Methods: In paper#1, in-depth interviews were conducted with 27 community residents randomly selected from nine Primary Health Care Units (PHCU) in BrazilÃÂ¢Ã¢âÂ¬Ã¢âÂ¢s Family Health Strategy (FHS). A deductive approach was used to analyze the data. In paper#2, we conducted two separate focus groups - supervisors (n=6) and EDs (n=7). Thematic analysis was used to identify salient themes. Paper#3 is a program evaluation of CI Project using interviews and surveys with CHWs, CHW employers, and evaluators in Michigan.
Results: In paper#1, residents reported that CHWs were successful in imparting health education and mobilizing communities through interpersonal strategies of concern, trustworthiness, empathy, perseverance, patience, attentiveness, friendly demeanor, and communication that is free of medical jargon. Residents discussed the lack of CHW credibility as perceived by physicians and lack of wellness initiatives for CHWs. In paper#2, challenges identified by EDs included individual (poverty, lack of professionalism, trauma) and structural (low salaries, high turnover rates, recruiting CHWs, lack of trainings, limited or inactive referral networks, lack of observational aspects of CHWs evaluations). Supervisors noted similar individual (trauma, lack of ability to maintain professional boundaries) and systemic (negative public perceptions, high turnover rates) challenges. Paper#3 demonstrates focal outcome indicators that highlight that CHWs are uniquely suited to improve, including social and structural determinants of health and vulnerability, self-perceived health, empowerment, social support, and quality of life. CI Project also attends to policy and systems change, which is both a process that can enable CHW work, and an outcome that CHWs can mediate through their community organizing, advocacy, and coalitional activism.
Implications: These three papers shed light to the utility of CHWs and recommendations to improve CHW programs vis-ÃÆÃ -vis employers, managers (many of whom are social workers), and residents. Our papers underscore the need to support CHWs professional development and structured supervision. At the organizational level, data-driven referral processes, referral network management systems, wellness initiatives and a focus on team building is recommended. At the policy level, we suggest collective activism to ensure that adequate resources are allocated to CHW programs, and that CHWs are able to advocate for communities that they serve.