REACH SU COMUNIDAD
Community Health Workers (CHWs) have been long recognized as an important element of the health promotion team that enhance culturally appropriate outreach and delivery of services to low-income and other vulnerable populations (Cosgrove et al., 2014; Wiggins & Borbón, 1998). In some communities, CHWs are also recognized as advocates for social change to address underlying social determinants of health experienced by the populations they serve. The purpose of this article is to describe the roles and professional development of CHWs as social change agents in the REACH Su Comunidad (RSC) initiative, developed to address health disparities experienced by Hispanic/Latino (“Hispanic”) communities.
The RSC Consortium consisted of a partnership between 4 organizations: Hidalgo Medical Services Center for Health Innovation; Northwest Regional Primary Care Association; Center of Excellence in Women's Health, University of Arizona Mel and Enid Zuckerman College of Public Health; and the University of Texas, Health Science Center at Houston School of Public Health El Paso Regional Campus. In September 2012, Hidalgo Medical Services Center for Health Innovation was awarded a cooperative agreement from the Centers for Disease Control and Prevention (CDC) as 1 of 6 national networks under the PPHF 2012: Racial and Ethnic Approaches to Community Health (REACH) program, a program that it shared with the RSC Consortium partners. REACH 2012 funding followed several previous CDC REACH funding models, in which communities focused primarily on community health promotion and health education in communities of color, and over time expanded efforts to include policy, systems, and environmental (PSE) strategies to improve health equity. Implementation of PSE strategies to address racial/ethnic health disparities was the sole focus of the REACH 2012 funding.
The RSC Consortium provided funding and technical assistance to 10 communities across Arizona, New Mexico, Oregon, Texas, and Washington (“RSC Communities”) to address health disparities experienced by Hispanic populations resulting from lack of access to healthy food and physical activity opportunities. The RSC Consortium worked with organizations that had existing individual/family-level CHW programs, such as chronic disease management, patient navigation, and peer health education. The RSC goal was to expand the role, scope, and services of CHWs to implement PSE strategies that addressed barriers to healthy weight, healthy food access, and physical activity experienced by Hispanic populations. The core REACH program components in which CHWs were integrated included the formation of a new or enhanced community coalition to jointly engage in PSE work, completion of a community assessment and policy scan, and the development of a community action plan to implement specific PSE strategies chosen by the coalition.
Community coalitions have always been a central construct in the REACH model. Coalitions are generally composed of community stakeholders from a variety of sectors that share a common concern, including community members who are most impacted by the disparity. The community coalition approach ensures that a broad range of perspectives from different sectors of the community are represented. The collaboration of community members, organizations, and officials ensures that the strategies pursued are appropriate to meet community needs, priorities, and culture. In addition, it helps create a proactive culture of addressing healthy PSE inequities by giving nontraditional health partners a sense of ownership over a community health issue and inspiring them to create a healthier community through their sector (Butterfoss, 2007). In the RSC initiative, CHWs developed or were integrated into community coalitions, often as facilitators or in other leadership roles. In this role, CHWs served as a bridge between impacted community members and local organizations and officials to bring a community voice to and engage community members in the discussion. Both the existing CHW programs and the new or expanded multisector community coalitions served as significant community assets in the implementation of PSE strategies.
DISPARITIES ADDRESSED BY THE RSC COMMUNITIES
Hispanic adults and adolescents across the 5 intervention states suffer from overweight and obesity at a higher rate than non-Hispanic white adults and adolescents (CDC, 2010, 2011). Hispanic adults also have a higher prevalence of diabetes in Arizona, New Mexico, and Texas. Hispanic adults in all 5 states show considerably higher rates of self-reported fair or poor health than their non-Hispanic white peers. The higher overweight and obesity rates experienced by Hispanics are well explained by health behavior and risk conditions. Hispanic adults and adolescents consume fewer fruit and vegetables than their non-Hispanic white counterparts. Overall, rates of physical activity are also much lower among Hispanic adults and adolescents than their non-Hispanic white peers. Reasons for these disparities in physical activity and proper nutrition, often tied to social determinants of health including access to healthy food and safe physical activity environments, vary by community and subpopulation.
In many communities, Hispanics experience less access to affordable fresh fruit and vegetables due to residence in a food desert (no healthy food stores in close proximity), lack of transportation, and low rates of enrollment in nutrition assistance programs (Women, Infants, Children [WIC] and Supplemental Nutrition Assistance Program [SNAP]) or lack of retail venues that accept these benefits. In other cases, in-store marketing or point-of-purchase decision cues in stores in Hispanic neighborhoods may encourage individuals to choose unhealthy foods over healthier choices. School vending, school meals, grocery stores, convenience stores, and restaurant menu options may encourage the choice of less healthy foods. Lower rates of physical activity can also be attributed to a variety of structural causes in different communities (Umstattd Meyer et al., 2013). A lack of safe physical activity infrastructure including parks, playgrounds, sidewalks, and walking and bike paths contributes to sedentary behaviors. School recreational facilities may be closed to community members in places where there are no affordable options for exercise. Neighborhood violence and fear of racial profiling by law enforcement may also be a deterrent. School policies may result in limited opportunities for physical activity during the day.
Policy, systems, and environmental change strategies are the most appropriate method to address these types of structural barriers to healthy eating and physical activity because they address the underlying influences on poor health behaviors. The relationship between social determinants of health, health outcomes, and racial health disparities is well established (Brennan et al., 2008; Dean et al., 2013). Local PSE change efforts have a high potential to improve health outcomes because there are opportunities to engage individuals experiencing disparities in the assessment and change processes, identify and address the specific community barriers, and connect PSE change strategies to existing community resources such as health education, screening, and other health services.
SUPPORT FOR CHWs AS SOCIAL CHANGE AGENTS
Racial and ethnic health inequities often exist in marginalized, low-income communities of color. These are communities where CHWs typically work and can best facilitate community member engagement in change processes (Perez & Martinez, 2008). The approach of using CHWs as community change facilitators is grounded in an ecological systems framework presented by Balcazar et al. (2012) and adapted from Bartholomew et al. (2006). In this framework, change agents impact individual and community health at 5 levels: individual, interpersonal, organizational, community, and policy. The community and policy levels were the primary focus of RSC. Community health workers are natural leaders within their communities because their education and outreach work helps them identify systemic barriers to healthy living, and they also maintain strong ties with community-based organizations, local policy makers, and both formal and informal community networks and coalitions. A large number of REACH communities from prior REACH funding cycles successfully utilized CHWs to provide health education and outreach, as well as support implementation of local and statewide PSE strategies to improve social determinants of health (Cosgrove et al., 2014).
Ingram et al. (2008) found a correlation between CHWs who participated in leadership training and their participation in advocacy activities. Relevant CHW leadership and advocacy training was a component of the RSC model. As described in the studies by Jara et al. (2014) and Sabo et al. (2013), CHWs trained in leadership and advocacy are better able to support the engagement of affected community members in addressing social determinants of health. This was emphasized in the RSC model to ensure that marginalized racial/ethnic communities were empowered and their needs were met through the RSC community improvement process.
A key component of the RSC model was the use of popular education principles. Based on the work of Brazilian educator Paulo Freire, popular education seeks to empower the learner through a process of conscientization or critical consciousness, whereby the student-teacher didactic model is pushed aside in favor of a colearner model that values the knowledge each individual brings through his or her own life experience. Through a process of structured dialogue, colearners work together to identify issues and solve problems. Popular education has been used widely in health education, community-based participatory research, community development, and community organizing (Wallerstein & Duran, 2003; Wiggins et al., 2013). It is also a model that has tremendous merit for work with CHWs (Wiggins, 2010; Wiggins et al., 2013).
At the beginning of the RSC initiative, most of the 10 CHW programs did not incorporate a comprehensive or structured PSE strategy plan, nor formally engage CHWs in the PSE strategy work. However, a few communities did have previous experience with PSE change. The RSC Consortium partners were able to meet the diverse capacity-building and training needs of all of the participants through the utilization of a mixed-methods approach that included one-to-one technical assistance, webinars, peer-to-peer support, and conference-based workshops to enhance CHWs' role in stakeholder coalitions, development of community action plans, and community assessment strategies. All RSC professional development opportunities were open to CHWs, program managers, and community coalition members. Individual RSC community organizations also provided professional development according to their CHWs' experience and needs.
Webinars introduced technical components of core program requirements, listed later. Additional support for these core program components was provided through monthly technical assistance calls (described later). The following topics were covered on RSC developed webinars:
- Developing broad-based community coalitions. Corresponding written reso-urces were provided.
- Conducting community assessments and policy scans focused on social determinants of health and racial health equity. A corresponding toolkit containing assessment information and resources for assessing community needs and assets and an assessment template were provided.
- Developing relevant, achievable community action plans to implement PSE strategies.
- A 3-part series about developing a communications plan to educate the community about the PSE strategies being implemented and avenues for their participation. A corresponding toolkit and a communications plan template were provided.
Each community was assigned 1 of the 4 RSC Consortium partners as a technical assistance advisor, from whom the community received individual technical assistance through monthly technical assistance calls and periodic face-to-face assistance in the participating community. Both CHWs and program managers were encouraged to attend technical assistance calls. The content of these tailored calls was decided jointly between the community staff and the technical assistance partner, according to community needs. Technical assistance calls covered topics ranging from implementation of core REACH program components to challenges in engaging community members in the community coalition, challenges and approaches to implementation of PSE strategies, and additional professional development needs of managers and CHWs.
Community health workers in 6 communities participated in digital storytelling training, which included developing digital stories, utilizing digital stories as tools for community assessment and dissemination, and influencing policy makers. Digital stories can be used to educate policy makers and community partners or to start a community conversation by presenting a CHW or community member perspective that is often not considered by decision makers in marginalized communities. In one RSC community, digital stories by CHWs and community residents about the need for summer nutrition and physical activity opportunities were shown to the community coalition, which then prioritized the topic and formed a workgroup to specifically address the need. In a second RSC community, digital stories were used to increase medical care provider understanding about the numerous ways in which CHWs help address social determinants of health to improve patients' quality of life, increasing clinical staff support for CHWs.
Two RSC conferences included professional development for program managers, CHWs, and coalition members. The first took place 2 months into the RSC community grant period and covered basic program components and requirements, discussions concerning professional development needs of CHWs from the perspectives of both CHWs and program managers, experiences of prior REACH programs and CHW roles, evaluation concepts, and examples of PSE strategies in the context of a community health center. Both CHWs and managers also engaged in a popular education exercise to help them envision a healthier future for their community that could be created as a result of the REACH model. They first discussed what characteristics would define a healthier community and then drew a representation of this vision. Communities then shared these visions with each other to ask questions that helped further define the vision and to provide ideas and feedback. This process helped CHWs and program managers to communicate about their current perceptions of the community improvement goals and articulate the purpose of their work. English to Spanish interpretation was provided at this conference to accommodate monolingual Spanish speakers.
RSC Communities CHWs led the planning of the second conference to ensure their professional development needs were addressed and to support CHW leadership. Conference sessions included popular education strategies including interactive activities and discussion about power, privilege, and methods for increasing community participation in REACH initiatives and discussion about the core principles of popular education. In addition, the conference included discussion of community power structures, engagement of community members in the community coalitions, and presentations by each of the communities about their successful PSE strategies. Including CHWs in developing the conference agenda strengthened relationships between the 10 communities, built capacity among the CHWs in program planning, and promoted a sense of ownership among the CHWs that enhanced engagement during the conference sessions and improved learning of key topics important for PSE work. At both conferences, workshops targeted at program managers aimed to identify strategies and professional development opportunities that project managers and institutions can employ to effectively support CHW leadership within organizations and as community change agents. The second conference was completely English-Spanish bilingual, with approximately half the sessions presented in each language and bidirectional interpretation available, enhancing communication between monolingual English and Spanish speakers. This fully bilingual approach greatly increased the participation and leadership of CHWs and enabled more comprehensive peer learning opportunities.
Optional CHW peer support calls were conducted monthly to provide a forum for peer-to-peer mentoring, problem solving, and support. These calls had an informal structure, and discussion was guided by the most pressing needs of the participating CHWs. The calls reinforced the importance of CHW leadership in that they served as a forum both for less experienced CHWs to receive advice and support and for experienced CHWs to provide leadership and advice to their peers. This established an informal network of CHWs and facilitated sharing of successful and problem-solving strategies within the CHWs' project roles.
A project newsletter was sent to all program managers and CHWs twice per month. The newsletter included success stories from the participating communities, information about webinars and conferences, professional development opportunities, tools and resources, and relevant funding opportunities.
A coalition capacity assessment was conducted with members of each community coalition to identify strengths and challenges and set priorities for improving capacity. The capacity assessment tool was developed by the Nonprofit Resource Group, a program of the National Center for Frontier Communities. Coalition members rated the level of development of 52 indicators within 5 core areas: leadership and membership, structure and practice, activities and outcomes, community engagement, and racial equity. The 5 core areas are rooted in research that validates best practices for health equity impact and sustainability of community coalitions. Quantitative and qualitative data for the 5 core areas were summarized, and recommendations were made to each coalition. On the basis of the assessment results, the coalitions prioritized capacity development areas and developed work plans to accomplish their goals.
During the final months of the project, after identifying an ongoing need for CHW training, additional webinars were also provided in the following topics: creating a success story to disseminate your model; introduction to advocacy; the role of CHWs in building community power; and creating a culture of advocacy. These webinars were provided in both English and Spanish and targeted at CHWs. This additional training supported the capacity of CHWs to continue engaging in PSE strategies in their daily work after REACH project funding ended.
Over 17 months, the 10 communities successfully implemented 30 PSE changes that increased access to healthy food and safe physical activity environments. Examples of PSE changes are described in the Table. One example of CHW leadership can be illustrated in the addition of fresh fruit and vegetables in neighborhood markets. In a few communities, CHWs' roles in this process included conducting store food assessments, meeting with store owners/managers to discuss health impact of potential changes, involving store owners/managers in the community coalition, and educating the community about changes in the stores through media communications and existing community activities. A significant aspect of CHWs' roles in PSE strategies occurred through their leadership in the community coalitions, further described in the “Discussion” section. While it was not possible to measure changes in health behaviors or health indicators in the time frame of the RSC program, each of these PSE changes that support increased access to healthy food and physical activity environments has the potential to improve community health outcomes. Both the RSC Consortium and the RSC Communities learned much from this experience and provided information on important key factors for success that communities should consider when working with CHWs and community coalitions to promote PSE change in underserved communities.
CHWs as key stakeholders in community coalitions
Community health workers were integrated into the community coalitions, which was key to the success of the communities in implementing PSE strategies. This enabled them to facilitate communication between community entities and community members and engagement of community members directly in the coalition. In one RSC community that developed its first community coalition at the start of the REACH project, CHWs worked with community partners to identify and recruit members into the new coalition. In this development phase of the coalition, the CHWs were able to ensure inclusion of community residents most impacted by the disparities, providing a voice for stakeholders who traditionally lack power. The CHWs in this community went on to organize the agenda and facilitate coalition meetings, continuing to ensure the active participation of community members alongside local agencies and officials. A second RSC community discussed how the CHWs participated in the REACH coalition, as well as other local committees and coalitions, and as a result were able to increase collaboration between these different groups. Another RSC community said that CHWs facilitated collaboration between different coalition members to implement PSE strategies. The CHWs also modeled behaviors for participating in the coalition to impacted community members and supported the capacity of community members less experienced in advocacy so that the community members were able to work with local agency representatives and officials to implement PSE strategies. A fourth RSC community noted that including CHWs in the community coalition provided numerous opportunities to present their community work and progress on achieving strategies to the coalition members. This gave CHWs experience in public presentations and confidence that was beneficial when later speaking with local leaders and elected officials about the PSE priorities and strategies. Integration of CHWs in the community coalitions served both to increase community voice and involvement in community improvement strategies and to increase the capacity and skills of the CHWs themselves.
CHW professional development
The 7 core roles of CHWs identified in the National Community Health Advisor Study (1998) include cultural mediation, health education, assuring access to health care and other services, informal counseling and social support, individual and community advocacy, provision of direct service, and individual and community capacity building. The study also identified the following 8 core skills: communication, interpersonal, knowledge base, service coordination, capacity building, advocacy, teaching, and organizational skills. Conducting PSE work recognizes the importance of the CHW role in community change processes and community capacity building. To accomplish this role successfully, CHW host organizations need to ensure that there are adequate systems and training to develop and support service coordination, capacity building, and advocacy from a community health perspective. Awareness and understanding of CHWs roles and competencies are important to promote and support PSE work. In the following paragraphs, we describe some of the professional development areas found to be important for CHWs in the RSC initiative.
As part of advocacy training, it is important to ensure that CHWs have a strong understanding of the impact of social determinants of health in populations and how these can be impacted by PSE strategies. Initiating PSE change often can seem overwhelming, especially to CHWs and community-based program managers. Many of the CHWs in the RSC Communities traditionally focused on providing health education, screening, and navigation services to individuals. Some believed that PSE change occurs only at the macro level and did not realize the potential for PSE change at the institutional or community level. The RSC Consortium spent time distinguishing between PSE strategies at the institutional, local, state, and national levels, types of policy change, their impact on community health, and development of skills specific to PSE strategies.
In RSC, CHWs were key to engaging marginalized community members in addressing the PSE barriers impacting health. Therefore, CHWs working on PSE strategies should participate in professional development that increases their capacity for engagement of community members in PSE work. This should include leadership development and skills for building the capacity of community members. In addition to using Popular Education theory to conduct CHW professional development, CHWs should understand Popular Education theory and techniques to empower community members to create change.
During the course of the RSC program, the RSC Consortium moved from English-dominant resources to English to Spanish (one direction) translation and interpretation and finally to fully bilingual materials, conference, and webinars. This fully bilingual approach furthered RSC's ability to apply a popular education lens to the project, as it enabled bidirectional sharing between language groups and ensured that monolingual Spanish speakers were able to participate to the same extent as program managers. A fully bilingual approach should be utilized when providing professional development, as well as in considering the incorporation of CHWs in the leadership of community coalitions in Hispanic communities.
Support for CHW leadership
Upper management of an organization involved in change processes has a critical role in supporting CHW leadership and community engagement in PSE strategies. The RSC initiative recommends that managers are involved in these processes from the start and receive ongoing professional development about their role in supporting CHW leadership skill development and CHW PSE implementation. Senior managers' willingness to engage in PSE work as a means to address health disparities means that they are willing to support CHW work outside the clinic walls and to work with stakeholders at all levels, especially those affected most by health inequities. This includes working both with individuals served directly by the clinic or nonprofit organization and with those who traditionally are not, in order to achieve population-level improvements. Managers should also be willing to commit time and resources to CHW professional development and opportunities for peer learning and networking among CHWs.
Professional development of CHWs should extend beyond trainings and workshops to include progressive expansion of CHW leadership and responsibilities. Within the RSC initiative, CHWs accepted responsibilities in organizing an RSC conference and providing webinars and workshops to other RSC communities. Within their individual organizations, many CHWs adopted new responsibilities in facilitating coalition meetings, meeting with local officials, and publicly representing their REACH project in marketing and communications. Community health workers need sufficient support from their supervisors and organizations so that they have the capacity to represent their organization and coalitions to policy makers and the community.
Today, the growing interest in CHWs is closely tied to health care reform efforts and specifically the role that CHWs can play in helping to achieve the Triple Aim: better patient care, improved health outcomes, and lower costs. The Affordable Care Act includes a number of provisions related to the work of CHWs, including increasing access to care and the coordination of health care services. In considering the various roles of CHWs, what makes it such a powerful model is the ability that CHWs have to impact health at all levels of the ecological framework (Balcazar et al., 2012; Ingram et al., 2008; Perez & Martinez, 2008; Sabo et al., 2013). While CHWs working with an individual patient can help with the management of a chronic disease such as diabetes, it is equally important to recognize the role that CHWs can play in fostering PSE changes that lead to greater access to healthy foods and physical activity opportunities for populations at risk for poorer health outcomes based on social circumstances, thereby increasing opportunities for individual health improvement. Because of their knowledge of and relationship with the communities they serve, CHWs are uniquely qualified to understand and facilitate community-driven PSE strategies to address the social determinants of health.
The RSC Communities consistently noted the importance of a long-term investment in funding for CHWs to engage in PSE work. In communities in which the community coalition was new, a great deal of resources needed to be dedicated to capacity development of the coalition and developing both the capacity of CHWs to lead the coalition and the knowledge of managers and coalition members about how to best support the work and professional development of the CHWs. Even communities that had more experience with PSE strategies, coalitions, and CHW leadership noted that longer time frames were necessary to address the most deeply rooted disparities in a manner that appropriately engages all stakeholders. The implementation of PSE strategies is a long-term process that demands long-term support from funders and continued investment by host organizations in the professional development of CHWs.
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