In the medical field, the attention is usually paid to physicians and nurses. However, at the intersection of society, there are the community health workers (CHWs) who have the burden of walking footpaths to access the far-flung houses practicing health education in the sun and serving as the meeting point of the medical systems and the population. And in helping others, many do not take into consideration the price they pay psychologically.
CHWs are faced with grief, poverty, resistance, and structural constraints, and they receive no formal emotional or psychological services on a daily basis. The result? An increasing wave of burnout, anxiety, and depression which even remains unanswered by the systems in which they belong to.
Discover more about the life and functions of a community health workers and how one should take this area of their mental health more seriously.
This article reveals the underlying emotional stress that CHWs are grappling with and gives them a platform to voice their experiences with moving testimonies and suggests structural changes that could safeguard the mental state of CHWs.
The invisible Toll of Frontline Work
CHWs are part and parcel of the community they work in. They are not far away medical professionals, they are neighbours, sisters, brothers, mothers and friends. Coupled with building mutual trust, this proximity also implies that they have to take all the emotional impact as the community suffers.
- Exposure to Trauma
Community health workers witness:
- Maternal deaths and stillbirths
- Children dying from illnesses that are preventable or malnutrition
- Abuse and gender based violence
- Chronic condition in a bare or little support system of care environments
Such events are traumatic. However, CHWs have to hold on many times to show that they are powerful to patients.
“At a time I helped a mother deliver on the ground of a small shack. The baby unfortunately did not survive. She wailed all night while I stayed to comfort her. But who stayed beside me?” Fatima, Community Health Worker, Northern Nigeria
- Chronic Overwork and Burnout
Usually, CHWs have 10-14 hours of a working day. They do consider things to be done such as:
- Household surveys conducted
- Spearheading vaccination campaigns
- Getting in touch on treatment adherence
- Giving health lectures
- Reporting and collecting information
Majority of CHWs are poorly paid or receive low stipends despite the hectic work that they have to handle. They should never run out, they should always be emotionally there, they should always have a physical strength.
Emotional Outcomes Include:
- Cynicism toward the system or patients
- Chronic fatigue
- Emotional separation
- Job satisfaction decline
Isolation and Lack of Validation
In a lot of places, CHWs are the only agents assigned in the scattered rural areas. They do not meet supervisors or peers very often. Moreover, they are likely to be undermined on the basis of being “unskilled” or “voluntary” when they are performing the main care duties.
“No one raise claps for us. No one appreciates with a gratitude. We are invisible in the eyes of the government unless they need information.” Esther, Community Health Worker, Western Kenya. Such individual seclusion becomes aggravated by a sense of being of no use and results in depressive symptoms.
Gaps in Mental Health Support
Although CHWs are increasingly seen as key people in the medical industry, there are minimal programs that provide the mental healthcare that may be required to keep their emotional wellness. The gaps are some serious holes, which are the following:
❌No Structured Debriefing Sessions
Unlike the clinicians, CHWs have no formal avenues of debriefing the tough calls or the traumatizing incidences.
❌Lack of Access to Counselling or Therapy
Regardless of the area where mental health service is available, CHWs have scarcely been considered as either a client or a beneficiary.
❌No Psychological Training in CHEW Curricula
No training projects focusing on technology skills at the expense of the management of stress, trauma management, or emotional intelligence are available.
❌Absence of Workplace Policies on Burnout Prevention
In the majority of the ministries or NGOs, there are no protocols of CHW rest days, stress leaves, or emotional injury.
The Mental Health Consequences
CHWs are left on their own, resilience crumbles, they and literally and figuratively run out of their load of the emotional labor. Some of the common ones include:
- Burnout: A state of fatigue in emotional, physical and mental levels that reduce one to be less effective and less understanding
- Anxiety: continuous worrying about patient personal safety, outcomes or job security
- Depression: feelings of withdrawal, guilt, hopelessness or sadness
- Vicarious Trauma: Absorption of trauma of other people and resulting psychological discomfort in the long term
In severe cases, when mental health problems are untreated, the consequence of it may lead to:
- Family breakdowns
- Suicidal ideation
- Substance misuse
- Disengagement from health work
Real Stories, Real Struggles
Case 1: Grace, CHW in Rural Uganda
Grace assisted more than 200 families in an outbreak situation of typhoid. She would walk 15 km a day and most of the time used her own household food. She was exhausted after losing 3 children in her custody within seven days and this is when she collapsed. Nothing was followed up. It is two days later when she goes back to work, silently.
Case 2: Ahmed, CHW in Northen Nigeria
In one case, Ahmed was attacked by fellow members of the community who were wary of the vaccine during a polio vaccination campaign. He became extremely anxious, and did not know who to address to or whom to turn to with his emotions. He can no longer engage in campaigns and is scared to die.
According to these testimonies, we find that CHWs are forced to live with invisible wounds and no institutional mechanisms upon which they can be healed.
Why it Matters to Everyone
Mental health of CHWs is not a niche problem but the whole health system is challenged.
⚠️Poor CHW Mental Health Leads to:
- Reduced quality of service
- Errors in information treatment or reporting
- Higher absenteeism
- Increased dropout from health programs
✅ Mentally Well CHWs Contribute to:
- More community stronger relationships
- Better health care service to everybody
- Better health outcomes
We support the whole system when we take care of CHWs.
Institutional Changes That Must Happen
Now, it is high time to bring the mental health to the fore as an important element of the CHW program design. The recommendations involved the central evidence- and frontline-informed recommendations, which are as follows:
- Embed Mental Health Training in CHW Curriculum
Training of CHEW should entail mental health literacy. They must be subjects:
- Self care strategies
- Establishing emotional boundaries
- Emotional first aid
- Identifying signs of trauma and stress
This positions CHWs to be aware of their state of mind and help them get assistance at an early time.
- Create Structured Peer Support Networks
Peer networks enable CHWs to ventilate, talk, and have their issues understood since their counterparts are on the same shoes.
Model:
- Monthly virtual group or in person meetings
- Turning peer facilitators
- Privacy agreements to make sure there is safety
These networks of peers may be very helpful to avoid isolation and to normalize emotional communication.
- Provide Free or Subsidized Counselling Services
Mental health service should be offered to CHWs by the government agencies, non-governmental organizations or by donor organizations, including:
- Access to expert counsellors or therapists
- Helplines for crisis counselling
- Pathway referrals for traumatic treatments
These services are capable of being incorporated into the established health structures in order to reduce the costs involved.
- Institute Mandatory Debriefing After Critical Events
CHWs should be supported quickly with a psychological response after such incidences as child deaths, epidemics, or violence.
Process:
- Mental health professionals are able to conduct debriefing with individual patients or as a group
- Time to meditate, cope with feelings and acquire skills to control them
This reduces psychological exploitation and psychological damage in the long-term sense.
- Develop CHW Wellness Policies
Wellness needs to be made operational through policies which require:
- Regular rotational schedules and rest periods
- Mental health leave days
- Establish in time for peer check ins and reflection
- Reward systems and recognition
Institutions safeguard the long-term performance of their workers by incorporating a non-negotiable policy towards wellness in them.
A Global Shift: What Others Are Doing
Some countries have initiated the emanation of the CHW mental health support systems:
- India: Brought in the workshops of stress management and yoga sessions for ASHA’s known as “Accredited Social Health Activists.”
- Liberia: Learned and well thought mental health workers in providing debriefings for Community Health Workers after COVID-19 surges.
- Brazil: The community health agents get mental health days and the availability of psychologists on the municipal level.
The examples show that structural support can also be achieved with commitment and political willingness.
The Role of Communities
Communities also play a very important role in supporting community health workers:
- Giving CHWs a recognition when village meetings are done
- Giving emotional assistance when CHWs encounter stress or loss
- Giving an encouragement to CHWs to be able on taking some breaks when needed
- Adding CHWs in spiritual or cultural healing practices
Community culture of care should be established at the grassroots level and grow upwards.
Conclusion: We Must Do Better
CHWs are not robotized. A king is a man, he has to perform emotions based duties as well as physically challenging duties. They bear stories of mothers, misery of the sick and malfunction of faulty systems. However, no one is supposed to bear such weight all by himself.
To be able to maintain primary healthcare, we have to see beyond the frontlines. We need to realize the tears that people have suppressed, the exhaustion behind the smile and the strong person that is hidden behind the silence. and we must do something.
Let us construct systems in which Community Health Workers can be allowed to say, I am not okay, and be sure they will be listened. Will we make our future real and have treating the caregivers not an option, but a norm?
The ones who sustain the health of our communities should be whole as well.
