We present our findings first through a case study that illustrates several key themes emerging from the data set. The case study intends to provide a holistic analysis of the interactions between one CHW and one client. We then examine each of these key themes, in turn, drawing on additional examples from our dataset.

Case study—Priya (CHW) and Rita (PPSD)

Priya was a 24-year-old community worker who had completed 12 years of schooling and lived with her parents in a low-income community two kilometres from the community she worked in as an employed team member. She identified PPSD through door-to-door knocking and meetings in the low-income community adjacent to her home.

Rita was an 18-year-old young Muslim woman who lived with her widowed mother and two brothers in a tiny two-room house in an informal urban community. After her fathers’ death, Rita had been required to leave school after completing 10 years of schooling to tailor clothes in order to generate supplemental income for the family. Although Rita enjoyed tailoring at home, watching her peers go to school meant Rita felt socially isolated, disadvantaged and experienced frequent concerns about the future, and stayed at home without meeting friends and felt lonely. Rita’s mother being the key decision maker after her father’s death, also faced mental health problems, which further exacerbated Rita’s condition. Rita’s status as a young, unmarried Muslim woman restricted her freedom of movement, a common experience for people like her in north India [16].

CHW response

Priya visited Rita over a five-month period, and described spending time visiting and talking to Rita on multiple occasions to develop a relationship of mutual trust. She described their conversations to understand what being well would look like to Rita who described feeling lonely and wishing she could take more initiative. Addressing these hopes formed the basis of further responses.

Firstly, increasing opportunity for social connection required that the two women develop a three –step bespoke plan: Priya (CHW) reported that initially Rita felt embarrassed to meet up with others as she felt she could not converse well with her limited education. Further, after several months almost fully at home, Rita lacked social confidence. Priya described encouraging Rita to believe in herself and did this by role-playing peer conversations with Rita. When Rita felt more confident, Priya sought to support Rita to connect more socially by inviting her to join a sewing class in her neighbourhood for young women. Yet it was not so simple. Belonging to a minority religion with restrictions on freedom of movement, significantly reduced opportunities to leave the house for Rita. Priya problem-solved with Rita and together they proposed that Rita and her mother could host the local sewing group in their own household to avoid family disputes about Rita leaving the house without a male relative. This group sewing programme provided an opportunity to meet with peers and to work together while income generating. She could then converse with peers in the sewing class. Thus, Priya devised and adapted a bespoke intervention to support Rita to build new skills, attitudes and relationships and to increase her access to social connections.

Secondly, the CHW supported socio-culturally appropriate opportunities for income generation and further education. Priya described poverty as the key factor which restricted Rita’s access to education and social connections. Priya recognised sewing as a useful and culturally acceptable skill to generate income for young women from Muslim households as it can be done within the home [19]. Priya described that Rita did well with both learning sewing and making friends in the sewing group and participating also built her sense of self-confidence. Thirdly, describing education as a key health determinant, Priya supported Rita to resume education by introducing her to Open Schooling, a home-based correspondence school which would not constrain her from continuing with expected household roles and income generation with sewing. Priya suggested that Rita could study for a qualification which would help her in the long term. Initially, Rita’s mother was reluctant to allow her to pursue further education. But Priya addressed her concerns by including Rita’s mother in a support group, where multiple discussions on mental health knowledge, gender discrimination and the importance of education took place. She played videos such as the mental health episode of ‘Satyamev jayate’ (a popular television talk show) that talks about real-life incidents of women in distress and caregiving for people with mental illnesses on her phone. This helped Rita’s mother realise the importance of education and she allowed Rita to pursue further education.

Deep knowledge of context and social determinants

Community workers in our sample displayed a high degree of knowledge of the context of their client’s lives and were able to apply this in developing their responses. This included knowledge across a number of domains including both of more intimate spaces, like family dynamics, as well as wider forces such as environmental and social determinants. The knowledge of the context and structural health determinant was described as implicit (‘I just know’) and linked to their own experiences of living in communities that were socioeconomically similar.

The knowledge and analysis of context took place at different levels. For example, on a steamy afternoon in July, KM and Lalita, the CHW went to visit Deepak, a 25-year-old, unmarried man from the Sikh community. Lalita, the CHW squatted in a brick courtyard and gave KM a summary of Deepak’s story and family situation without any reference to notes. Her description engaged an understanding of the family history (two of Deepak’s uncle’s had gone to jail for an alleged murder), educational background (“He re-did his first grade several times but eventually he lost interest and when he was in his early teens, he started doing labouring work. Now he does any kind of mazdhuri (daily labouring) work.”).

She could then describe the sources of income for the family and the broader economic situation they faced (they owed money to multiple relatives and money lenders and were extremely anxious about this). Lalita could thus analyse the factors shaping Deepak’s poor mental health. KM also noted that Lalita knew the names and identities of all the people (grandma, nephew, niece and visiting friend) involved in Deepak’s life.

Lalita also described the story of Deepak’s issues with substance misuse, a problem that affects his father and his two brothers. Her detailed analysis of the family dynamics included descriptions of the impact of the father’s substance misuse on the poor relationships with the sons; and the mother’s relationship with Deepak.

Lalita also reviewed and discussed the outcomes of the psychosocial interventions she had employed with Deepak (psychosocial counselling and support). She described that they did not result in significant improvement in his situation, either in terms of the standardized scores of mental well-being used, or in convincing him to seek rehabilitation but she could reflect critically on possible reasons for this.

After spending time talking with Deepak who roused himself from a dark room off the courtyard, Deepak stated he needed to head out. Back at the office, Lalita continued telling of her analysis of the situation for him. She described that one benefit for Deepak after he joined a four-month psychosocial group intervention was that he engaged with others who had higher status in the community, which she hypothesized, improved Deepak’s social capital and connections. Lalita also suggested that this outcome was tempered by factors that limited Deepak’s ability to address substance misuse which included a circle of friends who sometimes financially supported his substance misuse and the disregard and negative judgement he experienced from his parents.

In this example, the CHW, Lalita, demonstrated how she had applied a nuanced understanding of the links between family history, education, social status and economic disadvantage to engage with the interplay of structural and environmental health determinants.

Pushpa is another CHW who described her work with Sunita and her family in a town on a steep hill. She lived in a house with tarpaulin for roofing, and a dirt floor and in monsoon water ran through her house. Pushpa described how this made it very difficult for Sunita’s children to play and that the wet and dirty house led to worsening mental distress. Pushpa had visited Sunita most weeks at different times of day over a period of four or five months and so she felt she had had a clear idea of the social and economic factors which led to Sunita’s mental distress. Pragmatically, she then supported Sunita and her neighbours to file a Right to InformationFootnote 1 request about why there was no water connection in their informal urban community, to prompt action by the local government.

CHWs described multiple ways that they engaged with social health determinants. For example, another CHW described negotiating with the parents of a 17-year-old PPSD client, to encourage them to allow her to attend school alongside her brothers, addressing gender relations. Another CHW described supporting a family with very low income to get access to epilepsy medicines by identifying local Government pharmacies who would provide them with free medication. Multiple CHWs described supporting families to complete the forms and doctors' assessments required in order to receive a disability pension, addressing the right to health.

Another example of a CHW addressing social determinants included engaging in dialogue with people in the neighbourhood to increase awareness about the medical condition of their young neighbour with epilepsy to reduce stigma and name calling.

In-depth knowledge of the context in some instances may have been negative for PPSD. For example, a community worker who knew a client and his family well judged that they were not likely to benefit from psychosocial support based on their family history, describing the criminal activities of his uncle and father. In this instance, family knowledge potentially led to prejudice and reduced psychosocial support.

Relational approach

CHWs described using a variety of practical and relational tools to build trust with a PPSD, which required a nuanced understanding of the local context and power relations. Relationships had typically been developed through multiple visits over many months and the ‘thickness’ of relationships was evident for example, Lalita’s description of Deepak’s family outlined above and her description of the range and quality of different relationships of Deepak without reference to any notes:

“Deepak travels a lot for work, he has been working to sell semi-precious stones and astrology for the last few years. This is his main income ( ) he’s married. They are expecting their first child. ( ) But because of travelling a lot he sometimes feels lonely and then he befriends others who are also travelling for work. ( ) He has described how he feels peer pressure from them to use mind altering substances. ( ) and then he also has unstable relationships with his family members and household.”

CHWs described that trust building happens over a long time period through multiple communications which facilitates a tailored response. In one situation, the CHW connected with a village head (known as a pradhan) who had an alcohol overuse problem. The process of building this relationship illustrated the practical and relational tools used, E.g., sharing a brochure, discussing strategies to reduce use, active listening and problem solving to build a relationship of trust as described below:

“Through our regular meetings I listened well and held dignified and respectful encounters. Then we developed action plans which Sanjay could do in the next week. So (using these) he could chart his progress and see that, and at same time he felt trustworthy and could complete his plans. A key part of this was our relationship in his house (and where we) showed told him how well he was doing.”

A further approach that improved outcomes, included supporting PPSD to build relationships with peers as a CHW working with a young man described in the quote below:

“Through an increased number of peer friendships and being a group member, I think Sunil’s self-image improved. He told me “Mujhe bahut izzit milte hai jab session chalet hai.” (I feel respected when I attend the sessions).