Strategies for Sustained Empowerment of Community Health Workers: A Qualitative Analysis of the Comprehensive Rural Health Project in Jamkhed, India

Abstract

To understand the core aspects of an empowerment-based Community Health Worker (CHW) training program, we studied the model of the Comprehensive Rural Health Project (CRHP) in Jamkhed, India—an organization known for facilitating empowerment of women as Village Health Workers (VHWs) and agents of community change. We define empowerment as a means by which individuals gain health and development-related skills and knowledge to facilitate positive change within their lives and communities. Using VHW training observations and semi-structured interviews with health workers and senior trainers, 6 themes were developed and applied in 4 focus group sessions with 18 multigenerational VHWs trained by the CRHP. Transcripts were qualitatively analyzed under 6 themes—selection, baseline training, continuing education and support, community participation, community empowerment, and commitment and longevity. Empowerment of VHWs was found to be an intentional process involving the creation of safe and supportive environments conducive to long-term participatory and experiential learning with professionals who facilitate and mentor. The impact of the baseline training is maintained through ongoing program-VHW interactions and knowledge reinforcement in both the field and training center. Importantly, these interactions reinforce VHWs’ credibility and confidence in communities served. Community participation was found to be of key importance starting at the selection phase. The methods used for selection, training and ongoing support are critical to developing a cadre of competent, effective and motivated VHWs as well as fostering long-lasting self-development and leadership skills. Downstream effectiveness of community empowerment on health outcomes is demonstrated through indicators such as access to safe deliveries, declining child malnutrition rates, high vaccination rates as well as reductions in stigmatization of illness and caste discrimination.

• What do we already know about this topic?

• Empowerment within the context of primary health care is a powerful tool to accelerate the socioeconomic and health-related development of women and other marginalized groups when strict social hierarchies driven by gender and caste discrimination lead to marked health disparities.

• How does your research contribute to the field?

• The present research provides a structured framework for program planners and researchers to further study and design health and development ecosystems to support the empowerment and long-term effectiveness of community health workers through baseline training and sustained supportive measures.

• What are your research implications toward theory, practice, or policy?

• The findings can inform and strengthen program design theory when it comes to ensuring a strong and reliable community health worker component and can influence funding priorities when it comes to the cost-effective management of such programs.

Introduction

A resurgence of global interest in community health worker (CHW) programs in low- and middle-income countries (LMICs) has emerged after a decline lasting through the 1990s.^1-6 The World Health Organization (WHO) called for renewed emphasis on primary health care in its 2008 World Health Report. ⁷ Initial enthusiasm for CHW programs was fueled by the 1978 Alma-Ata International Conference on Primary Health Care. The resulting Alma-Ata Declaration presented a holistic vision for health and development and called for more community collaboration and grassroots engagement in local health services delivery including recruitment and training of CHWs.^1,8 This model became known as community-based primary health care (CBPHC) and includes a variety of evidence-based interventions. These include nutrition (eg, reducing malnutrition, breastfeeding promotion), infection control and prevention (eg, increasing vaccine coverage and control of diarrhea, pneumonia, malaria, TB, and HIV), training and support of CHW’s, and women’s empowerment.^5,9 India has long served as a nascent home of historically important women’s empowerment or sashaktikaran programs, which have tested the strength and longevity of empowerment-based training concepts in social contexts that have suppressed the autonomy and civic participation of women, particularly from among the lower castes, Dalits and tribes.^10,11

In assessing the empowerment experience of CHWs, Kane et al ¹² applied the 4 dimensions of empowerment based on a framework by Lee and Koh. ¹³ These dimensions include Meaningfulness , referring to the alignment between a CHWs work and role with that of her beliefs, values and behaviors; Competence , referring to perceived self-efficacy; Choice , referring to autonomy in carrying out the duties of a CHW; and Impact , referring to the belief of a CHW that her actions are producing meaningful outcomes.^12,13 These 4 dimensions were utilized as a starting point in developing this qualitative study to expand and contextualize our understanding of the training methods needed to achieve sustained and long-lasting CHW empowerment through a real-world example of a multi-decade CHW training program.

Women’s empowerment has been recognized as a means of reducing poverty and improving the health of vulnerable populations.^14-17 Focusing empowerment interventions on women CHWs can be a practical means by which to influence the community at large. Studies on factors associated with CHW program success emphasize baseline training quality as well as ongoing support of CHWs, health system integration, community support and acceptance, access to essential medicines and equipment, worker incentives, and CHW empowerment.^14,18-21

Within the realm of primary health care, empowerment can be conceptualized as the process of individuals gaining mastery over their lives and communities to effect positive change and achieve desired health and socioeconomic outcomes. ²² Empowerment can also manifest as a form of individual and collective agency expressed as resistances to societal constrains that are inculcated by power differentials among groups of people in local communities and larger political and economic systems. ²³ Empowerment among CHWs in South Asian communities can enable women the ability to make strategic life choices leading to collective actions that produce social change and realign these power dynamics in favor of the historically marginalized.^14,24,25 Health and development programs that emphasize empowerment principles can activate individuals and groups to access the knowledge and tools that enable leadership over critical assessment, support decision-making capacity, and engage in meaningful collective action on issues of local importance.^26,27 Empowered and accountable CHWs working in supportive health systems can act as catalysts to steward social change.

Within the body of knowledge concerning CHW training and program implementation is the need to better define the specific training characteristics associated with sustainable empowerment of women as CHWs. The present research provides a structured framework (Figure 1) for program planners and researchers to further study and design health and development ecosystems that support the empowerment, retention and long-term effectiveness of CHWs through baseline training and key supportive structures and processes.

Figure 1.

Recommendations for an empowerment-focused community health worker training program.

The Jamkhed Model

The case study of the Comprehensive Rural Health Project (CRHP) in Jamkhed, India presents an opportunity to examine a sustained and multi-generational empowerment-based CHW training program that has been validated externally and proven effective.^28,29 This nongovernmental organization was founded in 1970 in a remote and drought-prone region of Maharashtra, India, the CRHP has been recognized for reducing child and infant mortality, malnutrition, maternal mortality, and successfully facilitating positive social change through interventions to reduce caste violence and women’s oppression. The CRHP is privately funded through grassroots fundraising, charitable foundations and revenue from training programs. This work takes place within poverty-stricken rural communities, starting with local women who train as CHWs or Village Health Workers (VHWs) as they are locally known. Table 1 depicts longitudinal health survey data collected in the CRHP project area. These results have been documented by the WHO and external studies conducted since the 1970s.^{9,14,19,28,30-33} The program and its methods have given VHWs the knowledge and confidence to address routine health issues including stigmatized illnesses (eg, HIV, TB, leprosy), counter the socio-political oppression of women and Dalits (“untouchables”), reduce caste violence, and tackle the root causes of poverty in their respective communities.

Table 1.

Comparative Health Statistics From CRHP Project Villages and India (1971-2016).

	1971	1976	1986	1999	2007	2011	2016	India a
Infant mortality rate (per 1000 live births)	176	52	49	26	24	18	18	41
Crude birth rate (per 1000 population)	40	34	28	20	14.8	23.1	23.1	19
Maternal health services
At least 4 ANC visits (%) by skilled provider	0.5	80	82	97	99	99	99	51.2
Skilled birth provider at delivery b (%)	<0.5	74	83	98	98	99.4	98	81
Child health services
Under-5 received third dose of DPT and Polio vaccines c (%)	0.5	81	91	99	87 d	99	99	78/73 e
Under-5 underweight (%)	40	30	5	5	<5	<5	9	36

Source. Monitoring and evaluation data from a representative sample of project villages in Ahmednagar district.

Source. Comprehensive Rural Health Project health information system.

^aInternational Institute for Population Sciences - IIPS/India and ICF. 2017. National Family Health Survey NFHS-4, 2015-16: India. Mumbai: IIPS, https://dhsprogram.com/pubs/pdf/FR339/FR339.pdf.

^bCRHP counts village health workers as skilled birth attendants if they meet all training and supervised apprenticeship requirements.

^cCRHP tracks DPT and Polio immunizations together.

^dIn 2001, CRHP transferred control of the immunization program to the government.

^eFor all India, DPT-3 is 78% and Polio is 73%.

The strategy developed by the CRHP relies on stakeholder development and long-term partnerships with local leaders and community groups. Health and development priorities are generated and mutually enacted by village leaders and the program staff who facilitate and provide technical support. In addition to the VHW training program, the CRHP works to train and organize farmer’s clubs and Mahila Mandals or women’s development groups, water conservation projects, community nutrition programs, and provision of direct healthcare services through a low-cost secondary care hospital.^34,35 This model defines health in a holistic sense by integrating nutrition, environment and agriculture, education, women’s status, sociocultural, political and economic factors in addition to medical care.

The CRHP invests most of its resources to the training and continuous support of VHWs in project villages. With the CRHP’s assistance, village elders are tasked with the initial selection of women who are sent to the CRHP center for intensive training. Interprofessional mobile health teams comprised of a nurse, clinician, and social worker liaise between the training center, including the main hospital, and each village. Following baseline training, all VHWs receive supportive services including field training, referral care, and health surveillance for epidemiologic monitoring. Weekly follow-up training is organized at the CRHP training center for established VHWs who gather to engage in collective problem-solving activities and skill building. Typical gatherings include 15 to 35 VHWs. These sessions are facilitated by a training staff facilitator and a senior VHW. Table 2 describes the 3 overarching goals and competencies of the VHW training curriculum.

Table 2.

Competencies of the CRHP Village Health Worker Training Program.

Knowledge training	Basic understanding of the etiology, pathogenesis, symptoms, and treatment of common diseases in the community
	Appropriate use of effective local/traditional remedies
	Basic understanding of pregnancy, childbirth, women’s health
	Child health and development
	Nutrition and malnutrition
	Referral process including indications for urgent hospital transfer
	Sanitation, water and air quality as health determinants
	Social analysis and women’s status
	Reconciling health and cultural beliefs
	Role and responsibility of government in health and development
	Working with non-governmental organizations
Skills training	Critical and systematic analysis of community problems
	Surveys, program monitoring, and disease surveillance
	Health communication
	Participatory rural appraisal (PRA) for community diagnosis
	Mobilizing the community to address local problems
	Income-generating activities to achieve self-dependence, economic freedom and social mobility
	Leveraging public and private resources to facilitate community projects
Personal development	Building self-esteem and confidence as a CHW
	Public speaking and story telling
	Equity in health and development
	Strengthening attitudes and values toward community service and volunteerism

Source. (M. Arole & Arole^31,35,39; R. Arole, 1999; R. Arole ²⁶ ).

Methods

Research Design

The analytical framework used by Lee and Koh defines the 4 dimensions of CHW empowerment as described above- meaningfulness, competence, choice and impact. ¹² This framework was used to develop guides for the semi-structured interviews (appendix 2) which were performed with a convenience sample of 6 VHWs of varying experience levels and 5 senior trainers from the CRHP. Materials were professionally translated into Marathi by a professional interpreter. This sample size was adequate as responses indicated a saturation point was reached. The interview responses and direct field observations of VHW refresher training sessions were used to generate 6 focus group discussion (FGD) themes that were used to develop the FGD guide (Appendix 1). The 6 themes (Figure 1) include (1) selection, (2) baseline training, (3) continuing education and support, (4) community organizing, (5) community empowerment, and (6) VHW commitment and longevity. These define the overall VHW training and support environment at the CRHP. The themes focus on characteristics of the learning environment and methods that foster VHW empowerment, along with internal qualities of VHWs- both inherent and elicited through this training and self-actualization process. The internal VHW training manual developed by CRHP was also reviewed to further validate these 6 themes against the CRHP training curriculum prior to conducting the FGDs.

Study Setting

All observations, interviews and FGD sessions were facilitated over a 2-month period by 2 members of the research team, including a medical anthropologist and a public health researcher with the assistance of a professional Marathi interpreter. All activities took place at the Jamkhed Institute for Training and Research in Community Health and Development in the Ahmednagar District of Maharashtra, India.

Sampling

FGD participants were selected through both random and convenience sampling in January 2010 during weekly VHW refresher trainings. All FGD sessions were completed over 4 weeks in January 2010. A comprehensive list of current VHWs was compiled from which every third name was selected. Among those selected VHWs who were also present at the training center during the study period, VHWs were offered the opportunity to participate in FGDs which led to a total of 18 participants out of 32 VHWs who were present at the training center during the study period. This participant number was limited by the time available to the investigators as VHWs must travel considerable distances to reach the training center. A relatively small sample size was used as the aim was not to evaluate the effectiveness of this training model, but rather the elucidation of key elements which accounted for its enduring success.

The CRHP provides all VHWs coming to the CRHP compound an honorarium to compensate them for their time and travel expenses. No additional compensation was offered to VHWs who provided voluntary written consent to participate and be audio and video recorded in the 90-minute FGD sessions.

Data Collection

The VHWs were stratified into 2 groups according to their baseline training date with a chosen cut-off date of January 1, 1995 (Table 3). Each of these groups was further divided in 2 to allow for a total of 4 separate FGD sessions with 4 to 5 participants each. The mean age of the participants in the older group was 57.9 years and the mean uninterrupted work experience was 28.9 years. The 2 groups of 9 junior VHWs trained after January 1, 1995 had a mean age of 32.3 years and mean work experience of 12.2 years. Each VHW participant represented a unique project village in which she lived and worked. This was based on the decreased presence of the CRHP’s founders, Drs. Raj and Mabelle Arole, in training the VHWs during the mid-1990s as leadership roles shifted to a younger generation. In the mid-1990s, some of the original VHWs who were trained had also begun to take on mentorship roles and facilitating the training process of the younger generation of VHWs. Additionally, the Jamkhed Institute became formalized by CRHP in 1994. Other contextual and environmental changes, such as changing health conditions in project villages, increasing literacy, education, and greater external influences (eg, media, commerce, international visitors, transportation and telecommunication technologies) all became more prominent after the mid-1990s.

Table 3.

Demographic Descriptors of Village Health Worker (VHW) Focus Group Participants.

Focus group type	Senior VHWs	Junior VHWs
Participants (n)	9	9
Mean age (range)	57.9 (41-70)	32.3 (28-40)
Mean number of years of work experience as a VHW (range)	28.9 years (23-34)	12.2 years (6-14)
Mean number of years of formal education (range)	1.6 (0-6)	4.7 (0-9)
% VHWs representing a marginalized caste, including Dalits	33%	44%

Analysis

The 4 FGD sessions were recorded and later transcribed verbatim in English. Each transcript was read several times by members of the research team. Transcripts were annotated, coded and analyzed using a thematic open coding approach. To ensure accuracy and confidence in the findings, the researchers restated questions in different ways to promote participant understanding. Additionally, detailed notes were taken during the actual FGD sessions by one of the researchers and used to validate the transcripts.

Ethical Considerations

All research materials and instruments were professionally translated between English and Marathi. IRB approval was granted by the Johns Hopkins Bloomberg School of Public Health Institutional Review Board as well as by the Jamkhed Research Ethics Board, a community-based IRB in India.

Results

Selection: Qualities and Qualifications for Community Acceptance of VHWs

Focus group participants reflected upon qualities that resulted in their selection and acceptance as VHWs by the community. A consistent set of values and qualities were perceived important in providing health care and mobilizing people around common interests. Prem and maya, meaning love and affection (toward the community), respectively, were often expressed. Other common qualities mentioned across all 4 groups included patience, compassionate nature, smiling face, willingness to abandon casteism and bigotry, lack of selfishness, even-temper, respect for others, generosity, active listening skills, hard work, humility, honesty, and boldness. Respondents acknowledged that these qualities may not be evident at the outset but can be learned behaviors developed through the critical consciousness approach employed in their training.

The question of educational requirement for VHWs spurred debate in all 4 focus groups. This is relevant given the Government of India’s requirement of a 10th-grade education for nearly 1 million Accredited Social Health Activists (called ASHAs), a country level program of the National Health Mission, which was partly inspired by the experience of the VHWs in Jamkhed. ³⁶ Most participants expressed strong disapproval of a formal educational requirement prior to selection and VHW training. One senior participant stated that “educated women will just open their notebook and not pay as much attention. It’s more important to have women who show interest in learning, have good memory and attention.” (FG3) Similarly, another senior participant stated, “education is less important than zeal and passion for this work [but] she should have an interest in learning to read and write.”(FG4) A junior participant commented that “it’s not just about education but how they use the knowledge. The previous VHW in my village was illiterate but she managed to change the people’s attitudes and improve life for many.” (FG1)

Junior VHWs were more likely to disagree with the government’s recommendation for stricter educational requirements. In contrast, a senior VHW stated that “standards should be set because it’s better to know some English as well as reading and writing skills to more easily learn new health knowledge.” (FG3) A junior participant expressed that “without literacy, women are more likely to be deceived or taken advantage of. If they are literate, it will help them and their work as VHWs.” (FG2)

Disagreement among VHWs may be linked to the increasing complexity of the training and information being shared with the VHWs at the CRHP training center. The CRHP leadership and staff reflected upon shifting health priorities in the project villages, from communicable diseases and malnutrition to chronic health problems (eg, diabetes, cardiovascular disease, cancer) and injuries. The involvement of VHWs in addressing chronic diseases, as well as behavioral health conditions (eg, depression, anxiety, intellectual disabilities) has required the introduction of new terminologies to describe these conditions and their symptoms, including English terms not easily translatable into Marathi. ³⁷ This presents a greater challenge for VHWs who have not completed primary school. However, most participants remained adamant that the growing complexity of knowledge, which they often referred to as “deep knowledge,” does not impede their ability to learn, adapt and apply this new information regardless of prior educational achievement. The process and ongoing enactment of empowerment set against a background of general educational advancement of rural women in India is leading to ongoing refinement and expansion in the methods and tools of VHWs to conduct community-based health education and service delivery. Furthermore, the Jamkhed model enables a critical consciousness to develop among VHWs, similar in approach to Freire’s critical pedagogy, which facilitates VHWs to examine the social, political and economic contradictions that lead to oppression of women and untouchables, eventually leading to social change.^14,38

Baseline Training: Effective Learning Methods and Settings

Participants in all groups were asked to describe which techniques of learning and teaching were most helpful in their baseline training as VHWs. The CRHP training program emphasizes the importance of providing evidence-based health education for VHWs while appreciating the importance of reframing these typically Western concepts within a context that is appropriate to local cultural frames of reference. The goals and competencies of CRHP’s training program includes 3 underlying themes—building relevant health knowledge, skills, and personal development- including leadership coaching (Table 2).

Most participants described the critical importance of group learning. One senior VHW stated, “we learn much from each other and discuss everything that happens in our villages. If I have trouble understanding some topic, I usually ask a [fellow VHW] to explain it to me or we discuss it in class with [the facilitator].” (FG3) Other participants expressed agreement, as one stated “all VHWs have love and concern for each other. We help each other learn about health and other topics and deal with difficult situations [in the community]. After class . . . we sit together and share experiences.” (FG3) Consistent responses among participants reveal the responsive nature of the training process and the learning environment created by the CRHP to stimulate an ongoing exchange of knowledge and experiences among the VHWs. In blurring the lines between teachers and learners, this structure minimizes the hierarchical role of the training staff given that the responsibility for sharing knowledge belongs to the entire group.

Decentralization of training in terms of authority and physical space is a major feature of the CRHP process. ³⁵ One senior participant noted, “if I miss a session at CRHP, I will always ask another VHW to tell me what they learned. When I started learning initially, I had trouble remembering the information, so I would ask the more experienced VHWs to explain the material.” (FG4) Such statements highlight the importance of establishing a network of CHWs who can interact regularly to exchange information and ideas in groups facilitated by local experts who provide guidance and skills training.

The CRHP placed significant emphasis on establishing a safe and welcoming learning environment where all VHWs receive equal respect and attention. At the training center, VHWs do not have to cook or do any cleaning. Time is maximized for knowledge gathering and skill development as well as exercises to promote leadership and team building. Staying on campus overnight further enhances this learning environment as the typical social restrictions are lessened.

During group sessions at the CRHP training center, participants described the use of skits and puppet shows, songs, anatomical models, clinical observations within the hospital and operating room, animal dissections, and visual media (eg, diagrams, pictures) to be most helpful in facilitating their understanding of health topics. The CRHP espouses that iterative, experiential and visual learning methods are effective educational strategies for low-literacy adult learners. ²⁶ Participants in each focus group were especially keen to acknowledge the insights they gained during a guided anatomical dissection of a goat, which led to a better understanding of physiology and pathophysiology.

Participants in all groups described experiential field learning with guidance and support by the mobile health team as the most effective method of understanding health concepts. A junior participant stated, “I learn from the mobile team the most because whatever we learn at the training center has to be put to use in the villages and the mobile team helps me practically implement the knowledge with guidance and support.” (FG2) Another participant noted that at the same time she was learning about diarrhea treatment and prevention at the training center, the mobile team would visit her village, examine children with diarrhea, and reiterate the process of preparing and administering oral rehydration solution to manage dehydration, which reflects the value of an iterative approach.

Continuing Education and Support: Developing Trusted Sources of Knowledge

An assessment of the learning environment created by the CRHP was conducted through discussions with staff and leadership and a review of training materials. This revealed distinct opportunities for VHWs to engage in a long-term process of responsive learning at the CRHP training center as well as in the project villages. Focus group participants identified references they prioritized and valued most for accurate information and guidance as part of routine practice in primary health care and medical emergencies. The importance of a central training center was a highly consistent response across all 4 groups. Only one junior VHW perceived the community-based training by the mobile health team to be a more impactful learning resource, stating that “the mobile health team comes to our village and provides training which is most important to me.”

When asked to describe the process used to acquire knowledge for managing health and social problems in the community, the responses were varied, especially between junior and senior VHWs. Senior VHWs had a more consistent response, identifying the CRHP training center as the principal source of information. Sixty percent of senior VHWs specifically named the organization’s founders as a vital and first-line source of knowledge in times of uncertainty while less than 25% of junior VHWs began their list by mentioning the founders when describing vital sources of new health knowledge. Among junior VHW participants, the first line of information gathering typically involved consulting with a community resource person or group, including a senior VHW (if present), the Sarpanch (mayor) in one instance, and community groups such as Mahila Mandals (women’s economic development groups) and Farmer’s Clubs. Of note, many of these community members acquired new health and development-related information from the staff of the CRHP mobile health team according to observations made by the research team. Junior VHWs noted that the first generation of VHWs trained by the CRHP played a vital role by sharing their wealth of experience, knowledge, and skills and by serving as highly valued mentors who were always available and willing to assist on a regular basis and in difficult situations. One junior participant noted that the “older VHW is still working in my village and helps me learn about health problems and assists when I have difficulties.” (FG1)

The field training provided by the mobile health team and by the CRHP training center staff were highly valued by all participants. Unique aspects of the Jamkhed model mentioned most frequently included the weekly follow-up group training sessions, strong mentorship by the founders and other key program staff, and the trainings provided by staff members including the CRHP hospital nurses and doctors. A major benefit of providing longitudinal training for the VHWs both at the training center and in the field is that consistent information is provided by different individuals at multiple levels, facilitating the VHWs’ learning process and reinforcing their trust in this knowledge.

Community Participation: Critical Assessment and Community Diagnosis

An integral component of the VHW training program is the development of a sustainable process of critical assessment of local health and development issues, which includes facilitated community self-diagnosis. This is possible as the VHWs are integral members of their communities and are well positioned to gradually chip away at inequity and injustice in a sustained and less threatening manner, which is a concern whenever existing paternalistic power structures become threatened.

Consciousness-raising and community-driven root-cause analysis of health and social problems is a task the VHWs are trained to implement. The CRHP programs have had a marked impact on people’s mindset toward health prevention and promotion practices, including the permeation of positive social values which reduced the occurrence of caste and gender disparities, illness stigmatization (eg, TB, HIV and leprosy), as well as fatalistic attitudes among poor and marginalized peoples.^{14,19,28,34,35} Participants shared stories revealing specific instances which contributed to the gradual breakdown of caste segregation. Examples included higher caste women experiencing labor complications or the child of a higher caste family falling ill where a trained VHW (in these cases, Dalit women) was permitted to provide emergency treatment or accompany the women during transfer to a healthcare facility. As health outcomes improved, communities began to place greater degrees of trust and respect in VHWs irrespective of caste.

All focus group participants discussed how their training empowered them for a life-long process of critical assessment. For instance, one senior participant stated that “many people used to drink contaminated water from the river, but I learned about the importance of clean drinking water and mobilized the village to petition the government . . . for a bore well, which we received.” (FG4) A junior participant described the changes taking place in her village:

Children used to die from measles and malnutrition and they had worms. But we learned about cleanliness, safe drinking water, sanitation . . . the use of soak pits, and nutrition. We talked about these things in our villages and over time these problems became less. We also were taught about the harm of some superstitious practices and this too we began to change. (FG1)

A similar description of the empowerment process was provided by another junior VHW,

Because of this training, I organized women’s groups and the members were divided into committees for water and sanitation, care of tuberculosis and leprosy patients, and care of children under 3. I worked with them to make [everyone] aware of the problems facing the poor and lower caste and the need to work together, especially with those people and to help integrate them into the village community. (FG2)

These examples reflect the transfer of knowledge and skills from the training center to the community level. Empowered VHWs gained a strong sense of ownership and pride in organizing health and development programs, especially those dealing with water and sanitation, that enabled communities to tackle the root causes of illness.

Community Empowerment: Defeating Stigmatization of Illness and Social Division

Participants were asked to reflect on the problem of stigmatized illnesses (eg, HIV, leprosy, tuberculosis, mental illness). In Jamkhed, as in many parts of rural India, the ostracization and lack of social support for afflicted individuals leads to severe marginalization and deprivation of even basic human rights. ³⁹ Without intervention, communities generally believe these illnesses to be incurable, highly infectious, and a divine punishment for past or present moral failings. ³⁹ VHWs described how women affected by these illnesses suffer the most, often removed from the household, denied adequate food, medical treatment, and even compassion. Poverty, illiteracy, unemployment, and poor self-esteem further aggravate the situation. As stigmatized illnesses are self-effacing (ie, those afflicted often hide their ailments from society), this impedes early diagnosis and treatment efforts. ³⁴

About 1 in 4 VHWs shared personal experiences of the social and physical challenges of living with such ailments, including friends and family who faced unimaginable hardship and suffering. One senior participant recounted that “[t]here is a fear that not only will the patient become stigmatized, but the entire household may as well.” (FG3) Participants recounted an abundance of tragic stories demonstrating the effects of stigmatization on people’s health and quality of life. A senior participant described an incident in her village in which “one TB patient. . . was rejected by his own mother who feared that she would get TB if she touched him and he [eventually] died due to neglect.” (FG4)

The situation in Jamkhed today is vastly different from that of the early 1970s. Participants were asked to estimate the percentage of their villages’ households that still held stigmatized views of people with certain communicable diseases. Essentially all participants estimated that fewer than 10% of families in their communities held harmful disease-related superstitious beliefs and practices. HIV was an exception as this figure increased to an estimated average of 70%, ranging from 50% to 90% and likely the result of HIV being a relatively new and misunderstood disease with a small prevalence in this region.

Participants described the process of their own abandonment of myths surrounding these illnesses, which ranged from as little as 4 months and up to 3 years after completion of baseline training. Many of the junior participants had the advantage of growing up with a practicing VHW in their village, which facilitated this personal as well as community mindset transformation. Overall, the VHWs reported a transition period of 6 months to 5 years for most of their community members to abandon the practice of stigmatizing illnesses. They described the love, support and encouragement they received from the CRHP during their initial and ongoing training process and how it strengthened their resolve to work for the poor and marginalized, especially women and people suffering from stigmatized illnesses. Among the techniques used to disseminate health knowledge regarding stigmatized illnesses has been CRHP’s highly popular Kalaa Pathak (health communication group), which performs dramas and songs containing elements of health education, dealing with stigma and positive social change. VHWs are active participants in these village dramas and skits.

Continuous, integrated, and community-wide efforts to promote culturally-sensitive health education through VHWs and community groups have markedly improved the situation. Health education offered through the CRHP’s empowerment-based training respects people’s knowledge, beliefs, and sacred values while reframing these illnesses in a more positive perspective with emphasis placed on treatability, prevention, and etiology. Most focus group participants remarked that medicines are not enough for these patients, with one senior VHW stating that above all “[t]hey need to be treated with good nutrition and love.” (FG3) All VHWs emphasized the value and importance of showing love and affection for people with stigmatized illnesses to enable rehabilitation. A junior participant described her approach, stating

I often invite these patients to my house for food or tea and spend time with them in public and show love and affection for them so others will not fear and do likewise. I also give health education to everyone, so they do not hold on to false superstitions that harm these patients. (FG1)

Commitment and Longevity: Motivation to Serve

Participants were asked to describe what motivates them to serve their communities as VHWs. Most VHWs described the deep inspiration they receive from the CRHP leadership. The leaders of the CRHP managed to inspire several generations of local women to stand up and act for themselves and their communities against social injustice including the deprivation of knowledge and other vital resources. A junior participant commented that

Dr. Raj Arole motivated me to be a VHW. He taught me how to keep people healthy, so they don’t end up having to go to doctors and spend a lot of money. He encouraged us to work for the community and to share all we learn. People now have a lot of respect for me and this gives me satisfaction. (FG1)

Participants described how the responsibility of being a VHW, combined with respect, trust and support from the community as well as from CRHP, provided the energy and motivation to serve. A junior participant stated, “I learned that we have a responsibility to share this knowledge and that health is everyone’s responsibility. People also look to me for guidance and support, which motivates me to do this work.” (FG2) Community appreciation and feeling valued was a highly consistent sentiment across all groups. A junior participant noted, “We are so lucky to have been given this knowledge because unlike doctors we didn’t have to spend so much money to receive it. We’re proud of that knowledge and that’s why we’re working in the village and people respectfully call us doctors.” (FG1)

Earning community respect was notably an empowering process for all VHWs in both younger and older groups, especially given the mistreatment, abuse, and neglect many had experienced earlier in life. Serving as stable and committed community leaders and role models provides them the opportunity to make meaningful changes that lead to improved health conditions and quality of life. Notably, all 18 focus group participants described having one or more local leadership roles, including as Sarpanch or mayor of the village, providing a platform to further spread awareness about health and social concerns.

Discussion

The utilization of an empowerment-based approach to improve the health of women and children has been gaining momentum ever since the 1978 Alma-Ata Declaration’s support of CHWs as an indelible aspect of primary health care. More recent calls for the large-scale deployment of CHWs as part of the health and social transformation process have resonated in countries such as India, Ethiopia, Brazil, Pakistan and Bangladesh where such programs are being nationalized.^6,8,40,41 At the same time, policy makers and researchers need evidence to guide the development and support of such programs to ensure that activities are well aligned with expected outcomes. Women’s empowerment can serve as a gateway to sustainable community development and health improvements. Ingredients for this process already exist in most communities, and the ability to activate the empowerment potential of CHWs depends on the creation of safe, supportive and relevant learning environments.

This study used a variety of qualitative methods to determine the 6 components of a successful empowerment-based VHW training program. These include the VHW selection process, baseline training, continuing education and support, community participation, community empowerment, and commitment & longevity (Figure 1). Given the reported health outcomes and longevity of the CRHP VHW training program, our aim was to obtain a deeper understanding of the nature of the empowerment process from the perspective of VHWs who have lived this experience and continue thriving in their roles.

Training that fostered women’s motivation included emphasis on core values to promote community development and cohesion, learning fundamental clinical skills, and long-term support with engagement through field training and mentorship in providing relevant health promotion, disease prevention and curative services (Table 2). The consistent themes of love and compassion permeate through all FGDs in terms of the comradery VHWs share amongst themselves, the love for their communities and the trust and support the communities place in these women. The degree of closeness that is shared among the VHWs and members of the CRHP team is noteworthy and is built upon trust which enables continual learning and improvement without fear of punishment for mistakes.

Despite the limited literacy of many VHWs, strong confidence is displayed in their ability to carry out the work. Buttressed by ongoing peer mentorship with staff support, VHWs assimilate evidence-based information and apply it in a practical manner. Indeed, the lack of an educational prerequisite enables more equitable participation of women from lower socioeconomic and caste groups who might otherwise be excluded from recruitment.

The training environment by design instills self-reliance and critical thinking skills through adult learning principles and teamwork. This learning environment reflects a Freirean educational philosophy known as critical pedagogy or the process of facilitating learners to attain a state of critical consciousness. ³⁸ Training may also be structured as per the priorities identified by the VHWs in conjunction with community groups, giving them a greater sense of agency and credit for helping identify the communities’ main health priorities.

Findings related to educational standards have relevance today as countries and NGOs take vastly different approaching when implementing health programs with a CHW component. ⁴² While some degree of education is needed to facilitate the training process, the determination and interest in learning as well as motivation to equitably serve the population, emerge as predominant determinants of outcomes in this study. Successful CHWs can demonstrate a commitment to community well-being, including serving the poor and marginalized, along with a willingness to change harmful cultural norms, partly through role modeling as well as mentoring adolescent girls and other women. What may be missing in other programs is a commitment to continuous learning in a supportive environment where trust is developed through mentorship and mutual respect. The value of inspirational leadership and personal connections to the trainers have emerged as salient themes through our interviews. Strong mentorship by organizational leaders and staff allowed these women to persevere despite grave challenges earlier in their lives. Success of these VHWs as community agents instilled in them a sense of self-worth, which is noteworthy in a culturally conservative rural context.

As members of the community, VHWs share the health-related cultural norms and beliefs of the people they serve. To gain success as change agents and community organizers, VHWs undergo a gradual transformation in their adherence to health-related traditional beliefs when those conflict with disease prevention and treatment goals. Training and ongoing support encourages a discourse regarding local norms and health information in a culturally sensitive and judgment-free environment. This allows for a reframing of local beliefs around stigmatized conditions such as TB, leprosy and HIV/AIDS.

The importance of incentives for CHW retention and motivation is a topic of much debate. Our study supports research demonstrating the power of nuanced incentive systems that factor in job satisfaction, heightened respect and social status, as well as access to economic opportunities and entrepreneurship training, which can serve as powerful motivators for long-term retention.^18,20,43 The evidence to support the long-term effectiveness of this approach can be found in external evaluations as well as the longitudinal comparative health and socioeconomic data shown in Table 1.^{9,14,19,30-33,37,44}

These results may support the development and scale-up of effective CHW programs with the aim of furthering the Sustainable Development Goals (SDGs). The fifth SDG of the UN’s 2030 Agenda for Sustainable Development seeks to achieve gender equality and the empowerment of women as a way of mitigating gender disparities and violence, emphasizing access to health services and participation in civil society. Empowering CHWs is one important step in achieving this goal as empowered CHWs interact with adolescent girls and other women and thereby serve an influential and mentoring role. These results are consistent with the body of evidence surrounding recommendations for the implementation of CHW programs in terms of supervision and support, reducing hierarchical structures, fostering community engagement and mobilization skills among CHWs.^21,45

Limitations of this study include a small sample size which may limit generalizability. However, the participants included women of varied ages, experience levels, and caste identity (Table 3). Response bias may be a concern as the interviews and FGDs took place at the CRHP training center. The impact of this may be minimal as information gleaned from the semi-structured interviews, observations and external studies reveal that the VHWs of Jamkhed see themselves as independent health workers rather than employees or contractors.

Conclusion

The case of CRHP presents an opportunity to study and promote best practices in facilitating and sustaining the empowerment of people, especially women of lower socioeconomic status and caste (Figure 1). Important in this process is the connection between formal training and experiential learning. Empowerment-centered training connects the learners’ open-ended life experiences with a systematic curriculum that gets molded to the health and development needs of each community.

The core themes in this study highlight milestones along the continuum from selection to training and eventually in community members gaining mastery over local health beliefs and behaviors to achieve desired health and development outcomes. The seeds for this process must be laid in the earliest stages of CHW selection and baseline training as well as creation of safe and supportive spaces for learning and personal development. This continues into mentored relationships with program specialists and subject matter experts through ongoing support in both the field and classroom, lending community credibility and social standing to CHWs. With time and ongoing skill acquisition, CHWs transition into leadership roles within their communities- further facilitating social change that promotes equity and cohesion. This includes increasing women’s status, breaking down caste discrimination and mobilizing community members to tackle long-standing health and social challenges through collective action.