All 53 participants spoke Spanish, with 14 of them speaking Quechua in addition to Spanish. The average number of years of CHA experience was 5.8 years for women in Trujillo and 4.5 years in Huancayo. Among participants in Trujillo, the highest level of education obtained was technical college (N = 6), but the majority of women listed secondary education as their highest level of education achieved (N = 10). Participants in Huancayo reported higher levels of education overall, listing University being the highest level of education accomplished (N = 5), with technical college being the level of education reported the most (N = 16). Additional characteristics of the study population can be found in Table 1.
Within the area of focus of women’s empowerment, four major themes emerged: (1) achievements, (2) agency, (3) meaningfulness, and (4) resources. The majority of the 409 coded themes were categorized as achievements (N = 215), followed by agency (N = 125), meaningfulness (N = 56), and resources (N = 13). Each of the themes and subthemes are described in detail below. A summary of our findings can be found in Table 2.
The sub themes that emerged describing achievements were: (1) family behavior, (2) self worth, (3) education, (4) health and nutrition, and (5) rights and politics. The most common sub theme was family behavior (N = 75), pursued second by self-worth (N = 49), followed by education (N = 44), then health and nutrition (N = 33), with rights and politics last (N = 14).
One common description that came up with family behavior was reflections on family dynamics. Family behavior encompasses the social norms that direct how families interact with one another. This is highly influenced by the Peruvian machismo culture. Family behavior was sometimes used in reference to increasing support from husbands and prioritizing family values.
Little by little he started to help me, now he picks up a broom and sweeps. At first, he didn't want his son to do the bed, he said that his son is a man... I talked to him about the things [CHAs] learned, and now he sends his son to help me. He is changing. (Trujillo)
Self-worth was coded to CHAs observations of internal changes and perceptions of increased recognition of their worth and value. Several women remarked improvements in their self-esteem as a result of their involvement with CMMB. Several experiences described the impact of their community role and connections with others on their self worth.
I feel fulfilled, I feel like a leader in my community…I see that I can support [them and] my family, and help them with anything and any doubts they may have about health. (Trujillo)
Education was referenced by several CHAs in reports of horizontal learning that had occurred between other CHAs and community members. Education here encompasses learning applicable skills and gaining relevant knowledge. Education was also sometimes coded in reference to internal changes and the resulting impact that CHAs described as coming with knowledge.
I have learned a lot through the workshops...there [have] been a lot of ideas exchanges [between CHAs], and I practice it with my family and [with the] mothers. (Huancayo)
Instances coded to health and nutrition were sometimes characterized by themes of learning and gaining awareness of foods and actions that can result in an increase in health. Several CHAs expressed changes they had made to improve health and nutrition behaviors as a result of this learning.
Now that [I see] the psychologist...I have learned about [healthy family communication], so I go home and say...we need to change. And as a community healthcare worker, I need to change first myself so I can guide my neighbors, right? (Huancayo)
Rights and politics was used to code descriptions of positive outcomes gained through advocacy or perceived entitlement to equitable treatment.
Now I feel that I have strength, courage, I value myself, men and women have the same rights. And I support my family even more strongly. (Trujillo)
The sub themes that emerged related to agency were: (1) voice, (2) confidence, (3) decision making, and (4) participation. Of these subthemes, voice (N = 62) was the most commonly referenced idea, followed by confidence (N = 30), then decision making (N = 20) and finally, participation (N = 12).
Voice was coded to instances of advocacy or actions that influenced agency and positive outcomes. Voice is defined as the ability to express opinions or attitudes openly. A common narrative that emerged with the CHAs was using their voice to advocate for rights within the community. Several CHAs shared their experiences of advocating for themselves and their peers in healthcare settings.
I felt powerless, but...when I joined the CMBB, they gave us the training regarding health care rights...I went to back to the center [where they mistreated my son], and I said: “You know what, bring me the complaint book because I will write mine down.” ...I said to them, …”I believe that [because] he is a human being, you need to [provide treatment]....how is it possible that you are treating us like this?” (Huancayo)
Confidence was coded to instances in which CHAs expressed having belief in their abilities. Confidence encompasses self-assurance and belief in one’s self and abilities. Some CHAs shared the positive impact that being confident in their information and knowledge had on their community interactions.
I didn't have much trust [from] the community, but now that I am a community agent I do have more trust with the mothers...I also tell them what information I receive...I share with them with more confidence. (Trujillo)
Decision making was coded when participants described their process in making strategic life choices or factors that influenced their decisions. Many women reported gaining the ability to make choices about themselves and their family. Some participants gave examples of how the CHA training led to them gaining knowledge that facilitated their ability to make choices related to advocacy and health.
I feel confident in making decisions. Because [of] the trainings...I know [which] symptoms [need us to visit] a health center...I am responsible for my children. (Trujillo)
It was also coded to larger strategic actions that some CHAs had taken to improve their lives, such as one instance in which a CHA described her decision to leave her abusive husband.
I gave myself the opportunity to say no...it ends here. And since [he was holding me back]...I was strong and said NO… [CMMB] never abandoned me. (Huancayo)
Participation was coded to descriptions of community involvement that resulted in achievements, positive outcomes, or increased agency. Multiple CHAs reported an increase in taking part in their communities. Several CHAs shared ways in which they became involved with their communities by providing others with support.
I’m more involved with the community around me. Seeing how they rely on me...and being able to respond, makes me feel like there are new doors opening since I’m now able to help and work with them better than ever before. (Huancayo)
Meaningfulness was coded to descriptions of aspects of working as a CHA that aligned with their values, felt internally rewarding, or increased agency. For many CHAs, working with CMMB and providing services to their community gave them significance in their lives. Common examples given were descriptions of the connections they build within the community, and in recognizing the value of their support and knowledge.
Being able to see the change in the health of the people and that the mothers are applying what we teach them...that’s my motivation, seeing that you are moving forward step by step. (Huancayo)
The theme of resources was coded to descriptions of preconditions that enhanced CHAs ability to exercise choice. Within the theme of resources, several sub themes emerged: (1) social, (2) human, and (3) material. There was a clear divide in the coding frequency between social (N = 12), human (N = 1) and material (N = 0) resources.
The items that were coded to the sub theme of social resources were resources that women had gained access to as a direct result of connections they had made through being a CHA, as well as their perceptions of changes in opportunities and agency as a result of this. Another common experience was related to community building through CHA work. Some participants discussed how changes in their relationships with other community members and connections they have built with the mothers that they visit are a result of mutually sharing information and spending more time out in the community.
I’m more involved with the community...there are new doors opening...not only because of my training but also because of the connections I’ve made (Huancayo)