Community Health Worker Policy Leadership and the COVID-19 Pandemic

Trinity College | American Honors

Community Health Worker Policy Leadership and the COVID-19 Pandemic

Brenda Piedras ’21

 

Community Health Worker (CHW): Community Health Workers (CHWs) are frontline public health workers who are trusted members of their communities, serving as intermediaries between health/social services, educators, informal counselors, and advocates. (National Association of Community Health Workers).

INTRODUCTION:
Figure 1. Key Relationships: Community health workers (CHWs) are trusted and uniquely connected to community members. CHWs facilitate community member access to healthcare systems and public health/ government but remain intrinsically connected to their communities.

There are an estimated 120,000 to 200,000 community health workers in the United States, who have expertise in recognizing social barriers to health. (1, 2) Community health workers (CHW) are frontline public health advocates and patient navigators with a unique and keen understanding of the communities that they serve. (3, 4, 5) CHWs often have short-term, skill-specific formal training, allowing them to work in domestic, clinical, public settings. (6, 7) The main responsibilities of CHWs typically include but are not limited to, patient care and disease management, medical referrals, health education, and advocacy. (8, 9) The National Association of Community Health Workers (NACHW) aims to unify CHWs nationally to increase health, equity, and social justice in communities. One way to achieve their mission is to embolden the voices of CHWs in health policy, especially in light of the COVID-19 pandemic. The U.S. The Department of Homeland Security insists that there is a “special responsibility to maintain… normal work” for CHWs given the COVID-19 pandemic. (NACHW)  I therefore investigated:

  1. What kind of leadership training and/or mentoring are necessary to increase CHW policymaking? 
  2. What do policymakers need to know about CHWs, especially in light of the COVID-19 pandemic? 

METHODS:
Figure 2. Sample Characteristics: Demographic representation of 10 total interviewees.

The National Association of Community Health Workers (NACHW) organized an informal national CHW COVID-19 survey in March 2020. The CHW COVID-19 survey found that CHWs are being excluded from planning emergency responses to the COVID-19 pandemic. (NACHW). Because CHWs are frontline public health workers, their involvement in emergency response plans is crucial, especially in vulnerable communities. I developed my interview guide as an extension of the national CHW COVID-19 survey to explore a) services and interventions, b) policy and advocacy activities, and c) barriers to CHW leadership. The study required a purposive sample of CHW emerging and current leaders in their communities. Participants were recruited with assistance from NACHW’s network of CHWs.  The interviews, which averaged 60 minutes in length, were conducted via Zoom and transcribed. Transcripts were coded in the software Dedoose using a grounded theory approach to identify key themes and patterns. Qualitative coding of the interviews aimed to categorize themes as a) factors that promote effective CHW policymaking and advocacy, b) factors that obstruct effective CHW policymaking and advocacy, and c) and factors that promote but may also obstruct CHW policymaking and advocacy. These factors included CHW a) mentoring and leadership training, b) professional or specialized-skill development, and c) healthcare system and public health/ government support.

Results and Discussion:

How can we most effectively increase CHW influence in policymaking?

Seven out of 10 interviewees identified past or current experiences with policymaking and advocacy as a CHW, ever more so with the COVID-19 pandemic. CHWs indicated that they attended or organized a town hall or commission meetings, referred clients to legal counsel, were a member of a coalition, conducted research on their communities, and developed or advocated for the legislation. The 3 interviewees that did not personally have past or current policymaking or advocacy experiences revealed that they were familiar with policymaking and advocacy within their organization. Of the 3 interviewees without policymaking and advocacy experience, 1 revealed that they applied to a seat on a municipal commission. Because CHWs want to be or are civically engaged, it is evident that they have the capacity and commitment to be leaders in policymaking concerning their communities and public health.

Figure 3. Factors Influencing CHW Policymaking and Advocacy

Factors Promoting Effective CHW Policymaking & Advocacy:

Education: Seven out of 10 interviewees held their undergraduate or graduate education prepared them to undertake policymaking and advocacy positions as CHWs. Interviewees asserted that their undergrad and grad programs a) inspired them to become CHWs, b) solidified their desire to work in public health, c) gave them access to mentors, and d) provided internship and field experiences. These CHWs believed that their education was instrumental to their current leadership position because these programs prepared them to be CHW professionals and be leaders in the workplace.

Research: Five out of 10 interviewees believed that their ability to contribute to public health research legitimized their policymaking activities. They believed that research on public health or their communities could be seamlessly directed by CHWs. Four out of these 5 interviewees asserted that the research already conducted by CHW had to be catered to funders or partners, and therefore were not accessible to the community. As such, 2 CHWs described that they specifically engaged in research projects that used community-based participatory approach models.

Trust: Ten out of 10 interviewees revealed that their communities’ trust in CHWs promoted their pursuit of policymaking and advocacy responsibilities. CHWs felt a responsibility to community members, specifically those serving underrepresented or vulnerable communities. CHWs felt the drive to always make decisions in the best interest of their communities by a) preserving the comprehensive scope of their services, evermore so with the COVID-19 pandemic, b) developing culturally and linguistically appropriate public health resources. Four out of 10 CHWs believed that their shared lived experiences with their communities allowed to advocate more conscientiously and with more confidence.  

Figure 4. Factors Influencing CHW Policymaking and Advocacy: Mentions are out of 10, since there were 10 interviewees total.

 

Factors Obstructing Effective CHW Policymaking & Advocacy:

Lack of Professionalization of CHWs: Eight out of 10 interviewees believed that CHW policymaking and advocacy activities would increase if stakeholders recognized the work of CHWs as a profession. Four of these CHWs specifically asserted that they were already providing CHW interventions and services to their communities before they received CHW certification or CHW employment. CHWs revealed that their capacity to engage as leaders, policymakers and advocates was compromised because of the a) uncertainty of CHW employment, b) existing CHW employment is primarily clinical, c) a lack of transparency in CHW hiring practices. One CHW specifically mentioned that there is consistent interest in being a CHW but there are not enough employment opportunities. The lack of stable CHW employment creates barriers to CHWs who wish to become leaders in their communities, and even more so for those interested in leading policymaking and advocacy.

Funding: Nine out of 10 interviewees believed that the lack of funding to CHWs and their programs severely limited the ability for CHWs to engage in policymaking and advocacy. CHWs find that a lack of funding has led to difficulties in a) attracting the attention of legislators, b) increasing training opportunities to enhance CHW skillsets, and c) serving as frontline COVID-19 public health professionals. 

Figure 5. CHW Certification Requirements by State
Circled states indicate where CHWs from the sample practice.
mapchart.net

 

Factors Promoting But Also Obstructing Effective CHW Policymaking & Advocacy: 

State-Issued CHW Certification: Nine out of 10 interviewees considered state-issued CHW certification to be an influential factor in CHW policymaking and advocacy. Seven out of these 9 interviewees believed that certification promoted CHW policymaking and advocacy, while 3 out of 9 believed that it would obstruct policymaking and advocacy. CHWs in favor of certification cited that it would allow CHWs to a) diversify and standardize their skillset, b) gain professional recognition and employment, c) increase CHW retention, and d) improve the quality of interventions and services for community members. CHWs in opposition to certification expressed concern rather than complete disagreement because they believed CHWs would risk a) limiting the scope of their intervention and services, b) disproportionately going into clinically-based work, and c) jeopardizing the trust of their communities, especially if they work under a powerful stakeholder. Surprisingly, the only interviewees that served in a state that had mandatory CHW certification are the ones that expressed the most concern with certification.

Partnerships: Nine out of 10 interviewees believed that partnerships contributed to CHW policymaking and advocacy. CHWs cited that their strongest partners were a) community-based organizations, b) academic institutions, state and city governments, and healthcare and hospital systems. Three out of these 9 interviewees expressed concern about the efficacy of partnerships in increasing CHW policymaking and advocacy. These CHWs believed that partnerships facilitated a) streamline CHW training, b) career advancement and mentorship, and c) creating culturally specific programs. However, they also felt that partnerships a) shifted the responsibility of policymaking and advocacy to partners even though CHWs are capable, and b) overwhelmed CHWs with unrealistic expectations.

Conclusion:

CHWs require a professionalization effort, funded by stakeholders, to popularize awareness of the CHW profession. Once CHWs are treated as professionals, they must create their own career advancement coalitions to create their own state certification and training programs. This way, certification programs are legitimized by Departments of Public Health, while allowing CHWs to have autonomy over the scope and nature of their interventions and services.  Recognition of CHWs by Departments of Public Health increase the likelihood that CHWs can successfully increase their civic engagement, policymaking, and advocacy. Because CHWs are trusted members of the community their successful civic engagement will bring awareness to the communities they serve, even sparking the possibility of research and investment in the community by stakeholders. CHWs are willing to offer and share their knowledge, data, and research with stakeholders, especially with the COVID-19 pandemic; it is simply a matter of whether audiences will be receptive to CHWs. Future research on CHWs should focus on the effectiveness of certification programs and professionalization efforts. It is also necessary to continue investigating the impact of CHWs during the COVID-19 pandemic and its long-lasting effects on the CHW profession.

 

Works Cited:
  1. Perry, H. B., Zulliger, R., & Rogers, M. M. (2014). Community health workers in low-, middle-, and high-income countries: an overview of their history, recent evolution, and current effectiveness. Annual review of public health, 35, 399-421.
  2. Rosenthal, E. L., Brownstein, J. N., Rush, C. H., Hirsch, G. R., Willaert, A. M., Scott, J. R., … & Fox, D. J. (2010). Community health workers: part of the solution. Health Affairs, 29(7), 1338-1342.
  3. Rosenthal et al. (2010)
  4. Lohr, A. M., Ingram, M., Nuñez, A. V., Reinschmidt, K. M., & Carvajal, S. C. (2018). Community–clinical linkages with community health Workers in the United States: a scoping review. Health promotion practice, 19(3), 349-360.
  5. Perry et al. (2018)
  6. Scott, K., Beckham, S. W., Gross, M., Pariyo, G., Rao, K. D., Cometto, G., & Perry, H. B. (2018). What do we know about community-based health worker programs? A systematic review of existing reviews on community health workers. Human resources for health, 16(1), 39.
  7. Perry et al. (2018)
  8. Jack, H. E., Arabadjis, S. D., Sun, L., Sullivan, E. E., & Phillips, R. S. (2017). Impact of community health workers on use of healthcare services in the United States: a systematic review. Journal of general internal medicine, 32(3), 325-344.
  9. Braun, R., Catalani, C., Wimbush, J., & Israelski, D. (2013). Community health workers and mobile technology: a systematic review of the literature. PloS one, 8(6), e65772.