Integrating Humanities in Healthcare: A Mixed-methods Study for Development and Testing of a Humanities Curriculum for Front-line Health Workers in Karachi, Pakistan

"I utilized the benefits of our training in my community. I started using easier language. If I am able to understand them, then they should (also) be able to understand what I am saying." (Sabiha, a lady health worker)

Lady health workers (LHWs) provide lifesaving maternal and child health services to more than 60% of Pakistan's population, and they are at the front lines of polio eradication efforts in the country. However, in addition to being poorly compensated and overburdened, LHWs do not receive enough training and support to nurture attributes necessary for equitable and holistic healthcare delivery. In response, this group of researchers developed an interdisciplinary humanities curriculum, deriving its strengths from local art and literature, to enhance character virtues such as empathy and connection, interpersonal communication skills, compassion, and purpose among LHWs. This paper describes the process of curriculum development and the results of a study to examine its feasibility and impact.

At the study outset, the team used Relational Systems Evaluation to develop a pathway model that presents the programme's underlying theory of change; see figure 1 in the paper. Based on this mode, the team developed an interdisciplinary humanities curriculum for LHWs in collaboration with faculty from the Social Development and Policy and Comparative Humanities Program at Habib University, Pakistan. The curriculum was developed in Urdu (local language) and consisted of local literary texts, dramas, and poetry intertwined with interactive activities that supported the education level and experiences of the LHWs. The curriculum was designed to: strengthen and expand LHWs' sense of self-worth and experience of joy in their work by encouraging self-reflection and insight; promote essential character virtues related to compassionate caregiving; and strengthen LHWs' feelings of connection to community, particularly across differences due to ethnic or other boundaries.

The researchers conducted a multiphase mixed-methods pilot study in two towns of Karachi, Pakistan, a low-resource setting. They delivered the humanities curriculum to 48 LHWs via 12 weekly sessions, from June 15 to September 2 2021. They developed a multiconstruct character strength survey that was administered preintervention and postintervention to assess the impact of the training. In-depth interviews were conducted with a subset of randomly selected participating LHWs.

Of 48 participants, 47 (98%) completed the training, and 34 (71%) attended all 12 sessions. Scores for all outcomes increased between baseline and endline, with highest increase (10.0 points, 95% confidence interval (CI) 2.91 to 17.02; p=0.006) observed for empathy/connection. LHWs provided positive feedback on the training and its impact in terms of improving their confidence, empathy/connection (especially for religious outgroups), and ability to communicate with clients. Participants also rated the sessions highly in terms of the content's usefulness (mean: 9.7/10; standard deviation (SD): 0.16), the success of the sessions (mean: 9.7/10; SD: 0.17), and overall satisfaction (mean: 8.2/10; SD: 3.3).

The main suggestions put forth by the LHWs included having interactive and innovative activities within the trainings (25%; 3/12), having similar trainings more consistently (25%; 3/12), conducting trainings in LHWs' offices instead of an external location (17%; 2/12); and using easier language in the content of the curriculum (8%; 1/12). One LHW specifically mentioned desiring recurrent trainings; otherwise, they would eventually forget what they were taught.

Reflecting on the findings, the researchers note that, "Since part of the task of Medical Humanities is to refocus the gaze of the provider on the person receiving care, rather than the body that requires fixing, it further reinforces the sense of well-being, meaningfulness and human connection. Moreover, pedagogical techniques employed in humanities disciplines encourage critical thinking and creative reflection. This enhances creativity and agency, which are correlated with well-being."

In conclusion: "A humanities-based training leveraging local arts and literature is a feasible intervention that demonstrates promise for nurturing key character strengths among LHWs. Evidence generated from this study highlights the importance of innovative training, grounded in local literature and cultural values, that goes beyond technical and theoretical skills and seeks to develop core character strengths among front-line workers. Training that focuses on character development can enable front-line workers to effectively address some of the most pressing issues such as polio eradication and is even more relevant in COVID-19 times when the healthcare workforce is recovering from the psychological aftermath of the pandemic."