Collage illustration of a butterfly, a flower being watered by a watering can, and the words "flourish," "transform, and "engage"

SEE Change: Improving Health Through Self-Empowerment

What can public health learn from an intervention that improves health outcomes—without targeting health?

By Jenn Walton • Illustrations by Dung Hoang

Anita Shankar spent more than 15 years studying vitamin A deficiency in Nepal and maternal health and childhood nutrition in India, Papua New Guinea, and Indonesia. While her work centered on health at the population level, Shankar heard stories of health and illness firsthand from the women she worked with and lived alongside. Their stories shared a common challenge: overwhelming responsibilities in managing their families. Their lives were consumed with caring for husbands, children, and elders in their homes—as well as others in their communities.

Although these women wanted to do the best for their families, they rarely had control over crucial health decisions, such as whether to take a child to a health center or which foods were purchased for the home. “Asking them to eat more healthy foods or travel long distances to get care was just an additional task that added to the worries they already had about their families,” says Shankar, PhD, MS, an associate scientist in International Health.

Upon returning to the U.S. in 2009, she realized she couldn’t leave those stories or those women behind. Shankar knew the programs she’d worked with and others like them were helping to improve people’s health—but she also knew that something was missing.

“We’re making a lot of people a little bit healthier, but we’re not addressing the core issues that are affecting their lives or their health,” Shankar now says. Because health is not just the absence of disease, she believes that public health also needs to support well-being, resilience, and flourishing in populations.

Much of current international development programming focuses on addressing basic needs like having enough food to eat, a decent place to live, and, for many, freedom from violence. The women Shankar worked with had none of those. What they did have was their own thoughts.

“Each of us can foster our own sense of agency to create a better life,” says Shankar, who is trained as a medical anthropologist. “We are more powerful than we know, and if given the chance, we can better harness our thoughts, beliefs, and actions toward [that] better life.”

That’s the basis of the Self-Empowerment and Equity for Change Initiative, or SEE Change, which Shankar founded and leads with funding support from USAID. The idea for the training program first began to take shape in 2010. Ten years of pilot programs and research led the way to its eventual implementation.

The training is usually run in conjunction with programs offered by communities, organizations, or groups that work with or employ women in resource poor areas. Over the course of three to five days, anywhere from a handful to several hundred participants spend roughly 30–50 hours exploring their past experiences, the sources of their own personal power, their core beliefs, and their goals.

No matter how many trainings you have, none of them will matter if participants don’t believe in themselves or have the agency to make change.

As they examine their current circumstances, participants are challenged to think about and discuss their limiting beliefs—the “I can’t” or “I don’t have enough” statements—to help them engage with underlying “why" questions: Why do I have the beliefs I have about myself? Why haven’t I made a shift to do something different? The goal is to uncover how one’s past or community has contributed to beliefs that make advancing seem impossible, says Joss Divin Ndikubwayo, a SEE Change trainer in Rwanda. As Shankar describes it, the program is “based on how we know people make decisions, how the brain functions, how social networks function, and how we can use [all of] that to lead to better outcomes.”

Once the women understand what drives their thoughts and behaviors, they develop the capacity and willingness to take purposeful action toward their goals, like owning their own business or climbing out of debt. For example, a woman from an urban slum in India who completed the training eventually decided, after passing several storefronts every day, to ask if any jobs were available and soon found one at a bakery.

When SEE Change was brought to women’s self-help groups in rural Kenya in 2012, most participants already had some type of informal business, such as selling bananas, tailoring, making soap, or selling solar lamps. One year after their training with SEE Change, participants reported significant improvements in their economic conditions, interpersonal relationships, and health-seeking behaviors, such as getting necessary and long overdue medical treatment.

Shankar and her team saw similar positive results when the program was introduced in 2014 to brothel-based sex workers in urban India. The women had been sold to the brothel as children by their families; to leave, the women would have to pay off their debt: the amount the brothel paid for them, and then some. A year after completing the program, nearly 35% of the women had paid off their debts and either left to start their own businesses or returned home to their families. All women who completed the program reported improved adherence to medication schedules (like those needed for HIV, diabetes, and tuberculosis) and increased health-seeking behaviors, such as seeing doctors when the brothel made them available.

SEE Change has since worked in 14 other countries—and seen substantial improvements in participants’ health and well-being in each location. A SEE Change training for health care outreach workers in four provinces in Maharashtra, India, combined with a digital medication adherence program called emocha, not only benefited the participants but those they served. Outreach workers said that the training made them feel less stressed on the job. It bolstered their relational skills, improving their ability to cultivate positive attitudes and help the women overcome barriers to care. They felt equipped and motivated to empower those they were serving—giving the workers power with communities instead of power over them. All of this made them better at their job. One result: A higher percentage of mothers with HIV used the preventive measures the health workers had taught them to ensure that they didn’t transmit HIV to their children.

“What’s really unique about this approach is that it addresses the personal empowerment and the agency piece which is often overlooked,” says Adrienne Raphael, Chief of Party for USAID’s Engendering Industries at Tetra Tech. (The global consulting and engineering firm works with the U.S. government to increase gender equality in male-dominated industries; it also subcontracts with SEE Change to support the initiative.) “With a health program, you’re told this is what you need for your diet, for your exercise, and this is how you get your outcomes. But no one’s looking at the psycho-social element. How do you have agency to believe you can get better? How do you get the confidence and the leadership to succeed? No matter how many trainings you have, none of them will matter if participants don’t believe in themselves or have the agency to make change.”

Almost a year after SEE Change’s global launch in November 2020, Shankar is looking forward. SEE Change is now set up in 16 countries, and with continued funding from USAID, Shankar and her team have plans to move into eight more. She wants to revolutionize how public health is done; she envisions a more positive public health. She cites approaches like strengths-based programming that helps people with addictions focus on their capabilities to achieve healing. The addiction is not the focus. “The focus is on the capabilities—what promotes well-being, what promotes resiliency, and what promotes adaptation,” Shankar says. “That requires a different shift in our focus from trying to figure out what’s wrong with us to what do we want in our lives and how do we use the resources that we have both internally and externally to create the life that we want.”