|Year : 2008 | Volume
| Issue : 2 | Page : 39
"Sitting in Different Chairs:" Roles of the Community Health Workers in the Poder es Salud/Power for Health Project
SA Farquhar1, N Wiggins2, YL Michael3, G Luhr1, J Jordan4, A Lopez2
1 Portland State University, Portland Oregon, USA
2 Multnomah County Health Department, Portland Oregon, USA
3 Oregon Health and Science University, Portland Oregon, USA
4 Lane County Public Health Department, Eugene, Oregon, USA
|Date of Submission||24-May-2007|
|Date of Acceptance||30-Apr-2008|
|Date of Web Publication||10-Sep-2008|
S A Farquhar
Portland State University, Portland Oregon
Source of Support: None, Conflict of Interest: None
Introduction: Evaluations of Community Health Worker programs consistently document improvements in health, yet few articles clearly describe the roles of Community Health Workers (CHWs) from the CHWs' perspective. This article presents the CHWs' points of view regarding the various roles they played in a community-based participatory research (CBPR) project, Poder es Salud/Power for Health in Portland, Oregon, including their roles as community organizers and co-researchers.
Methods: Authors draw from an analysis of transcript data from in-depth interviews conducted with CHWs to present a description of the strategies employed by the CHWs to build leadership skills and knowledge among community members. CHWs also discuss their own personal and professional development.
Results: The analysis of the interviews suggests that CHWs valued their multiple roles with Poder es Salud/Power for Health and their participation on the project's Steering Committee. Based on CHWs' descriptions of their work, this type of involvement appears to build the CHWs' leadership skills and sense of efficacy to create change in their communities.
Conclusion: By serving as community organizers and participating as producers of research, rather than acting merely as a deliverer of the intervention activities, the CHWs were able to build skills that make them more successful as CHWs.
Keywords: Community health worker, community-based participatory research, qualitative research, social capital, community organizing
|How to cite this article:|
Farquhar S A, Wiggins N, Michael Y L, Luhr G, Jordan J, Lopez A. "Sitting in Different Chairs:" Roles of the Community Health Workers in the Poder es Salud/Power for Health Project. Educ Health 2008;21:39
|How to cite this URL:|
Farquhar S A, Wiggins N, Michael Y L, Luhr G, Jordan J, Lopez A. "Sitting in Different Chairs:" Roles of the Community Health Workers in the Poder es Salud/Power for Health Project. Educ Health [serial online] 2008 [cited 2020 Aug 4];21:39. Available from: http://www.educationforhealth.net/text.asp?2008/21/2/39/101580
Community health workers (CHWs), also commonly referred to as promotores de salud, are community members who combine their lived experiences with specialized training to assist members of their communities (Love et al., 1997). Evaluations of CHW programs in developed and developing nations have documented improvements in individual and community health (Andrews et al., 2004; Hunter et al., 2004; Ahluwalia et al., 2003; Krieger et al., 1999; Eng & Young, 1992). For example, one program in rural India trained CHWs to identify and treat depression in areas where there are few psychiatrists. This project reduced the stigma of mental illness and increased access to basic mental health services (Isaacs et al., 2006). A recent international review of CHW programs noted that these programs are more likely to be successful when community mobilization occurs, and when the CHWs are valued for their contributions to improved community health (Lehmann & Sanders, 2007). Yet, much less information is available about what makes these programs successful from the perspective of the CHWs themselves. This article aims to address this gap by presenting the words and experiences of CHWs from the Poder es Salud/Power for Health project.
Poder es Salud/Power for Health Description
The primary goal of Poder es Salud/Power for Health, a three-year project funded by the Centers for Disease Control and Prevention (CDC) as a community-based participatory intervention project, was to work with CHWs to address the root causes of health disparities in Multnomah County, Oregon. CHWs from the local African American and Latino communities and parishes were employed and involved in all aspects of the intervention and research activities. A Steering Committee, which included representatives from community-based organizations, the county health department, local universities, and the general community (including the CHWs) guided the project’s evaluation and programs.
Poder es Salud/Power for Health’s primary outcome of interest was social capital, conceptualized as the community’s ability to work collectively to achieve mutually agreed upon goals and create a healthier community (Lochner et al., 1999; Farquhar & Michael, 2004). In addition to seeing increases in social capital and improvements in outcomes of physical and emotional well-being (results presented in Michael et al., 2008), the project was interested in better understanding how participation in Poder es Salud/Power for Health impacted project CHWs.
The project identified three Latino (two female and one male) and three African American (two female and one male) CHWs, all selected by leaders in their communities or parishes. The three African American CHWs worked with faith-based communities. One of the Latino communities was geographically defined and included three apartment complexes; the other Latino community was a coalition of five evangelical churches. All the Latino CHWs were immigrants from Mexico, and all of the African American CHWs were born and raised in the local area. The CHWs were from 31 to 50 years of age. Their previous or current occupations included homemaker, musician, secretary, and salesperson. In advance of advertising the CHW positions, the project identified specific skills and qualifications for prospective CHWs, including previous experience doing organizing and advocacy in the community. It should be noted that not all CHWs entered the project with prior community organizing experience. In fact, only one had previous formal experience as a CHW.
Project CHWs participated in the introductory 80-hour curriculum for CHWs developed and presented by the staff and director of the Community Capacitation Center, a center housed within the county health department. The curriculum, which was based on the findings of the National Community Health Advisor Study (Wiggins et al., 1998) was approved by the State of Oregon for academic credit. Curriculum modules included such topics as leadership, advocacy, community organizing, research design and evaluation, and health promotion. The staff and project partners who led the CHW trainings used popular education, an empowering philosophy and methodology most closely associated with Brazilian Paulo Freire. The active learning techniques they used included dinámicas (games with an educational and social purpose), brainstorming, sociodramas (short skits that represent an unresolved problem), role plays, simulations, and small group work. Popular education was intended to enhance CHWs’ skills as leaders and organizers, and to encourage them to define their own roles as CHWs early in the project.
From the beginning and throughout the course of the project, CHWs engaged with their communities to identify specific health priorities, projects, and ways to evaluate these projects. Although they primarily worked within their respective communities, the CHWs did partner on various activities that brought the communities together. The projects initiated and completed by the CHWs included the following: an Aztec dance class, a soccer team for Latina women, a series of popular education classes about gang violence for Latino community members, a series of diabetes education classes at an African American faith community, and the creation of a cooperative to improve health by addressing issues of poverty and unemployment in a Latino faith community.
To examine the project’s research questions, the Steering Committee and the researchers jointly created the semi-structured interview guide and protocol. A community member, who served on the project’s Steering Committee, conducted the face-to-face in-depth interviews, lasting 45 minutes on average. During these interviews, the CHWs were invited to discuss their roles as CHWs and as project Steering Committee members, the strategies they used to promote health in their communities, and the ways they evolved during the course of the project (see Table 1).
Table 1: Questions from the CHW in-depth interview guide
All six interviews were taped and transcribed using a professional transcription service. The full interviews were entered into Atlas/ti 4.2 qualitative data analysis software and analyzed by two of the project’s researchers using a modified focused coding method (Strauss & Corbin, 1990).
Analysis of the interviews revealed several primary themes. Principally, the CHWs valued having multiple roles, described by one CHW as “sitting in different chairs.” The CHWs served as community organizers, rather than solely as providers of direct service, and contributed to the research and evaluation of the project.
“I feel sometimes I’m bring(ing) information to people, then sometimes I feel like I’m an advocate really trying to get the help for them right away. Then sometimes I feel like I’m a healer where I come and pray for people. And…we wear a lot of hats; we’re not subject to just one.”
The CHWs’ ability to respond to multiple situations using a variety of skills and strategies was a direct result of how their role was designed, as well as the content of the CHW capacitation (training) sessions. The CHWs most frequently discussed their roles as community organizers and as members of the project’s Steering Committee.
Working as a Community Organizer
When invited to discuss the intervention strategies used to solve community concerns, all of the CHWs discussed community organizing and building community leadership as their primary methods of change. As one CHW explained, “We teach them how they can solve problems by themselves, how to get organized and how to be a leader.”
An important outcome of effective community building, as described by several of the CHWs, was increased cohesiveness and capacity to make things better. CHWs in the Latino community noted that the participating families and neighbors “have a greater sense of community… and now because of that they know they have the power to change things.” This transformation among community members from passive recipients of knowledge or programs to active change agents was described by one CHW:
“The role of community health workers has been good because we have taken away the paternalistic part of the education and offered self-sufficiency as an alternative.”
Serving as a Member of the Project’s Steering Committee
In addition to serving their communities, CHWs were challenged and gained skills by being on the project’s Steering Committee. One of the benefits, as described by the CHWs, was that they learned from others who had experience or knowledge different from their own.
“I’m able to gather information from all these people that sit on the Steering Committee, suggestions in case I have problems that come up or maybe somebody has worked on some issue. I think it makes your load lighter when you have this person or people you can come and say… ‘how would (you) suggest I handle this?’”
CHWs mentioned that their participation on the Steering Committee increased their knowledge of research. Additionally, the CHWs strengthened their professional skills, including computer skills, language skills, and meeting, planning and facilitation skills through their involvement with all aspects of the project.
“I also enjoy the role I played, when they invited you to do presentations in the schools, colleges, clinics, and in the community in general. If you are exposed to ideas from different viewpoints, from different professions, then it’s more easy when you go to the community and you use those things that you learned.”
The CHWs felt empowered by their role with the project, and a few of the CHWs sought additional training and similar CHW positions when the project funding ended.
CHWs are primarily identified as effective providers of health education, direct service, or outreach (for examples, see Love et al., 1997). Yet interview data and conversations with this project’s CHWs suggest that the CHWs acted primarily as community organizers. In the health promotion literature, there are only a few examples of CHWs working as community organizers. In a clinical journal, Ahluwalia and colleagues (2003) describe a project in two rural areas in Tanzania, where CHWs, trained in community organization, are addressing high maternal and child mortality rates. This Tanzanian project demonstrated that the high levels of community participation and strong local leadership generated by CHWs contributed to the program’s sustainability (Ahluwalia et al., 2003).
The Poder es Salud/Power for Health study also demonstrated that the CHWs valued their roles as members of the project’s Steering Committee. The expanded role of CHWs as partners in health research is gaining traction with several recent studies that conclude that CHWs can be effective research partners (see Brownstein et al., 2005; Martin et al., 2005). In rural Bolivia, an effort to address maternal and neonatal health priorities engaged CHWs to work with community members in reviewing health outcomes data collected by health care providers (Howard-Grabman, 1996).
The CHWs in the Poder es Salud/Project for Health study regularly framed their personal and professional growth in reference to their ability to work alongside and be supported by other organizations, including those represented by project Steering Committee members (e.g., the participating universities and county health department). The interview data suggest that by partnering with local organizations and professionals, the CHWs may have more effectively been able to identify solutions to community concerns. Lehmann and Sanders (2007) recommend that CHWs be given the chance to collaborate with other professionals and be offered adequate support to complete their work. In Brazil, the Programa do Agente Comunitario de Saude has had success over the last few decades in integrating CHWs into government programs and into a broader team of health professionals (Lehmann & Sanders, 2007).
Finally, longitudinal quantitative survey data from Poder es Salud/Power for Health (see Michael et al., 2008) revealed statistically significant improvements on certain self-report measures of well-being among survey respondents from the participating communities. Between the initiation and conclusion of the intervention, researchers identified increases in available social support (p<0.003), improvement in self-reported physical health (p<0.004), and an overall decrease in depressive symptoms (p<0.003).
The authors acknowledge that this study has limitations. The study is based on the responses of six CHWs. Three out of four of the participating sub-communities are faith-based and represent only two racial/ethnic communities in an urban setting, and thus, results may not be generalizable to other communities. Many variables, including the history and capacity of the participating communities, and the skills and knowledge of the CHWs, would need to be considered to better understand those other factors that increase the success of CHWs and participating community members.
The results of this study, based on in-depth interviews with CHWs, suggest that certain factors were associated with CHWs who experienced positive change and contributed to a more empowered community. The factors include: conceptualization of the CHW role as inclusive of community organizing, training of CHWs in a broad range of topics using popular education, and participation of the CHWs in project planning, research, and decision-making. Future projects can, hopefully, advance the science, education, and the practice of public health by increasing the CHWs’ capacity to act as community organizers and by meaningfully including the CHWs in the design of the intervention strategies and research protocol.
This research was supported by a grant from the Centers for Disease Control and Prevention (Grant #R06-CCR021527-02-02). Special thanks to Noëlle Wiggins, MSPH, Program Director, for initiating the project, assembling the project team, and identifying the project’s three key strategies. Thanks also to Teresa Rios, Capacitation Coordinator, for contributing her extensive experience as a CHW leader and trainer, and to Lawrence Wallack, DrPH, former Principal Investigator of Poder es Salud/Power for Health, for leadership. Special appreciation to the Community Health Workers Alicia Lopez, Linda Hornbuckle, Gonzalo Gonzalez, Robert Seay, Maria Avila, and Jovita Chaney, and to all members of the Poder es Salud/Power for Health Steering Committee and Research Advisory Board, including, Denise Johnson, Fred Miller, Joe Gallegos, Mandy Green, Maria Lisa Johnson, Pam Ballentine, Richard Loudd, Star Waters, and Ruth Kemp.
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