Community health workers and social change:

An anthropological history of Nepal's Female Community Health Volunteer program: gender, policy, and social change

BACKGROUND

Community health workers (CHWs) are central to Primary Health Care globally. Amidst the current flourishing of work on CHWs, there often is a lack of reference to history-even in studies of programs that have been around for decades. This study examines the 35-year trajectory of Nepal's Female Community Health Volunteers (FCHVs).

METHODS

We conducted a content analysis of an archive of primary and secondary research materials, grey literature and government reports collected during 1977-2019 across several regions in Nepal. Documents were coded in MAXQDA using principles of inductive coding. As questions arose from the materials, data were triangulated with published sources.

RESULTS

Looking across four decades of the program's history illuminates that issues of gender, workload, and pay-hotly debated in the CHW literature now-have been topics of discussion for observers and FCHVs alike since the inception of the program. Following experiments with predominantly male community volunteers during the 1970s, Nepal scaled up the all-female FCHV program in the late 1980s and early 1990s, in part because of programmatic goals focused on maternal and child health. FCHVs gained legitimacy as health workers in part through participation in donor-funded vertical campaigns. FCHVs received a stable yet modest regular stipend during the early years, but since it was stopped in the 1990s, incentives have been a mix of activity-based payments and in-kind support. With increasing outmigration of men from villages and growing work responsibilities for women, the opportunity cost of health volunteering increased. FCHVs started voicing their dissatisfaction with remuneration, which gave rise to labor movements starting in the 2010s. Government officials have not comprehensively responded to demands by FCHVs for decent work, instead questioning the relevance of FCHVs in a modern, medicalized Nepali health system.

CONCLUSIONS

Across public health, an awareness of history is useful in understanding the present and avoiding past mistakes. These histories are often not well-archived, and risk getting lost. Lessons from the history of Nepal's FCHV program have much to offer present-day debates around CHW policies, particularly around gender, workload and payment.

Opening up the 'black-box': what strategies do community mental health workers use to address the social dimensions of mental health?

PURPOSE

Community-based workers promote mental health in communities. Recent literature has called for more attention to the ways they operate and the strategies used. For example, how do they translate biomedical concepts into frameworks that are acceptable and accessible to communities? How do micro-innovations lead to positive mental health outcomes, including social inclusion and recovery? The aim of this study was to examine the types of skills and strategies to address social dimensions of mental health used by community health workers (CHWs) working together with people with psychosocial disability (PPSD) in urban north India.

METHODS

We interviewed CHWs (n = 46) about their registered PPSD who were randomly selected from 1000 people registered with a local non-profit community mental health provider. Notes taken during interviews were cross-checked with audio recordings and coded and analyzed thematically.

RESULTS

CHWs displayed social, cultural, and psychological skills in forming trusting relationships and in-depth knowledge of the context of their client's lives and family dynamics. They used this information to analyze political, social, and economic factors influencing mental health for the client and their family members. The diverse range of analysis and intervention skills of community health workers built on contextual knowledge to implement micro-innovations in a be-spoke way, applying these to the local ecology of people with psychosocial disabilities (PPSD). These approaches contributed to addressing the social and structural determinants that shaped the mental health of PPSD.

CONCLUSION

Community health workers (CHWs) in this study addressed social aspects of mental health, individually, and by engaging with wider structural factors. The micro-innovations of CHWs are dependent on non-linear elements, including local knowledge, time, and relationships. Global mental health requires further attentive qualitative research to consider how these, and other factors shape the work of CHWs in different locales to inform locally appropriate mental health care.

'Our hands are bound': Pathways to community health labour in Kenya

An ideal model of Community Health Worker (CHW) selection has existed since long before Alma Ata catalysed the community health approach, dating to late colonial times. In this model, a willing, trusted, relatively well-educated and secure member of the community with proven aptitude is openly elected by their leadership, peers or relevant committee. Their participation is entirely voluntary and that voluntarism is symbolic of their community's participation as a whole. While this imagery is long-embedded in CHW storytelling, such practice is rare. While elements of this 'model pathway' exist, a myriad of structural and agential factors shape who becomes a CHW, how and why. Through life history interviews over twelve months 2022-2023 with 68 CHWs in Isiolo, northern Kenya (known as CHVs), we explore predominant pathways to community health labour as told through stories. We articulate five such pathways: model, handpicked, shadow, outsider and, most importantly, dispossession. Through telling five CHVs' stories, we present each 'ideal type' but also explore how each pathway is not singular, rather overlapping in complex, context-specific ways. These pathways confound Western-centric, Western-promoted notions of voluntarism and indeed community health, which cannot explain why such labour endures. We conclude that our findings provide a timely commentary on how voluntary labour within health continues to tax structural poverty and frustrated life chances in lieu of concrete and expansive investments in human resources for health by governments and health agencies both North and South. In understanding voluntary labour as a form of structural violence, we can better elucidate the historical dependency on this work in impoverished regions and how the undervaluing of such work persists over time.

Patronage, partnership, voluntarism: Community-based health insurance and the improvisation of universal health coverage in Senegal

The turn towards Universal Health Coverage (UHC) in the past decade raises the question of the role of the state, following years of state withdrawal and a fragmented approach to public health. Senegal introduced its version of UHC, Couverture Maladie Universelle (CMU) in 2013 and this paper explores early efforts to fund it through the establishment of community-based health insurance (CBHI). The paper draws on ethnographic research at mutual health organisations, or mutuelles de santé as they are commonly referred to in francophone countries, which manage CBHI. The research was carried out as part of broader doctoral fieldwork on poverty and social protection in the capital, Dakar, in 2017-18. Responding to recent calls for the move away from the voluntary nature of CBHI with government subsidies and the professionalisation of management, this paper considers the financial strain that mutuelles were under. By drawing on the concept of 'improvisation' as it has come to be employed in recent ethnographies of health infrastructure in contexts of scarcity, the paper attends to the ways in which mutuelles and the voluntary workers that run them sought alternative forms of support, with a particular focus on patronage and partnership. I argue that what might appear to be very minimal gestures of support and material investment serve to maintain a sense of hope and potential in CMU, one however that is fragile and potentially unsustainable.

Health by the people, again? The lost lessons of Alma-Ata in a community health worker programme in Zambia

National community health worker (CHW) programmes were central to the vision of primary health care that emerged from the Alma-Ata declaration of 1978. CHWs were identified as agents who could offer basic medical treatment and promote community participation and empowerment. Despite the ambitions of this era, many national CHW programmes were neglected, starved of funding, or discontinued in the decades that followed. These programmes were difficult to sustain in a context of rising debt and structural adjustment, but they also suffered due to poor implementation and a lack of clarity about the role and identity of CHWs. Nevertheless, national CHW programmes have returned to the policy agenda in the past fifteen years and key figures and organisations within global health have begun to argue that they offer a way of strengthening health systems and achieving universal health coverage (UHC). Based on ethnographic research conducted between 2019 and 2020, this article examines a new national CHW programme that has been introduced in Zambia. However, as I show in this article, Zambia's new CHW programme has suffered from many of the same key problems that affected the programmes of the Alma-Ata era: insufficient funding, poor implementation, and a lack of clarity about the role of CHWs. This article shows how these mistakes have been repeated and asks why the lessons of the Alma-Ata era have been lost. Three central problems are identified: national CHW programmes continue to be underfunded and regarded as a "cheap" solution; global health organisations and actors today prioritise technical and quantitative approaches when they design and implement these programmes and therefore overlook the historical experiences and qualitative research of the past thirty years; and, finally, policymakers continue to gloss over the tensions and contradictions within the idea of the "community health worker" itself, creating unclear and unrealistic expectations for CHWs.

Working as frontline health facilitators, service providers, program supporters, and social health activists in Indian hilly terrain areas: A qualitative study of accredited social health activists' experiences before and during the COVID-19 pandemic

Background

Community health workers (CHW) contribute to achieving health targets of the Sustainable Development Goals (SDG) and Universal Health Care (UHC) in low- and middle-income countries (LMICs). In India, accredited social health activists (ASHAs) function as health facilitators, service providers, and programme supporters for rural and tribal communities and are at the frontline during the COVID-19 pandemic. We aimed to describe the ASHAs' work roles both before and during the COVID-19 pandemic, explore the tasks ASHAs performed throughout the pandemic, and understand its effects on the evolving role of ASHAs.

Methods

We used qualitative data from a pre-COVID-19 study conducted in 2018-2019 including face-to-face interviews with purposively sampled ASHAs and their health care supervisors (n = 18) from rural Maharashtra state (India), and a follow-up study during the COVID-19 pandemic using telephonic interviews with a subset of participants from the pre-COVID-study (n = 8). Data were analysed thematically using MAXQDA v11.00.

Results

The primary theme in the pre-COVID-19 study was ASHAs' role as described above, except as social health activists, linking beneficiaries to the local maternal and child health care services, distributing medicines for common illnesses, access to government schemes, and engaging in multiple health surveys. During the pandemic, raising awareness, screening of at-risk populations, arranging referrals, providing treatment and follow-up to COVID-19 patients, and supporting their family members. These activities increased the workload and health risks to ASHAs and their family, causing stress and tension among them. However, they had effectively carried out the new duties. ASHAs have improved their status, earning praise from families, society, and the government. They were honoured with the Global Health Leaders Award at the 75th World Health Assembly.

Conclusion

ASHAs' contribution to the health system improved the indicators related to maternal and child health during the pre-COVID-19 pandemic. Additionally, they maintained frontline health care during the COVID-19 pandemic, demonstrating resilience despite the challenges of increased workload and stress. However, the COVID-19 pandemic highlights the need to respond to and understand the implications of ASHAs' evolving roles.

The "Corona Warriors"? Community health workers in the governance of India's COVID-19 response

India's nearly 1-million strong band of quasi-volunteer accredited social health activists (ASHAs) have been key actors in government efforts to control COVID-19. Utilizing a nationalist rhetoric of war, ASHAs were swiftly mobilized by the government in March 2020 as 'COVID warriors' engaged in tracking illness, disseminating information, and caring for quarantined individuals. The speed at which ASHAs were mobilized into mentally and physically grueling labor was all the more stunning given these minimally paid community health workers have long been seen to have low morale given their precarious, informalized work arrangements. Building on work examining the spatialities of global health governance alongside literature on geographic contingency, this paper explores the ways that nationalist COVID-19 war rhetoric promulgated from Delhi worked as a technology of health governance to propel ASHAs into certain forms of action, yet also opened up spaces of potentiality for them to reimagine their relationship to both the state and the communities they serve. In particular, in our analysis of in-depth telephone interviews with ASHA workers in the state of Himachal Pradesh, we find that their hailing as COVID warriors inspired patriotic calls to duty and legitimized their (long over-looked) roles as critical governance actors, yet also was subject to resistance and reworking due to a combination of institutional histories, local politics, as well as happenstantial everyday encounters of ASHA work. The precarious employment of ASHAs - in terms of basic remuneration as well as the great on-the-job risks that they have faced - underscores both the fragile nature of India's health governance system as well as possible political movements for its renewal. We conclude by calling for geographers to give greater attention to community health care workers as a key window into understanding the uneven ways in which health systems are made manifest on the ground, and their ability to respond to citizens' healthcare needs - both in the COVID-19 pandemic and beyond.

Does social capital influence community health worker knowledge, attitude and practices towards COVID-19? Findings from a cross-sectional study in Malang district, Indonesia

Community health workers (CHWs) are the first point of contact with the primary health care system in many low- and middle-income countries and are situated to play a critical role in the public health response to the COVID-19 pandemic. The knowledge, attitude and practices of CHWs regarding COVID-19 may be influenced by their level of trust and participation in the community, collectively defined as their level of social capital. To assess whether social capital influences CHWs’ knowledge, attitude and practices related to COVID-19, we conducted a web-based survey of CHWs (n = 478) in Malang district, Indonesia between October 2020 and January 2021. CHW social capital was measured using the Shortened Adapted Social Capital Assessment Tool. Multiple logistic regression results show that cognitive social capital was associated with higher self-reported knowledge of COVID-19, more confidence in answering COVID-related questions from the community and feeling safe from COVID-19 when working. Membership of community organisations was associated with a higher number of COVID-related tasks conducted. Thus, CHWs in Malang district with higher levels of cognitive social capital were more likely to be confident in their knowledge and ability to respond to COVID-19, and CHWs embedded in their community were more likely to be engaged in pandemic response duties. Our findings suggest that policies aimed at promoting CHW embeddedness, targeted recruitment and addressing training needs hold promise in strengthening the positive contribution of the community health workforce to the COVID-19 response.

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We conducted a survey to examine how social capital influences CHW knowledge, attitudes and practices re COVID-19 in Malang district, Indonesia.

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Structural social capital was associated with a higher number of COVID-related tasks conducted.

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Cognitive social capital was associated with higher knowledge of COVID-19 and higher confidence in answering COVID-related questions.

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Promoting CHW embeddedness and targeted recruitment may strengthen the contribution of CHWs to future public health crises in Malang district.

A Community-Embedded Implementation Model for Mental-Health Interventions: Reaching the Hardest to Reach

The mental-health-care treatment gap remains very large in low-resource communities, both within high-income countries and globally in low- and middle-income countries. Existing approaches for disseminating psychological interventions within health systems are not working well enough, and hard-to-reach, high-risk populations are often going unreached. Alternative implementation models are needed to expand access and to address the burden of mental-health disorders and risk factors at the family and community levels. In this article, we present empirically supported implementation strategies and propose an implementation model-the community-embedded model (CEM)-that integrates these approaches and situates them within social settings. Key elements of the model include (a) embedding in an existing, community-based social setting; (b) delivering prevention and treatment in tandem; (c) using multiproblem interventions; (d) delivering through lay providers within the social setting; and (e) facilitating relationships between community settings and external systems of care. We propose integrating these elements to maximize the benefits of each to improve clinical outcomes and sustainment of interventions. A case study illustrates the application of the CEM to the delivery of a family-based prevention and treatment intervention within the social setting of religious congregations in Kenya. The discussion highlights challenges and opportunities for applying the CEM across contexts and interventions.

Don't change who we are but give us a chance: confronting the potential of community health worker certification for workforce recognition and exclusion

Background

For community health workers (CHWs) and promotores de salud (CHWs who primarily serve Latinx communities and are grounded in a social, rather than a clinical model of care), the process of certification highlights the tension between developing a certified workforce with formal requirements (i.e., certified CHWs) and valuing CHWs, without formal requirements, based on their roles, knowledge, and being part of the communities where they live and work (i.e., non-certified CHWs). California serves as an ideal case study to examine how these two paths can coexist. California’s CHW workforce represents distinct ideologies of care (e.g., clinical CHWs, community-based CHWs, and promotores de salud) and California stakeholders have debated certification for nearly twenty years but have not implemented such processes.

Methods

We employed purposive sampling to interview 108 stakeholders (i.e., 66 CHWs, 11 program managers, and 31 system-level participants) to understand their perspectives on the opportunities and risks that certification may raise for CHWs and the communities they serve. We conducted focus groups with CHWs, interviews with program managers and system-level participants, and observations of public forums that discussed CHW workforce issues. We used a thematic analysis approach to identify, analyze, and report themes.

Results

Some CHW participants supported inclusive certification training opportunities while others feared that certification might erode their identity and undermine their work in communities. Some program managers and system-level participants acknowledged the opportunities of certification but also expressed concerns that certification may distance CHWs from their communities. Program managers and system-level participants also highlighted that certification may not address all challenges related to integrating CHWs into health care systems. CHWs, program managers, and system-level participants agreed that CHWs should be involved in certification discussions and decision making.

Conclusions

To address participant concerns, our findings recommend California stakeholders build a voluntary certification process structured with multiple pathways to overcome entry barriers of traditional certification processes, maintain CHW identity, and protect diversity within the workforce. Positioning CHWs as decision makers will be critical when designing state certification processes.

Promising careers? A critical analysis of a randomised control trial in community health worker recruitment in Zambia

This paper examines an influential randomised control trial (RCT) that aimed to identify how to recruit the best community health workers (CHWs) in Zambia. The economists who designed the RCT found that when they used job advertisement posters that emphasised future career prospects, they attracted applicants who were more "effective" health workers (according to various quantitative measures). The Zambian government accepted this policy advice and recruited thousands of new CHWs using posters that highlighted the career path available. However, since rolling out the programme nationally, the Zambian government has not built a career ladder into this position and the recruitment process has offered false hope to those who were selected. While acknowledging the responsibility of the Zambian government, this paper analyses the role of the RCT in this outcome. Drawing on ethnographic research and interviews conducted between 2019 and 2020, the paper shows how the RCT was flawed. The economists who designed the RCT framed it as a study of "bureaucrats" and "civil servants" and therefore overlooked crucial academic and policy debates about the distinctive role of CHWs - including the well-documented reluctance of governments to offer them careers. By failing to consider the political context of the CHW programme, the economists who designed the RCT provided policy advice that "worked" for the Zambian government in the short-term but which has ultimately been harmful to CHWs. Drawing on this case study, the paper contributes to the growing critical scholarship on RCTs and raises questions about whether these studies objectively improve policymaking, as many of their proponents claim.

Beyond the "information deficit model" - understanding vaccine-hesitant attitudes of midwives in Austria: a qualitative study

BACKGROUND

Healthcare workers are considered key stakeholders in efforts to address vaccine hesitancy. Midwives' influence in advising expectant parents on early-childhood vaccinations is unquestioned, yet they remain an understudied group. The literature on midwives' attitudes towards vaccinations is also inconclusive. We therefore conducted an explorative qualitative study on midwives' vaccine-hesitant attitudes towards MMR (measles-mumps-rubella) vaccinations in Austria.

METHODS

We conducted 12 in-depth interviews on their knowledge, concerns, and beliefs with midwives who self-identified as hesitant or resistant towards early-childhood MMR vaccinations. We analyzed the data using a grounded theory approach to distill common themes and meanings.

RESULTS

Healthcare workers' stewardship to address vaccine hesitancy is commonly framed in terms of the "information deficit model": disseminate the right information and remedy publics' information deficits. Our findings suggest that this approach is too simplistic: Midwives' professional self-understanding, their notions of "good care" and "good parenthood" inflect how they engage with vaccine information and how they address it to their clients. Midwives' model of care prioritized good counseling rather than sharing scientific information in a "right the wrong"-manner. They saw themselves as critical consumers of that information and as promoting "empowered patients" who were free, and affluent enough, to make their own choices about vaccinations. In so doing, they also often promoted traditional notions of motherhood.

CONCLUSIONS

Research shows that, for parents, vaccine decision-making builds on trust and dialogue with healthcare professionals and is more than a technical issue. In order to foster these interactions, understanding healthcare professionals' means of engaging with information is key to understanding how they engage with their constituents. Healthcare workers are more than neutral resources; their daily praxis influenced by their professional standing in the healthcare system. Similarly, healthcare professionals' views on vaccinations cannot be remedied with more information either. Building better and more diverse curricula for different groups of healthcare workers must attend to their respective roles, ethics of care, and professional beliefs. Taken together, better models for addressing vaccine hesitancy can only be developed by espousing a multi-faceted view of decision-making processes and interactions of healthcare workers with constituents.

What about lay counselors' experiences of task-shifting mental health interventions? Example from a family-based intervention in Kenya

Background

A key focus of health systems strengthening in low- and middle-income countries is increasing reach and access through task-shifting. As such models become more common, it is critical to understand the experiences of lay providers because they are on the forefront for delivering care services. A greater understanding would improve lay provider support and help them provide high-quality care. This is especially the case for those providing mental health services, as providing psychological care may pose unique stressors. We sought to understand experiences of lay counselors, focusing on identity, motivation, self-efficacy, stress, and burnout. The goal was to understand how taking on a new provider role influences their lives beyond simply assuming a new task, which would in turn help identify actionable steps to improve interventions with task-shifting components.

Methods

Semi-structured interviews (n = 20) and focus group discussions (n = 3) were conducted with three lay counselor groups with varying levels of experience delivering a community-based family therapy intervention in Eldoret, Kenya. Thematic analysis was conducted, including intercoder reliability checks. A Stress Map was created to visualize stress profiles using free-listing and pile-sorting data collected during interviews and focus group discussions.

Results

Counselors described high intrinsic motivation to become counselors and high self-efficacy after training. They reported positive experiences in the counselor role, with new skills improving their counseling and personal lives. As challenges arose, including client engagement difficulties and balancing many responsibilities, stress and burnout increased, dampening motivation and self-efficacy. In response, counselors described coping strategies, including seeking peer and supervisor support, that restored their motivation to persevere. At case completion, they again experienced high self-efficacy and a desire to continue.

Conclusions

Findings informed suggestions for ways to incorporate support for lay providers into task-shifting interventions at initiation, during training, and throughout implementation. These include acknowledging and preparing counselors for challenges during training, increasing explicit attention to counselor stress in supervision, fostering peer support among lay providers, and ensuring a fair balance between workload and compensation. Improving and building an evidence base around practices for supporting lay providers will improve the effectiveness and sustainability of lay provider-delivered interventions.

Does volunteer community health work empower women? Evidence from Ethiopia’s Women’s Development Army

Of the millions of Community Health Workers (CHWs) serving their communities across the world, there are approximately twice as many female CHWs as there are male. Hiring women has in many cases become an ethical expectation, in part because working as a CHW is often seen as empowering the CHW herself to enact positive change in her community. This article draws on interviews, participant observation, document review and a survey carried out in rural Amhara, Ethiopia from 2013 to 2016 to explore discourses and experiences of empowerment among unpaid female CHWs in Ethiopia’s Women’s Development Army (WDA). This programme was designed to encourage women to leave the house and gain decision-making power vis-à-vis their husbands—and to use this power to achieve specific, state-mandated, domestically centred goals. Some women discovered new opportunities for mobility and self-actualization through this work, and some made positive contributions to the health system. At the same time, by design, women in the WDA had limited ability to exercise political power or gain authority within the structures that employed them, and they were taken away from tending to their individual work demands without compensation. The official rhetoric of the WDA—that women’s empowerment can happen by rearranging village-level social relations, without offering poor women opportunities like paid employment, job advancement or the ability to shape government policy—allowed the Ethiopian government and its donors to pursue ‘empowerment’ without investments in pay for lower-level health workers, or fundamental freedoms introduced into state-society relations.

She knows that she will not come back: tracing patients and new thresholds of collective surveillance in PMTCT Option B

BACKGROUND

Malawi, Uganda, and Zimbabwe have recently adopted a universal 'test-and-treat' approach to the prevention of mother-to-child transmission of HIV (Option B+). Amongst a largely asymptomatic population of women tested for HIV and immediately started on antiretroviral treatment (ART), a relatively high number are not retained in care; they are labelled 'defaulters' or 'lost-to-follow-up' patients.

METHODS

We draw on data collected as part of a study looking at ART decentralization (Lablite) to reflect on the spaces created through the instrumentalization of community health workers (CHWs) for the purpose of bringing women who default from Option B+ back into care. Data were collected through semi-structured interviews with CHWs who are designated to trace Option B+ patients in Uganda, Malawi and Zimbabwe.

FINDINGS

Lost to follow up women give a range of reasons for not coming back to health facilities and often implicitly choose not to be traced by providing a false address at enrolment. New strategies have sought to utilize CHWs' liminal positionality - situated between the experience of living with HIV, having established local social ties, and being a caretaker - in order to track 'defaulters'. CHWs are often deployed without adequate guidance or training to protect confidentiality and respect patients' choice.

CONCLUSIONS

CHWs provide essential linkages between health services and patients; they embody the role of 'extension workers', a bridge between a novel health policy and 'non-compliant patients'. Option B+ offers a powerful narrative of the construction of a unilateral 'moral economy', which requires the full compliance of patients newly initiated on treatment.

Perceptions of incentives offered in a community-based malaria diagnosis and treatment program in the Highlands of Papua New Guinea

What motivates community-based health workers to provide care in rural and remote areas, often on a voluntary or casual basis, is a key question for program managers and public health officials. This paper examines how a range of incentives offered as part of the Marasin Stoa Kipa program, a community-based malaria diagnosis and treatment program that has been implemented since 2007 within a major oil and gas development area in Papua New Guinea, are perceived and critiqued by community-based health workers. Nineteen interviews and seven focus group discussions with the workers who deliver services and members of the communities served by the program, conducted between November 4 and 25, 2015, reveal a pattern of mixed motivations and changes in motivation over time. This can be attributed partly to the unique social and economic circumstances in which the program is operating. Changes in the burden of disease as well as in global and national health services policy with implications for local level program operations also had an impact, as did the nature of relationships between program managers, community-based health workers, and program beneficiaries. Overall, the findings suggest that while financial and in-kind incentives can be a useful tool to motivate voluntary or minimally-compensated community-based health workers, they must be carefully structured to align with local social, economic, and epidemiological realities over the long-term.

Non-communicable disease syndemics: poverty, depression, and diabetes among low-income populations

The co-occurrence of health burdens in transitioning populations, particularly in specific socioeconomic and cultural contexts, calls for conceptual frameworks to improve understanding of risk factors, so as to better design and implement prevention and intervention programmes to address comorbidities. The concept of a syndemic, developed by medical anthropologists, provides such a framework for preventing and treating comorbidities. The term syndemic refers to synergistic health problems that affect the health of a population within the context of persistent social and economic inequalities. Until now, syndemic theory has been applied to comorbid health problems in poor immigrant communities in high-income countries with limited translation, and in low-income or middle-income countries. In this Series paper, we examine the application of syndemic theory to comorbidities and multimorbidities in low-income and middle-income countries. We employ diabetes as an exemplar and discuss its comorbidity with HIV in Kenya, tuberculosis in India, and depression in South Africa. Using a model of syndemics that addresses transactional pathophysiology, socioeconomic conditions, health system structures, and cultural context, we illustrate the different syndemics across these countries and the potential benefit of syndemic care to patients. We conclude with recommendations for research and systems of care to address syndemics in low-income and middle-income country settings.