You are just like them: The paradoxical position of Nairobi's community health promoters, a photovoice study

Kenya's community health promoters (CHPs) are essential in expanding healthcare access for vulnerable and marginalised populations, particularly in informal settlements. Embedded within these communities, CHPs facilitate culturally sensitive care, improve service access, and contribute to the efficiency of the local health system. Despite global literature on community health workforces, the specific roles CHPs play in informal settlements remain neglected and underexplored. Understanding their realities is vital for creating supportive health policies that address urban transitions and enable CHPs to fulfil their roles. This study uses photovoice with six CHPs in Nairobi's Viwandani settlement to document their experiences of marginalisation. Through co-analysis, we mapped the results using White's wellbeing dimensions, creating a framework for CHPs' lived realities in urban informality. Material challenges impacting CHP and community wellbeing include limited housing, water, sanitation, and employment. Social dimensions reveal complex dynamics between CHPs, community members, and government stakeholders, affecting CHPs' impact and community perceptions. Human dimensions reflect CHPs' aspirations, self-perception, and personal struggles, while subjective experiences intersect across all domains. We highlight practically and theoretically that CHPs occupy a paradoxical role as healthcare providers within an environment and health system that fails to meet their needs and those of their communities. Our framework provides a unique contribution to knowledge that can support health systems decision-makers in thinking differently about the role of CHPs and the support needed for transforming urban health systems. CHPs' vulnerabilities should be recognised and addressed as they are crucial to creating a just and sustainable urban health system.