Community Health Worker Roles and Effectiveness from the Perspective of Community Residents: A Global Approach

BACKGROUND & PURPOSE: Brazil’s Unified Health System Family Health Strategy (FHS) employs 300.000 Community Health Workers (CHWs), who create liaisons between professional care providers and community residents and disseminate public health information. CHWs help residents with chronic disease management, clinical care, social determinants, vertical disease programs and healthy pregnancy and child development promotion.  The roles performed by CHWs are well documented in the literature, but only from the perspective of CHWs. Lacking is research on community residents’ perceptions about the roles and effectiveness of CHWs charged to help them make and maintain behavioral changes. Better understanding CHWs’ roles and their interactions with the communities in Brazil may ultimately help inform other health care systems globally.

 METHODS: This cross-sectional study included in-depth interviews with 27 community residents enrolled in Brazil’s Family Health Strategy (ESF). Three participants were randomly selected/recruited from each of the nine ESF local units in the Municipality of Biriguí, São Paulo State. Sample: 18 females; 13 white, 12 mixed-race and two Black; three completed college, nine high school, six elementary, and nine partial primary education. Research assistants contacted participants in person or by phone using a standardized script. Interviews lasted 60-90 minutes and were recorded and transcribed verbatim. Interviewers were trained by the first author. The semi-structured script elicited participants’ perceptions of services rendered by CHWs. The ultimate goal was to corroborate previously collected data from CHWs describing their roles and effectiveness. Key prompts focused on eliciting details of CHWs’ informal and personal approach to treating community residents and how these may help them change or maintain health behaviors. Moreover, we collected data on participants’ perceptions of challenges and facilitators to CHWs’ didactic approaches.

 RESULTS: Participants confirmed that indigenous knowledge (i.e., empathic communication, perseverance and personal traits) helped CHWs address challenges (i.e., lack of resources and education) that might hinder their ability to help residents. CHWs’ effectiveness appears to come from their ability to impart health information using interpersonal strategies (i.e., concern, respect, empathy, perseverance, and jargon-free communication). Specific actions performed by CHWs that are helpful to residents included refilling prescriptions, referring to specialists and advising residents on how to keep their homes clean in order to prevent disease. Technical knowledge judged most helpful included how to change eating habits, adherence to prescribed medication, and personal hygiene. Most helpful didactic techniques included pamphlets on preventable diseases.

 CONCLUSION: Data showed that community residents perceive that how CHWs integrate indigenous and technical knowledge in their daily work does impact residents’ health behavior. Participants identified a set of variables, including challenges and facilitators that might influence how well CHWs help residents change health behaviors (or not). These variables corroborate previous findings and provide evidence for future intervention research (e.g., testing of CHW training), which may help validate CHWs’ effectiveness and consolidate their roles in improving public health. This study sheds light on a profession that is growing worldwide and which has been widely studied in Brazil’s Unified Health Care System; thus findings may inform practice and policy in other countries.