As frontline public health workers, community health workers (CHWs) fulfill diverse functions within health systems and community-based organizations. They offer culturally appropriate health information and outreach, provide health screenings and other direct services, coordinate care, assist with access to health insurance, build individual and community capacity, and offer social support and informal counseling.1–3 CHWs, also known as promotores de salud, lay health workers, and peer health advocates, typically come from the same cultural and/or linguistic background and have similar lived experiences as their clients.4 They are employed in a variety of health care settings (eg, ambulatory and primary care clinics, hospitals, faith-based health ministries, and community-based organizations) and are recognized as an effective means for managing chronic disease, promoting health, and providing health care services, particularly to underserved populations.1,5,6
CHWs have been part of the US public health workforce for more than 60 years,7 but the enactment of the 2010 Affordable Care Act (ACA) resulted in further expansion and recognition of the field.8,9 The ACA increased funding for preventive health care to underserved populations through interdisciplinary health care teams, which included CHWs.10,11 The Centers for Disease Control and Prevention has also promoted CHWs as a strategy for addressing community-clinical linkages.10 There are thus increasing opportunities for integrating CHWs and other nonlicensed providers into programs.12 While organizations may be increasingly interested in incorporating CHWs into the health care workforce,13 there are challenges to doing so.14,15 For example, CHWs have the potential to complement and expand upon the work of licensed health workers, yet the possible overlap between the duties and responsibilities of licensed health workers and CHWs could instead generate confusion and competition, which may impede CHW functioning and integration.15 Examining the barriers and enablers of CHW programs across diverse workplaces can provide important insights to public health practitioners involved in integrating CHWs into care teams.16,17 This study characterizes the successes and lessons learned from implementing new CHW programs as reported by CHWs and CHW supervisors in both clinical and community-based settings in 4 Gulf states. By examining the distinct and overlapping challenges and strategies in these 2 settings, this study demonstrates how organizational type may influence CHW functioning.
Context: GRHOP CHW Placement Program
The Gulf Region Health Outreach Program (GRHOP) CHW Placement Program is managed by the Environmental Health Capacity and Literacy Project (EHCLP) at Tulane University's Center for Gulf Coast Environmental Health Research, Leadership, and Strategic Initiatives in New Orleans, Louisiana. In September 2015, EHCLP issued 2-year subcontracts for CHW employment to 16 organizations in the oil spill–affected coastal counties and parishes of Louisiana, Florida, Alabama, and Mississippi. Each subcontract, selected by a competitive review process, funds salary and fringe benefits for 1 full-time or 2 part-time CHWs, as well as supervisory effort, travel, and supplies for the CHWs' work. All CHWs are employees of the funded organizations and were primarily trained by the GRHOP CHW Training Project, which is led by the University of South Alabama's Coastal Resource and Resiliency Center. An EHCLP staff member provides oversight to the CHW Placement Program through quarterly reporting, annual site visits to each organization, and phone and e-mail consultation. An annual meeting of all CHWs and supervisors provides opportunities for networking and professional development.
The CHWs employed through the program serve a variety of roles in clinical and community-based settings (Table 1). Many CHWs provide “wraparound” services, linking clients to resources to address medical, social, and emotional needs. The most common health issues addressed by the CHWs are nutrition, hypertension, diabetes, physical activity, breast cancer, and obesity.
Semistructured, in-person interviews were conducted with 22 CHWs and 17 CHW supervisors by the EHCLP staff member who managed the Placement Program during 2016 annual site visits. Interviews were conducted at all placement sites comprising 8 clinics and 8 community-based organizations in the 4 states. Interviews lasting 15 to 55 minutes were carried out with at least 1 CHW and 1 CHW supervisor from each organization to elicit individual perceptions of the implementation of a new CHW program. Participants were asked a range of questions about their experience with the program, including 2 questions about the top 3 barriers and enablers to the CHW's work. All interviews were audio-recorded with permission, transcribed verbatim, and validated manually for transcription error. Using Dedoose software to code transcripts,18 data were analyzed for perceived barriers and enablers to CHWs' work. Codebook categories were initially developed on the basis of an extensive literature review. Transcripts were reviewed to refine the initial codes, and the codebook was modified according to emerging themes in interviews. Each transcript was then coded according to the finalized codebook.19 To ensure intercoder reliability, a second researcher independently coded 10% of the transcripts and found high agreement in the way codes were applied to the text, with any coding discrepancies resolved through in-depth discussion to reach consensus.20 The study protocol was approved by the Tulane University Human Research Protection Office, and written consent was obtained from all participants.
Overlapping challenges and strategies reported in clinical and community-based settings
Most of the challenges reported by CHWs and supervisors were experienced in both clinical and community-based settings (Table 2). In this section, we describe these challenges and the corresponding strategies used to address them.
Limited organizational resources were described as key challenges in the CHWs' work. Participants discussed this issue in terms of funding, number of staff, available time for program development, and access to facilities for program activities. Amidst resource-limited environments, interviewees noted the benefit of working with volunteers and community partners. In one case, a partner organization provided lunch for an outreach event, alleviating the CHW program budget. CHW efficiency could also be improved, for example, by preparing materials in advance on topics commonly discussed with clients.
Participants reported 3 challenges related to accessing the client population. First, most CHWs experienced challenges in building and maintaining strong community relationships despite having preexisting relationships with community members. Consequently, participants highlighted the need for sustained rapport building and outreach throughout the program to maintain community buy-in and interest. Many CHWs reported that rapport and trust steadily improved, particularly after dedicating time to in-person interactions with clients. Several participants also suggested attending community events and networking with local organizations. Second, participants discussed communication challenges, including the issue of reaching clients who do not use e-mail or the Internet, frequently change phone numbers, and have limited availability due to work or family obligations. Leveraging locally appropriate methods of communication was important for addressing this issue. For one respondent, outreach efforts became more successful after utilizing local church announcements. Language barriers were also reported. Several CHWs acted as translators for Spanish- and Vietnamese-speaking clients, and some organizations subscribed to a phone translation service. Finally, physically bringing CHWs and clients together posed difficulties due to a lack of available transportation options and perceived neighborhood boundaries in communities. Some interviewees provided transportation vouchers or gift cards to offset clients' travel costs to the organization. Some CHWs reportedly drove clients to appointments, while acknowledging the liability that might incur on an organization. Others drove to homes or neighborhoods to reach certain client populations.
Establishing a scope of practice for CHWs is an ongoing process, as national and state standards for CHWs are set and refined.1 It is thus not surprising that, in this study, the challenge of defining a CHW's role necessitated strategies to manage perceptions of the CHW's scope of practice within the organization and community. For example, some CHWs reported struggling to obtain referrals from physicians, and colleagues occasionally provided inaccurate information to clients regarding CHW services at the start of the program. Frequent communication with all team members regarding the CHW's role was key to facilitating organizational understanding of the CHW's scope of practice. Participants described the importance of establishing an operational plan with clearly defined roles for the CHWs and other staff members, as well as building relationships and rapport among the team to understand roles. At times, community members were also unaware of the CHW's scope of practice, and some participants noted the misperception that CHW services incurred fees, deterring potential clients from pursuing services. Community understanding of the CHW's role improved as a result of time, continual outreach efforts, and multiple in-person interactions between the CHW and clients.
Challenges and strategies predominantly reported in clinical settings
In this section, we discuss issues that were predominantly raised by clinic-based participants, including staff coordination and client follow-through on appointments (Table 3). These issues were discussed by some community-based participants, although they were less significant than those of clinical settings.
Clinic-based CHWs and supervisors reported communication challenges among the CHW program, administrators, and other staff, possibly because regular meetings among team members and between the CHW and the supervisor could be inconsistent. Several participants also discussed the difficulty scheduling patients amidst the clinic's full schedule and the limited availability of certain medical providers. Organizational cohesion and coordination with the CHW reportedly improved with time. Several clinic-based participants noted the importance of fostering trust, rapport, and buy-in for the CHW position with the other staff. Building this rapport was facilitated by establishing a clear and explicit workflow, frequent communication between CHWs and staff, as well as opportunities to socialize and network. It was also important to include CHWs in weekly team meetings and colocate the CHWs in the same workspace as other staff to increase the CHW's visibility within the organization.
The issue of “no-shows” and lack of client follow-through on appointments were also challenges for CHWs working in clinic-based settings. Several participants emphasized the importance of building and maintaining strong partnerships with the community, local organizations, and other stakeholders to improve client utilization of CHW services. Two organizations successfully enacted strategies to reduce the rate of no-shows, including phone calls with individual clients who missed appointments.
Challenges and strategies predominantly reported in community-based settings
In this section, we describe the benefit of diversifying training for community-based CHWs and strategies to improve community participation in CHW programs, both of which were predominantly discussed in interviews with community-based participants (Table 4).
Participants discussed the varied skill set that CHWs must have to work effectively in community-based settings. Interviewees talked about the need for more diverse and specialized training for community-based CHWs on various topics related to basic health issues, as well as program management. Providing regular opportunities for continuing education and training was considered a priority for many community-based participants. Participants preferred short individual training sessions that took place over several weeks or months, rather than weeklong intensive courses. Several participants noted the importance of training CHWs in “soft” skills (eg, evaluation, advocacy, event planning, and management). Interviewees also discussed the usefulness of the professional development opportunities offered by EHCLP at the annual meetings, as well as the benefits of maintaining a network of CHWs outside of the meetings to share knowledge and skills.
Whereas clinic-based participants discussed the lack of follow-through by individuals on scheduled appointments, community-based participants described the challenge of engaging certain portions of the client population in CHW events and services. For example, 2 interviewees noted how residents of one county were more actively involved in the CHW program than those of a neighboring county, although services were offered in both areas. Spending time in the community outside of official CHW initiatives and maintaining a presence at community events were considered key to facilitating participation in the CHW's work. One organization presented information on the CHW program to all stakeholder organizations in the area at the start of the CHW program to increase awareness of the resources offered by the CHW. Creating a schedule of CHW events and services and raising local awareness of them through local channels of communication were also important.
Given the geographic focus of this study, findings may not be nationally representative. However, the challenges and strategies found here significantly overlap with those in the recent literature (see the “Discussion” section). Moreover, participant interviews were carried out by an EHCLP staff member, which might have biased participants to share positive aspects of the program. To address this, before beginning the interview, the interviewer emphasized the confidential nature of the study, as well as the fact that the data would have no impact on the organization's current or future funding from EHCLP. Potential bias was also limited by focusing data analysis on challenges to CHW functioning, as well as strategies used to overcome those challenges. Finally, the findings represent the perspectives of the CHWs and supervisors and do not reflect the perspectives of clients or other stakeholders. Examining the perceptions of CHWs and supervisors provided important insights into CHW integration, but future research should examine this issue from other perspectives.
This study contributes to the literature, indicating that workplace setting is an important factor in determining the types of challenges experienced by CHWs and the appropriate strategies to address those challenges.5 Participants from predominantly clinical settings described the importance of strong organizational cohesion and coordination, as well as ways to improve client follow-through on appointments. Interviews with community-based participants placed a relatively greater emphasis on the need for specialized training for CHWs working in community-based organizations, as well as strategies to more effectively engage the community in the CHW program. However, it is noteworthy that most challenges and strategies in this study were reported by participants working in both clinical and community-based settings. In both work environments, participants indicated that CHW functioning was constrained by organizational resources, difficulty accessing the client population, and limited knowledge regarding the CHW's scope of practice. Strategies to improve CHW functioning in both settings included investing in local partnerships, streamlining resources, prioritizing strong communication and outreach, and establishing an explicit operating procedure. It is possible that the overlap between barriers reported in clinical and community-based settings reflects the fact that CHWs in both environments were new to the organization. Relatedly, the majority of participants noted that challenges lessened over time. Other studies have similarly highlighted how the newness of the CHW position within an organization and community can initially constrain CHW functioning, with challenges eventually lessening.13,17 Documenting the key challenges in new CHW programs and the potential strategies to address those challenges is critical for practitioners planning to integrate CHWs into existing initiatives or organizations, reducing the time needed to ramp up programs.17,21,22
The key challenges and strategies characterized in this study have been documented elsewhere, with recent literature emphasizing how barriers to CHW functioning interact to further constrain CHW functioning.3,12–15,17,23–27 This study and the recent literature have suggested several strategies to facilitate the integration of CHWs in both clinical and community-based settings (Table 5).12–17,23–25,27–29 However, it is notable that many of the barriers reported here and elsewhere relate to upstream factors, such as access to transportation and communication technologies, limited reimbursements for CHW services, and other governance issues.14,25,30 These systemic barriers will be difficult to overcome without addressing public health policies and procedures.29 Further research is also needed to understand how contextual factors influence the success of a CHW, particularly in community-based settings in the United States.12,13,15,17
Implications for Policy & Practice
- This study provides important insights into how to successfully integrate CHWs into the public health workforce, as well as how to maximize CHWs' abilities to address clients' health needs in underserved communities.
- This study reiterates the importance of building and maintaining strong relationships with community members, staff members, and stakeholders in both clinical and community-based settings.
- Establishing clear workflows, maintaining communication, and consistently engaging in outreach may also enable new CHW programs in a variety of workplaces.
- The strategies identified in this study also have implications for workforce development, highlighting areas in which CHWs should be competent and the content and skills that should be incorporated into training and certificate programs.
- This study also indicates the need for policy reform to address upstream barriers to CHW programs, including limited transportation access. Amidst potential changes to the ACA, it will be critical to secure and diversify long-term funding for CHW programs.
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