570632
research-article2015
HPPXXX10.1177/1524839915570632Health Promotion PracticeLechuga, Garcia / Latino Community Health Workers
Health Promotion With Latino Communities
Latino Community Health Workers and the Promotion of Sexual and Reproductive Health Julia Lechuga, PhD1 Dina Garcia, MPH2 Jill Owczarzak, PhD3 Maria Barker4 Meghan Benson, MS4 Community health worker (CHW) programs have existed for over 50 years across the world. However, only recently has research evidence documented their effectiveness. Research is still needed to identify issues related to implementation and sustainability of CHW programs. This article explores the role and challenges of U.S. Latino CHWs trained to deliver a comprehensive sexual and reproductive health educational intervention to Latino families. We conducted a semistructured interview with a purposive convenience sample of 19 CHWs. Findings suggest that CHWs occupy roles that go beyond those they were trained for. CHWs serve not only as educators but also as providers of social support, facilitators of access to resources, patient navigators, and civil rights advocates. Lack of clarity of the role of a CHW influenced perceptions of adequacy of compensation, training, and integration into the agency that trained them. Policy facilitating the standardization of the CHW occupational category and role expectations is imperative to ensure successful implementation and sustainability of U.S. CHW programs. Keywords: community health workers; promotores de salud; sexual and reproductive health; Latinos
(Pew Hispanic Research Center, 2011; Centers for Disease Control and Prevention [CDC], 2012). Unfortunately, Latinos in the United States face considerable health disparities in multiple domains, particularly in sexual and reproductive health. For example, the rate of HIV infections among Latinos since 2006 is 2.5 times that of non-Hispanic Whites (CDC, 2009). In addition, Latinas are 2 times more likely to be diagnosed with other sexually transmitted infections such as chlamydia (CDC, 2009) and cervical cancer than non-Hispanic White women (American Cancer Society, 2009). Latinas are less likely to get screened for cervical cancer and receive follow-up treatment once cervical abnormalities are detected (American Cancer Society, 2009). Research also indicates that ethnic disparities exist in other sexual and reproductive health domains such as unintended pregnancies and incorrect use of contraceptives. Specifically, approximately 70% of Latinas aged 15 to 44 years surveyed in the 2006-2010 National Survey of Family Growth reported ever being pregnant and that 51% of such pregnancies were unintended. Participants also reported that half of these unintended pregnancies followed after incidents of 1
The University of Texas El Paso, El Paso, TX, USA The Medical College of Wisconsin, Milwaukee, WI, USA 3 Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA 4 Planned Parenthood of Wisconsin, WI, USA 2
L
atinos comprise 16.3% of the total U.S. population, and it is expected that by 2050 the Latino population will reach 132.8 million people
Health Promotion Practice May 2015 Vol. 16, No. (3) 338–344 DOI: 10.1177/1524839915570632 © 2015 Society for Public Health Education
338
Authors’ Note: This work was supported by the Medical College of Wisconsin through The Wisconsin Partnership Program, Milwaukee, Wisconsin, USA, awarded to the first, fourth, and fifth authors. Address correspondence to Julia Lechuga, Department of Psychology, The University of Texas El Paso, 500 W. University Avenue, El Paso, TX 79902; e-mail: [email protected].
improper condom use and perceptions of low risk of pregnancy (Masinter, Feinglass, & Simon, 2013). Research indicates that limited access to cultural and linguistically appropriate sexual health information and health care services is an important determinant of Latino health disparities (Cashman, Eng, Siman, & Rhodes, 2011). Furthermore, Latinos face multiple barriers to accessing and receiving adequate health care, including language barriers, confusion or lack of knowledge on how to navigate the health care system, possible fears related to immigration status, and potential lack of “cultural competence” on the part of the health care system (Marshall, Urrutia-Rojas, Soto Mas, & Coggin, 2005). These challenges underscore the need to devise nonstandard ways to address the health care needs of this population. Community health worker (CHW) programs have been proposed and developed as one such alternative. CHW programs consist of training lay community members to perform health care-related tasks and address the needs of medically underserved populations (American Public Health Association, 2009). In 2011, the Health Resource and Services Administration (HRSA) defined the roles of CHWs as bridges between the health care system and vulnerable populations, managers of the health care of vulnerable populations, promoters of providers’ cultural competence, advocates of health care access, informal counselors, and promoters of community capacity to become advocates. Research indicates that CHW programs increase the quality and cultural competence of health care services by improving provider–patient communication, trust, and rapport, leading to better adherence to medical regimens (Balcazar et al., 2011). Despite the promise of CHW programs and increased efforts to formalize their role within the U.S. health care system, the United States lacks a comprehensive policy regarding the implementation and institutionalization of CWH programs within health care organizations. Questions remain regarding implementation and institutionalization of CHW programs, including CHW capacity building, education and training, roles, and payment mechanisms (Balcazar et al., 2011). Answers to these questions will facilitate strategic planning regarding capacity building and remuneration issues and possibly inform strategies to promote successful implementation and sustainability. Our study answers questions of process of an institutionalized CHW program in the area of sexual and reproductive health. Data presented will shed light on roles, characteristics, and challenges faced at the organizational and personal levels by CHWs. Our study adds to the CHW literature as most of CHW programs targeting Latinos address chronic illnesses such as diabetes and child and maternal health (Rhodes, Foley, Zometa, & Bloom, 2007).
The present study stems from a community–academic partnership between Planned Parenthood of Wisconsin, Inc. (PPWI) and The Medical College of Wisconsin to evaluate PPWI’s sexual and reproductive health intervention delivered by CHWs. PPWI’s sexual and reproductive health curriculum is delivered in a “health party” setting. Within this model, CHWs recruit members of the community (hosts) who then recruit 8 to 10 members of their social network to attend a health party. The CHW delivers the curriculum, which consists of seven informational and skill-building sessions covering topics of sexuality and reproductive health, in the host’s home or in another community venue. Both CHW and host receive incentive payments. CHWs receive $15 per hour spent delivering each educational session. The host, who recruits members of his or her social network, receives $50 per educational session. Each session lasts 2 to 3 hours. CHWs receive round-the-clock support from a program coordinator who meets in person with them at least once a month. CHWs are encouraged to seek support any time they need it by phoning the program coordinator who makes herself available around the clock. According to the CHW training typology developed by the HRSA (2011) and published in the Community Health Workers Evidence-Based Models Toolbox, CHWs were trained by PPWI as health educators to implement the sexual and reproductive home health party curriculum and as outreach workers to serve as the bridge between the community and the sexual and reproductive health services offered by PPWI. CHWs were trained for 8 weeks (20 hours per week). Training was done formally by the program coordinator. The training consisted of didactics on the topics addressed in the intervention, role-plays, skits, and small group discussions. In 2013, a total of 675 health parties were delivered.
Method >> We employed a qualitative research approach. A convenience sample of CHWs were recruited to answer a semistructured interview organized around three sections, each exploring broad topics such as the roles CHWs played in promoting sexual and reproductive health and the challenges faced at the organizational and personal levels. Furthermore, CHWs answered a questionnaire assessing basic demographic characteristics. CHWs were eligible to participate if they had completed the required training mentioned above and successfully delivered at least one health party as determined by observers from PPWI who trained them. Prior to data collection, study procedures were approved by the Medical College of Wisconsin Institutional Review Board. All interviews were
Lechuga et al. / LATINO COMMUNITY HEALTH WORKERS 339
conducted in Spanish by a bilingual, bicultural researcher. Interviews were audio recorded and transcribed verbatim for analysis. Prior to the start of each interview, participants completed a written informed consent. Participants received $25.00 as compensation for their time.
Analysis >> Written transcripts were analyzed using MAXQDA qualitative software. Two bilingual researchers coded the data and transcripts were reviewed to identify statements reflecting categories, concepts, or themes regarding roles CHWs played and challenges faced when delivering PPWI’s sexual and reproductive health educational intervention. Because the interviews had the specific focus of elucidating three main topics, codes were developed a priori. However, these were expanded if comments did not fit within the a priori coding category. Participant statements were identified and used to highlight recurring themes. Each transcript was coded by one coder and reliability was enhanced by reviewing all coding for discrepancies by the research team. Survey data were analyzed with descriptive statistics.
Results >> A total of 19 CHWs (63% female) with a mean age of 41.39 years (SD = 14.88, range 21-77 years) participated in the study. Eighteen CHWs were foreign born and the countries of origin were Mexico (N = 10), Colombia (N = 2), Bolivia (N = 2), Guatemala (N = 1), and Honduras (N = 3). Foreign-born CHWs reported a mean of 9.39 years lived in the United States (SD = 7.44, range 1-26 years). Approximately 63% were married and 78% identified only Spanish as their preferred language. Regarding education level, 53% reported to have a college degree obtained in their country of origin. CHWs reported conducting a mean of 5.88 health parties (SD = 8.06, range 1-20 health parties) and engaged in unpaid volunteer work an average of 3.66 hours per week (SD = 3.33, range 1-10 hours). The most common site where health parties were conducted was a home. Key Roles of CHWs in Sexual and Reproductive Health Promotion CHWs were trained to deliver sexual and reproductive health information along with information about available PPWI services and teach skills that will enable health party attendees to enact protective behaviors. However, as the next quotes illustrate, CHWs performed a variety of other roles. For example, as the following quotes illustrates, many interviewees had 340 HEALTH PROMOTION PRACTICE / May 2015
experienced the social conditions affecting the Latino community and consequently felt responsible for linking community members to other resources. Once I do a sexuality education home health party and people tell me about all their problems including deportation, substance abuse, domestic violence, poverty . . . and more questions come up . . . it is my obligation to follow-up with them and help them find answers . . . even if it means taking them by the hand to places . . . (CHW female)
Another role identified was that of providing social support to health party attendees even after their CHW’s role of health educator had ended. One CHW shared her experience of making herself available for continuing support to community members who had attended a health party she facilitated. At four in the morning I received a call from a person who attended one home health party asking me, are you the person who gave that health party? Yes . . . she told me she had a problem . . . the condom broke . . . I told her what to do and where to go . . . (CHW female)
CHWs also saw themselves as patient navigators to the point of actually accompanying people to their appointments. As I worked with people I found myself more involved. I even had a case of a woman who was afraid of accessing services . . . and well I supported her a lot by going with her to the clinic and helping her fill out paperwork . . . (CHW female)
In addition to their roles as helping the community access resources, sources of social support, and patient navigation, CHWs expressed a need to advocate for equal rights. I like to work with the community especially with immigrants . . . One wants to tell more . . . so that we can have rights, political rights also because unfortunately it is only by becoming involved with politics that we acquire rights. Immigrants need to become aware that right now there is not an equal balance of opportunities especially for the Latino community. (CHW male)
Organizational Challenges Encountered by CHWs Monetary monetary
Compensation. Perspectives regarding compensation for their work varied
highlighting the potential conflict between how CHWs perceive themselves, what they were specifically trained to do, and what they expect from the agency for which they work. CHWs’ varied perspectives on what constitutes fair compensation reveal the ambiguity of their role.
As this CHW conveyed, CHW work does not entail performing the tasks of professionally trained health care providers. On the other hand, the majority of participants voiced the need to receive additional training. Particularly, many participants voiced the need to have access to more in-depth trainings on a variety of topics.
I have thought that it is not fair but when you love the community I think that you do not do the health parties for the money. When you see all of the unmet needs surrounding the Latino community, you do it more for love . . . I do not live off of that compensation and I think it is a pay that is not a salary that I can count on, and I like to do it for my love for the community. (CHW female)
Questions always arise that are not within the work plan. And as a CHW one has to be available to the community to answer these questions. Find the information and disseminate it to the community when we do not have the answers. (CHW female)
This CHW’s perspective underscores a sense of altruism and desire to help the community, a value system in which additional financial compensation has no place. However, other CHWs felt that the compensation provided does not adequately compensate for their time, effort, and transportation costs. The pay is not appropriate because to facilitate a health party one has to invest so much time in preparing for questions and making yourself available after. So finding resources, books, readings, and doing the party you have to plan the time and the place, right? And it is difficult. We need to rent a place, gather people, it is a bit difficult. So considering that, I think that it would be great to pay CHWs more. (CHW male)
The conflicting stance regarding monetary compensation illustrates lack of consensus by CHW themselves about how their work should be compensated. On one hand there is a feeling that altruism should be a primary motivator and hence no or minimal compensation is appropriate, and on the other, a feeling that CHW work is intensive, goes beyond providing information, and requires compensation at the semiprofessional or professional level. Training and Integration Within the Agency. CHWs expressed two views regarding their level of satisfaction with the training they received. On one hand, few CHWs saw their training as sufficient. I think the training was sufficient because one does not become a doctor or nurse. We inform the community about the services the agency offers. So I think it is perfect. (CHW female)
This CHW recognized that her interactions with members of the community would raise issues beyond those included in the sexual and reproductive health curriculum, and therefore wanted additional training in order to be prepared to address the broad needs of health party participants. Likewise, CHWs understood the rapidly changing field of health care delivery and health-related information. They thought that continued training and education were necessary to stay current on these changes and provide their constituents with the most accurate, up-to-date information possible as the next quote illustrates. We need a little more training on anything new that comes out . . . Any new thing that comes out, for example, the changes to the Pap smear, we need to have an immediate meeting with all of the CHWs and be informed about the change. Immediately when the clinics know about something they should inform the CHWs so that they can disseminate the right information. (CHW female)
The manner in which CHWs were integrated into the agency was a significant challenge. For example, one CHW reported feeling demoralized when she took a health party attendee to one of the clinics because although she represents the clinic through her work, she was not formally introduced to full-time, clinicbased staff. I think that they should give us a bit more of access or take us one day when the clinic is operating so that we can see how it operates . . . About four months ago a woman had a problem and she knows I am a CHW for the agency and so I took her to the clinic. I was embarrassed to realize I did not know the professional staff working there by name and they did not know me either. How could I ask
Lechuga et al. / LATINO COMMUNITY HEALTH WORKERS 341
the community to give me credibility as a CHW? (CHW female)
The lack of familiarity with the agency’s clinics can directly affect the CHWs’ ability to help individuals navigate the health care system. Although they are seen as leaders and resource in the community, CHWs’ ability to perform these roles is inhibited if they feel they lack an understanding of how the health care system works within their affiliated agency. It is very important that we are trained about how the clinic works because the people that do not know the clinics when they hear that I am a CHW for the clinic they expect that I will be knowledgeable about certain information regarding what to expect when they go to the clinic to seek services. (CHW female)
Overall, CHWs’ perceptions about training and integration reveal that to perform CHW work, which goes beyond providing information, continuous training on a variety of topics is necessary as well as integration within the agency they work for. Personal Challenges Encountered by CHWs CHWs are members of the communities they serve and are themselves sometimes affected by the same issues. Furthermore, as a result of their training and development as CHWs, some experience changes in their personal lives that may be considered sources of burden and raise ethical dilemmas for organizations recruiting and training CHWs. Together, these aspects of the CHW role presented challenges to sustaining their work as CHWs. For example, being a CHW could be an emotionally demanding job, as one CHW described. You knock doors and you never know what you will find. You find a lot of problems and a lot of need . . . you find people frightened by all these laws, they don’t know if they can drive, if they will be stopped by the police and will be deported . . . and they tell you all of their concerns expecting that you will help them . . . and oh my God . . . this is what affects me the most emotionally. (CHW female)
The demanding nature of the CHW role suggests that CHWs feel a need to be supported in other areas besides professional development.
342 HEALTH PROMOTION PRACTICE / May 2015
I started to notice demoralization of my fellow CHWs and I thought, many of us are going through heavy emotional problems . . . I asked my coordinator if she knew of a good psychologist that could advise some of us . . . she did bring a psychologist to one of the monthly meetings and this motivated us a lot . . . (CHW female)
In this case, the program coordinator was open to bringing a psychologist to provide support to CHWs struggling through emotional problems. In some cases, the emotional problems stemmed from changes in CHWs’ personal lives as a result of becoming a CHW. I have never worked outside the home and after I became a CHW and learned so many things and became really involved my husband told me that it was either my work as a CHW or him . . . he would reproach me that I was gone all day and left the house unattended . . . I finally got my certificate and showed it to him and he still doubted saying that he did not know how that was going to be useful to me I told him that maybe not today but with time. (CHW female)
In short, serving as a CHW can be both personally transformative and disruptive to established family relationships.
Discussion >> CHW programs in the United States began in the 1960s as part of efforts to address poverty issues in underserved populations rather than as health promotion interventions (DHHS, 2007). Increased recognition in the late 1990s of the potential role of CHWs in reducing health disparities prompted the introduction of several unsuccessful legislative initiatives to support CHW programs. There is much to be done in this arena as the United States lacks a comprehensive policy regarding the implementation and institutionalization of CWH programs within health care organizations. Research is still needed on issues related to implementation and sustainability of CHW programs to inform policy changes. The purpose of our study was to shed light on the experiences of CHWs who formed part of an institutionalized CHW-led intervention. Our goal was to elucidate potential strategies that can inform implementation and sustainability strategies. We now turn to our findings by emergent theme. Regarding key roles CHWs play while promoting sexual and reproductive health, our findings suggest that CHWs trained to deliver education in sexual and
reproductive health went beyond their role as health educators, serving also as facilitators of access to varied community resources and not only those offered by PPWI, sources of social support, patient navigators, and civil rights advocates. Regarding organizational challenges faced and perceptions of adequacy of training and integration within the agency, views varied, with some CHWs feeling adequately compensated and prepared and others not so much. It was interesting to note that CHWs who perceived themselves as strictly health educators perceived their training and compensation as adequate. Conversely, CHWs who went above and beyond their call of duty conveyed some discontent and desired more training, greater compensation, and integration within the agency. Our findings highlight a conflict between how CHWs perceive themselves, what they were specifically trained to do, and what they expect from the agency for which they work. To our knowledge, this is the first study that highlights such a conflict, which threatens the sustainability of the program. CHWs are defined as follows: [L]ay members of communities who . . . offer interpretation and translation services, provide culturally appropriate health education and information, assist people in receiving the care they need, give informal counseling and guidance on health behaviors, and advocate for individual and community health needs . . . (DHHS, 2007, p. 3).
We argue that this is a broad and ambiguous definition that may contribute to role confusion on behalf of CHWs and agencies. The current definition of the role of a CHW may be promoting a lack of standardization of the CHW role across agencies. This is a significant roadblock to the sustainability of CHW programs as lack of standardization may also contribute to the lack of standardization of a training curriculum as pointed out in the Community Health Workers Evidence-Based Models Toolbox (HRSA, 2011). Our findings suggest the need for policy to standardize the occupational role that CHWs play as role definition marks the boundaries of training, performance expectations and influences CHW satisfaction with training, compensation, and integration with the agency. Regarding personal challenges faced by CHWs, findings suggest that performing multiple roles has led to stress, burnout, and demoralization, which can lead to turnover and consequently threaten the sustainability of the program. CHWs’ sense of responsibility to be a holistic resource for the multitude of needs that the community faces may underpin the perceived need for more comprehensive training on a variety of topics.
Many CHWs are members of the communities they serve and themselves experience some of the same problems faced by the people they help. In addition, CHWs experienced changes at the personal level as a result of undergoing CHW training, such as change in gender roles and relationship problems that these may cause. These findings may indicate that an ethical responsibility of agencies may be to provide ongoing resources and support for CHWs who find themselves in such situations. Our study has limitations such as a small convenience sample of CHWs, which limits the generalizability of our findings. However, our findings corroborate prior findings with comprehensive samples. Furthermore, our findings that CHWs implement activities that go beyond those they were trained for, and on occasion the cause of stress and burnout, is an important finding suggesting the need for broad policy that will promote standardization of the occupation based on agreed-on competencies. Only in 2006 was a patient navigator bill enacted to support the role of CHWs in the reduction of health disparities (DHHS, 2007). In recognition of the potential benefits of CHW programs in reducing health disparities, the 2010 Patient Protection and Affordable Care Act includes the provision of federal funding to promote the use of CHW programs (Mason et al., 2011). However, lack of standardization of the CHW role continues to threaten the implementation and sustainability of U.S. CHW programs. Ultimately, CHW programs will be more sustainable when research is disseminated about the impact of such programs on health outcomes and less tangible domains such as community capacity and advocacy, and we wish to make a call to researchers to engage in such research. References American Cancer Society. (2009). Cancer facts and figures for Hispanics/Latinos. 2009-2011. Atlanta, GA: Author. American Public Health Association. (2009). Support for community health workers to increase health access and to reduce health inequities (Policy No. 20091). Washington, DC: Author. Retrieved from http://www.apha.org/policies-and-advocacy/ public-health-policy-statements/policy-database?q=20091&y=2009 Balcazar, H., Rosenthal, E. L., Brownstein, J. N., Rush, C. H., Matos, S., & Hernandez, L. (2011). Community health workers can be a public health force for change in the United States: Three actions for a new paradigm. American Journal of Public Health, 101, 2199-2203. Cashman, R., Eng, E., Siman, F., & Rhodes, S. D. (2011). Exploring the sexual health priorities and needs of immigrant Latinas in the Southeastern US: A community-based participatory research approach. AIDS Education and Prevention, 23, 236-248.
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Centers for Disease Control and Prevention. (2009). Sexually transmitted disease surveillance, 2008. Retrieved from http:// www.cdc.gov/std/stats08/surv2008-complete.pdf Centers for Disease Control and Prevention. (2012). Hispanic or Latino populations. Retrieved from http://www.cdc.gov/minorityhealth/populations/REMP/hispanic.html Department of Health and Human Services. (2007). Community Health Worker National Workforce Study. Retrieved from http:// bhpr.hrsa.gov/healthworkforce/reports/chwstudy2007.pdf Health Resource and Services Administration. (2011). The community health workers evidence-based models toolbox. Washington, DC: U.S. Office of Rural Health Policy at the U.S. Department of Health and Human Services. Marshall, K. J., Urrutia-Rojas, X., Soto Mas, F., & Coggin, C. (2005). Health status and access to health care of documented and undocumented immigrant Latino women. Health Care for Women International, 26, 916-936.
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Masinter, L. M., Feinglass, J., & Simon, M. A. (2013). Pregnancy intention and use of contraception among Hispanic women in the United States: Data from the National Survey of Family Growth, 2006-2010. Journal of Women’s Health, 22, 862-870. Mason, T., Wilkinson, G. W., Nannini, A., Martin, C. M., Fox, D. J., & Hirsch, G. (2011). Winning policy change to promote community health workers: Lessons from Massachusetts in the health reform era. American Journal of Public Health, 101, 2211-2216. Pew Hispanic Research Center. (2011). Census 2010. 50 million Latinos. Hispanics account for more than half of the nation’s growth population. Washington, DC: Author. Rhodes, S. D., Foley, K. L., Zometa, C. S., & Bloom, F. R. (2007). Lay health advisor interventions among Hispanics/Latinos: A qualitative systematic review. American Journal of Preventive Medicine, 33, 418-427.
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research-article2015
HPPXXX10.1177/1524839915570632Health Promotion PracticeLechuga, Garcia / Latino Community Health Workers
Health Promotion With Latino Communities
Latino Community Health Workers and the Promotion of Sexual and Reproductive Health Julia Lechuga, PhD1 Dina Garcia, MPH2 Jill Owczarzak, PhD3 Maria Barker4 Meghan Benson, MS4 Community health worker (CHW) programs have existed for over 50 years across the world. However, only recently has research evidence documented their effectiveness. Research is still needed to identify issues related to implementation and sustainability of CHW programs. This article explores the role and challenges of U.S. Latino CHWs trained to deliver a comprehensive sexual and reproductive health educational intervention to Latino families. We conducted a semistructured interview with a purposive convenience sample of 19 CHWs. Findings suggest that CHWs occupy roles that go beyond those they were trained for. CHWs serve not only as educators but also as providers of social support, facilitators of access to resources, patient navigators, and civil rights advocates. Lack of clarity of the role of a CHW influenced perceptions of adequacy of compensation, training, and integration into the agency that trained them. Policy facilitating the standardization of the CHW occupational category and role expectations is imperative to ensure successful implementation and sustainability of U.S. CHW programs. Keywords: community health workers; promotores de salud; sexual and reproductive health; Latinos
(Pew Hispanic Research Center, 2011; Centers for Disease Control and Prevention [CDC], 2012). Unfortunately, Latinos in the United States face considerable health disparities in multiple domains, particularly in sexual and reproductive health. For example, the rate of HIV infections among Latinos since 2006 is 2.5 times that of non-Hispanic Whites (CDC, 2009). In addition, Latinas are 2 times more likely to be diagnosed with other sexually transmitted infections such as chlamydia (CDC, 2009) and cervical cancer than non-Hispanic White women (American Cancer Society, 2009). Latinas are less likely to get screened for cervical cancer and receive follow-up treatment once cervical abnormalities are detected (American Cancer Society, 2009). Research also indicates that ethnic disparities exist in other sexual and reproductive health domains such as unintended pregnancies and incorrect use of contraceptives. Specifically, approximately 70% of Latinas aged 15 to 44 years surveyed in the 2006-2010 National Survey of Family Growth reported ever being pregnant and that 51% of such pregnancies were unintended. Participants also reported that half of these unintended pregnancies followed after incidents of 1
The University of Texas El Paso, El Paso, TX, USA The Medical College of Wisconsin, Milwaukee, WI, USA 3 Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA 4 Planned Parenthood of Wisconsin, WI, USA 2
L
atinos comprise 16.3% of the total U.S. population, and it is expected that by 2050 the Latino population will reach 132.8 million people
Health Promotion Practice May 2015 Vol. 16, No. (3) 338–344 DOI: 10.1177/1524839915570632 © 2015 Society for Public Health Education
338
Authors’ Note: This work was supported by the Medical College of Wisconsin through The Wisconsin Partnership Program, Milwaukee, Wisconsin, USA, awarded to the first, fourth, and fifth authors. Address correspondence to Julia Lechuga, Department of Psychology, The University of Texas El Paso, 500 W. University Avenue, El Paso, TX 79902; e-mail: [email protected].
improper condom use and perceptions of low risk of pregnancy (Masinter, Feinglass, & Simon, 2013). Research indicates that limited access to cultural and linguistically appropriate sexual health information and health care services is an important determinant of Latino health disparities (Cashman, Eng, Siman, & Rhodes, 2011). Furthermore, Latinos face multiple barriers to accessing and receiving adequate health care, including language barriers, confusion or lack of knowledge on how to navigate the health care system, possible fears related to immigration status, and potential lack of “cultural competence” on the part of the health care system (Marshall, Urrutia-Rojas, Soto Mas, & Coggin, 2005). These challenges underscore the need to devise nonstandard ways to address the health care needs of this population. Community health worker (CHW) programs have been proposed and developed as one such alternative. CHW programs consist of training lay community members to perform health care-related tasks and address the needs of medically underserved populations (American Public Health Association, 2009). In 2011, the Health Resource and Services Administration (HRSA) defined the roles of CHWs as bridges between the health care system and vulnerable populations, managers of the health care of vulnerable populations, promoters of providers’ cultural competence, advocates of health care access, informal counselors, and promoters of community capacity to become advocates. Research indicates that CHW programs increase the quality and cultural competence of health care services by improving provider–patient communication, trust, and rapport, leading to better adherence to medical regimens (Balcazar et al., 2011). Despite the promise of CHW programs and increased efforts to formalize their role within the U.S. health care system, the United States lacks a comprehensive policy regarding the implementation and institutionalization of CWH programs within health care organizations. Questions remain regarding implementation and institutionalization of CHW programs, including CHW capacity building, education and training, roles, and payment mechanisms (Balcazar et al., 2011). Answers to these questions will facilitate strategic planning regarding capacity building and remuneration issues and possibly inform strategies to promote successful implementation and sustainability. Our study answers questions of process of an institutionalized CHW program in the area of sexual and reproductive health. Data presented will shed light on roles, characteristics, and challenges faced at the organizational and personal levels by CHWs. Our study adds to the CHW literature as most of CHW programs targeting Latinos address chronic illnesses such as diabetes and child and maternal health (Rhodes, Foley, Zometa, & Bloom, 2007).
The present study stems from a community–academic partnership between Planned Parenthood of Wisconsin, Inc. (PPWI) and The Medical College of Wisconsin to evaluate PPWI’s sexual and reproductive health intervention delivered by CHWs. PPWI’s sexual and reproductive health curriculum is delivered in a “health party” setting. Within this model, CHWs recruit members of the community (hosts) who then recruit 8 to 10 members of their social network to attend a health party. The CHW delivers the curriculum, which consists of seven informational and skill-building sessions covering topics of sexuality and reproductive health, in the host’s home or in another community venue. Both CHW and host receive incentive payments. CHWs receive $15 per hour spent delivering each educational session. The host, who recruits members of his or her social network, receives $50 per educational session. Each session lasts 2 to 3 hours. CHWs receive round-the-clock support from a program coordinator who meets in person with them at least once a month. CHWs are encouraged to seek support any time they need it by phoning the program coordinator who makes herself available around the clock. According to the CHW training typology developed by the HRSA (2011) and published in the Community Health Workers Evidence-Based Models Toolbox, CHWs were trained by PPWI as health educators to implement the sexual and reproductive home health party curriculum and as outreach workers to serve as the bridge between the community and the sexual and reproductive health services offered by PPWI. CHWs were trained for 8 weeks (20 hours per week). Training was done formally by the program coordinator. The training consisted of didactics on the topics addressed in the intervention, role-plays, skits, and small group discussions. In 2013, a total of 675 health parties were delivered.
Method >> We employed a qualitative research approach. A convenience sample of CHWs were recruited to answer a semistructured interview organized around three sections, each exploring broad topics such as the roles CHWs played in promoting sexual and reproductive health and the challenges faced at the organizational and personal levels. Furthermore, CHWs answered a questionnaire assessing basic demographic characteristics. CHWs were eligible to participate if they had completed the required training mentioned above and successfully delivered at least one health party as determined by observers from PPWI who trained them. Prior to data collection, study procedures were approved by the Medical College of Wisconsin Institutional Review Board. All interviews were
Lechuga et al. / LATINO COMMUNITY HEALTH WORKERS 339
conducted in Spanish by a bilingual, bicultural researcher. Interviews were audio recorded and transcribed verbatim for analysis. Prior to the start of each interview, participants completed a written informed consent. Participants received $25.00 as compensation for their time.
Analysis >> Written transcripts were analyzed using MAXQDA qualitative software. Two bilingual researchers coded the data and transcripts were reviewed to identify statements reflecting categories, concepts, or themes regarding roles CHWs played and challenges faced when delivering PPWI’s sexual and reproductive health educational intervention. Because the interviews had the specific focus of elucidating three main topics, codes were developed a priori. However, these were expanded if comments did not fit within the a priori coding category. Participant statements were identified and used to highlight recurring themes. Each transcript was coded by one coder and reliability was enhanced by reviewing all coding for discrepancies by the research team. Survey data were analyzed with descriptive statistics.
Results >> A total of 19 CHWs (63% female) with a mean age of 41.39 years (SD = 14.88, range 21-77 years) participated in the study. Eighteen CHWs were foreign born and the countries of origin were Mexico (N = 10), Colombia (N = 2), Bolivia (N = 2), Guatemala (N = 1), and Honduras (N = 3). Foreign-born CHWs reported a mean of 9.39 years lived in the United States (SD = 7.44, range 1-26 years). Approximately 63% were married and 78% identified only Spanish as their preferred language. Regarding education level, 53% reported to have a college degree obtained in their country of origin. CHWs reported conducting a mean of 5.88 health parties (SD = 8.06, range 1-20 health parties) and engaged in unpaid volunteer work an average of 3.66 hours per week (SD = 3.33, range 1-10 hours). The most common site where health parties were conducted was a home. Key Roles of CHWs in Sexual and Reproductive Health Promotion CHWs were trained to deliver sexual and reproductive health information along with information about available PPWI services and teach skills that will enable health party attendees to enact protective behaviors. However, as the next quotes illustrate, CHWs performed a variety of other roles. For example, as the following quotes illustrates, many interviewees had 340 HEALTH PROMOTION PRACTICE / May 2015
experienced the social conditions affecting the Latino community and consequently felt responsible for linking community members to other resources. Once I do a sexuality education home health party and people tell me about all their problems including deportation, substance abuse, domestic violence, poverty . . . and more questions come up . . . it is my obligation to follow-up with them and help them find answers . . . even if it means taking them by the hand to places . . . (CHW female)
Another role identified was that of providing social support to health party attendees even after their CHW’s role of health educator had ended. One CHW shared her experience of making herself available for continuing support to community members who had attended a health party she facilitated. At four in the morning I received a call from a person who attended one home health party asking me, are you the person who gave that health party? Yes . . . she told me she had a problem . . . the condom broke . . . I told her what to do and where to go . . . (CHW female)
CHWs also saw themselves as patient navigators to the point of actually accompanying people to their appointments. As I worked with people I found myself more involved. I even had a case of a woman who was afraid of accessing services . . . and well I supported her a lot by going with her to the clinic and helping her fill out paperwork . . . (CHW female)
In addition to their roles as helping the community access resources, sources of social support, and patient navigation, CHWs expressed a need to advocate for equal rights. I like to work with the community especially with immigrants . . . One wants to tell more . . . so that we can have rights, political rights also because unfortunately it is only by becoming involved with politics that we acquire rights. Immigrants need to become aware that right now there is not an equal balance of opportunities especially for the Latino community. (CHW male)
Organizational Challenges Encountered by CHWs Monetary monetary
Compensation. Perspectives regarding compensation for their work varied
highlighting the potential conflict between how CHWs perceive themselves, what they were specifically trained to do, and what they expect from the agency for which they work. CHWs’ varied perspectives on what constitutes fair compensation reveal the ambiguity of their role.
As this CHW conveyed, CHW work does not entail performing the tasks of professionally trained health care providers. On the other hand, the majority of participants voiced the need to receive additional training. Particularly, many participants voiced the need to have access to more in-depth trainings on a variety of topics.
I have thought that it is not fair but when you love the community I think that you do not do the health parties for the money. When you see all of the unmet needs surrounding the Latino community, you do it more for love . . . I do not live off of that compensation and I think it is a pay that is not a salary that I can count on, and I like to do it for my love for the community. (CHW female)
Questions always arise that are not within the work plan. And as a CHW one has to be available to the community to answer these questions. Find the information and disseminate it to the community when we do not have the answers. (CHW female)
This CHW’s perspective underscores a sense of altruism and desire to help the community, a value system in which additional financial compensation has no place. However, other CHWs felt that the compensation provided does not adequately compensate for their time, effort, and transportation costs. The pay is not appropriate because to facilitate a health party one has to invest so much time in preparing for questions and making yourself available after. So finding resources, books, readings, and doing the party you have to plan the time and the place, right? And it is difficult. We need to rent a place, gather people, it is a bit difficult. So considering that, I think that it would be great to pay CHWs more. (CHW male)
The conflicting stance regarding monetary compensation illustrates lack of consensus by CHW themselves about how their work should be compensated. On one hand there is a feeling that altruism should be a primary motivator and hence no or minimal compensation is appropriate, and on the other, a feeling that CHW work is intensive, goes beyond providing information, and requires compensation at the semiprofessional or professional level. Training and Integration Within the Agency. CHWs expressed two views regarding their level of satisfaction with the training they received. On one hand, few CHWs saw their training as sufficient. I think the training was sufficient because one does not become a doctor or nurse. We inform the community about the services the agency offers. So I think it is perfect. (CHW female)
This CHW recognized that her interactions with members of the community would raise issues beyond those included in the sexual and reproductive health curriculum, and therefore wanted additional training in order to be prepared to address the broad needs of health party participants. Likewise, CHWs understood the rapidly changing field of health care delivery and health-related information. They thought that continued training and education were necessary to stay current on these changes and provide their constituents with the most accurate, up-to-date information possible as the next quote illustrates. We need a little more training on anything new that comes out . . . Any new thing that comes out, for example, the changes to the Pap smear, we need to have an immediate meeting with all of the CHWs and be informed about the change. Immediately when the clinics know about something they should inform the CHWs so that they can disseminate the right information. (CHW female)
The manner in which CHWs were integrated into the agency was a significant challenge. For example, one CHW reported feeling demoralized when she took a health party attendee to one of the clinics because although she represents the clinic through her work, she was not formally introduced to full-time, clinicbased staff. I think that they should give us a bit more of access or take us one day when the clinic is operating so that we can see how it operates . . . About four months ago a woman had a problem and she knows I am a CHW for the agency and so I took her to the clinic. I was embarrassed to realize I did not know the professional staff working there by name and they did not know me either. How could I ask
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the community to give me credibility as a CHW? (CHW female)
The lack of familiarity with the agency’s clinics can directly affect the CHWs’ ability to help individuals navigate the health care system. Although they are seen as leaders and resource in the community, CHWs’ ability to perform these roles is inhibited if they feel they lack an understanding of how the health care system works within their affiliated agency. It is very important that we are trained about how the clinic works because the people that do not know the clinics when they hear that I am a CHW for the clinic they expect that I will be knowledgeable about certain information regarding what to expect when they go to the clinic to seek services. (CHW female)
Overall, CHWs’ perceptions about training and integration reveal that to perform CHW work, which goes beyond providing information, continuous training on a variety of topics is necessary as well as integration within the agency they work for. Personal Challenges Encountered by CHWs CHWs are members of the communities they serve and are themselves sometimes affected by the same issues. Furthermore, as a result of their training and development as CHWs, some experience changes in their personal lives that may be considered sources of burden and raise ethical dilemmas for organizations recruiting and training CHWs. Together, these aspects of the CHW role presented challenges to sustaining their work as CHWs. For example, being a CHW could be an emotionally demanding job, as one CHW described. You knock doors and you never know what you will find. You find a lot of problems and a lot of need . . . you find people frightened by all these laws, they don’t know if they can drive, if they will be stopped by the police and will be deported . . . and they tell you all of their concerns expecting that you will help them . . . and oh my God . . . this is what affects me the most emotionally. (CHW female)
The demanding nature of the CHW role suggests that CHWs feel a need to be supported in other areas besides professional development.
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I started to notice demoralization of my fellow CHWs and I thought, many of us are going through heavy emotional problems . . . I asked my coordinator if she knew of a good psychologist that could advise some of us . . . she did bring a psychologist to one of the monthly meetings and this motivated us a lot . . . (CHW female)
In this case, the program coordinator was open to bringing a psychologist to provide support to CHWs struggling through emotional problems. In some cases, the emotional problems stemmed from changes in CHWs’ personal lives as a result of becoming a CHW. I have never worked outside the home and after I became a CHW and learned so many things and became really involved my husband told me that it was either my work as a CHW or him . . . he would reproach me that I was gone all day and left the house unattended . . . I finally got my certificate and showed it to him and he still doubted saying that he did not know how that was going to be useful to me I told him that maybe not today but with time. (CHW female)
In short, serving as a CHW can be both personally transformative and disruptive to established family relationships.
Discussion >> CHW programs in the United States began in the 1960s as part of efforts to address poverty issues in underserved populations rather than as health promotion interventions (DHHS, 2007). Increased recognition in the late 1990s of the potential role of CHWs in reducing health disparities prompted the introduction of several unsuccessful legislative initiatives to support CHW programs. There is much to be done in this arena as the United States lacks a comprehensive policy regarding the implementation and institutionalization of CWH programs within health care organizations. Research is still needed on issues related to implementation and sustainability of CHW programs to inform policy changes. The purpose of our study was to shed light on the experiences of CHWs who formed part of an institutionalized CHW-led intervention. Our goal was to elucidate potential strategies that can inform implementation and sustainability strategies. We now turn to our findings by emergent theme. Regarding key roles CHWs play while promoting sexual and reproductive health, our findings suggest that CHWs trained to deliver education in sexual and
reproductive health went beyond their role as health educators, serving also as facilitators of access to varied community resources and not only those offered by PPWI, sources of social support, patient navigators, and civil rights advocates. Regarding organizational challenges faced and perceptions of adequacy of training and integration within the agency, views varied, with some CHWs feeling adequately compensated and prepared and others not so much. It was interesting to note that CHWs who perceived themselves as strictly health educators perceived their training and compensation as adequate. Conversely, CHWs who went above and beyond their call of duty conveyed some discontent and desired more training, greater compensation, and integration within the agency. Our findings highlight a conflict between how CHWs perceive themselves, what they were specifically trained to do, and what they expect from the agency for which they work. To our knowledge, this is the first study that highlights such a conflict, which threatens the sustainability of the program. CHWs are defined as follows: [L]ay members of communities who . . . offer interpretation and translation services, provide culturally appropriate health education and information, assist people in receiving the care they need, give informal counseling and guidance on health behaviors, and advocate for individual and community health needs . . . (DHHS, 2007, p. 3).
We argue that this is a broad and ambiguous definition that may contribute to role confusion on behalf of CHWs and agencies. The current definition of the role of a CHW may be promoting a lack of standardization of the CHW role across agencies. This is a significant roadblock to the sustainability of CHW programs as lack of standardization may also contribute to the lack of standardization of a training curriculum as pointed out in the Community Health Workers Evidence-Based Models Toolbox (HRSA, 2011). Our findings suggest the need for policy to standardize the occupational role that CHWs play as role definition marks the boundaries of training, performance expectations and influences CHW satisfaction with training, compensation, and integration with the agency. Regarding personal challenges faced by CHWs, findings suggest that performing multiple roles has led to stress, burnout, and demoralization, which can lead to turnover and consequently threaten the sustainability of the program. CHWs’ sense of responsibility to be a holistic resource for the multitude of needs that the community faces may underpin the perceived need for more comprehensive training on a variety of topics.
Many CHWs are members of the communities they serve and themselves experience some of the same problems faced by the people they help. In addition, CHWs experienced changes at the personal level as a result of undergoing CHW training, such as change in gender roles and relationship problems that these may cause. These findings may indicate that an ethical responsibility of agencies may be to provide ongoing resources and support for CHWs who find themselves in such situations. Our study has limitations such as a small convenience sample of CHWs, which limits the generalizability of our findings. However, our findings corroborate prior findings with comprehensive samples. Furthermore, our findings that CHWs implement activities that go beyond those they were trained for, and on occasion the cause of stress and burnout, is an important finding suggesting the need for broad policy that will promote standardization of the occupation based on agreed-on competencies. Only in 2006 was a patient navigator bill enacted to support the role of CHWs in the reduction of health disparities (DHHS, 2007). In recognition of the potential benefits of CHW programs in reducing health disparities, the 2010 Patient Protection and Affordable Care Act includes the provision of federal funding to promote the use of CHW programs (Mason et al., 2011). However, lack of standardization of the CHW role continues to threaten the implementation and sustainability of U.S. CHW programs. Ultimately, CHW programs will be more sustainable when research is disseminated about the impact of such programs on health outcomes and less tangible domains such as community capacity and advocacy, and we wish to make a call to researchers to engage in such research. References American Cancer Society. (2009). Cancer facts and figures for Hispanics/Latinos. 2009-2011. Atlanta, GA: Author. American Public Health Association. (2009). Support for community health workers to increase health access and to reduce health inequities (Policy No. 20091). Washington, DC: Author. Retrieved from http://www.apha.org/policies-and-advocacy/ public-health-policy-statements/policy-database?q=20091&y=2009 Balcazar, H., Rosenthal, E. L., Brownstein, J. N., Rush, C. H., Matos, S., & Hernandez, L. (2011). Community health workers can be a public health force for change in the United States: Three actions for a new paradigm. American Journal of Public Health, 101, 2199-2203. Cashman, R., Eng, E., Siman, F., & Rhodes, S. D. (2011). Exploring the sexual health priorities and needs of immigrant Latinas in the Southeastern US: A community-based participatory research approach. AIDS Education and Prevention, 23, 236-248.
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Centers for Disease Control and Prevention. (2009). Sexually transmitted disease surveillance, 2008. Retrieved from http:// www.cdc.gov/std/stats08/surv2008-complete.pdf Centers for Disease Control and Prevention. (2012). Hispanic or Latino populations. Retrieved from http://www.cdc.gov/minorityhealth/populations/REMP/hispanic.html Department of Health and Human Services. (2007). Community Health Worker National Workforce Study. Retrieved from http:// bhpr.hrsa.gov/healthworkforce/reports/chwstudy2007.pdf Health Resource and Services Administration. (2011). The community health workers evidence-based models toolbox. Washington, DC: U.S. Office of Rural Health Policy at the U.S. Department of Health and Human Services. Marshall, K. J., Urrutia-Rojas, X., Soto Mas, F., & Coggin, C. (2005). Health status and access to health care of documented and undocumented immigrant Latino women. Health Care for Women International, 26, 916-936.
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Masinter, L. M., Feinglass, J., & Simon, M. A. (2013). Pregnancy intention and use of contraception among Hispanic women in the United States: Data from the National Survey of Family Growth, 2006-2010. Journal of Women’s Health, 22, 862-870. Mason, T., Wilkinson, G. W., Nannini, A., Martin, C. M., Fox, D. J., & Hirsch, G. (2011). Winning policy change to promote community health workers: Lessons from Massachusetts in the health reform era. American Journal of Public Health, 101, 2211-2216. Pew Hispanic Research Center. (2011). Census 2010. 50 million Latinos. Hispanics account for more than half of the nation’s growth population. Washington, DC: Author. Rhodes, S. D., Foley, K. L., Zometa, C. S., & Bloom, F. R. (2007). Lay health advisor interventions among Hispanics/Latinos: A qualitative systematic review. American Journal of Preventive Medicine, 33, 418-427.
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