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Walking Miles for an Interview: Lessons from the Household Level Survey in Barishal and Mymensingh
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Walking Miles for an Interview: Lessons from the Household Level Survey in Barishal and Mymensingh

Walking Miles for an Interview: Lessons from the Household Level Survey in Barishal and Mymensingh

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We often walked for hours through fields, woods, and along riverbanks just to find one household. And sometimes, by the time we arrived, the man we were supposed to interview had already left the house for work.

Between February and March 2025, the SHINE Bangladesh team travelled to Mymensingh and Barishal to conduct a baseline survey for the SHINE project.  Our plan was to cover five subdistricts each in the Barishal and Mymensingh districts. The subdistricts in Barishal are mostly river-oriented and remote, where commuting often requires crossing waterways. In contrast, the subdistricts in Mymensingh are largely industrial and host internally migrated communities. There are areas located near the international border where movement by outsiders is often restricted due to political tensions and limited transportation options. It was fulfilling work but also full of twists, turns, and lessons we didn’t expect.

According to the sampling design, we had to move every 10 households to collect data.  The distance between two homes wasn’t just a number. The maps don’t tell you how rough the roads are—or how much your legs will feel it later. Especially in Barishal’s char areas (river islands), reaching homes was a journey in itself. We walked through muddy paths and broken roads and even crossed small rivers. Sometimes, a boat was the only way forward, and we had to wait for hours to get a boat to cross the river. Other times, it was a hired motorbike ride followed by a 30- to 40-minute walk on the edge of a paddy field. Some clusters were so scattered that reaching the next household felt like trekking to a new village altogether.

Even after walking for miles to reach the households with the formed clusters at villages, one thing quickly became clear that in both districts, catching the male household head at home was not an easy task. In most cases, they would be out of their houses for work; some were nearby, others far away. It got even tougher during the harvesting season. We found ourselves going back to those homes more than once, adjusting our timing or rescheduling the interview.

Almost half of the data collection happened during the holy month of Ramadan, and that changed a lot of our daily work patterns. Many women were busy with prayers, preparing iftar, or simply didn’t feel up to talking during the day while fasting. On the other hand, in more conservative char regions, sometimes religious norms made it difficult for male data collectors to speak directly to women, which meant in those cases we had to rely more on female team members or reschedule visits, or sometimes both.

The sampling plan looks good in the office, but in real life, villages don’t always follow our spreadsheets. In some places, there just weren’t enough eligible households, so we had to move beyond the original boundary. That meant more walking, more coordination, and fewer interviews per day. And the “every 10th household” rule? In areas where homes are far apart or irregularly spaced, sticking to that “every 10th household” rule became a logistical puzzle. We had to have an instant short team meeting at field sites with the team lead and field team to make adjustments while keeping the integrity of our data quality.

In the Dhobaura subdistrict, Mymensingh, we hit a difficult situation. A recent incident of sexual violence had shaken the community where we were supposed to collect data, and the atmosphere was tense. Police patrols and local gatherings made it nearly impossible to continue fieldwork for a while. We had to be very strategic and careful during that tense time. And in border-side unions like Dokkhin Maijpara, in Dhobaura subdistrict, where cross-border unrest is common, outsiders (like us) weren’t always welcomed with open arms. Some community members were wary or suspicious, and earning trust became part of the job. Inspection by border guards was common while commuting to the targeted households.

If this fieldwork taught us anything, it is that maintaining methodological rigor while remaining flexible, both in scheduling and in mindset, is essential. In future field plans, we need to consider wider data collection windows, aligned with local routines (i.e., harvesting time, Ramadan, etc.). We should consider gender-matched field teams, especially in culturally sensitive areas like ours. Field plans should have time for community outreach ahead of data collection, to ease suspicion and build rapport, and account for terrain and travel time, not just sample size.

SHINE isn’t just about surveys. It’s about connecting with communities, listening closely, and making sure those often left out are finally counted—and heard.

Written by: .
Ranjan Koiri (Senior Research Associate, BRAC JPGSPH, BRAC University),

Sukamal Chakma (Sr. Officer, Data Management, BRAC JPGSPH, BRAC University),

Md. Arfat Uddin (Sr. Officer, Data Management, BRAC JPGSPH, BRAC University)

Prioritising the Mental Well-being of Community Health Workers: SHINE Project

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

Data Linkage

The hidden burden: The Reasons Community Health Officers feel more stress than Community Health Promoters

Community Health Officers (CHOs) supervise the CHAs inorder to ensure they fulfil their performance goals and provide high-quality healthcare services. It was clear from a recent meeting in Korogocho (which is an urban informal settlement) with both CHOs and CHPs that CHOs frequently endure higher stress levels than CHPs.

The CHOs expressed that their stress stems from the fact that their performance is directly tied to the success or failure of the CHPs. If CHPs do not meet their targets or fail to deliver as expected, it negatively impacts the CHOs’ evaluations. Additionally, CHOs are often caught between the demands of their supervisors and the challenges in the community that are managed by the CHPs, creating a high-pressure environment.

One major source of stress for CHOs is the performance-based system implemented through the electronic Community Health Information System (eCHIS). Under this system, in order for the CHPs to get their stipend they must achieve an 80% target by visiting at least 33 households and making referrals, unlike when the process was manually because the CHOs now have no control over the system-generated results. Previously, CHOs could intervene to adjust scores to ensure CHPs received their stipends, but this is no longer possible.

Sometimes CHPs achieve the required 80% but still do not receive their stipends. When this happens, CHAs must handle complaints and provide explanations, despite having no control over the system. When the stipends delay, the CHOs are usually called late at night or early morning by the CHPs seeking answers, further adding to the CHO’s stress. In many cases, CHOs are forced to give CHPs false reassurances just to prevent excessive follow-up calls, all while dealing with the uncertainty themselves.

CHPs receive a total stipend of Ksh6,000, comprising Ksh3,500 from the performance-based and Ksh2,500 from the national government. However, these payments are not made simultaneously, and the national government often delays disbursements for months. This financial uncertainty contributes to frustration among CHPs, which in turn increases the stress on CHOs who must handle their grievances.

Both CHOs and CHPs acknowledged that the pressures of their roles contribute to burnout, disagreements, and workplace tension though afterwards they laugh about them. There was a request for a structured mental well-being interventions and debriefing sessions for both CHOs and CHPs to help them cope with the demands of their work.

The role of CHOs extends beyond supervision for they are the bridge between CHPs and the healthcare system, often bearing the brunt of systemic failures. It is important to address their mental well-being for it will be impactful to effectively fulfill their critical roles in community health services.

By Faith Munyao

what motivated me to take this picture was the realization that, as a volunteer caregiver

Through the Lens of Mercy: The Silent Struggles of a Community Health Promoter

Mercy* is a Community Health Promoter (CHP) in Viwandani, an informal settlement in Nairobi, Kenya. The name Viwandani, which means “Industries” in Kiswahili, reflects the settlement’s proximity to numerous factories. It is a place known for its bustling workforce, narrow pathways, and a maze of loosely hanging electrical wires—some dangerously exposed. Navigating these precarious conditions is a skill on its own, and for CHPs like Mercy, it’s just one of the many daily challenges they face.

The Backbone of Primary Healthcare

Globally, Community Health Workers (CHWs)—now referred to as CHPs in Kenya—are the lifeline between informal communities and formal healthcare systems. In low-resource settings, they are often the only accessible health providers for many urban and rural poor. In September 2023, the Kenyan government rebranded CHWs as CHPs, making them the key drivers of Universal Health Coverage. Each CHP is responsible for at least 100 households, visiting them to promote health awareness and prevent diseases. However, for Mercy, this number has increased to 117 households following the devastating floods of August 2024, which left many CHPs displaced and communities in turmoil.

Despite their critical role, CHPs remain overworked, underpaid, and largely unrecognized, facing immense emotional and financial strain. The mental toll of their work is often overlooked, yet emerging evidence from Africa and Asia highlights the severe stress they endure due to excessive workloads, inadequate training, and insufficient compensation.

The NHIR-SHINE Study: A Glimpse into the Lives of CHPs

Mercy is among the 14 co-researchers participating in the NHIR-SHINE study, a collaborative initiative led by LVCT Health in Kenya, APHRC, BRAC in Bangladesh, and LSTM in the UK. This study seeks to explore the strengths, challenges, and opportunities for enhancing CHPs’ mental well-being in low- and middle-income countries.

Utilizing mixed methods, including surveys and Community-Based Participatory Research (CBPR) approaches such as Photovoice, Narrative Timeline Interviews, and Body Mapping workshops, the study captures the realities of CHPs’ lived experiences. Through Photovoice, Mercy has visually documented the challenges and motivations that shape her daily work. Her images tell a story of resilience, hardship, and hope.

 

what motivated me to take this picture was the realization that, as a volunteer caregiver

“What motivated me to take this picture was the realization that, as a volunteer caregiver, I couldn’t provide a balanced diet for my own family. It hurt me a lot because I am the one who goes out to teach others about healthy eating, yet I can’t afford it for my own children. It causes me so much stress.”

Mercy’s struggle is not unique. A report by the African Cities Research Consortium (ACRC) highlights that residents of informal settlements suffer from malnutrition, stunted growth, and micronutrient deficiencies due to food insecurity. The paradox is painful—those tasked with promoting nutrition are often the ones struggling to afford it.

With meagre earnings, CHPs like Mercy are forced to take up side jobs, hoping to supplement their income. Some days they find work; other days, they don’t. The stipend they receive is barely enough to survive, yet they continue serving their communities with unwavering dedication.

In Mercy’s case, the preacher who preaches wine ends up drinking water! This causes significant stress to Mercy as she helplessly watches her young family feed an unbalanced diet due to her financial limitations. “This condition exists because, as a CHP, the income I receive is very little, so I have to push myself to find other side jobs to supplement the stipend I get. Sometimes I manage to find extra work, and sometimes I don’t, and whatever I earn from that is what I use to provide for my children at home. So, the little we earn as CHPs also contributes to this situation.” She speaks.

Living in Constant Fear: The Burden of Uncertainty
Anxiety has become a constant companion for many CHPs, exacerbated by unsafe living conditions. Studies show that chronic anxiety not only affects mental health but also has severe physical consequences. The fear of losing everything at any moment adds an emotional burden to an already overwhelming job.

the houses got burned

“…the houses got burned. [Pauses] What this represents to me is the fear that I can leave home to work, only to return and find everything I own is gone. Every time I leave, even now as I’m here, I worry if I will find my things intact when I return.”

In Mercy’s community, fires frequently break out due to poor infrastructure, illegal electrical connections, and unsafe cooking practices. The lack of proper roads makes it nearly impossible for emergency services to respond in time.
“The biggest challenge is our infrastructure. Fire engines can’t access our homes when there’s an emergency. Most power connections are illegal, done by people without proper training, making it even more dangerous.”

An Overwhelming Workload: A System Pushed to the Brink
A 2024 systematic review on CHW workload and supervision in Indonesia revealed that many felt burdened by unrealistic workloads, disproportionate responsibilities, and inadequate incentives. The situation is no different in Kenya.
Although the Primary Health Care Act (2023) outlines CHPs’ roles, many find themselves drowning in additional, unofficial tasks. Mercy’s experience is a testament to this:
“As CHPs, we’ve been given so much work, yet our pay is so little. We are told to volunteer for two hours, but that’s impossible. We have to visit 33 households per month, collecting data on everything from child nutrition to maternal health. If one household has five people, we attend to all of them. By the end of the month, we’re exhausted, unable to look for other jobs, and surviving on a stipend that barely covers a meal for our children.”
The excessive workload, coupled with financial strain, takes a heavy toll on CHPs’ mental well-being. They find themselves stretched thin, juggling between serving their communities and meeting their own basic needs.

The Way Forward: A Call for Action
Mercy’s story is not an isolated case—it is the reality for thousands of CHPs across Kenya and beyond. To safeguard their mental well-being and improve healthcare outcomes, urgent interventions are needed:

  • Realistic Workload Planning: Policymakers must ensure CHPs’ responsibilities are manageable, allowing for a proper work- life balance.
  • Fair Compensation: Adequate stipends and financial incentives should be provided to sustain CHPs and their families.
  • Supervisory Support & Mental Health Services: Structured debriefing sessions and one-on-one counselling should be integrated into CHPs’ schedules.
  • Infrastructure Improvement: Informal settlements need better roads, safer electrical connections, and accessible emergency services.
I love going to watch the sunset

“I love going to watch the sunset because it makes you reflect on how life and nature are beautiful. Yeah, despite all the challenges you may be going through in life, the sunset reminds you that even though today is ending, tomorrow will bring a new day, new opportunities.””

CHPs are the backbone of Kenya’s primary healthcare system. Investing in their well-being is not just a moral obligation but a strategic move towards strengthening healthcare for all.

*Mercy’s name has been changed to protect her identity.

Blog by Patricia V. Okoth