A Community Health Promoter (CHP) guides colleagues through a grounding exercise taught in the SHINE project’s mental health training.
Every day, Kenya’s community health promoters enter homes
where families are struggling with illness, hunger and poverty. They listen,
check on patients, identify health problems and help people seek treatment. But
when they leave those homes, the worries they encounter do not always stay
behind.
Some return home thinking about a child who needs medical
care or a family that cannot afford food. Others struggle with heavy workloads,
delayed payments and the cost of carrying out their duties. Many face these
pressures while dealing with their own family responsibilities.
Now, research by LVCT Health and the African Population and
Health Research Centre (APHRC), in partnership with the Liverpool School of
Tropical Medicine and other health sector partners, is drawing attention to the
mental health burden among these frontline workers.
The SHINE study, which examined the experiences of community
health promoters in Nairobi and Kiambu counties, found that more than one in
five participants had symptoms suggesting depression. Nearly one in three
screened positive for anxiety, while about one in eight showed signs of stress.
The findings raise concern about whether Kenya is giving
enough attention to the wellbeing of the workers expected to bring healthcare
closer to millions of households.
Dr Stephen Mulupi, Head of Research at LVCT Health and
Principal Investigator of the SHINE Project, says health systems have traditionally
concentrated on what community health promoters deliver rather than how the
work affects them.
“The system has always been asking what community health
promoters can do for us. During monthly meetings, much of the time is spent
asking how many households they visited, how many women they referred or how
many mosquito nets they distributed. But this study is asking a different
question: we know they are doing a lot, but do we also care about them?” he
said.
The SHINE research surveyed 1,236 community health promoters
in Nairobi’s informal settlements of Viwandani and Korogocho, as well as rural
areas of Kiambu County, between 2023 and 2025. Researchers also interviewed 66
national and county decision-makers and used participatory methods to understand
the workers’ experiences.
Across the two counties, 22.4 per cent of those surveyed had
symptoms consistent with moderate or higher levels of depression. Anxiety
symptoms were recorded among 30.6 per cent, while 12.7 per cent screened
positive for stress.
The burden was greater in Nairobi. About 26.4 per cent of
promoters there screened positive for depression, compared with 8.2 per cent in
Kiambu. Anxiety symptoms affected 33.8 per cent in Nairobi and 18.9 per cent in
Kiambu. For stress, the figures were 15.4 per cent and three per cent,
respectively.
These results do not mean that everyone who screened
positive has been diagnosed with a mental health condition. Rather, they show
that many workers may need further assessment and appropriate support.
The study also points to difficult working conditions.
Between 93 and 97 per cent of the promoters surveyed considered their stipends
inadequate or unfair. Between 92 and 94 per cent said they regularly spent
their own money on work-related costs, including transport, airtime and
expenses linked to helping community members access care.
Workloads were another concern. Only eight per cent of
promoters in Nairobi considered their workload manageable, compared with 24 per
cent in Kiambu. Just 12 per cent in Nairobi said they completed their tasks on
time.
For workers who are already struggling to meet their own
household needs, the demands can become difficult to bear.
Veronica Muthengi, a community health promoter in Viwandani,
says visiting families in distress can leave her carrying their pain long after
she has completed her duties.
“Sometimes, I return home carrying the weight of what I have
witnessed. I may have food in my house, but when I sit down to eat, I remember
a client who has nothing. I lose my appetite and become sad because I have seen
the suffering they are going through,” she said.
Before receiving training through the SHINE Project,
Muthengi says she would sometimes consider giving struggling families food or
money from her own pocket. The training helped her understand that she could
care for people without taking personal responsibility for solving every
problem they faced.
“I would like to call on both the national and county
governments to make our work easier by providing lighter equipment bags and
increasing our stipend. We carry many items during household visits, and
better, more practical equipment would reduce the burden. Our current stipend
is not enough to meet our basic needs. Increasing it would go a long way in
supporting us as we continue serving our communities,” she said.
Her experience reflects the difficult balance facing workers
who live among the people they serve. They may identify a medical problem and
refer a patient, but they cannot always provide food, pay hospital bills or
resolve the wider problems affecting a household.
The research also found that some promoters work beyond
their expected hours, respond to calls late at night and struggle with
electronic reporting systems. Technical problems with the electronic Community
Health Information System can force them to repeat tasks, adding to their
workload.
Female promoters reported another concern: harassment during
household visits. Some said they did not know where to report frightening or
inappropriate behaviour in confidence.
Judith Adhiambo, who works with Nairobi County’s Mental
Health and Psychosocial Support Unit, says community health promoters are
increasingly expected to deal with problems that go beyond their formal health
duties.
“We agree with the President that CHPs are the backbone of
healthcare in the country,” Adhiambo said.
However, she acknowledges the pressure this places on them.
“The work is really overwhelming to the CHP,” she said.
Dr Stephen Mulupi, Head of Research at LVCT Health and Principal Investigator of the SHINE Project.
As well as identifying health concerns and referring
patients, promoters may be called upon to respond to violence, poor sanitation
and other social problems. Families often turn to them because they are
accessible and familiar, even when the problems require services or resources
beyond their reach.
Adhiambo says their role has also changed over time.
“Now the role has moved from identifying to actually
offering an intervention in the community,” she said.
The SHINE brief says this growing responsibility must be
matched by clear limits, effective referral systems and support from supervisors
and health professionals. Without these, promoters risk being left to manage
difficult situations without the authority, training or resources to resolve
them.
Led in Kenya by LVCT Health and APHRC, the SHINE Project has
developed and is testing a package of measures to improve workers’ mental
health and wellbeing. The initiative has reached 500 community health promoters
and 50 community health assistants in Nairobi and Kiambu.
The package combines mental health education, a five-week
peer-led self-care programme based on the World Health Organization’s Doing
What Matters in Times of Stress guide, training for supervisors in supportive
supervision, and text messages that encourage promoters and direct them to
available mental health services.
Mulupi says the intervention is intended to help workers
recognise distress, develop practical ways to manage stress and support one
another, while ensuring that supervisors pay attention to their wellbeing as
well as their performance.
“The intervention is aimed at helping community health
promoters understand mental health, practise self-care and support one another,
while supervisors learn how to provide more supportive supervision,” he said.
But the policy brief makes clear that training alone cannot
solve the problems identified by the research.
It calls on the Ministry of Health to make the mental health
and wellbeing of community health promoters and their supervisors a funded part
of the Community Health Strategy. It also recommends including mental health
indicators in the electronic reporting system and teaching workers basic skills
in psychological first aid and psychosocial support.
County governments are urged to pay stipends on time and in
full, review whether the amounts are adequate, and ensure that promoters are
not assigned unrelated duties, such as cleaning health facilities. The brief
also calls for appropriate supervisor-to-worker ratios and confidential systems
for reporting harassment and gender-based violence.
It recommends bringing county mental health professionals
into routine community health meetings, supervision and referral systems, so
workers can access help when they need it.
The researchers further urge government, donors and
implementing partners to support expansion of the four-part intervention beyond
the pilot sites to Kenya’s wider workforce of about 107,000 community health
promoters.
Mulupi says the project is examining whether the
intervention improves mental health outcomes and whether it can be extended to
other counties.
“The project is assessing changes in stress, depression and
anxiety to understand the impact of the intervention. We hope county
governments will budget for the programme and extend it to the other 45
counties that did not participate. The approach could also be adapted for
refugee communities, where health workers face different pressures,” he said.
The results of that evaluation will be important in
determining how the package can be implemented more widely. For now, the
research makes one point clear: community health promoters need more than
encouragement to keep serving their neighbours.
Reliable payments, reasonable workloads, safer working
conditions and access to mental health support are also essential if Kenya is
to protect the people who help deliver healthcare at the household level.