, which is funded from local sources and four major federal grants-Maternal and Infant Care Project, Children and Youth Project, an Office of Economic Opportunity grant, and a Public Health Service grant--and administered by the Denvet Department of Health and Hospitals. The Neighborhood Health Program delivers health care to the needy families of Denver in two health centers and eight satellite health stations. At the present time, approximately 25,000 children are enrolled in the program. Each screening technician is assigned an office in one of the above-mentioned health facilities; some spend part of their time screening in homes located in the poverty target area (frequently their own neighborhoods). The job description for the screening technicians required an ability.to read the manuals, which were written at the seventh grade level; to administer tests to standards of proficiency; to calculate the age of children (which required an ability to perform arith-
The Journal of Pediatrics October 1970
metic at the fourth grade level); to write the results legibly; and to have good rapport with the poor and the fellow health workers. In addition, dependability was essential since many of the children would be scheduled for the screening procedures. A career ladder is being established for the screening technicians. The job gradations vary in title, education, screening experience, responsibility, and pay. The entrance level, which is as a screening aide, has no educational prerequisites. The level of screening technician I is attained upon the successful completion of the training program. Screening technician II is attained after one year's experience as a screening technician I; it also requires a high school diploma or its equivalent. To qualify as a screening technician I I I (supervisor), the technician must have one year's experience as a screening technician II, in addition to satisfactory completion of 9 college credit hours in subjects related to the work. Funds and endorsement. General principles. Prior to the selection and training for new careers, it is essential to have adequate funds and sufficient job openings to assure an opportunity for the new careerist to apply her new skills. All too often a person completing a new training program finds that no job openings exist. The pay scale should be well above the welfare payment levels to minimize the employee's regression to welfare status. If the new job is part of one formerly performed by a professional specialist, it is important to obtain the endorsement of the training program by the organizations representing the specialist prior to the program's initiation. Application of principles. The screening technicians initially were paid from funds of the Neighborhood Health Program. Those screening technicians performing satisfactorily 6 months after entry into the training program are eligible to transfer to Career Service status, which assures them of longterm job security. An advisory committee with respresentatives from the various specialty groups such as speech and hearing societies, medical groups, nursing groups,
Volume 77 Number 4
and the Department of Health was established for the program. This committee has offered an avenue for explaining the program and exchanging ideas with the various groups for further improvement in the training program. Endorsement of the new career and additional employment opportunities have also been requested of the groups through the Advisory Group. Selection procedure. General principles. An ideal selection procedure would make it possible to select only those individuals who can master the knowledge and skills required for the work and who will fulfill all of the facets of the job for an indefinite period of time. Selection of candidates solely on the basis of financial need without regard for abilities is certain to result in failure of some of the trainees to master the skills and knowledge required. Failure of trainees to master the work is not only demoralizing to the trainees but is also uneconomical. The ideal selection process should also thoroughly acquaint work applicants with the career for which they are applying; thorough familiarity reduces the loss of personnel due to misunderstanding of what is entailed in the work. The use of reliable measures of the candidate's skills and knowledge in terms of leal~ing the career can greatly minimize dropouts secondary to lack of ability. Additional selection criteria such as financial need, racioethnic origin, bilingualism, area of residence, age, and sex may be equally important selection factors. One error frequently made by persons selecting career applicants, among the indigenously poor is the selection of those with middle class outlook rather than those with firm roots in their community; the latter may be more effective in working with the poor. Application of principles. Potential applicants for the screening technician positions were selected from nonprofessional persons living in the area serviced by the neighborhood health program and seeking employment at the neighborhood health center. Prior to evaluating the applicants, the work of the technicians was explained and
Training indigenous nonpro[essional
56 7
demonstrated. Candidates were selected on the basis of evaluations made by interviews and tests. The individual interview was designed to evaluate each applicant Oil the basis of financial need, the number of preschool dependents, availability of babysitters, health of candidate and family members, emotional stability, motivation, and maturity. The ability to relate to others was evaluated through group discussions. Each applicant was further evaluated in intelligence (the Shipley Hartford Intelligence Scale), arithmetic skills (simple addition and subtraction calculations similar to those required of the technician), and reading ability (the reading scale of the Wide Range Achievement Test). Of the fifteen people considered for the training program, two were excluded from further consideration because they could not read at the seventh grade level. Training procedure. General principles. The learning skills of the trainees, the number of individuals to be trained at one time, and the frequency of training periods must be considered in planning a sound training program. If one or two persons are to be trained, the training may best consist of tutoring by a professional person. If more than ten people are to be trained, it may be best to utilize written materials and films to minimize the personnel time required to teach and to insure uniformity of standards. The teachers' use of daily lesson plans with specified goals assures continuity, completeness, and efficiency. Periodic evaluations of the trainees' progress in the acquisition of the knowledge and skills make it possible to continue the training at maximum efficiency, to identify the trainee requiring extra help, and to determine when the training program should be terminated. Periodic evaluations are also helpful in letting the trainees know how they are progressing. Prolonged training periods without an opportunity to provide some meaningful service or application of new skills frequently lead to discouragement and withdrawal from the program; it is important to provide the new careerist with opportunities to
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apply some aspect of his new skills within the first week of training. Application of principles. Since it was anticipated that there would be a large demand for screening technicians locally and nationally, the selection procedure and all of the factual information required by the screening technicians were presented in manuals which were designed and written specifically for the project. The screening manuals were written at the seventh grade reading level; attempts were made to include only information which was relevant to the actual screening procedures. Video tapes were developed to demonstrate the administration and interpretation of the screening procedures; some of the tapes also demonstrated various types of abnormalities that would be encountered during screening. Initially, three screening technicians were trained by professional personnel; thereafter, these three were given the sole responsibility for training five new technicians. One screening procedure was taught at a time. Of the four screening procedures, articulation screening was considered to be the easiest to master and was taught first. Developmental screening, which includes the greatest number of subtests and was considered to be the most difficult to master, was taught last. To become thoroughly :familiar with administering the screening procedure, the trainees first tested each other; when they had achieved proficiency, they evaluated preschool-aged children. Instructors utilized the television camera to film the students screening the children; thus it was possible for the students to observe themselves screening and to enter into critiques of their performances. From the first day the trainees spent the afternoons in pediatric clinics testing actual patients under the direction of one of the screening instructors. All five trainees mastered the four screening procedures in four weeks (articulation in two days, hearing in two d@s, eye in six days, and development in ten days) and spent the fifth week in clinics testing children with the combined four screening procedures. Three days of the sixth week were utilized by professional personnel (pediatrician, audi-
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ologist, speech pathologist, psychologist 1 to evaluate the screening proficiency of the trainees. All five trainees met screening proficiency requirements without further training. They obtained interobserver reliability of 90 to 100 per cent with their professional counterparts on ten consecutive children tested with each of the screening procedures. The project staff anticipates that with minor revisions of the training procedure and the use of skilled screening technicians to evaluate screening proficiency, it will be possible for the present screening technicians to fully train twice their number of new trainees in a total of four weeks. T h e cost of personnel for training the screening technicians is therefore nominal. Performance on the job. General principles. Once the new careerist is placed in his new job, it is important to make frequent evaluations of his general working habits and performance. Such evaluations are of utmost importance for the trainees' reassurance and awareness of areas requiring improvement, and also make it possible to identify without undue delay a careerist who is unable to work satisfactorily on the job despite being made aware of substandard performance. In addition, periodic evaluations of working skills are necessary to assure a continued high standard of work.
Application of principles. After the new screening technicians were placed on the job, they were evaluated upon their general working habits in the assigned clinics by professional personnel associated with them. Although the initial adjustment of the new technicians to the work was good, in a few instances counseling regarding attitudes and work habits was necessary. All of the technicians were eager to discuss their evaluations and to improve their performances. Evaluations of screening skill were scheduled three months after the initial training and every six months thereafter and have proven necessary to assure a continued high level of performance. Group meetings. General principles. Placement of persons into new careers is certain to arouse anxieties.
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The long-term degradation and spiritual depression of poverty make it particularly difficult for the indigenous to assume a career with all of its responsibilities. The purpose of the group meetings is to help the new careerist to effectively adapt to his new role through achieving greater insight into his own feelings and those of others. In addition, these sessions can play a vital role in encouraging the indigenous to effectively adapt to the job requirements rather than giving up and leaving the program. A frequently encountered problem is that of overidentification with professional persons and the professional role. This tendency causes the new careerist to emulate the manner and the approach o f the professional, decreases the effectiveness of the indigenous worker in working with the poor, and may lead to conflict with the professionals and inappropriate service to the clients. As the new careerist adapts in greater degree to habits of punctuality, dependability, and neatness, he may begin to look down upon his poor clients. Awareness of these attitudes and their consequences can greatly aid indigenous workers in adapting to and maintaining effectiveness in their new career. Application of principles. Weekly group meetings with a psychologist have had a significant impact on the technicians' performance. For instance, when the experienced technicians were asked to teach the screening skills to the new technicians, they readily agreed to do so. However, during one of the group meetings it became apparent that they inwardly rejected the assignment. Some of their reluctance was based on the fear that their prestige would be diminished if there were many other screening technicians performing the same duties. Others felt overwhelmed by the responsibility of teaching. Throug h discussions the group members became aware of their added importance if they served as teachers. Through role playing and mutual help as well as staff-sponsored teaching workshops, the technicians had no difficulty with teaching assignments. During t h e past year numerous other topics such as attitudes toward peers and supervisors, personal and family problems, problems of iden-
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tity (feeling themselves to be neither members of the poverty class nor yet of the middle class), and many others relevant to their present lives have been discussed. It is the conviction of the professional staff that these discussions have had a significant impact upon the private lives and careers of the technicians. Furthermore, these sessions have decreased absenteeism and withdrawals from the program and have helped the new careerist to develop new methods of dealing more effectively with difficult situations encountered in everyday life. Success of the program. The technicians. The technicians were asked to express their reactions to the program and the impact of the program upon themselves. Most of them mentioned that the program gave them more responsibility, offered them prestige, and made them more aware of the effect of health problems upon the behavior of children. They also believed that their work was rewarding because they were helping children. Most expressed greater interest in furthering their education and training, as well as advancement in the job. While working as screening aides, one has received her General Education diploma (high school certificate); the other two are actively pursuing studies to obtain the diploma. Some technicians have also expressed an interest in taking necessary college courses to advance up the career ladder. Unfortunately, none have been in a position to save enough money to guard against a loss of income through prolonged illness. Two technicians have sought and obtained educational scholarships for three of their children. To date one technician has been in the program for two years, three for twelve months, and five for six months.
Physicians and nurses working with the technicians. In general, the physicians and nurses working in the neighborhood health program are very positive in their appraisal of the work of the technicians. In fact, several physicians have asked for additional screening technicians. The physicians believe that the technicians are liked and accepted by the parents, although at times there have been minor communication difficulties.
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T h e poor. Perhaps, the greatest success of the program has been that while screening over 3,000 children the technicians have uncovered numerous, previously unsuspected health problems, confirmed by follow-up diagnostic evaluations by professional personnel. Though it is widely recognized that the poor generally fail to take advantage of preventive health care, many parents have requested the technicians to screen their other children and the children of relatives. Such requests demonstrate better than any other that the technicians have reached the "unreachable." CONCLUSION The indigenously poor offer a vast pool of insufficiently used manpower and talent. The challenge is to successfully train these people for careers in which manpower shortages exist now and in the future. Random selection, lack of supervision, and lack of opportunities for advancement all too frequently result in failure and migration to another training program. Often failures on the part of the trainees are the failures of the training programs to meet the needs of the trainees rather than a failure of the trainees themselves. Careful career planning in terms of work selection and description, selection of applicants, training procedures, and personal advancement can make possible a successful training program. The authors have presented an application of the above principles in the training of screening technicians. Through the use of previously trained tech-
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nicians, it has been possible to keep the personnel training cost down to a nominal sum. Use of similar training programs will help alleviate manpower shortages, provide services previously not possible, and offer opportunities for self-improvement to the indigenous poverty residents. REFERENCES 1. Reiff, R., and Riessman, F.: The indigenous nonprofessional: A strategy of change in community action and community mental health programs, Monograph of the National Institute of Labor Education Mental Health Program. 2. Irelan, L. M.: Low-income life styles, U. S. Dept. of Health, Education, and Welfare Administration, Division of Research, Washington, D. C., 1967, U. S. Government Printing Office, p. 51. 3. Riessman, F.: Two anti-poverty strategies: New careers versus the guaranteed annual income, paper distributed by New Careers Development Center, New York University, January, 1967. 4. Rosen, S. M.: An introduction to new careers, paper presented to Adult Education Summer Conference, University of Wisconsin, Madison, Wisconsin, July 1, 1968. 5. Frankenburg, W. K., and Dodds, J. B.: The Denver Developmental Screening Test, J. PRDIAT. 71: 181, 1967. 6. Hardy, W. G., Brinker, C. H., Frazier, T. M., and Dougherty, A.: Auditory screening of infants, Ann. Otol. 71: 759, 1962. 7. Templin, M. C.: Norms on a screening test of articulation for ages three through eight, J. Speech Hearing Dis. 18: 323, 1953. 8. Allen, H. F.: A new picture series for preschool vision testing, Amer. J. Ophthal. 44: 38, 1957. 9. Preschool vision screening, publication P-253, New York, 1965, National Society for Pre;r of Blindness.