Accelerating Best Practices in Peer Support Around the World

What makes people lose trust in CHWs: CHW perspectives in Bangladesh

Melissa Mayer, MPH Candidate

Peerness and trust are key ingredients for successful peer support programs and community health worker (CHW) interventions. However, when peer supporters and CHWs lack the resources they need to achieve program goals, their hard-earned trust in the community erodes and they become demoralized. Such setbacks can prevent these frontline workers from reaching their potential as agents of change for community health.

In a recent article, Puett and colleagues set out to understand barriers to the effectiveness of CHW intervention methods. The investigators conducted focus group discussions (n=10) with two groups of CHWs working on preventive care and community case management of common childhood illnesses in Bangladesh. One group was trained to treat acute respiratory infection (ARI) and diarrhea, while the other addressed severe acute malnutrition (SAM). The findings highlighted the importance of having proper community resources in place, providing useful insights for peer support programs and CHW interventions in general.

Community trust in CHW services is undermined by limited community resources

The CHWs charged with treating ARI and diarrhea reported that the medications needed to treat these conditions were often out of stock. Even when CHWs could access these medications, they were seldom in adequate quantities to meet local demand for these medications. Puett et al. posit that community trust in CHW services is undermined by limited community resources. They suggest that “by threatening a CHW’s standing in the community as a source of reliable care, resource constraints in the public health care system can affect her self-efficacy and motivation to strive for high-quality service provision.”

Similarly, resource constraints limit the extent to which community members are able to apply health education in their day-to-day lives. CHWs who counseled families on treating malnutrition commented on the main barriers to families; adequate food and time to prepare it. Among very poor families, all family members, including the mother, worked many hours and lacked the extra time to spend feeding a baby with SAM. The barriers to feeding a malnourished child among families who lack adequate food and time cannot be addressed by CHW education alone.

“Sometimes they fail to keep their faith in us”

The authors raise important concerns about employing CHWs in regions with poor healthcare infrastructure.  If a CHW cannot address a community’s most urgent health needs, the ability of a CHW to establish and maintain community trust may be threatened. The title, “sometimes they fail to keep their faith in us” is excerpted from a quote from one of the CHWs, describing the loss of trust that results when a CHW is unable to meet client needs.  If CHWs are tasked with treating a particular illness, it is essential that they be provided a steady supply of the needed materials. If they are tasked with treating SAM, there must be supports in place to help families to access high-quality food, as well as to find time to care for a malnourished child.

Around the world, peer supporters and CHWs find themselves working among populations that lack access to health services and in places with gaps in the healthcare infrastructure. That these frontline workers can achieve so much in spite of their resource-limited environments is a reflection of their creativity, initiative, and hard work. Imagine how much more they can accomplish with more resources and administrative support. This study serves as a reminder that CHWs and peer supporters cannot be a ‘panacea for weak health systems’ (Haines et al., 2007). In order for them to meet the high expectations for their work, the question of what resources they need must remain at the forefront of program planners’ minds.



Haines A., Sanders D., Lehmann U., Rowe A.K., Lawn J.E., Jan S. et al. (2007) Achieving child survival goals: potential contribution of community health workers. Lancet 369, 21212131

Puett, C., Alderman, H., Sadler, K., & Coates, J. (2013). ‘Sometimes they fail to keep their faith in us’: community health worker perceptions of structural barriers to quality of care and community utilisation of services in Bangladesh. Maternal & child nutrition.

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