Community Health Representative Workforce: Integration across systems and teams to address the social determinants of indigenous health and wellbeing

Tribally employed, Community Health Representatives (CHRs) serving Indigenous and American Indian and Alaskan Native (AIAN) peoples are culturally and linguistically embedded community leaders, with the unique ability to serve as the link and intermediary between community members and systems. Unique to the CHR workforce scope of practice is the expectation for high level integration within the medical and social service care team. This explicit role outlined in the scope of work sets an expectation for both CHR and care teams to deliver integrated patient, family, and systems level care coordination and case management. This paper aims to build from our previous manuscript published in Volume 1 of the special issue Community Health Workers Practice from Recruitment to Integration. In that Volume, we explored through a Community Case Study CHR Managers' perspectives on the challenges and opportunities for full CHR integration into health systems and teams serving AIAN. In this paper, we offer new information about the current CHR and CHR Managers' involvements and perceived level of integration within health care teams and the broader public health systems addressing the social and structural determinants of health. We approach this topic considering the COVID-19 pandemic and how CHRs and CHR Programs were included and not included in tribal pandemic response efforts.

Assessing Knowledge and Perceptions About Cancer Among American Indians of the Zuni Pueblo, NM

American Indians (AIs) in New Mexico have lower cancer screening rates compared to other populations and are more likely to be diagnosed with cancer at an advanced stage of the disease as reported by Li et al. (Archives of Internal Medicine 163(1):49-56, 2003). AIs also have the lowest 5-year cancer survival rates compared to any ethnic/racial group in the USA as reported by Clegg et al. (Arch Intern Med 162:1985-1993, 2002) and Edwards et al. (Cancer 97:1407-1427, 2005). Numerous barriers such as cultural beliefs, fear, fatalism, mistrust, stigma, and lack of culturally appropriate interventions could contribute to low cancer screening rates as reported by Daley et al. (J Health Dispar Res Pract 5(2), 2012); Filippi et al. (J Prim Care Community Health 4(3):160-166, 2013); James et al. (Prev Chronic Dis 10:E170, 2013); and Schumacher et al. (Cancer Causes Control 19(7):725-737, 2008). Trained Community Health Representatives (CHRs) from the Zuni Pueblo and native Zuni undergraduate students led six 1-h focus group sessions using a structured focus group guide with probes. The focus groups were conducted among 51 participants from different age groups (20-29 years, n = 19; 30-49 years, n = 17; and 50 years and older, n = 15) stratified by sex. Focus groups were conducted in both English and Shiwi (Zuni) languages. Sessions were audio recorded, and team members took notes. CHRs transcribed the notes and audio recordings, and created a codebook for qualitative data analysis. In the focus groups, participants provided Zuni-specific cultural context, opinion, and experience regarding (1) general knowledge about cancer, (2) cancer risk, (3) cancer risk reduction, (4) personal experiences with cancer, and (5) culturally competent delivery of cancer information and resources. Understanding the perceptions of cancer within the Zuni Pueblo is an essential component in the development of interventional/preventative measures and improvement of current care. Ultimately, this information will provide a basis for the next steps in culturally sensitive cancer care for the Zuni Pueblo.

A Snapshot of Oklahoma's CHR/CHW Workforce: Results from the Region 6 Training Needs Assessment Survey, 2019

BACKGROUND –

The Region 6 South Central Public Health Training Center conducts needs assessments to inform the development of online trainings tailored to the HRSA Region 6 health and public health workforce. The purpose of this study was to assess Oklahoma's Community Health Representative (CHR) / Community Health Worker (CHW) workforce characteristics, current trainings, and training needs to guide the development of online trainings.

METHODS –

This survey-based needs assessment for health and public health workforce training needs asked about alternative job titles, top three health issues addressed, roles played, skills used, current trainings, and training needs. Descriptive statistical analysis provided insights about CHRs/CHWs. The Fisher's exact test was used to compare frequency of responses between CHRs and CHWs, with p-values <0.05 considered significant. We analyzed qualitative data by using a modified content analysis.

RESULTS –

Fifty-one self-identified CHRs/CHWs in Oklahoma participated in the 2019 regional health and public health training needs assessment. Most CHRs/CHWs were female and identified as "frontline public health workers." Respondents reported a range of educational attainment and diverse job titles. CHRs worked at tribal health or public health organizations primarily in rural areas. Most CHWs worked in urban areas and were employed by state and local health departments or community-based organizations. CHRs/CHWs had a broad spectrum of roles and skills, with required trainings reflecting various organizational needs. CHRs/CHWs expressed strong interest in receiving additional trainings via multiple delivery formats.

DISCUSSION AND CONCLUSIONS –

Oklahoma's CHRs/CHWs would benefit from and utilize workforce development, including trainings on a broad spectrum of roles and skills in multiple delivery formats. Potential employers and funders across the state would benefit from education on CHRs/CHWs as a workforce, team-integration, and sustainable funding.

Cultural elements underlying the community health representative - client relationship on Navajo Nation

Background

Navajo Nation Community Health Representatives (CHR) are trained community health workers (CHWs) who provide crucial services for patients and families. The success of the CHRs’ interventions depends on the interactions between the CHRs and their clients. This research investigates the culturally specific factors that build and sustain the CHR-client interaction.

Methods

In-depth interviews were conducted with 16 CHRs on Navajo Nation. Interviews were transcribed and coded according to relevant themes. Code summaries were organized into a narrative using grounded theory techniques.

Results

The analysis revealed four findings critical to the development of a CHR-client relationship. Trust is essential to this relationship and provides a basis for providing quality services to the client. The ability to build and maintain trust is defined by tradition and culture. CHRs must be respectful of the diverse traditional and social practices. Lastly, the passing of clients brings together the CHR, the client’s family, and the community.

Conclusion

Understanding the cultural elements of the CHR-client relationship will inform the work of community partners, clinical providers, and other indigenous communities working to strengthen CHR programs and obtain positive health outcomes among marginalized communities.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1956-7) contains supplementary material, which is available to authorized users.