The role of community health workers (CHWS) in addressing social determinants of health in Chhattisgarh, India
The aim of this research was to describe the role of Community Health Workers, in the Mitanin Programme, in addressing social determinants of health in Chhattisgarh State of India, with the view to identify the pathways for strengthening and making recommendations on this aspect of the CHW’s work for existing or future CHW programmes. A comparative case study design using qualitative research methods was adopted for the study, with the sample comprising of two case studies of action on social determinants by CHWs. The definition of a case was ‘successful action by a CHW (Mitanin) or team of CHWs (Mitanins) on nutrition or violence against women in the village or cluster of villages for which the CHW/s are responsible’. The sampling of the cases followed the ‘replication logic’, that is, examination of similar cases to draw general lessons. Data collection was undertaken through In-depth Individual Interviews and Group Interviews with CHWs, community members and programme staff that participated with the CHWs in, and also benefitted from, their action on social determinants. Respondents were identified through a process of snowball sampling. Seventeen in-depth interviews and ten group interviews (total 27) were conducted as part of the study. A broad conceptual framework of the factors facilitating and constraining the action on social determinants by the CHWs, along with the pathways for action on social determinants by the CHWs, along with the pathways for action on social determinants by CHWs and their role, was developed at the start of the research. The analysis was done using this conceptual framework, which was refined during analysis, resulting in an explanatory framework. The analysis was two-fold. Firstly, both cases were analysed and written up separately and then they were analysed together in order to draw cross case conclusions. Thematic analysis was undertaken. Ethical Clearance was obtained from the UWC Senate Research Committee and permission was obtained from the State Health Resource Center, the body coordinating the Mitanin Programme in Chhattisgarh. A Participant Information Sheet and Informed consent forms for both the individual and the group interviews were prepared and administered. The form for the group interview included a confidentiality-binding clause. The study showed that the Mitanins in Durgkondal and Manendragarh (the Blocks under study) had effectively and successfully addressed the issues of nutrition and xvii violence against women as social determinants, in a manner visualized in the initial programme documents. Despite threats to the autonomy of the programme, pressures to formalise the Mitanin’s role, and backlash from vested interests, such action remained sustained, nearly ten years since the start of the programme.