Using Ethnographic Research to Strengthen Local CHW Programs
Melissa Mayer, MPH Candidate
“To build productive partnerships, health institutions and donors that recruit and deploy CHWs need to know where individuals within these ranks are coming from and where they want to go, morally, socially, and economically. Paying attention to the life histories of CHWs is also an important part of recognizing that CHWs are actors who could play a bigger role in policy change and implementation.”
Health institutions that work with CHWs need to understand the histories of the individuals with whom they work and the hopes of these individuals, “morally, socially, and economically.” Conducting local ethnographic research can promote positive working relationships between CHWs, their host agencies, and communities receiving services, making those programs more effective and sustainable. This research can help program administrators involve CHWs in joint decision-making and provide appropriate compensation. Understanding why CHWs are motivated to do the work can ensure that CHWs have the opportunities and support to transform the health of their communities.
Kenneth Maes and colleagues conducted ethnographic research to explore three main areas of inquiry. First, they wanted to explore how the life experiences of CHWs influence their motivations to address health and economic challenges. Second, they explored relationships between CHWs and recipients of their services, especially where recipients were in positions of greater economic or social marginalization than CHWs. Finally, they explored participation of multiple stakeholders (i.e., policymakers, donors, and CHWs) in policy formation surrounding CHWs.
The team conducted observations and interviews with CHWs, policymakers, and program implementers in three countries: Ethiopia, Pakistan, and Mozambique. In Ethiopia, research focused on volunteer CHWs specializing in HIV/AIDS care and treatment support. In Mozambique, research focused on volunteer CHWs working within HIV/AIDS treatment programs. In Pakistan, research focused on Lady Health Workers (LHWs) employed by the health department, who provide a wide range of services, such as family planning education and tuberculosis treatment support.
CHWs are Motivated by Good Jobs and Positive Relationships
In their discussions with CHWs, investigators found that structural violence had affected the lives of many CHWs and their communities. Second, CHWs’ own hardships motivate them to improve the economic and health statuses of their communities. And third, CHWs are motivated to improve others’ lives because of values they have formed because of relationships with family, friends, and religious community members.
The authors go on to discuss the importance of labor relations between CHWs and employers. Despite the broad recognition that CHWs provide essential health services in underserved areas, there is a persistent view that they should be motivated by the desire to serve, and are thus often underpaid, if paid at all. However, there is precedent for CHWs to organize for adequate compensation. For example, LHWs in Pakistan successfully organized and went on strike until they were awarded the minimum wage. The authors posit that CHWs may come to demand better compensation, motivated by “awareness of the intense social and emotional work they put in, their sense of inequity in comparison with salaried elites in government or NGOs, or their desires to experience progress from past and present situations involving poverty and conflict.”
Agents of Social Change
The article also delves into an important topic that has received little attention in research—how CHWs address their own prejudices when serving clients. CHWs in all three contexts varied in the extent to which they actively counteract prejudices held against certain minority groups. While CHWs should be expected to confront these prejudices, selecting and training people who are prepared to actively combat societal prejudices is no easy task. The authors argue that solutions require “diligent ethnographic description, analysis, and interpretation of what is actually occurring in CHWs’ engagements with intended beneficiaries, and how practices are experienced and explained by those involved.” Engaging in this work would help to create dialogue about how to eliminate discrimination in healthcare services, starting with CHW-client interactions.
The methods and findings of this ethnographic study have important implications for CHW program implementation. Tailoring CHW models to local realities requires understanding the motivations of CHWs to do the work, the dynamics of CHW-community interactions, and the involvement of CHWs in decision-making about programs in which they are involved. This study is one of a growing body of literature suggesting that CHWs are not merely workers to be deployed to address health issues. They come to programs with multiple, various motivations, and hopes for their communities and themselves. Developing models that meet the needs of all stakeholders—funders, administrators, CHWs, and beneficiaries—is in everyone’s interest.
Maes, K., Closser, S., & Kalofonos, I. (2014). Listening to Community Health Workers: How Ethnographic Research Can Inform Positive Relationships among Community Health Workers, Health Institutions, and Communities. American journal of public health, 104(5), e5-e9.