Kerstin M. Reinschmidt

Predictors and a Framework for Fostering Community Advocacy as a Community Health Worker Core Function to Eliminate Health Disparities

OBJECTIVES Using a mixed-method, participatory research approach, we investigated factors related to community health worker (CHW) community advocacy that affect social determinants of health. METHODS We used cross-sectional survey data for 371 CHWs to assess demographics, training, work environment, and leadership qualities on civic, political, and organizational advocacy. We present advocacy stories to further articulate CHW activities. The data reported are from the recently completed National Community Health Workers Advocacy Study. RESULTS CHWs are involved in advocacy that is community-focused, although advocacy differs by intrinsic leadership, experience, training, and work environment. We propose a framework to conceptualize, support, and evaluate CHW advocacy and the iterative processes they engage in. These processes create opportunities for community voice and action to affect social and structural conditions that are known to have wide-ranging health effects on communities. CONCLUSIONS The framework presented may have utility for CHWs, their training programs, and their employers as well as funders and policymakers aiming to promote health equity.

A community health worker intervention to address the social determinants of health through policy change.

Public policy that seeks to achieve sustainable improvements in the social determinants of health, such as income, education, housing, food security and neighborhood conditions, can create positive and sustainable health effects. This paper describes preliminary results of Acción para la Salud, a public health intervention in which Community health workers (CHWs) from five health agencies engaged their community in the process of making positive systems and environmental changes. Academic-community partners trained Acción CHWs in community advocacy and provided ongoing technical assistance in developing strategic advocacy plans. The CHWs documented community advocacy activities through encounter forms in which they identified problems, formulated solutions, and described systems and policy change efforts. Strategy maps described the steps of the advocacy plans. Findings demonstrate that CHWs worked to initiate discussions about underlying social determinants and environment-related factors that impact health, and identified solutions to improve neighborhood conditions, create community opportunities, and increase access to services.

Taking a Community-Based Participatory Research Approach in the Development of Methods to Measure a Community Health Worker Community Advocacy Intervention

Background: Public health advocacy is by necessity responsive to shifting sociopolitical climates, and thus a challenge of advocacy research is that the intervention must by definition be adaptive. Moving beyond the classification of advocacy efforts to measurable indicators and outcomes of policy, therefore, requires a dynamic research approach. Objectives: The purposes of this article are to (1) describe use of the CBPR approach in the development and measurement of a community health worker (CHW) intervention designed to engage community members in public health advocacy and (2) provide a model for application of this approach in advocacy interventions addressing community-level systems and environmental change. Methods: The Kingdon three streams model of policy change provided a theoretical framework for the intervention. Research and community partners collaboratively identified and documented intervention data. We describe five research methods used to monitor and measure CHW advocacy activities that both emerged from and influenced intervention activities. Discussion: Encounter forms provided a longitudinal perspective of how CHWs engaged in advocacy activities in the three streams. Strategy maps defined desired advocacy outcomes and health benefits. Technical assistance notes identified and documented intermediate outcomes. Focus group and interview data reflected CHW efforts to engage community members in advocacy and the development of community leaders. Application of Lessons Learned: We provide a model for application of key principles of CPBR that are vital to effectively capturing the overarching and nuanced aspects of public health advocacy work in dynamic political and organizational environments.

Taking a Broad Approach to Public Health Program Adaptation: Adapting a Family-Based Diabetes Education Program

Diabetes health disparities among Hispanic populations have been countered with federally funded health promotion and disease prevention programs. Dissemination has focused on program adaptation to local cultural contexts for greater acceptability and sustainability. Taking a broader approach and drawing on our experience in Mexican American communities at the U.S.–Mexico Border, we demonstrate how interventions are adapted at the intersection of multiple cultural contexts: the populations targeted, the community- and university-based entities designing and implementing interventions, and the field team delivering the materials. Program adaptation involves negotiations between representatives of all contexts and is imperative in promoting local ownership and program sustainability.

Symptoms of Depression in a Hispanic Primary Care Population With and Without Chronic Medical Illnesses

OBJECTIVE To describe somatic and psychiatric symptoms reported by Hispanic primary care patients with and without depression and/or chronic medical illnesses. METHOD Adult Hispanic patients (n = 104) in a Mobile Health Program in underserved southern Arizona participated in a survey conducted between September 2006 and February 2007 to obtain information about the somatic and psychiatric symptoms that they were experiencing. They were asked to rate the severity of their symptoms listed in the depression screen Personal Health Questionnaire-9 (PHQ-9), the Symptom Checklist-90-Revised (SCL-90-R), and 5 new symptoms described by patients in focus groups conducted in the first phase of the project. Patients were categorized as depressed if their PHQ-9 scores were 10 or above, and they were further categorized as having or not having chronic illnesses based on self-report. Analyses of variance were conducted for each SCL-90-R symptom dimension to compare across the 4 groups (group 1: not depressed and not medically ill; group 2: medically ill but not depressed; group 3: depressed but not medically ill; and group 4: depressed and medically ill). RESULTS Patients with chronic medical illnesses comorbid with depression were found to report significantly more somatic symptoms than those with only chronic medical illnesses or depression alone (P ≤ .001). They also reported significantly more psychopathology than patients with depression alone (P ≤ .05 or better). CONCLUSIONS Patients with medical illnesses comorbid with depression are more likely to exhibit psychopathology than patients with medical illnesses or depression alone.

Dance for Your Health: Exploring Social Latin Dancing for Community Health Promotion

ABSTRACT The goal of Dance for Your Health was to explore the relationship between social Latin dance and health as described by members of the Tucson social Latin dance community. Social Latin dance was selected because of the variety of dances, cultural relevance and popularity in Tucson, and the low-key, relaxed atmosphere. Dance has been prescribed to help manage diseases such as Parkinson’s; however, not much is known about the use of dance for health promotion. Through qualitative methodologies, the project focused on the role dance can play in health promotion and in creating community connections. The project explored personal stories and experiences on the broader impact of health, the meaning of community from the social Latin dancer’s point of view, thoughts on how social Latin dancing could be applied to help people in the community live healthier lives, and how to demystify social Latin dancing for people who are not currently dancing.

Using Active Learning Strategies Linked to CBPR Principles in a Semester-Long Class Project to Teach Qualitative Research Methods in Public Health

The use of active learning strategies to engage students in public health education has shown to be effective in promoting meaningful learning experiences. These educational approaches include inquiry- or problem-based, and group-based learning that allow for deeper understanding and internalization of the content material. This type of active learning can extend into the community by applying community-based participatory research (CBPR) principles. Using CBPR can engage both the community and the students on a project, thus benefiting all parties involved. This article describes the components of a class project that linked the active learning strategies of inquiry and group-based learning to CBPR principles as an innovative teaching approach in public health. The design and implementation of the class project is conceptualized in four activity types: (1) engaging the community, (2) working with students, (3) conducting behind the scenes work, and (4) bringing the students and the community together. The project demonstrates the benefits of using CBPR principles in conjunction with active learning principles. It also provides recommendations to public health instructors in higher education, which include the requirements of instructors’ established relationship with the community, commitment to project coordination, flexibility regarding project implementation and class time, and university support for sustaining innovative teaching efforts.

Community–Clinical Linkages With Community Health Workers in the United States: A Scoping Review

Despite the proliferation of community–clinical linkage (CCL) interventions with community health workers (CHWs), little is known about the components of these programs or how linkages are realized. In this scoping review, we synthesize evidence concerning the role of CHWs in creating and sustaining CCLs aimed at improving individual health outcomes. Our inclusion criteria included peer-reviewed articles that described a CHW intervention in the United States that used a CCL model. A total of 2,776 titles and/or abstracts were screened and 47 articles underwent full text review. Two independent reviewers rated the screened articles based on additional criteria including the CHW connection to community and evidence of linkage follow up rather than simple referral. For the 11 peer-reviewed articles included in the final review, we describe the CHW’s relationship to the community, training, and role within the intervention, linkage, and outcomes. We used a standardized framework to determine commonalities in CHW roles across the interventions. CCLs with CHWs positively affect the delivery of both clinical care and community resources across a range of disease areas in a variety of contexts. To identify effective CCL models, additional information on CHW training, CCL follow-up methods, and the CHW role in CCLs is recommended.

The Impact of Integrating Community Advocacy Into Community Health Worker Roles on Health-Focused Organizations and Community Health Workers in Southern Arizona.

Organizational environments may encourage community health workers (CHWs) to engage community members in improving their communities. We conducted open-ended interviews and focus groups to explore how participation in the Acción intervention, which trained CHWs in community advocacy, affected organizational capacity to support their CHWs. Supervisors described improved organizational recognition and trust of CHWs. Organizational leaders reported organizational benefits and increased appreciation of CHW leadership. Both expressed increased interest in future advocacy trainings. Limiting factors included organizational mission, CHW position descriptions, and funding. Findings indicate that, with training and funding, CHW community advocacy can be integrated into organizations with congruent missions.

Documenting Community Health Worker Roles in Primary Care: Contributions to Evidence-based Integration Into Health Care Teams, 2015

The Patient Protection and Affordable Care Act provided community health workers (CHWs) with new opportunities, and current efforts develop evidence-based guidelines for CHW integration into clinical teams. This qualitative study documents CHW roles and activities in 3 federally qualified health care centers in southern Arizona. Community health worker clinical roles, activities, and integration varied by health center and were in flux. Integration included complementary roles, scheduled and everyday communications with team members, and documentation in the electronic health records. These findings contribute to evidence-based guidelines for CHW integration into clinical teams that are critical to maximizing CHW contributions to patient health improvements.