Abstract

Based on a felt need for training of community health workers on ethics and professionalism, we embarked on an attempt to develop a curriculum for the short course. We conducted interviews among community health workers and community members in Tamil Nadu and compiled a set of case vignettes to use in this course. Then we gathered an expert panel to come together for a two-day consultative workshop to develop and refine this curriculum. This expert panel had community health workers, civil society representatives, representatives from non-governmental organisations working in the health sector and academics and researchers from public health. We deliberated on various aspects of the course. In this report, we describe the participative process of curriculum development for training of community health workers on ethics and professionalism.

Keywords: ethics, professionalism, community health workers, training, curriculum

Community health workers (CHWs) deliver primary healthcare services at the grassroots level in India. The Auxiliary Nurse Midwives (ANM) are key frontline workers delivering maternal and child health services at the community level. These CHWs work closely with communities, providing care work and have a deep connect with the community. Therefore, their work is likely to have several important ethical issues embedded in it.

When visiting and providing care for a member of the community at the village level, how does a CHW ensure privacy? How does a CHW negotiate the power hierarchies within the health system and within the community, to function as an effective healthcare provider? These are some examples of important ethical issues that the CHWs confront. With these in mind, we embarked on a project to develop a curriculum for training of CHWs on ethics and professionalism in their work. We initially targeted this at the various cadres of CHWs in Tamil Nadu, namely, the village health nurses, the mid-level health providers, the women health volunteers and several CHWs working in the voluntary health sector. We subsequently plan to take this to the national level covering Accredited Social Health Activists (ASHAs), Auxiliary Nurse Midwives (ANMs) and Anganwadi Workers (AWWs) across the country, after adapting the curriculum within a cultural and linguistic context.

We conceptualised a curriculum development project in which we first conducted qualitative interviews and focus group discussions among members of the community to understand their perceptions of practice of ethics and professionalism in the work of the CHWs. Based on all the findings of the interviews, we identified key training needs. We identified the following ethical issues as commonly faced by CHWs in their work.

• Challenges and difficulties of doing good

• Duty to care and the extent to which one should go beyond the call of duty

• Prevention of harms

• Autonomy

• Conflicts between autonomy and doing good

• Justice and non-discrimination

• Privacy and confidentiality

• Conflicts of interest

• Power hierarchies hampering work in the community

We documented narratives from the CHWs and the community of anecdotes that involved ethical conflicts and dilemmas, some of which we developed as case vignettes for our course materials. We convened a panel of consultants to provide their insights on the curriculum for teaching ethics and professionalism for CHWs. Besides academic scholars in bioethics, and public health, we also invited practitioners working in the public health and voluntary health sectors, senior community health workers, health activists and representatives of civil society to participate in the curriculum development process. We organised a consultative workshop and invited all the 11 experts, for a two-day meeting to discuss and develop the curriculum. Prior to this workshop, we prepared a framing document which explained the nature of work of CHWs, the common ethical issues faced by them during their work, and the need for a curriculum and training on ethics and professionalism. We also developed 10 case vignettes covering the various common ethical issues faced by the CHWs derived from the narratives in our field research. We prepared both these documents in English and Tamil, the local language in which the course will be delivered initially. We circulated it among the panellists in preparation for the deliberations.

We outlined the content that we proposed to teach in each of the sessions which was followed by detailed deliberations. We spent about two hours discussing each topic and the discussions spanned the following aspects:

• Specific learning objectives under that theme

• Glossary of terms — in English and Tamil

• Discussions on ethical concepts

• Teaching-learning methods to be used

• Adult learning principles to be applied

Further, we divided the participants into small groups, each group with an academic expert, a community health worker, a voluntary health organisation representative / health activist / community representative. Each small group discussed the various case vignettes and provided feedback about the clarity of the vignette, its appropriateness to teach the relevant ethics concept, the various ethical issues that can be discussed based on the vignette, and the best method to teach using it as a narrative case study, cartoon strip, video clip or role play. We documented the minutes of all the discussions, clarified several doubts and questions we had and used the contents of the deliberations for developing the curriculum. Academic institutions usually have a Board of Studies meeting in which academic experts in the subject matter come together to discuss and review content in the curriculum. The group provides inputs based on which the curriculum is revised and then approved by the Academic Council. This peer review helps ensure the rigor of the curriculum and the course taught. In such academic curriculum development meetings, the voice of the end beneficiary of the course is seldom represented. In stark contrast to this, this curriculum development workshop was participative and had inputs from all important stakeholders. It was a curriculum for community health workers by community health workers. We consider this the greatest strength of the curriculum that is currently under development.

One of the important concerns we had while inviting panellists to the workshop was the inherent power differentials between community members, CHWs and doctors and other academic scholars participating in the meeting. We were worried that the community members, CHWs and practitioners from the voluntary health sector may not have a space to voice their opinions in the presence of academics and scholars, who may dominate the discourse. Some of the selection criteria for panellists ensured that a non-threatening and collegial environment was created, where everyone could voice their opinions. First, the constitution of the panel with eight women, two men and one transgender woman ensured an equitable gender representation in the panel as most community health workers are women. Secondly, there were four junior persons with limited experience, three persons with a few years of experience and four senior persons with more than 20 years’ experience among the panellists. We conducted the entire discussion in two languages, predominantly Tamil and some English as all but one participant were fluent in Tamil. Adequate time was allotted to the breakout small group sessions, where the participants mingled with one another and had free discussions. We believe that these factors ensured a free and uninhibited exchange of ideas in the panel. We also observed that a warm camaraderie developed among the participants over the course of the two-day workshop. We are now working on developing this material as curriculum and support documents. The plan is to have the prepared curriculum peer-reviewed by experts in bioethics and public health, and deliver pilot training using the curriculum to two batches of CHWs. Based on their feedback after the training, further modifications will be incorporated. The last stage of the project will be dissemination of the finalised curriculum to key stakeholders including the public health system of Tamil Nadu. After dissemination of this curriculum, we expect that it will be adapted and used to train CHWs at various levels all over the country on ethics and professionalism.

Acknowledgment: The authors would like to acknowledge the following members of the curriculum development committee namely, Prof Mala Ramanathan, Dr Varalakshmi Elango, Dr Sunu C Thomas, Dr Arunmozhi Ravikumar, Ms Geetha Veliah, Mr Anandan, Mr Suresh D, Ms Delfina Kanchana Sundar, Mrs Thamaraiselvi, Mrs D Selvi, Mrs A Sathya, for their active participation and immense contributions to the curriculum development.

Conflict of Interest: VG is a working editor of the Indian Journal of Medical Ethics. He recused himself from any editorial decision making with respect to this article.

Funding: This curriculum development work is funded by the Thakur Foundation, USA.

Statement of similar work: No similar work is published or under consideration in this or any other journal.