Breaking the Silence on Gendered Harassment and Assault of Community Health Workers: An Analysis of Ethnographic Studies

"Taking gendered harassment and violence seriously in CHW programmes is critical for research and practice."

Globally, most community health workers (CHWs) are women. One reason for this tendency is gender norms: Accessing spaces inside households is often difficult for men, and, across a variety of programmes and contexts, women are often drawn to working as a CHW in the context of limited available options for paid labour. At the same time, gender norms are at the heart of many of the challenges and inequities these workers encounter. This article explores how gender roles and a lack of formal worker protections leave CHWs vulnerable to violence and sexual harassment, common occurrences that are frequently downplayed or silenced. It also provides suggestions for transformative ways forward, generated by CHWs themselves who have a vision of female CHWs being valued, supported, and empowered.

Written by a group of researchers who work on CHW programmes in a variety of contexts globally, this paper features three examples drawn from their ethnographic research over several decades (participant observation and in-depth interviews) - with details removed to avoid putting CHWs from identified research projects at risk.

For instance, example 3 is drawn from a study of "an internationally organised and funded CHW programme, implemented in collaboration with local governments and carried out by a local research team with a deep understanding of cultural context....The job carried a range of acute risks, both physical and social, but the value of a job that paid above minimum wage was sufficiently enormous - and rare - for women in this context that it was worth it to them to weather those risks....In this context, where local norms restricted women's mobility, and where there was community mistrust towards government and international actors, going door-to-door carried the potential to damage women's reputations...; gossip could lead both to community rejection and the loss of family support for working outside the home....Aside from pervasive anxiety about presenting themselves in a respectable manner, CHWs (and their male managers) also faced severe, intermittent violence in the course of their work. This ranged from being yelled at, to being hit with household objects, to being threatened with murder....A particularly painful aspect of workplace hierarchies and the vulnerability of CHWs in the setting of example 3 was sexual harassment....A harassment allegation could boomerang into a character smear with severe social and economic consequences. This made it difficult for CHWs to come forward."

CHWs in this example 3 study outlined a number of ways these dynamics interfered with their ability to provide quality health services. "First, when workers were scared for their safety in the field, they could not focus on activities like social mobilisation and data collection in the relaxed and meticulous way necessary for good relations and high coverage of interventions....Second, workers commented that when community abuse went unchecked, it exacerbated community perceptions that they had no real government backing, and their work was thus taken less seriously."

The CHWs in example 3 argued that programmes should continue to employ vulnerable women in low-income communities but that steps should be taken to protect them in their work, such as:

• To reduce community harassment: Increase their legitimacy and support from the government through documentation such as ID cards and public statements delivered via advertising and news programmes.
• To tackle harassement by supervisors: Establish a system where complaints could be made anonymously and carefully investigated, and perhaps hold regular harassment trainings to aid in culture change.
• To create the space and support for job advancement: Allow CHWs to have time off to take the examinations to gain the qualifications needed for higher-level (e.g., management) positions.

Overall, these three examples highlight that there are particular aspects of programmes and the societies in which they are embedded that make CHW harassment and violence more likely to happen, less likely to be reported, or both. The framework in figure 1 of the paper outlines these determinants and shows their effects. Identifying the determinants of violence can provide specific arenas in which to intervene to reduce the likelihood of these events.

Some of the domains in this framework - societal gender roles, and economic and social conditions - are largely beyond the power of health programme administrators to change. But others are within the purview of health policymakers. The paper reviews action steps for each of these areas that underlie CHW vulnerability:

• Hierarchy: "One clear take-away from the work featured here is that leadership matters. Good supervisors create the enabling conditions for healthy relationships, but the organisational structures that those leaders exist within are an even more important enabler of healthy workplace culture."
• Community-programme relations: "CHWs will also be safer if the people they are serving trust the model of service provision....CHWs are often deployed to convince hesitant communities to accept health interventions in cases where there may be opposition to those interventions [e.g., polio vaccination]. They are very effective at this - but we should also be aware that this can put them at risk and pay particular attention to safety in such situations."
• CHW spaces: "CHWs themselves are the experts in this arena and can suggest workflows that keep them safe. For example, safety considerations can lead to safer workplans such as events happening only during daylight hours, CHWs working in pairs rather than alone and regular reviews of CHW safety..."

The paper goes on to examine best practices - including training, assistance and counselling, and regular monitoring and evaluation - for dealing with harassment and violence when it occurs, offering several examples.

To help strengthen future research efforts in this sensitive, even risky, area of study, the researchers offer a research agenda that includes: encouraging CHWs to speak by building trust; taking coded language seriously; and actually listening. Beyond qualitative work, quantitative work can help illuminate the extent of the issue; a number of tools are listed.

In conclusion: "Fulfilling CHWs' vision of health programmes that value them, support them and give them opportunities may be a way for CHW programmes to lead the way in gender-transformative labour practices."