Abstract

Community health workers are the link between the community and the health system, delivering primary care services at the frontline. Every profession has its own ethics and professional values, and there is a need to formulate the ethics of community health work which should be informed by their rich experiential wisdom. In one such effort, we interviewed a senior community health worker in the Tamil Nadu health system and present it here as a virtue ethics case study. Several situations of ethical conflict arising in her work, and her process for resolving these conflicts were discussed during the interview. The worker discussed some ethical principles: doing good, not doing any harm, maintaining justice, being honest, providing respectful care, maintaining self-respect, being accessible, earning the community’s trust, and building solidarity. This interview confirms the assumption that ethics and professionalism are inherent in this community health worker, and emphasises the need for systematic research to document the experiences of such frontline workers, and to frame relevant standards of ethics and professionalism in the local context.

Keywords: virtue ethics, community health worker, village health nurse.

Introduction

Community Health Workers (CHW) are the pillars of public health in India, delivering services directly to people at the field level. They act as a link between the health system and the community [1]. In India, there are several cadres of CHWs, namely Accredited Social Health Activists (ASHAs), Anganwadi Workers (AWW), and Auxiliary Nurse Midwives (ANM), delivering primary care services at the frontline [2]. Initially, they focused on delivering maternal and child healthcare in the communities. Over the last 50-60 years, the scope of their services has expanded to cover control of communicable and non-communicable diseases [3]. However, their primary focus continues to be maternal and child health in the field, owing to the larger emphasis on reducing maternal and child mortality in India. Every profession has its own code of ethics and professionalism. Doing good, avoiding harm, respecting individual autonomy, treating everyone fairly, avoiding conflicts of interest, respecting individual privacy and confidentiality, are some ethical values that healthcare professionals follow [4]. In professional courses like medicine and nursing, ethics and professionalism are taught as part of the formal curriculum. However, CHWs like Village Health Nurses (VHN) — the term used for ANMs in Tamil Nadu state — or ASHAs, are not provided training in ethics and professionalism in their curriculum. After a review of the ANM syllabus and regulations and ASHA training modules, we found that there is no specific curriculum for ethics and professionalism [5, 6]. Of course, having no formal training in ethics does not mean individuals do not practise ethics and professionalism. As moral agents, each CHW makes decisions daily on right and wrong and on the appropriate course of action in their routine work, which means they practise ethics and professionalism from their own moral standpoint. However, there is a need to codify the ethics of community health work. Such systematisation of ethics and professionalism must be informed by the rich experiential wisdom of CHWs. To explore this experiential wisdom among CHWs, we interviewed a senior village health nurse working in the Tamil Nadu health system, with 38 years of field experience delivering primary healthcare services. This interview documents her experiences of practising ethics and professionalism in her work.

Why use virtue ethics to understand ethics and professionalism in community health work?

Normative theories of ethics fall broadly into three types: utilitarian, deontological, and virtue ethics. Utilitarian ethics is based on the concept of the “greatest amount of good for the greatest number of people”. This theory determines right from wrong based on the outcomes or consequences of an action [7]. Deontology ascribes intrinsic value to actions themselves, not based on their consequences. Only those actions which are said to be virtuous can be declared as universal norms [8]. Virtue ethics looks at the virtues or moral character of the individual who carries out certain actions. Rather than asking “What should I do?”, it asks, “What kind of person should I be?” [9]. As there is no existing ethical framework for community health work in the Indian context, we have adopted the virtue ethics paradigm to analyse the virtues that this senior CHW followed. The virtue ethics paradigm is adopted, using role modelling as a strategy to highlight what is the right and wrong approach in community health practice. We consider this CHW a role model for other CHWs to emulate. Hence, we present this interview using a virtue ethics approach to highlight the characteristics of a role model or virtuous person.

In community health work, especially in rural areas, the line between the personal and the professional is blurred. This is because the CHW is often from the same rural area and is related to several people in the community, making it difficult for her to distinguish between what is personal and professional. For example, it becomes difficult both for the CHW and the beneficiary while eliciting sensitive aspects of patient history. It also reduces the CHW’s objectivity while rendering her services, making professional boundaries difficult to maintain. Prescribing guidelines and expecting people to adhere to those guidelines in such settings is less feasible. Therefore, the guidelines for ethics and professionalism cannot be determined so much by what one should do, as by how one should be. It would be useful to present the model of an ideal VHN, demonstrating how a VHN should be. This would give an overall view and not prescribe what action to take in particular situations. It may be more feasible to emphasise the intentions leading to actions and what a morally conscious agent would do, rather than have a code of principles and guidelines [9, 10].

Background of the interview

Both authors conducted the interview with the CHW. AK is an MBBS graduate and currently a freelance health researcher. SS is a community physician primarily teaching in a medical college. Neither of the authors had known the CHW (identified hereinafter as Ms XY) well prior to this. Ms XY was identified and invited for the interview by SS, who had met her on an academic work-related visit to the medical college where the CHW worked as a Health Educator. During this conversation, the CHW shared her work experience and how she approached challenges. From the experiences she shared, she seemed to be a model CHW — committed to her work, articulate and having strong moral values. This suggested that a conversation with her would help us understand the values underpinning her community health work. SS explained the objectives of the interview, received her verbal consent over the phone, and fixed an appropriate date and time for our interview.

Ms XY had joined the service 38 years earlier as a Community Nutrition Worker. She served in this post for ten years. She completed her 10th and 12th standard examinations during this service period. After completing ANM training, she worked as a Village Health Nurse for 15 years. During this term, she completed her MA in Sociology in 1998 through distance learning, which facilitated her career growth. She was promoted as a health educator to another medical college for a year, was then transferred to the current institution in 2010, and has been working there since. XY was born into an agricultural family belonging to a backward community. She is married to a mason and has three children. She had received a certificate of appreciation for her relief work during the 2015 floods in Chennai. Based on her performance, she was selected as the CHW representing her district for a training programme on the Indian System of Medicine.

AK and SS met her at her workplace on the fixed date and interviewed her. Informed written consent was obtained before the interview. The interview was also audio recorded with her permission. She also shared with us some documents and photos to substantiate her statements. We recorded notes of the documents and photos shared by her during the interview. After the interview, we read the notes and listened to the recordings repeatedly until we understood her experiences and the wisdom of ethics and professionalism in her practice. The interview was analysed for codes, and similar codes were grouped to form themes. We summarised these themes as the various ethical values and virtues she espoused. Subsequently, we contacted her over the phone to verify some factors and get her to approve our summary. This is not a research study as we did not follow any of the requirements of a qualitative exploration. This is a summary of learnings from an interview of a senior CHW from a virtue ethics perspective.

The ethics of community health work

A community health worker should do only those activities which are beneficial to people. She should show enthusiasm and interest in her job. She should consider that her work is not just any job but an honourable profession.

Ms XY showed great interest in her work. She kept her workplace as clean as her home. Maintaining a clean work environment is a mark of commitment to one’s work and gives a sense of pride and honour in one’s work. For instance, XY had used auto-disabled syringes (AD syringes), preferred as more hygienic, for the immunisation of children even before the public health system introduced and provided them. These are single-use syringes, which she would motivate the mothers to buy from local pharmacies and use them for immunisation. For those who could not afford them, she would buy them with her own money. She ensured that all the beneficiaries in her villages received the services they needed by reaching out to people who found it difficult to access them.

A community health worker should never do anything that could cause harm to people. Harm includes committing harmful actions, failing to perform good acts, and includes allowing goods and services to go to waste.

In the villages, women often did not enjoy autonomy over their bodies, as their family members largely influenced their decision-making. In this situation, CHWs are often obliged to take the responsibility to protect women’s rights. Ms XY narrated one experience of how she helped to protect women’s rights. In a village she served, women were not allowed to adopt family planning practices if their husbands had migrated for work for prolonged periods. The mothers in law of the village believed that this would ensure a check on their fidelity, as the fear of unwanted pregnancy would prevent them from exercising their sexual needs. XY fought against this by explaining the need for family planning and helped the women make their own decisions regarding adoption of family planning services. She believed that her primary duty was to protect the women both from being controlled as well as from unwanted pregnancies. She ensured that all the medicines she received at her sub-centre were distributed to the beneficiaries and not wasted, as she considered wastage of any medicine or consumable a sin, and ensuring that goods and services reached the appropriate people was essential.

A community health worker should make every effort to uphold justice. She should not discriminate between people for any reason, such as gender, religion, caste, race, or economic status. Everyone should be treated as equal.

The CHW gave an example of her practice of non-discrimination between ordinary citizens and higher officials. She had the habit of keeping the sub-centre very clean and did not allow anyone to enter without removing their footwear. Her superior officer had once visited the centre and entered it with his footwear on. She immediately asked the officer to leave his shoes outside, as she would tell any other visitor, though she was worried about offending the officer. On this occasion, the superior officer appreciated her conscientious approach. She also mentioned that she always served her beneficiaries on a “first come, first served” basis and never gave preferential treatment to anyone. These practices demonstrated her virtues of justice and fairness.

A healthcare worker should practise honesty, speak the truth, and maintain transparency. They should not misuse their power with malicious intentions.

The CHW wields the power of regulating access to public health services in the community. She could abuse this power for her own benefit as well as to favour powerful sections of society. But Ms XY narrated an instance where she practised integrity and refused to misuse the power bestowed upon her. The village headman had approached the CHW requesting her to sanction an amount as conditional cash transfer to his relative. This scheme is meant to motivate women from deprived sections to give birth in health facilities. However, this woman referred by the village headman was not poor. Ms XY did not oblige and refused to process the cash transfer. The headman was furious and began verbally abusing her. Despite knowing of his power in the area, she was steadfast in her integrity and commitment as a public health practitioner. She also reported that in her 38 years of service, she has never accepted bribes from anyone.

Community health workers should treat people with respect and speak with respect. They should serve according to the needs of the people.

Respect is contextual to social and cultural mores. In some cultures, addressing people by their names, especially the young, is considered respectful. The CHW addressed everyone respectfully by their names, or by using respectful titles used for family members, like Amma (mother), Aiyya (Sir), Thangam (used as a term of endearment). She felt this brought her very close to the community members and made her one among them.

Community health workers should respect their job. They should believe that the work they do is critical. If they carry out their job with self-respect, the community will accept and respect them.

Throughout the interview with XY, the pride and the respect that she had for her job were very evident. She had voluntarily undergone various trainings and courses to build her skills and capacity, which she felt would be helpful for the people she served. This revealed an attitude in favour of self-improvement and seeing herself as a meaningful contributor to the health system. She had received appreciation and recognition in her career, which she proudly shared. It showed that she cared about her profession and took pride in being a CHW. This, in turn, would be reflected in how far the community accepted and respected her and in the quality of her work as a CHW.

Community health workers should be easily accessible. As far as possible they should stay at the place where they work. They should share their contact details with the beneficiaries.

Often healthcare workers do not stay in the same village where they are posted, because of the lack of basic facilities like markets, schools, and entertainment facilities in those villages. They often stay in nearby towns and cities and commute daily to the village for their work. This would make them available to the village folk only during specific times, as they have to return home after work. The CHW we interviewed always stayed with her family in the health sub-centre where she worked. Staying in the place of posting made it easier for people to access her. This virtue helped her earn the trust of the community. The community members said, “Akka (elder sister) will be available any time we see her.” This was a matter of comfort for the community.

Unity and solidarity among people are the strength of the community. Community health workers should make efforts to build and maintain solidarity among people during their fieldwork.

Hierarchies are inherent in rural communities. People remain divided on the lines of socioeconomic status, caste, gender, religion, and many such variables. The CHW must understand these dynamics and, at the same time, make attempts to bring people together in the interests of their health. Women from various castes, socioeconomic classes, and religions attend the health centre of the CHW to receive antenatal care. XY saw this as an opportunity to unite people in solidarity. During their visits, she involved the women in cooking and eating together in the common kitchen. For this, she would provide provisions from the allotted budget for community activities and encourage them to interact. This enabled her to build solidarity among the women and to forget the divisions between them, at least during their clinic visits.

A community health worker should build the community’s trust by being honest, sincere, doing good, avoiding harm, treating people justly, and building unity in the community.

Once when the Ms XY was alone in the sub-centre, a person under the influence of alcohol started creating problems for her. The village people immediately came to her rescue, which made her feel that she was not alone. She believed this was possible only because she had earned the people’s trust. On another occasion, the local people gave her space in the village and built her a house to stay in, as her previous house had become run down and uninhabitable. The people did this to show her their gratitude. The CHW also associated this act of people with the trust she earned because of her sincere services. The CHW quoted the following attributes as essential for trust building: developing their skills, being easily accessible, maintaining confidentiality, acting with a sense of responsibility for the well-being of the people, and being respectful.

Discussion

We have presented the interview of a senior CHW, using a virtue ethics approach. We are aware that we have only met and interacted with her on a few occasions and verified some records and documents. This does not give us the authority to portray her as the most virtuous of community health workers. Our interactions with her and our understanding of her experiences of negotiating ethics and professionalism in her work make us believe that she is someone who comes close to being a virtuous community health worker, and from whose experience we can learn some aspects of ethics and professionalism in community health work. If we interview other CHWs like her, we would likely derive a diverse set of virtues by which they practise their profession. It is the first step in understanding the experiences of ethics and professionalism in community health work from the perspective of a senior CHW.

Virtue ethics is about what kind of person one should be, rather than how one should act. Most of the virtues mentioned in this article are simple. A few of them are difficult to follow. For example, not everyone can be expected to have the courage to stand up to their superiors to maintain justice. This would be very difficult to adopt depending on the specific circumstances of the health worker. For example, if she is the sole earning member of her family, she may not have the courage to take such a stand against her superior officer. Many women in community health work do not have the support of their families. Therefore, living in the local posting area and working from there may not be a choice for them. Sometimes speaking the truth may itself pose a danger to the CHW from powerful people in the village. Thus, the question arises as to whether it is right for each CHW to have her own set of virtues that she is comfortable living by. Do the circumstances decide what is right or wrong? [11] This is a major question of moral relativism and is not easy to settle in this interview. This is where codes of ethics and their wide dissemination are necessary.

This interview confirmed our assumption that ethics and professionalism are inherent in community health work. The CHW discussed several situations of ethical conflict and her approach to resolving these conflicts. Doing good, not doing harm, maintaining justice, being honest, providing respectful care, maintaining one’s self-respect, being accessible, earning the community’s trust, and building solidarity are some of the ethical principles that the CHW discussed. These are all universally accepted principles of the ethics of public health [12]. The fact that Ms XY could articulate these principles without any ethics training in community health work goes to prove our earlier assumption.

However, there are other important virtues like confidentiality, privacy, and autonomy that did not come up clearly in this interview. This could be because these virtues are not seen as a priority in rural areas in India. When someone falls ill in the village, everyone knows about it; in some instances, the entire village sometimes visits patients in the hospital to express solidarity. This is probably why the CHW did not mention this virtue.

Conclusion

CHWs encounter several ethical issues in their practice. They negotiate and handle these situations through their years of experience in the field. Documentation of their experiences will lead to building collective knowledge and wisdom and should be done. A systematic research study documenting these experiences from many more CHWs would give a rich wealth of information on the relevant standards of ethics and professionalism in the local context. This can inform the development of a code of ethics and professionalism for community health workers.

Acknowledgment: We would like to acknowledge Rural Women’s Social Education Centre RUWSEC and Thakur Foundation for the fellowship. We would also like to acknowledge the resource faculty and other fellows for their constructive feedback given during the writeshop.

Conflict of Interest: SS is one of the co-investigators in the funded research project of which the Public Health Writeshop is a part.