Empowering Community Health Workers to Support Behavior Change in Mothers
Community health workers (CHWs) are increasingly deployed to support mothers’ adoption of healthy home practices in low- and middle-income countries. However, little is known regarding the best methods to train them for the capabilities and cultural competencies needed to effectively engage with mothers and facilitate behavior change.
We tested a novel CHW training approach called “Sharing Histories” (SH) in a cluster-randomized trial in rural Peru. In this method, CHWs recount their own personal experiences of childbearing and childrearing, which serve as the foundation for building new learning and skills. Government health staff trained female CHWs using either the SH approach (experimental clusters) or standard training methods (control clusters). All other training and system-strengthening interventions were equal between the two study arms.
Key Findings:
- In the experimental group where CHWs were trained using the SH method, child stunting (low height-for-age) was significantly lower compared to the control group, but only among children of literate mothers.
- Literate mothers in the experimental group reported more positive health behaviors, such as handwashing and proper child feeding, compared to the control group.
- Qualitative interviews revealed that the SH training approach helped build CHWs’ confidence, empathy, and cultural competence in supporting behavior change among mothers.
These results suggest that the SH training method may empower CHWs to become more effective agents of behavior change, particularly for mothers with some education. This approach appears to resonate with traditional notions of knowledge-building through personal experience, fostering trust and engagement between CHWs and the mothers they serve.
Reaching Vulnerable Mothers through Culturally Competent CHWs
Peru is facing one of the fastest-growing equity gaps among low- and middle-income countries (LMICs) in the distribution of the benefits of development. The isolated and mostly rural Huánuco Region, located on the eastern slope of the Andes mountains, has one of the highest rates of child stunting (low height-for-age) in the country. Stunting is a key indicator of overall child well-being, reflecting the cumulative effects of poor fetal growth, inadequate nutrition, and infectious disease during the critical first 2 years of life.
These disparities are often rooted in deficient home practices related to maternal nutrition, breastfeeding, complementary feeding, micronutrient consumption, access to health services, and water, sanitation, and hygiene (WASH). Strikingly absent in Peru and elsewhere is an effective system to reach vulnerable, lesser-educated mothers with communication strategies that can change these entrenched health behaviors and practices.
Community health workers (CHWs) are well-positioned to address these challenges in a culturally appropriate way. However, a key question is how to help CHWs develop the cultural and personal competencies needed to effectively support behavior change among mothers, particularly those with low educational attainment.
Testing the “Sharing Histories” Approach for CHW Training
Our study tested the impact of the Sharing Histories (SH) training method, which is designed to improve CHWs’ cultural competencies and their ability to support improved maternal health behaviors. The SH approach is built on the premise that personal experience is the traditional basis of learning in many cultures. By having CHWs share their own memories and stories of pregnancy, childbirth, and childcare, the method aims to foster trust, empathy, and a deeper understanding of local cultural beliefs and practices.
We conducted a cluster-randomized trial in 18 matched clusters (primary health facility catchment areas) in rural Peru. In the experimental clusters, government health staff trained female CHWs using the SH approach. In the control clusters, CHWs received standard training methods. All other training and system-strengthening interventions were equal between the two study arms.
All CHWs then conducted home visits with pregnant women and children under 2 years of age, providing health education, monitoring practices, and making referrals as needed. The primary outcome measured was child height-for-age, a key indicator of stunting.
Sharing Histories Improves Outcomes for Children of Literate Mothers
The analysis revealed that in the experimental group where CHWs were trained using the SH method, the prevalence of child stunting was significantly lower compared to the control group – but only among children of literate mothers.
Specifically, the difference-in-differences analysis showed that among children of literate mothers, the mean height-for-age Z-score improved by an average of 1.03 points in the experimental clusters compared to the control clusters from baseline to endline (p=0.059).
In contrast, for children of illiterate mothers, there was no significant difference in height-for-age changes between the experimental and control groups.
These findings were further supported by the multivariate analysis, which demonstrated that the SH training method had a significant interaction effect with maternal literacy. The SH approach was associated with reduced stunting among literate mothers, but not among illiterate mothers, even after adjusting for other covariates.
Empowering CHWs to Become Effective Agents of Behavior Change
Qualitative interviews with CHWs and their supervisors provided insights into how the SH training approach may have contributed to these positive outcomes. The SH method appears to have resonated with the CHWs, who valued the opportunity to share their own personal experiences and memories.
Several key mechanisms emerged:
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Grounding in Local Beliefs and Practices: The SH approach explicitly builds on the CHWs’ own cultural knowledge and experiences, rather than simply imparting standardized health information. This helps ensure the relevance and acceptability of the new behaviors being promoted.
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Confidence and Self-Efficacy: By sharing their stories in a supportive group setting, the CHWs reported feeling more confident and empowered to share their newfound knowledge with mothers. This boost in self-esteem and self-efficacy appeared to make them more convincing and effective as agents of behavior change.
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Empathetic Connections: The process of sharing personal, sometimes emotionally-charged memories helped foster empathetic bonds and trust between the CHWs and the mothers they visited. This rapport was key to the CHWs’ ability to discuss sensitive cultural practices and motivate behavior change.
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Collective Learning: Hearing the diverse experiences of their peers during the SH sessions helped the CHWs collectively adjust to new ways of thinking and doing things, further strengthening their commitment to the new behaviors.
These findings suggest that the SH approach may be a powerful tool for training and empowering CHWs to become more effective in supporting behavior change among mothers, particularly those with some level of education. By tapping into personal experiences and local cultural knowledge, the method appears to build CHWs’ confidence, cultural competence, and ability to foster trust and engagement with the mothers they serve.
Implications for Improving Maternal and Child Health Globally
Our study extends the research on effective implementation of CHW programs. To our knowledge, this is the first randomized trial to test the use of autobiographical memories as a systematic method for training CHWs to become more capable change agents in their communities.
The results have important implications for reaching vulnerable populations of women and children in low-resource settings. Many traditional societies place a low value on women’s personal experiences, yet the SH approach explicitly recognizes and builds upon these memories as a foundation for learning and empowerment.
For culturally traditional women, even those with some education, this type of approach may be essential for effective health promotion. By tapping into personal stories and shared cultural beliefs, the SH method appears to resonate with these mothers in a way that standard health education often fails to achieve.
However, the benefits of the SH approach were limited to children of literate mothers in our study. The persistently high rates of stunting among children of illiterate mothers suggest that addressing the complex, multifaceted determinants of child growth in such contexts may require more comprehensive, multi-sectoral interventions.
Nevertheless, our findings indicate that integrating the SH approach into CHW training and deployment could be a valuable strategy for quickly reducing global stunting rates, particularly by targeting the “low-hanging fruit” of children from moderately educated households. Further implementation research is needed to optimize this approach and explore its potential for scalability and sustainability within primary health care systems.
Ultimately, more effective community-based health promotion strategies will be essential for achieving the Sustainable Development Goals related to maternal, newborn, and child health. Strengthening the capabilities of CHWs through methods like Sharing Histories, while also ensuring supportive supervision and an enabling environment, can contribute to realizing the basic health rights of vulnerable populations.
