For some prospective community health workers, things that might have kept them from getting a job in the past – such as a history of incarceration or homelessness – are actually a benefit.
The Institute for Family Health, a New York-based federally qualified health center network, is developing a new program that recruits and trains community health workers with lived experiences that are similar to those of their patient population.
“We want to reframe their experience, which society has framed as negative…as experiences that we think are valuable,” said Maxine Golub, the Institute’s senior vice president for planning and development.
That’s because, for community health workers, having backgrounds that reflect the communities they serve is an important part of establishing trust.
Many people still haven’t heard of community health workers – specially trained lay workers who conduct outreach and education in local communities, and who connect people to health and other services. However, there’s no question that the profession, which exists all over the world, is becoming more widespread and prominent in the United States.
According to the Bureau of Labor Statistics, employment of health education specialists and community health workers is projected to grow 17% from 2020 to 2030, with an average of more than 16,000 new positions each year. (The average growth rate for all occupations is expected to be eight percent.) President Joe Biden’s $1.9 trillion American Rescue Plan called for hiring 100,000 community health workers to support the prevention and control of Covid-19.
And as the profession grows, the hope is that people – particularly those who have been historically disenfranchised and marginalized by the health care system – will be healthier as a result.
Deeply trusted sources
As a general rule, community health workers – or promotores de salud, a similar term that’s sometimes used interchangeably – are well-known among the people they serve. They usually have similar identities and lived experiences.
“They are deeply trusted and have relationships with communities,” said Denise Smith, executive director of the National Association of Community Health Workers. “I’m leveraging my relationship, my experiences, my friends and neighbors, my faith-based community, my hood” to improve health and access to food, transportation, housing and other elements that contribute to health outcomes.
Those elements are known as the “social determinants of health” – important factors in a person’s circumstances that can’t be fixed by simply providing standard medical care. “Almost all of our patients need more than what they can get from the doctor or nurse practitioner,” Golub said.
Community health workers are trusted for good reason, said Javier Arellano, a program manager at the Chicago-based group Illinois Unidos. The organization has a current program employing promotores to increase Covid-19 vaccination rates among Latinos, who have been hit especially hard by the pandemic.
While doctors and nurses are supposed to be authoritative sources of information, they’re often mistrusted by communities who have experienced discrimination and marginalization. “The more power you get, the more you’re seen as being disconnected from the community,” Arellano said.
For example, Golub explained that a young member of the LGBTQ+ community who’s been rejected by their family has “every reason to be mistrustful, so they’re much more likely to open up to someone who has had a similar experience.”
At the Institute for Family Health, the goal is eventually for each of the community health workers they hire to work with a caseload of thirty to forty patients – about 85-90% of whom are people of color and many of whom are uninsured.
An essential history
According to Smith, increasing health equity is fundamental to the history and practice of community health workers. She explained that the profession’s history in the U.S. has roots in communities of Indigenous and enslaved people during early colonialism.
Living in perilous and oppressive circumstances, some individuals “developed care services, advocacy, capacity building,” delivered babies, and treated disease and injury, she said. “We have history that shows that there were these very dangerous but necessary relationships.”
But Smith emphasized that many different traditions of community health workers exist in the United States, as they do elsewhere. For example, promotores play significant and well-recognized roles in Latin American cultures, and thus are widely recognized in U.S. Latino communities.
And even today, increasing health outcomes is fundamental to the work of community health workers, Smith said: “These systems were not designed for us. That’s the nature of inequity.”
Fighting the pandemic
The Covid-19 pandemic is a telling example. Lisa Aponte-Soto, Illinois Unidos’s director of community engagement for resource and capacity building, explained that not only has the disease itself hit Chicago’s Latino community hard, it’s caused severe indirect consequences, including increases in job loss, homelessness, mental health concerns, and health issues.
“Covid has been setting back a lot of the gains that Latinos had been making before the pandemic,” she said.
And promotores have an important role to play in mitigating those effects, whether it’s connecting people to social services or – through Illinois Unidos’s new program – helping them decide to get a vaccine.
At the California-based organization Vision y Compromiso, which trains, supports, and advocates for community health workers and promotores, executive director Maria Lemus explained that many of these workers have their roots in informal volunteering.
Lemus’s mother, Manuela, worked in the fields and at restaurants, and also cleaned houses – but in her spare time, she brought food and other resources to members of her community. “How I grew up is typical of the network that exists within our community,” Lemus said.
For a new warmline called Estamos Juntos (“We Are Together”), Vision y Compromiso is building on that model, training promotores to help people experiencing grief and loss, isolation, and domestic violence, among other issues. Promotores can connect people to support groups, educational programs, or other resources, and are also trained to identify more serious mental health issues that require referral to another organization.
Since it began, the warmline has reached thousands of people.
But there’s an important difference from the work that Lemus’s mother once did for friends and neighbors: With help from a Direct Relief grant, Vision y Compromiso is paying for benefits for its promotores. The organization is also one of those offering a living wage – a strategy that Lemus explained is also “a women’s equity issue,” since so many promotores are women.
Looking to the future
As misinformation becomes rampant and health care remains inaccessible to many, Arellano feels that the importance of community health workers is becoming more recognized. “These skills that have been deemed more soft skills or not as important in the past…it’s really important now to have that trust,” he said.
And the roles of these workers are evolving as well. Smith said that community health workers are increasingly working to influence the very policies that affect their patients – including those that shape affordable housing, safe streets, employment, and reliable power to keep medications refrigerated. “You can’t really address [issues related to health] unless you move policy,” she said.
Smith emphasizes that, as the profession grows, it’s important to bear in mind that most community health workers feel called to do this work. “It’s not a substitute for medical school,” she said. And that’s precisely the point: “We need community health workers to stick around because of what we all know, which is that 80% of what happens to a person’s health happens outside a doctor’s office.”
Direct Relief, through its Fund for Health Equity, is committed to supporting organizations that recruit, train, advocate for, and employ community health workers caring for diverse communities across the United States. The Fund for Health Equity recently granted more than $238,000 to the Institute for Family Health, $250,000 to Illinois Unidos, and $50,000 to Vision y Compromiso.
