Community health workers "101" for primary care providers and other stakeholders in health care systems

Today's ambulatory care providers face numerous challenges as they try to practice efficient, patient-centered medicine. This article explains how community health workers (CHWs) can be engaged to address many patient- and system-related barriers currently experienced in ambulatory care practices. Community health workers are frontline public health workers who serve as a trusted bridge between community members and health care providers. Among their varied roles, CHWs can educate and support patients in managing their risk factors and diseases and link these patients to needed resources. As shown in this overview (CHW 101), including CHWs as members of multidisciplinary care teams has the potential to strengthen both current and emerging models of health care delivery.     

"I was not invited to be a [CHW] ... I asked to be one": motives for community mobilization among women community health workers in Mexico.

Despite health educators' revitalized interest in community mobilization for health, little attention has been given to participants' motives for mobilizing. The purpose of this article is to contribute to the understanding of community mobilizing by analyzing the motives for mobilization among a group of women community health workers (CHWs), members of a community-based organization in Mexico. The study is guided by critical feminist and social constructivist theories. It aims at identifying the categories of motives used by women CHWs and exploring how these motives are created while presenting women's own voices. Women's motives fall into four categories: getting out, serving, learning, and women's betterment. These motives blend personal andpublic motives. The analysis suggests that mobilization for health may be enhanced by addressing both the personal satisfaction of individuals and the accomplishment of public goods. The study of motives may be useful for the recruitment and retention of participants in community mobilization efforts.     

Challenges facing community health workers in Brazil's Family Health Strategy: A qualitative study

Community health worker (CHW) programs are implemented in many low‐ and middle‐income countries such as Brazil to increase access to and quality of care for underserved populations; CHW programs have been found to improve certain indicators of health, but few studies have investigated the daily work of CHWs, their perspectives on what both helps and hinders them from fulfilling their roles, and ways that their effectiveness and job satisfaction could be increased. To examine these questions, we observed clinic visits, CHW home visits, and conducted semistructured interviews with CHWs in 7 primary care centers in Brazil—2 in Salvador, Bahia, and 5 in São Paulo, SP—in which CHWs are incorporated into the work of all primary care health teams. In addition to enhancing communication between the medical system and the community, CHWs consider their key roles to be helping persuade community members to seek medical care and increasing health professionals' awareness of the social conditions affecting their patients' health. Key obstacles that CHWs face include failure to be fully integrated into the primary care team, inability to follow‐up on identified health needs due to limited resources, as well as community members' lack of understanding of their work and undervaluing of preventative medicine. Increased training, better incorporation of CHWs into clinic flow and decision making, and establishing a clear community awareness of the roles and value of CHWs will help increase the motivation and effectiveness of CHWs in Brazil.     

'I've never ever let anyone hold the kids while they've got ciggies': moral tales of maternal smoking practices

Smoking in the home is, potentially, the next frontier in tobacco control in the developed world. As smoking regulations in public space are extended, attention is turning to private spaces and the contribution of parental, particularly maternal, smoking to children's health and socio-economic inequalities in family health. Yet relatively little is known about mothers' smoking practices within the home and the social meanings of smoking that are constructed by these practices. In this paper we explore how mothers who smoke construct moralities of their smoking behaviour, particularly in relation to where and with whom they smoke. Drawing on in-depth Biographic Narrative Interpretative Method, in interviews with 12 smoking mothers, and their partners, we consider how these moral tales involve comparisons with other smokers and the importance of community endorsement of smoking practices, particularly around children. We also consider the role of children in the home and how children are actively involved in the regulation of smoking behaviours. Finally, we consider the implications of these moral tales for interventions around smoke-free homes.     

The benefits of respectful interactions: fluid alliancing and inter‐occupational information sharing in primary care

Though inter‐occupational interactions in health care have been the focus of increasing attention, we still know little about how such interactions shape information sharing in clinical settings. This is particularly true in primary care where research on teams and collaboration has been based on individual perceptions of work (using surveys and interviews) rather than observing the interactions that directly mediate the inter‐occupational flow of information. To explore how interactions shape information sharing, we conducted a secondary analysis of ethnographic data from 27 primary care practices. Ease of information sharing among nurses and doctors is linked to the degree to which practices feature respectful interactions, with practices in the sample falling into one of three categories (those with low, uneven, and high degrees of respectful interactions). Those practices with the highest degree of respectful interactions demonstrate what we describe as fluid‐alliancing: flexible interactions between individuals from different occupational groups in which bidirectional information sharing occurs for the benefit of patients and the efficacy of the practice community. We conclude by arguing that this process unlocks the strengths of all practice members, and that leadership should encourage respectful interactions to augment organisational efficacy and the ability of individual practice members to provide quality patient care.     

Becoming and remaining community health workers: Perspectives from Ethiopia and Mozambique

Many global health practitioners are currently reaffirming the importance of recruiting and retaining effective community health workers (CHWs) in order to achieve major public health goals. This raises policy-relevant questions about why people become and remain CHWs. This paper addresses these questions, drawing on ethnographic work in Addis Ababa, the capital of Ethiopia, between 2006 and 2009, and in Chimoio, a provincial town in central Mozambique, between 2003 and 2010. Participant observation and in-depth interviews were used to understand the life histories that lead people to become CHWs, their relationships with intended beneficiaries after becoming CHWs, and their social and economic aspirations. People in Ethiopia and Mozambique have faced similar political and economic challenges in the last few decades, involving war, structural adjustment, and food price inflation. Results suggest that these challenges, as well as the socio-moral values that people come to uphold through the example of parents and religious communities, influence why and how men and women become CHWs. Relationships with intended beneficiaries strongly influence why people remain CHWs, and why some may come to experience frustration and distress. There are complex reasons why CHWs come to seek greater compensation, including desires to escape poverty and to materially support families and other community members, a sense of deservingness given the emotional and social work involved in maintaining relationships with beneficiaries, and inequity vis-à-vis higher-salaried elites. Ethnographic work is needed to engage CHWs in the policy process, help shape new standards for CHW programs based on rooting out social and economic inequities, and develop appropriate solutions to complex CHW policy problems.     

Theories of practice and public health: understanding (un)healthy practices

Psychological understandings and individualistic theories of human behaviour and behaviour change have dominated both academic research and interventions at the ‘coalface’ of public health. Meanwhile, efforts to understand persistent inequalities in health point to structural factors, but fail to show exactly how these translate into the daily lives (and hence health) of different sectors of the population. In this paper, we suggest that social theories of practice provide an alternative paradigm to both approaches, informing significantly new ways of conceptualising and responding to some of the most pressing contemporary challenges in public health. We introduce and discuss the relevance of such an approach with reference to tobacco smoking, focusing on the life course of smoking as a practice, rather than on the characteristics of individual smokers or on broad social determinants of health. This move forces us to consider the material and symbolic elements of which smoking is comprised, and to follow the ways in which these elements have changed over time. Some of these developments have to do with the relation between smoking and other practices such as drinking alcohol, relaxing and socialising. We suggest that intervening in the future of smoking depends, in part, on understanding the nature of these alliances, and how sets of practices co-evolve. We conclude by reflecting on the implications of taking social practices as the central focus of public health policy, commenting on the benefits of such a paradigmatic turn, and on the challenges that this presents for established methods, policies and programmes.     

‘It’s in our veins’: caring natures and material motivations of community health workers in contexts of economic marginalisation

Khayelitsha, an economically marginal peri-urban settlement in Cape Town, is home to a number of ‘flagship’ public health interventions aimed at HIV/AIDS and TB. Alongside these high-profile, foreign donor-driven treatment and care programmes are a plethora of NGOs that provide a wide range of community-based carework. Some of these organisations are large, well funded and well connected globally, while others are run by a few unemployed women responding to care needs in their neighbourhoods. This article explores the ways that community health workers (CHWs) who work for these organisations understand and speak about their involvement in carework as volunteers, employees or managers of community-based care organisations. Many CHWs framed their work through discourses of gender, religion or culture (‘African-ness’). They also described forms of material or economic benefits of providing carework, but many were concerned that these might be seen as existing in tension with more socially accepted, altruistic motivations for care. We explore here how CHWs narrate and understand their roles and motivations as carers and members of a resource-constrained community.     

Performance Evaluation of Community Health Workers: Case Study in the Amazon of Peru

A shortage in human resources for health is a growing crisis that has led to an inability to provide adequate health services to impoverished populations. By “task-shifting”, health systems can delegate certain activities, such as health promotion and referral, to trained community members to help fill the human resource gap. An effective community health agent program can improve maternal and child health and overall effectiveness of rural health systems. Such a program is most effective when the community health agents receive supervision and evaluation of their performance. There is a shortage of literature that provides instruction and example on how to conduct a performance evaluation in the developing world to improve maternal and child health outcomes. The current study provides a case study of a performance evaluation in the Amazon region of Peru and how the findings can be used to make program adjustments. A set of instruments to measure the performance of CHWs was adapted from the literature and then implemented in the field. The instruments were used to measure the quality of home visits by the CHWs, their knowledge of the health topics, and structural activities. Three communities with an active CHW program in Loreto, Peru were chosen to receive the evaluation. All CHWs in the communities were evaluated. The scores from the evaluation were compared internally to identify strengths and weaknesses of the program and within the population of CHWs. The evaluation was completed on 52 home visits and 27 CHWs in three communities. The CHWs were found to be most effective at creating good relationships with caregivers and delivering health messages, and least effective at interacting with the child during the home visit and using material to deliver health messages. The evaluation instruments were well suited for the CHW program that utilizes home visits to teach about child health and development.     

The work of community health workers in major cities in Brazil: mediation, community action, and health care

This paper examines the role of community health workers (CHWs) and discusses the challenges in performing their multiple functions as: mediators linking the community and health services, community organizers, and care providers. A survey of CHWs was conducted in four towns in Brazil. The results indicate that during their home visits and community actions, the CHW perform educational and care activities for priority groups. Some CHWs work in health centers, where their functions include care management for chronic patients. The results indicate gaps in the work actually done, mainly as regards the expectation that CHWs would play a more political role, mediating between the communities and public policies, especially health policy. The CHWs in Brazil are general-purpose health personnel with a hybrid role that oscillates from technical to political profile.     

Enhancing social networks: a qualitative study of health and social care practice in UK mental health services

People with severe mental health problems such as psychosis have access to less social capital, defined as resources within social networks, than members of the general population. However, a lack of theoretically and empirically informed models hampers the development of social interventions which seek to enhance an individual's social networks. This paper reports the findings of a qualitative study, which used ethnographic field methods in six sites in England to investigate how workers helped people recovering from psychosis to enhance their social networks. This study drew upon practice wisdom and lived experience to provide data for intervention modelling. Data were collected from 73 practitioners and 51 people who used their services in two phases. Data were selected and coded using a grounded theory approach to depict the key themes that appeared to underpin the generation of social capital within networks. Findings are presented in four over‐arching themes – worker skills, attitudes and roles; connecting people processes; role of the agency; and barriers to network development. The sub‐themes which were identified included worker attitudes; person‐centred approach; equality of worker–individual relationship; goal setting; creating new networks and relationships; engagement through activities; practical support; existing relationships; the individual taking responsibility; identifying and overcoming barriers; and moving on. Themes were consistent with recovery models used within mental health services and will provide the basis for the development of an intervention model to enhance individuals’ access to social capital within networks.     

Food and eating as social practice – understanding eating patterns as social phenomena and implications for public health

Globally, public health agencies recognise obesity trends among populations as a priority. Explanations for population obesity patterns are linked to obesogenic environments and societal trends which encourage patterns of overeating and little physical activity. However, obesity prevention and nutrition intervention focus predominantly on changing individual level eating behaviours. Disappointingly, behaviour‐based nutrition education approaches to changing population eating patterns have met with limited success. Sociological perspectives propose that underlying social relations can help explain collective food and eating patterns, and suggest an analysis of the sociocultural context for understanding population eating patterns. We propose a theoretical framework for the examination of eating patterns as social phenomena. Giddens’ structuration theory, in particular his concept of social practices understood as an interplay of ‘agency’ and ‘social structure’ (rules and resources), is used to study food choice patterns. We discuss the application of these concepts for understanding routine food choice practices of families, elaborating how rules and resources configure the enabling or constraining conditions under which actors make food choices. The framework assists in characterising how social structural properties are integral to food choice practices, and could direct attention to these when considering nutrition interventions aimed at changing population eating patterns.     

A Community Health Worker Intervention to Address the Social Determinants of Health Through Policy Change

Public policy that seeks to achieve sustainable improvements in the social determinants of health, such as income, education, housing, food security and neighborhood conditions, can create positive and sustainable health effects. This paper describes preliminary results of Acción para la Salud, a public health intervention in which Community health workers (CHWs) from five health agencies engaged their community in the process of making positive systems and environmental changes. Academic-community partners trained Acción CHWs in community advocacy and provided ongoing technical assistance in developing strategic advocacy plans. The CHWs documented community advocacy activities through encounter forms in which they identified problems, formulated solutions, and described systems and policy change efforts. Strategy maps described the steps of the advocacy plans. Findings demonstrate that CHWs worked to initiate discussions about underlying social determinants and environment-related factors that impact health, and identified solutions to improve neighborhood conditions, create community opportunities, and increase access to services.     

Bonding versus bridging social capital and their associations with self rated health: a multilevel analysis of 40 US communities

STUDY OBJECTIVE: Few studies have distinguished between the effects of different forms of social capital on health. This study distinguished between the health effects of summary measures tapping into the constructs of community bonding and community bridging social capital. DESIGN: A multilevel logistic regression analysis of community bonding and community bridging social capital in relation to individual self rated fair/poor health. SETTING: 40 US communities. PARTICIPANTS: Within community samples of adults (n = 24 835), surveyed by telephone in 2000-2001. MAIN RESULTS: Adjusting for community sociodemographic and socioeconomic composition and community level income and age, the odds ratio of reporting fair or poor health was lower for each 1-standard deviation (SD) higher community bonding social capital (OR = 0.86; 95% = 0.80 to 0.92) and each 1-SD higher community bridging social capital (OR = 0.95; 95% CI = 0.88 to 1.02). The addition of indicators for individual level bonding and bridging social capital and social trust slightly attenuated the associations for community bonding social capital (OR = 0.90, 95% CI = 0.84 to 0.97) and community bridging social capital (OR = 0.96, 95% CI = 0.89 to 1.03). Individual level high formal bonding social capital, trust in members of one's race/ethnicity, and generalised social trust were each significantly and inversely related to fair/poor health. Furthermore, significant cross level interactions of community social capital with individual race/ethnicity were seen, including weaker inverse associations between community bonding social capital and fair/poor health among black persons compared with white persons. CONCLUSIONS: These results suggest modest protective effects of community bonding and community bridging social capital on health. Interventions and policies that leverage community bonding and bridging social capital might serve as means of population health improvement.     

Community health workers in Canada and the US: working from the margins to address health equity

In this commentary, we address community health workers’ (CHWs) marginalized social location within the health care systems of Canada and the US. This marginalization is due, in part, to their being a workforce shaped by socio-structural factors, such as gender discrimination, racism, and poor socio-economic conditions. This marginalization challenges their ability to address health equity. We propose system-level and workforce-level policy changes that build toward an empowerment path for CHWs to realize their full potential to address health equity. Regarding the work they do and the populations they serve, system-level changes would allow CHWs to strengthen their intimate connection with, and commitment to, advancing health and well-being in their marginalized communities. Workforce-level changes would target their peripheral status by addressing multiple structural factors and altering organizational arrangements to remove their marginalization as a workforce. Together these system-level and workforce-level changes would greatly enhance the health and social services systems.     

Giving a voice to medically vulnerable populations: A mixed‐methods investigation of their unique perceptions and needs in emergency situations

Older adults in poor health represent a growing sector of the population worldwide. These medically vulnerable individuals often tend to be ill‐prepared for emergencies. In times of crisis they are at higher risk of experiencing adverse health outcomes and are liable to place an additional burden on health and social care services. The aim of this study was to explore the unique perceptions and diverse needs of community‐dwelling medically vulnerable individuals in Israel in order to gain insights that could be used to promote future preparedness. A mixed methods design was employed that included 16 in‐depth interviews, followed by a quantitative survey of 179 participants. Data were collected between 2016 and 2017. The analysis process included thematic analysis for qualitative data. Quantitative data analysis focused on estimating associations between preparedness levels and participants’ characteristics and perceptions. The results indicated low levels of preparedness—only 13.5% of participants reported having prepared a full emergency kit with supplies. Family members played a key role in almost every dimension related to emergency preparedness; alongside certain authorities perceived by the participants as responsible for initiating the preparedness process. Additional issues that emerged were related to information and communication and to the logistics of medication handling and special nutrition. The findings suggest that it is vital to adopt a proactive approach to the problem of preparedness in this population. This conclusion should be of value to health and social care practitioners in the community as well as to family members and caregivers. Practical and simple recommendations for enhancing preparedness based on these findings are provided. Viewing preparedness as a process that is the joint responsibility of the individual, the family, caregivers, and community health and social welfare services could contribute to maintaining continuity of care among vulnerable populations and mitigate adverse health outcomes in future events.     

Community Health Worker Employer Survey: Perspectives on CHW Workforce Development in the Midwest

A statewide Community Health Worker Employer Survey was administered to various clinical, community, and faith-based organizations (n?=?240) across a range of rural and urban settings in the Midwest. At least 80% of participants agreed or strongly agreed that items characterized as supervisory support were present in their work environment. Thirty-six percent of respondents currently employed CHWs, over half (51%) of survey respondents reported seeing the need to hire/work with more CHWs, and 44% saw the need for CHWs increasing in the future. Regarding CHW support, a majority of respondents indicated networking opportunities (63%), paid time for networking (80%), adequate time for supervision (75%), orientation training (78%), mandatory training (78%), ongoing training (79%), and paid time for training (82%). Open-ended responses to the question "In your organization, what needs could CHWs meet?" resulted in the largest number of respondents reporting mental health issues as a priority, followed by connecting people with services or resources, educating the public on preventive health, family support, and home care/visitations. Our findings suggest that respondents, who largely have supervisory or managerial roles, view workplace environments in Nebraska favorably, despite the fact that nearly two-thirds of respondents typically work well over 40 h per week. In addition, CHWs could help address mental and physical health needs in a variety of community and clinical settings through primary and secondary prevention activities, such as provision of health screenings, health and nutrition education, connecting people to resources and empowering community members through these activities and more.     

Community health worker training and certification programs in the United States: findings from a national survey

OBJECTIVE: To analyze trends and various approaches to professional development in selected community health worker (CHW) training and certification programs in the United States. We examined the expected outcomes and goals of different training and certification programs related to individual CHWs as well as the community they serve. METHOD: A national survey of CHW training and certification programs. Data collection was performed through personal interviews, phone interviews and focus groups. Data sources included public health officials, healthcare associations, CHW networks, community colleges, and service providers. Initial screening interviews resulted in in-depth interviews with participants in 19 states. We applied human capital theory concepts to the analysis of the rich qualitative data collected in each state. RESULTS: CHW programs in the U.S. seem to have been initiated mainly due to lack of access to healthcare services in culturally, economically, and geographically isolated communities. Three trends in CHW workforce development were identified from the results of the national survey: (1) schooling at the community college level - provides career advancement opportunities; (2) on-the-job training - improves standards of care, CHW income, and retention; and (3) certification at the state level - recognizes the work of CHWs, and facilitates Medicaid reimbursement for CHW services. CONCLUSION: Study findings present opportunities for CHW knowledge and skill improvement approaches that can be targeted at specific individual career, service agency, or community level goals. Trained and/or certified community health workers are a potential new and skilled healthcare workforce that could help improve healthcare access and utilization among underserved populations in the United States.     

Are community health workers more effective in identifying persons in need of home and community-based long-term services than standard-passive approaches

Consumers prefer home and community-based long-term care (LTC) services (HCBS) but lack information on those services. We examined the use of community health workers (CHWs) to find and help Medicaid beneficiaries with unmet LTC needs access HCBS compared to standard HCBS outreach approaches. We found that CHWs were very effective at finding persons with greater needs and were better able to help them access a greater range of HCBS services. We also found that five times fewer HCBS beneficiaries helped by CHWs had to use nursing home care services than those not helped by the CHWs despite the fact that their health status was poorer than those not helped by the CHWs. Our study provides evidence of the effectiveness of CHWs for HCBS service awareness and navigation.     

Legal foundations for a national public health agency in Canada

This commentary addresses some of the key legal challenges associated with establishing a national public health agency in Canada. These include issues related to privacy and confidentiality of personal health information in the public health context, constraints on the jurisdiction and powers of a national agency, the need to respect individual rights and freedoms in an outbreak situation, and international cooperation in infectious disease control. The authors are part of a research initiative, comprised of experts in law, public health policy and medicine, that is currently analyzing legal considerations that may influence the mandate of a national public health agency in regard to infectious disease activities. This article discusses critical issues raised at a meeting in August 2004 that brought the research team together with key federal and provincial policy-makers and members of the public health community. The commentary emphasizes that law sets the foundation for public health activities, and the promise of a national public health agency will only be realized if significant legal issues are examined early on to ensure the agency is built on a robust legal and policy framework.