CHWs as Researchers.

Lwala Community Alliance

THE PROBLEM & OUR APPROACH

A FOCUS ON COMMUNITY HEALTH.

CHWs bring primary health services straight to their neighbors’ doorsteps, extending the reach of the healthcare system to rural and remote communities. Their roles and work have been increasingly a focus of research – 2000 studies focussed on CHWs globally have been published over the last five years alone! Despite this, CHWs are often excluded as authors and key decision-makers in this research.

This exclusion potentially hinders the quality, relevance, and effect of CHW-related research. As trusted community members with a unique understanding of the local context, meaningful involvement of CHWs can enhance many aspects of research design, processes, and outcomes. 

No estimates existed on the role of CHWs as co-authors or the extent to which they are acknowledged for their role in this work. As a Coalition, we set out to change this. Our research team consisted of 34 co-authors from 4 WHO Regions, 62% based in a low-and- and middle-income countries, and 12 of whom are CHWs. Together we conducted a scoping review to identify all relevant publications between 2018-2023, logging the specific design, implementation and dissemination roles of CHWs in 2000 studies. And we conducted an email survey to corresponding authors requesting they indicate which, if any, of the authors in their manuscript were CHWs.

EXCLUDED FROM RESEARCH

Our findings confirmed that CHWs were rarely included meaningfully in community health research. CHWs were only involved in study design 7% of the time and dissemination 2% of the time. And while CHWs played a role in study implementation 45% of the time, CHW researchers were only named as co-authors in 15%, and acknowledged at all in 32%, of studies! 

This under-appreciation reflects systemic power imbalances within global health research, which often fails to adequately recognise or involve non-academic actors. One cause may be stringent guidelines concerning authorship attribution, which can inadvertently exclude CHWs by prioritising scholarly contributions over technical tasks. Barriers to inclusion across the research process, like language differences and a lack of training in research methods also prevent meaningful participation in data analysis and manuscript writing.

Dimagi

FIXING AN INEQUITABLE SYSTEM.

These moral and technical failings exist within global health systems that are all too often held up by the unpaid and undervalued labor of CHWs.

As trusted community members with a unique understanding of the local context, meaningful involvement of CHWs can enhance many aspects of research design, processes, and outcomes. They can ensure the choice of suitable methods for the context, ensure inclusion of under-represented populations, and provide contextual interpretation for data analysis. And as recognized community leaders CHWs can share findings within their communities and encourage access and uptake of interventions. 

For too long, discussions about community health workers have been happening without CHWs. It’s time for a change. Formal acknowledgement as co-authors promotes equity, fosters a sense of shared ownership and responsibility, and cultivates inclusive research practices. It can also be leveraged by CHWs for professional development and career progression.

Ultimately, recognising the contributions of CHW researchers supports more equitable, impactful global health research.

AUTHORS PODCAST.

Recently, two of the papers authors Dr. James O’Donovan, Director Research, Community Health Impact Coalition and Dickson Nansima Mbewe, CHW Advocate and Organizer, Ministry of Health Malawi sat down with the ‘Survey & Beyond’ podcast to discuss our findings and next steps.

Listen on Spotify

Wandikweza

THE ROAD AHEAD.

WE MUST WORK TOWARDS THE EQUITABLE INCLUSION OF CHWS AT EVERY STAGE OF RESEARCH.

In conclusion, Coalition researchers noted:

“Our findings highlight the significant gap between the extensive focus on CHWs in research and their recognition as coauthors. This gap reflects both systemic power imbalances between researchers and CHWs and few opportunities for meaningful participation of CHWs.”

 

Crucial next steps involve:

  • investigating the presence and effect of inclusivity mechanisms adopted by journals and funders supporting CHWs that act as gatekeepers.
  • updating and tailoring authorship guidelines to better reflect global health research contributions from non-academic actors.
  • exploring practical and desirable approaches to integrate CHWs into the research process.
  • developing standardised reporting guidelines for CHW involvement.

Get the details in Lancet Global Health