The aim of SHINE’s research is to explore the stressors faced by Community Health Workers using a community-based participatory research (CBPR) approach, and to co-develop, pilot, and evaluate holistic health system support packages in two different LMIC contexts – Bangladesh and Kenya. These packages will focus on strengthening CHWs’ mental well-being and agency, ultimately contributing to greater health system resilience. We will address this long-neglected area by drawing on mental well-being and resilience frameworks and by strengthening both the hardware (e.g., training) and software (e.g., community cohesion and support) components of the health system.
Working in community health is not for the faint-hearted. As one community health worker put it, “You need a heart to continue.” This simple but powerful sentiment speaks volumes about the challenges faced by community health promoters – especially when it comes to their mental well-being. Through the SHINE study, taking place in Nairobi County’s Korogocho area and Kiambu County’s Limuru, a comprehensive approach is being developed to foster resilience, well-being, and support for these crucial frontline workers.
Prioritising people over pay
For community health promoters, the mission is about transformation, not targets. Their purpose is driven by the impact they see in the communities they serve. Often, they are called to action at all hours, ready to help someone get to a hospital, even if that means dipping into their own resources or taking on debt. This dedication is a powerful example of how a people-first approach lies at the heart of their work.
Yet this relentless dedication, while admirable, can be mentally taxing. The emotional weight of being continually on call, coupled with the financial strain, can be a serious drain on mental health.
The role of people skills and negotiation
Mental well-being: The need for regular debrief sessions
The SHINE study recognises the mental toll of this work and has created debrief sessions to support community health promoters. Here, they can share experiences, discuss challenges, and rejuvenate their spirits for the week ahead. These sessions are essential for emotional resilience, allowing them to process the week’s hardships and renew their focus. However, these sessions need to happen more regularly to be fully effective, as the demands on their time and energy continue to rise.
Why mental health matters for community health promoters
A healthy mind produces healthy results. For community health promoters to thrive and continue their impactful work, their mental well-being must be a priority. Unfortunately, community members don’t always understand the weight or complexity of their workload, which can lead to a lack of appreciation and support. The SHINE study’s focus on mental well-being is a critical step forward, but it’s also vital that we continue raising awareness around the needs of these health promoters. Continuous counselling, regular debrief sessions, and community sensitisation are essential in ensuring their mental resilience.
Investing in the mental health of community health promoters isn’t just a matter of supporting individuals—it’s about ensuring the well-being and longevity of the communities they serve. When we take care of those who care for us, everyone benefits.
In the densely populated urban slums of Korogocho, Nairobi, Community Health Promoters (CHPs) play a pivotal role in bridging the gap between healthcare systems and the local communities. One such remarkable individual is Wasiaya (aka Wasee), a CHP whose life story illustrates not only personal transformation but also the critical importance of mental health support, self-care, and ongoing training for CHPs.
A Role Model Born from Chaos
Wasiaya’s journey into community health work was anything but straightforward. Before stepping into the role of a CHP, Wasee’s life was marked by turmoil and emotional distress. Growing up in Korogocho, she experienced the harsh realities of urban slum life – domestic violence, substance abuse in her community, and the constant threat of gender-based violence (GBV). The lack of support systems and mental health resources left her feeling isolated and unable to cope with the trauma she carried.
Her chaotic past manifested in anger and emotional instability, making it difficult to navigate personal relationships and community interactions. Yet, these challenges shaped her and motivated her to change. “I was chaotic,” Wasee recalls. “I didn’t know how to deal with my emotions, and I felt trapped in a cycle of pain…”
Wasee’s transformation began when she was introduced to a training program by Amnesty International, focusing on GBV and Violence Against Children (VAC) prevention. The training not only equipped her with knowledge and skills to support victims of violence but also provided her with coping mechanisms to address her own trauma.
Working in Kisumu Ndogo, an area within Korogocho notorious for high cases of GBV and VAC, Wasee began to connect with survivors and support them in accessing health services and legal aid. Through this work, she found a sense of purpose and healing. “Helping others allowed me to heal parts of myself,” she reflects.
Mental Health Gaps: A Hidden Burden
As a CHP, Wasee quickly realised that mental health was an often-overlooked aspect of community well-being. Many community members, burdened by poverty and violence, struggle with anxiety, depression, and trauma. However, stigma and lack of access to mental health services prevent them from seeking help.
“There’s some stress that can’t be hidden,” Wasee says. “But people here fear judgment, so they suffer in silence.” During a mental health session in Mathare, another informal settlement in Nairobi, she witnessed how stigma silenced those in need of support.
For CHPs like Wasee, the mental health burden is twofold—they not only support their community but also carry the emotional weight of the stories they hear. “We carry the community’s struggles on our shoulders, but who carries us?” she asks.
In her experience, women are more open to sharing their struggles, while men often suppress their emotions due to cultural expectations. This gender disparity further complicates mental health interventions in Korogocho. “The ladies are able to share,” Wasee notes, “but men feel that admitting to mental health challenges makes them weak.”
One of the most significant barriers Wasee faces in her work is the broken referral system. While CHPs are trained to identify mental health issues and refer severe cases to healthcare facilities, the limited availability of mental health professionals and long waiting times often leave patients without support. “It’s hard to refer someone when you know they might not get help soon enough,” she says.
While CHPs are vital in linking communities to healthcare services, being a CHP means carrying the weight of the community’s health, encountering difficult conditions and significant struggles, including:
Heavy Emotional Burden: CHPs often bear the emotional weight of community members’ struggles, leading to stress and burnout.
Limited Mental Health Support: There is minimal access to mental health support for CHPs themselves, despite their exposure to trauma.
Stigma and Discrimination: Mental health stigma in communities makes it difficult for CHPs to address these issues openly.
Inadequate Training: Short, one-off training sessions are insufficient. Continuous and inclusive training is necessary for CHPs to stay effective.
Referral Challenges: Limited healthcare infrastructure and long waiting times hinder effective referrals for mental health cases.
Gender Disparities: Women are more likely to share their struggles, while men often suppress their emotions due to cultural expectations.
Lack of Recognition and Support: CHPs are often undervalued and lack financial support and resources to perform their roles effectively.
Wasee believes that for CHPs to be effective, continuous training is essential. “One or two days of training is not enough,” she emphasises. “We need ongoing learning opportunities that are inclusive of all CHPs, especially in mental health support.”
Today, she is recognised as a role model in her community. Her journey from chaos to advocacy inspires other young women and men to join the fight against GBV and support mental health initiatives. Through her work, she is not only helping to heal her community but also breaking the stigma surrounding mental health.
“I found my healing in helping others,” Wasee says with pride. “But I also know that as CHPs, we need support too. When we are mentally well, we can serve our communities better.”
Wasee’s story is a powerful reminder that CHPs are not just service providers; they are individuals with their own struggles and triumphs. Investing in their mental well-being, providing continuous training, and creating supportive networks are essential to building resilient health systems in communities like Korogocho.
As the SHINE project continues to advocate for the mental well-being and agency of CHPs, stories like Wasee’s serve as a beacon of hope and a call to action for policymakers, healthcare providers, and community members to prioritise mental health at all levels.
Written by Freshiah Njoroge, a communication expert supporting the SHINE project, at LVCT Health
Community Health Workers (CHWs) are essential to the success of healthcare systems, particularly in low- and middle-income countries (LMICs) like Kenya and Bangladesh. CHWs bridge the gap between formal healthcare facilities and underserved populations, ensuring that even the most marginalised communities receive basic health services. However, their role comes with immense challenges, from overwhelming workloads to a lack of resources, training, and psychological support. These stressors often take a toll on their mental well-being and can hinder their ability to deliver quality care.
Recognising this, the Strengthening health systems by addressing community health workers’ mental well-being and agency (SHINE) project has embarked on an innovative approach to strengthen health systems by addressing the mental health and agency of CHWs in both urban slums and remote rural areas in Kenya and Bangladesh. In Kenya, the urban informal study sites are; Viwandani and Korogocho, both in Nairobi City County. The rural setting study sites on the other hand are Lari and Gatundu North which are both in Kiambu County. The project, which runs from 2023 to 2026, aims to ensure that CHWs are resilient, well-supported, and equipped to thrive in their roles. The interdisciplinary team comprises researchers, implementers, policymakers, CHWs, government (National and County) and, non-governmental organisations.
Understanding the Challenges Faced by CHWs
CHWs often find themselves working in some of the most challenging environments, dealing with heavy caseloads, limited training, and poor working conditions. These issues are amplified in LMIC contexts, where health systems are already strained. In Kenya’s urban slums and Bangladesh’s rural regions, CHWs are critical in providing preventive care services at household level s ranging from infectious diseases, water and sanitation, maternal and child health. However, the personal and professional stressors they face—be it societal expectations, financial constraints, or limited access to mental health services—can diminish their productivity and emotional resilience.
Without appropriate support structures, these health workers are at risk of poor mental health outcomes, which could ultimately affect the communities they serve.
SHINE is designed to tackle these complex challenges by focusing on four main objectives:
1. Identifying strategies for well-being
The project aims to develop strategies and programs that promote CHW mental health in a way that is equitable, sustainable, and contextually appropriate. By examining the diverse experiences of CHWs in Kenya and Bangladesh, SHINE will gather insights into the most effective ways to address mental well-being within these settings.
2. Co-designing innovative interventions
At the heart of the project is co-design. CHWs, along with healthcare system leaders, are involved in shaping innovative interventions tailored to their unique challenges. These interventions will address not only the mental health aspects but also social, material, and human stressors that affect CHWs on a daily basis.
3. Enhancing existing support approaches
SHINE seeks to enhance the quality and equity of existing support structures within the health systems of both countries. By doing so, the project will ensure that CHWs receive adequate mental health support, with a focus on addressing their diverse needs, whether they arise from personal stress or job-related demands.
4. Advocating for CHW mental well-being
Beyond direct intervention, SHINE also aims to contribute to the growing body of evidence on CHW mental health. The project’s findings will provide critical insights for future program design and research, influencing policy-makers and health system stakeholders to prioritize mental health support for CHWs across other LMICs.
The lessons learned from the SHINE project are not limited to Kenya and Bangladesh. By conducting cross-contextual and cross-country comparisons, SHINE will develop a scalable framework that can be adapted and implemented in other LMICs. The goal is to create a global movement that recognizes the mental well-being of CHWs as central to the functioning of robust health systems.
As the project progresses, SHINE will engage with various stakeholders, including local communities, health system leaders, and international organizations, to ensure that the support structures developed are inclusive, sustainable, and adaptable.
Written by Freshiah Njoroge, a communication expert supporting the SHINE project, at LVCT Health
Imagine giving someone a camera and asking them to tell their story through images. The narrative shifts from words alone to something more powerful—visual, tangible, and deeply personal. This is the essence of Photovoice, a participatory research method that merges photography with storytelling, empowering individuals to share their lived experiences. Developed by Wang and Burris in the 1990s, Photovoice serves as a tool for community engagement, fostering dialogue, bridging gaps in understanding, and inspiring action. By enabling individuals to document their realities, it elevates marginalised voices and presents compelling visual narratives that demand attention and change (Hanna & Hanna, 2023).
In mental health research, Photovoice has gained prominence as an approach that uncovers deep insights into lived experiences. One study highlighted how participant-produced photographs captured the stigma, struggles, and recovery journeys of individuals with mental illness (Han & Oliffe, 2016). This demonstrates the transformative potential of Photovoice—not just in research, but as a means of advocacy and system-wide change. The SHINE Project—Strengthening Health Systems by Addressing Community Health Workers’ Mental Well-Being and Agency—integrates Photovoice to document the realities of Community Health Workers (CHWs). Through this method, CHWs become active participants rather than subjects of research, using photography to illustrate their daily experiences. A picture of an empty clinic, an overburdened health worker, or a rare moment of camaraderie among colleagues tells a story that words alone may struggle to convey. By capturing these moments, CHWs highlight their challenges, their resilience, and the systemic changes required to support their mental well-being.
My life feels like this tree — tired and worn from the daily struggles of work and home. But I still have hope. Just like the tree grows new leaves after a tough season, I believe better days will come for me too. – Farida, Female, Barisal
This participatory approach strengthens advocacy efforts by ensuring CHWs’ voices are heard in discussions with policymakers and health system stakeholders. The images they produce serve as evidence, making the case for more supportive policies, better working conditions, and mental health resources within the healthcare system.
However, it’s important to remember that every step of the photovoice process—from building rapport to sharing the findings—shapes the quality and impact of the outcome. Photovoice is not simply about taking random pictures; —it’s about seeing the world through the eyes of those who live in it. Imagine a group of participants gathering in a small room, some hesitant, others excited, holding cameras or smartphones in their hands. Their mission? To tell their own stories, in their way. Here’s a glimpse into how it was done:
Implementing photovoice in SHINE: a step-by-step process on how to implement photovoice in mental health research
1. Setting the stage: Start with a purpose
The orientation begins with a conversation. Not a lecture, but a dialogue—where laughter, concerns, and curiosity mix. In this stage, researchers inform the participants- co-researchers- about the project goal, and CHWs discuss their role in shaping its outcomes. Participants express their hopes, concerns, and the hidden realities they want to bring to light. Trust-building is crucial—Photovoice is not about perfect images but meaningful storytelling
2. Finding the storytellers
Participants are chosen based on their lived experiences within the healthcare system. A diverse group, considering factors such as age, gender, and geographical location, enriches the collective narrative.
3. Learning the art of seeing
Before stepping into the field, participants engage in hands-on practice. This is a good time to inform them about the ethical considerations of taking pictures. Some are familiar with photography; others hold a camera for the first time. They discuss angles, lighting, and framing, but most importantly, they explore what makes an image speak. Every shot has a purpose. A discarded prescription slip, a quiet street at dusk, a waiting room filled with anxious faces—each image carries a message.
4. Capturing everyday realities
CHWs document their daily experiences over a set period, capturing the struggles, triumphs, and nuances of their work. These images provide raw, unfiltered insights into their mental well-being and professional challenges.
5. Analyse together- bringing stories to life
When the CHWs reconvene, they sit in a circle, sharing their photos one by one. Participants explain the significance of their photos, providing context and depth. Themes and patterns emerge as participants and researchers collaboratively interpret the photographs. This shared process ensures the findings remain authentic and representative of diverse community voices.
6. Turning images into action
The final phase involves using these visual narratives for advocacy. CHWs decide how their stories will be shared— whether through community exhibitions, policy forums, or digital campaigns. The images become powerful tools for influencing decision-makers and advocating for systemic improvements in mental health support for CHWs.
Photovoice is more than just a research method – it is a tool for empowerment, advocacy, and change. By integrating Photovoice into the SHINE Project, CHWs are given a platform to voice their realities in ways that demand attention and action. Their stories, captured in powerful images, illuminate the urgent need for mental health support and systemic reform within community health systems. Through this approach, the SHINE Project not only amplifies CHWs’ voices but also paves the way for a more responsive and supportive healthcare environment.
Written by Obaida Karim and Semonty Jahan
References:
● Hanna, L., & Hanna, L. (2023, November 16). Photovoice as a research method for community development. Applied Worldwide | Making Sociology Count. https://appliedworldwide.com/photovoice-as-a-research-method/
● Strack, R. W. (n.d.). What is Photovoice: a brief summary. In University of North Carolina Greensboro. Retrieved December 19, 2024, from https://communityengagement.uncg.edu/wp-content/uploads/2019/11/What-is-Photovoice-A-Breif-Summary_Strack-Dec-2017.pdf
● Skovdal, M., & Rumi, Sk. R. Ullah. (n.d.). Photovoice guidance: 10 simple steps to involve children inneeds assessments. Save the Children. https://bangladesh.savethechildren.net/sites/bangladesh.savethechildren.net/files/library/Photovoice_needs_assessment_guidelines_full_report_0.pdf
● Han, C. S., & Oliffe, J. L. (2016). Photovoice in mental illness research: A review and recommendations. Health:, 20(2), 110-126. https://www.jstor.org/stable/26652338
