Community Health Workers in Action

Table of contents :
Cover
Community Health Workers in Action
Copyright
Dedication
Contents
Preface
Acknowledgments
Section 1 Context
1. Overview
Introduction
What Constitutes a Profession?
Peer Leaders/​Community Health Workers
Historical Origins of Community Health Workers
Health Inequity
An Expanding Universe for Community Health Care Worker Coverage
Evolution of Innovative Interventions
Values and Principles Guiding Community Health Workers
A Focus on Community Health Workers and Four Special Population Groups
Book Goals
Conclusion
2. Culture and Health
Introduction
Nature and Extent of Relationship Between Health and Culture
Intersectionality and Health
Acculturation Status and Stress
Conclusion
3. Health Inequity
Introduction
Definition and Overview
Conclusion
4. Challenges and Barriers to Urban Health Care Delivery
Introduction
Key Demographic Profiles and Trends
Organizational Access Barriers
Geographical/​Physical
Psychological
Cultural/​Language
Operational/​Financial
Conclusion
Section 2 Theoretical Foundation
5. Values, Guiding Principles, Conceptual Foundation, and Framework
Introduction
Values and Principles Guiding Community Health Worker Interventions
Values
Principles
Conceptual Frameworks
Community Capacity Enhancement
Life Course Perspective
Conclusion
7. Recruiting, Training, and Supporting Promotores (Paid and Volunteer)
Introduction
Key Research Questions
Recruiting and Screening
Training and Supervision
Organizational Support
Advancement
Conclusion
Section 3 Reflections from the Field
8. Special Population Case Illustrations
Introduction
Special Population Groups
The Formerly Incarcerated as Community Health Workers
The Formerly Unauthorized as Community Health Workers
The Formerly Homeless (Unhoused) as Community Health Workers
Persons in Recovery as Community Health Workers
Conclusion
9. Recommendations for Practice and Research
Introduction
New Approaches and Models
Demand for Community Health Workers Will Only Increase
Evolving Roles
Research by, for, and on Community Health Workers
Conclusion
10. Practice Challenges and CHWs as Researchers
Introduction
Challenges and the Field of Community Health Work
Rewards and Challenges in Community Health Worker–​Initiated and –​Involved Research
Promising Research Methods and Approaches
Community-​Based Participatory Research
Photovoice
Ethnographic Research
Case Studies
Community-​Led Mapping
Other Less Known or Emerging Research Methods
Ethical Conflicts and Considerations
Conclusion
References
Index

Citation preview

Community Health Workers in Action

Community Health Workers in Action The Efforts of “Promotores de Salud” in Bringing Health Care to Marginalized Communities M E LV I N D E L G A D O

1

3 Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and certain other countries. Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY 10016, United States of America. © Oxford University Press 2020 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by license, or under terms agreed with the appropriate reproduction rights organization. Inquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above. You must not circulate this work in any other form and you must impose this same condition on any acquirer. CIP data is on file at the Library of Congress ISBN 978–​0–​19–​069102–​8 1 3 5 7 9 8 6 4 2 Printed by WebCom, Inc., Canada

v

To Denise, Laura, and Barbara for their patience and support in writing this book.

Contents

Preface Acknowledgments

xi xiii

1. CONTEXT 1. Overview Introduction What Constitutes a Profession? Peer Leaders/​Community Health Workers Historical Origins of Community Health Workers Health Inequity An Expanding Universe for Community Health Care Worker Coverage Evolution of Innovative Interventions Values and Principles Guiding Community Health Workers A Focus on Community Health Workers and Four Special Population Groups Book Goals Conclusion

2. Culture and Health Introduction Nature and Extent of Relationship Between Health and Culture Intersectionality and Health Acculturation Status and Stress Conclusion

3. Health Inequity Introduction Definition and Overview Conclusion

3 3 12 14 18 20 23 25 28 32 33 34

35 35 36 42 44 46

47 47 48 51

viii Contents

4. Challenges and Barriers to Urban Health Care Delivery Introduction Key Demographic Profiles and Trends Organizational Access Barriers Geographical/​Physical Psychological Cultural/​Language Operational/​Financial

Conclusion

52 52 53 54 56 56 57 57

58

2 .   T H E O R E T IC A L F OU N DAT IO N 5. Values, Guiding Principles, Conceptual Foundation, and Framework Introduction Values and Principles Guiding Community Health Worker Interventions Values Principles

Conceptual Frameworks Community Capacity Enhancement Life Course Perspective

Conclusion

6. Community Health Workers/​Promotores de Salud:  Definition, Parameters, and Challenges Introduction Promotores de Salud: Who Are They and Why Are They So Important? Classification of Community Health Workers Effectiveness of Community Health Workers Certification of Community Health Workers: Rewards and Challenges Effective of Community Health Workers The Glue That Makes Them Effective Trust Motivation Intimate Knowledge of Community Language, Cultural Competencies, and Humility Empathy Commitment

61 61 61 62 64

67 68 70

71

73 73 74 83 86 87 87 90 91 93 95 96 97 98

Contents  ix Home Visiting Appeal Logistical and Safety Challenges Ethical Dilemmas

Community Institutions as Collaborators Definitional Challenges Role Definition and Diffusion Community-​Organizational Conflictual Demands

Ethical Dilemmas Conclusion

7. Recruiting, Training, and Supporting Promotores (Paid and Volunteer) Introduction Key Research Questions Recruiting and Screening Training and Supervision Organizational Support Advancement Conclusion

98 101 103 104

104 105 105 106

107 109

110 110 113 113 114 117 118 118

3 .   R E F L E C T IO N S F R OM T H E   F I E L D 8. Special Population Case Illustrations Introduction Special Population Groups The Formerly Incarcerated as Community Health Workers The Formerly Unauthorized as Community Health Workers The Formerly Homeless (Unhoused) as Community Health Workers Persons in Recovery as Community Health Workers

Conclusion

9. Recommendations for Practice and Research Introduction New Approaches and Models Demand for Community Health Workers Will Only Increase Evolving Roles Research by, for, and on Community Health Workers Conclusion

121 121 122 123 132 137 143

151

152 152 153 154 154 156 158

x Contents

10. Practice Challenges and CHWs as Researchers Introduction Challenges and the Field of Community Health Work Rewards and Challenges in Community Health Worker–​Initiated and –​Involved Research Promising Research Methods and Approaches Community-​Based Participatory Research Photovoice Ethnographic Research Case Studies Community-​Led Mapping Other Less Known or Emerging Research Methods

Ethical Conflicts and Considerations Conclusion

References Index

160 160 161 168 170 170 172 172 173 173 174

175 176

177 245

Preface As this book goes out for review and eventual print, there is a cloud hanging over the impact of consistent attempts at repealing various aspects of the Affordable Care Act, and the eventual influence these actions have on health care and the field. What the future holds for health insurance remains unclear. There is no disputing that initiatives funded through the use of these funds have played an instrumental role in fostering the growth of the community health worker (CHW) field and its evolution. Efforts to repeal this Act and undermine several of its aspects are imprinted in the national consciousness. Much of this attention has focused on those who are insured possibly losing their insurance, and its current and long-​term consequences for the health of millions of Americans and health care delivery. Virtually no attention has been paid to the health force consequences, including CHWs. It can certainly be argued that their work with the marginalized has never been more important, but their invisibility in the national discourse has proven worrisome for this author.

Acknowledgments I particularly want to thank Richard Lopez, Case Esperanza (Boston), for taking time from his busy schedule to share his experiences and wisdom in carrying out a community health worker role.

SECTION 1

C ON T E XT Section 1, which consists of 4 chapters, provides a conceptual and historical grounding on the origins and evolution of community health workers, and the interplay of several major factors in shaping how their roles unfold, including some of the major challenges they face in carrying out their responsibilities. An in-​depth understanding and appreciation of the work undertaken by CHWs will only enhance our appreciation of their place within the world of health care. This section will serve as a foundation for this journey of understanding and appreciation.

1 Overview Introduction Writing a book on any aspect of health brings great excitement and trepidation because no single author, or book, can do justice to such an immense and important topic, particularly one accounting for approximately one sixth of the nation’s economy. This chapter provides a roadmap to the complexity of the topic. Health and health care touch all lives (Glasby, 2017). This takes on added meaning with the marginalized members of society. This introductory chapter will ground readers on a variety of topics usually covered in an opening chapter, as well as other subjects not normally found in such a chapter, including what constitutes a profession. Health is a universal topic, although it is complex to understand. Adequately covering the subject of health requires the introduction of an historical context and sociocultural factors, and in the process, discussing how values played critical roles in shaping a worldview of health and the right to quality care. How do values influence our discourse and policies on health? They do so in profound ways that may be subtle and obvious at the same time, bringing clarity as well as a nuanced context (Haralambous et al., 2016). There is a close relationship between health and well-​being across the life span (Patton et  al., 2016; Quick, Gatchel, & Cooper, 2015), including the lifelong consequences of childhood stress for those living in and/​or exposed to violence (Middlebrooks & Audage, 2008). There is a divide between health and quality care in this country for certain groups and geographical settings, compromising the democratic principles this nation was founded upon (Baron et al., 2014; Shortell, 2013). This divide is most serious in urban centers heavily populated by low-​ income people of color, including those who are undocumented. When viewed from a world perspective, more than half of the population still lives in rural areas, calling for a flexible way of conceptualizing health care systems (World Health Organization, 2010). Although this book focuses on urban settings, community health workers (CHWs) have found success

4 Context

among low-​income rural residents and migrant workers, illustrating the broad reach of this health corps (Litzelman et  al., 2017; Schoenberg, Ciciurkaite, & Greenwood, 2017; Tripathy, Goel, & Kumar, 2016). Clarke et al. (2013) found that 30 years of disparity research has focused on patients rather than how can we make health care systems more responsive to communities of color, reflecting an implicit value bias. This conclusion calls for an understanding on how best to bridge the gap between ideals and reality of health care in the United States for millions across all areas and regions, particularly in light of dramatic current and projected demographic changes. Health and health inequities touch the lives of millions of people of color across all regions, resulting in a desperate search for innovative ways of reaching them in an affirming and cost-​effective manner (Barnett et al., 2018; Nester, 2016; Perez-​Escamilla & Melgar-​Quinonez, 2011; San Miguel et  al., 2016). This search translates into cultural and linguistic programs that empower and foster social change, bringing immense rewards and challenges (Abrahams-​Gessel et al., 2016; Fiscella & Sanders, 2016). These challenges require development of innovative community-​centered responses in reaching the most vulnerable. Goodwin and Tobler (2008) provide a summary of US health challenges, setting the stage for using CHWs as a key force in helping to relieve the strain on the nation’s health care system: Ensuring that underserved populations receive needed health care services is a challenge for policymakers. The changing landscape of the U.S. population, which is growing older and more diverse, coupled with other challenges—​the increasing complexity of the health care system, rising health care costs, growing numbers of uninsured, more people with chronic diseases, and provider shortages—​have policymakers looking for ways to extend the already strained health care system and more effectively reach underserved communities. (p. 1)

Health touches all facets of a community’s life and represents a significant part of any form of human capital. Unhealthy communities face severe disadvantages in this society. When intersectionality is introduced, it further relegates these communities to the margins and severely limits their contributions to their families, communities, and society (Collins & Bilge, 2016; Duarte, 2016).

Overview  5

The complexity of these challenges defies a simple and immediate solution, requiring research, thought, and a comprehensive, multifaceted, innovative approach in an increasingly and highly diverse nation (Clarke et al., 2013): For quite some time, we have understood that the causes of disparities are multi-​factorial, yet integrated solutions remain elusive. Today we are primed to devise creative interventions to improve minority health. The Affordable Care Act pushes for innovation in healthcare delivery, the marketplace demands value in healthcare, and there is realization that disparities, in part, reflect a problem with the quality of care. New organizational structures, such as Accountable Care Organizations, offer fresh incentives to care for populations by integrating the strengths of the healthcare system with the strengths of the community. These trends in healthcare practice and policy are creating a unique opportunity to reduce racial and ethnic disparities in care.

Pinto, da Silva, and Soriano (2012) argue that the rapid expansion of CHWs has been undertaken without an attempt to understand their “praxis” (the combining of indigenous and technical knowledge, overcoming challenges, and impacting patient outcomes). Praxis grounds achievements within a sociopolitical context to develop a more robust and nuanced understanding of a crisis situation (Singh et al., 2016). Praxis is a construct that also relies upon dialogue and places health within this context, an essential grounding for advocacy and social change to emerge. Advocacy can break down consumer barriers as well as personal advocacy for profession advancement (Sabo et al., 2015). The barriers to engaging people of color are numerous, including the presence and interplay of racism, language differences, cultural values, lack of insurance, and fears of deportation in the case of the unauthorized, to list several prominent social, political, cultural, and economic barriers (Becerra, 2016; Gonzalez, 2014). Harris (2013) argues that high-​resource nations can learn from low-​resource nations in how best to introduce and support CHWs. The utilization of voice-​and Web-​based feedback, for instance, has been successful in supporting CHWs in low-​resource settings, and more so when administrators actively seek and involve them in designing these systems (DeRenzi et  al., 2017). These lessons go beyond

6 Context

structural considerations and involve the role of trust and interpersonal relationships between consumer and provider. High-​resource nations, too, can share lessons with low-​resource nations, sharing ideas and solutions, particularly models that are exportable to these nations when necessary changes can be incorporated to make them feasible locally. CHWs, too, are increasingly being called to help meet a growing world health care crisis (Crisp & Chen, 2014): There is a global crisis of severe shortages and marked maldistribution of health professionals that is exacerbated by three great global transitions—​ demographic changes, epidemiologic shifts, and redistribution of the disability burden. Each of these transitions exerts a powerful force for change in health care systems, the roles of health professionals, and the design of health professional education. Every country will have to respond to these global pressures for change. (p. 950)

Low-​and middle-​resource nations, too, can influence, and be influenced by, how high-​resource nations utilize CHWs by establishing the feasibility and cost-​effectiveness of these approaches (Glenton et al., 2013; Mills, 2014; Mutamba et al, 2013). Worldwide current and projected shortages of medical personnel and cost considerations have thrust CHWs to the forefront as viable and cost-​ effective corps in undertaking medical care normally reserved for those with extensive formal education and established medical disciplines (Dynes et  al., 2014). One dated estimate on the global health workers shortage noted that there was a shortage of over 3.5 million at the facility and community levels (Save the Children, 2011). Zambruni et al. (2017) address the worldwide importance of CHWs: “We agree with the Editorial (May, 2017) that stated ‘community health workers are desperately needed globally’ but ‘often still stand  .  .  .  at the fringes of the health system, undefined and unsupported and therefore unable to completely fulfil their potential.’ As the 40th anniversary of the Alma Ata Declaration approaches, it is time to appropriately recognise the role and potential of community health systems” (p. e866). Although there is no consensus on the subject, some US researchers are projecting shortages of 85,000 doctors by 2020, and 260,000 nurses by 2025 (American Medical Association, 2009; Buerhaus, Auerbach, & Staiger, 2009; MacLean et al., 2014). These anticipated shortages do not take into account

Overview  7

increases, actual and projected, in groups requiring services in languages other than English. Nor do they take into account cultural traditions and values outside of the national norms, not to mention a highly charged political climate in discussing those who are undocumented (Daar, Alvarez-​ Estrada, & Alpert, 2018). Playing word association with community health care workers will invariably bring forth home health care and the role of CHWs in helping those forced to stay in their homes because illnesses prevent them from venturing outside of the confines of this place. This necessitates a host of services being provided within homes. It is also a term often associated with those who are “old,” an important community segment; those who are homebound are a significant aspect of health care service delivery. Care provision in the home covers a wide territory, complicating efforts to classify providers of care and services in this setting (Boris & Klein, 2012): “The term ‘home care’ includes a variety of skills and occupations, ranging from visiting nurse to physical therapist to housekeeper” (pp. 5–​6). Home health care’s importance has cast CHWs as an increasingly important segment of this nation’s health care system, and this importance will increase as the nation’s continues its graying process. The increasingly graying of the nation’s population necessitates the development of bold initiatives to meet their complex health needs that are increasingly financially costly (Bartels & Naslund, 2013; Gillespie et al., 2012). This call must be viewed against a backdrop of insufficient dollars, and a lack of qualified personnel to meet US mental health needs, for example (Weil, 2015). Other health needs fall into this category. Boris and Klein’s (2015) excellent book Caring for America: Home Health Workers in the Shadow of the Welfare State grounds home health care within the broader crisis of long-​term care in this country, viewing this subject from a social, political, cultural, and economic point of view. “Home” is the primary focus of health and daily living assistance and care, but to be effective it must overcome potential logistical and interpersonal challenges. Home, too, is often the primary setting where CHWs operate when addressing certain age groups and medical issues. Balcázar and de Heer (2015) summed up the appeal of CHWs:  “Community health workers are a vibrant and unique workforce ideally positioned to function as members of interdisciplinary teams needed to address the global burden of non-​communicable diseases” (p. E508). These CHWs are often the primary health care providers in many

8 Context

nations, with China, the world’s most populated country, being one prime example (Blumenthal & Hsiao, 2015; Li et al., 2014; Lin et al., 2015). CHWs are in demand throughout the world (Johnson et al., 2013; Maes, 2017). Singh and Sachs (2013) enthusiastically embrace health workers, citing an impetus (need and effectiveness) to continue their international expansion and influence: During the past 10  years, community health workers (CHWs) have emerged as a focal point of international discussions of primary health-​ care systems. Although lay community-​based health workers have been active for at least 60 years, the Millennium Development Goals (MDGs) in 2000 prompted new discussion of how these workers can help to extend primary health care from facilities to communities. CHWs have since been part of an international attempt to revise primary health-​care delivery in low-​income settings, and CHW programmes have been changed accordingly. (p. 363)

CHWs are a worldwide health force that can proudly stand alongside other more popular, and more conventional, health professionals rather than as an ancillary workforce. It would be a mistake to relegate CHWs to developing nations, as evidenced by their popularity in the United States, Australia, Canada, Netherlands, United Kingdom, and other postindustrialized nations (Harris & Haines, 2012; Ospina et  al., 2012; Schmidt, Campbell, & McDermott, 2015; Smylie et  al., 2016; South, Kinsella, & Meah, 2012; South, Meah, & Branney, 2012; Torres et al., 2013; Verhagen et al., 2015; Xavier et al., 2016). This listing is illustrative rather than exhaustive, highlighting their almost universal appeal. In the United States, CHWs are very popular and effective in delivery of a range of services, including getting the uninsured to enroll in health insurance programs made available through the Patient Protection and Affordable Care Act (ACA), a widely acknowledged critical step in accessing health care (Lang et  al., 2014; Martin, 2014). Terms such as promotora, which are ubiquitous in the professional literature, may not translate, figuratively and literally, into other languages, bringing a new dimension to terminology (Schwingel et  al., 2017). Semantic discrepancies can have a negative impact on recruiting potential CHWs.

Overview  9

Their effectiveness has translated into an increasing workforce numbering in the tens of thousands and expanding across the nation and world (Ollove, 2016): Many now recognize that providing good health care has to go beyond the doctor’s office—​especially for minorities and low-​income people. Limited access to healthy food, environmental perils, crime, insecure housing, insufficient recreational opportunities and the absence of affordable transportation all can have a huge effect on a person’s health. These factors, often called the social determinants of health, are hard for clinicians to address during medical appointments. To contend with them, hospitals, community health clinics, public health agencies, and some health plans are increasingly turning to community health workers like Nelson. Thanks in part to federal grants awarded under the Affordable Care Act, the number of community health workers is growing. In 2015, there were 48,000 of them working in the U.S., up from 38,000 three years earlier, a 27 percent increase, according to the U.S. Department of Labor.

The Affordable Care Act (ACA, 2010)  is a landmark legislation that increases mental health services to those who would normally be ineligible, including almost 11 million Latinx adults (Villatoro, Dixon, & Mays, 2016). Not surprisingly, it is highly recommended that CHWs play an active role in the planning and implementation of the ACA because of their unique insights and talents (Islam et al., 2014). The ACA represented a major national political step forward in expanding the use of CHWs, further institutionalizing their presence in the nation’s health care system (Shah, Heisler, & Davis, 2014): The ACA not only serves as the most comprehensive healthcare law enacted since the advent of Medicare and Medicaid, but as an evidence-​ based sequence of opportunities for CHWs to fill broad gaps in the US healthcare system. A focused agenda for CHWs will provide a vision for highlighting the strengths and potential of these community-​oriented individuals working on behalf of patients and neighborhoods. The areas described in this review highlight areas in which CHWs can play key roles that connect to some of the most salient parts of health reform. By demonstrating the value of CHW-​led initiatives in these areas, proponents

10 Context of CHW approaches can advance the agenda of sustainable integration of CHWs in the healthcare team. (p. 19)

CHWs can broaden their reach and increase their political capital in service to undervalued communities, making them an integral part of the health care scene. They must be meaningfully and effectively integrated into health care systems to achieve this goal (Hsu et al., 2016; Manchanda, 2015). Marginalized people face incredible health challenges that compromise their overall well-​being and their ability to meet daily economic and social needs, further pushing them to the margins of society (Cataletto, 2015; Lane, 2015). The search for more effective service delivery models is ever constant, and the use of indigenous health promoters (CHWs) has received increased attention, nationally and internationally (Abrahams-​ Gessel, Denman, & Gaziano, 2016; Balcazar et al., 2016; Brunie et al., 2014; Bucher, Jäger, & Prado, 2016; McPhail-​Bell et al., 2016; Wilkinson et al., 2016). The field’s scholarly popularity is also evident by the publication of an extensive annotated bibliography that highlights its definition, history, key elements, utility, results, and applicability to a range of health issues (WestRasmus et al., 2012). Although promotores de salud, which is another common term used in the literature to describe CHWs, is a service model associated with Latinxs in the United States, other groups that do not have English as their primary language or do not possess dominant cultural values can benefit from indigenous health promoters. Latinxs are not the only non-​English linguistic group that CHWs have focused on. Islam et al. (2015), in a literature review on CHWs focused on Asian Americans (AAs), and Native Hawaiians and Pacific Islanders (NHPIs), found the following: The majority of articles focused on cancer disparities (41/​75 articles), the leading cause of death among AAs and NHPIs, with breast and cervical cancer as the top two focus areas. However, hepatitis B and liver cancer, which disproportionately affect AAs, were only addressed in 5 articles. . . . The growing burden of heart disease, diabetes, and associated risk factors such as hypertension and obesity are reflected in the growing number of studies reporting CHW interventions in these health topic areas (24/​ 75 articles). Other leading health issues in this population, however, including maternal or child health, injury, and HIV/​AIDS, were poorly represented in the literature or not at all. . . . There are few CHW programs

Overview  11 addressing mental health, another significant disparity area for AAs and NHPIs. . . . Few CHW studies addressed modifiable risk factors such as obesity, physical activity, or nutrition, or systems level issues such as access to care. (p. 19)

This literature analysis is the first systematic review of CHW initiatives in AA and NHPI communities to highligh areas of knowledge and gaps that must be addressed in future efforts involving health workers. Latinxs, for example, are more likely to be diagnosed with advanced-​stage cancer, and because it is the leading cause of death when compared to non-​ Latinx counterparts, it calls for concerted early diagnosis efforts (Yanez et al., 2016). CHWs can be in a position to reinforce positive health beliefs and behaviors that are culturally based (Rios-​Ellis et  al., 2014). There is no disputing that these health workers have a long association with Latinxs, and why the concept of promotores de salud, a Spanish title, is in the title of this book, and why it enjoys nationwide popularity within this community (De Jesus et al., 2014; Kieffer et al, 2013; Prezio et al., 2013; Segura-​Pérez, Balcazar, & Morel, 2011). Landers et al. (2014) and Slover (2011) point out why CHWs are a tour de force in the health field and how their power and influence can be enhanced with the garnering of social and political support: CHWs represent the intersection between risk and resilience, between institution and community, and between research and practice. Depending on the support for and capacity of CHWs, these lines can become blurred. The move to professionalize the role of CHWs is ongoing and poses questions regarding the underlying theory, methods, and measurement for understanding how CHWs impact health. The meaning and purpose of CHWs varies depending on their training and the complexity of the health issue. However, the overarching goal of improving the health of the community (in the broadest sense of that word) remains the same. (p. 2198)

Broadening the concept of health taps into the potential of CHWs going beyond conventional boundaries typically associated with this construct to meet the health needs of their communities in a culturally affirming manner.

12 Context

What Constitutes a Profession? Readers may initially react to the question of what constitutes a profession and wonder why to bother with this question. Why do so in the introductory chapter? This potential reaction is understandable, but we must plow through and address this question because, when answered, it has profound implications for CHWs, policymakers, and academics. Are CHWs professionals? Answering this question comprehensively requires a multidisciplinary perspective and multiple book volumes to do justice to the topic. However, this section only highlights several key considerations. It is widely accepted that professions must have legitimacy to generate consumer trust (Vargas, 2016). Generally, this legitimacy originates from expertise (academic degrees and professional credentials) and institutional legitimacy (organizations employing them and accrediting bodies). These legitimacies may not have the same power as other forms of legitimacy, such as ethical or consumer legitimacy (Rein, 1969). Professionalism is closely associated with entrance into the middle class in the United States (Bledstein, 1976). Pellegrino (1983), almost 25  years ago, addressed the question of profession within the context of allied health, arguing that the Western world has a long tradition of embracing the ideal, and idea, of professions and the importance of placing the greater good over self-​interest in guiding actions. Klass (1961), well over 50 years ago, argued that a profession is closely tied to ideas and ideals with origins in higher education, and the scholarship that emanates from that institution and aims at achieving excellence. Achieving professional status also serves a gatekeeping function—​ keeping people in and out. Namely, this status brings rules, regulations, standards, credentialing, and responsibilities that can effectively restrict practice but with the benefit of instrumental and expressive rewards. As discussed in greater depth in Chapter  6, achieving a professional status brings with it credentialing of individuals as professionals but also the accreditation of professional bodies to bestow this status (Redelsheimer, Boldenow, & Marshall, 2015). Casting CHW as a profession has immediate and long-​term implications, including influencing our narratives and the topics that get scholarly attention regarding this field. CHWs fulfill many duties in a variety of settings, meaning that their deployment is only limited by our imagination, allowing them to respond to

Overview  13

local needs and circumstances in a fast and expedient manner. They can be hired into this position, or other positions, and be deployed as CHWs without the benefit of the title; they can be volunteers and fall within the realm of peers, complicating the designation of “profession.” The amorphous role of CHW is its strength, because it brings flexibility to health care while being a weakness because it cannot be all things to all people. I prefer to cast them as amorphous because it fits best with my vision of social work practice, whereby no two days are alike. Is CHW a profession or a “quasi-​profession”? The question of health work as a profession will be addressed in various sections of this book because of its importance today and in the future. For those who are strong advocates, there are clear advantages and disadvantages for making it a profession. For those with strong feelings against making it a profession, there are clear advantages and disadvantages, too. The forces having them acquire a professional status are quite strong, with the next decade promising to witness major advances. When health work is contextualized within a community, as in the case of sub-​Saharan Africa, there may be a two-​tiered system of CHWs, one formalized through paid employment, and the other informal volunteers that can coexist, with the latter going unrecognized and therefore unsupported (Leon et al., 2015). Volunteering potentially brings immense instrumental (concrete) and expressive (psychological) benefits. These helpers can be found in nontraditional settings and as next door neighbors, illustrating a parallel health care system that often is invisible. I undertook a community needs assessment in a large Latinx community in New England, and one of the primary goals was to assess help-​ seeking patterns. We fully expected the “usual” suspects to appear in the help-​seeking process. We found, instead, that six nonorganizationally affiliated individuals kept reappearing in the responses. We decided to seek them out and find out why they played such an important community role. Surprisingly, upon locating and interviewing them, all were former CHWs. This finding resulted in efforts to support them through consultation and other forms of support, expanding our system of care. This group of CHWs falls into yet another category—​those who were formerly CHWs but stopped and now continue in an unofficial capacity. Thus, they may “technically” fall into a volunteer position but are not new to this position based upon prior education, training, and experience. This example is purposefully provided to illustrate the fluidity of those who

14 Context

occupy the position of health workers and the challenge of classifying or standardizing who is a “community health worker.” Professional socialization embraces basic assumptions of illness and care. In the case of Latinx caregivers with children with chronic health conditions, this potentially clashes with their cultural beliefs, necessitating their belief systems be taken into account and integrated into health care strategies (Desai, Rivera, & Backes, 2016): Health care providers also are socialized into the culture of their profession (e.g., doctors, nurse practitioners, and nurses) and have their own set of beliefs, practices, norms, rituals, likes, dislikes, and myths; they adhere generally to the modern allopathic system of health care delivery, and with few exceptions, they fail to recognize or use any sources of treatment or medication other than those considered useful by scientific methods. . . . When these health care providers encounter Latino families who may have different beliefs regarding their child’s health and illness, unless the providers are culturally competent and try to understand the complex intersections of cultural factors related to Hispanic folk illnesses and the U.S.  biomedical belief systems, it is likely that a barrier of misunderstanding might arise between the two, leading to a communication breakdown, and generally the consumer is disadvantaged. (p. 107)

CHWs are very effective in increasing adherence to medication among people of color, as in the case of antipsychotic medications, by taking into account belief systems (Allen, Sugarman, & Wennerstrom, 2017). They are in an excellent position to address and bridge these beliefs because of their own backgrounds—​in this case, as Latinxs. Cultural beliefs combine with structural factors, limiting access to quality health care.

Peer Leaders/​Community Health Workers The concept of peer leader, or peer-​led intervention, has entered into the literature and captured the imagination, importance, and influence of sharing similar ethnic/​racial backgrounds and experiences as the consumers. Peer support is widely considered to be a positive factor in reaching those most disengaged from, and in greatest need for, health care (Sokol & Fisher, 2016; Zhang et al., 2016).

Overview  15

Peer-​led interventions, within correctional settings, cover a wide range of types, and these efforts can be categorized under a broad category of “peer interventions.” Woodall et al. (2015) define this category: “ ‘Peer intervention’ is used . . . as an umbrella term to cover a myriad of approaches, ranging from peer education, mentoring, peer support, peer counselling, peer training. Whilst each approach may have individual nuances, the premise is the same—​programmes delivered by prisoners for prisoners” (p. 87). This definition can be challenging because its boundaries can be porous and open to interpretation, making any effort at quantifying the process at determining these resources different and generalizations difficult. Gopalan et al. (2017), in an extensive literature review of peers in services to youth with emotional and behavioral challenges, provide a summary definition of peer-​led services that captures the parameters, purpose, and benefits of using this model of service, with implications for peer-​led services for all groups: By virtue of their lived experience, YPs are often perceived as more credible and understanding of youth concerns compared to adult providers . . . and may help alleviate the chronic difficulties of engaging youth in mental health treatment  .  .  .  YPs are also important resources for young adults (age 18–​25) who continue to manifest many of the developmental features of adolescence (e.g., identity exploration, increased risk-​taking . . . ), yet also struggle when learning to live independently. . . . YP’s are important resources who can help young adults navigate through the disconnected child and adult systems in order to facilitate a successful transition to adulthood. (p. 88)

Peers bring unique lived experiences that cannot be learned in a classroom and turn these lived experiences into assets by reaching and engaging those facing similar life histories and circumstances (Delgado & Zhou, 2008). Youth can be part of teams consisting of members covering a wide age span, allowing for flexibility in responding to age-​specific health needs (Aziato et al., 2017). Defining what is meant by “peer leaders” does pose significant challenges for those in this category. Older, formerly incarcerated individuals who have been successful in making the community re-​entry process, for example, are in a position to help the younger counterpart do the same, and enlisting their support provides them with an opportunity to give back to the community

16 Context

(Inderbitzin, Walraven, & Anderson, 2016). The cases in Chapter  8 illustrate their potential contributions. It is important to examine the role of labels, role differentiation, and task sharing, to understand the nature, extent, and evolution of their position (Kemp & Henderson, 2012). Einstein (2012) takes a very unique perspective on the labels used to capture a workforce segment of the substance use and misuse field, raising concerns about the use of a peer label:  “ ‘Peer worker/​health counselor’ also known as an active drug user who is engaged in intervention activities (i.e., dissemination of information and selected harm reduction materials facilitating treatment compliance, serving as ‘injection doctors,’ etc.), with active drug users or other targeted populations, for a range of (primary, secondary, and not-​too-​often tertiary) prevention goals is, at best, a misleading categorization” (p. 573). These roles are far from conventional, calling for a shift in paradigms. Repper et  al. (2013) provide a succinct and effective definition of peer support: “Peer support is offering and receiving help, based on shared understanding, respect and mutual empowerment between people in similar situations” (p. 1). Peers in the field of substance abuse take on a different meaning from that of other fields. Differentiating between staff who previously were homeless or incarcerated from those who are currently unauthorized or not in recovery captures a different set of lived experiences (past versus current). Youth CHWs capture yet another dimension when they eventually age-​out and enter adulthood, limiting their potential direct contributions to a limited number of years. HIV prison peer women programs have been particularly helpful in developing peer attachments, generating relationship experiences that can transfer over to life in the community upon their return (Collica-​Cox, 2016):  “When female prisoners lack strong prosocial attachments to both individuals and institutions prior to incarceration, little prevents them from recidivating. Although this is not always the case, bonds established before incarceration can weaken during a prisoner’s time away, and the longer one is incarcerated, the more likely these bonds will further deteriorate. . . . If social bonds are cultivated before a prisoner’s release, she has a greater chance of maintaining a crime-​free lifestyle” (p. 1). Peer-​based programs promoting health in correctional settings have also been used in the United Kingdom to benefit helpers and beneficiaries of the engagement (Mehay & Meek, 2016). Peer support and mentoring are not restricted to a small slice of a community. In principle, it is a concept that

Overview  17

has universal appeal. It has also found saliency for those who have histories of incarceration (Marlow et al., 2015). CHWs bring legitimacy (experiential and consumer) to work with those who are incarcerated or formerly incarcerated. Peer education involving older adults has also been found to help address internalized stigma associated with depression (Lucksted & Drapalski, 2015). Those with criminal justice experiences offer the field of health services the potential to address new health conditions. The expansiveness of the peer-​led field is ever increasing, covering numerous areas, such as fall prevention (Birgit Wurzer et al., 2015), diabetes (Park et al., 2015), HIV (Brashers et al., 2017), cardiovascular disease (Witt et al., 2016), and veterans (Bauer et al., 2016), for example. This expansiveness has made it difficult to fully grasp the parameters of this field, just like the challenges of grasping the parameters of an expanding universe. It is, after all, an expanding universe, with all of the rewards and challenges associated with rapid expansion. Peer-​led intervention has been differentiated from CHWs, in this case focused on Latinxs with diabetes, and has been found to be effective (Tang et  al., 2014). In this instance, peers were volunteers and paid a modest stipend, and CHWs were paid staff. Although both groups can share experiences and ethnic and racial backgrounds, one is a professional, and the other is a volunteer. Not unexpectedly, there is no consensus definition of peers and recovery coaches (Bassuk et  al., 2016). Thus, it can be confusing when discussion focuses on peers versus CHWs. Peer volunteers can be CHWs, and peers employed in a staff capacity, too, can be CHWs (Thom et al., 2013). CHWs cover a broad territory. The importance of peer support is a key element in using indigenous CHWs, and it also has been identified as a powerful mechanism for changing behavior that can lead to poor health outcomes among the marginalized, stigmatized, and those in greatest need (Alamo et al., 2012; Daaleman & Fisher, 2015; Fisher et  al., 2012; Garcia, 2013; Mayer et  al., 2016; Primero, 2015; Walker & Bryant, 2013). It is no mistake that a peer approach taps into values, such as collectivism and cooperation, which are often found among groups such as first-​generation Latinxs, increasing the viability of a family, collective, or group approach (Delgado, 2018; Shepherd-​Banigan et  al., 2014). CHWs undertaking family-​focused interventions, such as those targeting Latinxs,

18 Context

have been successful because of how they value and incorporate familismo (stressing the importance of family first and foremost) into these encounters (Cruz-​Saco & López-​Anuarbe, 2017).

Historical Origins of Community Health Workers Tracing the historical origins of any concept is never easy and always fraught with sociopolitical pitfalls. The quote by Napoleon Bonaparte that “History is the set of lies agreed upon” sums up the challenges of putting a historical context on any phenomenon. Tracing the origins of CHWs, unfortunately, is no exception. However, a fundamental question needs to be asked: Why devote attention to tracing its origins? In other words, who cares? Developing an understanding and appreciation of their history helps us comprehend the social and economic forces that led to their creation and maintained this movement to the present. Each country brings its own unique sociocultural perspective to this history, yet there is a sharing of paths that cannot be ignored, even when addressing different health concerns because this movement is universal (Schneider, Hlophe, & van Rensburg, 2008; Standing & Chowdhury, 2008). Tracing the origins of CHWs is much more than an academic exercise because the origins of this concept of health care delivery say so much about how it has evolved and why. There is no clear consensus on the history of these CHWs. Some scholars, for instance, have traced their origins to the 1950s and 1960s nationally, and even further back internationally (Bate-​Ambrus,  2014). Sanders and Stover (2011) trace CHWs back to the birth of the public health profession in the United States. Kangovi, Grande, and Trinh-​Shevrin (2015), in turn, traced the history of CHWs back to Russia and the 1800s, and its eventual evolution during the 1920s with the eventual initiation of China’s “barefoot-​doctor” program and that country’s efforts to reach out to its rural population during the mid-​to late 1960s (Zhang & Unschuld, 2008). The 1960s also witnessed the barefoot-​doctor/​CHWs gaining greater acceptance as a means of countering spiraling health care costs in the United States and other countries, although there was a waning in their popularity during the 1980s (Perry, Zulliger, & Rogers, 2014). Rosenthal (2009) provides a very detailed historical chronology of CHWs in the United States, going back to the late 1950s and early 1960s,

Overview  19

with organized efforts within Native American and migrant farmer communities, two highly marginalized groups. However, regardless of whether CHWs have a 65-​or 215-​year history, for our purposes, it is sufficient to say that they have a long and distinguished history, and their evolution and contributions to the health field stand as testaments to their importance (Rosenthal & Brownstein, 2016). The 1978 World Health Organization’s Alma Ata Declaration recognized the importance and need of community health advisors in the delivery of primary health care to community members (Koskan et  al., 2013). The Alma-​Ata declaration on primary health care (PHC) represented a major stage in the history of CHWs when it called for a paradigm shift in how best to address the world’s major health issues, representing a change from an almost exclusive focus on hospital-​based and physician-​centered approaches to a participatory approach. This declaration called for a community-​centered and actively engaged approach, with CHWs assuming a more prominent position within health care systems that traditionally favored the more formal highly educated (Pérez & Martinez, 2008; Ruano et al., 2012). The values and principles articulated at the Alma Ata Conference almost 30 years ago are still relevant today (Tulenko et al., 2013). Some advocates trace the origins to this declaration. Bovbjerg et  al. (2013a,b), for instance, traces the origins of CHWs in the United States to the 1960s and the employment of “neighborhood health aides.” The evolution of CHWs waxed and waned during this 50-​year period (Perry, Zulliger, & Rogers, 2014). This long history stands as a testament to their value and ability to evolve and respond to ecological forces during changing social and political times to maintain their relevance and viability. The following quote sums up why this book should be welcomed by the field and help fulfill its destiny (Kangovi, Grande, & Trinh-​Shevrin, 2015): “The current policy environment has created a historic opportunity to improve health care delivery in the United States through the effective use of CHWs. It will take hard work at the implementation level to maximize the likelihood of success” (p. 2270). Implementation of social policies has a rich and long history of study, with CHW policy and programming not an exception. This brief historical overview highlights the difficulty in arriving at a consensus origin of this workforce or movement. Although the origins of CHWs are subject to debate, their history and evolution are the result of an

20 Context

institutional response to a social justice ecological community crisis with profound health consequences for some of society’s more marginalized groups.

Health Inequity This nation has numerous challenges in fulfilling its goal of ensuring that everyone has an equal opportunity to succeed (Gilbert et al., 2016; Henry-​ Sanchez & Geronimus, 2013; Kutcher et al., 2015). Health inequities have decreased between 2010 and 2016 for a number of groups (US Department of Health and Human Services, 2017). Most have not changed for people of color, highlighting the need for innovative models. The American Academy of Social Work and Social Welfare summarized this country’s health crisis (Walters et al., 2016): Although the United States is among the wealthiest nations in the world and spends far more per person on health care than any other industrialized nation, its health is rapidly deteriorating. Over the past three decades, the U.S.  population has been dying at younger ages than those of the populations in peer nations and has endured a pervasive pattern of poorer health throughout the life course, from birth to old age. . . . The United States now ranks 27th out of 34 industrialized nations in terms of life expectancy. Moreover, population health diminishes along a social gradient: Populations that experience high rates of social, racial, and economic exclusion bear the greatest burden of poor health and premature mortality. These experiences lead to the current high rates of racial and ethnic health disparities within the United States. (p. 4)

The interrelationship between health and social context is universally recognized and cannot be ignored in increasing the health of the most marginalized. Health is contingent upon equal opportunity, bringing an important social-​ecological dimension (Chin et al., 2012). Balcazar et al. (2011) comment on this condition: We recognize that, for many years, health care in the United States has not been considered a fundamental human right and, instead, has been

Overview  21 guided by a set of economic principles in a market economy where health care is considered a commodity whose consumption is guided by complex elements of demand and supply. In such a market economy, not everyone wins, which is evident for many vulnerable populations, including those left outside the health care system, often called the “hard to reach.” (pp. 2199–​2200)

The absence of health is one area that is glaring, and so is a lack of equal access to quality care among those with low income and low wealth standing out in importance (Braveman & Gottlieb, 2014; Noonan, Velasco-​ Mondragon, & Wagner, 2016; Sanchez et al., 2015). Living and working in certain urban environmental conditions increase the likelihood of acquiring illnesses and diseases, and when acquired, they can be compounded by lack of access to quality care (Corburn, 2005; Earnshaw et  al., 2016; Hatton, 2016). Latinxs, for example, are at increased risk for asthma because of environmental circumstances, and they are more likely to suffer greater consequences. Puerto Rican children are three times more likely to report having asthma when compared to White, non-​L atinx children. Latinx children have more severe consequences resulting from asthma, with a 40% greater chance of dying when compared to their White, non-​L atinx counterparts (Office of Minority Health, 2016). The importance of committed community partners has been recognized as instrumental in achieving success in CHW initiatives, in this case asthma in a Latinx community (Peretz et al., 2012). They help increase adherence to asthma guidelines (Cloutier, 2016). Health care access is rarely due to one factor and is the interplay of various factors, including those that would be considered social-​ cultural in origin (Ring, Nyquist, & Mitchell, 2016; Shishehgar et  al., 2017). One conceptualization has lack of access as consisting of four separate, yet interrelated, dimensions:  (1) geographical and physical; (2)  psychological; (3)  cultural; and (4)  operational and financial (Delgado, 2018). Each dimension, as addressed in Chapter  4, wields considerable influence in shaping service access and, in combination, poses significant organizational obstacles to reaching groups and communities with the greatest need for health and other services. Unequal access has prompted the search for innovative models that can reach these communities in a culturally affirming and cost-​effective manner

22 Context

(Frieden, 2014). Promotores, for example, have reduced unnecessary emergency room visits, thereby reducing health care costs (Enard & Ganelin, 2013). Use of health promoters who share an understanding of the community and possess the requisite competencies to engage and serve in a culturally competent/​humble way has been advanced as a strong rationale for their viability and cost-​effectiveness (Brown III et al., 2012; Chang, Simon, & Dong, 2012; Gaziano, 2015; Moffett, Kaufman, & Bazemore, 2018; Sabo, 2015). Telleen et  al. (2012) draw attention to Latina mothers’ beliefs on early preventive dental care and, if positive, increase the chances of continuing care, calling attention to the importance of culturally competent initiatives on oral health promotion. One example is the promoter-​led “Contra Carias,” an initiative that tapped important cultural values but also emphasized the importance of character traits (Hoeft et  al., 2015):  “Participants wanted promotoras who have ‘a good character and that you feel enough trust to express your point of view.’ Participants preferred classes be taught in Spanish by women, particularly mothers who have experience raising and caring for children” (p. 1). “Good character” is a proxy for a host of Latinx social-​ cultural values and factors. A  preference for experiential expertise, in addition to educational expertise, is also a characteristic often mentioned in the field. CHWs are in a propitious position to assist Latinxs in diabetes management (Kane et al., 2016; Wagner et al., 2015; West, 2013), prevention and management of hypertension (Ferdinand et  al., 2012), diabetes awareness and prevention (Bonilla & Grant, 2015; Cruz et  al., 2013; Garcia & Grant, 2015), increasing awareness of Alzheimer’s disease (Carrillo, 2014), increasing access to diagnosis and treatment of children with autism spectrum disorders (Magaña et al., 2013), occupational safety (Juárez-​Carrillo, 2014; Liebman, 2013; Liebman et  al., 2014), health food consumption (McDonough, 2013), oral health (Steen, 2014), and other illnesses and diseases. The prominent role that agriculture plays in the occupational arena for Latinxs exposes them to the potential harm of pesticides, calling for promotora-​led initiatives for field workers and their families (Trejo et  al., 2013). This industry stands alongside mining and construction as one of the most hazardous occupations in the United States, and Latinxs often find themselves disproportionately in two of these fields, with mining being the exception (Rauscher & Myers, 2016).

Overview  23

The barriers to cultural competentence/​humility identified in this section promise to continue to grow in significance in the immediate future, bringing a set of new challenges for CHWs, the organizations that employ them, and those that fund them (Jackson & Garcia, 2014). Culturally competent/​humility practice is not possible without attention to the forces of acculturation and racism/​discrimination. CHWs have an instrumental role to play in addressing health inequities (Cosgrove et  al., 2014). Their natural abilities, which can be enhanced, make them excellent researchers, too, bringing added value to health care teams, as discussed later in this book (Hohl et al., 2016; Krok-​Schoen et al., 2016; Pérez & Martinez, 2008).

An Expanding Universe for Community Health Care Worker Coverage What better way can indigenous resources be tapped in creating health-​ focused social interventions that are fearless in seeking social change in the process of meeting current or future health needs? The answer enhances a variety of aspects related to human, social, and cultural capital development nationally and internationally, including the direction of current and future CHW initiatives (Sabo et al., 2017). First, it provides a vehicle for residents to enter a career path with potential for advancement. Second, it enhances community health, an important aspect of human capital. Third, it breaks down significant barriers between community and health care systems. I am at loss at arriving at a better alternative when viewed from a community-​centered and capacity enhancement perspective, and one needing to address multiple social, political, and economic consequences associated with intersectionality. CHWs enjoy consumer legitimacy because they often represent the same profile as those they help, minimizing differences resulting from key socioeconomic backgrounds. In many instances, CHWs live in communities where they work, further minimizing cultural and geographical distances often associated with providers working and living in different communities (Green et al., 2012). Much more needs to be learned about those who volunteer to be CHWs and how they are retained in very demanding and extremely difficult-​to-​fill positions (Maes & Kalofonos, 2013). There seems to be no area, arena, or group where CHWs have not been used, illustrating their wide appeal and potential. The scholarly literature

24 Context

has addressed their use and does a wonderful job of showing the impact of their range: amyotrophic lateral sclerosis (Pinho & Gonçalves, 2016), sleep education (DelRosso et al., 2016), heavy drinking (Moore et al., 2016), depression and chronic care (Bloomstine, 2016; Ell et al., 2016), psychiatric rehabilitation (Cook & Mueser, 2015), breast examination (White & Camper, 2016), colon cancer screening (Arsenault, John, & O’Brien, 2016), nutrition (Creed‐Kanashiro et  al., 2016), Ebola (Koch, 2016a,b; Perry et  al., 2016), identifying child abuse and neglect (Sahebihagh et  al., 2017), cancer prevention and cardiovascular risk reduction (Kim et  al., 2016), family planning (Braun, et  al., 2016), gambling (Mundy-​McPherson, 2016), intimate partner violence (Serrata, Hernandez-​ Martinez, & Macias, 2016), prevention of readmission from heart failure (Panjrath et  al., 2016), natural disaster management and services (Gilmore et  al., 2016; Jackson et  al., 2017), oral decay prevention (Telleen et  al., 2012), serious mental illness (Corrigan et  al., 2017), smoking cessation (Alaszewski, 2016), improving palliative care outcomes (Fischer et  al., 2015), maternal and infant care (Floyd & Brunk, 2016; Moimaz et  al., 2017), perinatal depression (Atif et  al., 2016), sickle cell awareness and treatment (Hsu et al., 2016), eye care (Mafwiri et al., 2016), hearing loss (Jacob, 2016), and promotion of drinking water at home (Barrett et al., 2016), for instance.

Readers can appreciate the expansiveness of CHWs’ reach across national boundaries and health areas, and population groups, as well as the potential for innovative programs reaching hard-​to-​engage groups (Barnett et al., 2016; le Roux et al., 2013). Lopez (2014, p.  1), for instance, highlights the critical role that CHWs play in the lives of those who are “dual eligible” (Medicare and Medicaid): “Individuals dually eligible for Medicare and Medicaid, known as ‘dual eligibles,’ represent one of the most vulnerable populations under the purview of America’s public insurance programs. Characterized by advanced age and functional limitations, dual eligibles present complex health care needs that have historically been mismanaged by the separate Medicare and Medicaid entities” (p. 1). They face a host of health conditions that are exacerbated by an aging process compromised over an extended period of time.

Overview  25

Latinx older adults are a group that are ideally suited to be engaged by promotores de salud who can communicate in Spanish and understand and value their cultural values and beliefs. Asian older adults, too, are receptive to engagement by CHWs (Blair, 2012). In the case of Latinx older adults, they are a subgroup that will continue increasing in representation in the immediate and distant future, and they are a vital segment of the nation’s graying trend (National Hispanic Council on Aging, 2012, 2015).

Evolution of Innovative Interventions CHWs have tackled numerous health conditions under the most difficult of circumstances in all regions of the world. In the United States, for instance, they have also been effective in reducing cardiovascular disease in a high-​risk Latinx border population (Balcázar et al., 2010), supporting infant nutrition and breastfeeding among Latinas (Rios-​Ellis et al., 2015), intimate partner violence (Moya et al., 2016), and chronic disease management (Mayer et al., 2016). Perez et al. (2015) report on the effective use of photovoice by promotoras (Amigas Latinas Motivando el Alma) as a tool in working with Latina immigrants to identify significant issues and concerns, as well as providing approaches for action through collaborative partnerships. The topic of genomic literacy, one that most practitioners either never discuss, or if they do, it is in passing, has been applied to the work of CHWs with Latinxs helping display misinformation on this subject (Allen et al., 2015). Lykes and Scheib (2016), based upon their experience in conducting visually informed research on African American and Latina health promotion in post-​Katrina New Orleans, advocate using this methodology to obtain insights into the health of groups for which we have limited understanding. Visual ethnography introduces a worldview that is arduous to capture using conventional means, and it does so by encouraging participatory democratic principles that also empower. Houses of worship in marginalized urban communities bring strategic advantages to health promotion efforts, with religious leaders potentially playing instrumental roles (Abara et  al., 2015; Ahn, 2013; Banerjee et  al., 2015; Iheanacho et al., 2016; Sutton & Parks, 2013; Webb, Bopp, & Fallon, 2011). Houses of worship, for instance, are attractive settings for provision of mental health services to Latinxs, bringing potential benefits of reducing

26 Context

health inequities while strengthening community-​ based institutions (Villatoro, Dixon, & Mays, 2016). These institutions are often geographically centered within areas of high concentrations of people of color, with religious leaders being strategically situated to promote the health of congregations that have deep religious beliefs, and hold these leaders in a special position, as in the case of Nigeria’s Islamic religious leaders project (Maiwada et al., 2016) and a project in a Latinx church (Galiatsatos & Hale, 2016). These institutions represent effective vehicles for reducing the impact of barriers addressed in Chapter 4. Expanding who can undertake health promotion opens up the field for innovative and participatory initiatives, allowing organizations to quickly respond to new, and emerging, communities of newcomers, for instance. The concept of indigenous CHW can also be applied to residents and parents, introducing new dimensions that have not been explored and epitomize an empowerment value (Bastien et  al., 2016; Bellissimo-​Rodrigues et  al., 2016; Bustillos & Sharkey, 2015; Stacciarini et  al., 2012; Trinh & Le, 2016). CHWs can be conceptualized as catalysts and role models by empowering communities with increased knowledge and support (Rachlis et al., 2016). Recognition of the importance of self-​care has provided a conceptual lens for understanding why, and how, parents are fulfilling an increasingly enhanced role in health promotion efforts (Wight & Fullerton, 2013). This development opened the door for social scientists to study this phenomenon, furthering the conceptual base for innovative strategies and programs (Pelicand et al., 2015): The concept of self-​care seems to be a promising alternative to self-​ management, to guide patient education interventions in the field of paediatric diabetes. In the broader perspective of health promotion and general well-​being, as opposed to narrow disease management and prevention, the concept of self-​care was defined by  .  .  .  integrating three dimensions:  psychosocial life, general health and responses to illness demands. More precisely, self-​care represents “the range of behaviours undertaken by individuals to promote and restore their health” with a psychosocial dimension that is as important as the strictly medical dimension, to promote one’s health. (p. 306)

Overview  27

Self-​care is familiar to most in the health and social services fields, bringing flexibility in taking into account cultural views, and manifestations of health, making it relevant within communities that do not share dominant conceptions of health and health seeking. Although promotores de salud can be of either gender or involve a range of ages, there is no disputing that based upon the existing literature, they are disproportionately female, and adults of a certain or limited age range, and generally exclude youth and older adults (Abimbola et  al., 2012; Alam, Tasneem, & Oliveras, 2012; Lewycka et al., 2013; Maes, 2016; Sarin & Lunsford, 2017; Soofi et al., 2017). Men, too, can assume this role when enlisted and supported, while acknowledging their immense potential for reaching their peers (Villa Torres, 2013; Villa-​Torres, Fleming, & Barrington, 2015). Programs with male promotores place them in an enhanced position to relate to other Latino males, possibly tapping machismo themes in crafting an intervention (Documet et  al., 2016; Fleming, 2013). Male CHWs have not received the attention they deserve, including their roles within reproductive, maternal, newborn, and child health services (Elazan et al., 2016). Greater involvement of males, as in the case of maternal health to improve maternal and newborn health outcomes, necessitates use of models that are gender sensitive (August et  al., 2016; Furman et  al., 2016; Vermeulen et al., 2016). Gender is a key social variable in outreach to specific Latinx and other groups (Larsen et al., 2015; Maneesha, Abraham, & Prasad, 2014; Pederson, 2016). Matching groups on country of origin, and level of acculturation, minimizes distrust, making it easier to establish relationships based on confianza (confidence), for instance. Broadening the possibilities of other groups becoming CHWs expands the possibility of innovative health initiatives for those who have gone unnoticed. Research approaches, too, have embraced peers as a strategy and instrumental means of enhancing researcher abilities to minimize potential cultural and linguistic barriers (Anders, Balcazar, & Paez, 2006; Cupertino et  al., 2013; Sprague-​Martinez et  al., 2017). Peer involvement and even peer-​led help ensure that research results can be more effectively translated into meaningful initiatives with high likelihoods of being successfully implemented in a community-​focused and culturally affirming manner (Delgado, 2009; Delgado & Zhou, 2008; Garcia-​Huidobro et al., 2016).

28 Context

Values and Principles Guiding Community Health Workers CHWs are guided by a set of values and principles, which may be implicit or explicit, warranting closer attention due to the tremendous influence they wield in how this role is conceptualized and implemented in the scholarly literature and practice. Eight values stand out, serving as a foundation from which to shape key program principles and effectively bridge values and theory: 1 . Enhance the importance of social relationships or social capital. 2. Acculturation must be taken into account in the planning of services, but within a context that acknowledges discrimination and racism in the lives of consumers. 3. Health and social needs must be understood within the local context. 4. Services must seek to be integrated into the social and cultural fabric of the community. 5. Assets and strengths should be first at all times (political, cultural, human, economic, social, physical and intangible). 6. Fostering positive ethnic identity must be embraced. 7. Bilingual/​bicultural staff are best situated to provide culturally competent/​humility-​based community health services. 8. Social justice, as manifested through advocacy and social change efforts, must play a prominent role in guiding service delivery models. Readers can discern an explicit sociopolitical (critical) stance that embraces empowerment, social justice, advocacy, social change, and culture-​ specific perspective on how indigenous health promoter roles must evolve for this approach to maximize their potential reach among the marginalized and those in greatest need (Cohen & Marshall, 2016; Jarvis et al., 2016; Kutcher et al., 2015; Reinschmidt et al., 2015; Schachter et al., 2014). It is critical this stance be understood and open for debate for the field’s advancement to maximize resources and potential benefits to marginalized communities (London et al., 2018; Lynch, 2013; Wiggins et al., 2009). This type of discourse helps ensure that the ultimate outcome is relevant to the lived experience. Introducing a social change dimension to CHW roles

Overview  29

brings an important, and highly charged, dimension to the role (Wiggins et al., 2013). CHWs, too, can assume leadership roles within their communities, and this role can be enhanced when understood and supported through appropriate training, supervision, and consultation (Ingram et al., 2016). This aspect has not received the attention it deserves in the scholarly literature, even though its importance cannot be underestimated when discussing underrepresented groups. There is a call for practical approaches toward implementing CHW programs, but they are firmly based upon requisite preparation and support. The National Council of La Raza, for instance, developed a toolkit for increasing the skill set of CHWs in advocating for policy changes and the funding of community peer-​support interventions (McDonough & Hernández, 2015). Spencer (2016) discusses the unintended consequences of empowerment, which may be accompanied by ethical issues and manifested in non-​ health-​promoting behavioral outcomes. Empowerment is not a universal concept, and it can appear in many different ways according to ethnic/​racial backgrounds and other demographic factors, such as age. Youth empowerment often differs from their adult counterparts, and this applies to those of color, too, bringing a highly contextualized and intersectionalized perspective to this important construct. Although the literature has proliferated on the importance and use of promotores, it has neglected detailing the process used in recruiting, training, and supporting them once hired (Allen et  al., 2015; Johanson, 2016; Kim et  al., 2016; Suarez et  al., 2012). This glaring absence will be addressed in this book and include identifying challenges they face in carrying out their work in the field. One of those challenges is serving as advocates, which can put them in a politically precarious position within their organizations. Extraordinary work necessitates extraordinary support, and this declarative statement certainly applies in this book. CHW training needs are closely related to how their roles are conceptualized and comprehensively supported by the organizations employing them and those who fund those programs: Well-​articulated training needs and CHW roles can help improve the relationship and understanding of non-​CHWs in the care team and give

30 Context non-​CHW team members an understanding of how to support and work with CHWs.  .  .  . Training, both in the beginning and throughout the lifespan of the CHWs time at an organization, helps to further CHWs’ competency and allows CHWs to feel supported in providing services while also ensuring fidelity of evidence-​based service delivery. Without well-​defined roles and clearly articulated training needs, the workforce may not be meeting the needs of its clients and may not have a recognized role and skillset in the healthcare delivery system. (p. 4)

A quest for more defined roles can be challenging when culture and local factors shape how roles unfold and training needs are met (Kok et al., 2015; Sosa, Biediger-​Friedman, & Yin, 2013). Promotores’ demographic profiles share similarities with those they help, and this is an advantage that they bring to health promotion and how these similarities foster development of trust and effective working relationships (Ackatia-​Armah et  al., 2016; Allen et  al., 2015; Segura-​Perez, Balcazar, & Morel, 2011). These similarities bring inherent tensions and challenges that must be acknowledged and addressed if this health promotion strategy is to achieve its goals of reaching those in greatest need, and not do a disservice to CHWs in the process. Role identity theory has been put forth as a way of understanding why they have volunteered to assume a formalized helper role, but one that has an extensive history prior to this formalization, and how organizations can support them in carrying out unique roles within health care systems (Mlotshwa et al., 2015). When disaster strikes their community, CHWs can assume and broaden their provider roles (Gilmore et al., 2016; Johnson & Boodram, 2017; Nicholls et al., 2015). They are in need of assistance, yet they are called to assist at a distressing time in their lives (Powell, 2015). CHWs can also be targets of violence, compromising their personal safety, and even their lives (Aiga & Pariyo, 2013). This distressing situation highlights how they are always on the job, regardless of how local circumstances place them in a vulnerable position. Although violence directed at CHWs must be guarded against, women take on an even greater vulnerable position, particularly in societies or communities where men are in a dominant position culturally and socially. Although health promoters are an international phenomenon, this book will select a number of case illustrations from throughout the country to

Overview  31

highlight various models or approaches used in deploying promotores to address “high-​risk” population groups, issues, and community-​based settings. This book will also address key benefits and challenges (conceptual, implementation, ethical, and research) faced in engaging CHWs as an urban strategy addressing health disparities within urban communities of color (Barnett et al., 2018). This is not to say that people of color and other groups in suburban and rural sections of the country do not face challenges receiving quality health care because they certainly do, and more so, in the case of those who are also unauthorized, for example (Caldwell et al., 2017; Probst et al., 2018). The concentration of people of color within urban areas, which are often referred to as “ghettos” and “high-​crime areas,” introduces social ecological dynamics that shape their health and help-​seeking behaviors (Okechukwu, Davison, & Emmons, 2014). Every effort has been made to seek case illustrations covering a wide range of health foci and regions of the country, with a particular focus on high-​risk and marginalized groups. In addition, an effort will be made to select examples highlighting innovative ways of using health promoters. Use of photography, or more specifically photovoice (photographs with accompanying narratives), has introduced visual ethnographic innovative health promotion initiatives (Baquero et al., 2014; Delgado, 2015; Einberg et al., 2016; Kingery et al., 2016; Moya et al., 2015). Photography allows participants with varying degrees of English language competencies to record images and share their narratives in groups, using language and symbols familiar to them, and providing CHWs with another “tool” can enhance participation and introduce an element of “fun” in the process. Storytelling often has cultural meaning and a shared language (Haines, Du, & Trevorrow, 2015). Shared histories can be beneficial and even transformative to both CHWs and their consumer (Altobelli, 2017). Use of digital storytelling illustrates how the field has evolved, tapping into deeply held cultural values and customs to advance health promotion, and bringing in new forms of engagement (Brabazon, 2016; Benitez, 2014; Clement, 2014; Cueva et al., 2015; Kutcher et al., 2015; Lal, Donnelly, & Shin, 2015). Social media advances, too, bring exciting potential for innovative CHW programs (Waycott et  al., 2016), with information technology being manifested in a multitude of ways to enhance CHW capacity (Prentiss et al., 2017).

32 Context

A Focus on Community Health Workers and Four Special Population Groups This book focuses on four marginalized population groups—​ the formerly incarcerated, the unauthorized, the formerly homeless, and those in recovery—​ that are hard to reach in urban centers of the country (Chapter 8). They often exist side by side in geographical areas, yet they are generally invisible to the broader community. Focus on these groups affords readers an opportunity to develop a more informed and nuanced understanding of CHWs and why they are so important to engageng effectively in health care. Although this book focuses on four groups, they are not the only groups that could benefit from CHWs addressing their unique needs and social circumstances (Ulibarri et  al., 2015). Sex workers are such an example. There is a prodigious amount of stigma among sex workers, and models must take this into account (Erausquin et al., 2012; Goldenberg et al., 2016; Landers et al., 2014; Scorgie et al., 2013). Ex–​sex workers are in propitious positions to assume CHW roles in reaching out to current sex workers, who are highly vulnerable to contracting, and spreading, sexually transmitted diseases (Kerrigan et al., 2013; Torri, 2014). The identified groups for focus capture a significant community segment with above-​average health needs and challenges, whose needs must be met in an affirming and empowering manner. CHWs have played, or have a potential to carry out, enhanced roles in shaping delivery of health care to these groups. The concept of peer providers has emerged to capture those in positions to help others sharing similar life experiences (Chappell Deckert & Statz-​Hill, 2016). CHWs/​peer providers bring unique and valuable capital to the field. The formerly incarcerated, undocumented, homeless, and/​or in recovery bring unique challenges and rewards for CHWs. CHWs who are former members of these groups minimize miscommunication and facilitate relationship based upon mutual trust (Segura-​Perez, Balcazar, & Morel, 2011). These attributes also bring challenges. The groups selected stand out because of their health needs and the extreme challenges they pose to conventional urban health care systems. Each group will receive in-​depth attention in the hopes of highlighting how they

Overview  33

can be served through CHWs. Writing a book is always a process of discovery, and other special groups and initiatives emerged and were added to illustrate key points (Gill et al., 2013). Readers now have an understanding of how this book will unfold and why it advances the CHW field, with implications for other countries, too. It is appropriate to quote Pittman et al. (2015) on the importance of CHWs having a more central role in community health: Today we face so many challenges providing care to patients with complex illnesses, lowering health care costs, and advancing a population health framework. An innovation such as CHWs in team-​based care, which can help address all three issues, is too valuable to let flounder at the margins. It is time for our health care practice, financing, and training to catch up. It is time to bring CHW practice into the mainstream of U.S. health care. (p. 6)

CHWs are not on the fringes of urban health care. Their role is only destined to continue to grow and influence this nation’s health care system.

Book Goals Seven goals guide this book, with each addressing a different but significant aspect of this field:  (1) provide an updated view of major health issues confronting urban communities of color across the nation; (2)  examine the historical emergence and use of CHWs as a vehicle for reaching marginalized groups; (3) critique the use of CHWs, including their benefits and challenges; (4) ground CHWs within a community capacity enhancement paradigm that taps nontraditional settings as viable for health promotion; (5) focus on four special population groups that will benefit from increased attention (those formerly incarcerated, those who are unauthorized/​undocumented, those in recovery, and those who were formerly homeless); (6)  provide case illustrations to highlight different approaches and health needs that CHWs can address; and (7)  present recommendations for how best to conceptualize, implement, and evaluate this service delivery approach.

34 Context

Conclusion Readers have hopefully developed an understanding of the twists and turns that will follow in this book, including subjects that can be expected in a book on CHWs and other subjects that proved surprising. There are many publications attesting to its importance and the excitement that it has generated. The absence of a book of this scope makes it difficult to turn to one source for a particular perspective on this field. CHWs are a health force to be reckoned with throughout the world. Their emergence as a health corps is not new, but their presence and influence are ever expanding. Their immense popularity and distinguished history do not take away from the challenges they face. How we respond to these challenges shapes their reach of this country’s most marginalized. This chapter outlined how this book will unfold in creating a collective pause to understand the complex nature and evolution of their role and success. How best to recruit, screen, train, support, and compensate CHWs will prove extremely important and equally challenging. The next chapter provides a cultural and intersectional context for understanding marginalized group health status and help-​seeking patterns, with an emphasis on urban people of color.

2 Culture and Health Introduction The embrace of cultural competency or cultural humility necessitates a firm grounding in culture and its impact on health and help-​seeking patterns. The interrelationship of health and culture is undeniable, manifesting itself in perceptions of health, presenting symptoms, and help-​seeking patterns (Good & Hannah, 2015; Napier et al., 2014; Seo, Bae, & Dickerson, 2016; Wong, 2017). Gesler and Kearns (2005) argue that culture, health, and illness are best understood and addressed when place is factored into the analysis, bringing geographers into a field historically dominated by sociologists, anthropologists, psychologists, and helping professions. The social ecology of health grounds “community” into health care delivery, enhancing its significance even further when focused on undervalued groups. Culture is critical to human existence, yet how it can be used to guide health resources is seriously lacking, considering its influence on health research (Singer et al., 2016). Prüll et al. (2016) provide an excellent rationale for having culture play an even greater role in shaping our understanding of health and illness: Health and illness are an intrinsic element of culture, and in an increasingly globalized world, health concerns and approaches to healthcare are inextricably linked with the often radically different cultures of patients, clinicians, and researchers. While modern medical applications have not least contributed to a significant increase in life expectancy, concomitantly new complex problems have arisen from developments such as the use of modern technologies at the beginning and end of life, reproductive medicine, organ transplantation, or the decoding of the human genome and subsequent genomic intervention. Considering that these interventions are being used in a globalized world, the ensuing problems are of lasting intimate concern to members of all the various cultural spheres found around the globe and accordingly call for culturally appropriate ethical

36 Context sensitivity towards the ever-​changing normative and ontological aspects of health and illness. (p. 1)

One can see why culture assumes such a prominent role in discussing community health workers (CHWs) and their efforts to reach underserved communities. This emphasis will only gain in importance in the immediate future. There is increasing scholarly material and practice wisdom on culture, health, and illness, and this bodes well for the future of CHWs and the health field in general, nationally and internationally (Read, 2013; Sobo, 2016). The interjection of CHWs as interpreters and brokers of culture and health grounds this field at the crux of a social-​ecological context, marginalization, and intersectionality. Health services must take into account cultural values, beliefs, symbols, and assets, for instance (Gone, 2013; Huff, Kline, & Peterson, 2014; Pérez & Luquis, 2013). Although this chapter focuses on culture from ethnic and racial perspectives, culture and health can take on other dimensions, such as creating a “culture of health,” or introducing intersectionality and other elements of social identity, such as age (Plough, 2014; Schubert, 2015; Trujillo & Plough, 2016). This chapter, however, does not seek to engulf readers in all of the intricacies of the relationship between culture and health. Rather, it highlights the multifaceted ways these concepts come together and interact, setting the stage for the invaluable ways that CHWs serve communities. These concepts were influenced by sociocultural context. This relationship is exciting and troubling as we gain a better grasp of CHWs, culture, and health, because culture, as in the case of health, is never stagnant.

Nature and Extent of Relationship Between Health and Culture Understanding and brokering the interrelationship between culture and health is one of the basic tenets of CHWs, placing them in a unique position to bridge the old and new world for immigrants to this country: It is widely believed that the concept of health should be considered within a cultural context, given that cultural, social, and family



Culture and Health  37 influences are central forces that shapes attitudes and beliefs. . . . Culture provides a milieu through which worldviews are explored and may influence how people perceive their health and health problems, especially how they seek out health care services, and how they react to recommendations to modify certain lifestyle behaviors, follow through with health care interventions, or adhere to medical treatment. (Valera et al., 2018, p. 844)

The contextualization of health outlooks, behaviors, and help seeking introduces the influence of culture in shaping beliefs and actions (Mendoza & Lopez, 2017). There are no aspects of health that are exempt from having a cultural lens influence what we see and respond to. Health communication, for instance, has embraced the importance of messaging being culturally informed to increase adherence to prescription regimes (Betsch et  al., 2016). Culture influences all aspects of help seeking (Asad & Kay, 2015; Jeffreys, 2015; Meagley et al., 2016; Sue et al., 2012; Unger et al., 2013). Cultural capital, too, wields prodigious influence within highly marginalized groups facing discrimination (Madden, 2015). Singer (2012) warns us about making culture the primary factor in explaining health outcomes: Despite over 40 years of research and program efforts to eliminate the disproportionate degree of poorer health outcomes borne by communities of color, the gap in health outcomes not only persists, but is widening. . . . One of the major contributing factors identified for the unequal burden of diseases such as infant mortality, cancer, kidney disease hypertension, and diabetes is culture; yet the actual contribution of culture to health outcomes is virtually unknown. (p. 357)

Culture’s role in the conception of health, illness, and care is well understood in community health; culture does not wield absolute influence. The end result is a powerful interaction between culture and health care systems. Culture remains a key concept in shaping health beliefs and outcomes, but its multiple dimensions make it challenging to specifically pin down its role since it is ever changing in response to ecological factors: “Culture is not static—​it doesn’t stand still. It is dynamic, constantly changing and evolving with us. Culture is also multifaceted. It incorporates and includes ethnic identity, immigration status and experience, sexual orientation, gender

38 Context

identity, religion and spirituality, social class, family background, language, physical ability, traditions, and much more” (Rincon, 2009, p. 141). Culture defines us and influences our worldview and behaviors. CHWs must place this concept front and center in work with marginalized groups. The concept of cultural humility, which will be addressed again in the next chapter, helps center the importance of being open to learning and affirming new cultural stances, which enrich our own cultural understanding in the process. Landers and Levinson (2016) concluded that there is mounting evidence that CHWs are effective because of their close association with the values and practices found within their communities. CHWs have also been found to be effective in addressing intimate partner violence but not without challenges regarding psychosocial barriers undermining efforts at achieving safety and security (Rodgers et al., 2017). Effective CHWs have a deep and profound understanding of complex structural, cultural, and community factors (De Jesus, 2013). Newcomers, be they authorized or unauthorized, have been referred to as “geographically displaced clients,” capturing their geographical state of being and challenges in having their needs met in a culturally affirming and respectful manner (Jones, 2012). Folk-​based health care has survived over time because of the cultural symbolism that it incorporates, and some would argue, its effectiveness, too (Juckett, 2013; Lemley & Spies, 2015; López et al., 2016). Folk beliefs on illness are founded upon long traditions and influence help-​seeking patterns related to engagement of native healers in virtually all regions of the world. Indigenous, or folk, healers are as old as civilization itself in every part of the world, including in US communities of color, and coexist alongside formal health care providers. How health care systems interact with these cultures varies according to community and local circumstances (Delgado, 2018; Vandebroek et al., 2007). These systems may ignore folk healers or actively undermine their influence; formal systems may learn from them and modify practices accordingly. Botanicas, for example, are cultural variations of pharmacies and play influential roles in the informal health care systems within Latinx communities (Gushue, 2016; Murphy, 2015). Such as in the case of botanical shop oweners, who have a willingness to collaborate if approached respectfully, and with an understanding that they are equal partners in these ventures (Delgado & Santiago, 1998).



Culture and Health  39

CHWs must contend with the prevalence of self-​medication within the communities they serve, which can be manifested in various forms according to demographic, regional, and cultural factors, and one of which involves herbal medicines within certain racial and ethnic communities: Every day, we are practicing self-​medication in the form of self-​care of our health.  .  .  . Around the 1960’s in the West self-​care and self-​medication were regarded as unnecessary and potentially even unhealthy practices. This paternalistic approach to medicine, supported by health systems designed to treat sickness (rather than to prevent disease)[,]‌remains a familiar aspect of health care in many countries to this day.  .  .  . Self-​ medication has traditionally been defined as “the taking of drugs, herbs or home remedies on one’s own initiative, or on the advice of another person, without consulting a doctor.” . . . Families, friends, neighbors, the pharmacist, previous prescribed drug, or suggestions from an advertisement in newspapers or popular magazines are common sources of self-​ medications. Now-​a-​days, self-​medication should be seen as the “desire and ability of people/​patients to play an intelligent, independent and informed role, not merely in terms of decision-​making but also in the management of those preventive, diagnostic and therapeutic activities which concern them.” (Bennadi, 2014, p. 19)

Health and health care cannot be divorced from how communities meet their needs through indigenous means. CHWs face the challenge of respecting indigenous efforts while simultaneously providing viable alternatives where these efforts are undermining consumer health. Latinx cultural traditions and beliefs wield considerable influence among those who are classified as low or partially acculturated; acculturation can also be applied to other groups in this country. Conventional efforts at reaching and serving these Latinxs often present serious challenges to health care organizations. In the case of those partially acculturated, help seeking may entail utilizing formal, and informal, or traditional systems, frustrating providers because of potential competing health treatments (Findley & Matos, 2015). For those who are unauthorized, fears of deportation are a constant threat and often result in avoidance of seeking help from medical organizations, necessitating relying on traditional sources of care, even if they wish to venture into the formal system. Anxiety about being deported, and the

40 Context

corresponding depression once it occurs, have long-​lasting mental health implications (Drotbohm & Hasselberg, 2015). This creates a family narrative that remains part of family lore, and it can be powerful because of its intergenerational potential to shape health beliefs and help-​seeking patterns. Hospital deportations of Latinxs, for instance, bring practice and ethical challenges for social workers and other helping professionals (Sullivan & Zayas, 2013). Pedraza and Zhu (2015) introduce the concept of the “chilling effect” and its relationship to Latinx deportations, although applicable to other unauthorized groups, as one of the deleterious consequences of these immigration policies, illustrating how it influences everyday behavior: “The journalists and President Obama were discussing a dynamic that scholars of social insurance program participation refer to as the ‘chilling effect.’ The ‘chilling effect’ argument says that measures restricting immigrant access to public welfare and social insurance programs unintendedly reduce participation among eligible persons” (p. 2). Hospital deportations compromise these settings within the Latinx community and those employed by them, reinforcing a narrative that no place is safe from the immigration authorities (Delgado, 2018). CHWs in hospitals and community settings must first acknowledge, and then actively counter, these feelings and suspicions, and be prepared to act on behalf of service recipients through engagement in advocacy. Culture and health must be grounded within a local context to fully comprehend how best to reach communities in a culturally affirming and empowering manner. Health promoters are able to navigate formal and informal care systems, fulfilling needed cultural broker roles within these communities (Lebron et al., 2015). Their knowledge of local geography is enhanced when they not only work in these communities but also live there. CHWs, in addition, fulfill a variety of instrumental, expressive, and informational roles, including that of community navigators for those who are lost in the maze that often accompanies health care services (Hilfinger-​ Messias et  al., 2013; Shommu et  al., 2016; Torres et  al., 2013; Zulliger, Moshabela, & Schneider, 2014). They also can assume a generalist practice, or specialized role, depending upon competencies and local circumstances (Koon, Goudge, & Norris, 2013). Both of these roles have a prominent place within urban health care systems. Culture and health, and the paucity of medical personnel with bilingual and bicultural competencies, shape the role of CHWs. In examining one such community, Latinxs stand out because of their projected numerical



Culture and Health  41

increases in the immediate and near future. Latinx doctors, for example, have not kept up with demands. In 1980, there were 135 doctors per 100,000 Latinxs in the United States. In 2010, they dropped precipitously to 105 per 100,000, or 22%. This contrasts with an increase for White, non-​ Latinxs, from 211 per 100,000 to 315 per 100,000, or 33% (Rivero, 2015; Toledo, 2014). Similar shortages are found among nurses and other health personnel, signaling a significant crisis in health care personnel shortages. Hufford (1992), almost 25 years ago, identified five key points that are frequently overlooked in any discussion of healing systems and still have applicability today: (1) American healing systems are numerous and varied—​this country’s system of health care is not monolithic with many different cultural healing traditions, and thus an “official” designation is wishful thinking at best; (2)  “rational” and “logical” do not equate with “correct” and “true”; (3)  “understanding” does not equal “agreement”—​ differences related to conceptualizations of health can be considered irreconcilable and are significant in shaping help seeking and help provision; (4)  “honesty”—​having differences pertaining to different concepts of health cannot be dealt with by pretending to agree but doing something else; and (5) “alternative health systems are extremely vigorous and persistent”—​alternative systems have largely been ignored by medical systems, even though they are not only present but wielding significant influence as complementary or competitive systems. Although Hufford’s points were postulated in what seems like a lifetime ago, the issues discussed persist in various manifestations today. The nation has gotten more diverse from an ethnic and racial perspective, further accentuating these points when discussing health care that is culturally based, opening the door for alternative conceptualizations of health and how best to respond to ill health. Readers may be surprised by Asad and Kay’s (2015) statement on the legitimacy of integrating culture prominently into interventions through careful attention to local contextualization: That culture matters for health interventions is not a novel contention. Scholars and practitioners increasingly argue that an intervention’s success depends on the extent to which it is tailored to the local cultural and political context. . . . This is particularly crucial for specialists working in developing regions, where adjusting an intervention to suit a specific cultural and political setting often determines whether the local government will allow its implementation and provide resources to institutionalize it. (p. 79)

42 Context

The question of culture is not whether it is integrated into health care, but rather, how it is done, symbolizing a socio-​cultural-​political stance that must be integrated into all facets of health care planning, implementation, and research. US health is generally conceptualized as an individual phenomenon, with the identified patient being the focus of care. Culturally, this is not necessarily the case with certain ethnic and racial groups. Among Latinxs, particularly those who are not highly acculturated, health is still a family phenomenon (Delgado, 2018; Hu et  al., 2016). This translates to a patient’s family, along with religious leaders (if very religious), attending a scheduled appointment or an emergency room visit, for instance.

Intersectionality and Health The concept of intersectionality has found increasing relevance in scholarship and practice related to marginalized group identities and the social-​ political-​economic consequences that get manifested as a result of being pushed to the margins of society, including health. It is wise to pause here and provide a definition of what is meant by intersectionality before focusing on health. The definition of intersectionality by Collins and Bilge (2016) highlights why this concept shapes how CHWs carry out their work with urban marginalized communities: Social justice may be intersectionality’s most contentious core idea, but it is one that expands the circle of intersectionality to include people who use intersectionality as an analytic tool for social justice. Working for social justice is not a requirement for intersectionality. Yet people who are engaged in using intersectionality as an analytic tool and people who see social justice as central rather than as peripheral to their lives are often one and the same. These people are typically critical of, rather than accepting of, the status quo. (p. 30)

Health inequity among marginalized groups necessitates a wide lens to generate the necessary understanding to create interventions that address the social forces exerted by key institutions in shaping health.



Culture and Health  43

Kapilashrami, Hill, and Meer (2015) provide a historical context from which intersectionality emerged, and they help ground readers on this concept’s relevance for health: “Intersectionality” describes a cluster of theoretical positions which seek to revise the view that our social relations are experienced as “separate roads.” . . . While this necessarily takes in more than ethnicity or gender, the provenance of the concept may be traced to a particular black feminist critique of the ways in which mainstream (white) feminism had historically ignored the intersections of race and patriarchy . . . intersectionality has compelled feminist researchers to explore how their “moral positions as survivors of one expression of systemic violence become eroded in the absence of accepting responsibility of other expressions of systemic violence.” (pp. 7–​8)

Intersectionality provides a holistic perspective, capturing the interplay of social identities, social location, and historical oppression context (Corus & Saatcioglu, 2015; Etherington, 2015; Kapilashrami, Hill, & Meer, 2015; Rosenfield & Mouzon, 2013). Davis (2015) examined the intersectionality of social determinants and health care beliefs of African American women, concluding that the inequities preventing them from having their basic human needs met also carry over into having their basic health needs met, too, necessitating that health inequities be grounded within a much larger social context. Social justice has a natural home in intersectionality and health (Bowleg, 2012; Desrosiers, Mallinger, & Bragg-​Underwood, 2017; Im, 2016; Viruell-​ Fuentes, Miranda, & Abdulrahim, 2012). Mullings and Schulz (2006), over a decade ago, called for an interdisciplinary group of scholars from the social sciences and public health to come together to advance intersectionality and health. Unfortunately, there are a paucity of public health studies grounded within an intersectionality construct (Hankivsky, 2012). Addressing health inequities requires that social justice and intersection­ ality come together in the analysis and conceptualization of interventions: There is growing consensus that the most effective way to promote health and decrease health inequities is by creating more just economic, social and political conditions. . . . The connections between health and social

44 Context justice are increasingly apparent, whether in the form of relative income equality  .  .  .  , equitable workplace conditions  .  .  .  or racial/​ethnic equity. . . . Much less clear, however, are concrete ways in which public health practitioners can work with communities to address inequities such as poverty, racism and powerlessness. Such strategies are desperately needed. (Wiggins, 2011, p. 356)

Public health’s understanding of intersectionality and health suffers from quantitative literature that over simplifies important variables in increasing our understanding of the topic (Koehn et al., 2013). Bauer (2014) calls for more thoughtful incorporation of intersectionality to promote results that have greater applicability in population-​level interventions. Our understanding of intersectionality will be advanced by CHWs, and no more so than when they play a meaningful role in research and the scholarship that emerges.

Acculturation Status and Stress A book on CHWs requires careful attention to the role of acculturation and corresponding stress, when discussing newcomers whose primary language is not English and other communities of color who do not share the dominant view of culture. Acculturation and stress play prominent roles in this book, and it will unfold ranging from culture and health to how health promoters achieve success in reaching, and engaging, people of color and those who are newcomers to this country. This study area offers insights into the struggles of adjusting or acculturating to a society with values that are often counter to those of the newly arrived in this country, with profound impact on how health and illness are conceptualized and health care delivered. Reconciling differences results in stress with a wide accompanying set of symptoms or illnesses, which can be more effectively addressed through the deployment of health promoters within a community context and when culturally affirming (Cristofalo et  al., 2015). This is not to say that this concept has not been extensively critiqued (Doucerain, Segalowitz, & Ryder, 2016). Acculturation is a concept with a long history stretching back to the 1930s in the work by Redfield, Linton, and Herskovits (1936). The popularity of



Culture and Health  45

this concept has continued to the present day. Acculturation is arguably best defined by Massey, Zambrana, and Bell (1995), well over 20 years ago, as “a preference for culturally specific foods, language, social activities and English language, as well as level of education, place of birth, and number of years in the United States. This concept has served as a proxy indicator for socioeconomic status, generational status, and place of birth” (p. 191). Acculturation is an individual adjustment process consisting of behaviors, beliefs, and cultural values that change as a result of adopting dominant views in society (Hollingshead et al., 2016). There are a number of criticisms of how language has assumed a prominent role in shaping its use in research and practice. Doucerain, Segalowitz, and Ryder (2016) specifically take issue with the role of language and how it is operationalized in assessment: We would encourage researchers to define “acculturation” independently from the language skills that are necessary to negotiate it, so that it becomes possible to study how language serves as a mediating mechanism in the acculturation processes of cultural acquisition and maintenance. As well, we would encourage researchers to look beyond operationalizations of language skills in terms of simple measures of use, preference, and global proficiency (interesting and valuable as these might be). Instead, we suggest that researchers investigate variables that touch on skills regarding the sociolinguistic uses of language as well as knowledge of fixed expressions, idioms, and speaking styles, all of which provide minority speakers important keys to gaining access to the mainstream community and retain access to the heritage community in culturally appropriate and effective ways. Pragmatic and sociolinguistic aspects of language are closely tied to cultural norms and conventions. (p. 21)

Readers may be surprised by this centrality of language critique and its operationalization. There is no denying that CHWs encounter acculturation stress when serving those with low levels of acculturation. It is irresponsible to view acculturation stress in isolation from stressors associated with racial discrimination (Baldwin-​White et al., 2017; Lorenzo-​ Blanco et al., 2016; Zeiders et al., 2016). Racial discrimination, for instance, is a major contributor to acculturative stress among Cuban, Mexican, and Puerto Rican women, for example, requiring micro-​and macro-​focused

46 Context

social interventions (Bekteshi et al., 2017). These interventions necessitate empowerment being a central element or goal to counter the forces operating to further disempower marginalized groups.

Conclusion Health and culture is a topic too complex to be adequately addressed in one chapter. This does not mean that its scope is beyond conventional boundaries. The excitement of pausing and focusing the attention this topic deserves is beyond dispute and essential to appreciate the role of CHWs and their deep reach into underserved communities. There is no disputing the importance of social justice in shaping our understanding of health and health care and how best to meet the ever-​ increasing needs of marginalized groups in this country and world. A number of perspectives lend themselves to setting the foundation for the work undertaken by CHWs. Culture, for instance, allows them to validate the social identities of those they seek to serve; intersectionality brings a critical sociopolitical dimension for achieving social change while concomitantly meeting the health needs of groups with marginalized social identities.

3 Health Inequity Introduction This chapter provides readers with an overview on health inequities and why community health workers (CHWs) can be expected to play a critical role in this nation’s urban centers for health care delivery. The importance of health care being responsive to the nation’s most vulnerable is well established, and so is the call for aggressive approaches to improve the health trajectory of these groups (Braveman & Gottlieb, 2014; Paz & Massey, 2016; Purnell et al., 2016). Health permeates all aspects of life, bringing a health dimension to human rights and social justice when these communities are socially marginalized (Benfer, 2015). A  legal advocacy perspective is an attractive and effective tool to advance a health equity and rights agenda on improving access and quality. The quest for health equity is a value and goal well understood and embraced for those serving marginalized communities (Watson-​Thompson,  2016). Health is a critical and often overlooked dimension of human capital. When viewed in this fashion, enhancing it has multiple outcomes that also touch economic capital, for example. Yet any discussion of health inequity uncovers numerous marginalized groups whose health needs often go unmet, or when addressed, are done so in less than an optimal manner, with implications touching on other forms of capital. Health inequities cover a vast terrain, and a thorough review is beyond the scope of this book and chapter. Readers will be introduced to this concept, for those who are new to this topic, with certain aspects being highlighted demonstrating the importance of this subject for marginalized groups across the nation, and a specific focus on four targeted groups that will be addressed throughout this book. There are no aspects of daily life that health does not impact. The topic of influenza and illness outbreaks in this country is influenced by social determinants and subject to social justice analysis and response (Cordoba & Aiello, 2016). Health insurance coverage of substance use

48 Context

disorders, too, cannot escape a social justice and equity lens (Wang & Xie, 2017). Transgender women sex workers, for instance, have generally been overlooked in the scholarly literature focused on HIV risk, also making them invisible in general (Poteat et al., 2015). Stigma and discrimination, resulting from certain illnesses, broaden the concept of health equity beyond “conventional” health and community settings (Roessler et al., 2016). The relationship between place and health is well established, and this applies to urban and rural places, although this book focuses on the former (Fitzpatrick & LaGory, 2002). Urban centers bring tremendous health care challenges for low-​income and low-​wealth communities of color (Knopf et al., 2016; Liburd, 2010). Cities, too, have great natural and built resources that can be tapped for enhancing resident health and well-​being (Douglas, 2012; Marshall, Brauer, & Frank, 2015). Concentration of marginalized groups within distinct geographical areas also facilitates service delivery and resource allocation. It is no mistake that India’s Accredited Social Health Activist (ASHA) program, with a goal of having a local female health worker in every village with a population over 1,000, is considered the largest CHW program in the world (Walsh, 2016). Rural areas, too, bring unique social circumstances that lend themselves to the introduction of CHWs due to cost and logistical considerations.

Definition and Overview CHWs invariably devote considerably more time to addressing health inequities when compared to health providers from other disciplines, making them that much more attractive to reach very marginalized groups in their quest for social justice (McCalmont et  al., 2016). Pobutsky et  al. (2015), although referring to Hawaii but applicable to other communities, address health disparities from a multifaceted perspective to understand the multiplicity of factors that must be taken into account in developing appreciating health equity:  “Communities in Hawaii can be defined in a number of different ways for health disparities:  high risk groups based on disease burden data (mortality, morbidity and disability), specific geographic areas, ethnic make-​ up of the population, and/​ or divergent culture(s) or norms (e.g. rural areas, mixed ethnic groups or ‘locals’)” (p. 2). Health inequities through various points of view, including poorest versus



Health Inequity  49

wealthiest counties in the United States, which is counter to a focus on states, can hide extreme outcomes related to poverty and its consequences (Egen et al., 2017). Although health social determinants are well established, a broadening of determinants to include cultural, religious, and community factors has been called for to develop a comprehensive understanding of the forces shaping health and help-​seeking behavior (Firoz et al., 2016; Mackenbach, 2012; Pobutsky et  al., 2015; Viner et  al., 2012). Successful CHWs understand this important conclusion because of how well they are grounded within a community’s lived experiences, including their experiences with institutions that are supposed to serve them fail to do so in an affirming manner. Embracing a community lived experience perspective broadens the arena where health equity concerns must be addressed (Corburn, 2017): Healthy and equitable urban places are crucial for achieving health for all populations. Yet, an exclusive focus on either built environments or single risk factors will not address the multiple, often cumulative, social and environmental exposures that exist in cities today and are contributing to inequities disproportionately burdening urban poor communities. A  relational perspective of urban places and health equity can help encourage disparate disciplines and institutions to work together, and with the urban poor themselves, to analyze and solve problems. We recognize that this will not be easy and the evidence base for how to do this most effectively is still emerging. Our challenge is great but on an urban planet, environmental public health is urban health, and health equity should be our goal.

Alegria et  al. (2016) identified three basic assumptions underpinning most efforts at addressing racial and ethnic disparities in behavioral health care:  (1) improvement in health care access alone will reduce disparities, (2)  current service planning addresses people of color preferences, and (3)  evidence-​based interventions are readily available for diverse population groups. These assumptions have profound consequences for how we view inequities/​disparities of any kind. Critics argue that the term “US health care system” is a misnomer; it is not an organized system, but one consisting of disparate parts, making delivery of quality care across the age and racial spectrum a leap of faith (Finocchio & Wu, 2009):

50 Context Health care in the United States is not organized into a “coherent” system in which all the different components work together to achieve a common goal. Instead, health care in the United States is a complicated and uncoordinated mix of parts with few common goals and no central leadership. As a result, people in the United States are not served equally, and many, especially low-​income working families, do not get health care when they need it. (p. 113)

Finocchio’s conclusions make CHW effectiveness difficult to achieve, and if so, not without a great effort necessitating that they go far beyond what can typically be expected of health providers. A number of diseases and illnesses have received considerable attention in the health equity literature regarding communities of color, with diabetes being one. A number have escaped in-​depth attention, and three have been selected to illustrate this point. Lyme disease is one example. The chances of Latinxs contracting Lyme disease is similar to non-​Latinxs, yet they are more likely to be underdiagnosed than non-​Latinxs during summer months and the onset of fall months, calling for public education efforts targeting them (Nelson et al., 2016). Advanced care directives, too, have largely gone underreported in the literature, yet there is a tremendous need for them, since only 10% of Latinx adults have them when compared to 26% for their non-​Latinx counterparts (McLean, Habicht, & Foote, 2016). One example shows how it can be addressed. CHWs are in a unique position to engage older adults in advanced care planning because of a close and trusting relationship that they can establish when providing home health care (Litzelman et al., 2017). Finally, work-​related injuries account for 30% of all injuries in this country, and this statistic is higher, with even greater significance, when discussing workers of color because they are often overrepresented in occupations with high rates of injuries. It should not be surprising that race-​ related health care inequities among California workers, for instance, where Latinxs had the highest rates of occupationally injured and the highest chances of admission and annual incidence of emergency department–​ treated injuries (McCoy et al., 2016). Finally, Latinx horse workers, for instance, are in an occupation that is highly dangerous but often overlooked in discussion of occupations that have work-​related injuries and diseases (Swanberg et al., 2016).



Health Inequity  51

Conclusion Health inequities are not equally spread across the age, socioeconomic class, racial/​ethnic, gender, or sexual identity continuum, for instance. The presence of multiple jeopardies makes some groups more vulnerable than others, complicating our understandings and approaches toward eliminating health inequities. Use of a community capacity enhancement approach toward eliminating these inequities, as in the case of using CHWs, was proposed in this chapter, and offers much promise for furthering enhancing indigenous community assets (Delisle et al., 2017). The following chapter addresses the presence of barriers to access and quality health services. Readers will be familiar with some, if not all, of these barriers. In their totality, these barriers are significant and impact the daily lives of those in greatest need of quality health services.

4 Challenges and Barriers to Urban Health Care Delivery Introduction Although approaches that blame culture as a key factor in health inequities will consistently emerge, these “blame the victim” approaches have receded in importance in setting health care policies and shaping the research informing these practices. This does not mean that significant strides are not necessary and challenges are not significant. Impeded access represents a key element in any effort to address health inequities, but it is only part of the solution (Heaman et al., 2015; Sorkin et al., 2016). Barriers are an integral subject related to outcomes. Readers interested in evidence base and evaluation effectiveness will find this material in Chapter 6. Once someone experiences a significant barrier in seeking assistance, she is left to her own devices to have her needs met with home or cultural remedies, for instance, or bearing the consequences of having an illness go untreated. Eliminating health care barriers is the most significant initial step in reducing inequities. Unimpeded care access brings multifaceted benefits for individuals, communities, and society, and no nation can thrive with large portions of its citizenship being ill (Gulliford & Morgan, 2013). Conceptualizing health care as a human right highlights why it plays such a prominent role in a nation’s well-​being and introduces social justice values and principles into subsequent action to rectify this injustice. Passage of the Affordable Care Act (ACA) has not resolved the problem of having 30  million adults and children still without health insurance (Sommers, 2015):  “The Affordable Care Act (ACA) has passed its fifth birthday and completed two enrollment periods for coverage in the state-​ based insurance exchanges and Medicaid. The U.S. uninsured rate is lower than ever, and coverage gains appear to be improving access to primary care and medications, affordability of care, and self-​reported health. But challenges for health care reform persist: millions of Americans are still uninsured, and even for those with coverage, substantial barriers remain to



Challenges and Barriers to Urban Health Care Delivery  53

obtaining affordable, high-​quality care” (p. 2395). The need for a comprehensive approach and corresponding solutions is in order. Understanding demographic profiles and trends is essential for developing a health care system that addresses immediate and long-​range needs of all groups (Powell et al., 2016). This is challenging in the case of those who are undocumented. A  conceptual base on barriers to quality health care grounds readers with an understanding of the immensity of the tasks to achieve a barrier-​free health care society. This chapter exposes readers to important demographic trends, and it provides one four-​part perspective on conceptualizing major barriers to help seeking in health care. This conceptionalizing of barriers, in turn, will highlight why community health workers (CHWs) are so needed and effective in helping to connect with population groups that historically have had difficulty in having their health needs met.

Key Demographic Profiles and Trends The nation is graying (getting older) and browning (diversifying ethnically and racially), setting the stage for a country that will look very different in the future from what it looks like today (Delgado, 2015; Tavernise, 2018). Demographic patterns pertaining to different groups, such as Latinxs, will challenge health systems in the country without a long tradition of having Latinx communities (Betts, 2016; Keig, Mata, & Cervantes, 2016; Myers, 2016). Demographics play a critical role in shaping current and future health care responses if community compositions are to influence the planning and implementation of services. Communities of color and other highly marginalized groups, such as the homeless, veterans, and sexual minorities, are highly marginalized and in desperate need of care that is responsive to their lived situations (Dahlhamer et  al., 2016; Matarazzo et  al., 2016; Roberts & Fantz, 2014). Focusing on a key demographic group brings this observation to life. The high percentage of youth of color stands out as a powerful rationale for enlisting them as CHWs and part of project advisory committees in helping to shape how these projects should unfold to reach fellow youth (León & Clinton, 2016). Price and Khubchandani (2016) call attention to the Latinx population and the general absence of health-​related literature focused on

54 Context

them. Latinx youth CHWs are in a propitious position to undertake this form of work, and this will be a focus of this section. Latinx youth are the largest ethnic and racial group under 18 years of age in the nation (Patten, 2016), and in 2013, they represented approximately 17.7 million, or 16.5% of the Latinx population in the United States, making them an attractive target for community CHWs. More specifically, Latinx children under the age of 5  years numbered almost 5  million, or almost 30% of all Latinx youth under the age of 18 years. According to the Pew Research Center, based on the 2012 US Census Bureau data, there were 17 states where Latinx constituted at least 20%, or 1 out of every 5 of the kindergarten population, representing more than doubling of the 8 states in 2000 (Krogstad, 2014). CHWs cannot ignore Latinx children in the immediate and near future, and they are in a propitious position to make a profound impact (Segura-​Perez, Balcazar, & Morel, 2011). Potential barriers, as in the case of Latinx and other youth of color, in relationship development between youth and CHWs due to age and cultural differences, can be minimized when youth are enlisted as health promoters (Alli, Maharaj, & Vawda, 2013; Delgado & Zhou, 2008; Denno, Hoopes, & Chandra-​Mouli, 2015). Culture is often relegated to ethnicity and race, and we tend to forget that youth bring their own culture, which is significantly different from that of adults, with their own language, symbols, and worldviews. Youth with problematic relationships with health care providers are destined to continue to have these types of relationships as they age into adulthood. An unhealthy start in life is compounded when carried out over the following decades, compromising their well-​being and engagement in career pursuits. Their communities also suffer because they cannot contribute to well-​being in the manner that occurs in communities where youth are not compromised. Youth compromised health radiates out, impacting those around them and their communities.

Organizational Access Barriers Understanding organizational access requires a multifaceted perspective to capture its complexity and development of strategies to overcome



Challenges and Barriers to Urban Health Care Delivery  55

these barriers (Bloemraad & Terriquez, 2016; Roth & Allard, 2016; Shin et al., 2017). Organizational barriers are rarely simple to identify or easily addressed, including how service information is disseminated to hard-​to-​ reach groups (Kelley, Su, & Britigan, 2016). Barriers must be grounded within the broader context of a health system, which is widely considered to be “broken.” Martinez (2014) identifies one critical source for this dysfunction: The U.S.  healthcare system functions as a business, not a basic human right, and what ensues is unequal access to services and differential health risks/​privileges for the subordinate and dominant groups. Understanding how capitalism and colonization have created a system of racial and economic dominance within American institutions, 12 including the healthcare system, is crucial to understanding the barriers to people of color’s access to resources, and the disproportionately positive health outcomes for Whites. (pp. 11–​12)

CHWs can help connect those struggling with addictions to resources and family, which is a critical dimension in any effort to marshal attention and resources (Adorno et  al., 2013). Recognition of the family as a cultural asset is enhanced when the CHWs share similar backgrounds with consumers. It is critical that any analysis not underestimate the need for a comprehensive and nuanced understanding of the challenges, including innovative perspectives. Cutts et al. (2016) describe an innovative use of community asset mapping of Latinx health seekers and providers, and they found that the most common barriers related to cost, their documentation status, lack of access to public transportation, racism, quality care, experiencing respect, and education/​language. Four organizational barriers will be discussed, which can exist in various combination or permutations: (1) geographical/​physical, (2) psychological, (3) cultural/​language, and (4) operational/​financial. These barriers can be put on a continuum from 1 (minor) to 10 (significant) in assessing their strengths, bringing depth to any analysis. The greater the number of barriers present, and the stronger they are, the greater the challenge to access.

56 Context

Geographical/​Physical An analysis of geographical and physical barriers to health care is usually the first factor, or step, that is identified in addressing services to marginalized groups, and that is no mistake. Availability increases the likelihood of use, as in community health centers (Kirby & Sharma, 2017). Geographical and physical barriers lend themselves to visual perceptions, which are easily understood. A building without a ramp, for instance, effectively limits access to those who need a ramp because of a physical impairment. Services targeting those who are low income/​low wealth and cannot afford private transportation, and thus are heavily dependent upon public transportation, lead a very circumspect life that geographically limits their world to where this transportation exists. This barrier can be manifested through limited access to transportation (Segura-​ Perez, Balcazar, & Morel, 2011; Syed, Gerber, & Sharp, 2013), physical inaccessibility due to disabilities (Pharr & Chino, 2013), or as often the case, both. Not unexpectedly, these barriers can also exist alongside other barriers that follow.

Psychological Psychological barriers are multifaceted and generally refer to stigma associated with seeking assistance (Mehta, 2015; Metzl & Hansen, 2014; Misra-​ Hebert et al., 2015). Negative “feelings” on seeking assistance can be equally as significant a factor as the other barriers addressed in this chapter and, it can be argued, more difficult to identify and address. Organizational reputation becomes a key factor in increasing access to highly marginalized groups. An exhaustive listing of stigmatized population groups and their struggles to access care would be too long to address in this section, or book, for that matter. Sex workers (Levi-​Minzi et  al., 2016; Scorgie et  al., 2013; Socias et al., 2016), those with HIV/​AIDS (Anderson et al., 2016; Genberg et al., 2016; Okoro & Odedina, 2016), and the formerly incarcerated (Bolano et  al., 2016; Davoren et  al., 2015)  are special population groups, for instance, who often experience the consequences of being fearful that they will be stigmatized and not respected. Fear of experiencing racial discrimination remains a potent barrier to service utilization (Myers, 2016; Velez et  al., 2017). A  desire to engage in



Challenges and Barriers to Urban Health Care Delivery  57

shared decision making versus being told what to do (Yin et al., 2012), and troubling attitudes of providers toward marginalized groups (Twamley et al., 2014), for instance, provide a window into psychological barriers to quality health care provision. These fears are not unfounded.

Cultural/​Language Differences in cultural values and language proficiency are often cited as playing instrumental roles in erecting a barrier between a consumer and a provider who do not share similar backgrounds. Issues related to limited English proficiency (LEP) (Brisset et  al., 2014; Merchant et  al., 2015; Steinberg et al., 2016; Tsoh et al., 2016), cultural values (Purnell, 2012), and cultural beliefs on causes of illness (Hamilton, 2017; Jin & Acharya, 2016; Tejeda et al., 2017) typify cultural and language barriers to effective service delivery.

Operational/​Financial Operational barriers capture the broad parameters of organizational procedures that severely limit access to services. These are typically related to days, hours of operation, and limits on coverage of certain services. Financial barriers capture factors related to payment, such as high cost sharing and limited provider networks (Castañeda & Melo, 2014; Jacobs et al., 2012; Kim, 2015; Rowan, McAlpine, & Blewett, 2013), long wait time, legal status (Allen, 2016; Copeland & Clark, 2013; Vargas & Ybarra, 2017), complicated referral procedures (Zuckerman et al., 2013), lack of insurance (Heintzman et al., 2017), cost coverage and copayments (Flinn & Foo, 2013; Shippee et  al., 2014), post follow-​up (Palmer et  al., 2015), navigating the health care system (Gilbert, Elder, & Thorpe Jr, 2016), and poor discharge planning (Okoniewska et al., 2015). The interactions of operational and insurance coverage are quite powerful, taking on greater significance in the case of those who are undocumented. Alcalá et  al. (2017) found that the ACA has been effective in reducing barriers to access and utilization of health care among most Latinxs, with those who are undocumented still suffering from a lack of access.

58 Context

Those who are undocumented face the added burden because of the threat of being deported influencing their help-​seeking patterns, severely limiting their options, and essentially making them invisible from a service demand perspective. Their invisibility does not make their pain and worries any less real; rather, their invisibility means that extraordinary efforts must be made to reach deep into these communities and institutions that they trust and respect. Expecting them to go to health centers may be impossible. Thus, we must reach them where they work, worship, and recreate, be it factories, small churches, or soccer fields, for instance.

Conclusion Health service access is never a straightforward process of eliminating one factor. Often it entails dealing with multiple factors, some obvious and relatively easy to address, and others not so obvious and more difficult to address. Organizations employing CHWs must be prepared to develop strategies with high likelihoods of success that require minimizing organizational factors that may inhibit quality health services from reaching those in greatest need. This chapter conceptualized organizational barriers along four dimensions, with each being significant in itself. When combined in various combinations and permutations, these obstacles take on significance and effectively limit access to and provision of quality health services for those most in need and undervalued by society. These initiatives must embrace a set of explicit values and a conceptual foundation and framework that resonates with their sense of self. The following chapter provides one perspective that can prove very effective in bringing this goal to realization.

SECTION 2

THEOR ET IC A L F OUNDAT ION Section 2 consists of 3 chapters and provides readers with the requisite parameters of how to conceptualize the values and principles guiding CHWs, as well as the dilemmas they encounter. Community health workers do not operate in a vacuum. And a keen understanding of the values and principles shaping their actions is essential in comprehending how their roles unfold in various settings. Finally, readers will be exposed to best practices in recruiting, training, and supporting these workers in the field, including the challenges we face in helping to ensure the best quality of health care delivery with them playing an instrumental role.

5 Values, Guiding Principles, Conceptual Foundation, and Framework Introduction The future of community health workers (CHWs) rests upon a solid foundation of explicit values, practice principles, empirical evidence, and an embrace of a conceptualization that emanates from this foundation. Discussion of values and principles shapes language and discourse on how best to create an environment or climate that enhances the chances that CHWs can be effective in meeting current and emerging needs of communities, whether urban or rural. This chapter lays out a set of values, principles, conceptual foundation, and framework for bringing values and principles to fruition for community-​responsive services. There are other values, principles, conceptual foundations, and frameworks that can be applied to CHWs and the role they function within community health care systems. This chapter will rely upon a life span and community capacity enhancement paradigm. Consequently, the content that follows is one person’s version of the “truth,” with an understanding that there are other truths out there. Practitioners and scholars interested in CHWs, too, must take an accounting of the values and principles guiding their views of this workforce, practice field, conceptual paradigms, and frameworks. This chapter exposes readers to this content and how it helps guide the journey for CHWs navigating the urban terrain.

Values and Principles Guiding Community Health Worker Interventions I like to view values and principles as having the power that DNA possesses in shaping human beings. This is not to disregard the immense influence of environment and how socioecological forces shape interventions. Those

62  Theoretical Foundation

engaged in social intervention must have a firm and explicit understanding of values and principles to guide them through turbulent waters.

Values Where would CHWs be without a firm grounding in values? Values guide our worldview, including health care. Laverack (2005), although specifically addressing public health, introduced the importance of social justice and empowerment as key values in shaping a health view that is affirming, participatory, capacity enhancing, and embracing social change to influence health: The different interest[s]‌within public health help to shape what it looks like and the directions it takes as a professional practice by competing for limited resources, and the control over decisions and the development of national policies. Public health also involves “communities” and incorporates methods that connect collective action to the broader aims of political influence. Power and empowerment are therefore key concepts to a public health practice that seeks to redress inequalities in health and to change the determinants of health through collective and community-​ based action. (p. 1)

One can appreciate this health view and why it lends itself to CHWs playing a role in embracing social justice and seeking social change within their communities. A deep and abiding embrace of the following values stands out in importance in shaping a health care corps that has, and is expected to, wield significant influence within health care systems. Each value stands alone in importance. When combined, they have a powerful synergistic influence on shaping how CHW roles unfold.

Social Justice It is impossible to think of a social justice value in the abstract without connecting it with social change (Casey, 2017; Strang & Braithwaite, 2017; Thompson, 2016). Social justice is a value that is either explicitly or implicitly embraced by CHWs (Sabo et al., 2013; Wiggins et al., 2013). When explicitly embraced, it casts CHWs as advocates and social change agents in



A Conceptual Foundation and Framework  63

the process of delivering much needed health care. Their responsibilities go beyond the immediate consumer to altering the social circumstances creating that illness or disease. Their job description, as a consequence, will list the legitimacy of social justice/​social change tasks to be an integral part of their intervention. Even when discussing CHW engagement in research, which often takes the form of “action research” (Munn-​Giddings & Winter, 2013), change remains an objective. In cases where CHW job descriptions omit social justice and social change, they must assume these goals and tasks without getting “credit” for undertaking these efforts.

Empowerment Empowerment is a value that permeates all forms of initiatives targeting those who are marginalized. Thus, it should not be surprising to see this value emerge in CHW initiatives, empowering consumers and CHWs in the process (Buehler, Ruggiero, & Mehta, 2013; Cupertino et  al., 2013; Murray & Ziegler, 2015). We cannot embrace empowerment as a guiding value without it impacting those who are instruments of empowerment. Empowerment needs to be modified to take into account local circumstances and the culture of those empowered. Empowerment, although a universal concept, does not get operationalized universally. Those who are undocumented, for instance, have more limited options when compared to a comparable group that has legal status, even when they share similar ethnic backgrounds, for instance (Delgado, Jones, & Rohani, 2005; Forenza & Mendonca, 2015; Gates, 2017; Meng, 2015). Their worldview and options, including cultural values, cannot be ignored in applying such a powerful value in the help-​seeking and help-​provision process. Cultural Competence Readers can discern the role and influence of the metavalue of culture and cultural humility and integrity in shaping conceptions of health and our responses to it (Bibus, 2017; Danso, 2016; Jagers, Mustafaa, & Noel, 2017; Ong-​Flaherty et al., 2017). It can be argued that an overarching value is too important to be relegated to an individual slot as if its influence is limited to a narrow confine. However, for our purposes, it will. One of the earliest references in the scholarly literature to cultural humility can be traced to the late 1990s (Tervalon & Murray-​Garcia, 1998). A hallmark of cultural humility and integrity is our willingness and ability

64  Theoretical Foundation

to engage in self-​reflection and critique, as well as embrace the evolution of culture and its adaptation to local social circumstances. Diversity and power imbalance are considered to be the antecedents to cultural humility (Foronda et  al., 2016). This view fits well with a social justice and social change approach toward health inequity, making the job of CHWs easier to carry out in the course of meeting health needs.

Participatory Democracy Participatory democracy is not an abstract value, and it is one not restricted to political participation in elections either, finding its way into the health field (Chandra et al., 2016; Myers, 2016; Sprague Martinez et al., 2017). Its broad reach permeates all facets of life starting in the home and radiating outward to the immediate environment outside to our institutions. Participatory democracy in the health field is manifested through meaningful efforts at obtaining the participation of consumers and communities (Rifkin, 2014): Community participation is increasingly recognized as key to improving and maintaining interventions that improve health outcomes. To date, community participation has most often been seen as an intervention to improve health outcomes rather than a process to implement and support health programmes to sustain these outcomes. To understand the relationship between community participation and improved health outcomes, new frameworks are needed. Examining community participation as a process and dealing with critical issues around empowerment, ownership, cost-​effectiveness and sustainability of health improvements would move this dialogue further. (p. ii104)

CHWs are in unique positions to bridge the worlds of consumer and health care by facilitating consumer/​ community participation (Alicea-​ Alvarez et  al., 2016; Kok et  al., 2017; Smylie et  al., 2016). Bridging these worlds increases the likelihood of services being culturally relevant.

Principles It is essential to separate values from principles, although they can be considered the other side of the same coin. It is best to think of principles as



A Conceptual Foundation and Framework  65

acting as a bridge between values and theoretically informed practice, and helping translate theory into practice. A  total of eight principles emerged corresponding to the eight values addressed earlier. Practitioners are not bound by all of these principles, and this can lead to a combination that best meets local needs and circumstances. It is best to view these eight principles as forming the foundation for CHW initiatives. These principles are synergistic, feeding off each other to create an environment supporting initiatives with a high chance of succeeding. If readers are looking for guarantees, there are none; if looking for a way to increase the odds of success, these principles, based upon multiple sources (reviewing of the literature and responses from the field), will definitely be useful. (1) Embrace the importance of social relationships or social capital. Helping professions, and certainly CHWs, are predicated upon social relationships being positive and facilitating of service delivery. Uplifting the value that “good” services rely upon positive social relationships, and all that it entails, stands out in importance, and particularly in cases where the values of the consumer play an active role in shaping how interactions between provider and consumer must unfold. Among Latinxs, for instance, cultural values such as personalismo (relationship to individuals rather than institutions), sympathia (warmth and importance of relations), familismo (centrality of family), and respecto (respect), to select four critical ones, wield a profound influence. These values affect how Latinxs, particularly those with low levels of acculturation, shape interactions and relationships (Delgado, 2018). These cultural values are not limited to Latinxs and are shaped by the nature and quality of newcomers’ interactions with their new homeland. These values are not absolute with every family member sharing them to the same extent, and this requires that CHWs understand subtle nuances in order to differentiate between dominant and latent values in delivering their services. This ability to differentiate between these values is critical in establishing needed rapport between worker and consumer. (2) Acculturation must be taken into account in the planning of services, but within a context that acknowledges discrimination and racism in the lives of consumers. Although acculturation remains an imperfect concept, or one that is still evolving, as addressed earlier, it provides an important window through which to examine health beliefs and help-​ seeking patterns, including the emergence of stress to capture competing

66  Theoretical Foundation

forces shaping the existing of individuals negotiating two different worlds. (3) Health and social needs must be grounded and understood within the local context. Place and space shape worldviews, giving meaning to lived experiences, and this applies to how needs are conceptualized and acted upon in the help-​seeking process. I  am fond of saying that context shapes practice, and practice must be flexible to take into account local circumstances to be meaningful and effective. (4) Services must be integrated into the social and cultural fabric of the community. “Community-​centered” captures a place and space that is conducive for engaging and serving highly marginalized groups because it offers familiarity, safety, a common language, and respect for the lived experience of consumers and providers. Social and cultural fabric brings an added perspective to a community by emphasizing how socialization influences worldviews and help-​seeking behaviors. Grounding CHWs helps increase their awareness and corresponding actions. (5) Assets and strengths first at all times (political, cultural, human, economic, social, physical, and intangible). The language of assets/​strengths first may be new to some readers, but such a stance goes far beyond semantics and represents a worldview or stance that is significant when viewed from a community health perspective, and more so when addressing highly marginalized groups. (6) Fostering of positive ethnic identity must be embraced. Social identity is widely understood to represent the cornerstone of self-​worth, a critical element in the crafting of health perceptions and corresponding help-​seeking (Meyer, Teylan, & Schwartz, 2015; Nicdao, Duldulao, & Takeuchi, 2015; Powell et al., 2016). Identity, too, has a critical focus on intersectionality, as discussed earlier. Race and ethnicity are influential parts of social identity, and when taking intersectionality into consideration, other dimensions, too, play an influential role. (7) Bilingual/​bicultural and bilingual staff are best situated to provide culturally competent/​humility-​based community health services. The concept of matching worker and consumer backgrounds can be a goal that is certainly not new or restricted to CHWs, particularly in the area of behavorial health (Blank et al., 1994; Vega & Lopez, 2001). This principle acknowledges the potential of racial and ethnic barriers, and it seeks to minimize communication and treatment adherence barriers due to ethnic, racial, and cultural differences between provider and consumer.



A Conceptual Foundation and Framework  67

(8) Social justice, as manifested through advocacy and social change efforts, must play a prominent role in guiding service delivery models. An embrace of social justice often represents the guiding philosophical stance when addressing marginalized population groups and the health field. Such a stance effectively places changing the social conditions that lead to health inequities in a central position in any health initiative. Rincon (2009) provides a challenge for CHWs in integrating social justice as part of their work: “Your ability to work with diverse communities will also depend on your willingness to examine how larger societal practices influences health status. As CHWs, we must be ready to understand the impact of discrimination based on ethnicity, nationality, immigration status, sex, gender identity, sexual orientation, and other identities on the lives and health status of the clients and communities you work with” (p. 139). The embrace of intersectionality is associated with a social justice value and brings the burden of simultaneously addressing health needs and social justice in interventions, regardless of their focus. The values ingrained in an intersectionality perspective ground health and provision of care within a human rights and social justice context, and an agenda that emphasizes a social-​cultural ecological (intersectionality) understanding, which is essential in the case of marginalized groups. Embracing this approach requires CHWs and their organizations to be vigilant on how social systems compromise health of marginalized groups and communities.

Conceptual Frameworks Health occurs within a complex and multifaceted context that grounds it within an individual, group, and community. This calls for an embrace of an intervention that is conceptually grounded that systematically builds upon a clear set of values and principles, as addressed earlier, and acknowledges a complex and multifaceted context. The focus on community may make practical and political sense, but the concept of community remains conceptually thorny with the potential of creating confusion and service delivery conflicts (Burgess & Mathias, 2017). CHWs are freed to view their consumers and community in an encompassing and highly interrelated manner.

68  Theoretical Foundation

Community Capacity Enhancement The importance of a conceptual foundation and framework in shaping a response toward highly marginalized groups and communities is well understood, and no more so than when referring to health. I  have chosen a conceptual foundation, or paradigm, that is referred to as community capacity enhancement. Community capacity enhancement can have many different manifestations. The community-​built paradigm (Melcher, Stiefel, & Faurest, 2017)  is one perspective on identifying and mobilizing a community’s assets in collaboration with external resources (government and private) to address local built issues. Identifying, supporting, and collaborating with nontraditional support systems, too, can be a part of this paradigm when specifically tapping cultural values and traditions. Readers can certainly appreciate CHWs, who are indigenous to the community being served, as community assets. Identifying potential residents who can fulfill CHW roles, or in the case where they are currently employed in this role, investing resources in further enhancing their capacities and credentials, is a form of community capacity enhancement. Community capacity enhancement first found saliency in the early 2000s, and it focused on urban centers throughout the United States, although its applicability was not restricted to these geographical settings (Delgado, 2000). Since this initial period, other scholarship has emerged embracing the concept of capacity enhancement but using other terms such as “community built,” based upon many of the fundamental premises and values first proposed in the early 2000s. CHWs must take a strengths and assets approach in conceptualizing their work if they hope to not only address pressing needs but also enhance community capacity in the process to address future health challenges. Collaboration with key community institutions is often advocated in CHW programs wishing to reach hard-​to-​engage groups (Allen et al., 2015; Balaji et al., 2012; Baron et al., 2014), and this strategy is a theme throughout this book, particularly when utilizing an assets paradigm focused on enlisting the support of nontraditional settings. Community partnerships are essential to the overall success of CHW programs, including obtaining funding and facilitating implementation of initiatives (Del Bianco et  al., 2014; Dennis et al., 2015). Nontraditional settings such as houses of worship, for instance, can initiate health programs or be sites for outposting CHWs to conduct screenings



A Conceptual Foundation and Framework  69

and activities (Galiatsatos & Hale, 2016; Iheanacho et al., 2016; Poole et al., 2016). These settings take on added importance within marginalized communities because of the degree of trust they engender. A number of paradigms and approaches have emerged in the scholarly literature emphasizing the importance of culture and assets (Delgado, 1999, 2000; Perez-​Pena, 2003). Paradigms that stress community strengths and cultural assets provide a counternarrative to the more typical deficit or charity approaches that often dominant the literature on marginalized groups (Hanna & Ortega, 2016; Malachowski, 2014; Wiggins et al., 2009). CHWs can implicitly or explicitly embrace such a worldview, with asset paradigms providing conceptual underpinnings because they affirm the communities they serve (Bouchon, 2012; Caron & Merrick, 2012; Mayberry, Willock, & Daniels, 2012; Murray & Ziegler, 2015). Embracing a social justice value facilitates achieving advocacy and community-​ building goals, which are closely associated within CHW programs, increasing the likelihood of effectiveness when they do so (Bush et al., 2014): Advocacy and capacity-​building roles are clearly critical for promotoras working with low-​wage, immigrant workers as they seek to address workplace health and safety conditions that are largely controlled by employers and contractors. The presence of trained promotoras contributes to community capacity, and that increased capacity can play a pivotal role in linking together the different levels of the ecological model. Key components of increased community capacity include the development of leadership in the community, accessible resources, and community knowledge about the problem and about existing prevention efforts. . . . Strengthening a community’s ability to support individual and community level actions to protect workers’ health can in turn support needed structural/​ policy changes. These include improvement in government subcontracting policies and enforcement of, and employer compliance with, existing labor and workplace health and safety regulations. (p. 790)

Bush and colleagues highlight the overlooked role CHWs play in fostering a community’s capacity approach to health issues within a sociocultural context. Embracing a cultural or community assets paradigm does not mean that these communities do not have serious needs. It means that CHWs must

70  Theoretical Foundation

start with what is right about a community before focusing on their needs. These resources must be identified and enlisted in interventions (Delgado & Humm-​Delgado, 2009), with health care needs being grounded within existing formal and informal services to maximize outreach and effectiveness (Chang, Polesky, & Bhatia, 2013; Tavernise, 2012). Community health fairs are another example of an ideal setting for reaching Latinxs and other groups reluctant to engage formal health care settings (Delgado, 1999; Murray et al., 2014; Yates-​Doerr & Carney, 2016). Attendees are in the “proper” state of mind and the atmosphere is celebratory and nonthreatening or nonstigmatizing. Further, it transpires within the geographical setting of the community, increasing physical accessibility. This “climate” is possible because it is based on all facets of what is commonly referred to as community base.

Life Course Perspective The CHW field is immense and ever expanding, making grasping its significance difficult to capture and analyze. A  life course perspective serves a useful purpose by examining how CHWs function across different major age groups, and in this case, the focus will be on youth, adults, and older adults. Each age group covers a major period of time, and within-​ group differences take on significance in influencing developmental stages and tasks. Although the literature is not evenly distributed across the life span, and youth and older adults have not been beneficiaries when compared to adults, this approach still has relevance in reporting major findings and recommendations for four population groups (formerly incarcerated, unauthorized, homeless, and those in recovery). These groups are not mutually exclusive, making individuals sharing multiple jeopardies even more marginalized and arguably in greatest need. Further, these groups are not restricted to any one age group, with youth, adults, and older adults being represented, and each group bringing unique as well as universal needs and challenges. This life course perspective will be applied to four major groups that have particular relevance for the field of CHWs because of their marginalized status. Figure 5.1 provides a visual representation of how this section will unfold.



A Conceptual Foundation and Framework  71

Figure 5.1.  Life Course and Special Population Groups

Readers are warned that a life course perspective emphasizing three major age groups brings tremendous limitations to any analysis. Each age group brings diversity within a group due to sociocultural and demographic considerations. These age groups are not monolithic, making generalizations arduous. Baby boomers can fall under an adult or older adult category; latency age youth are different than late aged adolescents. The greater the specificity, the more targeting CHW interventions can occur. Not all groups have received equal attention. CHWs targeting urban youth have started to achieve a high degree of attention, but these efforts still pale by comparison with efforts focused on adults (Subtirelu et  al., 2014). Such an appreciation toward team members provides CHWs with flexibility in crafting place-​based interventions, for example. There is utility in thinking about using age groups in developing an in-​depth and nuanced understanding of how age influences perceptions and experiences, with health and health care and the role that can influence how it unfolds in health interventions. A life span perspective is familiar to those in human and health services, bringing concepts and language that can resonate when applied to marginalized groups.

Conclusion The importance of establishing a foundation from which to undertake an examination of CHWs and their role and significance in this and other countries is undeniable. These workers have emerged because of a dire need to serve undervalued groups throughout the world, but they face incredible challenges in having needs met in an affirming and effective manner. This chapter provided a vision, informed by values, principles, conceptualization, and a life course framework and capacity enhancement paradigm guiding the unfolding of the role and services provided by CHWs. The

72  Theoretical Foundation

following chapter focuses on the rewards and challenges of understanding their role within a highly diverse practice field, but one promising to increase in the near future. An expanding universe continues to expand! Some of the values and principles discussed in this section may resonate, while others may be foreign or not shared. How they get sorted is an important process, with outcomes being manifested in community health interventions. CHWs must be able to sort and operationalize these values; supervisors must help them in this process and in obtaining necessary consultation and training.

6 Community Health Workers/​Promotores de Salud Definition, Parameters, and Challenges

Introduction The previous chapter provided a foundation for examining how community health workers (CHWs) are influenced in carrying out their responsibilities. This chapter, in turn, provides a detailed examination of how their roles unfold on a daily basis and why this health care force is playing a critical role in the nation. Important attention will be paid to defining CHWs, although that task is complicated. The parameters of CHWs’ work translate into a practice world that seems to have no limits, and having such an extensive arena brings immense challenges in supporting, understanding, and appreciating their work, and their potential reach, if properly supported. CHWs face an ethical minefield that increases in significance as this field expands. The nature of their work is fluid, and often necessitates that it transpire in nontypical settings, and this requires the “right” people, with requisite screening, training, and ongoing support (supervision and consultation), for them to be successful in carrying their responsibilities. I  find “fluid” work attractive; it can also be a nightmare for others. That does not make the former “good” and the latter “bad.” In the case of those who fall into the latter category, it means that this work is not their cup of tea and other forms of work are more conducive to their preferences and competencies. Finding their niche is a process. For some, it begins very early in their lives (a calling); for others, it may occur later in life as a result of an event, such as being at the right time and place.

74  Theoretical Foundation

Promotores de Salud: Who Are They and Why Are They So Important? The question of who are promotores de salud is not meant to be provocative, although the answer will prove complex, as evidenced by the list of names they go by (see Chapter 1). The answer of who they are is dependent upon where one sits because they can be employed or volunteer, can function without the awareness of those employed in the field, and may even be invisible to those who volunteer. Obtaining a comprehensive inventory is needed. If achieved, the inventory will become dated the moment it is compiled because of the dynamic nature of this field. CHWs’ importance is enhanced because of their effectiveness in reaching difficult-​ to-​ engage groups under less than ideal circumstances, and in settings not normally associated with quality health care. A  literature review on improving the health care for newcomers and people of color using community navigators, which are different from conventional CHWs, concluded the following (Shommu et al., 2016): Community navigators are trained, culturally perceptive healthcare workers who serve as a link between patients and healthcare providers in order to reduce healthcare disparities. They may also be referred to as patient navigators, community health workers, outreach workers, promotoras, lay health educators, health advocates, peer counselors or medical assistants. Unlike physicians and nurses, community navigators do not provide healthcare services directly; they offer culturally tailored educational support to patients, aid communication between patients and physicians, and guide patients in overcoming barriers to obtaining appropriate healthcare. The first community navigator program was developed in New  York City, USA to serve African American women with breast cancer in 1990. In Canada, the navigation program was first adopted in the cancer care system of Nova Scotia in 2001.

Shommu et al. (2016) concluded that US health navigators usually carried out roles requiring provision of “culturally tailored health education, lifestyle workshops, and self-​care training and guidance to overcome barriers to accessing the healthcare system.” As noted in Chapter 1, CHW definitions and historical origins are closely tied together to the point that they are inseparable, facilitating and hindering



Community Health Workers/​P romotores de Salud  75

analysis. The question of who are the promotores de salud is not meant to be provocative, although the answer will prove increasingly complex, and with any degree of complexity, comes tensions and conflicts. The answer is dependent upon where they are employed or volunteer; if the latter, they function without the awareness of those in the health field, and they may even be invisible to others who volunteer, existing as if in parallel universes. CHWs have been the recipient of considerable scholarly attention due to their role and importance over the past 15 years, although the modern-​day concept has been traced back to the early 1970s, if not earlier (Menéndez, 2016). According to the National Community Health Advocacy Study, which is almost 20  years old, there are 66 titles for CHWs (Rosenthal et al., 1998). The following are the most popular names that CHWs can go by, illustrating the immensity of the challenge of developing a comprehensive understanding of this field (Somsanith, 2009):  Case Manager, Case Worker, Community Health Extension Worker, Community Health Outreach Worker, Community Health Representative, Community Liaison, Community Organizer, Community Connector, Enrollment Specialist, Health Ambassador, Health Advisor, Health Educator, Health Worker, Indigenous Helper, Lay Advisor, Natural Helper, Patient Navigator, Peer Coach, Peer Counselor, Peer Educator, Promotor/​a, Public Health Aide, and Village Health Worker. Many of these titles provide evidence of the primary role of health workers in reaching those in greatest need (Kwesigabo et al., 2012; Suther et al., 2016). The term “community health worker” is arguably the most popular one used in the English-​speaking world and the one primarily used in this book, including “health worker” and “promotores de salud.” Thus, “community health worker” can be a name for the position as well as the broad category that can encompass numerous job titles that fall under this classification, illustrating the challenge of nomenclature, a critical step in mapping this practice and scholarship universe. The American Public Health Association (2014), a significant health association with a large and influential membership, defined CHWs as encompassing many of the key elements associated with various definitions in the field, and this definition guides this book: [A community health worker is] a person who is a trusted member of and/​or who has an unusually close understanding of the community

76  Theoretical Foundation served in the delivery of health-​related services through either working directly with providers or their partner organizations. This trusting relationship with the community enables community health workers to serve as a liaison between health and social services and the community to facilitate members’ access to services and improve the quality and cultural competence of services delivered. Community health workers build individual and community capacity by increasing health knowledge and self-​sufficiency through a range of activities such as outreach, community education, informal counseling, social support and advocacy.

This definition incorporates many key concepts introduced and developed in this book, including having CHWs enhance community capacity and be a source of key role and practice conflicts and challenges. The Institute of Medicine of the National Academies identified a list of CHW initiatives and programs across the United States, highlighting the popularity of these workers (Pittman et al., 2015). CHW appeal goes beyond any one age group, and it is best to think about them as providing a range of services across the life span (Gambin et al., 2015; Kayemba Nalwadda et al., 2013; Rapkin, 2015; Shaw, 2015; Singh, Cumming, & Negin, 2015; Smylie et al., 2016; Wenzel et al., 2012). There is little question that the future remains bright for these workers, and that their respective communities will receive needed care and services. The Department of Labor, as cited in, predicts that CHW demand exceeding that of any other profession by 2024. This prediction calls for taking stock of where this profession has been and developing a greater understanding of why, and how, it has made such an impact in the field of health care. In 2009, the Office of Management and Budget published a comprehensive revision to the Standard Occupational Classification System and added CHWs to the taxonomy, a major step forward for this field. Achieving a distinct classification by the federal government can be considered a monumental achievement and testament to their long journey to occupy a prominent place in the health care field. This does not mean that obtaining a seat at the table did not ruffle any feathers, such as with whom CHWs were initially combined with in the classification “Health Educators and Community Health Workers” (Gilkey, Garcia, & Rush, 2011):



Community Health Workers/​P romotores de Salud  77 Neither health educators nor community health workers were pleased by the prospect of a shared title. Health educators argued that their occupation, which typically requires at least a bachelor’s degree, is broader than that of community health workers’ and encompasses not only health-​ related instruction but also program planning, management, and evaluation. Organized by groups, including the Society for Public Health Education (SOPHE), health educators wrote to the Department of Labor to oppose the new title and to express concerns that the compound classification would render workforce data collected about their occupation meaningless. CHWs were equally unhappy with the shared designation. Although they too recognized shared ground with health educators, they wished to see the distinctive features of their occupation acknowledged. For example, they perceived a greater emphasis in their work on social support, service coordination and referral, and individual and grassroots advocacy. (p. 179)

Functional task overlaps (shared interests and expectations) help create potential collaborative undertakings and competition/​ conflicts between health care providers by providing CHWs with the necessary flexibility at the local level in responding to emerging health needs, tapping social support in the process (Engle, 2016; Taylor, Mathers, & Parry, 2018, 2019). How CHWs are defined is dependent on who is defining them, which is never a “small” task, dictating the “official” numbers in the United States. One estimate by the US Department of Labor (2015) found over 48,000 CHWs across the country. A  dated estimate (2005) of the number and distribution of CHWs in the country found those numbering 120,000. There is a tremendous disparity between these two estimates. Although CHWs can be found across all regions of the country, they were concentrated in New York and California (approximately 8,000 or more in each) and Florida, Pennsylvania, and Texas (3,500 per state) (Goodwin & Tobler, 2008). It is no mistake that these states are highly populated and have a significant number of people of color, with sizable numbers of newcomers whose English is not their primary language. Other regions, such as New England, have CHWs, too (Nelson, 2014). University certification of CHWs has a long history in the United States. The quest to certify CHWs involving college can be traced back over 25  years, and the development of a certificate program founded on performance-​ based methods and popular education principles (Love

78  Theoretical Foundation

et al., 2004). The long history of these efforts is a testament to the recognition of higher learning institutions being responsive to the communities CHWs serve. Riegelman and Wilson (2016) discuss the evolution of CHWs into an academic realm when the Association of Schools and Programs of Public Health’s Framing the Future Task Force and the League for Innovation in the Community College (the League) cosponsored the Community Colleges and Public Health Report. This report advanced recommendations targeting community colleges considering offering public health associate degrees and academic certificate programs. In addition, this report put forth two potential curriculum models, which were supported by the Office of the Assistant Secretary for Health of the US Department of Health and Human Services. Community colleges have been signaled out as having a potential to assume a prominent role in educating CHWs, particularly those from underrepresented groups (Johnson, 2016; Riegelman & Wilson, 2016; Wilson & Riegelman, 2016). The Affordable Care Act places considerable emphasis on prevention (Okechukwu, Davison, & Emmons, 2014)  and provided incentives in reducing health inequities, and institutions of higher learning have responded to produce a needed workforce. The following few examples illustrate this national response: Malcom X College (City of Chicago) developed a CHW basic certificate program in collaboration with several community-​based partners (Haywood et al., 2016). City College of San Francisco is another example of a college offering a Community Health Worker Certificate (https://​www.ccsf.edu/​en/​ educational-​programs/​cte/​student-​resources.html). University of Hawaii Maui College’s (http://​maui.hawaii.edu/​ communityhealth/​) Community Health Worker Certificate of Competence requires 15 semester credits that can be taken over two semesters. Thomas Jefferson University (Philadelphia, PA), in turn, through its Institute of Emerging Professions, offers a Community Health Worker Certificate (http://​www.jefferson.edu/​university/​emerging-​health-​ professions/​programs/​community-​health-​worker-​certificate.html), which can be completed in 10 months through evening classes.



Community Health Workers/​P romotores de Salud  79

Other university/​college examples can be found throughout this book, and these efforts only promise to increase in frequency in the forthcoming decade, providing important data for creation of a comprehensive listing of programs and themes that can aid in future research and evaluation undertakings. The ACA, which made funding available to foster employment of CHWs in underserved areas, provided a needed revenue stream and further legitimized them as an integral part of the nation’s health care system (Bovbjerg et  al., 2013b):  “The ACA and these simultaneous efforts have created a watershed moment for community health workers (CHWs). Both coverage expansions and a new focus on creating value in health care and public health offer new opportunities for CHWs” (p. 1). ACA, too, has the potential of creating greater CHW name recognition, or branding if you wish, to increase their visibility within and between communities (Martinez et al., 2011; Rosenthal et al., 2010). CHWs are receiving increased and well-​deserved recognition in the United States. For example, in 2016, the State of Michigan (with over 600 CHWs) declared August “Community Health Worker Appreciation Month” (http://​www. michigan.gov/​snyder/​0,4668,7-​277-​57577_​59874-​391183-​-​,00.html). Major national organizations, such as the National Council of La Raza, have assumed instrumental roles in moving this field forward, and in this instance, one focused on Latinxs, a group increasing demographically and facing serious challenges in having their health needs met. The US Surgeon General, the nation’s chief medical leader, too, calls attention to the important role that promotores de salud play in this nation’s community health system, and why they have a prominent role to play in future health care (Surgeon General, 2014). Cultural-​asset paradigms can be manifested through Asian, Latinx, and Afro-​ centric cultural embraces and racial/​ ethnic identity (Bridgeman-​ Bunyoli et al., 2015). The continued acceptance of a cultural assets paradigm (Delgado, 2018) reflects on the importance of services being locally based, embracing cultural values and beliefs, setting a foundation for enlisting residents as providers of services, including health promotion, and the support of community organizations central to the social fabric of these communities (Bloemraad & Terriquez, 2016; Coe & Castro, 2013; Omelas et al., 2015; Urrutia-​Rojas & Luna-​Hollen, 2012).

80  Theoretical Foundation

Health promotion focused on Latinxs, for example, can be well received and effective if cultural factors are respected and integrated, and there is a willingness of health educators to modify current approaches to take into account Latinx diversity of composition (Arellano-​Morales et  al., 2016). The Spanish expression “La Cultura Cura,” which translated means “Culture Cures,” captures the sentiments on the importance of culture in the lives of marginalized people. CHWs save lives, making them very socially popular within their communities (Findley & Matos, 2015). CHWs are in a propitious position to be the point providers in delivery of a comprehensive and coordinated system of health care to groups with extensive needs (Brooks et al., 2015). The popularity of CHWs is such that in 2011 the American Journal of Public Health devoted an entire issue to them; their success spurred an increasing number of states to institute laws, regulations, and efforts to address training, credentialing, and cost reimbursements for their services (Kim et al., 2016; Landers & Levinson, 2016). Developing a CHW profile is an important foundation step in advocating for these workers (Ingram et al., 2012). Instituting certification, too, can advance this field in ways that few initiatives can, shaping this field’s evolution in the future. Specialized training and credentialing go hand in hand with professionalization, bringing advantages and disadvantages that must be understood. Increased regulation has the dual purposes of increasing the status and rewards of these positions, but also instituting constraints on them, and possibly undermining or destroying the “essence” of what has made CHWs popular and effective (Siemon & Mendelson, 2012). Massachusetts, Texas, and Ohio, for example, have established certification programs. Benefits to the field can be anticipated or unanticipated. One study of state certifications found that the most frequently authorized component was a defined scope of practice (authorized by eight states), followed by a standard core competency curriculum and inclusion of CHWs in multidisciplinary health care teams, authorized by six states (Barbero et al., 2016). Story and To (2016) report on their study of community health advisor core competencies and identified two very powerful competencies—​an ability to understand through caring, and an ability to deal with pressure from difficult individuals and tension within groups of individuals, which generally go unreported in the professional literature. These “negotiation”



Community Health Workers/​P romotores de Salud  81

skills are predicated upon an individual with strong interrelationship skills and are able to engender feelings of trust. Temple University’s Center for Social Policy and Community development, as part of their CHW training program, identified nine core competencies: (1) Advocacy Skills; (2) Capacity Building Skills; (3) Cultural Competency Skills; (4)  Communication Skills; (5)  Interpersonal Skills; (6) Ethical Practice; (7) Health Promotion Skills; (8) Service Coordination Skills; and (9)  Organizational Skills. The range of these competencies illustrates the incredible challenges CHWs face in carrying out work. Although California has played a pivotal role in the history of CHWs, and it was one of the first states to certify them, it has faced its share of challenges in organizing their association (West, 2014). In the case of Massachusetts, a total of 10 competencies areas were developed to assess certification of CHWs (Wilkinson, 2013). Massachusetts created an association in an effort to give political voice to these workers. New Mexico, however, is credited with establishing the first association of CHWs in the early 1990s (Rosenthal, 2009). Unfortunately, many areas of the country do not have these types of associations (Wennerstrom, 2014). Miller, Bates, and Katzen (2014) identified seven questions that state credentialing authorities must answer in the certification of CHWs: 1. What will be the state’s definition of a CHW? What skills and core competencies will be required? Will the definition address qualifications related to a candidate’s relationship to (or understanding of) the community to be served, which is central to many definitions of the CHW? 2. Will the credentialing be a certification system, in which certified CHWs are designated as qualified to work in the field or a licensure system, in which only licensed CHWs are permitted to perform CHW tasks? 3. Will the state government create and manage the credentialing system? If so, which state entity will handle these tasks? If not, how will the state recognize a private credentialing program? 4. Will CHWs need the credential in order to practice or only need the credential to receive payment for their services? 5. Will the state establish a state training program or establish standards that private entities must meet in order to operate approved training programs?

82  Theoretical Foundation

6. Will people be able to obtain a credential through completion of a training program, through qualifying work experience, or both? 7. Through what process will the credential and training system be designed? Who will be involved in the process? (pp. 2–​3) One can see the magnitude of the challenges facing credentialing authorities in creating and maintaining a new workforce seeking to reach historically underserved groups throughout all regions of the country. Institutions of higher learning instituting various levels of degree programs will aid the credentialing process to unfold in a planned and systematic fashion. These authors also identify four key themes of great relevance for this book and the future advancement of CHWs, including the consequences of excluding those with great potential for contribution to this field of practice at a critical moment in time (Miller, Bates, & Katzen, 2014): 1. Community health workers must be full participants in system design, including identifying skill and core competency requirements, training standards, and certification requirements. 2. Training and certification standards should be flexible enough to accommodate those who may already have been in the field for some time, and those for whom classroom and written learning may be challenging. This includes work experience or grandfathering solutions, as well as appropriate language training. 3. Some risks of certification—​the potential to exclude some members of the traditional CHW group through background checks or insufficient training locations—​may be mitigated through careful design and sufficient stakeholder identification of such concerns before policies are adopted. 4. States have not yet incorporated into credentialing standards any criteria related to the candidate’s relationship to or knowledge of the community, despite wide acceptance of such qualifications as essential to the CHW’s role. This aspect of standard setting may represent the greatest public policy challenge in future efforts to codify CHW qualifications. (p. 24) Certifications are constantly evolving; they serve as an indicator of how these CHWs have started to get noticed and have their unique and universal



Community Health Workers/​P romotores de Salud  83

needs met. There have been lessons learned, and the process is not without its faults and challenges A paucity of research on how state certifications have altered CHW delivery of services has hampered our understanding (Siemon, Shuster, & Boursaw, 2015). Stelzig (2015) examined the role of certification in motivating CHWs to upgrade their knowledge and skill sets to qualify for renewal, but this motivation continued post certification, highlighting how formalized self-​improvement undertakings can be considered a lifelong educational journey, enhancing their human capital. Social communication advances have found their way into the field. The potential of e-​learning, for example, has been explored as a means of increasing the competencies and expanding the options for training that are no longer restricted by organization and geography (Garcia, 2013). Mobile technology and social media, too, emerged, adding new and exciting dimensions, and facilitating service delivery by promotores de salud (Ayiasi et  al., 2015; Baezconde-​Garbanati, 2013; Braun et  al., 2013; Payne et al., 2015). It also added formidable challenges (Jones et al., 2012; Leon, Schneider, & Daviaud, 2012). These new methods for engaging groups have added to CHW job descriptions and furthered the need for a dynamic definition of their roles (Palmisano, 2014; Tumusiime et  al., 2014). These methods can be very empowering, too, which is essential for them in carrying out their historic community-​centered mission (Buehler, Ruggiero, & Mehta, 2013); however, increasing stressors in being all things to all people result in poor-​quality services and staff turnover.

Classification of Community Health Workers We must fight the temptation to develop an elaborate and inclusive classification system of CHWs. This declarative statement is not meant to be provocative or an attempt to “take the easy way out” on a difficult task. Rather, this charge is made in the spirit of capturing the expanding nature of this field. Efforts to certify CHWs bring advantages and disadvantages for this profession. If addressed well, it enhances their position within the health care field; if handled poorly, it diminishes and limits the nature of their potential contributions.

84  Theoretical Foundation

CHW roles are continually evolving and expanding into new arenas. Variability in role expectations brings with it inherent challenges in understanding their effectiveness and calling for identification of core elements (Arvey & Fernandez, 2012; Rodríguez & Peterson, 2016; Taylor, Mathers, & Parry, 2018, 2019). As addressed in Chapter 1, it limits their reach into new and exciting community arenas, representing the heart of the health care arena. Singh and Chokshi (2013) discuss the functions that CHW can fulfill, illustrating their attractiveness for engaging those not comfortable or feeling safe with existing care systems, and how different they are from their more conventional health care colleagues, including assuming a brokering role between consumer and organization: Beyond reducing readmissions, CHW programs may help to address the root causes of preventable chronic disease. Social exclusion, poverty, marginalization, and the built environment contribute to the high burden of chronic disease, particularly in low-​income communities. But social services addressing these social determinants of health are too often fragmented. CHWs who can integrate knowledge of the local social service milieu with knowledge of patients’ individual circumstances can create a vital link for vulnerable populations. In concert with social workers, CHWs can mobilize social support, create avenues for family members to engage in the care process, and strengthen long-​term community relationships that help patients sustain healthful behaviors. (p. 894)

CHWs are well integrated into the social fabric of their communities, increasing the strengths of their relationships, insights, and abilities to socially navigate multiple roles and demands upon them (Kok et  al., 2017; Lichtveld et al., 2016). Their strategic position is essential in making them effective. CHWs can find themselves socially marginalized within the health care systems employing them, mirroring the communities they serve, and necessitating changing multiple structural factors and organizational arrangements (Torres et al., 2018). Findley et  al. (2012), in a unique geographic-​bound study of CHWs and employers on their scope of practice in New  York City, identified a



Community Health Workers/​P romotores de Salud  85

consensus on five scopes of practice elements helping frame the expansiveness of their work (outreach and community organizing, case management and care coordination, importance of home visits, health education and coaching, and brokering social systems). In addition, they identified several key elements for each. These efforts are playing instrumental roles in bringing clarity to this field, particularly as it continues its evolution in an expanding care arena. Geographic-​bound studies of CHWs are important because they provide the opportunity to undertake case studies capturing the role of socioecological factors in shaping how they carry out their roles. These studies introduced mixed methods to gather culturally informed qualitative and quantitative data, and develop a nuanced understanding of CHW–​ environment interactions. It is easy to become overwhelmed in developing a comprehensive understanding of what CHWs do and their needs to carry out their roles in an efficient manner. Frameworks provide a tool that helps in classifying their functions and competency needs. Fortunately, there are a number of frameworks that have been used in the field. Frameworks give order to roles that appear to be too ambiguous to understand, bringing together values, theory, and political considerations (politics) as a way of grounding a perspective within the “real world.” CHW classification is best grounded within a series of frameworks on models of care, core functions, and skill sets. Somsanith (2009) identified five care models that lend themselves to incorporating CHWs, with each bringing distinct advantages and disadvantages from an organizational and service delivery perspective: (1) as a member of a care delivery team; (2) navigator (broker); (3) screening and health educator (provider of tests and education); (4)  outreach/​enrolling/​informing agent (disseminator of information in the community); and (5)  organizer (advocate and social change agent on specific health concerns). These models necessitate core functions (roles) to be carefully defined and supported with corresponding skill sets (competencies), including training and supervision, which are essential in helping CHWs carry out their roles. These core functions cross conventional boundaries usually associated with health, with organizing as a prime example.

86  Theoretical Foundation

Effectiveness of Community Health Workers Any discussion of CHW effectiveness is fraught with political, conceptual, and methodological pitfalls and challenges, although the topic itself is unavoidable in any meaningful discussion of the topic. Yet valiant efforts at addressing effectiveness have been attempted, as covered in this chapter. The search for a definitive answer, such as the search for “truth,” depends upon who is posing the questions that will lead to the “right” answers. The process is “messy,” requiring multidisciplinary efforts, including CHWs having a significant voice in these efforts. One must never fear posing questions concerning effectiveness. The process of seeking the answer must not eschew a serious look at the values forming the foundation of the methodology and how effectiveness is framed—​in other words, effectiveness according to whose standards. Finally, there is no disagreement that CHWs must play an integral role in shaping the entire research process from the formation of the questions, selection of the methodology, gathering of the data, interpreting the results, and issuing a report and recommendations. CHWs symbolize hope for a better future in marginalized communities and for good reason, and this hope is contagious for those they serve and also critical for their well-​being (Shelton et al., 2016): Programs and policies that support the use of community-​based lay health advisors (LHAs) hold tremendous promise for reducing cancer disparities. LHAs are trained peers or community members who share similar social, economic, cultural, and linguistic characteristics with the population of interest and typically deliver health education, navigation, and support in a range of community-​based and clinical settings. LHAs are often referred to as promotoras(es), peer educators, community health advisors, navigators, or peer outreach workers in the literature. Such programs are based on the premise that engaging community members contributes to community empowerment and capacity building, while also raising awareness of health and social justice issues, enhancing access to care, and improving health behaviors and outcomes. LHA programs are increasingly being implemented in the USA and globally for a wide range of health issues.

This description of lay CHWs illustrates the wide scope of services that they provide and why they represent hope in the health field addressing



Community Health Workers/​P romotores de Salud  87

health inequities and providing a foundation for achieving social justice.

Certification of Community Health Workers:  Rewards and Challenges Certification of CHWs was initially broached in the introductory chapter and will be touched upon here. A number of university efforts at offering CHW certificates were cited earlier in this chapter. These higher education efforts are reinforced by states moving to certify CHWs. In 2016, there were an estimated 16 states across the country with CHW certification programs, with indications of more to come (http://​www.cthealth.org/​publication/​ state-​chw-​certification/​). Dower, Moore, and Langelier (2013) issue a charge to restructure health professions’ scope of practice regulation and licensure for the nation to support workforce innovations in desperate need to ensure the success of the Affordable Care Act. The authors argue the existence of disconnects between state-​based laws, regulations, and practitioner competencies, and legal scope-​of-​practice laws, which have existed due to lack of uniformity across state laws and regulations. CHWs illustrate an extensive practice range with differences existing between states in how they are regulated. The benefits of a centralized national clearinghouse for gathering scope-​of-​practice information are well understood if organizations and state regulatory bodies are to make decisions based on the latest information.

Effectiveness of Community Health Workers The topic of “effectiveness” is bound to come up in any discussion of CHWs (Hoffmann, 2016), and it will come up again throughout this book because of its significance. This subject matter needs to be addressed in a purposeful manner for the field to continue to advance. Fortunately, this subject has received considerable scholarly attention, and this attention only promises to continue in the future (Bellhouse et al., 2018; Khetan et al., 2017; Lohr et al., 2018). CHWs’ impact or effectiveness can be viewed from a multiplicity of perspectives with four views enjoying popularity (Malcarney et  al.,

88  Theoretical Foundation

2017):  (1) ability to conduct outreach; (2)  trust-​ building capability; (3) empowerment of consumer and community; and (4) a focus on social determinants of health. Malcarney and colleagues (2017) note: The ability to articulate these modes of impact could help CHWs defend and protect their unique contribution, especially as they increasingly form part of team-​based clinical care. The modes of impact may also assist in the review of current lists of CHW competencies, as they place the focus squarely on the reasons CHWs are being hired and help to categorize the activities that generate impact. To the extent that this helps identify additional competencies that may be lacking from current competency sets, the use of competencies in any state standardization process will be more likely to maximize the unique roles and capabilities of CHWs. (p. 378)

Understanding the impact of CHWs is closely tied to understanding their competencies, and how best to identify and enhance them through supervision and training. Franlin et  al. (2015) identified five key themes in increasing the effectiveness of CHWs and health care teams: (1) shared understanding of roles, norms, values, and goals of the team; (2)  egalitarianism; (3)  cooperation; (4) interdependence; and (5) synergy. Jack et al. (2017), in a review of the literature on CHWs, found that these workers can play a significant role in reducing unnecessary care utilization, with resulting cost savings. CHWs have proven to be effective in improving childhood nutrition, preventing and treating serious childhood illness, treating malaria, reducing maternal mortality, reducing HIV transmission and tuberculosis, and addressing multiple Millenium Development Goal (MDGs), to list several major health concerns (Perry & Zulliger, 2012). CHWs have been effective in LMICs (noncommunicable diseases prevention and control), with particular significance with initiatives focused on tobacco cessation, blood pressure treatment, and diabetes control (Jeet et al., 2017). Our understanding of benefits that CHWs bring is starting to expand beyond traditional views to encompass new perspectives, such as the role they play in increasing the effectiveness of interdisciplinary teams (Brownstein & Hirsch, 2017). Enriquez and Conn (2016), in a review of the literature on Latinx obesity interventions, found strong evidence for the effectiveness of promotora-​ led interventions in reducing obesity and other related health conditions,



Community Health Workers/​P romotores de Salud  89

indicating that peer-​facilitated interventions offer great promise in medication adherence by encouraging healthful behaviors. Peer-​to-​peer training brings an added dimension that has great potential and will increase in importance in the future for engaging and preparing a cadre of workers (Willock et al., 2015). Lay health workers are effective in promoting wellness within their respective communities, bringing added dimensions to their roles (Galiatsatos et al., 2016). Peers are in a propitious position to understand the influence of cultural values by being able to speak in their own language, having knowledge of the barriers or challenges they face in creating proper diets and exercise regimes, and taking into account their local circumstances (Fisher et al., 2015; Siantz, Henwood, & Gilmer, 2016; Subtirelu et al., 2014). Peer-​ led efforts, such as the case of Latina volunteers and cancer, were found to be very beneficial to the volunteer by improving their health through increased use of cancer screening opportunities, and that of their immediate family and friends, bringing instrumental benefits to their lives (Molina et al., 2018). CHWs, too, have assisted in medication management in newcomer communities and among other groups, a community with historically low health literacy, expanding their reach into a range of health services (Bailey et al., 2016; Buckley, 2013; El-​Khayat, 2017; Rojas et al., 2015). Newcomer health literacy among those who do not have English as their primary language is a critical barrier in provision of quality health services, as with Latinx newcomers (Becerra, Arias, & Becerra, 2017; Calvo, 2016). CHW effectiveness continues to be a focus as nations, and particularly the United States, attempt to reduce health inequities by maximizing resources. According to the World Health Organization (Lehmann & Sanders, 2007), CHWs may not be inexpensive, but still they have proven to be effective: “Given present pressures on health systems and their proven inability to respond adequately, the existing evidence overwhelming suggest that particularly in poor countries CHW programmes are not cheap or easy but they are nonetheless a good investment” (p. 27). Innovation is closely tied to CHWs, with advances in this field finding their way into other arenas, furthering their influence. Martin (2015) notes that despite a proliferation of health worker programs across the nation, and greater attention paid to their cost-​effectiveness, research on financial and health impacts is still inadequately documented. Vaughan et al. (2015), in a literature review on costs and cost-​effectiveness

90  Theoretical Foundation

of these workers, concluded that they can be cost-​effective from an economic perspective. This is too narrow a view, and cost-​effectiveness must be viewed from a “nontangible costs and nonhealth benefits” standpoint, broadening our understanding of this workforce initiative, and introducing qualitative measures that can capture cultural nuances. These nuances must cast CHWs into a prominent position in structuring the research and the questions sought to be answered. Rush (2012) argues that CHWs have been cost-​effective, and a return on investment brings an enhanced rationale for using, and expanding, their utilization. CHWs share a vision for their communities that is affirming and empowering, although they do not belong to any one profession or discipline, bringing flexibility in local conditions and circumstances dictating who can become a health promoter and how their role can unfold. Perry and Zulliger (2012) give voice to a movement that further advances the mission and effectiveness of CHWs across the world’s health sectors: Governments, civil society (including NGOs), communities, international health organizations, technical organizations, and donors need to support the groundswell of support that is emerging to transform health systems. Doing so will enable CHWs to play a foundational role in reaching every household with essential services and providing a referral link to enable people to more readily and effectively access higher-​level services within the health system. It is in everyone’s interest for large-​scale CHW programs to work effectively. (p. 12)

CHWs play significant roles in this nation and other nations across the world. This call to action will be accomplished against a background of monumental challenges and rewards (London et al., 2018). For CHWs to be effective, they must be grounded in their daily lives within larger social, economic, and political contexts (Maes, 2017). This is facilitated when they live in the communities they serve.

The Glue That Makes Them Effective There is agreement on the importance of using a glue metaphor in determining what makes CHWs effective since it seems to have universal meaning regardless of the subject being discussed. A glue metaphor seeks to



Community Health Workers/​P romotores de Salud  91

capture the “magic” of how a phenomenon is kept together to achieve a particular goal. Efforts to understand CHW effectiveness require that a process of deconstruction take place, with corresponding research and examination of values. Readers are referred to Chapter 4 and the discussion of how organizational barriers are influenced by organizational values and those we embrace, as well as our willingness to question conventional approaches to service delivery. Six factors have been identified for discussion because they strike at the core of effectiveness due to interpersonal relationships. The following are not the only factors but stand out in importance:  (1) trust; (2)  motivation; (3)  intimate knowledge of the community; (4)  language/​cultural competencies/​humility; (5)  empathy; and (6)  commitment. Each element is worthy of a book(s) being devoted to it but only touched upon here. Readers, it is hoped, will develop an appreciation of how these factors interact. These factors are not in any order of importance.

Trust It should not be surprising that the start of the “glue” coverage of CHWs focuses on the importance of trust; after all, trust often represents the cornerstone of any fruitful relationship, whether it is professional or personal, and it is quality that cannot be taught but must be fostered for a helping relationship to evolve (Mundorf et al., 2017). It is often taken for granted that trust must be present until proven otherwise. This conclusion is arguably false. Trust needs to be developed with explicit deliberations and actions, although individuals may be prone to be “trusting” by nature (Ackatia-​ Armah et al., 2016). It takes a long time to develop trust and an instant to lose it, and the importance of gaining and keeping this trust takes on greater significance when CHWs live in the communities that they serve. What is meant by trust? Davis (2008) provides a workable definition of trust: “Despite this complexity, some consensus does exist. Scholars appear to agree that trust involves some degree of risk because the trusting individual (hereafter, the trustor) lacks complete knowledge and control over the current and future actions of others. . . . By trusting others, we are able to act despite such risk. Trust enables individuals to engage in the tasks of today and approach those of tomorrow” (p. 4). This definition captures its immediate and future importance and its elusiveness.

92  Theoretical Foundation

Although the focus of this section is on trust and CHWs, trust must be viewed from multiple perspectives, including trust in the health system (Ozawa & Sripad, 2013). What is the “glue” that binds CHWs and consumers? That answer is at the crux of their effectiveness and worthy of further study (Gampa et  al., 2017). A  trusting and respectful relationship between CHWs and consumers is at the crux of what makes them successful (Greenberg, 2016): These last few years the buzzword in health care has been to be “patient-​ centered.” But I  don’t believe in it. I  believe in being “relationship-​ centered.” And this is not semantics. This is a shift of mindset. Being relationship-​centered emphasizes partnership, support, union and compassion. It brings the expertise of both provider and patient to the interaction. It strengthens both their skill sets as they work together. And it aims for both to be more successful. I’m not telling you anything new. You know this. By merely being human, you know the need you have for, and the power of, relationships in your life. You know how the good ones make you better, stronger, more complete, more confident and comfort you in times of need. They also make you healthier. It should come as no surprise that social connectivity and relationships is one of the commonalities shared by people who live in the Blue Zones. Places across the globe where people are the healthiest and live the longest.

Trust is a key factor in the relationship between provider and recipient of services (Ackatia-​ Armah et  al., 2016; Nxumalo, Goudge, & Manderson, 2016). The ability to be free to open up and share, as well as follow through on advice, is predicated upon the presence of trust. There also seems to be a deep and abiding sense of caring, a critical element in any form of meaningful relationship (personal or professional), at the core of CHWs (Eriksen et al., 2013; Ruano et al., 2012). Vargas (2016) provides an in-​depth glimpse into what makes health navigators successful, with establishment of trust fulfilling a critical element in their success: The provision of health insurance benefits to disadvantaged minority populations requires navigators to have an assortment of repertoires for establishing legitimacy and trust. Navigators must build rapport,



Community Health Workers/​P romotores de Salud  93 respond to challenges to their integrity, and thoughtfully describe their purpose to clients. Successful accomplished this by deploying a combination of repertoires such as ceding control, distancing, and building ethnic solidarity. Effective navigators validated clients’ concerns and directly responded to skepticism. In contrast, ineffective navigators took their legitimacy for granted. These navigators either informed or insisted that clients enroll without building legitimacy during the interaction. (p. 267)

Trust represents a core element in facilitating the use of varied techniques that, when they come together, lead to successful engagement of highly marginalized people. Trust cannot be taught, unlike other techniques, and trustworthiness becomes a factor that must be screened for when hiring CHWs.

Motivation Motivation is well recognized as a key factor in any helping professional entering this type of role, just like it is when discussing a help-​seeking process, and it plays an influential role in CHW effectiveness because of how it translates into practice. Are the factors similar or different between those who volunteer and those who elect to enter this role as a career? What motivates (intrinsic and extrinsic) volunteer CHWs to assume this role is deserving of in-​depth examination (Glenton et al., 2013). Developing a profound understanding of CHW motivation brings immediate and long-​term benefits (Squires & O’Brien, 2012): Understanding the process of becoming a promotora may help new groups assume this role more effectively and may cause existing promotora groups to evaluate ongoing personal and professional transformations that could influence their work. We anticipate that this study and others focusing on promotoras’ occupational development will help uncover important factors that promote the success of such programs. Developing an experienced promotora workforce may not only help improve health outcomes locally but also serve as a culturally appropriate model for reducing Latino health disparities nationwide. (p. 470)

94  Theoretical Foundation

The field cannot be expected to thrive and maximize resources without policymakers understanding their rationale for joining this workforce. This knowledge will inform recruitment, training, and support for these workers within the health care field. Understanding CHW motivation is an essential element to better screen, train, and support this workforce (Singh et al., 2016; Strachan et al., 2012). The fact that CHWs tend to be of color or with other socially marginalized backgrounds, and specifically wish to serve their communities, translates into a marginalized group wishing to reach another marginalized group, undermining their power within the health care system (Maes, Kohrt, & Closser, 2010). Gilkey, Garcia, and Rush (2011) note that resistance within CHW ranks to professionalization and compromising their perceived mission to serve their respective communities. It is important to reemphasize that not all CHWs are paid staff. Assuming the role of CHW has been referred to as transformative for them when examined from a role theory perspective, which emphasizes aspects related to identity, culture, behavior, and cognitive processes. Squires and O’Brien (2012) undertook a qualitative study of Latina promatoras’ motivation for assuming this role and found that they were driven by a desire to develop as individuals and to give back and serve their community as advocates. Knowledge acquisition benefits them personally and their families, reinforcing the importance of familismo values. Social recognition, developing a sense of social responsibility, and self-​ efficacy, for example, were strong motivators in a study in India (Gopalan, Mohanty, & Das, 2012; Takasugi & Lee, 2012). These factors are not unique to India and can be found manifested in a variety of ways within the United States. Greenspan et  al. (2013), in a literature review from 1987 to 2012 (25  years), and a qualitative study of 20 volunteer CHWs in Tanzania, concluded that motivation is the result of an interplay of several interacting key factors: Because volunteer CHWs may not be able to depend on financial earnings to meet their basic needs or to provide sufficient motivation, they are forced to accumulate a set of motivators that provides moral, material, and financial support and allows them to devote time to CHW-​related activities. In this study, the family, while not highlighted in the existing literature, was found to be a particularly important source of motivation. In order to sustain the family as a source of support, program implementers



Community Health Workers/​P romotores de Salud  95 should consider providing compensation packages that relieve the burden that supporting CHWs can place on families. In addition, financial incentives and in-​kind alternatives provided at the organizational level that allow CHWs to worry less about other income-​generating activities and devote more time to CHW tasks can make CHWs feel more supported in their work and thereby reinforce the altruism that CHWs already exhibit.

Although the generalizability of the Tanzania study findings are limited, and more specifically because of the focus on volunteers, it raises important policy and programmatic implications for the recruitment, training, and support of health workers. Male CHWs, not surprisingly, have largely escaped attention in the scholarly literature. A rare study focused on Latinx CHWs found that three key motivators emerged to play a significant influence on their engagement (Macia et al., 2016): (1) Promotores helping others was a prime reason for becoming a worker but being paid was important; (2) Promotores’ valued learning as an ongoing process that was facilitated by the creation of culture that emphasized cooperation among them and learning to listen; and (3) Promotores experienced great difficulty separating their personal lives and their role as promotores, bringing added meaning in their lives. (p. 314) The introduction or reinforcement of meaningful purpose becomes a significant theme and energy in the lives of CHWs, regardless of their gender or sexual identity, introducing a key element of motivation that cannot be taught and must ideally be screened for in selecting CHWs.

Intimate Knowledge of Community Readers may wonder whether getting to “know” a community only requires reading the right documents, watching appropriate documentaries, walking and observing the neighborhood (ethnographic), and talking with the “right” residents. True, this process as outlined earlier, provides a “nice”

96  Theoretical Foundation

knowledge of the community, but it does not translate into “really” knowing the community as a resident and active participant in a community’s history that comes from longevity, sharing the language and culture, and not leaving the neighborhood at the end of a workday to go somewhere else to live. CHWs invariably live within the community they serve and have an invaluable vantage point—​a view that outsiders do not possess. Further, they are comfortable being there, increasing their ability to socially navigate to increase their knowledge base. The community knows them because they are neighbors, they may attend local houses of worship, and they participate in the life and celebrations of the community as insiders. They are not extraneous but central to their respective communities. This observation is not meant to dissuade outsiders from becoming CHWs; it is meant to convey the importance that intimate knowledge that locally based, or indigenous, CHWs possess (experiential knowledge) that cannot be obtained in a book, regardless of how well it is written. Understanding and valuing an intimate knowledge of a community is a form of knowledge that must be tapped in the recruitment and support of CHWs, and more so when they target marginalized groups.

Language, Cultural Competencies, and Humility Possessing community knowledge, language, and culture must be accompanied by competencies in those areas, and this is where indigenous CHWs (those who share background with those they seek to serve) become a critical factor in making them acceptable, particularly among groups highly suspicious of outsiders, as evident in the special populations selected for focus in this book. Understanding, communicating, and embracing cultural values is a proven way to minimize or reduce barriers between service providers and consumers of services. When CHWs share the same ethnic or racial background, it minimizes the potential barriers, although it does not guarantee this to always to be the case, increasing positive outcomes (Murayama et  al., 2017). These competencies must be integrated into job notices and descriptions and be part of the competencies that will be valued and promoted once hired. As summarized by Ballard et  al. (2018), the incentivization of CHWs is a subject that has been widely debated.



Community Health Workers/​P romotores de Salud  97

I often refer to culture using the metaphor of a cloud. We can see and describe a cloud and track its movement. However, try grabbing a cloud, and it quickly becomes apparent that it can be challenging. Assessing language competencies is much easier, although the presence of various dialects makes communication different. Spanish spoken in Texas or Arizona differs considerably from the Spanish spoken in Miami and New  York City, for instance. Language and cultural affirmation require a nuanced assessment that takes into account local circumstances and needs.

Empathy Empathy allows CHWs to place themselves in the lives of those they serve. There is extensive research highlighting the role and importance of empathy in the helping process (Peak et  al., 2016; Sassenrath, Pfattheicher, & Keller, 2017). The ability to not only feel someone’s anxiety, pain, and frustration but also being able to share similar experiences that help convey this understanding and appreciation is a key element in CHWs’ effectiveness. Empathy is facilitated when a CHW and consumer share similar life histories (Subramoney, 2016). Here readers cannot help but see how the boundary between trust and empathy gets breached. Mind you, these are separate concepts. One can easily argue that they are both sides of the same coin (Loyola, 2016): “Skilled helpers . . . use empathy to build the foundation of a trusting relationship for the purpose of establishing an effective working alliance with others. It is also a means of increasing practitioners’ interpersonal effectiveness and in enhancing outcomes with their clients. Thus, empathy can be used as therapeutic leverage  .  .  .  suggest[ing] that possessing the skills of empathy is needed for one to become a competent helper” (p. 26). A shared history often facilitates a bonding experience. Is it automatic? No. Having a shared experience enhances the probability that it will lead to an openness that can prove fruitful in conceptualizing and delivering services. Helping professionals are well acquainted with this concept and how it maximizes the benefits from work undertaken by helping professionals. The literature on effectiveness of CHWs working with marginalized groups sharing similar ethnic and racial backgrounds and socioeconomic class was addressed earlier in this book and is quite clear. Those

98  Theoretical Foundation

CHWs possess epistemological knowledge that must not be overlooked or undervalued in understanding their effectiveness.

Commitment Could it not be argued that everyone in the health care field is committed, otherwise why go into this profession? I would not leap to this inspirational conclusion. Some of us may have started with the noblest of intentions and “we lost our way” in life’s journey; others, unfortunately, never lost our way because that was never our motivation. Commitment is a concept that covers attitude and outcome, such as a willingness to continue to remain employed in a particular job or profession (Tourangeau et al., 2017). The earlier discussion on CHW motivations identified a series of factors, most notably a desire to make a difference in the lives of consumers, for entering this field, be it as a volunteer or as a career. It is arduous to reinforce motivation if we are not clear about the factors that are operating for creating this motivation in the first place. Although payment for engaging in community health work has emerged in the scholarly literature as important, at no time have the topics of becoming rich, acquiring prestige, and attaining power found their way into this literature, for obvious reasons. Discussion with anyone in human services will quickly uncover a series of factors for entering these professions, but power, prestige, and wealth will not be part of the motivation and commitment. Thus, CHWs make a commitment to serve their community that goes far beyond the typical factors associated with professionalism.

Home Visiting Adam (2012) traces a very detailed history of home health visiting in England to 150  years ago and issues a challenge that resonates among CHWs:  “If they are to maximise potential impact in the future, it is important that health visitors now strengthen their own identity—​both with the public and with politicians. One way of doing so would be to improve the professional research base, but another is to ensure that their voice is heard.” The theme of health worker voices permeates this book.



Community Health Workers/​P romotores de Salud  99

Home visits have a long history within the United States and are certainly not limited to profession (Patten et  al., 2018). Professions such as nursing, corrections, and social work stand out in this historical account, with CHWs taking on this mantle. Ferguson (2018) argues convincingly that home visits are best thought of as a distinct form of practice rather than an extension of organizational practice because homes represent “a distinct sphere of practice and experience in its own right” (p. 66). It can be argued that what transpires during home visits is more than an actual intervention, making physical location take on greater significance; this “natural environment” is conducive for engagement because it increases the likelihood of attendance and goal setting, and conveys a stance that the consumer matters (Corr et  al., 2018; Morrison, 2017; Shumskiy, Raju, & Tschudy, 2016). Home visits have been referred to as “cultural windows” into intervention priorities because they place a CHW in the midst of the world of the consumer regarding culture and its symbols (Lamorey, 2017). The concept of home is one that is heavily laden with emotional meaning for those on both sides of the divide of provider and recipient of services. Its symbolism is only matched by its potential in reaching and serving those in need. The Patient Protection and Affordable Care Act established the Maternal, Infant, and Early Childhood Home Visiting Program, which has provided $1.5 billion to states over a 5-​year period for home visiting program models. Ollove (2016) illustrates the experiences of CHWs: On a beautiful early summer day, Tara Nelson navigates her sturdy Kia Forte along Rochester streets from one home visit to another. First she helps a recently divorced Mexican immigrant and mother of four boys clear up an insurance snafu that has taken Nelson months to unravel. The mix-​up had left the woman with a $69,000 medical debt she had no chance of repaying. Next, Nelson dropped off a doctor’s note at an assisted living facility that had refused to allow an elderly patient of hers with multiple chronic illnesses to receive visits from her beloved dog. She had gotten a statement from a doctor saying that the patient’s Maltese Shih Tzu was a “therapy dog”—​relieving anxiety and depression. The 84-​year-​old woman smiled broadly when she heard the news, her eyes filling with tears. Finally, she visited Linda Kerrigan, a 62-​year-​old woman, also with multiple illnesses, who lives in a public housing tower for those with disabilities. Kerrigan had suffered several falls from her bed at night.

100  Theoretical Foundation Nelson had repeatedly dropped by and left messages for a medical device supplier in town, trying to see if they would donate bed railings for the woman. But Nelson never found the place open and her calls went unreturned. Today, after helping Kerrigan fill out some disability forms, Nelson asks her if she’d be open to a prescription for a hospital bed. The woman agreed. “I couldn’t even imagine my life without her,” Kerrigan said of Nelson. For her part, Nelson said that after working as a security guard, a day care operator and a prison investigator, she knew this was the work she was meant to do. But, she said, it’s not for everyone. “You have to have the right kind of heart to do this job.”

This description humanizes these visits in a manner that statistics cannot. Not everyone can undertake this type of work in people’s homes, and this necessitates careful screening, training, and field support. A review of the literature on nursing home visiting in the United States over a 10-​year period (2005–​2015) uncovered evidence that these visits were an effective means of positively addressing social determinants of health and empowering people in the process (Abbott & Elliott, 2017). Another review of 32-​model programs found home visiting to be an effective strategy for reaching difficult-​ to-​ reach families (Avellar & Supplee, 2013). Home visiting is often a key aspect of the work of CHWs, and this epitomizes how deep into a community they can go in providing a service (Breysse et al., 2014; De Jesus et al., 2014; Grantham‐McGregor et al., 2014; Ochoa et al., 2013; Olds et al., 2014). An extensive literature review of CHW in homes with ill young infants found “moderate quality evidence” that home visits improved care seeking to health facilities in resource-​limited settings (Tripathi et al., 2016). Their willingness to venture into homes to assist is a behavioral indication of their comfort level with those they assist. The role and importance of providing services in the home thrusts CHWs into this arena, and it illustrates their ability to enter and be accepted and part of highly marginalized communities (Arrossi et al., 2015; Boris & Klein, 2012; Gertler et al., 2014; Gogia & Sachday, 2010; le Roux et al., 2013; Mannan et al., 2008; Salvy et al., 2017; Tripathi et  al., 2016). Home visits facilitate provider acquisition of knowledge concerning this environment and how it can facilitate or hinder benefits from health interventions (Hayashi & Leff, 2016).



Community Health Workers/​P romotores de Salud  101

In a randomized clinical trial, CHWs have been found to be effective in having patients follow up on posthospital visits, positively increasing posthospital outcomes, which often involve home visits (Kangovi et  al., 2014). Another randomized trial study of Latinxs with type 2 diabetes found them to be effective, too (Hughes et al., 2016). Home visiting can transpire without a place-​based focus. There is no denying that having a place-​based approach increases the attractiveness of home visiting. Place-​based CHWs, as in urban public housing, offer great potential for the field in reducing health disparities among highly marginalized groups (Lopez et al., 2017): This evaluation of a publicly funded, place-​based CHW initiative found using locally recruited CHWs and facilitated referrals to HAs to be well received by low-​income housing residents and effective at rapidly improving services navigation, self-​reported physical activity, and self-​management behaviors. Findings are consistent with literature suggesting that CHW programs generally achieve positive outcomes for chronic disease prevention and self-​management when supportive relationships with patients are developed, and high satisfaction levels and reduction can be achieved when programs established in public housing settings use residents as workers. (p. S286)

The attractiveness of place-​based CHWs goes beyond relationship building and crosses into the research arena, further enhancing the potential of CHWs in carrying out their historic mission.

Appeal The concept of home visiting is very warmly embraced by this author, although I try not to romanticize them. I have very fond memories of making home visits and being well received by many I  sought to help. Visiting a home represents entering into the heart of a family and community, and placing those whose homes I  visited in their most powerful of situations; in essence, I was on their turf, and they dictated the nature of the interactional circumstances. Home visiting has a long tradition within social work. This is not to say that challenges did not exist, particularly in circumstances

102  Theoretical Foundation

where the individual was required (coerced) to accept my visit. Yet these circumstances still involved the worker as a visitor. Findley and Matos (2015) identify home visiting as one of the appealing and worthwhile benefits of employing immigrants as CHWs: In a society where immigrants are fearful of the system and the potential for “the system” to trap and then deport them or to otherwise deny them access to treasured goals, such as family reunification, immigrants are loathe to come to the hospital or clinic unless they have no choice. Strangers who are not immigrants would be equally distrusted in their homes, but the immigrant CHWs are more likely to be welcomed and trusted in the home. Hence, home visits are an essential part of the work that immigrant CHWs do with immigrants. (p. 105)

The benefits identified by Findley and Matos can also be applied to other groups sharing similar concerns or attributes as newcomers. The center stage that homes acquire in health services necessitates supports be in place to maximize their benefits. Home visiting symbolizes community-​centered practice and all of the rewards and challenges associated with CHWs reaching out and engaging those experiencing great difficulty in going to an organization for services on their “home turf.” Logistical and communicational considerations dictate the extent of home visiting and the nature of the services that are feasible and best provided within this context. Home visiting has not generated a wealth of scholarship on the topic, or at least not what can be expected due to the importance of the subject. Much of the literature found its way into the research and human services literature, and researchers learned from this body of knowledge and applied it specifically to CHWs. Accessing a patient’s home is often considered the most accessible site for providing services, and it is the most arduous to achieve for any type of service provider. The Affordable Care Act (Section 2951 of Title II) specifically authorizes state-​sponsored home visiting programs for infants, young children, and mothers, providing CHWs with an attractive venue that increases the likelihood of success in bridging an institution and community divide (Shah, Heisler, & Davis, 2014).



Community Health Workers/​P romotores de Salud  103

Logistical and Safety Challenges Cost considerations and efficacy weigh heavily on home visit policies from an organizational perspective. “One size does not fit all,” and this requires that individual settings conceptualize home visits to take into account local circumstances (Melnick, Green, & Rich, 2016). For instance, home visits do not fall into the traditional Monday through Friday, 9:00–​5:00, holidays-​off schedule. Local communities with high numbers of night workers, for example, necessitate home visitors to take this into consideration. This flexibility brings with it incredible logistical challenges because at one extreme, no two CHWs will share the same schedule around home visits. Finding the “correct” or “optimal” time for a home visit, as a consequence, is arduous for a variety of reasons (Blachman & Blaum, 2016). Vehicle routing and scheduling bring an organizational tracking dimension to home visits (Fikar & Hirsch, 2017). Home visits can be combined with telephone calls (Behm, Ivanoff, & Zidén, 2013). The telephone calls can be substituted for home visits once a relationship has been established. Further, if circumstances allow it, video calls can be used to supplement home visits (Weller, 2017). Scheduling home visits brings a share of logistical and safety challenges to go along with health care provision in circumstances where no two homes are similar. This authors’ experiences in conducting home visits often meant that nextdoor neighbors would be there for a consult. Fear of physical injury and the experience of racial and ethnic discrimination, as in the case of home health workers working across racial and ethnic lines, have tremendous bearing on the level of job satisfaction, a key element in any form of job retention, and more so in the case of CHWs (Jang et  al., 2017; Zachariah et  al., 2009). Corr et  al. (2018) address safety and offer very specific recommendations for minimizing safety for providers of in-​home services: While supporting families who live in poverty, you may encounter locations and situations that are not familiar to you. It is important to always consider your own safety while you are working with families, while also remembering that poverty is not automatically associated with violence or threatening situations. Always be aware of your surroundings

104  Theoretical Foundation and become familiar with the communities in which you are working. The family that you are visiting can introduce you to neighbors or other individuals who you may frequently see. Ask the family for information regarding where to park your car. Keep any valuable or personal items in the trunk of your car and only carry what is necessary. Have a conversation with the family regarding safety tips; they may suggest that you call or text them as you arrive so that they can meet you at the front door or gate to the apartment building. Ensure that your supervisor or someone else listed on the IFSP knows your schedule, particularly if you are in a neighborhood that could be potentially unsafe. Set up an agreement with a coworker, friend, or family member that you will call or text when you leave a home or neighborhood in which you might be concerned for your safety. (p. 8)

The parameters of safety consideration outlined here ground this topic within an important contextual understanding and put the families being visited in helper roles in facilitating home visits. Communication procedures that let colleagues or supervisors know where you are going and have check-​ins help increase the safety of CHWs (Morrison, 2017).

Ethical Dilemmas It is impossible to discuss the valuable work that is provided in homes without corresponding attention paid to the ethical dilemmas associated with these visits. These ethical dilemmas or challenges require that CHWs and their supervisors be prepared and have the necessary protocols to help them when encountered. Informed consent, for instance, must be obtained to initiate home visits, and there may be a reluctance to granting this permission (Day, Leahy-​Warren, & McCarthy, 2016). Distrust or discomfort can be manifested in a variety of obvious and less obvious ways, such as providing wrong telephone numbers or simple refusal to grant permission for a home visit, for instance (Nguyen et al., 2017).

Community Institutions as Collaborators Community health practice casts CHWs within a local context that is intimately known by them, putting them in an advantageous position when



Community Health Workers/​P romotores de Salud  105

compared to their institutionally bound colleagues in responding quickly, and affirmatively, where consumers live. Their abilities to carry out their demanding job can be enhanced through active collaboration between their sponsoring organization and other community-​based organizations, formal and informal (nontraditional setting). These collaborations cover an extensive range from staff outstationing in community settings (placed on a regular basis), having settings provide space on an as-​needed basis for seeing consumers individually or in groups, making referrals, and distributing information on services provided by health workers, to list a few approaches toward collaboration with community-​based organizations.

Definitional Challenges Defining and classifying CHWs has been addressed throughout previous chapters, and it is worthy of further attention here. Efforts to standardize their functions are underway. The enhanced role of local circumstances in shaping how their roles unfold will prove additionally difficult in arriving at a consensus or standardized definition. Readers may be frustrated by this ambiguity. That is a reality and will likely remain the case for the foreseeable future. This does not mean that practical definitions at the local level do not exist, however. There is little question that any effective and operational definition of CHWs requires a collective approach, with current CHWs playing an instrumental role alongside key stakeholders and academics in arriving at this definition. This process must be viewed from an evolutionary perspective. This means that any viable definition must be dynamic and be expected to change over time.

Role Definition and Diffusion Task shifting, which is sometimes referred to as task sharing, is generally a term used to describe the process of having clinical care functions usually assigned from more specialized to less specialized CHWs, is advocated for by the World Health Organization (Kohrt & Mendenhall, 2016; Morris et  al., 2009). The importance of role clarity and the consequences of role diffusion, which can occur when there is lack of leadership and guidance,

106  Theoretical Foundation

for instance, represent serious challenges as well as opportunities for CHWs. Payne et al. (2017) found having clarity of roles being a key factor in enhancing CHWs’ organizational integration. Task shifting has implications up and down the management line if viewed from a socioecological perspective (Massimi et al., 2016). The open boundaries associated with CHWs can prove advantageous in reaching hard-​to-​reach groups in ever-​dynamic living situations, thereby increasing the potential flexibility in how CHWs carry out their tasks (Agyapong et al., 2016; Crowley & Mayers, 2015). This same flexibility can also result in dilemmas that can seriously undermine their effectiveness if not handled correctly, increasing stress on CHWs and their organizations (Lehmann et al., 2009): Reviews of evidence consistently show that delegation of tasks, whether from doctors to non-​physician clinicians, including nurses  .  .  .  from nurses to nursing assistants or aides or to non-​professional or lay health workers and patients  .  .  .  can lead to improvements in access, coverage and quality of health services at comparable or lower cost than traditional delivery models. The literature is also unanimous, however, that any long-​term success of task shifting hinges on serious political and financial commitments. Task shifting requires careful attention to organization, structure and resourcing of health services.

Task shifting, as addressed in the next chapter, complicates development of a uniform role definition of work responsibilities, making provision of training, consultation, supervision, and evaluation more labor intensive and expensive (Smith et al., 2014). Readers may argue that this downside does not counteract the benefits of CHWs assuming greater and more expansive roles in community health.

Community-​Organizational Conflictual Demands Community health initiatives that squarely put health workers in the midst of a community’s ecology bring the potential of immersing CHWs within community politics, and not just their cultural assets. These political tensions influence which organizations workers can reach out to without fear of retribution, and which they must avoid because of the negative



Community Health Workers/​P romotores de Salud  107

reputations that they have within a community. These CHWs, for better or worse, represent the organizations that employ them in the community. When these organizations have organizational legitimacy (positive reputations), their mission is made easier to conduct (Bitektine & Haack, 2015). These organizations are well in tune with community issues, being respected by key stakeholders that can facilitate service delivery, and can open up doors that were previously closed. When the organizations have negative legitimacy, their mission becomes more complicated because they must reconcile representing an institution while simultaneously separating themselves from the institutions employing them. This is certainly never easy but not impossible when CHWs enjoy positive reputations within their communities before being hired by these organizations. Navigating the organizational terrain becomes a part of a job description that is rarely articulated as such, and it is made difficult because conceptualization of organizational legitimacy changes over time (Deephouse et al., 2016). CHW effectiveness is increased when they can reach consumers with minimal disturbance or political resistance from existing organizations. Reconciling, or walking a dreaded tightrope, is part of a CHW’s toolbox.

Ethical Dilemmas It is appropriate to end this chapter with even more attention being focused on ethical dilemmas and CHWs. Early portions of this chapter addressed various dimensions, and earlier parts of this book have spotlighted ethical tensions. It is important to take a moment to define what is typically meant by “ethics” (World Health Organization, 2017):  “Ethics is concerned with what should, or ought to, be done. It includes consideration of the way we ought to live our lives (including our actions, intentions and habits). Due to cultural or religious differences, ethics can sometimes be a source of disagreement and conflict between people. However, through careful analysis and debate between all relevant stakeholders, it is often possible to arrive at a meaningful consensus regarding which actions or policies should be pursued” (p. 2). The subjects of ethics and ethical dilemmas are inherent in any serious discussion of health care (Pozgar, 2014; Purtilo & Doherty, 2015) and deeply embedded in a set of values, principles, and professional ethical standards. These topics take on particular prominence when discussing care provided

108  Theoretical Foundation

within a community and focused on marginalized groups, such as those focused on in this book. The adding of a new and highly evolving health care corps further emphasizes the importance of ethical conduct. Stone and Parham (2007), well over a decade ago, identified the importance of an ethical framework guiding CHWs and focused on three critical principles: equal and substantial respect, justice, and care. In 2008, the American Association of Community Health Workers promulgated a code of ethics (Indiana Government, 2008): The Community Health Worker Code of Ethics is based on and supported by the core values adopted by the American Association of Community Health Workers. The Code of Ethics outlined in this document provides a framework for Community Health Workers, supervisors, and employers of Community Health Workers to discuss ethical issues facing the profession. Employers are encouraged to consider this Code when creating Community Health Worker programs. The responsibility of all Community Health Workers is to strive for excellence by providing quality service and the most accurate information available to individuals, families, and communities. (p. 1)

This code of ethics consisted of four principles:  (1) Responsibilities in the Delivery of Care (ensuring that the all issues and priorities are given to quality health care; (2)  Promotion of Equitable Relationships (creation of partnerships based on the premise of trust and respect of indigenous knowledge); (3)  Interactions With Other Service Providers (an emphasis on cooperation and honesty in pursuit of best practices); and (4)  Professional Rights and Responsibilities (tapping individual, family, and community strengths in pursuit of health outcomes). These four principles are broad and all-​encompassing. Any discussion on CHWs and ethics must take into account intersection­ ality. There is a strong call for community bioethicists to counter the historical neglect of how structural factors or forces perpetuate health risk among CHWs (volunteer or paid, lay or professionals, clinic-​or community-​ based), taking on great prominence among historically underrepresented groups, for example (Boulanger, Hunt, & Benatar, 2016). Discussion of ethical dilemmas has started to gain traction and encompassing dimensions that have been normally overlooked, as in the case of remuneration. The subject of remuneration may be surprising to the



Community Health Workers/​P romotores de Salud  109

reader in any discussion of ethical issues related to CHWs, and more so in a system that heavily favors and rewards according to formal educational attainment. How it is recognized and addressed as an ethical issue speaks volumes about how they are viewed within organizations and the field, and worthy of being highlighted in this section. The popularity of CHWs takes on significance and how well they are financially compensated for their work, with remuneration probably the key indicator of this support. This subject has emerged in the scholarly literature (Boulanger, Hunt, & Benatar, 2016). “There is both a large spectrum of approaches to HCW remuneration and incentivization, particularly of lay HCWs, and a long-​standing debate about best practices.  .  .  . Perspectives on remuneration vary greatly, from fears that it is unsustainable to the view that it is a basic human right and a mechanism to achieve greater gender equity.”

Conclusion The excitement and rewards associated with CHWs are evident in this chapter and throughout this book. Unfortunately, the challenges are formidable and promise to increase in complexity and demands as this field expands its embrace of CHWs, and they draw greater attention from funders, regulators, and a demand for greater accountability. There are arguments that CHWs have not lived up to their expectations; another argument is that they have not been allowed to succeed (Ballard et al., 2018). Field-​ based examples are numerous, and the following chapter highlights this observation in regard to four specific undervalued groups. These examples, although presented in limited scale because of space considerations, concretize the work that these CHWs do with highly marginalized groups in our society. Readers will hopefully be able to relate to the critical role they fulfill in urban communities across the nation.

7 Recruiting, Training, and Supporting Promotores (Paid and Volunteer) Introduction Few in the field of health and human services will argue against the importance of supporting those on the frontlines of providing services. Further, this support is multifaceted, including provision of a career ladder that can be climbed for those with the motivation, ability, and tenacity to make a career of this service. Thus, the question of support becomes one of how rather than why. Health and marginalized communities must not be narrowly defined to exclude the role and impact of detrimental environmental forces and any support provided to community health workers (CHWs) to carry out their mission, which must also entail social change (Ortega-​Vélez et al., 2016). CHW expectations must be closely examined and tempered to ensure that they are reasonable and that sufficient organizational supports are available to help increase their likelihood of achieving success and avoiding burnout, which has tremendous implications beyond them and their communities. These expectations must be based on local circumstances, making them more difficult to cross geographical boundaries of communities, counties, states, and regions of the country. Utilization of CHWs is best conceptualized from a process or a continuum perspective consisting of various steps, actions, or stages, with each segment having distinct goals and outcomes that must be accomplished for the next stage to be successful. Sustainability becomes an integral goal throughout all of these phases (Pallas et  al., 2013). Any outcome analysis needs to be deconstructed according to the stage on a continuum since each stage brings its unique set of goals and challenges. Health workers must grasp the difficulties or challenges in socially navigating how different cultural and language competencies can be manifested in illnesses and help-​seeking patterns to be effective in practice and research (Krok-​Schoen et al., 2016; Nebeker et al., 2015). Acculturation



Recruiting, Training, and Supporting Promotores  111

gaps between a provider and recipient compound effective engagement, particularly when these gaps go unrecognized and unaddressed, influencing expectations, relationship building, trust, communications, and outcomes. These types of situations, and other ethical challenges, must be systematically addressed in recruiting, training, supervising, and supporting CHWs to avoid burnout, exposure to aggression, ethical dilemmas, and ineffective services (Gascon et  al., 2013; Gonzalez-​Hernandez, 2014; Jaskiewicz & Tulenko, 2012; Kok et  al., 2015; Maneesha, Abraham, & Prasad, 2014; Nading, 2013; Ndima et al., 2015; Nebeker et al., 2015; Salyers et al., 2013). Compassion fatigue, a term frequently used to capture the stresses associated with continual exposure to the trauma presented by consumers, has emerged in relation to CHWs, as evidenced in a recent literature review, and efforts to combat this work-​related condition (Cocker & Joss, 2016). Acculturation barriers undermine achievement of common ground between staff and consumers. Provision of training, for instance, positively influences CHW motivation and retention, conveying an organizational commitment to their progress (Mutale et al., 2013; Tosone, Nuttman-​Shwartz, & Stephens, 2012). Training can vary in length, content, previous experience, and local circumstances (McAlhaney et al., 2016). An inability to ensure the safety of a primarily female workforce delivering services in homes and communities can have many different consequences. Female CHWs necessitate important supports in the field, particularly in conflict areas, raising issues of safety that can ultimately involve their lives. For example, in Pakistan, December 2012, there were 9 polio workers killed by militants, and in early 2013 there were an additional 20 who were murdered (Closser & Jooma, 2013).These CHWs enter zones that can best be characterized as war zones. Supervision plays an influential role in maximizing the impact of CHWs, but there are a paucity of scholarly articles on the subject, which is very distressing (Hill et al., 2014; Leon, Schneider, & Daviaud, 2012). One study of CHW productivity uncovered three key influential factors, one of which entailed supervision: (1) knowledge and skills; (2) motivation; and (3) the work environment, which included workload, supervision, supplies and equipment, and level of respect that other health workers (Crigler, Gergen, & Perry, 2013). Supervision, in this age of modern information technology, can transpire in mobile devices in addition to more conventional methods involving in-​person meetings (Ali, 2016).

112  Theoretical Foundation

Supervision can play such an influential and professionally enhancing role in shaping productivity level and lowering staff turnover rates, as it has in general, and more so in situations where CHWs provide services in unconventional settings. Supervision must be undertaken in a purposefully planned manner and be responsive to the unique needs posed by CHWs to be successful (Crigler, Gergen, & Perry, 2013): Although very few program managers would take the position that supervision is not important, many programs fail to design and implement a supervision system that is both functional and beneficial. In large-​scale CHW programs, supervision is rarely implemented successfully. Providing effective supervision is not easy, and it is expensive. Unless programs have budgeted and planned appropriately, the likelihood is that it will not be implemented well. Poor supervision has been shown to be as ineffective as no supervision at all. (p. 3)

Failing to plan is planning to fail, as the saying goes. CHWs cannot be hired and deployed without careful planning of services and professional supports (Kaur, 2016). It is not unusual for CHWs to incur out-​of-​pocket costs in carrying out their duties, and effort must be made to help reimburse them (Sarin et al., 2016; Sips et al., 2014). Neglecting tasks they perform that go beyond what is part of their job description translates into neglecting to pay them for performing these tasks, thereby not supporting them in the manner they should be (Kok et al., 2015). Incentivizing CHWs has emerged as a way of increasing performance and retention in countries where these workers are not well compensated (Sarin et al., 2016). Salary becomes an important factor in retaining health workers. According to U.S. News and World Report, in the United States CHWs received a mean annual wage of $40,150 in 2015, and they are best paid when employed in cities, with the District of Columbia recording the highest salaries with an average of $62,010; followed by Tacoma, Washington ($60,530); Santa Maria, California ($58,930); Montgomery, Alabama ($58,790); and Denver, Colorado ($53,140). Obtaining fair salaries remains a key challenge for CHWs (Whatley et al., 2017) CHWs have identified the importance of receiving “strong” support from their team through provision of consultation and support in helping them negotiate their complex roles (Allen, 2015; Nelson, Money, & Petersen,



Recruiting, Training, and Supporting Promotores  113

2016). There is an awareness that CHWs often transcend roles they were trained for by necessity, which have resulted in difficulties in training or preparing them for role flexibility and expanding boundaries (Glenton et al., 2013; Lechuga et al., 2015; Wiggins et al., 2013). Having access to services because of CHWs has been effective in minimizing cultural and linguistic barriers, as in the case of those who are non-​English-​speaking and embrace values that are at odds with dominant societal values. This form of access (see Chapter 4’s discussion of barriers) requires a nuanced and well-​informed stance.

Key Research Questions Identifying “key” research questions is open to debate, and more so when addressing a topic that is relatively new and expanding in influence. Mahera and Comettob (2016) make a strong case for investing in researching CHWs and identified five key issues for expanding the knowledge base on their role and importance, with greater attention to the following: (1) their role in addressing noncommunicable diseases, which are gaining in significance worldwide; (2) crosscutting enabling factors that link them to professional cadres, motivation and remuneration, and provision of essential drugs and commodities; (3) closing the knowledge gap focused on ensuring sustainability of programs; (4) greater scientific rigor to strengthen and broaden the knowledge base from which to develop appropriate policies and practice; and (5)  finally, avoiding the narrowing of disease/​illness or intervention-​ specific foci and what constitutes effectiveness.

Recruiting and Screening Having a clear understanding of what factors lead to a successful CHW is essential in recruiting and screening for the requisite qualities to succeed in this position. Mind you, there are no guarantees, but we can increase the chances of success and maximize resource deployment by careful recruitment and screening of potential CHWs. Identifying the qualities that lead to success in carrying health roles within community settings, including homes, is a critical step in any systematic or concerted effort at enhancing the capacities of those who

114  Theoretical Foundation

become CHWs. In addition, this baseline of qualities shapes the evaluation questions that are posed in order to more fully understand why they are successful in this field.

Training and Supervision Provision of training is well recognized as essential in creating an organizational climate conducive to increasing CHW effectiveness (Kim et  al., 2016). Level of training and education has been viewed as a method for classifying and responding to their needs, including enhancing their effectiveness (Horwood et  al., 2017). Olaniran et  al. (2017), in a review of 119 scholarly sources (25 countries across seven regions of the globe) that provided definitions of CHWs, concluded that they can best be categorized into three groupings according to education and preservice training: These are lay health workers (individuals with little or no formal education who undergo a few days to a few weeks of informal training), level 1 paraprofessionals (individuals with some form of secondary education and subsequent informal training), and level 2 paraprofessionals (individuals with some form of secondary education and subsequent formal training lasting a few months to more than a year). Lay health workers tend to provide basic health services as unpaid volunteers while level 1 paraprofessionals often receive an allowance and level 2 paraprofessionals tend to be salaried.

CHWs have been classified along a variety of dimensions. Formal educational level and training can also be incorporated into most classification systems, as addressed earlier. The ability to shift tasks to rapidly respond to changing local needs can be enhanced through training and supervision (Agyapong et al., 2016; Mijovic et al., 2016). Task shifting brings tremendous advantages in helping CHWs to be more responsive to the presenting needs and situations of consumers. Task shifting, as already noted, brings stressors for these providers that, if left unrecognized and unaddressed, can lead to burnout and high turnover rates. Supervision should not be a time for just gaining concrete direction and emotional support; supervision is also a time for encouragement of



Recruiting, Training, and Supporting Promotores  115

reflection and insight into how a task(s) can be carried out more faithfully to the original intent, and an opportunity for generating a greater understanding of how a job can be made more fulfilling (Singh et al., 2016). It is important that supervisors keep in mind that staff motivation can be complex, and each worker brings unique perspectives on motivation. CHW motivations cannot be ignored in supervision. Training, as a consequence, must tap motivation and enhance it whenever possible. Provision of training to assist CHWs in assuming additional roles acknowledges that this phenomenon does occur and provides requisite tools and procedures to help navigate new terrain (Agyapong et al., 2015; de Souza et al., 2017). Training can be conceptualized in a variety of ways to account for program goals, organizational factors, local circumstances, and background of CHWs. Training must be of high quality to be effective (Jones et  al., 2016). Increasing reliance on modern technology enhances training and supports them in the field (Coetzee et al., 2018). CHWs have been effective on a wide variety of health issues and varied settings, in large part due to their receiving training to carry out new tasks. For example, training for recognizing behavorial health problems, destigmatizing, and increasing confidence in addressing this need has been successful (Hofmann-​Broussard et al., 2017). Training should not be limited to the entry period and be part of a lifelong organizational commitment, including sending CHWs to regional and national conferences. The Centers for Disease Control and Prevention (2016) published an extensive list of resources to prepare CHWs to address a multitude of health issues (https://​www.cdc.gov/​stltpublichealth/​chw/​index.html). For instance, in 2016, the Division for Heart Disease and Stroke Prevention made available a CHW training resource that consisted of 15 chapters for preventing heart disease and strokes. This guide serves two purposes:  “1. A  training manual for educating community health workers (CHWs) on heart disease and stroke for use by various instructors, health educators, nurses, and other health care professionals at health departments, community clinics, community colleges, and other organizations and agencies. Having experienced CHWs as part of the Training Resource training team can be most helpful to the learning process. 2. A reference and resource for CHWs working directly with community members” (p. v). Training can transpire in a variety of ways. Printed materials, for example, as manifested in written booklets, particularly when developed by CHWs for CHWs, have been effective in integrating key cultural factors,

116  Theoretical Foundation

as in the case of Alaska’s Native population (Cueva et  al., 2016). Training can involve medical procedures. Training to conduct home visits, too, must be made available. Sairenji et  al. (2016), although specifically referring to family medicine residents, outline the importance of training because of the complex interplay of personal and circumstantial factors operative in enhancing the value of home visits. Development of conferences for, and by, CHWs represents an emerging area for moving this field forward. These conferences serve multiple goals, including capacity enhancement of political capital (organizing and reputation), social capital (bonding and bridging), economic capital (pay and advancement), and cultural capital (awareness of how culture can be tapped), for example. These conferences can be part of overall conferences with a specific section devoted to CHWs, such as the American Public Health Association (https://​www.apha.org/​apha-​communities/​member-​sections/​ community-​health-​workers), or sponsored by universities with degree programs targeting these health workers, such as George Washington’s School of Medicine and Health Sciences’ conference (http://​smhs.gwu. edu/​cancercontroltap/​events/​eighth-​annual-​community-​health-​worker-​ conference), or state-​level conferences such as Ohio’s annual conference (https://​medicine.wright.edu/​pediatrics/​center-​for-​healthy-​communities/​ ohio-​chw-​conference-​2016), for example. Special attention must be paid to CHW supervisors to support them through consultation and training, for instance, in their support of these workers, with former CHWs taking on greater significance in helping them carry out their roles (Akintola & Chikoko, 2016). Finally, communities of scholars and practitioners are quite popular and set the stage for those composed of CHWs. Training, consultation, mutual support, and social networking in various permutations and combinations can transpire in these meetings. Communities of CHW practitioners can be sponsored by local institutions of higher learning, providing a much needed source of instrumental and expressive support (Zurawski et  al., 2016). These gatherings can also provide academics and researchers with an opportunity to engage in a dialogue with this health force to advance the field. It is important not to conceptualize training as one sided. Non-​CHW staff, too, must be trained on how CHWs carry out their functions to



Recruiting, Training, and Supporting Promotores  117

minimize misunderstandings and not counteract their ability to carry out their responsibilities (Findley et  al., 2014). Acknowledging this multifaceted view of training helps to ensure that CHWs’ roles are understood and supported throughout an organization.

Organizational Support Although CHWs bring challenges common to all, targeted population groups bring unique challenges. Unlike other peer models, those in the field of substance use disorder face particular challenges regarding relapse (Svan, 2015): The issue of lapse into drug use. Peer mentors have to be resilient in order to cope with this frequently occurring feature of recovery and the findings highlight the importance of ensuring that mentors are at the appropriate stage of their own recovery. Too early in the recovery process and he or she might be at risk of lapse, too late and they might no longer be considered a true peer by the mentee. Organisations have to effectively manage the relationship between peer mentor and mentee, explicitly discuss boundaries of confidentiality and be prepared to manage the impact of lapse on both mentors and mentees and the organisation. (p. 30)

CHWs in recovery effectiveness will be dependent upon the level and quality of support they receive from their organizations. Effective screening, supervision, training, and consultation are some of the most common ways of providing this support. Peer supervision brings an important dimension to this field. Organizational support helps CHWs provide services that are contextually driven (taking into consideration local needs, oppression, and culture), facilitating trust building with consumers (Nxumalo, Goudge, & Manderson, 2016). Trust development, as already addressed, is a critical element in any successful CHW-​led initiative. Trust is not a unidimensional concept, meaning that recipients of services must trust providers and vice versa. Providers must trust their supervisors and management team, too.

118  Theoretical Foundation

Advancement Having a career ladder must be stressed and not just because of instrumental gains related to increased authority and income; advancement brings added prestige, influence, and casts CHWs as important figures within organizations and their communities. Advancement also sends a signal to the communities that they, too, are valued in a world that very often signals that they are not. Having some administrative-​level people as advocates or “champions” for CHWs helps ensure that their unique needs do not get overlooked by an organization’s leadership, thereby increasing the potential for advancement (Findley et al., 2014). Advancement must be available so that CHWs can move beyond narrow role confinement to assume supervisory and even leadership of organizations. In other words, the ladder is not missing rungs, and one can only advance so much and then encounter a glass ceiling.

Conclusion CHW success is the result of a multitude of factors that range from personal qualities, organizational support, and community legitimacy, which all come together to create a climate that values and understands their unique position within the health field and community. Organizational commitment starts with a deliberative screening and hiring process, followed by supervision, training, and potential advancement. The following chapter relies upon a series of case illustrations to highlight how CHWs can recruit and deliver services to four highly marginalized groups.

SECTION 3

REFLEC T ION S F ROM T H E F I E LD The importance of models and approaches for shaping social interventions is beyond dispute, with community health workers (CHWs) being an example of an innovative approach toward solving what may appear as an unsolvable problem. Innovative approaches on intractable problems are not without critics, tensions, rewards, and excitement, because of the challenges they present. The introduction and evolution of this health workforce have not been dull, particularly when they engage in highly innovative approaches and venture into new settings and the homes of consumers. With a grounding in the evolution and parameters of CHWs, we can now turn to innovative approaches involving these workers that hold great promise for the next decade, as this field continues its meteoric expansion into previously unchartered terrain involving four highly marginalized groups (the formerly incarcerated; the formerly unauthorized; the formerly homeless; persons in recovery) often found in this nation’s urban centers. The literature and case illustrations covered in this section capture the excitement and a high level of commitment to reach underserved groups. Exciting conceptual and empirical advances have occurred in the field of community health work. The “bottom line” remains how these advances have been translated into practice. Case illustrations provide a glimpse into how CHWs socially navigate difficult circumstances to reach groups that can be challenging under the best of circumstances.

8 Special Population Case Illustrations Introduction This chapter builds on the theoretical, research, and practice information provided in previous chapters, offering readers an opportunity to apply the values and concepts, and to develop an understanding of the rewards and challenges that shape the following case studies. This chapter provides examples of how community health workers (CHWs) meet the needs of marginalized groups in this country, with potential for other countries, too, through the use of case studies. These examples are best thought of as illustrations rather than the conventional associations that case studies engender, which are highly detailed and cover a multitude of categories (Hancock & Algozzine, 2015; Yin, 2013). This chapter focuses on the formerly incarcerated, the formerly unauthorized, the formerly homeless (unhoused), and persons in recovery as CHWs. These groups are worthy of entire books being written on them, which has happened. Disentangling these groups is arduous and at times simplistic, because of the overlap between them. These are not this nation’s only “special population groups,” nor are they mutually exclusive of each other, making those who share multiple conditions that much more challenging in having their needs met and distrustful of outsiders. These groups will be viewed using two frameworks (see Chapter 5). The first views their roles from a life span perspective, with a focus on youth, adults, and older adults. Although the literature and research are not evenly distributed across these four areas according to age groups, this framework will help readers grasp the rewards and challenges CHWs bring to the health field, including the gaps in knowledge and the need for interventions to fill this gap. The second embraces a capacity enhancement framework and paradigm emphasizing strengths and assets as a fundamental building block for interventions employing CHWs. These two frameworks will be integrated throughout the case studies.

122  Reflections From the Field

The special population groups selected will be addressed through four aspects:  (1) a definition of what constitutes this special group; (2)  a brief demographic profile of the different age subgroups within this category; (3)  identification of the major health issues confronting them on a daily basis and potential strategies; and (4)  case illustration. These aspects are interrelated, highlighting the CHW potential to carry out a historic mission of serving marginalized groups, including challenges encountered in the course of reaching these groups.

Special Population Groups The concept of “special population group” is well understood in health and human services because it signals out groups that share certain characteristics that make them particularly vulnerable to a wide variety of needs that place them at greater risk. These characteristics require highly innovative strategies to effectively meet their needs. Attaching a special group status draws much needed attention, resources, including research, and intervention resources with a specific focus on special population groups (Bibbins-​Domingo et  al., 2017). The special groups discussed in this chapter will be self-​evident, highlighting the immense challenges urban CHWs and their organizations have in reaching these groups while drawing on insufficient resources and the need to constantly innovate in the process. Innovation’s path is never smooth or steady, yet there is no disputing its importance, and the energy and hope that it radiates for those who are marginalized. Although this book touches on four special population groups, and treats them as separate entities, in reality, there is overlap between them (Herbert, Morenoff, & HarDing, 2015). For instance, almost 10% of the nation’s people who are homeless have histories of incarceration (Kapetanovic, 2016). Reintroducing values of health self-​care takes on greater meaning in their circumstances, with CHWs playing influential roles fostering these attitudes and skill sets to supplement special care provision initiatives. The groups in this chapter are found throughout all regions of the country, including rural areas. However, there is little dispute that their concentration in the nation’s cities brings unique rewards as well as challenges for the health field and CHWs. Fortunately, CHWs are up to the task.



Special Population Case Illustrations  123

The Formerly Incarcerated as Community Health Workers The incarcerated and the formerly incarcerated get their share of national media attention, including the need for sentencing reform in progressive circles. Most of this attention has focused on a negative view of them and has generally overlooked their unique needs, as well as their strengths and potential contributions to their returning communities and society. Scholarship has started to take a different perspective by focusing on their needs, which are varied and extensive, and the quest for service innovative models taking into account their unique needs and strengths (Delgado, 2012). This change in paradigms, although worthy, is never accomplished without tensions and dramatic changes in research, theory, and service delivery. Health care reforms must not neglect those with histories of criminal justice involvement if they are to have a maximum impact on marginalized communities (Rich et al., 2014). Their perceptions must be actively solicited throughout all facets of health care delivery. The reentry process, it is important to emphasize, is not restricted to any single age group. Youth who were formerly incarcerated are rarely focused on in the literature (Adair, 2017), and the same can be said for older adults (Delgado & Humm-​Delgado, in press).

A Definition of What Constitutes This Special Group The formerly incarcerated go by many names in the field of practice and scholarship. Further, the term used to describe this group says a great deal about who is using this label and their views toward social justice, CHWs, and health. Thus, one of the major challenges that CHWs face is the stigma associated with having an incarceration background. This weight makes those working with the formerly incarcerated that much more important. The term “correctional involved” has saliency in the field. Those who are correctional involved addresses those who are on parole, probation, in custody awaiting trial, or incarcerated. This is an all-​encompassing term and masks between-​group differences. Those who have served their correctional terms are also referred to as “formerly incarcerated,” which is a term less stigmatizing than “ex-​convict” or “ex-​inmates,” for example. Although discussions of the incarcerated and formerly incarcerated invariably focuses on adults, youth, too, fall into this category and represent

124  Reflections From the Field

a group that CHWs have started to focus on. The Department of Justice classifies youth as anyone under the age of 21 years. Although the definition of adult is relatively easy, with anyone over the age of 21 years in this category. It is important to reintroduce the added category of older adult in this discussion. Incarcerated or formerly incarcerated older adults are those over the age of 50 to 55 years, which is not the typical definition (Williams, 2010). This is the result of having health issues normally associated with much older groups due, in large part, to lifestyle decisions.

A Brief Demographic Profile of the Different Age Subgroups Within This Category The United States has the distinction of having incarcerated more youth than any other nation, with almost 500,000 going through this nation’s detention centers in any single year, and 71,000 incarcerated at any one time (Hockenberry, 2010). In 2017, the number deceased from a rate of 334 per 100,000 in 2001 to 152 per 100,000 in 2015 (Olivares, 2017). African American/​Black youth (433 per 100,000) are incarcerated at a rate 500 times greater than their White, non-​Latinx counterparts, with 86 per 100,000 (Olivares, 2017). The adult incarcerated or formerly incarcerated, in similar fashion to its youth counterpart, is heavily of color with African American/​Blacks, Asians, and Latinxs. The racialization of those with criminal justice experiences is obvious, and so are their communities where they return to upon release. Identification of the Major Health Issues Confronting Them on a Daily Basis and Potential Strategies This country’s marginalized groups face a higher probability of being arrested, convicted, and incarcerated, severely impacting the communities with high concentrations of low-​income people of color, such as Boston (Crimaldi, 2016). African American/​Black and Latino men often have a distrust of medical services, which complicates service utilization by this group and increases the importance of enlisting a cadre of health workers who can engage them (Valera et al., 2018). Engagement of faith-​based communities in the reintegration of the formerly incarcerated in recovery can tap the concept of recovery capital (Connolly & Granfield, 2017). Examination of formerly incarcerated health needs will be compounded by their incarceration in facilities that often lacked proper health care they have received while imprisoned (Delgado & Humm-​Delgado, 2009). The



Special Population Case Illustrations  125

literature is bountiful on prison health care and for very good reason, with recognition that behavorial health systems require new approaches and models for addressing recidivism to counteract poor communication and relationships between behavorial health providers and the police, service fragmentation, and lack of buy-​in from community stakeholders (Compton et al., 2015). Efforts enlisting the formerly incarcerated to assume CHW roles focused on those reentering have shown promising results (Wang et  al., 2012). The emergence of urban transition clinics (medical facilities targeting them during community reentry) have emerged and provided the formerly incarcerated with an opportunity to assume CHW positions (Fox et al., 2014). The health (mental and physical) status of those who are incarcerated or formerly incarcerated is highly compromised (Delgado & Humm-​Delgado, 2009; Hean, Ødegård, & Willumsen, 2016; Maruschak et al., 2016; Thomas et al., 2016). The formerly incarcerated bring unique issues and needs that have been conditioned by having served time in correctional institutions, and often having an experience that prevented them from seeking and receiving health care, and more so with special population groups, such as women and older adults (Delgado & Humm-​Delgado, in press). These unique needs necessitate innovative initiatives and modifications of existing initiatives related to having spent consideration time in a total institution, such as a jail or prison. Health promotion, for example, can, and should, be undertaken within correctional settings as evidenced in Villabona, Spain (Muro et  al., 2016). CHWs, and particularly those with histories of incarceration, are in the best position to undertake this form of intervention because of having a shared experience that can facilitate trust and relationship building, as well as providing them with knowledge that can only be obtained through a lived experience (Buck, 2017). Peer-​led intervention is another way of conceptualizing CHWs. Bagnall et  al. (2015) review the effectiveness and cost-​effectiveness of peer education and peer support within prisons, finding strong support for the benefits (behavorial health and its determinants) that peer workers derive from helper roles: Peer-​based interventions can be considered a valuable mechanism to maintain or improve health and wellbeing in the prison setting, with positive effects seen on knowledge and behaviour of peer deliverers and

126  Reflections From the Field recipients. Peer education is less used in prisons in England and Wales than in the USA, perhaps reflecting more general trends in health promotion; however, the finding that peer education can increase knowledge and reduce risky health behaviours, particularly in relation to HIV prevention, suggests that consideration should be given to whether a peer education component should be introduced into other health behaviour change interventions.

These findings and recommendations hold much promise for health and criminal justice field. The close relationship between histories of incarceration and substance abuse brings these two major social issues together (Weston, 2016). Griffiths and Bailey (2015), too, undertook a review of the peer support prison literature, but focusing on self-​injury, and found prison peer support to be effective and should be conceptualized on a continuum using different degrees of peer involvement. Robinson et al. (2015), in a study of peer support as resiliency building among incarcerated men, found the development of trust to emerge as a benefit: “The programme significantly raised the perceived resilience of participants. Project activities promoted trusting informal social connections, gains in social capital arose through trusting relations and skill-​sharing, and peer-​peer action-​focused talk and planning enhanced men’s resilience” (p. 196). The formerly incarcerated, with training and support while in prison or jail, can provide community education on health-​related issues of particular concern to youth and others seeking to avoid engagement with the legal system (Camic, 2015). Having an incarceration history is not sufficient to achieve success with the formerly incarcerated; sharing demographic characteristics, such as age, facilitates relationship building. Incarcerated and formerly incarcerated older adult profiles differ significantly from their younger counterparts, translating into a need for innovative programs that acknowledge these different lived experiences, and respond accordingly, translating into initiatives that are based upon their own reality and voices (Rubero, 2015): To reiterate, it must be recognized that younger people adapt faster upon release from prison. Their minds are quicker and they are able to learn and adapt to technology with far greater ease. For older people, however, we need somebody to teach us—​and to have patience as we learn.



Special Population Case Illustrations  127 We need someone who has been through the same experiences mentally and emotionally. We are no harm to anyone except, perhaps, ourselves. We’ve paid our dues. Regardless of what we did, we are different people now. Everyone deserves a second chance, and that includes us aging long-​ termers. (p. 61)

Previously incarcerated CHWs understand the reentry process and can pass along their wisdom to others. Creation of a “buddy system,” where newly released older adult prisoners can be matched with counterparts previously released who been successful at making the transition, has been recommended (Roberts, 2015). The potential of prison radio, for example, has yet to be fully explored for undertaking health-​related projects in addressing inmate health concerns (Stone, 2015). Connecting the formerly incarcerated to formal and informal supports requires staff with knowledge and navigational skills to engage and connect them. For example, the role and significance of family on the social control and social support of formerly incarcerated Latino men has been established (Lee et al., 2016). Mechanisms that actively involve CHWs helping them reconnect with families and support systems is critical. A call to action for public health to address mass incarceration was issued in the American Journal of Public Health, including a call to public health agencies to employ the formerly incarcerated to be enlisted in undertaking treatment of those in recovery within a community context, illustrating the overlap of various labels (Cloud, Parsons, & Delany-​Brumsey, 2014; Fazel et al., 2016; Pocock & Sutton, 2015). Mass incarceration has had a particularly devastating impact on African American/​Blacks and Latinx communities, and the attention this subject has received this past year reflects on its importance to these communities and the nation (Bedell et  al., 2015):  “While the literature has examined the role and effectiveness of CHWs in other populations, there is a significant gap regarding the nature of the re-​entry CHW experience and how it may contribute to improved health outcomes and continued cost savings for healthcare systems” (p. 3). In conceptualizing the reach of the formerly incarcerated from a program model to a prevention model can have CHWs playing influential roles in brokering needed services, and helping them navigate their reentry process, and particularly those experiencing multiple forms of oppression (Semien, 2013; Woods et al., 2013). These positions are referred to as reentry CHWs.

128  Reflections From the Field

The health of the formerly incarcerated is of extreme importance (Graffam & Shinkfield, 2012; Massoglia & Pridemore, 2015; Morenoff & Harding, 2014), and rarely are their voices and insights actively taken into account in how best to structure services to reach them (Woodall, Dixey, & South, 2013). Seeking health care upon prison release is often a very low priority for the formerly incarcerated, necessitating extensive outreach and collaboration involving community-​ based organizations (Smith & Jemal, 2015). Connecting the formerly incarcerated with health insurance is a critical step in helping them reenter into society and meeting their health needs (Patel et al., 2014, p. 469): “Seeking health care after release from jail is often a low priority, although there is evidence that treating medical and behavioral health conditions improves the probability of successful reintegration into the community. Successfully connecting people released from jail with the health care system thus must be understood and addressed within the context of a wide spectrum of individuals’ survival priorities and reentry needs.” Specialized initiatives that actively engage them, such as CHWs, promise to further expand this field of practice in a high-​impact manner (Wang, 2014). These initiatives must be ethnically and racially centered. Cultural competency/​ humility principles must be essential factors in reentry programs (Woods et al., 2013). For example, in 2009, Latinxs became the largest ethnic group in federal prisons, making them a prime target for special CHW initiatives (Moore, 2009). This is due in part to a large number of immigrant-​related crimes and high numbers of drug convictions. The potential of peer-​led interventions holds promise for the field of community health (South et  al., 2014):  “There is good evidence that becoming a peer helper is linked to feeling more confident and having better health. Peer helpers can offer a valuable source of support within prisons, particularly for prisoners with mental health needs” (p. xxi). Peer-​ led models can be sufficiently flexible to take into account local circumstances and priorities, making these models attractive for utilizing CHWs to address a wide range of health conditions, and in a wide variety of settings and contexts (Tang et al., 2014). Bedell et  al. (2015) report on a rare CHW program on the formerly incarcerated reentry and identified six themes related to their successful reentry:  (1) advocacy and support (satisfaction of translating personal experiences into social activism); (2)  empathy emanating from a



Special Population Case Illustrations  129

personal history of incarceration (connectedness); (3)  giving back to recently released individuals (hard work and the role of motivation); (4) professional satisfaction and responsibilities (being part of a team sharing similar goals); (5)  personal resiliency and educational advancement (importance of believing in oneself); and (6)  experience of social and racial injustices (personally meaningful). These themes bring to the fore the importance of social justice and empowerment as guiding concepts and principles in shaping CHW engagement with them, and they open the door for the formerly incarcerated to assume CHW roles specifically focused on those with incarceration histories. The formerly incarcerated are in a propitious position to use their experiences to the benefit of others. CHWs bring the potential to reach underserved population groups, which sometimes are referred to as “special” because of how intersectionality has compromised their well-​being and made it arduous to reach them through conventional outreach and health education methods (Balian, 2016; Delgado & Humm-​Delgado, 2009, in press; Kouyoumdjian et  al., 2015; Willmott & van Olphen, 2005). Homeless and formerly incarcerated men, for instance, are often referred to as “invisible men” because of how they have become a blended part of the homeless world (Remster, 2013). We can also easily include the unauthorized in this category. South et  al. (2014) reviewed the literature on prison peer-​ based interventions and found these efforts successful in reducing health risk-​ taking behaviors, with implications for those who are incarcerated and those who are formerly incarcerated once back in the community. Peer education involving prison courses with student outsiders without correctional experiences, too, has been effective (Davis, 2016). The formerly incarcerated are in unique positions to bridge the distrust often associated with those released from jails and prisons because they share common experiences and language, and often share similar racial/​ethnic backgrounds, too. Trust takes on added significance when discussing this homeless group because their lives often depended on not exhibited trusting behaviors (Steers, 2012). Tapping them in helper roles brings advantages, which are rarely addressed in typical service provision models, and a potential workforce is not part of the policy discourse (Nayer et al., 2015). Employment of the formerly incarcerated is a significant challenge in their reentry process (Harding et  al., 2014; Mullings, 2014). The field of

130  Reflections From the Field

health care, which is expanding and in need of gaining greater diversity of staff from backgrounds that historically have not been a part of this system, opens up possibilities for them to be employed as CHWs, making them valuable contributing members of their respective communities. This is not to say that unique challenges of involving the formerly incarcerated as promoters of health are not present. This field benefits from more alternative models and intense scholarly attention and research. Demand for innovative models is ever constant for the formerly incarcerated (Delgado & Humm-​ Delgado, in press). Fortunately, this quest is being addressed. The Pew Charitable Trust recognized the gap between the formerly incarcerated and the health care field, opening up opportunities for employing “hard to place” individuals in jobs but also helping them give back to their communities (Quinton, 2017): With unemployment falling and workers hard to find, a growing number of health care employers are following Johns Hopkins’ lead and giving people with criminal records a second chance—​hiring them mainly into entry-​level jobs in food service, janitorial services and housekeeping. Studies show that employees with records stay in their jobs longer and are no more likely to commit workplace crimes than hires without them. This year, Illinois began allowing people with some forcible felony convictions to petition for professional licenses in health care. In 2015, Pennsylvania’s Supreme Court struck down a decades-​old law that had prohibited people with certain offenses—​from theft to murder—​from working in long-​term care facilities, home care agencies or adult day centers. But health care isn’t quite like any other business. Hospitals, nursing homes and doctor’s offices care for people in the most vulnerable moments of their lives. Citing public safety concerns, some states have gone in the opposite direction, passing laws to keep people with criminal records out of clinical jobs.

CHWs with incarceration histories and a desire to give back to their communities provide health organizations with an excellent opportunity to hire staff with this valuable experience that can be buttressed with formal education.

Case Illustration There is a recognition of the formerly incarcerated as representing an undertapped resource in underrepresented communities, and this has



Special Population Case Illustrations  131

resulted in a number of innovative efforts that have a direct consequence on CHW initiatives. Two case examples were selected for this section because of the presence of intense stigma attached to this group. In 2011, Transitions Clinic (http://​www.cachw.org/​1623-​2/​), with Langeloth Foundation funding, was established in 24 communities across the country and Puerto Rico, with the specific goal of reaching out to the formerly incarcerated as both consumers and providers. The example of Martha Shearer, a CHW (Post Prison Health Worker) in Birmingham, Alabama, highlights the potential contribution of someone with an incarceration history: “Despite holding two master’s degrees, I was fired from my last job after two and half years because my criminal background check finally came back.” . . . “I was devastated.” . . . Martha Shearer is a community health worker (CHW) at the Transitions Clinic in Birmingham, Alabama.  .  .  . “I’ve been working for Transitions Clinic for a little over a year,” Martha recalls, “and through my position as a community health worker, I’ve been able to develop a ‘common relationship’ with my clients and assist them in their transition out of prison.”  .  .  .  Despite the challenges, Martha is optimistic. Her clients keep their appointments, which is often half the battle—​and follow their medication regimen as outlined by the Transitions Clinic physician. “The model is working,” says Martha, “we just need to give them a chance.”

City College of San Francisco, for instance, in the tradition of other colleges credentialing CHWs, developed a Post-​ Prison Health Worker Certificate, which is open to those who are formerly incarcerated and those interested in serving this population group, in response to this pressing need in the Bay area. This type of focus is exciting and full of potential for significant strides in serving this group. The Johns Hopkins University is another case involving the formerly incarcerated because of its historical commitment to this group: The federal government put pressure on all employers to consider applicants with a criminal record in 2012, when a federal board, the Equal Employment Opportunity Commission (EEOC), warned that employers that exclude applicants because of their records may violate anti-​discrimination laws (Quinton, 2017). The Safer Foundation, a Chicago nonprofit that focuses on prisoner re-​entry, is about to launch a vocational training

132  Reflections From the Field initiative that will prepare ex-​offenders for jobs in health care, construction and other high-​demand industries. This week the foundation, along with the National Employment Law Project, is releasing a guide for health care employers looking to hire people with arrest or conviction records. Since it began piloting the program last year, Safer has placed 35 clients in health care jobs in the Chicago area.

The Formerly Unauthorized as Community Health Workers The subject of immigration, and more specifically that which captures those who are undocumented, has found a prominent place in national discourse since the election of President Trump. The attention has focused on criminalization and deportation, and generally overlooked the health needs of this group while they are in the country. Meeting their health needs is seriously compounded by their citizenship status and their limited options in a high charged political environment on how the nation should respond to millions of individuals spread throughout the nation and highly concentrated in urban centers (Beck et al., 2017; Gray et al., 2017). Fears pertaining to deportations significantly influence health-​seeking patterns (Becerra, 2016; Philbin & Ayón, 2016). Social determinants of health rarely take into account immigration status (Castañeda et al., 2015). Not surprising, health inequities are closely tied to immigration status (Philbin et al., 2018). There is a call for innovative policies, strategies, and programs to meet these needs in a manner that is responsive to their cultural heritage and that takes into account social justice issues (Berthold & Libal, 2016; Fabi & Saloner, 2016; Marrow & Joseph, 2015; López-​Sanders, 2017). This politically charged context has served to compound the health care needs and service delivery obstacles facing this group, further increasing the need for innovative and community-​centered solutions.

Definition of What Constitutes This Special Group The dimensions surrounding defining who is unauthorized typically focus on their legal status. The children of those who are unauthorized brought into the country as children are referred to as Dreamers or DACA (Deferred Action for Parents of Americans) and are protected by an executive order



Special Population Case Illustrations  133

signed by President Obama in 2014. They are able to attend school and work under this protected status, becoming a potential source of CHWs for health care targeting those who are unauthorized.

A Brief Demographic Profile of the Different Age Subgroups Within This Category Obtaining a demographic profile of those who are unauthorized is fraught with challenges because of their fear of being uncovered and possibly deported. It is estimated that 28% of this nation’s total foreign-​born population consists of those who are undocumented, yet the lack of demographic and epidemiologic data presents a serious challenge for the public health field (Messias, McEwen, & Clark, 2015). Although the membership of those who are unauthorized in the United States can be quite broad, there is little disputing that the majority of those in this category consist of those who are primarily Latinx, and more specifically, Mexican. There are an estimated 11.3 million individuals who are unauthorized, of which 75% being Latinxs, with Mexicans representing percentage of the total. The remaining approximately 25% originate from Asia and Europe (Voekel, 2016). It is estimated that there are 840,000 Dreamers (DACAs), many of whom are no longer young children and are aged in their 20s and 30s (Hirschfeld Davis & Steinhauer, 2017). DACAs represent a vast, generally untapped pool of potential CHWs. They share the backgrounds of those who are undocumented, are aware of their needs and assets, and can bridge the “old” world with the “new” world. Local responses shape DACA experiences, and these experiences can serve as a foundation for CHWs to better serve their communities (Singer, Svajlenka, & Wilson, 2015). Identification of the Major Health Issues Confronting Them on a Daily Basis and Potential Strategies The health of those who are undocumented is a subject that is laden with heavy emotional meaning and consequences. The health of DACA children and youth, for example, if they lose their protected status, has caused a great deal of consternation among pediatricians; prolonged exposure to stress (“toxic stress”) resulting from fears of deportation can impact unborn children (Reardon, 2017; Uwemedimo, Monterrey, & Linton, 2017). Shelters for homeless families allow CHWs to work as a team to address the needs of family members across the age spectrum (Chatterjee et al., 2017).

134  Reflections From the Field

Philibin et al. (2018), in a review of the literature on state-​level immigration and immigrant policies and the influence they wield on Latinx health disparities, identified four pathways:  “through stress related to structural racism; by affecting access to beneficial social institutions, particularly education; by affecting access to healthcare and related services; and through constraining access to material conditions such as food, wages, working conditions, and housing” (p. 29). Access to quality health care, it is well understood, is seriously impeded because of citizenship status (Berk et  al., 2017; Fernández & Rodriguez, 2017; Hainmueller et  al., 2017; Herbst et  al., 2016; Ku & Matani, 2017). The barriers that they encounter are significant across the entire life span (Herbst et al., 2016): Previous research indicates that undocumented immigrants experience more barriers than documented immigrants in accessing and utilizing medical healthcare services . . . and formal mental health services. . . . This is especially troubling in light of research indicating that having a consistent source of primary and preventative services diminishes racial and ethnic healthcare disparities.  .  .  . When undocumented immigrants do utilize healthcare, the type of medical services used differs from that typically used by citizens, both Latina/​o and non-​Latina/​o. Undocumented. (p. 91)

Case Illustration Those who are undocumented often share similar health needs with their authorized counterparts, as well as additional needs that are compromised because of the limited help-​seeking processes they must contend with, including potential of facing deportations (Becerra, 2016) and unequal treatment (Palmer, 2017). Torres and Young (2016) advocate for using a life course theoretical perspective when discussing the close relationships between legal status stratification and health outcomes. Unauthorized children, for example, must socially navigate a significant part of their lives in a world where their parents face increasing scrutiny and potential for detection and deportation (Becerra, 2016; Berthold & Libal, 2016). These fears translate into their children not enrolling in health care programs, for example (Higgins & Wagnerman, 2016). Older youth face additional and different sets of challenges (Oshiro, 2016; Teitel, 2016). CHWs can benefit from integration of strength-​focused paradigms such as



Special Population Case Illustrations  135

positive youth development, opening this field to inclusion of youth who share similar backgrounds as the communities they serve (Ferrera, 2017). Health initiatives specifically targeted this special population group, unfortunately, are often characterized as unsystematic and untested practices (Edward, 2014; Lanesskog, 2016). An intersectional view involving older adults who are LGBT and undocumented, and Chicanas and work exploitation, for example, brings additional sets of challenges in obtaining needed health care (Sokan & Davis, 2016). The politicization of citizenship status captured the attention of the nation in the 2016 national presidential election, which carried over afterward, and this context cannot be ignored in any in-​depth discussion of CHWs and those who are unauthorized. They have taken on a highly symbolic value in US society. The unauthorized have been forced further underground, taking on an even more invisible status; this group has multifaceted needs and are often exploited because of their legal status (Delgado, in press). Findley and Matos (2015) identified six specific benefits of immigrants becoming CHWs specifically serving newcomer communities: (1) shared immigrant experiences; (2) commitment to serving newcomer communities; (3)  possession of creativity and resourcefulness in engendering new approaches toward reaching immigrants; (4)  communication abilities to transcend conventional barriers encountered by newcomers; (5)  an embrace of undertaking home visits; and (6) two-​way communication and relationship building between health care organizations and new immigrants. The experiences of entering this country through nonauthorized channels cannot be taught through formalized courses, particularly when discussing the trauma experienced in this journey. Those without these experiences can certainly become sensitized to those with these experiences. There is no substitute for experience, and those having been through this journey are in a better position, when compared to those who have not, to reach, engage, and ultimately help these newcomers meet their health needs. The use of concept maps, for example, has been found to be particularly attractive for use with Latinx immigrants in helping them to visualize interventions with a high potential of success in reaching this group (Vaughn et al., 2016b). These maps, too, have the potential to be highly participatory, tapping the voices of previously ignored population groups, such as immigrants who are documented and undocumented. The health needs of those who are undocumented are extremely important and often go unmet. The subject of the unauthorized or undocumented

136  Reflections From the Field

is one that is highly politically charged in general, but it gets even more heated during national presidential elections. Their access to services is further challenged because of their legal status, compounding help-​seeking patterns, including fears of deportation. Their unique social-​ political circumstances compromise unimpeded access to health care in a timely manner (Becerra, 2016; Findley, & Matos, 2015). Their health is further compromised because they are often employed in highly dangerous fields, making them prone to accidents and occupational-​related diseases. Hiring the unauthorized is prohibited by law, with a direct impact on members of this community who would make excellent health promoters because of their position or status within their community. Finding advisory and informal support roles can supplement and enhance formerly unauthorized workers in carrying out their mission to help the unauthorized. The following case in North Carolina highlights how laws and policy decisions made it more difficult to engage the unauthorized as CHWs (Moore et al., 2012): Adult volunteers grapple with increasing complex barriers to health care access, particularly transportation. Under a recently enacted state law requiring a valid social security number or an unexpired visa to obtain a driver’s license, undocumented residents have lost their ability to drive legally, register their cars, and buy automobile insurance. As a result of this policy change, some promotores, like the residents they are trying to help, find themselves increasingly isolated and limited in their ability to bridge the gaps between members of their community and the health care system. (p. 393)

There can be creative ways of enlisting and supporting them in carrying out their responsibilities in programs, by viewing them from recipient and provider perspectives (Wieland et al., 2016). One effective way is to recruit those who are now permanent residents (“Green Card”) or citizens. Targeting the unauthorized requires social justice values and principles to guide interventions, and for health promoters to assume advocacy and social change roles to buttress the roles they normally assume in providing needed care. Advocating on behalf of a marginalized group places them in a position to challenge institutional systems, resulting in potential political backlash.



Special Population Case Illustrations  137

The Formerly Homeless (Unhoused) as Community Health Workers The image most people have of those who are homeless is of a group that should be avoided because it is highly stigmatized with multiple health and service needs. This stigma necessitates specialized outreach and service models to reach and engage this group. The experiences of being unhoused in this country make these people particularly vulnerable to health needs and challenging to reach in a culturally affirming manner. Housing is often essential as a portal for receiving a range of health and social services, highlighting its importance beyond shelter, which should not be minimized (Butler & Cabelo, 2018).

Definition of What Constitutes This Special Group The definition of homelessness can cover a variety of viewpoints, dimensions, and terms. However, having no place to live is one common way of defining homelessness. According to the federal government (US Department of Health and Human Services [HHS]): A homeless individual is defined in section 330(h)(5)(A) as “an individual who lacks housing (without regard to whether the individual is a member of a family), including an individual whose primary residence during the night is a supervised public or private facility (e.g., shelters) that provides temporary living accommodations, and an individual who is a resident in transitional housing.” A homeless person is an individual without permanent housing who may live on the streets; stay in a shelter, mission, single room occupancy facilities, abandoned building or vehicle; or in any other unstable or non-​permanent situation. (Section 330 of the Public Health Service Act [42 U.S.C., 254b]) An individual may be considered to be homeless if that person is “doubled up,” a term that refers to a situation where individuals are unable to maintain their housing situation and are forced to stay with a series of friends and/​or extended family members. In addition, previously homeless individuals who are to be released from a prison or a hospital may be considered homeless if they do not have a stable housing situation to which they can return. A recognition of the instability of an individual’s living arrangements is critical to the definition of homelessness. (HRSA/​

138  Reflections From the Field Bureau of Primary Health Care, Program Assistance Letter 99-​12, Health Care for the Homeless Principles of Practice)

Homelessness goes by many different names, complicating obtaining an accurate and comprehensive picture, as in the case of youth (Edidin et al., 2012):  “runaways (i.e., youth who have spent more than one night away from home without parental permission), throwaways (i.e., youth who have been forced to leave home by their parents), and street youths (i.e., youth who live in high risk nontraditional locations such as under bridges and in abandoned buildings), and systems youth (i.e., youth who have previously been involved in government systems such as foster care or juvenile justice)” (p.  355). These definitions draw upon a variety of sociopolitical stances and set of values.

Brief Demographic Profile of the Different Age Subgroups Within This Category In the United States in 2016, there were approximately 550,000 people who were homeless, with approximately 4.2% being so over a 1-​month period in their lives, and 1.5% being homeless over the past year (Tsai, O’toole, & Kearney, 2017). Homelessness cuts across age groups, with youth, too, being a part of this group (Brown et al., 2016, 2017; Thompson, 2017). The percentage of those who are homeless and of color is far greater, however, introducing the element of racism. Identification of the Major Health Issues Confronting Them on a Daily Basis and Potential Strategies The homeless pathway differs according to demographics. Discrimination against homeless youth compromises their health needs and help-​seeking patterns (Snyder et al., 2016) and constitutes a major barrier in meeting their needs. Youth who are homeless are considered an invisible group within the broader invisible homeless population (Governing the State and Localities, 2017): “They are the nation’s invisible homeless population, undercounted for years, hiding out in cars and abandoned buildings, in motels and on couches, often trading sex for a place to sleep. And now, for a complex variety of reasons, the number of youth—​teens and young adults—​living on the street appears to be growing.” The homeless pathway among older adults, for example, is best understood through a life course perspective, with those who first experienced



Special Population Case Illustrations  139

homelessness before age 50 differing from those with later onset of homelessness, with the former having higher likelihoods of having mental health and substance abuse histories and greater challenges in exercising instrumental activities of daily living (Brown et al., 2016). Sadly, being unhoused is associated with premature death due to complicated medical histories and substance abuse (Shulman et al., 2018). Those with histories of homelessness (transiently, episodically, and chronically homeless), and more so with men than women, and in this case veterans, share similarities with those faced by the formerly incarcerated (Tsai et al., 2014). Trauma among street-​involved youth is an ever-​present aspect of life on the streets, and being without a home does not define who they are (Hopper, Olivet, & Bassuk (2018): “We are so much more than homeless. ‘Homeless’ is not a character trait. It is just where we happen to be at the moment and the situation in which we find ourselves. We are often pretty phenomenal and interesting people—​get to know us beyond what you see on the surface—​without being too nosy about our histories” (p. 45). Older adults who are homeless, in turn, have health conditions that their nonhomeless counterparts also have, but these conditions are further exacerbated and added to with illnesses endemic to living on the streets and histories of health neglect (Brown et al., 2016). Lee and colleagues (2016) argue that older adults who are homeless tend to live in distinct spaces, which present different strengths and risks for them. They outline four clusters (unsheltered, cohabiters, institution users, and renters who recently became homeless) to help differentiate their homeless situation and dictate an appropriate response. Homelessness cannot be separated from the presence of various illnesses, nor can it be viewed from a nonracial perspective. Severe mental illness and homelessness are inseparable (Van Wormer, 2012). African American men who are homeless, for instance, have higher rates of depression when compared to those with homes, introducing a key behavorial health condition that complicates their help-​seeking process (Plowden, Adams, & Wiley, 2016). Those who are homeless and dyslexic face an added burden in receiving needed services (Macdonald & Deacon, 2015). It is important not to lose sight of their strengths and assets. For example, homeless individuals with histories of substance abuse (drugs and alcohol) have been found to maintain an active social network that can be tapped by

140  Reflections From the Field

providers, such as CHWs in developing outreach and engagement (Neale & Brown, 2015). Older adults who are homeless with extensive histories of incarceration face even greater challenges in avoiding reincarceration when compared to those who are homeless with less extensive histories of imprisonment (Tsai & Rosenheck, 2012). Those who are formerly homeless and have transitioned to supportive housing, for example, bring unique lived experiences that can be channeled into helping those who are currently homeless, if provided with a role that can tap these experiences (Raphael-​ Greenfield & Gutman, 2015). Rhode Island, for example, recognizes how the attributes of CHWs, including having requisite backgrounds with homelessness, are critical in reaching those who are homeless (Alexander-​Scott, Garneau, & Dunklee, 2018):  “Community Health Workers in Rhode Island go where health begins:  where we live, learn, work and play. Community Health Workers (CHWs) have a long track record in Rhode Island as frontline public health professionals who often have similar cultural beliefs, chronic health conditions, disability, or life experiences as other people in the same community. As trusted leaders, they serve as a link between their community and needed health or social services. Community health workers help to improve access to, quality of, and cultural responsiveness of service providers” (p. 6). The utilization of community-​ based services facilitates individuals who are homeless to remain in the community, which they may consider safe. This also allows them to rely on critical connections to pro-​social individuals, programs, and agencies, and in the process to avoid recidivism, bringing together the topics of homelessness and incarceration history (Hughes, 2012). Engaging people who are unhoused (who happen to consist of a high percentage of the formerly incarcerated and those who are undocumented) in gaining disability benefits can be successful when targeted outreach is done. This involves hiring staff with the requisite skills and backgrounds to undertake outreach and education, and it involves addressing a wide range of health issues, including trauma (Dennis et al., 2015; Ferrada, Anand, & Aboutanos, 2016; Tanaka, 2014). Challenges in addressing the needs of those who are homeless are such that conventional models of health service delivery are inadequate. No CHW knows this community better than one who is, or was, unhoused



Special Population Case Illustrations  141

at some time in their lives, bringing credibility and knowledge to projects targeting this special group (Asante & Meyer-​Weitz, 2015; Coles, 2013; Power, Little, & Collins, 2015). Conventional outreach models must be modified for services to be delivered in a manner that takes their unique circumstances into account, such as veteran status, for example (Nxumalo, Goudge, & Thomas, 2013; Rowe, Styron, & David, 2016; Robinson, 2015; Slesnick et al., 2016; Tsai et al., 2014; Zlotnick, Zerger, & Wolfe, 2013). Those currently homeless are a heterogeneous group necessitating the matching of provider with consumer along a variety of levels, keeping in mind that there is a high percentage who are formerly incarcerated and the undocumented. There is a high likelihood that urban centers will have large numbers of homeless people of color, highlighting the importance of intersectionality and need for taking into account local circumstances and geographical settings.

Case Illustration There are ample opportunities to engage the formerly homeless in service to this community, such as peer advocates, peer mentors, peer caseworkers, peer counselors, peer outreach workers, consumer case managers, and community living specialist, and housing managers, for instance (Olivet et al., 2010). Regardless of the label used, what makes an excellent CHW in working with the homeless? The following brief description captures many of the themes raised in this book (Robert Woods Johnson Foundation, 2016): Elizur Bello, a program manager at The Next Door who also trains community health workers, says the most effective ones are trusted members of a community. Not only can they connect neighbors to services, they also serve as the eyes and ears of policymakers and report back on problems or trends they observe in the field. “They understand the needs,” Bello says. Maria Antonia Plascencia de Sanchez has been doing the work of a health navigator since she was a little girl in Mexico, escorting adults by train to the doctor’s office in the city because she could read. Today, Sanchez goes to homes to talk to Latino women about breast cancer awareness. “But when you get to the home, you will be facing or talking about different needs, and you need to be receptive,” Sanchez says. Someone will not hear the message on cancer if they are thinking about food needs or

142  Reflections From the Field how they’re going to pay rent. “They start talking first and then we need to respect them and give them time,” she says.

A formerly unhoused person discusses the perspective that she brings to her work (National Health Care for the Homeless Council, 2017): “My work is influenced by my experience of being homeless and housing unstable as a kid. Because of the life experiences that come as part of that chaos, I know that under issues of untreated mental illness and substance abuse there is a person who just wants to be happy, like everyone else.” The formerly homeless, for example, can have an important role to play in end-​of-​life care for those who are homeless. Those who are homeless have a history of experiencing a high symptom burden at the end of their live. However, the field of palliative care service use is limited (Shulman et al., 2018). This field, which covers a wide terrain, can provide opportunities for the formerly homeless to assume supportive roles. Formerly homeless youth are in propitious positions to become CHWs in efforts targeting their homeless counterparts in building relationships based on trust and mutual respect (Black et al., 2018). They can be involved in outreach, community education, advocacy, and research, for example. The case example of Washington, D.C.’s Casa Ruby illustrates the power of someone who was formerly homeless creating a safe environment for other homeless youth and the importance of “street credit” in having been formerly homeless in creating this environment (Governing the States and Localities, 2017): “Casa Ruby was started in 2012 by Ruby Corado, a transgender woman who escaped the war in El Salvador only to end up homeless. (She started working with homeless youth 20  years ago and formed the organization in 2004.) Today, it has a drop-​in center that helps link young people to food, shelter and services such as case management for HIV-​positive transgender women. But demand often exceeds the number of beds she has available.” In the case of Casa Ruby, LGBTQ youth who are unhoused can be replicated across the nation and meet the needs of this invisible subgroup. It is important to end this section with a note of caution concerning the importance of supporting CHWs in this very important, yet arduous, form of work. A study of frontline workers in Los Angeles found that organizational factors influence degree of staff burnout and high turnover rates, seriously limiting potential benefits to those who are homeless in connecting them to health and social services (Rios, 2016). These factors, which have



Special Population Case Illustrations  143

been identified earlier, “involved lack of trust, communication and leadership, absence of participatory development and workforce capacity building, and discouragingly low wages.”

Persons in Recovery as Community Health Workers Substance use and misuse is a subject that is certainly not new in this nation’s history and health field, with every generation experiencing their own version of the epidemic. Certain groups and communities have had more than their share of experiences in combating substance misuse, with urban communities of color falling into this category. These communities, too, have had their fair share of contributions to the health field in helping to prevent and treat those needing to enter treatment and recovery programs.

Definition of What Constitutes This Special Group Substance use and abuse goes by many different names. An evolutionary perspective will find drug abuse and addiction to have a long history. More recently, substance use disorder has emerged in the literature. Substance use disorder recovery, or dependence recovery, has been defined by the Betty Ford Institute Consensus Panel (2007) as a “voluntary maintained lifestyle characterized by sobriety, personal health and citizenship” (p. 222). Alcohol and drugs cover an extensive variety of types. However, without question, alcohol, heroin, and opiates, in various manifestations, stand out in importance because of their reach across all segments of society, with particular deleterious consequences for low-​income communities of color. A Brief Demographic Profile of the Different Age Subgroups Within This Category The racial/​ethnic composition of those with substance use disorders invariably tends to be low income, low wealth, urban, and of color, although there has been an upsurge among White, non-​Latinxs, who are addicted to opiates and heroin, which has resulted in intense national publicity (Sanders, 2016; Valdiserri et al., 2014). This shift in demographic profile results in new attention, and corresponding funding, and more so as middle-​class, White, non-​Latinxs, struggle with this disorder, and their families put pressure on lawmakers to fund treatment programs, both inpatient and outpatient. Increased

144  Reflections From the Field

attention and funding, too, result in a call for innovative outreach, programming, and research. The costs of alcohol abuse ($740 billion annually), tobacco, and illicit drugs are staggering for the nation due to crime, lost work productivity, and health care (NIDA, 2017a). In 2009, it was estimated that 23.5 million persons (aged 12 years or older) needed treatment for alcohol abuse or illicit drug abuse, or 9.3%, with 2.6 million or 11.2% of those who needed treatment turning to a specialty facility (NIDA, 2017b). Many with substance use disorders also fall into the other special categories addressed earlier, such as the homelessness, formerly incarcerated, unauthorized, youth, and veterans (Finlay et al., 2016, 2017), and not to mention, women (West et  al., 2016), and those who are dual diagnosed (Havassy, Alvidrez, & Mericle, 2015), to list additional examples. The concept of intersectionality uplifts the importance of CHWs being trusted, as well as social justice in the development of assessment and interventions (Maes, 2017).

Identification of the Major Health Issues Confronting Them on a Daily Basis and Potential Strategies Those with substance abuse disorders, as with the other three special population groups covered in this chapter, have received tremendous attention across the country. There is a thin line between life and death, and the number of deaths resulting from heroin and opioids has generated a call for a national medical emergency (Seelye, 2018). Youth, in a similar fashion to their adult counterparts, can benefit in the recovery process from youth peer support (Barton & Henderson, 2016). A focus on physical health is much too narrow an approach toward major health issues associated with substance use disorders among communities of color. Intimate partner violence, for example, is one serious consequence of alcohol abuse (Caetano, Schafer, & Cunradi, 2017). HIV/​AIDS, too, is associated with sharing needles among those who use heroin (Collins et  al., 2017; Mitchell et  al., 2016). The wide impact of substance use and abuse in this country makes this health subject one that touches virtually every family throughout all regions, but with particular relevance in urban centers, although there are shifting patterns pertaining to this health need when discussing opioids (Chan et al., 2016; Cicero et al., 2014; Jiang, Sun, & Marsiglia, 2016; Keyes et al., 2014).



Special Population Case Illustrations  145

The opioid epidemic has generally focused on White, middle-​class, non-​ Latinxs, overlooking those who are of color, low income, and low wealth in this nation’s inner cities (DelReal, 2017). In 2016, there were 1,374 deaths due to overdoses, compared to 937 in 2015. It would be a mistake to think that this nation’s opioid crisis is limited to White, non-​Latinxs, because this epidemic has reached into this nation’s urban African American/​Black community (Katz & Goodnough, 2017). This epidemic has relied heavily upon outreach workers, with those with addiction histories playing an increasingly significant role. The upsurge in crystal meth across the country has reintroduced a drug that is “new” on the drug scene, highlighting how ease of availability has made this drug attractive (Robles, 2018). CHWs’ tasks in these locales have been made that much more difficult, straining the systems they work for. Substance abuse is rarely isolated from other health issues, such as Hepatitis C and HIV, two illnesses with devastating consequences within communities of color, and also found among those who were formerly incarcerated. The interplay of gender and race/​ethnicity, too, cannot be ignored in understanding help-​seeking patterns (Verissimo & Grella, 2017). This problem, with profound social and health consequences, has attracted CHWs because of the unique perch they occupy in the health field. The history of alcohol and drug treatment in the United States spans over 150 years, and the responses generally fall into three areas: (1) family, kinship, and informal social networks; (2)  peer-​based recovery mutual-​ aid societies; and (3) professionally directed treatment (White, 2004, 2010; White, Kelly, & Roth, 2012). There is no one “magic bullet” that can be put forth, requiring a multiprong approach that draws upon these three approaches, including CHWs who cross these spheres. California, for example, has increasingly relied upon peer providers, as in the case of mental health and substance abuse, in aiding those who have been formerly incarcerated or hospitalized, helping to bridge overlapping health needs (Chapman, Blash, & Spetz, 2018):  “Peer providers are part of the transformation of behavioral health systems to a recovery-​oriented model of care. This model empowers consumers and focuses on long-​term recovery. It extends and expands the traditional medical model of care with its emphasis on professionals providing diagnosis and treatment. Peer providers, once employed only in alternative recovery organizations, have become more common in traditional treatment settings” (p. 2).

146  Reflections From the Field

Peer support and addictions are closely associated, highlighting the importance of a shared lived experience (Valentine, 2010). This close relationship has laid the foundation for CHWs and their success (Bassuk et al., 2016): “Overall, the majority of studies indicated that participation of peers in recovery support interventions appeared to have a salutary effect on participants and made a positive contribution to substance use outcomes. While we can conclude that there is evidence for the effectiveness of peer-​ delivered recovery support services, additional research is necessary to determine the effectiveness of different approaches and types of peer support services, with regard to the amount, intensity, skill level of the peer, service context, and effectiveness among different target populations” (p. 7). Identifying and mobilizing “recovery capital” (internal and external resources) on behavior of initiating and maintaining recovery has taken on significance in the field (Ryan et al., 2008). Identifying strengths or assets is a key aspect of community capacity enhancement. The emergence of the title “recovery coach” is another example of how CHWs can go by different names yet fulfill critical care roles in different health arenas. The field has created this position, which often consists of those in recovery, to reach out to those struggling with addiction, as in the case of the seven recovery coaches hired by Boston’s Massachusetts General Hospital (Kowalczyk, 2016). Having prior arrest records, however, is a key barrier in hiring them. The State of Massachusetts, for example, is seeking ways to define and assess the roles of recovery coaches. It is estimated that in 2017 over 20 states had some form of peer recovery designation or regulation (Freyer, 2017). Massachusetts offers a 1-​week program followed by 500 hours of supervision as a coach, and in 2018 they will require students to pass an examination for certification as a recovery coach. Bureaucratic barriers to effective service delivery, as in the following testimonial on a divide between provider and consumer, calls for practitioners brokering these two worlds (White & Kurtz, 2006): A long-​tenured addictions counselor sheepishly shared that he was leaving the field—​that it was getting harder and harder for him to feel good about what he was doing. He elaborated as follows, “Something got lost on our way to becoming professionals—​maybe our heart. I feel like I’m working in a system today that cares more about a progress note signed by the right color of ink than whether my clients are really making progress toward recovery. I feel like too many treatment organizations have become



Special Population Case Illustrations  147 people and paper processing systems rather than places where people transform their lives. Too much of our time is spent fighting for another day or a couple of extra sessions for our clients. I’m drowning in paper. We’re forgetting what this whole thing is about. It’s not about days or sessions or about this form or that form, and it’s not about dollars; it’s about RECOVERY!” (p. 4)

This testimonial should resonate, highlighting the importance of staff carrying out their responsibilities in a manner that is affirming, empowering, and responsive to community needs. CHWs have the capability of bridging the worlds of administration and practice through their role as outreach, engagement, education, and advocacy. Recovery coaches are best understood within a broader contextual understanding of the field (White et al., 2012): “In the past two decades, a type of addiction recovery support has emerged that does not fit perfectly in either the category of peer-​led recovery organizations or professional addiction treatment. This service encompasses new social settings (e.g., recovery community organizations, recovery community centers, recovery homes, recovery schools, recovery industries, recovery ministries) and service roles (variably called recovery coaches/​guides/​mentors, recovery support specialists, or peer support specialists” (p. 2). Recovery coaches, when sharing a substance abuse history with consumers, are better able to establish rapport and trusting relationships, critical elements in the engagement process. Hansen (2012), in a unique study of people who were formerly addicted to drugs (primarily heroin) and became converts and leaders in Puerto Rico Pentecostal ministries, found that these roles provided an avenue for them to assume helper and leader roles within their communities, giving back to the field of addictions and community outside of the conventional realms. Overcoming stigma is a major theme for CHWs working in the field. Collica (2012) reports on the success of female peer programs focused on inmates with HIV/​AIDS and why these types of programs have much promise within and outside of correctional settings. This field is probably the first to recognize the value and potential contribution of CHWs in recovery in helping those in addiction enter detoxification and treatment. There is an understanding that those in recovery can even make excellent researchers, but not without challenges (Power, 2013). There is a workforce crisis calling for bold initiatives (Hoge et al., 2013).

148  Reflections From the Field

This workforce crisis is compounded by the stigma associated with alcohol and other drug abuse (Van Boekel et  al., 2013). Stigma or spoiled identity (Goffman, 1963)  results in significant communication and treatment barriers, calling for extensive screening, training, and support to overcome biases toward this group (Crawford & Bath, 2013; Lutman et al., 2015; Van Boekel et al., 2013). Denying or ignoring these long-​held beliefs as a part of a comprehensive response is ill advised, calling for innovative efforts that specifically tackle this stigma. As addressed in Chapter  1, these roles can even involve peers who are in the same situation as those that they are trying to reach, as in the case of active drug users reaching out to others, providing information that can be useful in meeting their pressing needs (Einstein, 2012). This stance is controversial but highlights the potential of peer engagement across a wide variety of circumstances. Another approach is to recruit, train, and support those in advanced stages of recovery to assume prominent roles in this field. CHWs are an underutilized cadre of staff for the addictions field and represent a potential staff that has largely gone unrealized. A  shift away from a medical to a recovery model provides conceptual underpinnings, creating requisite conditions for work with those in recovery and a potential for employment and career advancement (Kurtz, 2014). CHWs who have successfully entered recovery are in a position to bridge the worlds of the streets with (expertise and consumer legitimacy) services that those without this history would have great difficulty in delivering (Morgan, Lee, & Sebar, 2015). Bringing the knowledge, comfort level, language, and motivation of substance disorders places CHWs in recovery in a position to develop relationships based on mutual trust and respect, providing information and insights on the recovery journey. Relapse and stigma remain consistent challenges for CHWs who are in recovery because of their constant exposure to alcohol and drugs, which is a unique challenge when compared to the other special population groups addressed earlier, and must be addressed in supervision and training (Doukas & Cullen, 2013): Reducing stigma by fostering a supportive, non-​judgmental environment is paramount to an agency if it wants to encourage staff who are struggling with substance use issues to raise these concerns with their supervisor without the fear of being the topic of gossip. Many workers with substance



Special Population Case Illustrations  149 use issues resist seeking help because they fear gossip, or distrust confidentiality at work.

This calls for building extraordinary supports to prevent relapses, which may be accomplished through a peer supervisory model. Yet this potential for relapse must be purposefully uplifted and guarded against.

Case Illustration Selecting a case addressing the field of recovery was easy for me, and this takes on significance because the subject of substance abuse disorder is rarely isolated from other major health issues that can be contagious, making it that much more arduous to find a case illustration that gives justice to the subject. Two program stands out—​Boston’s Casa Experanza and Springfield, Massachusetts’s Tapestry Program. These cases were selected because I  am familiar with their histories and the work undertaken over the past several decades in reaching out to the Latinx community of Boston and Springfield. Their focus on the health of marginalized groups of color in addressing addictions and corresponding illnesses through the use of CHWs in a culturally responsive manners epitomizes the central thrust of this book. This section differs from the others because it will spotlight two programs, both Latinx focused and in Massachusetts and in different parts of the state. Casa Esperanza (https://​www.casaesperanza.org/​) is located in Boston and Tapestry (https://​givingcommon.org/​profile/​1102924/​tapestry-​ health-​systems-​inc/​) is located in Springfield, approximately 100 miles west of Boston. These programs have had a long history of collaboration with the Boston University School of Social Work, illustrating the importance of a close collaborative partnership with a university and school of social work in advancing CHWs across the country. Casa Experanza prides itself in providing comprehensive services to those in recovery in Spanish, and with expertise in services that are culturally grounded. It has made a conscious effort to hire those with these linguistic and cultural competencies who are in recovery as “peer recovery coaches.” These coaches, as in the case of Richard Lopez, bring life experiences beyond recovery, including being formerly homeless, having correctional experiences, and sharing the same ethnic and socioeconomic class background as the consumers, illustrating how the overlap between these three areas is not unique and is often necessary in reaching out to

150  Reflections From the Field

those in need. Consumers experiencing these three areas of needs present unique challenges that are best met by providers with similar experiences. Casa Esperanza also includes the families of those in recovery as a means of ensuring that they remain in recovery through their active support, which can often be challenging. If families have a limited understanding of what constitutes treatment and the underlying causes of substance misuse, they may mistakenly undermine treatment goals. For CHW services to be effective, they must seek to be inclusive of the families and loved ones of those being served. Tapestry represents a community effort addressing the needs of Latinxs, primarily Puerto Rican, in the western part of the state. Tapestry was founded in 1973 with an explicit mission to address health issues of marginalized groups, with Latinxs representing a major group: Tapestry Health is dedicated to being a leader in providing high quality, cutting-​edge, non-​ judgmental health services and advocacy for disenfranchised and underserved populations, with an emphasis on women and youth. Since its founding, it has expanded its health reach:  Today, Tapestry Health continues to expand in the number of people that we serve and range of services that we provide. From introducing HIV/​AIDS services to western Massachusetts in 1990, to operating the only needle exchange in Massachusetts west of Cambridge, to giving free nutritional food to families in Springfield, to being the sole family planning agency to offer state insurance enrollment, we remain committed to working on the cutting-​edge of public health through innovative and effective intervention programs.

Tapestry’s evolution reflects on how their concept of health has expanded to include topics of interest to Springfield and surrounding communities. This flexibility, a theme in this book, allows quick CHW responses to local concerns. Tapestry has maintained extensive collaboration with community-​based organizations and local businesses, central in any successful organization, and enlisting the support of advocates: “In addition to providing life-​saving and life-​changing care, at the heart of our agency is a desire to educate and empower people to speak out and make a difference in their community. We believe that our communities are stronger when all of our voices are heard”. Tapestry Health (Undated).



Special Population Case Illustrations  151

The threat of relapse is ever present in the lives of recovery coaches, and this calls for major institutional focus and support of their work in communities. This support can be manifested through supervision and training, as noted by Case Esperanza’s Richard. This support is critical in building an institution’s capacity to recruit and retain recovery coaches because much of their work is done out in a community where immediate supports may not be available.

Conclusion Important advances have occurred in the field targeting special groups, as evidenced in the case illustrations and background provided. This chapter concretized what CHWs mean for this nation’s marginalized groups. Although four groups were signaled, readers can see how CHWs can reach other highly marginalized groups in creative and highly culturally respectful ways. Each group highlighted the rewards and challenges, providing a wide range of health services in urban communities. The following chapter focuses on key themes from the scholarly literature and field of practice. Readers are in a much better position to appreciate these themes and how they will continue to unfold and influence the evolution of CHWs and their work in this nation’s urban centers. These and other themes will continue to evolve in the next decade, highlighting an expanding and influential field of practice.

9 Recommendations for Practice and Research Introduction This is an excellent time to reflect on the major lessons that emerged in earlier chapters, with readers being in a position to draw their own set of conclusions from the theoretical material, empirical findings, and case illustrations. These lessons may, or may not, be similar to mine. Numerous themes stand out, and only a few will be focused on because of how they stand out in importance in shaping the future of community health workers (CHWs), particularly in this country. These themes are indicative of a vibrant field that will continue to wield significant influence in the health field, with emerging issues having a profound impact. However, regardless of presidential administrations, CHWs have a vital role to play in the nation’s health field. Although we cannot oversing the praises of CHWs, they are not miracle workers and their ultimate success is dependent on the support they receive and the performance of other health segments (Schneider & Lehman, 2016): “Approaching CHW programs through a systems lens highlights that the attributes of the CHWs—​their technical roles, skills, and motivation—​ only partly determine their performance. Further, though CHWs may be the most visible manifestation of health action within communities, health gains at this level involve a far greater array of community and health system factors than the CHW cadres themselves” (p. 113). The need for further research on CHWs is often done under the most difficult of circumstances, and it permeates all facets of this book. The call for more research should not be surprising and how it unfolds promises to bring surprises, including how CHWs can play an influential role in bringing it to fruition within their respective communities. Research, and more specifically axiological (the influence of values on the research process) and methodological (the language and



Recommendations for Practice and Research  153

process of research) decisions, will be manifested in discussion of CHWs as researchers, and this bears attention because of how these decisions wield influence the process and the knowledge emanating from it. This chapter covers promising research approaches that take into account the unique circumstances that CHWs often find themselves in, including tensions and ethical dilemmas.

New Approaches and Models Innovation has found its way into the health field and CHWs, such as viewing them as “synthetic social support” (Gale et  al., 2018). This aspect of the field is essential and must be fostered whenever possible. This “expanding universe” of practice has been an essential component of CHW service provision in the past, and it remains so in the present and in the future. As long as the universe is expanding—​and it is only a matter of time before it stops and starts contracting—​there will be excitement, with its ultimate potential remaining to be fully realized, along with corresponding challenges. Development of workplace clinics, for example, has been proposed for reaching underserved population groups. These individuals are often in employment situations that can result in unhealthy states and, due to work requirements, make it arduous for them to attend community clinics (Tarp et  al., 2017). Efforts at integrating CHWs into medical homes is further proof of their expanding roles (Rogers et al., 2018). Free clinics, too, have emerged to help those who are unauthorized to obtain health care (Appold, 2015). These are but two examples of countless innovative service delivery approaches. Readers have no doubt developed an appreciation that innovative approaches have not all been smooth and without controversy and tensions, if not conflicts. The research field, which will be addressed in the next chapter, has benefitted and influenced the field of community health work and infused highly participatory and innovative approaches on informing the conceptualization of services that have been cutting edge (Shah, Heisler, & Davis, 2014; Simonsen et  al., 2017; Strachan et  al., 2015). These methods have influenced the field and will continue to do so in the immediate future because of how they embrace values that are empowering, asset driven, participatory, and social justice focused (Oetzel & Minkler, 2017).

154  Reflections From the Field

Demand for Community Health Workers Will Only Increase The presence of health inequities means that much progress needs to transpire in the coming decades for marginalized groups, particularly when there is a demand for service delivery models that are cost efficient and highly responsive to underserved groups with high health needs. Demographic trends continue to unfold in communities of color, urban centers, and nationally, and these have ripple effects throughout the health field, including the need for innovative programming and models, such as methods for recruiting, screening, training, supporting, and evaluating CHWs in a variety of contexts and health issues. Needs, when introducing immigrant status, increase in severity and complexity against a highly publically charged background that makes outreach and engagement more challenging, and more so in cases of those who are undocumented and their families, which may consist of mixed status members (Delgado, 2018). Jack et al.’s (2017) literature review on US CHW impact on use of health care services found that, although they may not be a panacea, they have been effective reducing costs in some instances and preventable utilization of services. Maximizing their efficiency is contingent on having the necessary supports in place.

Evolving Roles An evolving field brings excitement and frustrations. One area of frustrations is how roles get redefined continuously to encompass new activities. How and when these activities move from the informal to formal job descriptions always experiences a degree of lag time. Daniels et  al. (2017) argue the importance of the field differentiating between CHWs who are generally deployed by medical services and peer supporters (PSS), who are generally deployed by behavioral health: A key difference between the CHW and PSS workforces is the way in which they connect with the individuals they serve. The CHW often shares a social and a cultural background with those served; the shared background is based in common community experiences and shared institutional affiliations, including churches, schools, and other



Recommendations for Practice and Research  155 organizations. The PSS draws on some of the same community life–​based experiences and also uses his or her own lived experiences with behavioral and other health conditions to support engagement, recovery, and improved health activation. This shared experience with common health conditions fosters support and activation through a peer wellness–​based approach that has been credited with the promotion of hope and the belief that recovery is possible for those with behavioral health conditions. Both CHW and PSS roles foster improved understanding of existing health conditions and treatment alternatives, which are core tenets of health literacy.

Greater specificity on what is meant by peers and CHWs benefits the field in moving forward with requisite research to shed light on their role and effectiveness. This specificity will be difficult to obtain because how their roles unfold will be greatly dependent upon local circumstances, which is a strength of the field. Research is another area where CHW roles are evolving. Unfortunately, this topic has historically been associated with a staid environment and purpose: the advancement of knowledge. There is a tendency to treat this subject apolitically, generally eschewing a social justice mission or purpose. This is no longer the case, as evidenced by the explosion of research approaches and methods that explicitly embrace social change and social justice. The community health field is an arena where innovation has a long history, and one that will only increasingly be open for innovation, particularly that which is participatory (Miller, 2015; Suiter, 2017). Youth, too, are increasingly assuming highly participatory and decision-​making roles in community-​focused interventions and research (Ferrera, 2015; Garcia et  al., 2014; Rodríguez, Casanova, & Rodríguez, 2016; Sprague-​Martinez et  al., 2017). In health promotion, they generally remained as recipients rather than providers, with notable exceptions (Bastien et al., 2016; Delgado & Zhou, 2008; Fairchild, 2015; Ford-​Paz et al., 2015). The same can be said for older adults (Delgado, 2009). These two ends of the age continuum represent significant numbers of individuals in undervalued communities across the country, bringing unique sets of challenges, including being undervalued by a society that only highly values a certain age range of adults. This gap opens the door for innovative research approaches using democratic participatory principles.

156  Reflections From the Field

CHWs can play meaningful roles throughout all stages of a research project from the initial conceptualization on through to data interpretation and recommendation for programming and policies. Although their roles will and should vary, their presence and contributions must be actively sought. Corburn (2005, 2009)  has played an instrumental role in community participatory research and environmental health, illustrating the potential of this form of research to reach and engage local residents. CHWs with a focus on environmental health can be part of these community teams. CHW research roles must expand beyond conventional roles to include having them in leadership positions rather than being limited to interviewer or support roles. CHWs can be effective in recruiting and retention of residents’ research because the same qualities that they possess make them attractive providers of health care (Choi et al., 2016).

Research by, for, and on Community Health Workers Research will play an instrumental role in determining the level and scope of CHW initiatives. The value of collaborative or co-​practice can also be extended to community research if purposeful engagement and empowerment are central goals of an activity intent on reaching and engaging marginalized urban groups (Ayón et  al., 2016; Cortés et  al., 2017; Ramanadhan et al., 2016). Use of “big data” to solve health inequities must be carefully weighed (Bakken & Reame, 2016). Big data have historically blurred significant within-​and between-​group differences when addressing communities of color and been unable to ground data within the context that these groups live in. These data do not provide needed depth and nuance to aid local CHW initiatives. Any sustained effort to reform this nation’s health care system must be built upon research and advocacy, with the emphasis being debatable. Research is destined to play a prominent role in how far CHWs will be integrated into the nation’s fabric of health services (Webber et al., 2016). This research will be multifaceted, including that focused on health promoters, their consumers, and how they can assume research roles (Krok-​Schoen et  al., 2016). These perspectives bring unique rewards and challenges for this field and how it evolves in the near future (Vaz et al., 2014).



Recommendations for Practice and Research  157

Efforts to involve CHWs in research are increasingly playing a prominent role in the field and scholarly literature, particularly in community-​based research (Hilfinger-​Messias et  al., 2013; Hohl et  al., 2016; Otiniano et  al., 2012; Smith & Blumenthal, 2012; Tovar, 2015; Wells, 2015), including engaging communities in clinical trials (Angwenyi et al., 2013). Ethnographic research has been identified as an effective method for soliciting and listening to the voices of CHWs (Maes, Closser, & Kalofonos, 2014). Training curriculum for CHWs assuming research roles can be found in the literature, which fortunately has numerous examples to draw lessons from and is evolving the more we learn about this field (Dumbauld et  al., 2014). Increased attention to preparing CHWs to add research competencies to their vast array of health delivery competencies represents a natural evolution of this field and a step in the right direction in ensuring that findings are relevant to the work that they undertake. CHWs can fulfill a variety of health-​related research roles because the same qualities that make them excellent providers can also be used in community research (Ingram et  al., 2015). For example, they are effective in collecting complete and high-​quality vital events data, which are used to monitor annual changes in health conditions, and this can be a very difficult task (Silva et al., 2016). Latinx CHWs have been subject to small-​and large-​scale randomized control trials, in this case involving diabetes, and found to be highly effective (Carrasquillo et al., 2014; Koniak-​Griffin et al., 2015; Rothschild et al., 2014). These efforts, when applied to other illnesses and diseases, start the building of a comprehensive foundation defining this field in the immediate future, with an understanding that it will continue to evolve, with corresponding reconceptualization to follow. LySaught (2013) sums up the value of CHWs to communities and the field: Usually drawn from the communities they serve, community health workers possess firsthand understanding of patient culture, community, experience and language, and they are more often aware of the nonmedical barriers to accessing health care and maintaining health, as well as of local resources for improving patient care. Consequently, they “can help health systems overcome shortages of human and financial resources by providing high-​quality, low-​cost services to community members in their homes and by diagnosing diseases in their early stages, before they become more dangerous and expensive to treat.” (p. 46)

158  Reflections From the Field

It is clear that indigenous (born, raised, and/​or living within the community) CHWs bring considerable value to services that cannot be learned in school, although formal education can enhance their potential contribution and advance them professionally. Hilfinger-​Messias et  al. (2013) note that much of the existing research focused on CHWs themselves has focused on their personal traits, particularly their willingness to embrace in service to a community mantra (compassion, empathy, communication skill sets, and leadership qualities), access to and strength of social networks, and their engendering high levels of trust. These findings reinforced the unique qualities they possess, effectively placing them in a propitious position to act as social/​cultural brokers, or bridges, to communities that are islands within society (Massengale, Morrison, & Sudha, 2016; Robinson, 2015). Why engage in community health work? Becoming a CHW can be an identity and career transformative process. In the case of those without a high level of formal education, this work introduces avenues for employment in the health field. It can be said that the caring and motivation of CHWs are in their veins, and it is incumbent upon health systems to tap this resource (Swartz & Colvin, 2015). The potential personal impact on CHWs presents a dimension that must be fostered (Okello, 2016). A quest to make social contributions coexists with future rewards to motivate volunteer CHWs (Kasteng et al., 2016). They can be conceptualized as assets and their competencies enhanced through appropriate training and support (Abrahams-​Gessel et al., 2015; Young et al., 2012). Institutional resources invested in them must be conceptualized as investments in communities.

Conclusion The field’s expansiveness is only limited by our imagination. This chapter only scratched the surface on innovative CHW interventions and the challenges they face as it expands into new health arenas, which have rewards far exceeding the challenges. Any “good” field will always encounter challenges. The evolution of community health work has shown that there are no geographical boundaries to stop its progress and no health issue that cannot benefit from CHW involvement.



Recommendations for Practice and Research  159

The evolution will be dependent upon key forces coming together to create a climate encouraging innovation. The following chapter addresses recommendations on research and practice that help ensure CHWs continue to make contributions to the lives of urban marginalized groups. These recommendations capture the changes that have happened and must be continued in the immediate future.

10 Practice Challenges and CHWs as Researchers Introduction The proverbial quest for research to inform practice is also applicable in moving the community health work field forward, with twists and turns due to the unique perch it enjoys within communities. The advancement of knowledge on community health worker (CHW) roles, services, and practice settings is tied to reliance on research, particularly that which has them in a central role in selecting the questions and most appropriate methodology (Kia-​Keating et al., 2017). This chapter builds upon the values and principles addressed earlier, including ethical dilemmas and considerations, emphasizing participatory research methods that seek engagement of residents in carrying out health research in service to communities (Campbell et  al., 2014; Shelton et al., 2017; Vaughn et al., 2016a). This does not mean that other forms of research, such as quantitative, are not welcomed. It is fair to say that qualitative research will be emphasized because of its transformative potential for researchers and communities. The approaches and recommendations that follow will not be surprising because of how the values and principles outlined in Chapter 1 have been woven throughout early chapters. Although research can be conceptualized as an intervention, its function can extend to enhancing capacities and knowledge creation, too, because of an emphasis on building local assets that can also be rallied to aid others. No community is totally devoid of assets, and this premise must extend to research as a method; CHW initiatives can identify these assets and incorporate them in community initiatives. This final chapter presents one author’s conception of the challenges that will follow CHWs, including rewards, and how their role can continue to evolve to encompass new terrains, such as research, and the minefield of ethical challenges. It is important that CHW roles continue to evolve to take



Practice Challenges and CHWs as Researchers  161

into account major social, political, cultural, demographic, and economic changes in our country.

Challenges and the Field of Community Health Work Although this book devotes focused attention to the rewards and benefits that CHWs bring, immediate and future challenges cannot go unaddressed if we expect this progress to continue. A field without challenges is one in decline and irrelevant, with challenges, dilemmas, debates, and tensions as indicators of a field’s significance. Twombly, Holtz, and Stringer (2012) identified three challenges facing this field as it seeks to expand in the immediate future, and these challenges should not be surprising to readers:  (1) the paucity of standardized data on the various kinds of promotores’ programs; (2)  labor issues (roles, functions, ethical challenges); and (3) a grasp of organizational costs of various models and approaches. These areas are highly interrelated but of sufficient importance to be worthy of being a focus of attention and of having their own category. The nature of these challenges means that they will not be satisfactorily resolved in the near future. Although there is a universal understanding of the importance of CHWs in the United States, not all states share this enthusiasm, and when employed, they may not be found throughout state health systems, as in the case of Missouri (Rhodes et al., 2017). Further, CHWs are not universally accepted within health care settings. This resistance is primarily due to some physicians and nurses not being comfortable or trusting of those without comparable professional education (Mogere, Loum, & Kaseje, 2015). Lack of trust and open acceptance plays an instrumental role in minimizing the effectiveness of CHWs. A lack of definitional consensus is to be expected in a field with an international reach that is expanding rapidly, making clearly defined boundaries arduous to delineate. There is immense diversity of CHW programs, as in the case of HIV initiatives, across the country and world (De Neve et  al., 2017), bringing excitement and challenges for comprehending the boundaries of this field and its evolutionary path. Bovbjerg et  al. (2013a) identified a series of conceptual and practical challenges in developing a consensus definition, with none being easily addressed:

162  Reflections From the Field Developing a comprehensive and widely accepted definition of a community health worker is challenging. CHWs go by dozens of different titles—​ community health advisors, lay health advocates, “promotores(as),” outreach educators, community health representatives, peer health promoters, and peer health educators (among many others).  .  .  . They work in many settings—​in homes, in health clinics and medical offices, in hospitals, in rural and urban settings, domestically and internationally, in community based organizations, and in churches and other faith based institutions. And they interact with individuals who have or are likely to have particular health issues and with their families; doctors, nurses, and other medical professionals; social workers and social service providers; insurance companies and other third-​ party payers; and community leaders. (p. 5)

If these challenges are not difficult enough, we add others, such as an evolving service role and ever-​changing demographics, to a naming process of what to call them, a critical element in advancing any field of practice and scholarship. CHWs can be staff or volunteers, adding a complicated dimension while expanding the possibilities for tapping community assets (Alibhai et  al., 2017). CHWs can be conceptualized as catalysts and role models, and they achieve this by empowering communities with increased knowledge and support (Daniels et al., 2015; Rachlis et al., 2016). Further, their roles vary across national boundaries, making comparisons difficult (Javanparast et al., 2012). Acknowledging this challenge is an important initial step in undertaking research and rectifying permeable role boundaries. This flexibility is a strength and weakness, and expected of any relatively new field of practice, and we must not hold this field to any different standard. An evolutionary perspective helps us appreciate the ambiguity associated with an emerging field of practice, and to have an understanding of the anxiety that it causes both practitioners and academics, not to mention consumers of services. Nebeker and López-​Arenas (2016) address the importance of CHWs and their role in delivering needed services in underserved communities, yet they share similar qualities, roles, and functions within their respective communities and are potentially uniting a workforce with different cultural and linguistic backgrounds:



Practice Challenges and CHWs as Researchers  163 Community Health Workers (CHWs), also known as Promotores de Salud, are natural leaders and advisors who share the language, customs, ethnicity, and life experiences of the residents of their local community. A  CHW may be engaged as a volunteer or paid staff to deliver health services in hard-​to-​reach urban and rural communities where health disparities are prevalent.  .  .  . The World Health Organization reported that CHWs make up a significant part of the global work force and are identified by a wide variety of classifications including, to name a few: community nutrition worker (India), community resources person (Uganda), monitora (Honduras), promotores (Americas), and outreach educators (various countries). For this paper, we use the term “Community Health Workers” or “CHWs” recognizing that the term “CHW” covers a number of titles and/​or classifications. (p. 41)

There is no country where CHWs are not valued, and there is no reason to think that their value will not continue to increase in the immediate future, bringing incredible rewards and challenges for this field and a promise of more to come. Our understanding of what unites different CHWs and what is unique to their local circumstances advances this field well into the twenty-​first century. If CHWs are to achieve a greater scale of involvement, they must reconcile tensions between formal health care systems, which necessitate integration, community systems, and embedding in the community context (Schneider & Lehmann, 2016). Health care organizations can incorporate CHWs as core team members for specialized health promotion initiatives or as team members in other types of initiatives that tap their strategic position within their communities to enhance team goals (Zandee et al., 2013). Local circumstances and goals should dictate how roles unfold, and to what extent they represent the demographic characteristics of the communities they wish to reach in a culturally affirming and empowering manner. This latitude makes national generalizations of CHWs arduous. Although CHWs are associated with medical staff, such as nurses and physicians, other professions, too, can work with these staff. Social work, for instance, is a profession that shares many of the same values often adhered to by health promoters (Spencer, Gunter, & Palmisano, 2010). Social workers and CHWs can work effectively together, with each profession bringing complementary knowledge and skill sets (Aguilera-​Steinert,

164  Reflections From the Field

2018). Both professions share a passion for community-​based services, tapping strengths and assets, a social justice stance, and empowerment. CHWs function with challenges, and they can encounter difficult situations that place them in awkward positions resulting in ethical dilemmas and compromising their effectiveness, including undermining their community status (Boulanger, Hunt, & Benatar, 2016; Cribb, 2016). The work undertaken by CHWs necessitates that their organizations be prepared to undertake a balancing of bureaucratic procedures and structures, improving task allocations and synchronization of work schedules (Phuka et  al., 2014). This need is endemic to community-​centered services, requiring roles to be sufficiently flexible to respond to unanticipated encounters and local circumstances. Health navigators have shown great potential for overcoming significant bureaucratic barriers when there is an effort to tap their voices in understanding what they believe makes them successful (Vargas, 2016): From website glitches to misleading media coverage, millions of uninsured Americans did not know who or what to trust when the Affordable Care Act rolled out in 2013. In anticipation of such chaos, policymakers created a new health care work force called “health navigators,” who provide free “help to consumers, small businesses, and their employees as they look for health coverage options and complete enrollment forms.” . . . The U.S. Center for Medicare and Medicaid Services (CMS) allocated $67 million to fund navigator programs in 34 states that, in total, employ 28,000 health navigators nationwide.  .  .  . This new bureaucracy faces a classic problem of building legitimacy in the eyes of a clientele newly eligible for health insurance.  .  .  . This work is especially challenging in low-​income minority communities which have high levels of distrust toward both government bureaucrats and the medical profession.  .  .  . Using the case of health navigators, this article asks:  how do bureaucrats build legitimacy with distrustful low-​income clients? (p. 263)

The expansion of CHW initiatives through massive infusion of governmental funding creates a bureaucratic structure, and obstacles, which must be successfully navigated for this workforce to effectively reach marginalized groups. Organizations must be prepared to develop and implement delivery models with built-​in flexibility, including an explicit expectation of task



Practice Challenges and CHWs as Researchers  165

shifting, pertaining to requirements for employment and career advancement. This small, but significant step provides much needed organizational flexibility for institutions to be able to rapidly respond to new population groups entering their catchment areas, and emerging health issues, and to do so relatively quickly. Quick deployment helps ensure that organizations meet needs in a timely manner. The advancement of CHWs within organizations has been examined, and it was concluded that they must be incorporated into more permanently stable funding streams rather than relying on foundation/​corporate grants, helping to increase their chances of sustainability (Koskan et  al., 2013). Reliance on “soft” money makes it arduous for CHWs and their organizations to make long-​term commitments, although developing funding streams to ensure sustainability is feasible (Morgan et  al., 2016). Advancement has historically been tied to achievement of formal educational levels, raising questions about an invisible ceiling for them. CHWs are no longer relegated to the fringes of health systems, and this is exciting from a conceptual, practice, and sociopolitical stance (Parker et al., 2013). Balcazar et al. (2011) advance a three-​part agenda for health workers in this country for them to be a vital part of “community health teams” and “home health teams”: (1) including CHW perspectives; (2) promoting that they are integral in systems of health care; and (3) promoting health worker research and policy. According to a Department of Health and Human Services report on CHWs, three significant findings stand out regarding how this service model will continue to emerge in the immediate future, bringing added positive attention to CHWs and their contributions to the field (Synder, 2016): • Community Health Workers (CHWs) are an emerging group of health professionals that have recently drawn increased national attention because of their potential to deliver cost effective, high quality, and culturally competent health services within team-​based care models. • The apparent benefits of integrating CHWs into health care teams seem to depend on context. The strongest evidence of these benefits supports utilizing CHWs to deliver certain specific, high-​value, preventive services—​focused on reducing risk factors for cardiovascular disease and other chronic conditions—​to low-​income, minority, or other underserved populations.

166  Reflections From the Field

• Despite growing interest in engaging CHWs in national delivery system reform efforts, there are several uncertainties about how to best proceed with this. Questions remain around standardizing CHW training, certification, and licensure; establishing strong economic and other evidence to support their use; and securing reimbursement for their services to ensure financial sustainability of CHW programs. (p. 1) The prominence of CHWs requires greater research and evaluation efforts if they are to continue to expand and assume a more prominent role in delivery systems targeting marginalized groups, and even possibly expanding their roles. CHWs are wont to experience occupational stress, and this should not be surprising to anyone who has done any form of community practice (Banks et al., 2013; McDaniel, 2016). The loss or diminished passion for the work (occupational fatigue or burnout) can be the result of poor pay, lack of educational and self-​development, workload demands, inadequate support, and low organizational status, for example (Luo et al., 2014). When CHWs are volunteers, providing a per diem can assist in carrying out these roles without comprising their potential effectiveness that can occur when assuming a paid staff role (Closser et al., 2017). Occupational stress can have systems-​wide implications, including in the homes of these CHWs and their respective communities where they live and serve. Occupational stress, with at its most extreme resulting in burnout among CHWs, is well recognized (Rollins et al., 2016; Ruotsalainen et al., 2015). There is a surprising call for educating the public about the role of CHWs to reduce role stress, increase job performance, and reduce staff turnover (Kemp & Henderson, 2012). How organizations acknowledge and respond determines staff turnover rates and retention. Preservice, ongoing training, and education have increased CHW coping and performance skills (Haughton et al., 2016; Vesel et al., 2015). The “minority tax” represents a different dimension to stress in the case of CHWs of color, for example, creating a form of occupational stress and a concept that has mostly been applied to people of color in academia. This hidden tax places Latinxs, for example, in an untenable position of having to carry out responsibilities that White, non-​Latinxs are not asked to address as part of their responsibilities (Rodríguez, Campbell, & Pololi, 2015).



Practice Challenges and CHWs as Researchers  167

It certainly is not restricted to those in academia, and it can find a home when discussing those CHWs of color. The challenges to CHWs are many. There is one that has particular significance because the field is at a crossroads pertaining to its future. Their “professional identity” is critical because it shapes their views of themselves and how their respective communities view them. Clearly defining and defending CHW professional identity, and the role of standardization and certification, remains a key challenge for the field, and the outcome of these deliberations will have profound long-​term consequences for CHWs and the communities they serve (Malcarney et al., 2017): Of interest is whether standardization of the CHW profession is warranted, and, if so, what that should look like. . . . An emerging mechanism for CHW standardization is state certification or credentialing, present in several states and underway in others.  .  .  . However, standardization through certification involves gains and losses for different stakeholders.  .  .  . For CHWs themselves, certification can improve employment stability and lead to career pathways. . . . Payers may see certification as a way to guarantee a standard skillset and knowledge base for CHWs . . . and states may view it as an opportunity to bring consistency to a growing area of the health care workforce . . . and increase funding for services.  .  .  . However, for an emerging occupation, the prospect of standardization may mean that a “professionalized” workforce in which standards are defined and enforced could potentially threaten what makes CHWs unique—​the trust of the community served. . . . This would represent a significant break with the historical roots of the CHW movement and could create barriers to entry into the profession. . . . For this reason, CHWs themselves have set out to establish their own standards. (pp. 360–​361)

National efforts to “legitimize” CHWs cannot be allowed to occur without having these workers play a meaningful role in shaping these efforts. It is impossible to empower communities while not empowering providers. This point is obvious, and when it does not occur, it becomes profound.

168  Reflections From the Field

Rewards and Challenges in Community Health Worker–​Initiated and –​Involved Research The degree to which the health field moves forward in an encompassing and affirming manner in addressing the health needs of marginalized groups is greatly dependent upon how CHWs are able to carry out their historic mission (Terpstra et al., 2011): “There are a number of advantages in having CHWs as an integral part of a research team, including increased recruitment, participation, and retention of participants; ensuring that research procedures are culturally appropriate for the target population; and providing feedback about the feasibility of using outcome assessments in the target population. . . . In fact, CHWs may be a crucial part of the intervention effectiveness in minority and underserved populations” (p. 86). The advantages that CHWs bring to the field can be built upon to also engage in research, but it should not be expected to be smooth sailing, so to speak (Holzer, Calhoun, & Strong, 2017). Terpstra et al. (2011) go on to identify several key challenges in having CHWs assume research roles, when they conduct research that can have profound consequences for how this field unfolds in the near future. These challenges are multifaceted and can be both expected and unexpected in all realms of service delivery, including research. As the CHW role in research becomes increasingly more involved, so do the complications and challenges associated with carrying out their responsibilities as a research team member.  .  .  . Work by Earp and colleagues illustrates some of these complications such as CHWs recruiting family and friends to meet their recruitment goals when the research protocol stipulated that participants were to be chosen randomly.  .  .  . In addition, CHWs may introduce some degree of selection bias to a study by choosing participants who are more likely to follow all of the CHWs’ intervention instructions, thus making them “look good.”.  .  .  Given the popularity of the CHW model in health promotion research . . ., it is important to understand the unique challenges that are presented when CHWs adopt research roles within their communities. Many of these challenges concern the underlying conflict between the



Practice Challenges and CHWs as Researchers  169 needs of underserved communities and those of research studies within these communities. (p. 86)

When findings are contingent on researchers’ quest for inclusion and empowerment, and those they seek to reach having a close and trusting relationship with them, it brings life and meaning to the findings, but it can also blur boundaries, leading to potential ethical dilemmas and breaches that compromise outcomes and potential for systematic changes. Any assessment of the value of CHWs initiating and assuming a prominent role in research will identify numerous rewards and many challenges in bringing them into the mainstream of a field that historically has been dominated by academics and those with many initials after their surnames (educational expertise). An excessive amount of value placed on educational expertise at the expense of experiential expertise limits the potential of research to make a significant impact on the day-​to-​day workings of these workers and their communities. CHW research roles are not limited to those without formal educational levels and may involve college-​ level attendance (Medhanyie et al., 2017). Democratizing research roles by emphasizing experience with necessary on-​the-​job training broadens those who can call themselves “researchers.” Dawson et  al. (2018), in a review of the literature on people of color’s engagement in health and social care research, found that when involvement did transpire, it was generally limited to the design phase, and least so during analysis and interpretative phases. This proclivity to limit involvement and not seek active and meaningful engagement during all phases of a research undertaking, including issuing recommendations, is less likely to occur in nonparticipatory studies. However, participatory studies do not guarantee that engagement occurs across the entire spectrum and in an empowering manner (Martinez, 2014). Tapestry, as discussed in Chapter 8 (Adorno et al., 2013; Martinez, 2014), illustrates potential partnership rewards that can emerge between settings employing CHWs and universities with capabilities and desires to inform this field in urban settings. This relationship, when based upon mutual trust and respect, facilitates engagement in innovative approaches. CHW researchers can be conceptualized as “cultural navigators,” helping to ensure

170  Reflections From the Field

that findings are relevant to their communities (Ozano & Khatri, 2018). However, they, too, can get lost because they are human.

Promising Research Methods and Approaches The CHW field is bound to be associated with exciting and bold research approaches that match the challenges and rewards attached to their work. These efforts opened up new doors toward providing invaluable insights into their work and success, including emerging areas of practice, and the promise of collaborative learning (de Wit et al., 2018; Frerichs et al., 2016). The approaches that follow can fall into three possible classes pertaining to their embrace in the field (Delgado, 2006): (1) conventional; (2) emerging; and (3) unorthodox. This framework is arbitrary but helps us grasp potential resistance to findings. Conventional approaches refer to tried and true methods that enjoy wide acceptance in the scientific community. Emerging approaches capture new methods that will find wide acceptance and join conventional approaches or be considered on the fringe. Finally, unorthodox approaches are new and few researchers are familiar with them, with only time determining their ultimate place among the conventional approaches. This continuum is dynamic in a field that is, too, dynamic, making for an exciting period of advancement. Readers must determine where the following methods fall within this continuum and the likelihood of their future projection. Those initiated by CHWs or those in which they play prominent roles across the research continuum would fall into the latter two categories with hopes that they eventually find their rightful place in the first category and be widely accepted. Time will be the ultimate judge. The following are several of the most promising approaches. Readers can add their own.

Community-​Based Participatory Research Community-​ based participatory research (CBPR) is a broad term incorporating multiple research approaches stressing participatory democratic principles. CBPR has proven fruitful in reaching into immigrant and other communities in the United States, helping to overcome suspicions



Practice Challenges and CHWs as Researchers  171

of outsiders, language and cultural barriers, and translation issues usually associated with research undertaken by “outsiders” (Katigbak et  al., 2016; Oetzel & Minkler, 2017; Sprague-​Martinez et al., 2017, 2018). Many readers will no doubt place CBPR into the emerging category of research. CBPR has been found to be extremely successful when based upon local residents engaging in this research across groups of color and various health condition (Berkley-​Patton et  al., 2018; Brown Speights et  al., 2017; García-​Rivera et al., 2017; Kim et al., 2016; Oetzel & Minkler, 2017; Tremblay et  al., 2017). Its attractiveness is increased when research is focused on marginalized groups (Coughlin, 2016). When residents are conceptualized as “experts” of their own lives, hiring them and providing them with needed training and ongoing support becomes a prudent act that helps to increase the likelihood of a research project experiencing success. It can make the research findings relevant and allow for community capacity enhancement (Hardy et  al., 2016). Conceptualizing residents as “experts” places them in a prominent position at the table where decisions are made. Youth, for instance, find this approach both empowering and meaningful, bringing an added benefit to go with newfound knowledge that can help a community (Delgado, 2006; Dimitriadis, 2008). Older adults, too, can engage in this research when taking into account health and mobility considerations (Delgado, 2009). When CBPR is undertaken by highly marginalized groups, its significance increases the relevance of the findings and enhances their capacities in the process, too. CBPR increases our understanding of community events and issues, and the crafting of dissemination of findings and creation of solutions that on the surface seem intractable. Working with, rather than for, communities allows us to navigate our way to workable solutions (Mayan & Daum, 2016). In addition, CBPR can bring together community residents and students from similar ethnic backgrounds to develop local capacity that can be tapped in current and future research. Coconstruction (bidirectional learning) of knowledge is one of the key features and benefits of engaging in CBPR, taking on even greater significance in cases where cultural values and folk beliefs are counter to the Western ones our health systems are founded upon (Nguyen-​Truong, Tang, & Hsiao, 2017). Coconstruction is also predicated upon the value of collaboration and cooperation, key ingredients of engagement in undervalued communities.

172  Reflections From the Field

CBPR provides local resident participants with an opportunity to assume health advocate roles due to their experiences, highlighting the capacity enhancement outcome of involvement in participatory research and its potential for achieving social change (Minkler & Wallerstein, 2011; Purvis et  al., 2017). Immigrants, for example, can be enlisted to be integral members of CBPR efforts, bringing a needed and nuanced view on how best to reach out to their own communities and surmounting outreach barriers (Vaughn et al., 2016a). Finally, trust is essential in CBPR, as it is with CHW, and for any meaningful research, but more so when participatory democratic principles serve as a foundation (Holzer, Calhoun, & Strong, 2017).

Photovoice Visually informed research has shown tremendous promise over the past decade, and it promises to continue to do so into the immediate future as fields of practice embrace this approach (Mitchell, 2012; Pink, 2007; Stanczak, 2007). The emergence of photovoice as a research method this past decade has introduced this method to a wider audience and for use in a variety of settings, populations, and issues across the life cycle (Delgado, 2015; Musoke et al., 2016). Photovoice is often considered to be an arts-​based qualitative research method grounded with CBPR. Its origins can be traced back to Wang’s groundbreaking work in China during the 1990s. Its popularity erupted as the result of Broski and Kauffman’s documentary Born Into Brothels, which won the 2005 Academy Award for Best Documentary. Photovoice lends itself, and is best utilized, as a participatory research method to be used by marginalized groups. Photovoice has been used in helping youth define their health, illustrating its potential use by CHWs across age groups (Jennings, 2011). It brings tremendous flexibility and can accommodate a wide range of participants, budgets, sophistication, and goals.

Ethnographic Research The inclusion of ethnographic research should not be surprising to readers versed in virtually any form of community-​centered research. Ethnographic studies have certainly taken a prominent place alongside other qualitative



Practice Challenges and CHWs as Researchers  173

research (Creswell & Poth, 2017). Ethnography is dependent upon theory and multifaceted observations. This medium brings incredible potential for use among marginalized groups to capture abstract concepts such as hope, as in the case of African American adolescents (Harley, 2015). Its potential has only recently begun to be realized, particularly when focused on culture and single health issues (Rashid, Caine, & Goez, 2015). Waiting is a dimension of ethnographic research (“wait upon” others) that doesn’t get the attention it warrants, even though it plays such a prominent role (Palmer, Pocock, & Burton, 2017), as it also does in CHW practice. It requires researchers to have tremendous patience, flexibility, and willingness to allow the research process to unfold according to local circumstances, allowing for emergence of “surprises” that provide insights where few exist, and more so among those distrustful of outsiders.

Case Studies Case studies do not receive the respect that they deserve in a world dominated by quantitative research and clinical trials. The nature of this evolving field places case studies in a prominent position to make substantive contributions with translation potential when local nuanced factors need to be captured (Yin, 2015). Case studies can consist of different lengths, budgets, and goals, with the level of detail being influenced accordingly. They are particularly attractive in the case of CHWs because of the prominence of context and nuance in shaping interactions and outcomes, with real-​life and immediate implications for service delivery. Case studies are attractive because they provide very detailed contextualization that allows practitioners, and academics, to ascertain what factors facilitate or hinder application of findings based upon their own circumstances and considerations. Critics bemoan the lack of generalizability of findings. The benefits of case studies far exceed drawbacks, and more so with CHWs working in marginalized and diverse communities.

Community-​Led Mapping Readers may not be familiar with community mapping as a research method for identifying community resources (formal and informal) (Delgado,

174  Reflections From the Field

2000). Its applicability to the health field is also well established, although when conceptualizing it as community led, it is far from prosaic (Corburn, 2017; Eldredge et al., 2016). Geographic information systems (GIS), for example, are finding increasing use across a variety of settings and population groups nationally and internationally (Fleming et  al., 2017; Goldenburg et al., 2017; Munyaneza et al., 2014; Socias et al., 2016; van Heerden et al., 2017; West et al., 2017). Mapping provides health care systems with an opportunity to target resources and deploy CHWs to maximize their potential contribution (Thomas et  al., 2015). The potential of community mapping to engage urban communities in conducting research on a broad scale is just one of its many attributes; its potential for action brings an added dimension to the field (Schneider & Lehmann, 2016). Involving CHWs and residents in mapping of community health hazards is one way to systematically provide organizations with data to advance a social justice agenda with implications for environmental health. This research brings a high level of community visibility with potential to result in a social change effort. Community mapping does not have to be deficit focused and can be asset driven by identifying indigenous health care institutions within a neighborhood, such as botanical shops (cultural variations of pharmacies) (Delgado & Humm-​Delgado, 2013).

Other Less Known or Emerging Research Methods A call for implementation research utilizing CHWs has made it easier to understand and refine translating theory into practice, an essential element in moving the field forward (Luckow et al., 2017). Insight into how policies get manifested at the local level is essential in better supporting CHWs and as a means of maximizing resource impact in highly marginalized communities. Digital storytelling, for instance, builds upon long-​ held cultural traditions in story sharing as a means of conveying information that is important to a group of people (Lambert, 2013). Soliciting and distributing these stories provides valuable insights into how health is conceptualized in highly diverse communities. Further, digital storytelling can be used across



Practice Challenges and CHWs as Researchers  175

the life span, but it is particularly useful for engaging youth (Lambert & Keogh, 2014). If there is a brave new world concerning CHW research, it would be youth-​led and other forms of community-​led research (Oetzel & Minkler, 2017). Youth-​led research is conceptualized as separate from CBPR because of the age of the researcher and their efforts to reach other youth (Cammarota & Fine, 2010; Delgado, 2006; Ozer, 2017; Sun et  al., 2018; Teixeira & Gardner, 2017). This approach for, and by, youth epitomizes the promise of research to help transform this field even further (Noguera, Cammarota, & Ginwright, 2013).

Ethical Conflicts and Considerations Research is usually a minefield when viewed from an ethical perspective, and when involving CHWs, there is no exception. Many of the ethical conflicts or dilemmas associated with service delivery can be found in research. The challenges are further compounded when researchers are community residents who will return to their roles as residents after work or when a project is completed. Confidentiality must never be breached, and if done, it seriously undermines the credibility of the organization undertaking the research and possibly future research. Qualitative research methods bring tremendous advantages as well as potential ethical conflicts for CHWs (Sanjari et al., 2014): “The relationship and intimacy that is established between the researchers and participants in qualitative studies can raise a range of different ethical concerns, and qualitative researchers face dilemmas such as respect for privacy, establishment of honest and open interactions, and avoiding misrepresentations. Ethically challenging situations may emerge if researchers have to deal with contradicting issues and choose between different methodological strategies in conflict arises” (p. 8). Ethnographic methods, although attractive for capturing the work of CHWs, bring ethical challenges when the setting is the home of the patient (Rasoal, Kihlgren, & Skovdahl, 2017). Home-​based services bring challenges and rewards for the health field. CHWs, it must be emphasized, are there at the will, or as guests, of the recipient of services. This stance can place CHWs in conflict with organizational practices.

176  Reflections From the Field

Conclusion Readers may not have an active interest in conducting research. Even when this is the case, consuming and encouraging research is an essential element in any form of work in community health, and more so when CHWs are playing instrumental roles throughout the research process. CHWs interested in carrying out research roles will find themselves in a brave new world in developing collaborative research projects that venture into previously unchartered terrain. This chapter and book captured an expanding universe at a moment in time, and the promise of new discoveries and paradigm shifts are just around the corner to further this field’s advancement. The promise of new insights and developments will serve as an impetus for this field to continue to thrive regardless of national political climate because of the good that is done by CHWs in this nation’s most marginalized communities and among its most marginalized groups.

References Abara, W., Coleman, J.  D., Fairchild, A., Gaddist, B., & White, J.  (2015). A  faith-​ based community partnership to address HIV/​ AIDS in the Southern United States:  Implementation, challenges, and lessons learned. Journal of Religion and Health, 54(1), 122–​133. Abbott, L.  S., & Elliott, L.  T. (2017). Eliminating health disparities through action on the social determinants of health: A systematic review of home visiting in the United States, 2005–​2015. Public Health Nursing, 34(1),  2–​30. Abimbola, S., Okoli, U., Olubajo, O., Abdullahi, M. J., & Pate, M. A. (2012). The midwives service scheme in Nigeria. PLoS Medicine, 9(5), e1001211. Abrahams-​Gessel, S., Denman, C. A., & Gaziano, T. A. (2016). Challenges facing successful scaling up of effective screening for cardiovascular disease by community health workers in Mexico and South Africa: Policy implications. Health System Policy Research, 3(1). Abrahams-​Gessel, S., Denman, C. A., Gaziano, T. A., Levitt, N. S., & Puoane, T. (2016). Challenges facing successful scaling up of effective screening for cardiovascular disease by community health workers in Mexico and South Africa: Policy implications. Health Systems and Policy Research, 3(1). Abrahams-​Gessel, S., Denman, C.  A., Montano, C.  M., Gaziano, T.  A., Levitt, N., Rivera-​Andrade, A., . . . Puoane, T. (2015). Training and supervision of community health workers conducting population-​based, noninvasive screening for CVD in LMIC: Implications for scaling up. Global Heart, 10(1),  39–​44. Ackatia-​Armah, N. M., Addy, N. A., Ghosh, S., & Dubé, L. (2016). Fostering reflective trust between mothers and community health nurses to improve the effectiveness of health and nutrition efforts:  An ethnographic study in Ghana, West Africa. Social Science & Medicine, 158 (June), 96–​104. Adair, K. (2017). Becoming free. PhD thesis, Georgetown University, Washington, D.C. Adam, C. (2012, November 27). The history of health visiting. The history of health visiting. Sign, 3531 (934). Adorno, E., Chassler, D., D’Ippolito, M., Garte-​Wolf, S., Lundgren, L., & Purington, T.  (2013). Predisposing, enabling, and need factors associated with addiction treatment among Massachusetts Puerto Rican drug users. Social Work Research, 37(3), 195–​206. Affordable Care Act. Enacted in 2010. https://​w ww.thebalance.com/​2010-​patient​protection-​affordable-​care-​act-​3306063 Aguilera-​Steinert, J.  (2018). Building the dream team:  Social workers and community health workers. Social Work Voice, 1(1),  18–​19. Agyapong, V. I., Osei, A., Farren, C. K., & McAuliffe, E. (2015). Task shifting—​Ghana Community Mental Health Workers’ experiences and perceptions of their roles and scope of practice. Global Health Action, 8. http://​www.globalhealthaction.net/​index. php/​gha/​article/​view/​28955

178 References Agyapong, V.  I., Osei, A., Mcloughlin, D.  M., & McAuliffe, E.  (2016). Task shifting—​ perception of stake holders about adequacy of training and supervision for community mental health workers in Ghana. Health Policy and Planning, 31(5), 645–​655. Ahn, J. A. (2013, November). Trained community health workers can successfully implement a health literacy-​focused intervention in a community-​based randomized trial. In 141st APHA Annual Meeting (November 2–​November 6, 2013). Boston, MA: APHA. Aiga, H., & Pariyo, G. W. (2013). Violence against health workers during armed conflict. Lancet, 381(9874), 1276. Akintola, O., & Chikoko, G. (2016). Factors influencing motivation and job satisfaction among supervisors of community health workers in marginalized communities in South Africa. Human Resources for Health, 14(1), 54. https://​human-​resources-​health. biomedcentral.com/​articles/​10.1186/​s12960-​016-​0151-​6 Alam, K., Tasneem, S., & Oliveras, E. (2012). Performance of female volunteer community health workers in Dhaka urban slums. Social Science & Medicine, 75(3), 511–​515. Alamo, S. T., Colebunders, R., Ouma, J., Sunday, P., Wagner, G., Wabwire-​Mangen, F., & Laga, M. (2012). Return to normal life after AIDS as a reason for lost to follow-​up in a community-​based antiretroviral treatment program. Journal of Acquired Immune Deficiency Syndromes (1999), 60(2). http://​www.ncbi.nlm.nih.gov/​pmc/​articles/​ PMC3872063/​ Alaszewski, A. (2016). Risk, medicine and health. In A. Burgess & A. Alemanno (Eds.), Routledge handbook of risk studies (pp. 231–​240). New York, NY: Routledge. Alcalá, H.  E., Chen, J., Langellier, B.  A., Roby, D.  H., & Ortega, A.  N. (2017). Impact of the Affordable Care Act on health care access and utilization among Latinos. The Journal of the American Board of Family Medicine, 30(1),  52–​62. Alegría, M., Alvarez, K., Ishikawa, R. Z., DiMarzio, K., & McPeck, S. (2016). Removing obstacles to eliminating racial and ethnic disparities in behavioral health care. Health Affairs, 35(6), 991–​999. Alexander-​Scott, N., Garneau, D., & Dunklee, B. (2018). Community health workers in Rhode Island: Growing a public health workforce for a healthier state. Rhode Island: R.I. Document. Ali, F.  (2016). Equipping India’s community health worker supervisors with a mobile phone based supervisory application. International Journal of Infectious Diseases, 45, 160. http://​www.ijidonline.com/​article/​S1201-​9712(16)30362-​9/​abstract Alibhai, A., Kipp, W., Saunders, L.  D., Rubaale, T., Mill, J., & Konde-​Lule, J.  (2017). Relationship between characteristics of volunteer community health workers and antiretroviral treatment outcomes in a community-​based treatment programme in Uganda. Global Public Health, 12(9), 1092–​1103. http://​www.tandfonline.com/​doi/​ abs/​10.1080/​17441692.2016.1170179 Alicea-​Alvarez, N., Reeves, K., Lucas, M.  S., Huang, D., Ortiz, M., Burroughs, T., & Jones, N. (2016). Impacting health disparities in urban communities: Preparing future healthcare providers for “neighborhood-​engaged care” through a community engagement course intervention. Journal of Urban Health, 93(4), 732–​743. Allen, C. (2015, November). “A little fish in a big pond”: Strategies to improve supervision and support for community health workers. Presented at the 143rd APHA Annual Meeting and Exposition (October 31–​November 4, 2015). Chicago, IL: APHA. Allen, C., Brownstein, J.  N., Jayapaul-​Philip, B., Matos, S., & Mirambeau, A.  (2015). Strengthening the effectiveness of state-​level community health worker initiatives

References  179 through ambulatory care partnerships. The Journal of Ambulatory Care Management, 38(3), 254–​262. Allen, C. D. (2016). Estimating the effects of Arizona-​style omnibus immigration policies on Latino children’s access to health care. PhD dissertation, University of Tennessee, Knoxville, TN. Allen, C.  G., Sugarman, M.  A., & Wennerstrom, A.  (2017). Community health workers:  A resource to support antipsychotic medication adherence. The Journal of Behavioral Health Services & Research, 44(2), 341–​346. http://​link.springer.com/​article/​10.1007/​s11414-​016-​9515-​x Alli, F., Maharaj, P., & Vawda, M. Y. (2013). Interpersonal relations between health care workers and young clients: Barriers to accessing sexual and reproductive health care. Journal of Community Health, 38(1), 150–​155. Altobelli, L.  C. (2017). Sharing histories—​A transformative learning/​teaching method to empower community health workers to support health behavior change of mothers. Human Resources for Health, 15(1), 54. https://​human-​resources-​health. biomedcentral.com/​articles/​10.1186/​s12960-​017-​0231-​2 American Medical Association. (2009). AMA marks National Doctors’ Day with an eye to the future. News release of the American Medical Association, Chicago, IL, March 12, 2009. American Public Health Association. (2014). Support for community health workers to increase health access and to reduce health inequities. http://​www.apha.org/​policies-​ and-​advocacy/​publichealth-​policy-​statements/​policy-​database/​2014/​07/​09/​14/​19/​ support-​for-​community-​healthworkers-​to-​increase-​health-​access-​and-​to-​reduce-​ health-​inequities). Anders, R.  L., Balcazar, H., & Paez, L.  (2006). Hispanic community-​based participatory research using a promotores de salud model. Hispanic Health Care International, 4(2),  71–​78. Anderson, S., Shannon, K., Li, J., Lee, Y., Chettiar, J., Goldenberg, S., & Krüsi, A. (2016). Condoms and sexual health education as evidence: Impact of criminalization of in-​ call venues and managers on migrant sex workers access to HIV/​STI prevention in a Canadian setting. BMC International Health and Human Rights, 16(1), 30. Angwenyi, V., Kamuya, D., Mwachiro, D., Marsh, V., Njuguna, P., & Molyneux, S. (2013). Working with Community Health Workers as “volunteers” in a vaccine trial: Practical and ethical experiences and implications. Developing World Bioethics, 13(1),  38–​47. Appold, K. (2015). Treatment challenges. Hospitalist, 2015(12). Arellano-​Morales, L., Elder, J. P., Sosa, E. T., Baquero, B., & Alcántara, C. (2016). Health promotion among Latino adults: Conceptual frameworks, relevant pathways, and future directions. Journal of Latina/​o Psychology, 4(2),  83–​97. Arrossi, S., Thouyaret, L., Herrero, R., Campanera, A., Magdaleno, A., Cuberli, M., . . .  EMA Study team. (2015). Effect of self-​collection of HPV DNA offered by community health workers at home visits on uptake of screening for cervical cancer (the EMA study): A population-​based cluster-​randomised trial. The Lancet Global Health, 3(2), e85–​e94. Arsenault, P. R., John, L. S., & O’Brien, L. M. (2016). The use of the whole primary-​care team, including community health workers, to achieve success in increasing colon cancer screening rate. Journal for Healthcare Quality, 38(2),  76–​83.

180 References Arvey, S. R., & Fernandez, M. E. (2012). Identifying the core elements of effective community health worker programs:  A research agenda. American Journal of Public Health, 102(9), 1633–​1637. Asad, A. L., & Kay, T. (2015). Toward a multidimensional understanding of culture for health interventions. Social Science & Medicine, 144 (November), 79–​87. Asante, K.  O., & Meyer-​Weitz, A.  (2015). International note:  Association between perceived resilience and health risk behaviours in homeless youth. Journal of Adolescence, 39(1),  36–​39. Atif, N., Lovell, K., Husain, N., Sikander, S., Patel, V., & Rahman, A.  (2016). Barefoot therapists:  barriers and facilitators to delivering maternal mental health care through peer volunteers in Pakistan:  A qualitative study. International Journal of Mental Health Systems, 10(1), 1.  https://​ijmhs.biomedcentral.com/​articles/​10.1186/​ s13033-​016-​0055-​9 August, F., Pembe, A.  B., Mpembeni, R., Axemo, P., & Darj, E.  (2016). Community health workers can improve male involvement in maternal health:  Evidence from rural Tanzania. Global Health Action, 9.  http://​www.ncbi.nlm.nih.gov/​pmc/​articles/​ PMC4720685/​ Avellar, S. A., & Supplee, L. H. (2013). Effectiveness of home visiting in improving child health and reducing child maltreatment. Pediatrics, 132(Suppl. 2), S90–​S99. Ayiasi, R. M., Atuyambe, L. M., Kiguli, J., Orach, C. G., Kolsteren, P., & Criel, B. (2015). Use of mobile phone consultations during home visits by Community Health Workers for maternal and newborn care: Community experiences from Masindi and Kiryandongo districts, Uganda. BMC Public Health, 15(1), 560. Ayón, C., Baldwin, A., Umaña-​Taylor, A.  J., Marsiglia, F.  F., & Harthun, M.  (2016). Agarra el momento/​seize the moment:  Developing communication activities for a drug prevention intervention with and for Latino families in the US Southwest. Qualitative Social Work, 15(2), 281–​299. Aziato, L., Majee, W., Jooste, K., & Teti, M. (2017). Community leaders’ perspectives on facilitators and inhibitors of health promotion among the youth in rural South Africa. International Journal of Africa Nursing Sciences, 7, 19–​125. Baezconde-​Garbanati, L.  (2013, November). Using mobile technology and social media to engage promotoras de salud in Latino health. In 141st APHA Annual Meeting (November 2–​November 6, 2013). Boston, MA: APHA. Bagnall, A. M., South, J., Hulme, C., Woodall, J., Vinall-​Collier, K., Raine, G., . . . Wright, N. M. (2015). A systematic review of the effectiveness and cost-​effectiveness of peer education and peer support in prisons. BMC Public Health, 15(1), 1. Bailey, J. E., Surbhi, S., Bell, P. C., Jones, A. M., Rashed, S., & Ugwueke, M. O. (2016). SafeMed: Using pharmacy technicians in a novel role as community health workers to improve transitions of care. Journal of the American Pharmacists Association, 56(1),  73–​81. Bakken, S., & Reame, N.  (2016). The promise and potential perils of big data for advancing symptom management research in populations at risk for health disparities. Annual Review of Nursing Research, 34(1), 247–​260. Balaji, M., Chatterjee, S., Koschorke, M., Rangaswamy, T., Chavan, A., Dabholkar, H., . . . Patel, V. (2012). The development of a lay health worker delivered collaborative community based intervention for people with schizophrenia in India. BMC Health Services Research, 12(1), 1.

References  181 Balcazar, H., Lee Rosenthal, E., Nell Brownstein, J., Rush, C. H., Matos, S., & Hernandez, L. (2011). Community health workers can be a public health force for change in the United States: Three actions for a new paradigm. American Journal of Public Health, 101(12), 2199–​2203. Balcazar, H., Perez-​Lizaur, A. B., Izeta, E. E., & Villanueva, M. A. (2016). Community health workers-​promotores de salud in Mexico:  History and potential for building effective community actions. The Journal of Ambulatory Care Management, 39(1),  12–​22. Balcázar, H.  G., & de Heer, H.  D. (2015). Community health workers as partners in the management of non-​communicable diseases. The Lancet Global Health, 3(9), e508–​e509. Balcázar, H. G., de Heer, H., Rosenthal, L., Aguirre, M., Flores, L., Puentes, F. A., . . . Schulz, L. O. (2010). A promotores de salud intervention to reduce cardiovascular disease risk in a high-​risk Hispanic border population, 2005–​2008. Prevention of Chronic Disease, 7(2), A28. http://​www.cdc.gov/​PCD/​ISSUES/​2010/​mar/​09_​0106.htm Baldwin-​White, A. J. M., Kiehne, E., Umaña-​Taylor, A., & Marsiglia, F. F. (2017). In pursuit of belonging: Acculturation, perceived discrimination, and ethnic–​racial identity among Latino youths. Social Work Research, 41(1),  43–​52. Balian, A. A. (2016). Health Care Disparities Among Ethnic Minorities with Histories in the Justice Systems. National Social Sciences Journal, 47(1), 83. Ballard, M., Madore, A., Johnson, A., Keita, Y., Haag, E., Palazuelos, D., & Rosenberg, J. (2018). Community health workers. America, 1,  35–​37. Banerjee, A. T., Kin, R., Strachan, P. H., Boyle, M. H., Anand, S. S., & Oremus, M. (2015). Factors facilitating the implementation of church-​ based heart health promotion programs for older adults: A qualitative study guided by the precede-​proceed model. American Journal of Health Promotion, 29(6), 365–​373. Banks, S., Butcher, H., Orton, A., & Robertson, J. (Eds.). (2013). Managing community practice: Principles, policies and programmes. Bristol, UK: Policy Press. Baquero, B., Goldman, S., Siman, F., Muqueeth, S., Villa-​Torres, L., Eng, E., & Rhodes, S.  D. (2014). Mi Cuerpo, Nuestra Responsabilidad:  Using Photovoice to describe the assets and barriers to sexual and reproductive health among Latinos in North Carolina. Journal of Health Disparities Research and Practice, 7(1), Article 7. Barbero, C., Gilchrist, S., Chriqui, J. F., Martin, M. A., Wennerstrom, A., VanderVeur, J., . . . Brownstein, J. N. (2016). Do state community health worker laws align with best available evidence? Journal of Community Health, 41(2), 315–​325. Barnett, M.  L., Davis, E.  M., Callejas, L.  M., White, J.  V., Acevedo-​Polakovich, I.  D., Niec, L. N., & Jent, J. F. (2016). The development and evaluation of a natural helpers’ training program to increase the engagement of urban, Latina/​o families in parent-​ child interaction therapy. Children and Youth Services Review, 65(1),  17–​25. Barnett, M. L., Gonzalez, A., Miranda, J., Chavira, D. A., & Lau, A. S. (2018). Mobilizing community health workers to address mental health disparities for underserved populations:  A systematic review. Administration and Policy in Mental Health and Mental Health Services Research, 45(2), 195–​211. Baron, S. L., Beard, S., Davis, L. K., Delp, L., Forst, L., Kidd‐Taylor, A., . . . Welch, L. S. (2014). Promoting integrated approaches to reducing health inequities among low‐income workers: Applying a social ecological framework. American Journal of Industrial Medicine, 57(5), 539–​556.

182 References Barrett, N., Elkins, A., Colón-​Ramos, U., Rivera, I., Evans, W. D., & Edberg, M. (2016). Promotion of drinking water among Latino immigrant youth. http://​hsrc.himmelfarb. gwu.edu/​gw_​research_​days/​2016/​GWSPH_​Marvin/​25/​ Bartels, S. J., & Naslund, J. A. (2013). The underside of the silver tsunami—​older adults and mental health care. New England Journal of Medicine, 368(6), 493–​496. Barton, J., & Henderson, J. (2016). Peer support and youth recovery: A brief review of the theoretical underpinnings and evidence. Canadian Journal of Family and Youth/​ Le Journal Canadien de Famille et de la Jeunesse, 8(1),  1–​17. Bastien, S., Hetherington, E., Hatfield, J., Kutz, S., & Manyama, M. (2016). Youth-​driven innovation in sanitation solutions for Maasai pastoralists in Tanzania:  Conceptual framework and study design. Global Journal of Health Education and Promotion, 17(1),  14–​37. Bassuk, E. L., Hanson, J., Greene, R. N., Richard, M., & Laudet, A. (2016). Peer-​delivered recovery support services for addictions in the United States:  A systematic review. Journal of Substance Abuse Treatment, 63,  1–​9. Bate-​Ambrus, V. (2014, November). CHW workforce development and training: Strategies that work! Presented at the 142nd APHA Annual Meeting and Exposition (November 15–​November 19, 2014). New Orleans, LA: APHA. Bauer, G.  R. (2014). Incorporating intersectionality theory into population health research methodology:  Challenges and the potential to advance health equity. Social Science & Medicine, 110,  10–​17. Bauer, S. M., McGuire, A. B., Kukla, M., McGuire, S., Bair, M. J., & Matthias, M. S. (2016). Veterans’ pain management goals: Changes during the course of a peer-​led pain self-​ management program. Patient Education and Counseling, 99(12), 2080–​2086. Becerra, B. J., Arias, D., & Becerra, M. B. (2017). Low health literacy among immigrant Hispanics. Journal of Racial and Ethnic Health Disparities, 4(3), 480–​483. Becerra, D. (2016). Anti-​immigration policies and fear of deportation: A human rights issue. Journal of Human Rights and Social Work, 1(3), 109–​119. Beck, T. L., Le, T. K., Henry-​Okafor, Q., & Shah, M. K. (2017). Medical care for undocumented immigrants. Primary Care: Clinics in Office Practice, 44(1), e1–​e13. Bedell, P., Wilson, J.  L., White, A.  M., & Morse, D.  S. (2015). “Our commonality is our past”: A qualitative analysis of re-​entry community health workers’ meaningful experiences. Health & Justice, 3(1),  3–​19. Behm, L., Ivanoff, S.  D., & Zidén, L.  (2013). Preventive home visits and health—​ experiences among very old people. BMC Public Health, 13(1), 378. Bekteshi, V., Van Hook, M., Levin, J., Kang, S. W., & Van Tran, T. (2017). Social work with Latino immigrants: Contextual approach to acculturative stress among Cuban, Mexican and Puerto Rican women. British Journal of Social Work, 47(2), 447–​466. Bellhouse, S., McWilliams, L., Firth, J., Yorke, J., & French, D. P. (2018). Are community‐ based health worker interventions an effective approach for early diagnosis of cancer? A systematic review and meta‐analysis. Psycho‐Oncology. https://​onlinelibrary.wiley. com/​doi/​abs/​10.1002/​pon.4575 Bellissimo-​Rodrigues, F., Pires, D., Zingg, W., & Pittet, D. (2016). Role of parents in the promotion of hand hygiene in the paediatric setting: A systematic literature review. Journal of Hospital Infection, 93(2), 159–​163. Benfer, E. A. (2015). Health justice: A framework (and call to action) for the elimination of health inequity and social injustice. American University Law Review, 65(2), 275.

References  183 Benitez, A. M. (2014, November). Promoting the dignity of parenting youth: Digital storytelling and organizing as tools to engage young parenting Latinas. Presented at the 142nd APHA Annual Meeting and Exposition (November 15–​November 19, 2014). New Orleans, LA: APHA. Bennadi, D. (2014). Self-​medication: A current challenge. Journal of Basic and Clinical Pharmacy, 5(1),  19–​23. Berk, M. L., Schur, C. L., Chavez, L. R., & Frankel, M. (2017). Health care use among undocumented Latino immigrants. Health Affairs, 19,  51–​64. Berkley-​Patton, J., Thompson, C. B., Bradley-​Ewing, A., Berman, M., Booker, A., Catley, D., . . . & Aduloju-​Ajijola, N.  (2018). Identifying health conditions, priorities, and relevant multilevel health promotion intervention strategies in African American churches:  A faith community health needs assessment. Evaluation and Program Planning, 67,  19–​28. Berthold, S.  M., & Libal, K.  (2016). Migrant children’s rights to health and rehabilitation:  A primer for US social workers. Journal of Human Rights and Social Work, 1(2),  85–​95. Betsch, C., Böhm, R., Airhihenbuwa, C.  O., Butler, R., Chapman, G.  B., Haase, N., . . . Nurm, Ü. K. (2016). Improving medical decision making and health promotion through culture-​sensitive health communication: An agenda for science and practice. Medical Decision Making, 36(7), 811–​833. Betts, J. M. (2016). Health care access of Hispanic immigrants in the Kansas City metropolitan area. PhD dissertation, University of Missouri–​Kansas City. Betty Ford Institute Consensus Panel. (2007). What is recovery? A working definition from the Betty Ford Institute. Journal of Substance Abuse Treatment, 33, 221–​228. Bibbins-​ Domingo, K., Whitlock, E., Wolff, T., Ngo-​ Metzger, Q., Phillips, W.  R., Davidson, K. W., . . . García, F. A. (2017). Developing recommendations for evidence-​ based clinical preventive services for diverse populations:  Methods of the US Preventive Services Task Force Clinical Preventive Services Recommendations for Diverse Populations. Annals of Internal Medicine, 166(8), 565–​571. Bibus, A. A. (2017). Virtue ethics. Social Work, 62(1),  95–​95. Bitektine, A., & Haack, P.  (2015). The “macro” and the “micro” of legitimacy:  Toward a multilevel theory of the legitimacy process. Academy of Management Review, 40(1),  49–​75. Birgit Wurzer, M., Waters, D. L., & Hale, L. A. (2015). Fall-​related injuries in a cohort of community-​dwelling older adults attending peer-​led fall prevention exercise classes. Journal of Geriatric Physical Therapy, 39(3), 110–​116. Blachman, N.  L., & Blaum, C.  S. (2016). Integrating care across disciplines. Clinics in Geriatric Medicine, 32(2), 373–​383. Black, E.  B., Fedyszyn, I.  E., Mildred, H., Perkin, R., Lough, R., Brann, P., & Ritter, C. (2018). Homeless youth: Barriers and facilitators for service referrals. Evaluation and Program Planning, 68,  7–​12. Blair, T. R. (2012). “Community ambassadors” for South Asian elder immigrants: Late-​ life acculturation and the roles of community health workers. Social Science & Medicine, 75(10), 1769–​1777. Blank, M.  B., Tetrick, F.  L., Brinkley, D.  F., Smith, H.  O., & Doheny, V.  (1994). Racial matching and service utilization among seriously mentally ill consumers in the rural south. Community Mental Health Journal, 30(3), 271–​281.

184 References Bledstein, B. (1976). The culture of professionalism: The middle class and the development of higher education in America. New York, NY: W.W. Norton. Bloemraad, I., & Terriquez, V.  (2016). Cultures of engagement:  The organizational foundations of advancing health in immigrant and low-​income communities of color. Social Science & Medicine, 165 (September), 214–​222. Bloomstine, J.  W. (2016). The role of community health workers in delivering interventions targeting depression for priority populations. 2015 NCUR. Blumenthal, D., & Hsiao, W.  (2015). Lessons from the East—​China’s rapidly evolving health care system. New England Journal of Medicine, 372(14), 1281–​1285. Bolano, M., Ahalt, C., Ritchie, C., Stijacic‐Cenzer, I., & Williams, B.  (2016). Detained and distressed: Persistent distressing symptoms in a population of older jail inmates. Journal of the American Geriatrics Society, 64(11), 2349–​2355. Bonilla, C., & Grant, R. W. (2015). New approaches to reduce barriers to care for Latinos with poorly controlled Type 2 diabetes. Diabetes Management, 5(4), 267–​276. Boris, E., & Klein, J. (2012). Caring for America: Home health workers in the shadow of the welfare state. New York, NY: Oxford University Press. Bouchon, A. (2012). Community health systems. http://​womennc.org/​2012CSW/​Papers/​ Research/​Abby.pdf Boulanger, R. F., Hunt, M. R., & Benatar, S. R. (2016). Where caring is sharing: Evolving ethical considerations in tuberculosis prevention among healthcare workers. Clinical Infectious Diseases, 62(Suppl. 3), S268–​S274. Bovbjerg, R. R., Eyster, L., Ormond, B. A., Anderson, T., & Richardson, E. (2013a). The evolution, expansion, and effectiveness of community health workers. Washington, DC: The Urban Institute. Bovbjerg, R.  B., Eyster, L., Ormond, B.  A., Anderson, T., & Richardson, E.  (2013b). Opportunities for community health workers in the era of health reform. Washington, D.C.: The Urban Institute. Bowleg, L. (2012). The problem with the phrase women and minorities: Intersectionality—​ an important theoretical framework for public health. American Journal of Public Health, 102(7), 1267–​1273. Brabazon, T.  (2016). “Let’s talk about something important. Let’s talk about me.” In T. Brabazon (Ed.), Life, community and culture through digital storytelling (pp. 205–​ 223). New York, NY: Springer International. Brashers, D.  E., Basinger, E.  D., Rintamaki, L.  S., Caughlin, J.  P., & Para, M.  (2017). Taking control:  The efficacy and durability of a peer-​ led uncertainty management intervention for people recently diagnosed with HIV. Health Communication, 32(1),  11–​21. Braun, R., Catalani, C., Wimbush, J., & Israelski, D.  (2013). Community health workers and mobile technology: A systematic review of the literature. PloS One, 8(6), e65772. Braun, R., Lasway, C., Agarwal, S., L’Engle, K., Layer, E., Silas, L., . . . Kudrati, M. (2016). An evaluation of a family planning mobile job aid for community health workers in Tanzania. Contraception, 94(1),  27–​33. Braveman, P., & Gottlieb, L. (2014). The social determinants of health: It’s time to consider the causes of the causes. Public Health Reports, 129(Suppl. 2),  19–​31. Breysse, J., Dixon, S., Gregory, J., Philby, M., Jacobs, D. E., & Krieger, J. (2014). Effect of weatherization combined with community health worker in-​home education on asthma control. American Journal of Public Health, 104(1), e57–​e64.

References  185 Bridgeman-​ Bunyoli, A., Mitchell, S.  R., Abdul’Hafeedh, M., Schwoeffermann, T., Phoenix, T., Goughnour, C., . . . Wiggins, N. (2015). “It’s in my veins”: Exploring the role of an Afrocentric, popular education-​based training program in the empowerment of African American and African community health workers in Oregon. The Journal of Ambulatory Care Management, 38(4), 297–​308. Brisset, C., Leanza, Y., Rosenberg, E., Vissandjée, B., Kirmayer, L.  J., Muckle, G., . . . Laforce, H.  (2014). Language barriers in mental health care:  A survey of primary care practitioners. Journal of Immigrant and Minority Health, 16(6), 1238–​1246. Brooks, B. A., Davis, S., Kulbok, P., Frank-​Lightfoot, L., Sgarlata, L., & Poree, S. (2015). Aligning provider team members with polyvalent community health workers. Nursing Administration Quarterly, 39(3), 211–​217. Brown III, H. S., Wilson, K. J., Pagán, J. A., Arcari, C. M., Martinez, M., Smith, K., & Reininger, B. (2012). Cost-​effectiveness analysis of a community health worker intervention for low-​income Hispanic adults with diabetes. Prevention of Chronic Disease, 9, E140. http://​www.cdc.gov/​pcd/​issues/​2012/​12_​0074.htm Brown, R. T., Goodman, L., Guzman, D., Tieu, L., Ponath, C., & Kushel, M. B. (2016). Pathways to homelessness among older homeless adults:  Results from the HOPE HOME Study. PloS One, 11(5), e0155065. Brown, R. T., Hemati, K., Riley, E. D., Lee, C. T., Ponath, C., Tieu, L., . . . Kushel, M. B. (2017). Geriatric conditions in a population-​based sample of older homeless adults. The Gerontologist, 57(4), 757–​766. Brown Speights, J.  S., Nowakowski, A.  C., De Leon, J., Mitchell, M.  M., & Simpson, I.  (2017). Engaging African American women in research:  An approach to eliminate health disparities in the African American community. Family Practice, 34(3), 322–​329. Brownstein, J. N., & Hirsch, G. R. (2017). Transforming health care systems: CHWs as the glue in multidisciplinary teams. The Journal of Ambulatory Care Management, 40(3), 179–​182. Brunie A., Wamala-​Mucheri, P., Otterness, C., Akol, A., Chen, M., Bufumbo, L., & Weaver, M.  (2014). Keeping community health workers in Uganda motivated:  Key challenges, facilitators, and preferred program inputs. Global Health:  Science and Practice, 2(1), 103–​116. Bucher, S., Jäger, U., & Prado, A. M. (2016). Scaling private health care for the base of the pyramid:  Expanding versus broadening service offerings in developing nations. Journal of Business Research, 69(2), 736–​750. Buck, G. (2017). “I wanted to feel the way they did”: Mimesis as a situational dynamic of peer mentoring by ex-​offenders. Deviant Behavior, 38(9), 1027–​1041. Buckley, T.  (2013, November). Partnering pharmacists with community health workers to deliver culturally appropriate medication management to an immigrant community. Presented at the 141st APHA Annual Meeting and Exposition (November 2–​ November 6, 2013). Boston, MA: APHA. Buehler, B., Ruggiero, R., & Mehta, K. (2013). Empowering community health workers with technology solutions. IEEE Technology and Society Magazine, 32(1),  44–​52. Buerhaus PI, Auerbach DI, Staiger DO. (2009). The recent surge in nurse employment: Causes and implications. Health Affairs (Millwood), 28, w657–​w668. Burgess, R., & Mathias, K. (2017). Community mental health competencies: A new vision for global mental health. In R.  G. White, S.  Jain, D.  M. R.  Orr, & U.  M. Read (Eds.), The Palgrave handbook of sociocultural perspectives on global mental health (pp. 211–​235). Backingstoke, UK: Palgrave Macmillan.

186 References Bush, D.  E., Wilmsen, C., Sasaki, T., Barton‐Antonio, D., Steege, A.  L., & Chang, C.  (2014). Evaluation of a pilot promotora program for Latino forest workers in southern Oregon. American Journal of Industrial Medicine, 57(7), 788–​799. Bustillos, B. D., & Sharkey, J. R. (2015). Development and implementation of a culturally and linguistically centered nutrition education program for promotoras de salud (community health workers) to foster community health education and outreach in Texas border colonias. Journal of Hunger & Environmental Nutrition, 10(3), 299–​312. Butler, S., & Cabelo, M. (2018). Housing as a hub for health, community services, and upward mobility. Washington, D.C.: Brookings Institute. Caetano, R., Schafer, J., & Cunradi, C. B. (2017). Alcohol-​related intimate partner violence among white, black, and Hispanic couples in the United States. In M. Natarajan (Ed.), Domestic violence:  The five big questions. Persons in recovery health needs (pp. 58–​65). New York, NY: Routledge. Caldwell, J. T., Ford, C. L., Wallace, S. P., Wang, M. C., & Takahashi, L. M. (2017). Racial and ethnic residential segregation and access to health care in rural areas. Health & Place, 43, 104–​112. Calvo, R.  (2016). Health literacy and quality of care among Latino immigrants in the United States. Health & Social Work, 16(1), e44–​e55. Camic, P.  M. (2015). Community cultural development for health and wellbeing. In S.  Clift & P.  M. Camic (Eds.), Oxford textbook of creative arts, health, and wellbeing:  International perspectives on practice, policy and research (pp.  49–​53). New York, NY: Oxford University Press. Cammarota, J., & Fine, M. (Eds.). (2010). Revolutionizing education: Youth participatory action research in motion. New York, NY: Routledge. Campbell, N., Schiffer, E., Buxbaum, A., McLean, E., Perry, C., & Sullivan, T. M. (2014). Taking knowledge for health the extra mile:  Participatory evaluation of a mobile phone intervention for community health workers in Malawi. Global Health: Science and Practice, 2(1),  23–​34. Caron, R.  M., & Merrick, J.  (2012). Building community capacity:  Minority and immigrant populations. http://​scholars.unh.edu/​hmp_​facpub/​110/​ Carrasquillo, O., Patberg, E., Alonzo, Y., Li, H., & Kenya, S. (2014). Rationale and design of the Miami Healthy Heart Initiative: A randomized controlled study of a community health worker intervention among Latino patients with poorly controlled diabetes. International Journal of General Medicine, 7(1), 115–​126. Carrillo, E.  (2014, November). Increasing awareness of Alzheimer’s disease in the Latino community. Presented at the 142nd APHA Annual Meeting and Exposition (November 15–​November 19, 2014). New Orleans, LA: APHA. Castañeda, H., Holmes, S. M., Madrigal, D. S., Young, M. E. D., Beyeler, N., & Quesada, J.  (2015). Immigration as a social determinant of health. Annual Review of Public Health, 36, 375–​392. Castañeda, H., & Melo, M.  A. (2014). Health care access for Latino mixed-​status families:  Barriers, strategies, and implications for reform. American Behavioral Scientist, 58(14), 1891–​1909. Casey, K. (2017). I answer with my life: Life histories of women teachers working for social change. New York, NY: Routledge. Cataletto, M.  (2015). Focusing on high-​needs Hispanic populations with high prevalence of asthma. Pediatric Allergy, Immunology, and Pulmonology, 28(3), 143–​143.

References  187 Centers for Disease Control and Prevention. (2016). A community health worker training resource for preventing heart disease and strokes. Atlanta, GA:  Author. https://​www. cdc.gov/​dhdsp/​programs/​spha/​chw_​training/​pdfs/​chw_​training.pdf Chan, Y.  F., Lu, S.  E., Howe, B., Tieben, H., Hoeft, T., & Unützer, J.  (2016). Screening and follow-​up monitoring for substance use in primary care: An exploration of rural–​ urban variations. Journal of General Internal Medicine, 31(2), 215–​222. Chandra, A., Miller, C. E., Acosta, J. D., Weilant, S., Trujillo, M., & Plough, A. (2016). Drivers of health as a shared value: Mindset, expectations, sense of community, and civic engagement. Health Affairs, 35(11), 1959–​1963. Chang, A. H., Polesky, A., & Bhatia, G. (2013). House calls by community health workers and public health nurses to improve adherence to isoniazid monotherapy for latent tuberculosis infection: A retrospective study. BMC Public Health, 13(1), 1. Chang, E.  S., Simon, M., & Dong, X.  (2012). Integrating cultural humility into health care professional education and training. Advances in Health Sciences Education, 17(2), 269–​278. Chapman, S. A., Blash, L., & Spetz, J. (2018). California peer providers in transitions of care. University of California, San Francisco: Healthforce Center. Chappell Deckert, J., & Statz-​Hill, M. (2016). Job satisfaction of peer providers employed in mental health centers: A systematic review. Social Work in Mental Health, 14(5), 564–​582. Chatterjee, A., So, M., Dunleavy, S., & Oken, E. (2017). Quality health care for homeless children: Achieving the AAP recommendations for care of homeless children and youth. Journal of Health Care for the Poor and Underserved, 28(4), 1376–​1392. Chin, M. H., Clarke, A. R., Nocon, R. S., Casey, A. A., Goddu, A. P., Keesecker, N. M., & Cook, S. C. (2012). A roadmap and best practices for organizations to reduce racial and ethnic disparities in health care. Journal of General Internal Medicine, 27(8), 992–​1000. Choi, E., Heo, G. J., Song, Y., & Han, H. R. (2016). Community health worker perspectives on recruitment and retention of recent immigrant women in a randomized clinical trial. Family & Community Health, 39(1),  53–​61. Cicero, T.  J., Ellis, M.  S., Surratt, H.  L., & Kurtz, S.  P. (2014). The changing face of heroin use in the United States: A retrospective analysis of the past 50 years. JAMA Psychiatry, 71(7), 821–​826. Clarke, A.  R., Goddu, A.  P., Nocon, R.  S., Stock, N.  W., Chyr, L.  C., Akuoko, J.  A., & Chin, M.  H. (2013). Thirty years of disparities intervention research:  What are we doing to close racial and ethnic gaps in health care? Medical Care, 51(11). http://​www. ncbi.nlm.nih.gov/​pmc/​articles/​PMC3826431/​ Clement, J.  (2014, November). Transcending place–​ Using digital tools to engage Community Health Workers in digital health promotion to reduce infant mortality among high risk African-​American women in 3 Detroit neighborhoods. Presented at the 142nd APHA Annual Meeting and Exposition (November 15–​November 19, 2014). New Orleans, LA: APHA. Closser, S., & Jooma, R. (2013). Why we must provide better support for Pakistan’s female frontline health workers. PLoS Medicine, 10(10), e1001528. Closser, S., Rosenthal, A., Justice, J., Maes, K., Sultan, M., Banerji, S., . . . Nyirazinyoye, L.  (2017). Per diems in polio eradication:  Perspectives from community health workers and officials. American Journal of Public Health, 107(9), 1470–​1476.

188 References Cloud, D.  H., Parsons, J., & Delany-​Brumsey, A.  (2014). Addressing mass incarceration:  A clarion call for public health. American Journal of Public Health, 104(3), 389–​391. Cloutier, M.  M. (2016). Asthma management programs for primary care providers: Increasing adherence to asthma guidelines. Current Opinion in Allergy and Clinical Immunology, 16(2), 142–​147. Cocker, F., & Joss, N.  (2016). Compassion fatigue among healthcare, emergency and community service workers:  A systematic review. International Journal of Environmental Research and Public Health, 13(6), 618. http://​www.mdpi.com/​1660-​ 4601/​13/​6/​618/​htm Coe, M.  K., & Castro, F.  (2013). Promoting health in Latino communities:  The role of promotoras as cultural agents of community health. http://​digitalcommons.utep.edu/​ psych_​papers/​16/​ Coetzee, B., Kohrman, H., Tomlinson, M., Mbewu, N., Le Roux, I., & Adam, M. (2018). Community health workers’ experiences of using video teaching tools during home visits—​A pilot study. Health & Social Care in the Community, 26(2), 167–​175. Cohen, B.  E., & Marshall, S.  G. (2016). Does public health advocacy seek to redress health inequities? A scoping review. Health & Social Care in the Community, 25(2), 309–​328. Coles, E.  (2013). A qualitative exploration of the public and private faces of homelessness: Engaging homeless people with health promotion. PhD dissertation, University of Dundee, Dundee, Scotland. Collica, K.  (2012). Female prisoners, AIDS, and peer programs:  How female offenders transform their lives. New York, NY: Springer Science & Business Media. Collica-​Cox, K.  (2016). All aboard the desistance line:  First stop, producing prosocial prison attachments within an HIV prison-​based peer program. Journal of Prison Education and Reentry, 3(2). https://​jper.uib.no/​jper/​article/​view/​1001 Collins, D. A., Shamblen, S. R., Strader, T. N., & Arnold, B. B. (2017). Evaluation of an evidence-​based intervention implemented with African-​American women to prevent substance abuse, strengthen relationship skills and reduce risk for HIV/​AIDS. AIDS Care, 29(8), 966–​973. Collins, P. H., & Bilge, S. (2016). Intersectionality. Cambridge, UK: Polity Press. Compton, M.  T., Kelley, M.  E., Pope, A., Smith, K., Broussard, B., Reed, T.  A., . . . Lott Haynes, N. (2015). Opening doors to recovery: Recidivism and recovery among persons with serious mental illnesses and repeated hospitalizations. Psychiatric Services, 67(2), 169–​175. Connolly, K., & Granfield, R. (2017). Building recovery capital: The role of faith-​based communities in the reintegration of formerly incarcerated drug offenders. Journal of Drug Issues, 47(3), 370–​382. Cook, J. A., & Mueser, K. T. (2015). Community health workers: Potential allies for the field of psychiatric rehabilitation? http://​psycnet.apa.org/​journals/​prj/​38/​3/​207/​ Copeland, C.  T., & Clark, J.  (2013). Native Hawaiian/​Pacific Islanders & American Indian/​ Alaska Natives:  Common barriers to healthcare. Prevention and Health Promotion, 6(2),  27–​28. Corburn, J. (2005). Street science: Community knowledge and environmental health justice. Cambridge, MA: The MIT Press. Corburn, J. (2009). Toward the healthy city: People, places, and the politics of urban planning. Cambridge, MA: The MIT Press.

References  189 Corburn, J.  (2017). Urban place and health equity:  Critical issues and practices. International Journal of Environmental Research and Public Health, 14(2), 117. Cordoba, E., & Aiello, A.  E. (2016). Social determinants of influenza illness and outbreaks in the United States. North Carolina Medical Journal, 77(5), 341–​345. Corus, C., & Saatcioglu, B.  (2015). An intersectionality framework for transformative services research. The Service Industries Journal, 35(7–​8), 415–​429. Corr, C., Spence, C., Miller, D., Marshall, A. A., & Santos, R. M. (2018). Beyond “hoping for the best” home visits in impoverished urban areas. Young Exceptional Children, 21(2), 111–​120. http://​journals.sagepub.com/​doi/​pdf/​10.1177/​1096250616674332 Corrigan, P. W., Torres, A., Lara, J. L., Sheehan, L., & Larson, J. E. (2017). The healthcare needs of Latinos with serious mental illness and the potential of peer navigators. Administration and Policy in Mental Health and Mental Health Services Research, 44(4), 547–​557. Cortés, Y. I., Arcia, A., Kearney, J., Luchsinger, J., & Lucero, R. J. (2017). Urban-​dwelling community members’ views on biomedical research engagement. Qualitative Health Research, 27(1). http://​journals.sagepub.com/​doi/​abs/​10.1177/​1049732315627650 Cosgrove, S., Moore-​Monroy, M., Jenkins, C., Castillo, S.  R., Williams, C., Parris, E., . . . Brownstein, J. N. (2014). Community health workers as an integral strategy in the REACH US program to eliminate health inequities. Health Promotion Practice, 15(6), 795–​802. Coughlin, S. S. (2016). Community-​based participatory research studies on HIV/​AIDS prevention, 2005–​2014. Jacobs Journal of Community Medicine, 2(1). https://​www. ncbi.nlm.nih.gov/​pmc/​articles/​PMC5215619/​ Crawford, S., & Bath, N.  (2013). Peer support models for people with a history of injecting drug use undertaking assessment and treatment for hepatitis C virus infection. Clinical Infectious Diseases, 57(Suppl. 2), S75–​S79. Creed‐Kanashiro, H., Bartolini, R., Abad, M., & Arevalo, V.  (2016). Promoting multi‐ micronutrient powders (MNP) in Peru: Acceptance by caregivers and role of health personnel. Maternal & Child Nutrition, 12(1), 152–​163. Creswell, J. W., & Poth, C. N. (2017). Qualitative inquiry and research design: Choosing among five approaches. Thousand Oaks, CA: Sage. Cribb, A. (2016). Operating from different premises: The ethics of inter-​disciplinarity in health promotion. Health Promotion Journal of Australia, 26(3), 200–​204. Crigler, L., Gergen, J., & Perry, H. (2013). Supervision of community health workers. file://​ /​C:/​Users/​delgado/​Documents/​Health%20Promotion/​09_​CHW_​Supervi sion.pdf Crimaldi, L. (2016, November 11). Incarceration’s toll falls unevenly in Boston: People of color fare much higher rates. The Boston Globe, pp. B1, B4. Crisp, N., & Chen, L. (2014). Global supply of health professionals. New England Journal of Medicine, 370(10), 950–​957. Cristofalo, M., Boutain, D., Schraufnagel, T.  J., Bumgardner, K., Zatzick, D., & Roy-​ Byrne, P.  P. (2015). Unmet need for mental health and addictions care in urban community health clinics:  Frontline provider accounts. Psychiatric Services, 60(4), 505–​511. Crowley, T., & Mayers, P.  (2015). Trends in task shifting in HIV treatment in Africa:  Effectiveness, challenges and acceptability to the health professions. African Journal of Primary Health Care & Family Medicine, 7(1),  1–​9. Cruz, Y., Hernandez-​Lane, M. E., Cohello, J. I., & Bautista, C. T. (2013). The effectiveness of a community health program in improving diabetes knowledge in the Hispanic

190 References population: Salud y Bienestar (Health and Wellness). Journal of Community Health, 38(6), 1124–​1131. Cruz-​Saco, M. A., & López-​Anuarbe, M. (2017). Ageing and long-​term care planning perceptions of Hispanics in the USA:  Evidence from a case study in New London, Connecticut. Ageing International, 42(4), 488–​503. Cueva, K., Cueva, M., Dignan, M., & Landis, K.  (2016). Print material in cancer prevention: An evaluation of three booklets designed with and for Alaska’s community health workers. Journal of Cancer Education, 31(2), 279–​284. Cueva, M., Kuhnley, R., Revels, L., Schoenberg, N.  E., & Dignan, M.  (2015). Digital storytelling:  A tool for health promotion and cancer awareness in rural Alaskan communities. International Journal of Circumpolar, 74. http://​www.ncbi.nlm.nih.gov/​ pmc/​articles/​PMC4561227/​health Cupertino, A.  P., Suarez, N., Cox, L.  S., Fernández, C., Jaramillo, M.  L., Morgan, A., . . . Ellerbeck, E.  F. (2013). Empowering promotores de salud to engage in community-​based participatory research. Journal of Immigrant & Refugee Studies, 11(1),  24–​43. Cutts, T., Langdon, S., Meza, F. R., Hochwalt, B., Pichardo-​Geisinger, R., Sowell, B., . . . Jones, M. T. (2016). Community health asset mapping partnership engages Hispanic/​Latino health seekers and providers. North Carolina Medical Journal, 77(3), 160–​167. Daaleman, T.  P., & Fisher, E.  B. (2015). Enriching patient-​centered medical homes through peer support. The Annals of Family Medicine, 13(Suppl. 1), S73–​S78. Daar, D.  A., Alvarez-​ Estrada, M., & Alpert, A.  E. (2018). The Latino physician shortage:  How the Affordable Care Act increases the value of Latino Spanish-​ speaking physicians and what efforts can increase their supply. Journal of Racial and Ethnic Health Disparities, 5(1), 170–​178. Dahlhamer, J. M., Galinsky, A. M., Joestl, S. S., & Ward, B. W. (2016). Barriers to health care among adults identifying as sexual minorities:  A US national study. American Journal of Public Health, 106(6), 1116–​1122. Daniels, A. S., Bergeson, S., & Myrick, K. J. (2017). Defining peer roles and status among community health workers and peer support specialists in integrated systems of care. Psychiatric Services. Daniels, K., Sanders, D., Daviaud, E., & Doherty, T. (2015). Valuing and sustaining (or not) the ability of volunteer community health workers to deliver integrated community case management in Northern Ghana: A qualitative study. PloS One, 10(6), e0126322. Danso, R.  (2016). Cultural competence and cultural humility:  A critical reflection on key cultural diversity concepts. Journal of Social Work. Davis, K.  (2008). Trust in the lives of young people:  A conceptual framework to explore how youth make trust judgments. http://​thegoodproject.org/​wp-​content/​uploads/​ 2012/​09/​52-​Trust-​in-​the-​Lives-​of-​Young-​People.pdf Davis, K. E. (2015). The intersectionality of social determinants and healthcare beliefs of African American women. PhD dissertation, Capella University. Davis, S. W. (2016). Ripping off some room for people to “breathe together”: Peer-​to-​ peer education in prison. Social Justice, 42(2), 146–​158. Davoren, M., Fitzpatrick, M., Caddow, F., Caddow, M., O’Neill, C., O’Neill, H., & Kennedy, H. G. (2015). Older men and older women remand prisoners: Mental illness, physical illness, offending patterns and needs. International Psychogeriatrics, 27(5), 747–​755.

References  191 Dawson, S., Campbell, S. M., Giles, S. J., Morris, R. L., & Cheraghi‐Sohi, S. (2018). Black and minority ethnic group involvement in health and social care research: A systematic review. Health Expectations, 21(1),  3–​22. Day, M.  R., Leahy-​ Warren, P., & McCarthy, G.  (2016). Self-​ neglect:  Ethical considerations. Annual Review of Nursing Research, 34(1), 89–​107. De Jesus, A.  S., dos Anjos Santos, F.  P., Rodrigues, V.  P., Nery, A.  A., Machado, J.  C., & Couto, T. A. (2014). Atuação do agente comunitário de saúde: Conhecimento de usuários [Community health agent role:  users’ knowledge]. Revista Enfermagem UERJ, 22(2), 239–​244. De Jesus, M.  (2013, November). Promoting immigrant women’s health:  Cape verdean community health workers’ perspectives and practice. Presented at the 141st APHA Annual Meeting (November 2–​November 6, 2013). APHA. De Neve, J.  W., Boudreaux, C., Gill, R., Geldsetzer, P., Vaikath, M., Bärnighausen, T., & Bossert, T.  J. (2017). Harmonizing community-​based health worker programs for HIV:  A narrative review and analytic framework. Human Resources for Health, 15(1),  15–​45. de Souza, C. F., Dalzochio, M. B., Zucatti, A. T. N., De Nale, R., de Almeida, M. T., Gross, J. L., & Leitão, C. B. (2017). Efficacy of an education course delivered to community health workers in diabetes control: A randomized clinical trial. Endocrine, 57(2), 280–​286. de Wit, L., Fenenga, C., Giammarchi, C., di Furia, L., Hutter, I., de Winter, A., & Meijering, L.  (2018). Community-​ based initiatives improving critical health literacy:  A systematic review and meta-​synthesis of qualitative evidence. BMC Public Health, 18(1), 40. Deephouse, D. L., Bundy, J., Tost, L. P., & Suchman, M. C. (2016). Organizational legitimacy: Six key questions. University of Alberta School of Business Research Paper No. 2016–​901. Del Bianco, A., Rivera, K., Bernstein-​Baker, J., Kelemen, N., Tobin, A., Shanfeld, G., & Mattei, A.  (2014). Building a culture of collaboration. In T.  Hansen-​ Turton, R.  Gordon, & N.  D. Torres (Eds.), Partnerships for health and human service nonprofits: From collaborations to mergers (pp. 63–​85). New York, NY: Springer. Delgado, M.  (1999). Social work practice in nontraditional urban settings. New  York, NY: Oxford University Press. Delgado, M. (2000). Community social work practice in an urban context: The potential of a capacity enhancement perspective. New York, NY: Oxford University Press. Delgado, M.  (2006). Designs and methods for youth-​ led research. Thousand Oaks, CA: Sage. Delgado, M.  (2009). Older adult-​led health promotion in urban communities:  A special focus on urban older adults of color. Lanham, MD: Rowman & Littlefield. Delgado, M.  (2012). Prisoner re-​entry and work:  Adding business to the mix. Boulder, CO: Lynne Rienner. Delgado, M. (2015). Baby boomers of color: Social work policy and practice. New York, NY: Columbia University. Delgado, M.  (2015). Urban youth and photovoice:  Visual ethnography in action. New York, NY: Oxford University Press. Delgado, M.  (2018). Social work with Latinos (2nd ed.). New  York, NY:  Oxford University Press. Delgado, M., & Humm-​Delgado, D.  (2009). Health and health care in the nation’s prisons: Issues, challenges, and policies. Lanham, MD: Rowman & Littlefield.

192 References Delgado, M., & Humm-​Delgado, D.  (2013). Asset assessments and community social work practice. New York: Oxford University Press. Delgado, M., & Humm-​Delgado, D. (in press). Older adult prisoners: A challenge within a challenge for policy, research, and practice. New York, NY: Routledge. Delgado, M., Jones, L. K., & Rohani, M. (2005). Social work practice with immigrant and refugee youth in the United States. Boston, MA: Allyn & Bacon. Delgado, M., & Santiago, J. (1998). HIV/​AIDS in a Puerto Rican/​Dominican community: A collaborative project with a botanical shop. Social Work, 43(2), 183–​186. Delgado, M., & Zhou, M. (2008). Youth-​led health promotion in urban communities: A capacity enhancement perspective. Lanham, MD: Rowman & Littlefield. Delisle, H., Shrimpton, R., Blaney, S., Du Plessis, L., Atwood, S., Sanders, D., & Margetts, B.  (2017). Capacity-​building for a strong public health nutrition workforce in low-​ resource countries. Bulletin of the World Health Organization, 95(5), 385–​388. DelReal, J. A. (2017, October 13). Overdoses in the Bronx spur a quiet, brutal war: An opioid epidemic in a borough inured to addiction. The New York Times, A20–​A21. DelRosso, L.  M., Cielo, C.  M., D’Ulisse, E., Elliot, J., Galea, L., Slavich, L., & Murphy, M.  (2016). Efficacy of sleep education in a Dominican Republic neighborhood through training of community health promoters. Sleep Health, 2(2), 175–​178. Dennis, D., Lassiter, M., Connelly, W.  H., & Lupfer, K.  S. (2015). Helping adults who are homeless gain disability benefits: The SSI/​SSDI Outreach, Access, and Recovery (SOAR) program. Psychiatric Services, 62(11), 1373–​1376. Dennis, S., Hetherington, S.  A., Borodzicz, J.  A., Hermiz, O., & Zwar, N.  A. (2015). Challenges to establishing successful partnerships in community health promotion programs:  Local experiences from the national implementation of healthy eating activity and lifestyle (HEAL™) program. Health Promotion Journal of Australia, 26(1),  45–​51. Denno, D. M., Hoopes, A. J., & Chandra-​Mouli, V. (2015). Effective strategies to provide adolescent sexual and reproductive health services and to increase demand and community support. Journal of Adolescent Health, 56(1), S22–​S41. DeRenzi, B., Dell, N., Wacksman, J., Lee, S., & Lesh, N.  (2017, May). Supporting community health workers in India through voice-​and web-​based Feedback. In Proceedings of the 2017 CHI Conference on Human Factors in Computing Systems (pp. 2770–​2781).  ACM. Desai, P. P., Rivera, A. T., & Backes, E. M. (2016). Latino caregiver coping with children’s chronic health conditions: An integrative literature review. Journal of Pediatric Health Care, 30(2), 108–​120. Desrosiers, P. L., Mallinger, G., & Bragg-​Underwood, T. (2017). Promoting socially just healthcare systems:  Social work’s contribution to patient navigation. Advances in Social Work, 17(2), 187–​202. Dimitriadis, G. (2008). Studying urban youth culture. New York, NY: Peter Lang. Documet, P.  I., Macia, L., Thompson, A., Gonzalez, M., Boyzo, R., Fox, A.  R., & Guadamuz, T. E. (2016). A male promotores network for Latinos process evaluation from a community-​based participatory project. Health Promotion Practice, 17(3), 332–​342. Doucerain, M.  M., Segalowitz, N., & Ryder, A.  G. (2016). Acculturation measurement: From simple proxies to sophisticated toolkit. In S. J. Schwartz & J. Unger (Eds.), Oxford handbook of acculturation and health (pp.  97–​117). New  York, NY:  Oxford University Press.

References  193 Douglas, I.  (2012). Urban ecology and urban ecosystems:  understanding the links to human health and well-​being. Current Opinion in Environmental Sustainability, 4(4), 385–​392. Doukas, N., & Cullen, J. (2013). Recovered addicts working in the addiction field: How do substance abuse treatment agencies work with substance abuse relapse among addiction counsellors who are in recovery? Journal of Addiction Research & Therapy. http://​www.omicsonline.org/​recovered-​addicts-​working-​in-​the-​addiction-​field-​how-​ do-​substance-​abuse-​treatment-​agencies-​2155-​6105.1000106.php?aid=4 Dower, C., Moore, J., & Langelier, M. (2013). It is time to restructure health professions scope-​ of-​ practice regulations to remove barriers to care. Health Affairs, 32(11), 1971–​1976. Drotbohm, H., & Hasselberg, I. (2015). Deportation, anxiety, justice: New ethnographic perspectives. Journal of Ethnic and Migration Studies, 41(4), 551–​562. Dumbauld, J., Kalichman, M., Bell, Y., Dagnino, C., & Taras, H.  L. (2014). Case study in designing a research fundamentals curriculum for community health workers: A university–​community clinic collaboration. Health Promotion Practice, 15(1),  79–​85. Duarte, C. C. (2016). Exploring the intersectionality of undocumented LGBTQ Latino persons aka undocuqueer Latinos: A qualitative study. California State University, Long Beach. https://​web.csulb.edu/​colleges/​chhs/​departments/​social-​work/​documents/​ ePoster_​ChavezD.Cristina_​UndocuQueeLatinos.pdf Dynes, M.  M., Stephenson, R., Hadley, C., & Sibley, L.  M. (2014). Factors shaping interactions among community health workers in rural Ethiopia:  Rethinking workplace trust and teamwork. Journal of Midwifery & Women’s Health, 59(s1), S32–​S43. Earnshaw, V.  A., Rosenthal, L., Cunningham, S.  D., Kershaw, T., Lewis, J., Rising, S.  S., . . . Ickovics, J.  R. (2016). Exploring group composition among young, urban women of color in prenatal care: Implications for satisfaction, engagement, and group attendance. Women’s Health Issues, 26(1), 110–​115. Edidin, J.  P., Ganim, Z., Hunter, S.  J., & Karnik, N.  S. (2012). The mental and physical health of homeless youth:  A literature review. Child Psychiatry & Human Development, 43(3), 354–​375. Edward, J. (2014). Undocumented immigrants and access to health care: Making a case for policy reform. Policy, Politics, & Nursing Practice, 15(1–​2),  5–​14. Egen, O., Beatty, K., Blackley, D. J., Brown, K., & Wykoff, R. (2017). Health and social conditions of the poorest versus wealthiest counties in the United States. American Journal of Public Health, 107(1), 130–​135. Einberg, E.  L., Nygren, J.  M., Svedberg, P., & Enskär, K.  (2016). “Through my eyes”: Health‐promoting factors described by photographs taken by children with experience of cancer treatment. Child: Care, Health and Development, 42(1),  76–​86. Einstein, S. (2012). “Peer workers/​health counselors”: A new label for a labeled population: A work-​in-​progress which may not progress. Substance Use & Misuse, 47(5), 573–​586. El-​Khayat, Y.  M. (2017). A  new approach to health literacy:  Working with Spanish speaking community health workers. Medical Reference Services Quarterly, 36(1),  32–​41. Elazan, S.  J., Higgins-​Steele, A.  E., Fotso, J.  C., Rosenthal, M.  H., & Rout, D.  (2016). Reproductive, maternal, newborn, and child health in the community: Task-​sharing

194 References between male and female health workers in an Indian rural context. Indian Journal of Community Medicine, 41(1),  34–​38. Eldredge, L.  K. B., Markham, C.  M., Ruiter, R.  A., Kok, G., & Parcel, G.  S. (2016). Planning health promotion programs: An intervention mapping approach. New York, NY: John Wiley & Sons. Ell, K., Aranda, M. P., Wu, S., Oh, H., Lee, P. J., & Guterman, J. (2016). Promotora assisted depression care among predominately Hispanic patients with concurrent chronic illness: Public care system clinical trial design. Contemporary Clinical Trials, 46(1),  39–​47. Enard, K. R., & Ganelin, D. M. (2013). Reducing preventable emergency department utilization and costs by using community health workers as patient navigators. Journal of Healthcare Management/​American College of Healthcare Executives, 58(6), 412–​428. Engle, D. C. (2016). Psychosocial support by community health workers of children living with chronically ill family members. PhD dissertation, North-​West University (South Africa, Potchefstroom Campus). Enriquez, M., & Conn, V.  S. (2016). Peers as facilitators of medication adherence interventions: a review. Journal of Primary Care & Community Health, 7(1),  44–​55. Erausquin, J. T., Biradavolu, M., Reed, E., Burroway, R., & Blankenship, K. M. (2012). Trends in condom use among female sex workers in Andhra Pradesh, India:  The impact of a community mobilisation intervention. Journal of Epidemiology and Community Health, 66(Suppl. 2), ii49–​ii54. Eriksen, K. Å., Arman, M., Davidson, L., Sundfør, B., & Karlsson, B. (2013). “We are all fellow human beings”: Mental health workers’ perspectives of being in relationships with clients in community-​based mental health services. Issues in Mental Health Nursing, 34(12), 883–​891. Etherington, N. (2015). Race, gender, and the resources that matter: An investigation of intersectionality and health. Women & Health, 55(7), 754–​777. Fabi, R., & Saloner, B. (2016). Covering undocumented immigrants—​State innovation in California. New England Journal of Medicine, 375(20), 1913–​1915. Fairchild, E. (2015, March). Enhancing practice for community health and youth workers to address children’s exposure to violence. Presented at the 7th Biennial National Conference on Health and Domestic Violence. Washington, D.C.: NCHDV. Fazel, S., Hayes, A.  J., Bartellas, K., Clerici, M., & Trestman, R.  (2016). Mental health of prisoners: prevalence, adverse outcomes, and interventions. The Lancet Psychiatry, 3(9), 871–​881. Ferdinand, K. C., Patterson, K. P., Taylor, C., Fergus, I. V., Nasser, S. A., & Ferdinand, D.  P. (2012). Community‐based approaches to prevention and management of hypertension and cardiovascular disease. The Journal of Clinical Hypertension, 14(5), 336–​343. Ferguson, H. (2018). Making home visits: Creativity and the embodied practices of home visiting in social work and child protection. Qualitative Social Work, 27(1),  65–​80. Fernández, A., & Rodriguez, R.  A. (2017). Undocumented immigrants and access to health care. JAMA Internal Medicine, 177(4), 536–​537. Ferrada, P., Anand, R., & Aboutanos, M. (2016).The uninsured, the homeless, and the undocumented immigrant trauma patient. Revealing health-​care disparity at a Level 1 Trauma Center. The American Surgeon. https://​search.proquest.com/​openview/​1fa3 4db13b41635e7f307ab06a9ae9bf/​1? pq-​origsite=gscholar&cbl=49079

References  195 Ferrera, M. (2015, November). Community voices in the Chicago area youth health service corps:  Hearing from youth participants. Presented at the 2015 APHA Annual Meeting & Expo (Oct. 31–​Nov. 4, 2015). Chicago, IL: APHA. Ferrera, M. J. (2017). Integrating principles of positive minority youth development with health promotion to empower the immigrant community: A case study in Chicago. Journal of Community Practice, 25(3–​4), 504–​523. Fikar, C., & Hirsch, P.  (2017). Home health care routing and scheduling:  A review. Computers & Operations Research, 77,  86–​95. Finlay, A. K., Smelson, D., Sawh, L., McGuire, J., Rosenthal, J., Blue-​Howells, J., . . . Bowe, T.  (2016). US Department of Veterans Affairs Veterans Justice Outreach Program connecting justice-​involved veterans with mental health and substance use disorder treatment. Criminal Justice Policy Review, 27(2), 203–​222. Finley, E.  P., Noël, P.  H., Mader, M., Haro, E., Bernardy, N., Rosen, C.  S., . . . Pugh, M. J. V. (2017). Community clinicians and the Veterans Choice Program for PTSD care: Understanding provider interest during early implementation. Medical Care, 55, S61–​S70. Findley, S., & Matos, S. (2015). Bridging the gap: How community health workers promote the health of immigrants. New York, NY: Oxford University Press. Findley, S., Matos, S., Hicks, A., Chang, J., & Reich, D. (2014). Community health worker integration into the health care team accomplishes the triple aim in a patient-​centered medical home: A Bronx tale. The Journal of Ambulatory Care Management, 37(1),  82–​91. Findley, S.  E., Matos, S., Hicks, A.  L., Campbell, A., Moore, A., & Diaz, D.  (2012). Building a consensus on community health workers’ scope of practice: Lessons from New York. American Journal of Public Health, 102(10), 1981–​1987. Finocchio, L., & Wu, E. (2009). An introduction to health care and health policy in the United States. In T.  Berthold, J.  Miller, & A.  Avila-​Esparza (Eds.), Foundations for community health workers (pp. 111–​134). San Francisco, CA: Jossey-​Bass. Firoz, T., Vidler, M., Makanga, P. T., Boene, H., Chiaú, R., Sevene, E., . . . Munguambe, K. (2016). Community perspectives on the determinants of maternal health in rural southern Mozambique: A qualitative study. Reproductive Health, 13(2), 112. https://​ reproductive-​health-​journal.biomedcentral.com/​articles/​10.1186/​s12978-​016-​0217-​x Fiscella, K., & Sanders, M. R. (2016). Racial and ethnic disparities in the quality of health care. Annual Review of Public Health, 37, 375–​394. Fischer, S. M., Cervantes, L., Fink, R. M., & Kutner, J. S. (2015). Apoyo con Cariño: A pilot randomized controlled trial of a patient navigator intervention to improve palliative care outcomes for Latinos with serious illness. Journal of Pain and Symptom Management, 49(4), 657–​665. Fisher, E.  B., Ayala, G.  X., Ibarra, L., Cherrington, A.  L., Elder, J.  P., Tang, T. S., . . . Simmons, D. (2015). Contributions of peer support to health, health care, and prevention: Papers from Peers for Progress. The Annals of Family Medicine, 13(Suppl 1),  S2–​S8. Fisher, E. B., Boothroyd, R. I., Coufal, M. M., Baumann, L. C., Mbanya, J. C., Rotheram-​ Borus, M. J., . . . Tanasugarn, C. (2012). Peer support for self-​management of diabetes improved outcomes in international settings. Health Affairs, 31(1), 130–​139. Fitzpatrick, K., & LaGory, M. (2002). Unhealthy places: The ecology of risk in the urban landscape. New York. NY: Routledge. Fleming, P.  J. (2013, November). Are men willing to participate?:  A participatory research approach to involving Latino men in sexual and reproductive health promoter

196 References programs. Presented at the 141st APHA Annual Meeting (November 2–​November 6, 2013). Boston, MA: APHA. Fleming, P.  J., Villa‐Torres, L., Taboada, A., Richards, C., & Barrington, C.  (2017). Marginalisation, discrimination and the health of Latino immigrant day labourers in a central North Carolina community. Health & Social Care in the Community, 25(2), 527–​537. Flinn, N.  A., & Foo, S.  (2013). Poster 126 copays as barriers to care:  What are the consequences? Archives of Physical Medicine and Rehabilitation, 94(10), e56–​e57. Floyd, B.  O. M., & Brunk, N.  (2016). Utilizing task shifting to increase access to maternal and infant health interventions: A case study of midwives for Haiti. Journal of Midwifery & Women’s Health, 61(1), 103–​111. Ford-​Paz, R.  E., Reinhard, C., Kuebbeler, A., Contreras, R., & Sánchez, B.  (2015). Culturally tailored depression/​suicide prevention in Latino youth:  Community perspectives. The Journal of Behavioral Health Services & Research, 42(4), 519–​533. Forenza, B., & Mendonca, C.  (2015). Dream big:  Exploring empowering processes of DREAM Act advocacy in a focal state. Journal of Latinos and Education, 38(1),  12–​21. Foronda, C., Baptiste, D.  L., Reinholdt, M.  M., & Ousman, K.  (2016). Cultural humility: A concept analysis. Journal of Transcultural Nursing, 27(3), 210–​217. Fox, A. D., Anderson, M. R., Bartlett, G., Valverde, J., MacDonald, R. F., Shapiro, L. I., & Cunningham, C.  O. (2014). A  description of an urban transitions clinic serving formerly incarcerated persons. Journal of Health Care for the Poor and Underserved, 25(1), 376–​382. Franklin, C. M., Bernhardt, J. M., Lopez, R. P., Long-​Middleton, E. R., & Davis, S. (2015). Interprofessional teamwork and collaboration between community health workers and healthcare teams. Health Services Research and Managerial Epidemiology. Frerichs, L., Lich, K. H., Dave, G., & Corbie-​Smith, G. (2016). Integrating systems science and community-​based participatory research to achieve health equity. American Journal of Public Health, 106(2), 215–​222. Freyer, F. J. (2017, December 11). For recuperating addicts, a hand up. The Boston Globe, B1, B4. Frieden, T. R. (2014). Six components necessary for effective public health program implementation. American Journal of Public Health, 104(1),  17–​22. Furman, L., Killpack, S., Matthews, L., Davis, V., & O’Riordan, M. A. (2016). Engaging inner-​city fathers in breastfeeding support. Breastfeeding Medicine, 11(1),  15–​20. Gale, N.  K., Kenyon, S., MacArthur, C., Jolly, K., & Hope, L.  (2018). Synthetic social support: Theorizing lay health worker interventions. Social Science & Medicine, 196, 96–​105. Galiatsatos, P., & Hale, W. D. (2016). Promoting health and wellness in congregations through lay health educators: A case study of two churches. Journal of Religion and Health, 55(1), 288–​295. Galiatsatos, P., Sundar, S., Qureshi, A., Ooi, G., Teague, P., & Hale, W. D. (2016). Health promotion in the community:  Impact of faith-​based lay health educators in urban neighborhoods. Journal of Religion and Health, 55(3), 1089–​1096. Gambin, G., Molzahn, A., Fuhrmann, A.  C., Morais, E.  P., & Paskulin, L.  M. (2015). Quality of life of older adults in rural southern Brazil. Rural Remote Health, 15(3), 3300. http://​www.rrh.org.au/​Articles/​subviewnew.asp?ArticleID=3300

References  197 Gampa, V., Smith, C., Muskett, O., King, C., Sehn, H., Malone, J., . . . Nelson, A. K. (2017). Cultural elements underlying the community health representative–​client relationship on Navajo Nation. BMC Health Services Research, 17(1), 19. Garcia, A. P., Minkler, M., Cardenas, Z., Grills, C., & Porter, C. (2014). Engaging homeless youth in community-​based participatory research: A case study from Skid Row, Los Angeles. Health Promotion Practice, 15(1),  18–​27. Garcia, M. E., & Grant, R. W. (2015). Community health workers: A missing piece of the puzzle for complex patients with diabetes? Journal of General Internal Medicine, 30(7), 878–​879. Garcia-​Huidobro, D., Allen, M., Rosas-​Lee, M., Maldonado, F., Gutierrez, L., Svetaz, M. V., & Wieling, E. (2016). Understanding attendance in a community-​based parenting intervention for immigrant Latino families. Health Promotion Practice, 17(1),  57–​69. García-​ Rivera, E.  J., Pacheco, P., Colón, M., Mays, M.  H., Rivera, M., Munet-​ Díaz, V., . . . Morales, A. (2017). Building bridges to address health disparities in Puerto Rico: The “Salud para Piñones” project. Puerto Rico Health Sciences Journal, 36(2), 92–​100. Gascon, S., Leiter, M. P., Andrés, E., Santed, M. A., Pereira, J. P., Cunha, M. J., . . . Martínez‐ Jarreta, B. (2013). The role of aggressions suffered by healthcare workers as predictors of burnout. Journal of Clinical Nursing, 22(21–​22), 3120–​3129. Gates, A. B. (2017). “No one will speak for us”: Empowering undocumented immigrant women through policy advocacy. Journal of Community Practice, 25(1),  5–​28. Gaziano, T. (2015). CVD screening by health workers cost effective. Pharmaco Economics & Outcomes News, 737,  12–​26. Genberg, B.  L., Shangani, S., Sabatino, K., Rachlis, B., Wachira, J., Braitstein, P., & Operario, D.  (2016). Improving engagement in the HIV care cascade:  A systematic review of interventions involving people living with HIV/​AIDS as peers. AIDS and Behavior, 20(10), 2452–​2463. Gertler, P., Heckman, J., Pinto, R., Zanolini, A., Vermeersch, C., Walker, S., . . . Grantham-​ McGregor, S. (2014). Labor market returns to an early childhood stimulation intervention in Jamaica. Science, 344(6187), 998–​1001. Gesler, W. M., & Kearns, R. A. (2005). Culture/​place/​health. New York, NY: Routledge. Gilbert, K. L., Elder, K., & Thorpe Jr, R. J. (2016). Health-​seeking behavior and meeting the needs of the most vulnerable men. In J. J. Heidelbaugh (Ed.), Men’s health in primary care (pp. 33–​44). New York, NY: Springer International. Gilbert, K. L., Ray, R., Siddiqi, A. A., Shetty, S., Baker, E. A., Elder, K., & Griffith, D. M. (2016). Visible and invisible trends in African American men’s health:  Pitfalls and promises for addressing racial, ethnic and gender health inequities. Annual Review of Public Health, 37(1), 295–​311. Gilkey, M., Garcia, C.  C., & Rush, C.  (2011). Professionalization and the experience-​ based expert: Strengthening partnerships between health educators and community health workers. Health Promotion Practice, 12(2), 178–​182. Gill, P., MacLeod, U., Lester, H., & Hegenbarth, A. (2013). Improving access to health care for Gypsies and Travellers, homeless people and sex workers. Birmingham, UK: Royal College of General Practitioners. Gillespie, L. D., Robertson, M. C., Gillespie, W. J., Sherrington, C., Gates, S., Clemson, L. M., & Lamb, S. E. (2012). Interventions for preventing falls in older people living in the community. Cochrane Database System Review, 9(11). http://​onlinelibrary.wiley. com/​doi/​10.1002/​14651858.CD007146.pub3/​abstract

198 References Gilmore, B., Adams, B. J., Bartoloni, A., Alhaydar, B., McAuliffe, E., Raven, J., . . . Vallières, F. (2016). Improving the performance of community health workers in humanitarian emergencies:  a realist evaluation protocol for the PIECES programme. BMJ Open, 6(8), e011753. Glasby, J.  (2017). Understanding health and social care (3rd ed.). New  York, NY: Policy Press. Glenton, C., Colvin, C.  J., Carlsen, B., Swartz, A., Lewin, S., Noyes, J., & Rashidian, A.  (2013). Barriers and facilitators to the implementation of lay health worker programmes to improve access to maternal and child health: Qualitative evidence synthesis. The Cochrane Library. http://​onlinelibrary.wiley.com/​doi/​10.1002/​14651858. CD010414.pub2/​pdf Goffman, E. (1963). Stigma: Notes on a spoiled identity. Helsinki, Finland: Jenkins, JH & Carpenter. Gogia, S., & Sachday, H. S. (2010). Home visits by community health workers to prevent neonatal deaths in developing countries: A systematic review. Geneva, Switzerland: World Health Organizations. Goldenberg, S. M., Brouwer, K. C., Jimenez, T. R., Miranda, S. M., & Mindt, M. R. (2016). Enhancing the ethical conduct of HIV research with migrant sex workers:  Human rights, policy, and social contextual influences. PloS One, 11(5), e0155048. Goldenburg, S.  M., Deering, K., Amram, O., Guillemi, S., Nguyen, P., Montaner, J., & Shannon, K.  (2017). Community mapping of sex work criminalization and violence:  Impacts on HIV treatment interruptions among marginalized women living with HIV in Vancouver, Canada. International Journal of STD & AIDS, 28(10), 1001–​1009. Gopalan, G., Lee, S. J., Harris, R., Acri, M. C., & Munson, M. R. (2017). Utilization of peers in services for youth with emotional and behavioral challenges: A scoping review. Journal of Adolescence, 55, 88–​115. Gone, J. P. (2013). Redressing First Nations historical trauma: Theorizing mechanisms for indigenous culture as mental health treatment. Transcultural Psychiatry, 50(5), 683–​706. Gonzalez, G. (2014, November). Promoting healthy choices and community change: An e-​learning program for promotores de salud. Presented at the 142nd APHA Annual Meeting and Exposition (November 15–​ November 19, 2014). New Orleans, LA: APHA. Gonzalez-​Hernandez, L. (2014, November). Promotores & public health students in a joint public health internship/​mentorship collaboration. Presented as the 142nd APHA Annual Meeting and Exposition (November 15–​November 19, 2014). New Orleans, LA: APHA. Good, M. J. D., & Hannah, S. D. (2015). “Shattering culture”: Perspectives on cultural competence and evidence-​based practice in mental health services. Transcultural Psychiatry, 52(2), 198–​221. Goodwin, K., & Tobler, L. (2008). Community health workers. Communities, 1, 2. http://​ www.machw.org/​documents/​NationalConferenceStateLegislatorsCHWBrief  Pdf Gopalan, S.  S., Mohanty, S., & Das, A.  (2012). Assessing community health workers’ performance motivation:  A mixed-​methods approach on India’s Accredited Social Health Activists (ASHA) programme. BMJ Open, 2(5), e001557. Governing the State and Localities. (2017, July 17). Why youth homelessness is on the rise. http://​www.governing.com/​topics/​health-​human-​services/​sl-​youth-​homelessness. html

References  199 Graffam, J. H., & Shinkfield, A. (2012). Strategies to enhance employment of Indigenous ex-​ offenders after release from correctional institutions. Southbank, Victoria, Australia: Closing the Gap Clearinghouse. Grantham‐McGregor, S. M., Fernald, L. C., Kagawa, R., & Walker, S. (2014). Effects of integrated child development and nutrition interventions on child development and nutritional status. Annals of the New York Academy of Sciences, 1308(1),  11–​32. Gray, N. A., Boucher, N. A., Kuchibhatla, M., & Johnson, K. S. (2017). Hospice access for undocumented immigrants. JAMA Internal Medicine, 177(4), 579–​580. Green, M. A., Perez, G., Ornelas, I. J., Tran, A. N., Blumenthal, C., Lyn, M., & Corbie-​ Smith, G.  (2012). Amigas Latinas Motivando el ALMA (ALMA):  Development and pilot implementation of a stress reduction promotora intervention. Californian Journal of Health Promotion, 10(1),  52–​64. Greenberg, R.  (2016, March 21). What community health workers can teach us. Huffington Post. http://​www.huffingtonpost.com/​riva-​greenberg/​the-​power-​of-​ community-​he_​b_​9368886.html Greenspan, J.  A., McMahon, S.  A., Chebet, J.  J., Mpunga, M., Urassa, D.  P., & Winch, P. J. (2013). Sources of community health worker motivation: A qualitative study in Morogoro Region, Tanzania. Human Resources for Health, 11(1), 1.  http://​human-​ resources-​health.biomedcentral.com/​articles/​10.1186/​1478-​4491-​11-​52 Griffiths, L., & Bailey, D.  (2015). Learning from peer support schemes—​Can prison listeners support offenders who self-​ injure in custody? International Journal of Prisoner Health, 11(3), 157–​168. Gulliford, M., & Morgan, M.  (Eds.). (2013). Access to health care. New  York, NY: Routledge. Gushue, G. V. (2016). Beyond science: Miracles, miracle cures, and AIDS: The role of the psychotherapist. Psychotherapy and AIDS: The Human Dimension, 3. Hamilton, J. B. (2017). Cultural beliefs and cancer care: Are we doing everything we can? Cancer Nursing, 40(1),  84–​85. Hancock, D. R., & Algozzine, B. (2015). Doing case study research: A practical guide for beginning researchers. New York, NY: Teachers College Press. Haines, J., Du, J. T., & Trevorrow, E. (2015, July). Indigenous knowledge sharing and relationship building through narrative storytelling and creative activities. In Indigenous content in education symposium 2015 (Vol. 1, no.  1). Adelaide, University of South Australia. Hainmueller, J., Lawrence, D., Martén, L., Black, B., Figueroa, L., Hotard, M., . . . Laitin, D. D. (2017). Protecting unauthorized immigrant mothers improves their children’s mental health. Science, 357(6355), 1041–​1044. Hankivsky, O. (2012). Women’s health, men’s health, and gender and health: Implications of intersectionality. Social Science & Medicine, 74(11), 1712–​1720. Hanna, A. M. V., & Ortega, D. M. (2016). Salir adelante (perseverance): Lessons from the Mexican immigrant experience. Journal of Ethnic & Cultural Social Work, 16(1),  47–​65. Hansen, H. (2012). The “new masculinity”: Addiction treatment as a reconstruction of gender in Puerto Rican evangelist street ministries. Social Science & Medicine, 74(11), 1721–​1728. Haralambous, B., Dow, B., Lin, X., Goh, A., Pachana, N.  A., Bryant, C., & LoGiudice, D.  (2016). “Depression is not an illness. It’s up to you to make yourself happy”:  Perceptions of Chinese health professionals and community

200 References workers about older Chinese immigrants’ experiences of depression and anxiety. Australasian Journal on Ageing. http://​onlinelibrary.wiley.com/​doi/​10.1111/​ ajag.12306/​full Harding, D. J., Wyse, J. J., Dobson, C., & Morenoff, J. D. (2014). Making ends meet after prison. Journal of Policy Analysis and Management, 33(2), 440–​470. Hardy, L. J., Hughes, A., Hulen, E., Figueroa, A., Evans, C., & Begay, R. C. (2016). Hiring the experts:  best practices for community-​engaged research. Qualitative Research, 16(5), 592–​600. Harley, D. (2015). Reconceptualizing hope among urban African-​American adolescents through the lens of Photovoice. Journal of Ethnic & Cultural Diversity in Social Work, 24(4), 280–​299. Harris, M. (2013). Community health workers: An opportunity for reverse innovation. The Lancet, 382(9901), 1326–​1327. Harris, M.  J., & Haines, A.  (2012). The potential contribution of community health workers to improving health outcomes in UK primary care. Journal of the Royal Society of Medicine, 105(8), 330–​335. Hatton, C.  (2016). Moving from health disparities to health inequities—​and why it matters. Developmental Medicine & Child Neurology, 58(7), 660–​661. Haughton, J., de la Torre, C.  L., Elder, J.  P., Ayala, G.  X., & Arredondo, E.  M. (2016). Abstract A26: Best practices for implementing a promotora-​led cancer screening intervention in Latino communities. Cancer Epidemiology Biomarkers & Prevention, 25(3 Supplement), A26–​A26. Havassy, B. E., Alvidrez, J., & Mericle, A. A. (2015). Disparities in use of mental health and substance abuse services by persons with co-​occurring disorders. Psychiatric Services, 60(2), 217–​223. Hayashi, J. L., & Leff, B. (2016). Introducing home-​based medical care. In J. L. Hayshi & B. Leff (Eds.), Geriatric home-​based medical care (pp. 3–​7). New York, NY: Springer International. Haywood, M., Garman, A., Johnson, T., Christopher, B.  A. M., & Walker, R.  (2016). Advancing community health workers through higher education lessons learned from a basic certificate program implementation. Pedagogy in Health Promotion. http://​journals.sagepub.com/​doi/​abs/​10.1177/​2373379916671957 Heaman, M. I., Sword, W., Elliott, L., Moffatt, M., Helewa, M. E., Morris, H., . . . Cook, C.  (2015). Barriers and facilitators related to use of prenatal care by inner-​city women: Perceptions of health care providers. BMC Pregnancy and Childbirth, 15(1), 1. Hean, S., Ødegård, A., & Willumsen, E. (2016). Working with mentally ill offenders: Are current levels of collaboration between health/​social care professionals and prison officers sufficient? Medicine Science and the Law. Heintzman, J., Bailey, S. R., DeVoe, J., Cowburn, S., Kapka, T., Duong, T. V., & Marino, M.  (2017). In low-​ income Latino patients, post-​ Affordable Care Act insurance disparities may be reduced even more than broader national estimates: Evidence from Oregon. Journal of Racial and Ethnic Health Disparities, 4(3), 329–​336. Henry-​Sanchez, B.  L., & Geronimus, A.  T. (2013). Racial/​ethnic disparities in infant mortality among us Latinos. Du Bois Review: Social Science Research on Race, 10(1), 205–​231. Herbst, R.  B., Bernal, D.  R., Terry, J., & Lewis, B.  (2016). Undocumented Latina/​ o immigrants in multidisciplinary settings:  Behavioral health providers’ role in

References  201 promoting optimal, ethical healthcare. Journal for Social Action in Counseling and Psychology, 8(1), 89–​108. Herbert, C. W., Morenoff, J. D., & HarDing, D. J. (2015). Homelessness and housing insecurity among former prisoners. The Russell Sage Foundation Journal of the Social Sciences: RSF, 1(2),  44–​79. Higgins, T. C., & Wagnerman, K. (2016). Health care coverage and access for children in low-​income families:  Stakeholder perspectives from Colorado (No. 7fbf353170f 04d18b614173717765c76). Mathematica Policy Research. file://​/​C:/​Users/​delgado/​ Downloads/​CO_​stakeholder_​perspective_​IB2.pdf Hilfinger-​Messias, D. K. H., Parra-​Medina, D., Sharpe, P. A., Treviño, L., Koskan, A. M., & Morales-​Campos, D.  (2013). Promotoras de Salud:  Roles, responsibilities, and contributions in a multi-​site community-​based randomized controlled trial. Hispanic Health Care International: The Official Journal of the National Association of Hispanic Nurses, 11(2), 62–​71. http://​www.ingentaconnect.com/​content/​springer/​hhci/​2013/​ 00000011/​00000002/​ art00003 Hill, Z., Dumbaugh, M., Benton, L., Källander, K., Strachan, D., ten Asbroek, A., . . . Meek, S.  (2014). Supervising community health workers in low-​income countries—​a review of impact and implementation issues. Global Health Action, 7.  http://​www. globalhealthaction.net/​index.php/​gha/​article/​view/​24085 Hirschfeld Davis, J., & Steinhauer, J.  (2017, February 27). Trump’s soft spot for the Dreamers alienates immigration hard-​liners in his base. The New York Times, A10. Hockenberry, S.  (2010). Juveniles in residential placement. Washington, D.C.:  U.S. Department of Justice. Hoeft, K. S., Rios, S. M., Guzman, E. P., & Barker, J. C. (2015). Using community participation to assess acceptability of “Contra Caries,” a theory-​based, promotora-​led oral health education program for rural Latino parents: A mixed methods study. BMC Oral Health, 15(1), 1. Hoffmann, R.  (2016, July). When communities participate in primary health care:  A randomized controlled trial of an NGO led community health worker program in the Philippines. In Third ISA Forum of Sociology (July 10–​14, 2016). Isaconf. Hofmann-​Broussard, C., Armstrong, G., Boschen, M. J., & Somasundaram, K. V. (2017). A mental health training program for community health workers in India: Impact on recognition of mental disorders, stigmatizing attitudes and confidence. International Journal of Culture and Mental Health, 10(1),  62–​73. Hoge, M. A., Stuart, G. W., Morris, J., Flaherty, M. T., Paris, M., & Goplerud, E. (2013). Mental health and addiction workforce development: Federal leadership is needed to address the growing crisis. Health Affairs, 32(11), 2005–​2012. Hohl, S.  D., Thompson, B., Krok-​ Schoen, J.  L., Weier, R.  C., Martin, M., Bone, L., . . . Paskett, E.  D. (2016). Characterizing community health workers on research teams:  Results from the Centers for Population Health and Health Disparities. American Journal of Public Health, 106(4), 664–​670. Hollingshead, N. A., Ashburn-​Nardo, L., Stewart, J. C., & Hirsh, A. T. (2016). The pain experience of Hispanic Americans: A critical literature review and conceptual model. The Journal of Pain, 17(5), 513–​528. Holzer, J., Calhoun, K., & Strong, L. L. (2017). A retrospective on the vision for progress in community health partnerships: Research, education, and action. Progress in Community Health Partnerships, 11(1),  1–​11.

202 References Hopper, E. K., Olivet, J., & Bassuk, E. L. (2018). 1.4 Trauma-​informed care for street-​involved youth. In S. Kidd, N. Slesnick, T. Frederick, J. Karabanow, & S. Gaetz (Eds.), Mental Health & Addiction Interventions for Youth Experiencing Homelessness, 45–​58. Toronto, Canada. http://​homelesshub.ca/​sites/​default/​files/​COH-​MentalHealthBook_​0.pdf Horwood, C., Butler, L., Haskins, L., Grant, M., Rollins, N., Mntambo, N., . . . Phakathi, S. (2017). A continuous quality improvement intervention to improve the effectiveness of community health workers providing care to mothers and children: A cluster randomised controlled trial in South Africa. Human Resources for Health, 15(1), 39. Hsu, L. L., Green, N. S., Ivy, E. D., Neunert, C. E., Smaldone, A., Johnson, S., . . . Strouse, J.  J. (2016). Community health workers as support for sickle cell care. American Journal of Preventive Medicine, 51(1), S87–​S98. Hu, J., Amirehsani, K. A., Wallace, D. C., McCoy, T. P., & Silva, Z. (2016). A family-​based, culturally tailored diabetes intervention for Hispanics and their family members. The Diabetes Educator, 42(6), 299–​314. http://​journals.sagepub.com/​doi/​abs/​10.1177/​ 0145721716636961 Huff, R. M., Kline, M. V., & Peterson, D. V. (Eds.). (2014). Health promotion in multicultural populations: A handbook for practitioners and students. Thousand Oaks, CA: Sage. Hufford, D.  J. (1992). Folk medicine in contemporary America. In J.  Kirkland, H.  F. Mathews, C.  W. Sullivan III, & K.  Baldwin (Eds.), Herbal and magical medicine (pp. 14–​31). Durham, NC: Duke University Press. Hughes, C. (2012). Reducing the incarceration of the homeless: An examination of multi-​ service use and the utilization of institutional services. PhD dissertation, University of Louisville, Louisville, KY. Hughes, M.  M., Yang, E., Ramanathan, D., & Benjamins, M.  R. (2016). Community-​ based diabetes community health worker intervention in an underserved Chicago population. Journal of Community Health, 41(6), 1249–​1256. Iheanacho, T., Stefanovics, E., Ezeanolue, E.  E., & Rosenheck, R.  (2016). Beliefs and attitudes about mental illness among lay church-​based health workers and medical trainees in Nigeria. Journal of Psychiatry, 19(4), 1–​5. https://​pdfs.semanticscholar.org/​ 6e08/​7e6b5225943dd01208c1dcd8c459fdb2c32  b.pdf Im, E.  O. (2016). “Intersectionality” in Asian American women’s health. Asian/​Pacific Island Nursing Journal, 1(4), 194–​196. Inderbitzin, M., Walraven, T., & Anderson, J.  (2016). Leading by example:  Ways that prisoners give back to their communities. In L. S. Abrams, E. Hughes, M. Inderbitzin, & R. Meek (Eds.), The voluntary sector in prisons (pp. 85–​114). New York, NY: Palgrave Macmillan. Indiana Government. (2008). Code of ethics for community health workers. https://​www. in.gov/​isdh/​files/​CHW_​CodeofEthics_​approvedfinalJune2008.pdf Ingram, M., Chang, J., Kunz, S., Piper, R., de Zapien, J.  G., & Strawder, K.  (2016). Women’s health leadership to enhance community health workers as change agents. Health Promotion Practice, 17(3), 391–​399. Ingram, M., Murrietta, L., de Zapien, J.  G., Herman, P.  M., & Carvajal, S.  C. (2015). Community health workers as focus group facilitators:  A participatory action research method to improve behavioral health services for farmworkers in a primary care setting. Action Research, 13(1),  48–​64.

References  203 Ingram, M., Reinschmidt, K. M., Schachter, K. A., Davidson, C. L., Sabo, S. J., De Zapien, J. G., & Carvajal, S. C. (2012). Establishing a professional profile of community health workers:  Results from a national study of roles, activities and training. Journal of Community Health, 37(2), 529–​537. Islam, N., Nadkarni, S.  K., Zahn, D., Skillman, M., Kwon, S.  C., & Trinh-​Shevrin, C.  (2014). Integrating community health workers within Patient Protection and Affordable Care Act implementation. Journal of Public Health Management and Practice: JPHMP, 21(1),  42–​50. Islam, N. S., Zanowiak, J. M., Riley, L., Nadkarni, S. K., Kwon, S. C., & Trinh-​Shevrin, C. (2015). Characteristics of Asian American, Native Hawaiian, and Pacific Islander community health worker programs: A systematic review. Journal of Health Care for the Poor and Underserved, 26(20), 238–​268. Jack, H. E., Arabadjis, S. D., Sun, L., Sullivan, E. E., & Phillips, R. S. (2017). Impact of community health workers on use of healthcare services in the United States: A systematic review. Journal of General Internal Medicine, 32(3), 325–​344. Jackson, C. S., & Garcia, J. N. (2014). Addressing health and health-​care disparities: The role of a diverse workforce and the social determinants of health. Public Health Reports, 129(Suppl. 2),  57–​61. Jackson, S.  F., Fazal, N., Gravel, G., & Papowitz, H.  (2017). Evidence for the value of health promotion interventions in natural disaster management. Health Promotion International, 32(6), 1057–​1066. Jacob, D. T. S. (2016). Preparing community health workers to address hearing loss. PhD dissertation, University of Arizona, Tucson, AZ. Jacobs, B., Ir, P., Bigdeli, M., Annear, P.  L., & Van Damme, W.  (2012). Addressing access barriers to health services:  An analytical framework for selecting appropriate interventions in low-​income Asian countries. Health Policy and Planning, 27(4), 288–​300. Jagers, R. J., Mustafaa, F. N., & Noel, B. (2017). Cultural integrity and African American empowerment:  Insights and practical implications for community psychology. In M.  Bond, I.  E. Serrano-​Garcia, C.  B. Keys, & M.  E. Shinn (Eds.), APA handbook of community psychology:  Methods for community research and action for diverse groups and issues (Vol. 2, pp.  459–​474). Washington, DC:  American Psychological Association. Jang, Y., Lee, A.  A., Zadrozny, M., Bae, S.  H., Kim, M.  T., & Marti, N.  C. (2017). Determinants of job satisfaction and turnover intent in home health workers the role of job demands and resources. Journal of Applied Gerontology, 36(1),  56–​70. Jarvis, J. D., Kataria, I., Murgor, M., & Mbau, L. (2016). Community health workers: An underappreciated asset to tackle NCD. Global Heart, 11(4), 455–​457. Jaskiewicz, W., & Tulenko, K.  (2012). Increasing community health worker productivity and effectiveness: A review of the influence of the work environment. Human Resource Health, 10(1), 38. http://​human-​resources-​health.biomedcentral.com/​articles/​10.1186/​1478-​4491-​10-​38 Javanparast, S., Baum, F., Labonte, R., Sanders, D., Rajabi, Z., & Heidari, G. (2012). The experience of community health workers training in Iran: A qualitative study. BMC Health Services Research, 12(1), 291.

204 References Jeet, G., Thakur, J. S., Prinja, S., & Singh, M. (2017). Community health workers for non-​ communicable diseases prevention and control in developing countries: Evidence and implications. PloS One, 12(7), e0180640. Jeffreys, M. R. (2015). Teaching cultural competence in nursing and health care: Inquiry, action, and innovation. New York, NY: Springer. Jennings, D. (2011). Youth defining health: Photovoice in a tribal community for childhood obesity prevention. 73(3). Jiang, G., Sun, F., & Marsiglia, F. F. (2016). Rural-​urban disparities in adolescent risky behaviors: A family social capital. Journal of Community Psychology, 44(8), 1027–​1039. Jin, L., & Acharya, L. (2016). Cultural beliefs underlying medication adherence in people of Chinese descent in the United States. Health Communication, 31(5), 513–​521. Johanson, L. (2016). Caring for the vulnerable: An exploration of Guatemalan healthcare issues. Journal of Christian Nursing, 33(1),  44–​49. Johnson, C.  D., Noyes, J., Haines, A., Thomas, K., Stockport, C., Ribas, A.  N., & Harris, M.  (2013). Learning from the Brazilian community health worker model in North Wales. Globalization and Health, 9(1), 1.  https://​globalizationandhealth. biomedcentral.com/​articles/​10.1186/​1744-​8603-​9-​25 Johnson, E. J., & Boodram, C. A. S. (2017). Health, well-​being and quality of life of community members displaced after an industrial disaster in Trinidad. Journal of Public Health, 25(1),  69–​74. Johnson, K.  J. (2016). Health professions education:  A national survey of community college leaders. Pedagogy in Health Promotion, 2(1),  20–​33. Jones, B. (2012). Cultural considerations when caring for the geographically displaced client. In G.  Kersey-​Matusiak (Ed.), Delivering culturally competent nursing care (pp. 143–​155). New York, NY: Springer. Jones, C.  O., Wasunna, B., Sudoi, R., Githinji, S., Snow, R.  W., & Zurovac, D.  (2012). “Even if you know everything you can forget”: Health worker perceptions of mobile phone text-​messaging to improve malaria case-​management in Kenya. PLoS One, 7(6), e38636. Jones, S. A., Sam, B., Bull, F., James, M., Ameh, C. A., & van den Broek, N. R. (2016). Strengthening pre-​service training for skilled birth attendance—​An evaluation of the maternal and child health aide training programme in Sierra Leone. Nurse Education Today, 41,  24–​29. Juárez-​Carrillo, P. M. (2014, November). Beyond worker training—​The role of the community health workers in sustaining safe practices in an occupational setting. Presented at the 142nd APHA Annual Meeting and Exposition (November 15–​November 19, 2014). New Orleans, LA: APHA. Juckett, G.  (2013). Caring for Latino patients. American Family Physician, 87(1),  48–​57. Kane, E.  P., Collinsworth, A.  W., Schmidt, K.  L., Brown, R.  M., Snead, C.  A., Barnes, S. A., . . . & Walton, J. W. (2016). Improving diabetes care and outcomes with community health workers. Family Practice, 33(5), 523–​528. Kangovi, S., Grande, D., & Trinh-​ Shevrin, C.  (2015). From rhetoric to reality—​ community health workers in post-​reform US health care. The New England Journal of Medicine, 372(24), 2277. Kangovi, S., Mitra, N., Grande, D., White, M.  L., McCollum, S., Sellman, J., . . . Long, J.  A. (2014). Patient-​centered community health worker intervention to improve

References  205 posthospital outcomes: A randomized clinical trial. JAMA Internal Medicine, 174(4), 535–​543. Kapetanovic, T.  (2016). Re-​discovery of health self-​care among homeless men and women after an incarceration experience. Journal for Evidence-​ based Practice in Correctional Health, 1(1), 6. http://​digitalcommons.uconn.edu/​jepch/​vol1/​iss1/​6/​ Kapilashrami, A., Hill, S., & Meer, N. (2015). What can health inequalities researchers learn from an intersectionality perspective? Understanding social dynamics with an inter-​categorical approach? Social Theory & Health, 13(3–​4), 288–​307. Kasteng, F., Settumba, S., Källander, K., Vassall, A., & inSCALE Study Group. (2016). Valuing the work of unpaid community health workers and exploring the incentives to volunteering in rural Africa. Health Policy and Planning, 31(2), 205–​216. Katigbak, C., Foley, M., Robert, L., & Hutchinson, M. K. (2016). Experiences and lessons learned in using community‐based participatory research to recruit Asian American immigrant research participants. Journal of Nursing Scholarship, 48(2), 210–​218. Katz, J., & Goodnough, A.  (2017, December 22). Opoid deaths rising swiftly among Blacks. The New York Times, A1. Kaur, M. (2016). Community health workers—​Birth of a new profession. Generations, 40(1),  56–​63. Kayemba Nalwadda, C., Guwatudde, D., Waiswa, P., Kiguli, J., Namazzi, G., Namutumba, S., . . . & Peterson, S.  (2013). Community health workers—​A resource for identification and referral of sick newborns in rural Uganda. Tropical Medicine & International Health, 18(7), 898–​906. Keig, C. L., Mata, A., & Cervantes, R. C. (2016). Emerging Latino populations: Social, health and educational needs in Oklahoma City. Free Inquiry in Creative Sociology, 36(2), 119–​138. Kelley, M.  S., Su, D., & Britigan, D.  H. (2016). Disparities in health information access:  Results of a county-​wide survey and implications for health communication. Health Communication, 31(5), 575–​582. Kemp, V., & Henderson, A.  R. (2012). Challenges faced by mental health peer support workers:  Peer support from the peer supporter’s point of view. Psychiatric Rehabilitation Journal, 35(4), 337–​340. Kerrigan, D. L., Fonner, V. A., Stromdahl, S., & Kennedy, C. E. (2013). Community empowerment among female sex workers is an effective HIV prevention intervention: A systematic review of the peer-​reviewed evidence from low-​and middle-​income countries. AIDS and Behavior, 17(6), 1926–​1940. Keyes, K. M., Cerdá, M., Brady, J. E., Havens, J. R., & Galea, S. (2014). Understanding the rural–​urban differences in nonmedical prescription opioid use and abuse in the United States. American Journal of Public Health, 104(2), e52–​e59. Khetan, A., Purushothaman, R., Zullo, M., Gupta, R., Hejjaji, V., Agarwal, S., . . . Josephson, R. (2017). Rationale and design of a cluster-​randomized controlled trial to evaluate the effects of a community health worker–​based program for cardiovascular risk factor control in India. American Heart Journal, 185, 161–​172. Kia-​Keating, M., Santacrose, D.  E., Liu, S.  R., & Adams, J.  (2017). Using community-​ based participatory research and human-​centered design to address violence-​related health disparities among Latino/​a youth. Family & Community Health, 40(2), 160–​169. Kieffer, E. C., Caldwell, C. H., Welmerink, D. B., Welch, K. B., Sinco, B. R., & Guzmán, J. R. (2013). Effect of the healthy MOMs lifestyle intervention on reducing depressive

206 References symptoms among pregnant Latinas. American Journal of Community Psychology, 51(1–​2),  76–​89. Kim, K., Choi, J. S., Choi, E., Nieman, C. L., Joo, J. H., Lin, F. R., & Gitlin, L. N. (2016). Effects of community-​based health worker interventions to improve chronic disease management and care among vulnerable populations: A systematic review. American Journal of Public Health, 106(4), e3–​e28. Kim, K.  B., Kim, M.  T., Lee, H.  B., Nguyen, T., Bone, L.  R., & Levine, D.  (2016). Community health workers versus nurses as counselors or case managers in a self-​ help diabetes management program. American Journal of Public Health, 106(6), 1052–​1058. Kim, J.  S. (2015). Financial barriers to care among low-​ income children with asthma: Health care reform implications. Pediatrics, 136(Supplement 3), S267–​S267. Kingery, F.  P., Naanyu, V., Allen, W., & Patel, P.  (2016). Photovoice in Kenya using a community-​based participatory research method to identify health needs. Qualitative Health Research, 26(1), 92–​104. Kirby, J. B., & Sharma, R. (2017, January). The availability of community health center services and access to medical care. Healthcare, 5(4), 174–​182. Klass, A. A. (1961). What is a profession? Canadian Medical Association Journal, 85(12), 698–​701. Knopf, J. A., Finnie, R. K., Peng, Y., Hahn, R. A., Truman, B. I., Vernon-​Smiley, M., . . . Hunt, P. C. (2016). School-​based health centers to advance health equity: A community guide systematic review. American Journal of Preventive Medicine, 51(1), 114–​126. Koch, T.  (2016a). Ebola in West Africa:  Lessons we may have learned. International Journal of Epidemiology, 45(1),  5–​12. Koch, T.  (2016b). Fighting disease, like fighting fires:  The lessons Ebola teaches. The Canadian Geographer/​Le Géographe canadien, 60(3), 288–​299. Koehn, S., Neysmith, S., Kobayashi, K., & Khamisa, H.  (2013). Revealing the shape of knowledge using an intersectionality lens: Results of a scoping review on the health and health care of ethnocultural minority older adults. Ageing and Society, 33(3), 437–​464. Kohrt, B. A., & Mendenhall, E. (2016). Task-​sharing and alternative care models. In B. A. Kohrt & E.  Mendenhall (Eds.), Global mental health:  Anthropological perspectives (pp. 255–​258). New York, NY: Routledge. Kok, M.  C., Broerse, J.  E., Theobald, S., Ormel, H., Dieleman, M., & Taegtmeyer, M.  (2017). Performance of community health workers:  Situating their intermediary position within complex adaptive health systems. Human Resources for Health, 15(1), 59. https://​human-​resources-​health.biomedcentral.com/​articles/​10.1186/​ s12960-​017-​0234-​z Kok, M. C., Dieleman, M., Taegtmeyer, M., Broerse, J. E., Kane, S. S., Ormel, H., . . . de Koning, K.  A. (2015). Which intervention design factors influence performance of community health workers in low-​and middle-​income countries? A  systematic review. Health Policy and Planning, 30(9), 1207–​1227. Kok, M. C., Ormel, H., Broerse, J. E., Kane, S., Namakhoma, I., Otiso, L., . . . Dieleman, M. (2017). Optimising the benefits of community health workers’ unique position between communities and the health sector: A comparative analysis of factors shaping relationships in four countries. Global Public Health, 12(11), 1404–​1432. Koniak-​Griffin, D., Brecht, M. L., Takayanagi, S., Villegas, J., Melendrez, M., & Balcázar, H. (2015). A community health worker-​led lifestyle behavior intervention for Latina

References  207 (Hispanic) women:  Feasibility and outcomes of a randomized controlled trial. International Journal of Nursing Studies, 52(1),  75–​87. Koon, A.  D., Goudge, J., & Norris, S.  A. (2013). A  review of generalist and specialist community health workers for delivering adolescent health services in sub-​Saharan Africa. Human Resource Health, 11(1), 54. https://​human-​resources-​health. biomedcentral.com/​articles/​10.1186/​1478-​4491-​11-​54 Koskan, A., Friedman, D. B., Messias, D. K. H., Brandt, H. M., & Walsemann, K. (2013). Sustainability of promotora initiatives:  Program planners’ perspectives. Journal of Public Health Management and Practice: JPHMP, 19(5),  E1–​E9. Kouyoumdjian, F.  G., McIsaac, K.  E., Liauw, J., Green, S., Karachiwalla, F., Siu, W., . . . Korchinski, M. (2015). A systematic review of randomized controlled trials of interventions to improve the health of persons during imprisonment and in the year after release. American Journal of Public Health, 105(4), e13–​e33. Kowalczyk, L.  (2016, October 12). Recovery aid from those who known. The Boston Globe, A1, A6–​A7. Krogstad, J.  M. (2014). A view of the future through kindergarten demographics. Washington, D.C.: Pew Research Center. Krok-​Schoen, J.  L., Weier, R.  C., Hohl, S.  D., Thompson, B., & Paskett, E.  D. (2016). Involving community health workers in the Centers for Population Health and Health Disparities Research Projects: Benefits and challenges. Journal of Health Care for the Poor and Underserved, 27(3), 1252–​1266. Ku, L., & Matani, S. (2017). Left out: Immigrants’ access to health care and insurance. Health Affairs, 20, 247–​256. Kurtz, L.  F. (2014). Recovery groups:  A guide to creating, leading, and working with groups for addictions and mental health conditions. New York, NY: Oxford University Press. Kutcher, R., Moore-​Monroy, M., Bello, E., Doyle, S., Ibarra, J., Kunz, S., . . . Alfero, C. (2015). Promotores as advocates for community improvement: Experiences of the western states REACH Su Comunidad Consortium. The Journal of Ambulatory Care Management, 38(4), 321–​332. Kwesigabo, G., Mwangu, M.  A., Kakoko, D.  C., Warriner, I., Mkony, C.  A., Killewo, J., . . . Freeman, P.  (2012). Tanzania’s health system and workforce crisis. Journal of Public Health Policy, 33(1), S35–​S44. Lal, S., Donnelly, C., & Shin, J. (2015). Digital storytelling: An innovative tool for practice, education, and research. Occupational Therapy in Health Care, 29(1),  54–​62. Lambert, J.  (2013). Digital storytelling:  Capturing lives, creating community. New  York, NY: Routledge. Lambert, V., & Keogh, D. (2014). Health literacy and its importance for effective communication. Part 1. Nursing Children and Young People, 26(3),  31–​37. Lamorey, S.  (2017). Home visiting in two cultures. Journal of Research in Childhood Education, 31(1),  71–​83. Landers, S., Closson, E. F., Oldenburg, C. E., Holcomb, R., Spurlock, S., & Mimiaga, M. J. (2014). HIV prevention needs among street-​based male sex workers in Providence, Rhode Island. American Journal of Public Health, 104(11), e100–​e102. Landers, S., & Levinson, M.  (2016). Mounting evidence of the effectiveness and versatility of community health workers. American Journal of Public Health, 106(4), 591–​592.

208 References Lane, V.  (2015, November). Addressing hypertension and diabetes through community health workers in an underserved urban community. Presented at the 143rd APHA Annual Meeting and Exposition (October 31–​November 4, 2015). Chicago, IL: APHA. Lanesskog, D. M. (2016). Improvised care: Public health with Latinos in new immigrant destinations (Doctoral dissertation, University of Illinois at Urbana-​ Champaign, Illinois). Lang, D., Cragin, L.  J., Raymond, D., & Kane, S.  (2014). In a neighborhood near you:  How community health workers help people obtain health insurance and primary care. Journal of Health Care for the Poor and Underserved, 25(1), lviii–​lxiii. Larsen, B. A., Noble, M. L., Murray, K. E., & Marcus, B. H. (2015). Physical activity in Latino men and women facilitators, barriers, and interventions. American Journal of Lifestyle Medicine, 9(1),  4–​30. Laverack, G.  (2005). Public health:  Power, empowerment and professional practice. New York, NY: Palgrave Macmillan. le Roux, I.  M., Tomlinson, M., Harwood, J.  M., O’Connor, M.  J., Worthman, C.  M., Mbewu, N., . . . Weiss, R. E. (2013). Outcomes of home visits for pregnant mothers and their infants: A cluster randomised controlled trial. AIDS, 27(9), 1461–​1471. Lebron, C. N., Reyes-​Arrechea, E., Castillo, A., Carrasquillo, O., & Kenya, S. (2015). Tales from the Miami Healthy Heart Initiative:  The experiences of two community health workers. Journal of Health Care for the Poor and Underserved, 26(2), 453–​462. Lechuga, J., Garcia, D., Owczarzak, J., Barker, M., & Benson, M.  (2015). Latino community health workers and the promotion of sexual and reproductive health. Health Promotion Practice, 16(3), 338–​344. Lee, C. T., Guzman, D., Ponath, C., Tieu, L., Riley, E., & Kushel, M. (2016). Residential patterns in older homeless adults:  Results of a cluster analysis. Social Science & Medicine, 153(March), 131–​140. Lee, J. J. H., Guilamo-​Ramos, V., Muñoz-​Laboy, M., Lotz, K., & Bornheimer, L. (2016). Mechanisms of familial influence on reentry among formerly incarcerated Latino men. Social Work, 61(3), 199–​207. Lehmann, U., & Sanders, D. (2007). Community health workers: What do we know about them? The state of the evidence on programmes, activities, costs and impact on health outcomes of using community health workers. Geneva, Switzerland:  World Health Organization. Lehmann, U., Van Damme, W., Barten, F., & Sanders, D. (2009). Task shifting: The answer to the human resources crisis in Africa? Human Resources for Health, 7(1), 49. https://​human-​resources-​health.biomedcentral.com/​articles/​10.1186/​1478-​4491-​7-​49 Lemley, M., & Spies, L.  A. (2015). Traditional beliefs and practices among Mexican American immigrants with type II diabetes:  A case study. Journal of the American Association of Nurse Practitioners, 27(4), 185–​189. León, M., & Clinton, A. (2016). Promoting psychological well-​being in Puerto Rico. In B. K. Nastasi & A. P. Borja (Eds.), International handbook of psychological well-​being in children and adolescents (pp. 137–​149). New York, NY: Springer. Leon, N., Sanders, D., Van Damme, W., Besada, D., Daviaud, E., Oliphant, N.  P.,  .  .  .  Doherty, T. (2015). The role of “hidden” community volunteers in community-​based health service delivery platforms:  Examples from sub-​Saharan

References  209 Africa. Global Health Action, 8. http://​www.globalhealthaction.net/​index.php/​gha/​article/​view/​27214 Leon, N., Schneider, H., & Daviaud, E.  (2012). Applying a framework for assessing the health system challenges to scaling up mHealth in South Africa. BMC Medical Informatics and Decision Making, 12(1), 1. Levi-​Minzi, M. A., Surratt, H. L., O’Grady, C. L., & Kurtz, S. P. (2016). Finding what works: Predicting health or social service linkage in drug using, African American, female sex workers in Miami, FL. Health Care for Women International, 37(7), 744–​759. Lewycka, S., Mwansambo, C., Rosato, M., Kazembe, P., Phiri, T., Mganga, A., . . . Pulkki-​ Brännström, A. M. (2013). Effect of women’s groups and volunteer peer counselling on rates of mortality, morbidity, and health behaviours in mothers and children in rural Malawi (MaiMwana):  A factorial, cluster-​ randomised controlled trial. The Lancet, 381(9879), 1721–​1735. Li, L., Zhang, Z., Sun, Z., Zhou, H., Liu, X., Li, H., . . . Coyte, P. C. (2014). Relationships between actual and desired workplace characteristics and job satisfaction for community health workers in China: A cross-​sectional study. BMC Family Practice, 15(1), 1. Liburd, L. C. (Ed.). (2010). Diabetes and health disparities: Community-​based approaches for racial and ethnic populations. New York, NY: Springer. Lichtveld, M. Y., Shankar, A., Mundorf, C., Hassan, A., & Drury, S. (2016). Measuring the developing therapeutic relationship between pregnant women and community health workers over the course of the pregnancy in a study intervention. Journal of Community Health, 41(6), 1167–​1176. Liebman, A. K. (2013, November). A local perspective on a global challenge: Health and safety perceptions and practices of immigrant workers in Wisconsin’s dairy industry. Presented at the 141st APHA Annual Meeting (November 2–​November 6, 2013). Boston, MA: APHA. Liebman, A.  K., Juárez-​Carrillo, P., Reyes, I.  A. C., & Keifer, M.  C. (2014). A  model health and safety intervention for Hispanic immigrants working in the dairy industry. Journal of Agromedicine, 19(2),  78–​82. Lin, W. Q., Wu, J., Yuan, L. X., Zhang, S. C., Jing, M. J., Zhang, H. S., . . . Wang, P. X. (2015). Workplace violence and job performance among community healthcare workers in China:  The mediator role of quality of life. International Journal of Environmental Research and Public Health, 12(11), 14872–​14886. Litzelman, D.  K., Inui, T.  S., Griffin, W.  J., Perkins, A., Cottingham, A.  H., Schmitt-​ Wendholt, K. M., & Ivy, S. S. (2017). Impact of community health workers on elderly patients’ advance care planning and health care utilization: Moving the dial. Medical Care, 55(4), 319–​326. London, K., Damio, G., Ferrazo, M., Perez-​Escamalla, R., & Wiggins, N. (2018). Policy brief:  Addressing social determinants of health through community health workers:  A call to action. Hartford, CT: Hispanic Health Council Policy. López, L., Tan-​ McGrory, A., Horner, G., & Betancourt, J.  R. (2016). Eliminating disparities among Latinos with type 2 diabetes: Effective eHealth strategies. Journal of Diabetes and Its Complications, 30(3), 554–​560. Lopez, P.  M., Islam, N., Feinberg, A., Myers, C., Seidl, L., Drackett, E., . . . Wyka, K.  (2017). A  place-​based community health worker program:  Feasibility and early outcomes, New  York City, 2015. American Journal of Preventive Medicine, 52(3), S284–​S289.

210 References Lopez, S. (2014). Threading the needle: Strategies to elevate the role of community health workers in emerging models of care for dual eligibles. http://​0-​www.oxy.edu.oasys.lib. oxy.edu/​sites/​default/​files/​assets/​UEP/​Comps/​2014/​ Lopez,Sarah_​Threading%20 the%20Needle.pdf López-​Sanders, L. (2017). Changing the navigator’s course: How the increasing rationalization of healthcare influences access for undocumented immigrants under the Affordable Care Act. Social Science & Medicine, 178,  46–​54. Lorenzo-​ Blanco, E.  I., Unger, J.  B., Oshri, A., Baezconde-​ Garbanati, L., & Soto, D.  (2016). Profiles of bullying victimization, discrimination, social support, and school safety: Links with Latino/​a youth acculturation, gender, depressive symptoms, and cigarette use. American Journal of Orthopsychiatry, 86(1),  37–​48. Lohr, A.  M., Ingram, M., Nuñez, A.  V., Reinschmidt, K.  M., & Carvajal, S.  C. (2018). Community–​clinical linkages with community health workers in the United States: A scoping review. Health Promotion Practice, 19(3), 349–​360. Love, M. B., Legion, V., Shim, J. K., Tsai, C., Quijano, V., & Davis, C. (2004). CHWs get credit:  A 10-​year history of the first college-​credit certificate for community health workers in the United States. Health Promotion Practice, 5(4), 418–​428. Loyola, M.  L. L.  (2016). The profile and empathy level of helping professionals. Asia Pacific Journal of Multidisciplinary Research, 4(3),  26–​33. Luckow, P. W., Kenny, A., White, E., Ballard, M., Dorr, L., Erlandson, K., . . . Ly, E. J. (2017). Implementation research on community health workers’ provision of maternal and child health services in rural Liberia. Bulletin of the World Health Organization, 95(2), 113–​120. Lucksted, A., & Drapalski, A. L. (2015). Self-​stigma regarding mental illness: Definition, impact, and relationship to societal stigma. Psychiatric Rehabilitation Journal, 38(2), 99–​102. Luo, Z., Bai, X., Min, R., Tang, C., & Fang, P. (2014). Factors influencing the work passion of Chinese community health service workers:  An investigation in five provinces. BMC Family Practice, 15(1), 1. Lutman, B., Lynch, C., & Monk-​Turner, E. (2015). De-​demonizing the “monstrous” drug addict: A qualitative look at social reintegration through rehabilitation and employment. Critical Criminology, 23(1),  57–​72. Lykes, M.  B., & Scheib, H.  (2016). Visual methodologies and participatory action research:  Performing women’s community-​based health promotion in post-​Katrina New Orleans. Global Public Health, 11(5–​6), 742–​761. Lynch, A. P. (2013, November). Community health promoters-​moving towards a healthier community through health justice and community development. Presented at the 141st APHA Annual Meeting (November 2–​November 6, 2013). Boston, MA: APHA. LySaught, M.  T. (2013). Reverse innovation from the least of our neighbors. Health Progress, Jan.–​Feb.,  45–​52. Macia, L., Ruiz, H. C., Boyzo, R., & Documet, P. I. (2016). Promotores’ perspectives on a male-​to-​male peer network. Health Education Research, 31(3), 314–​327. Mackenbach, J.  P. (2012). The persistence of health inequalities in modern welfare states: The explanation of a paradox. Social Science & Medicine, 75(4), 761–​769. MacLean, L., Hassmiller, S., Shaffer, F., Rohrbaugh, K., Collier, T., & Fairman, J. (2014). Scale, causes, and implications of the primary care nursing shortage. Annual Review of Public Health, 35(March), 443–​457.

References  211 Maes, K. (2016). Task-​shifting in global health: Mental health implications for community health workers and volunteers. In B.  A. Kohrt & E.  Mendenhall (Eds.), Global mental health: Anthropological perspectives (pp. 291–​296). New York, NY: Routledge. Maes, K. (2017). The lives of community health workers: Local labor and global health in urban Ethiopia (Anthropology and Global Public Health). New York, NY: Routledge. Maes, K., Closser, S., & Kalofonos, I.  (2014). Listening to community health workers: How ethnographic research can inform positive relationships among community health workers, health institutions, and communities. American Journal of Public Health, 104(5),  5–​9. Maes, K., & Kalofonos, I.  (2013). Becoming and remaining community health workers:  Perspectives from Ethiopia and Mozambique. Social Science & Medicine, 87(1),  52–​59. Maes, K. C., Kohrt, B. A., & Closser, S. (2010). Culture, status and context in community health worker pay: Pitfalls and opportunities for policy research. Social Science & Medicine, 71, 1375–​1378. Mafwiri, M. M., Jolley, E., Hunter, J., Gilbert, C. E., & Schmidt, E. (2016). Mixed methods evaluation of a primary eye care training programme for primary health workers in Morogoro Tanzania. BMC Nursing, 15(1), 41. Magaña, S., Lopez, K., Aguinaga, A., & Morton, H. (2013). Access to diagnosis and treatment services among Latino children with autism spectrum disorders. Intellectual and Developmental Disabilities, 51(3), 141–​153. Mahera, D., & Comettob, G. (2016). Research on community-​based health workers is needed to achieve the sustainable development goals. Bulletin of the World Health Organization, 94(11), 786. Maiwada, A. M., Rahman, N. A. A., Abdurrahaman, S., Mamat, N. M., & Ann-​Walker, J.  (2016). The Islamic religious leaders as health promoters:  Improving maternal health in selected communities of Zamfara State, Nigeria. Journal of Reproduction and Infertility, 7(1),  8–​14. Malachowski, M. (2014). Public libraries participating in community health initiatives. Journal of Hospital Librarianship, 14(3), 295–​302. Malcarney, M. B., Pittman, P., Quigley, L., Horton, K., & Seiler, N. (2017). The changing roles of community health workers. Health Services Research, 52(S1), 360–​382. Manchanda, R. (2015). Practice and power: Community health workers and the promise of moving health care upstream. The Journal of Ambulatory Care Management, 38(3), 219–​224. Maneesha, G., Abraham, S., & Prasad, J. (2014). Developing a training module for female health workers for the diagnosis of female reproductive tract infections—​An experience in South India. International Journal of Contemporary Medicine, 2(1), 145–​150. Mannan, I., Rahman, S. M., Sania, A., Seraji, H. R., Arifeen, S. E., Winch, P. J., . . . Baqui, A. (2008). Can early postpartum home visits by trained community health workers improve breastfeeding of newborns? Journal of Perinatology, 28(9), 632–​640. Marlow, E., Grajeda, W., Lee, Y., Young, E., Williams, M., & Hill, K.  (2015). Peer mentoring for male parolees:  A CBPR pilot study. Progress in Community Health Partnerships: Research, Education, and Action, 9(1), 91–​100. Marrow, H.  B., & Joseph, T.  D. (2015). Excluded and frozen out:  Unauthorised immigrants’ (non) access to care after US health care reform. Journal of Ethnic and Migration Studies, 41(14), 2253–​2273.

212 References Marshall, J.  D., Brauer, M., & Frank, L.  D. (2015). Healthy neighborhoods:  Walkability and air pollution. PhD dissertation, Vancouver, University of British Columbia. Martin, A.  (2014, November). Community health workers as health insurance marketplace navigators:  Lessons learned and paths forward. Presented at the 142nd APHA Annual Meeting and Exposition (November 15–​November 19, 2014). New Orleans, LA: APHA. Martin, A. (2015, November). Community health workers (CHWs) make cents: A return on investment analysis. Presented at the 143rd APHA Annual Meeting and Exposition (October 31–​November 4, 2015). Chicago, IL: APHA. Martinez, J., M. Ro, N. M. Villa, W. Powell, and J. R. Knickman. (2011). Transforming the Delivery of Care in the Post–​Health Reform Era:  What Role Will Community Health Workers Play? American Journal of Public Health, 101(12),  e1–​5. Martinez, V.  (2014). Conversations with the community:  An ethnography of two case studies highlighting community-​research partnerships in Springfield, MA. PhD dissertation, University of Massachusetts, Amherst, MA. Maruschak, L., Chari, K. A., Simon, A. E., & DeFrances, C. J. (2016). National survey of prison health care: Selected findings. National Health Statistics Reports, 96,  1–​23. Massengale, K. E., Morrison, S. D., & Sudha, S. (2016). Community health advocate—​ Identified enablers of HIV testing for Latina immigrant women. AIDS Education and Prevention, 28(4), 325–​340. Massey, D.  S., Zambrana, R.  E., & Bell, S.  A. (1995). Contemporary issues in Latino families:  Future directions for research, policy, and practice. In R.  E. Zambrana (Ed.), Understanding Latino families: Scholarship, policy, and practice (pp. 190–​204). Thousand Oaks, CA: Sage. Massimi, A., De Vito, C., Brufola, I., Corsaro, A., Marzuillo, C., Migliara, G., . . . Damiani, G.  (2016). Is the task-​shifting in self-​management support effective? A  systematic review and meta-​analysis. The European Journal of Public Health, 26(Suppl. 1), 164–​235. Massoglia, M., & Pridemore, W. A. (2015). Incarceration and health. Annual Review of Sociology, 41(August), 291–​310. Matarazzo, B.  B., Signoracci, G.  M., Brenner, L.  A., & Olson-​Madden, J.  H. (2016). Barriers and facilitators in providing community mental health care to returning veterans with a history of traumatic brain injury and co-​occurring mental health symptoms. Community Mental Health Journal, 52(2), 158–​164. Mayan, M. J., & Daum, C. (2016). Beyond dissemination: Generating and applying qualitative evidence through community-​based participatory research. In K.  Olson & R. A. Young (Eds.), Handbook of qualitative health research for evidence-​based practice (pp. 441–​452). New York, NY: Springer. Mayberry, R. M., Willock, R. J., & Daniels, P. V. (2012). Capacity building and the role of community health workers in CEOD. In F. Murphy (Ed.), Community engagement, organization, and development for public health practice (pp.  155–​175). New  York, NY: Springer. Mayer, M.  K., Urlaub, D.  M., Guzman-​Corrales, L.  M., Kowitt, S.  D., Shea, C.  M., & Fisher, E. B. (2016). They’re doing something that actually no one else can do. Journal of Ambulatory Care Management, 39(1),  76–​86. Macdonald, S. J., & Deacon, L. (2015). “No sanctuary”: Missed opportunities in health and social services for homeless people with dyslexia? Social Work and Social Sciences Review, 17(3),  78–​93.

References  213 Madden, E.  F. (2015). Cultural health capital on the margins:  Cultural resources for navigating healthcare in communities with limited access. Social Science & Medicine, 133, 145–​152. McAlhaney, M. S., Ndungu, J., Mbugua, S., Waithera, C., Jowi, B., & Adam, M. (2016). Effects of a short training course and professional background on the job performance of community health extension workers in Kenya. Annals of Global Health, 82(3), 481. McCalmont, K., Norris, J., Garzon, A., Cisneros, R., Greene, H., Regino, L., . . . Kaufman, A. (2016). Search family medicine share links. Family Medicine, 48(4), 260–​264. McCoy, C.  E., Woo, R., Anderson, C., & Lotfipour, S.  (2016). Race-​related healthcare disparities among California workers: Public health considerations for immigration reform. The Journal of Emergency Medicine, 50(1), 159–​166. McDaniel, M.  M. (2016). Occupational stress and coping in community mental health workers. PhD dissertation, University of British Columbia, Vancouver, Canada. McDonough, A. M. (2013, November). Comprando rico y sano: Promoting health-​conscious shopping in Latino communities. Presented at the 141st APHA Annual Meeting and Exposition (November 2–​November 6, 2013). Boston, MA: APHA. McDonough, M., & Hernández, J. (2015). Advocacy tool kit: Giving a voice to community health workers. Washington, D.C.:  National Council of La Raza. http://​www. theskinnyblog.com/​handle/​123456789/​237 McLean, E., Habicht, L., & Foote, J. (2016). Perceptions of advance care planning among Latino adults in the community setting. Creative Nursing, 22(2), 106–​113. McPhail-​Bell, K., Bond, C., Brough, M., & Fredericks, B. (2016). “We don’t tell people what to do”:  Ethical practice and Indigenous health promotion. Health Promotion Journal of Australia, 26(3), 195–​199. Meagley, K., Schriver, B., Geary, R.  S., Fielding-​Miller, R., Stein, A.  D., Dunkle, K.  L., & Norris, S. A. (2016). The gender dimensions of social networks and help-​seeking behaviors of young adults in Soweto, South Africa. Global Health Action, 9. https://​ www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC4911713/​ Medhanyie, A. A., Spigt, M., Yebyo, H., Little, A., Tadesse, K., Dinant, G. J., & Blanco, R.  (2017). Quality of routine health data collected by health workers using smartphone at primary health care in Ethiopia. International Journal of Medical Informatics, 101,  9–​14. Mehay, A., & Meek, R. (2016). The development of a peer-​based approach for promoting prisoner health in an English male young offender institution. In L.  S. Abrams, E. Hughes, M. Inderbitzin, & R. Meek (Eds.), The voluntary sector in prisons (pp. 143–​ 170). New York, NY: Palgrave Macmillan. Mehta, S.  (2015). Assessing the influence of stigma and discrimination on barriers to health care access in transgender populations. Global Health:  Annual Review, 1(1). https://​journals.mcmaster.ca/​ghar/​article/​view/​1062 Melcher, K., Stiefel, B. L., & Faurest, K. (Eds.). (2017). Community-​built: Art, construction, preservation, and place. New York, NY: Routledge. Melnick, G.  A., Green, L., & Rich, J.  (2016). House calls:  California program for homebound patients reduces monthly spending, delivers meaningful care. Health Affairs, 35(1),  28–​35. Mendoza, M. D., & Lopez, M. (2017). Culture, race, and ethnicity issues in health care. In P.  M. Paulman, R.  B. Taylor, A.  A. Paulman, & L.  S. Nasir (Eds.), Family medicine: Principles and practice (pp. 27–​38). New York, NY: Springer.

214 References Menéndez, E. L. (2016). Salud intercultural: Propuestas, acciones y fracasos. Ciência & Saúde Coletiva, 21(1), 109–​118. Meng, L. (2015, November). Analysis of risk factors among Asian Undocumented families and potential solution based on a social-​ecological model. Presented at the 2015 APHA Annual Meeting & Expo (Oct. 31–​Nov. 4, 2015). APHA. Merchant, R. C., Clark, M. A., Santelices, C. A., Liu, T., & Cortés, D. E. (2015). Efficacy of an HIV/​AIDS and HIV testing video for Spanish-​speaking Latinos in healthcare and non-​healthcare settings. AIDS and Behavior, 19(3), 523–​535. Messias, D. K. H., McEwen, M. M., & Clark, L. (2015). The impact and implications of undocumented immigration on individual and collective health in the United States. Nursing Outlook, 63(1),  86–​94. Metzl, J.  M., & Hansen, H.  (2014). Structural competency:  Theorizing a new medical engagement with stigma and inequality. Social Science & Medicine, 103(February), 126–​133. Meyer, I. H., Teylan, M., & Schwartz, S. (2015). The role of help‐seeking in preventing suicide attempts among lesbians, gay men, and bisexuals. Suicide and Life-​Threatening Behavior, 45(1),  25–​36. Middlebrooks, J.  S., & Audage, N.  C. (2008). The effects of childhood stress on health across the lifespan. http://​-​equity.pitt.edu/​932/​ Mijovic, H., McKnight, J., & English, M. (2016). What does the literature tell us about health workers’ experiences of task‐shifting projects in sub‐Saharan Africa? A  systematic, qualitative review. Journal of Clinical Nursing, 25(15–​16), 2083–​2100. Miller, P., Bates, T., & Katzen, A.  (2014). Community health worker credentialing. Cambridge, MA:  Center for Health Law and Policy Innovation at Harvard Law School. www. chlpi. org/​wp-​content/​uplo ads/​2014/​06/​CHW-​Credentialing-​Paper. Miller, W.  C. (2015). Evaluation of a community health worker training program in rural Appalachia, USA. International Journal of Medicine, 3(1),  33–​37. Mills, A. (2014). Health care systems in low-​and middle-​income countries. New England Journal of Medicine, 370(6), 552–​557. Minkler, M., & Wallerstein, N. (Eds.). (2011). Community-​based participatory research for health: From process to outcomes. New York, NY: John Wiley & Sons. Mlotshwa, L., Harris, B., Schneider, H., & Moshabela, M. (2015). Exploring the perceptions and experiences of community health workers using role identity theory. Global Health Action, 8. http://​www.globalhealthaction.net/​index.php/​gha/​article/​view/​28045 Misra-​Hebert, A. D., Santurri, L., DeChant, R., Watts, B., Rothberg, M., Sehgal, A. R., & Aron, D. C. (2015). Understanding the health needs and barriers to seeking health care of veteran students in the community. Southern Medical Journal, 108(8), 488–​493. Mitchell, C. (2012). Doing visual research. Thousand Oaks, CA: Sage. Mitchell, M.  M., Maragh-​Bass, A.  C., Nguyen, T.  Q., Isenberg, S., & Knowlton, A.  R. (2016). The role of chronic pain and current substance use in predicting negative social support among disadvantaged persons living with HIV/​AIDS. AIDS Care, 28(10), 1280–​1286. Moffett, M. L., Kaufman, A., & Bazemore, A. (2018). Community health workers bring cost savings to patient-​ centered medical homes. Journal of Community Health, 43(1),  1–​3. Mogere, D.  M., Loum, C.  S., & Kaseje, D.  (2015). Increasing households’ access to healthcare; Linking clinicians to community health workers through counter referral comments. Value in Health, 18(3), A275.

References  215 Moimaz, S. A. S., Serrano, M. N., Garbin, C. A. S., Vanzo, K. L. T., & Saliba, O. (2017). Community health workers and breastfeeding: Challenges related to knowledge and practice. Revista CEFAC, 19(2), 198–​212. Molina, Y., McKell, M.  S., Mendoza, N., Barbour, L., Berrios, N.  M., Murray, K., & Ferrans, C. E. (2018). Health volunteerism and improved cancer health for Latina and African American women and their social networks: Potential mechanisms. Journal of Cancer Education, 33(1),  59–​66. Moore, A. A., Karno, M. P., Ray, L., Ramirez, K., Barenstein, V., Portillo, M. J., . . . del Pino, H.  E. (2016). Development and preliminary testing of a promotora-​ delivered, Spanish language, counseling intervention for heavy drinking among male, Latino day laborers. Journal of Substance Abuse Treatment, 62(March), 96–​101. Moore, A., Peele, P.  J., Simán, F.  M., & Earp, J.  A. (2012). Lay health advisors make connections for better health. NC Medical Journal, 73(5), 392–​393. Moore, S.  (2009, February 19). Hispanics are largest ethnic group in federal prisons, study shows. The New York Times, A16. Morenoff, J.  D., & Harding, D.  J. (2014). Incarceration, prisoner reentry, and communities. Annual Review of Sociology, 40(July), 411–​429. Morgan, A. U., Grande, D. T., Carter, T., Long, J. A., & Kangovi, S. (2016). Penn Center for Community Health Workers: Step-​by-​step approach to sustain an evidence-​based community health worker intervention at an academic medical center. American Journal of Public Health, 106(11), 1958–​1960. Morgan, K., Lee, J., & Sebar, B. (2015). Community health workers: A bridge to healthcare for people who inject drugs. International Journal of Drug Policy, 26(4), 380–​387. Morris, M. B., Chapula, B. T., Chi, B. H., Mwango, A., Chi, H. F., Mwanza, J., . . . Reid, S. E. (2009). Use of task-​shifting to rapidly scale-​up HIV treatment services: Experiences from Lusaka, Zambia. BMC Health Services Research, 9(1), 5. Morrison, H. M. (2017). Home visits—​service delivery in the natural environment. In E. A. Rhoades & J. Duncan (Eds.), Auditory-​verbal practice: Family-​centered early intervention (pp. 266–​279). New York, NY: Charles C. Thomas. Moya, E.  M., Chavez, S., Martinez, O., & Covernali, M.  (2015). Identification of health improvements through Photovoice and community health workers. http://​ digitalcommons.utep.edu/​social_​papers/​42/​ Moya, E.  M., Chávez-​ Baray, S.  M., Martínez, O., & Aguirre-​ Polanco, A.  (2016). Exploring intimate partner violence and sexual health needs in the southwestern United States: Perspectives from health and human services workers. Health & Social Work, 41(1), e29–​e37. Mullings, L., & Schulz, A.  J. (2006). Intersectionality and health:  An introduction. San Francisco, CA: Jossey-​Bass. Mullings, S.  J. (2014). Employment of ex-​offenders:  The time has come for a true antidiscrimination statute. Syracuse Law Review, 64, 261. Mundorf, C., Shankar, A., Peng, T., Hassan, A., & Lichtveld, M. Y. (2017). Therapeutic relationship and study adherence in a community health worker-​led intervention. Journal of Community Health, 42(1),  21–​29. Mundy-​McPherson, S.  (2016). Attitudes about gambling:  A Durkheimian perspective. http://​aut.researchgateway.ac.nz/​handle/​10292/​9554 Munn-​Giddings, C., & Winter, R. (2013). A handbook for action research in health and social care. New York, NY: Routledge.

216 References Munyaneza, F., Hirschhorn, L. R., Amoroso, C. L., Nyirazinyoye, L., Birru, E., Mugunga, J. C., . . . Ntaganira, J. (2014). Leveraging community health worker system to map a mountainous rural district in low resource setting:  A low-​cost approach to expand use of geographic information systems for public health. International Journal of Health Geographics, 13(1), 49. https://​ij-​healthgeographics.biomedcentral.com/​articles/​10.1186/​1476-​072X-​13-​49 Murayama, H., Spencer, M. S., Sinco, B. R., Palmisano, G., & Kieffer, E. C. (2017). Does racial/​ethnic identity influence the effectiveness of a community health worker intervention for African American and Latino adults with type 2 diabetes? Health Education & Behavior, 44(3), 485–​493. Muro, P., Enjuanes, J., Morata, T., & Palasí, E. (2016). Health promotion in a prison setting: Experience in Villabona prison. Health Education Journal, 75(6), 712–​720. Murray, K., Liang, A., Barnack-​Tavlaris, J., & Navarro, A. M. (2014). The reach and rationale for community health fairs. Journal of Cancer Education, 29(1),  19–​24. Murray, M., & Ziegler, F. (2015). The narrative psychology of community health workers. Journal of Health Psychology, 20(3), 338–​349. Murphy, J. M. (2015). Botánicas: Sacred spaces of healing and devotion in urban America. Oxford: University Press of Mississippi. Musoke, D., Ndejjo, R., Ekirapa-​Kiracho, E., & George, A. S. (2016). Supporting youth and community capacity through photovoice: Reflections on participatory research on maternal health in Wakiso district, Uganda. Global Public Health, 11(5–​6), 683–​698. Mutale, W., Ayles, H., Bond, V., Mwanamwenge, M.  T., & Balabanova, D.  (2013). Measuring health workers’ motivation in rural health facilities: Baseline results from three study districts in Zambia. Human Resources for Health, 11(1), 1. https://​human-​ resources-​health.biomedcentral.com/​articles/​10.1186/​1478-​4491-​11-​8 Mutamba, B.  B., van Ginneken, N., Paintain, L.  S., Wandiembe, S., & Schellenberg, D. (2013). Roles and effectiveness of lay community health workers in the prevention of mental, neurological and substance use disorders in low and middle income countries: A systematic review. BMC Health Services Research, 13(1), 1. Myers, M.  (2016). Health care for Hispanic immigrants:  Improving the accessibility and quality of preventive services. PhD dissertation, Baylor University, Waco, TX. Myers, N.  (2016). Democracy, rights, community:  Examining ethical frameworks for federal public health emergency response. Public Integrity, 18(2), 201–​226. Nading, A. M. (2013). Love isn’t there in your stomach. Medical Anthropology Quarterly, 27(1), 84–​102. Napier, A.  D., Ancarno, C., Butler, B., Calabrese, J., Chater, A., Chatterjee, H., . . . Macdonald, A. (2014). Culture and health. The Lancet, 384(9954), 1607–​1639. National Health Care for the Homeless Council. (2017). Integrating community health workers into primary care practice:  A resource guide for HCH programs. https://​ www.nhchc.org/​chw-​2-​section3/​ National Hispanic Council on Aging. (2012). State of Hispanic Oler adults: An analysis and highlights from the field. http://​www.nhcoa.org/​wp-​content/​uploads/​2012/​10/​ State-​of-​Hispanic-​Older-​Adults-​Brief-​2012-​.pdf National Hispanic Council on Aging. (2015). Latinos age 65 years and older to increase by 224%. Washington, D.C.: Author. National Institute of Drug Abuse. (2017a). Trends and statistics. https://​www.drugabuse. gov/​related-​topics/​trends-​statistics

References  217 National Institite of Drug Abuse. (2017b). DrugFacts treatment statistics. https://​www. drugabuse.gov/​publications/​drugfacts/​treatment-​statistics Nayer, G., Gallo, R., Amos, C., & Colas, J. (2015). Prison reentry programs: The key to stop the revolving door. Journal of Criminal Justice & Law Review, 4. Ndima, S.  D., Sidat, M., Give, C., Ormel, H., Kok, M.  C., & Taegtmeyer, M.  (2015). Supervision of community health workers in Mozambique:  A qualitative study of factors influencing motivation and programme implementation. Human Resources for Health, 13(1), 63. https://​human-​resources-​health.biomedcentral.com/​articles/​ 10.1186/​s12960-​015-​0063-​x Neale, J., & Brown, C.  (2015). “We are always in some form of contact”:  Friendships among homeless drug and alcohol users living in hostels. Health & Social Care in the Community, 24(5), 557–​566. Nebeker, C., Kalichman, M., Talavera, A., & Elder, J. (2015). Training in research ethics and standards for community health workers and promotores engaged in Latino health research. Hastings Center Report, 45(4),  20–​27. Nebeker, C., & López-​ Arenas, A.  (2016). Building research integrity and capacity (BRIC):  An educational initiative to increase research literacy among community health workers and promotores. Journal of Microbiology & Biology Education, 17(1),  41–​45. Nelson, C. A., Starr, J. A., Kugeler, K. J., & Mead, P. S. (2016). Lyme disease in Hispanics, United States, 2000–​2013. Emerging Infectious Diseases, 22(3), 522–​525. Nelson, H. (2014, November). Community health workers improving childhood asthma through home visiting across New England. Presented at the 142nd APHA Annual Meeting and Exposition (November 15–​ November 19, 2014). New Orleans, LA: APHA. Nelson, S., Money, E.  B., & Petersen, R.  (2016). Community health workers an integral part of an integrated health care team. North Carolina Medical Journal, 77(2), 129–​130. Nester, J. (2016). The importance of interprofessional practice and education in the era of accountable care. North Carolina Medical Journal, 77(2), 128–​132. Nguyen, A. L., Yan, T., Ell, K., Gonzalez, J., & Enguidanos, S. (2017). Care transitions among Latino diabetics: Barriers to study enrollment and transition care. Ethnicity & Health, 22(4), 361–​371. Nguyen-​Truong, C.  K. Y., Tang, J., & Hsiao, C.  Y. (2017). Community interactive research workshop series:  Community members engaged as team teachers to conduct research. Progress in Community Health Partnerships: Research, Education, and Action, 11(2), 215–​221. Nicdao, E. G., Duldulao, A. A., & Takeuchi, D. T. (2015). Psychological distress, nativity, and help-​seeking among Filipino Americans. In J.  J. Kronenfeld (Ed.), Education, social factors, and health beliefs in health and health care services (pp.  107–​120). Emerald Group. Nicholls, K., Picou, J. S., Curtis, J., & Lowman, J. A. (2015). The utility of community health workers in disaster preparedness, recovery, and resiliency. Journal of Applied Social Science, 9(2), 191–​202. Noguera, P., Cammarota, J., & Ginwright, S.  (2013). Beyond resistance! Youth activism and community change: New democratic possibilities for practice and policy for America’s youth. New York, NY: Routledge.

218 References Noonan, A. S., Velasco-​Mondragon, H. E., & Wagner, F. A. (2016). Improving the health of African Americans in the USA: An overdue opportunity for social justice. Public Health Reviews, 37(1), 12. https://​publichealthreviews.biomedcentral.com/​articles/​ 10.1186/​s40985-​016-​0025-​4 Nxumalo, N., Goudge, J., & Manderson, L.  (2016). Community health workers, recipients’ experiences and constraints to care in South Africa—​A pathway to trust. AIDS Care, 28(Suppl. 4), 61–​71—​ Nxumalo, N., Goudge, J., & Thomas, L.  (2013). Outreach services to improve access to health care in South Africa:  Lessons from three community health worker programmes. Global Health Action, 6(6), 219–​226. Ochoa, T. J., Chea-​Woo, E., Baiocchi, N., Pecho, I., Campos, M., Prada, A., . . . & Cleary, T. G. (2013). Randomized double-​blind controlled trial of bovine lactoferrin for prevention of diarrhea in children. The Journal of Pediatrics, 162(2), 349–​356. Oetzel, J.  G., & Minkler, M.  (2017). Community-​ based participatory research for health: Advancing social and health equity. New York, NY: John Wiley & Sons. Office of Minority Health. (2016). Asthma and Hispanic Americans. Washington, D.C.: Health and Human Services Administration. Okechukwu, C., Davison, K., & Emmons, K. (2014). Changing health behaviors in a social context. In L. F. Berkman, I. Kawachi, & M. Glymour (Eds.), Social epidemiology (2nd ed., 365–​384). New York, NY: Oxford University Press. Okello, A.  (2016). I am someone now. The impact of the Jamii Centers Project on the Community Health Promoters of Western Kenya. Utrecht, the Netherlands:  Utrecht University. Okoniewska, B., Santana, M. J., Groshaus, H., Stajkovic, S., Cowles, J., Chakrovorty, D., & Ghali, W. A. (2015). Barriers to discharge in an acute care medical teaching unit: a qualitative analysis of health providers’ perceptions. Journal of Multidisciplinary Healthcare, 8(1),  83–​89. Okoro, O., & Odedina, F.  T. (2016). Improving medication adherence in African-​ American women living with HIV/​AIDS: Leveraging the provider role and peer involvement. AIDS Care, 28(2), 179–​185. Olaniran, A., Smith, H., Unkels, R., Bar-​Zeev, S., & van den Broek, N. (2017). Who is a community health worker? A systematic review of definitions. Global Health Action, 10(1). http://​www.tandfonline.com/​doi/​abs/​10.1080/​16549716.2017.1272223 Olds, D. L., Holmberg, J. R., Donelan-​McCall, N., Luckey, D. W., Knudtson, M. D., & Robinson, J. (2014). Effects of home visits by paraprofessionals and by nurses on children: follow-​up of a randomized trial at ages 6 and 9 years. JAMA Pediatrics, 168(2), 114–​121. Olivares, J.  (2017, September 27). Fewer youths incarcerated, but gap between blacks and whites worsens. WBUR. http://​www.npr.org/​2017/​09/​27/​551864016/​ fewer-​youths-​incarcerated-​but-​gap-​between-​blacks-​and-​whites-​worsens Olivet, J., McGraw, S., Grandin, M., & Bassuk, E.  (2010). Staffing challenges and strategies for organizations serving individuals who have experienced chronic homelessness. The Journal of Behavioral Health Services & Research, 37(2), 226–​238. Ollove, M.  (2016, July 8). Under Affordable Care Act, growing use of “community health workers.” Stateline. The Pew Charitable Trusts. http://​ www.pewtrusts.org/​ e n/​ r esearch-​ a nd-​ a nalysis/ ​ b logs/ ​ s tateline/ ​ 2 016/ ​ 0 7/ ​ 0 8/​ under-​affordable-​care-​act-​growing-​use-​of-​community-​health-​workers

References  219 Ong-​ Flaherty, C., Valencia-​ Garcia, D., Martinez, D.  A., Borges, W., & Summers, L.  (2017). Effectiveness of gaming in creating cultural awareness. Learning, Culture and Social Interaction. http://​www.sciencedirect.com/​science/​article/​pii/​ S221065611630126X Omelas, I. J., Allen, C., Vaughan, C., Williams, E. C., & Negi, N. (2015). Vida PURA: A cultural adaptation of screening and brief intervention to reduce unhealthy drinking among Latino day laborers. Substance Abuse, 36(3), 264–​271. Ortega-​Vélez, M.  I., Rosales, C., Gallegos, P.  A., Paniagua, A.  D. C., Valdez, L., De Zapien, J. (2016). Developing a network of community health workers: Improving the lives of migrant farmworkers. Open Journal of Social Sciences, 4(10), 140. Oshiro, M.  (2016). Within the shadows:  The qualitative experiences of undocumented youth. PhD dissertation, University of California Los Angeles, California. Ospina, J.  E., Orcau, À., Millet, J.  P., Sánchez, F., Casals, M., & Caylà, J.  A. (2012). Community health workers improve contact tracing among immigrants with tuberculosis in Barcelona. BMC Public Health, 12(1), 158. Otiniano, A.  D., Carroll-​Scott, A., Toy, P., & Wallace, S.  P. (2012). Supporting Latino communities’ natural helpers:  A case study of promotoras in a research capacity building course. Journal of Immigrant and Minority Health, 14(4), 657–​663. Ozano, K., & Khatri, R.  (2018). Reflexivity, positionality and power in cross-​cultural participatory action research with research assistants in rural Cambodia. Educational Action Research, 26(2), 190–​204. Ozawa, S., & Sripad, P. (2013). How do you measure trust in the health system? A systematic review of the literature. Social Science & Medicine, 91,  10–​14. Ozer, E. J. (2017). Youth‐led participatory action research: Overview and potential for enhancing adolescent development. Child Development Perspectives, 11(3), 173–​177. Pallas, S. W., Minhas, D., Pérez-​Escamilla, R., Taylor, L., Curry, L., & Bradley, E. H. (2013). Community health workers in low-​and middle-​income countries: What do we know about scaling up and sustainability? American Journal of Public Health, 103(7), e74–​e82. Palmer, B.  J. (2017). The crossroads:  Being black, immigrant, and undocumented in the era of# BlackLivesMatter. Georgetown Journal of Law & Modern Critical Race Perspectives, 9,  99–​99. Palmer, J., Pocock, C., & Burton, L.  (2017). Waiting, power and time in ethnographic and community-​based research. Qualitative Research, 14(4), 416–​432. Palmer, N. R., Weaver, K. E., Hauser, S. P., Lawrence, J. A., Talton, J., Case, L. D., & Geiger, A. M. (2015). Disparities in barriers to follow-​up care between African American and white breast cancer survivors. Supportive Care in Cancer, 23(11), 3201–​3209. Palmisano, G.  (2014, November). IDecide/​Decido Decision Aid:  The role of community health workers in the development and delivery of a tailored, interactive, web-​based decision aid to low-​income Latino and African American adults with poorly controlled type 2 diabetes who received care at a federally qualified health center in Detroit. Presented at the 142nd APHA Annual Meeting and Exposition (November 15–​November 19, 2014). New Orleans, LA: APHA. Panjrath, G.  S., Bostrom, L., Al-​Saleh, Q., Robie, S., Baute, S., Rhein, M., & Katz, R.  (2016). Community health workers reduce readmissions in a high risk heart failure population. Journal of the American College of Cardiology, 67(13S), 1434–​1434.

220 References Park, P. H., Wambui, C. K., Atieno, S., Egger, J. R., Misoi, L., Nyabundi, J. S., . . . Kamano, J. H. (2015). Improving diabetes management and cardiovascular risk factors through peer-​led self-​management support groups in Western Kenya. Diabetes Care, 38(8), e110–​e111. Parker, C., Stanback, J., Finger, B., Shaukat, F., Naeem, Z., Ahmed, Z., . . . Newton, L.  (2013). Injectable contraception provided by community-​ based health workers:  One important step toward meeting unmet need [editorial]. Global Health: Science and Practice, 1(3), 287–​288. Patel, K., Boutwell, A., Brockmann, B. W., & Rich, J. D. (2014). Integrating correctional and community health care for formerly incarcerated people who are eligible for Medicaid. Health Affairs, 33(3), 468–​473. Patten, E.  (2016, April 16). The nation’s Latino population is defined by its youth. Washington, D.C.: Pew Research Center. Patten, R., La Rue, E., Caudill, J.  W., Thomas, M.  O., & Messer, S.  (2018). Come and knock on our door: Offenders’ perspectives on home visits through ecological theory. International Journal of Offender Therapy and Comparative Criminology, 62(3), 717–​738. Patton, G. C., Sawyer, S. M., Santelli, J. S., Ross, D. A., Afifi, R., Allen, N. B., . . . Kakuma, R. (2016). Our future: A Lancet commission on adolescent health and wellbeing. The Lancet, 387(10036), 2423–​2478. Payne, H., Arredondo, V., West, J. H., Neiger, B., & Hall, C. (2015). Use and acceptance of social media among community health workers. Journal of Community Medicine & Health Education. http://​www.omicsonline.org/​open-​access/​use-​and-​acceptance-​ of- ​ s ocial- ​ m edia- ​ a mong- ​ c ommunity- ​ h ealth-​ w orkers-​ 2 376-​ 0 214-​ 1 000354. php?aid=54751 Payne, J., Razi, S., Emery, K., Quattrone, W., & Tardif-​Douglin, M. (2017). Integrating community health workers (CHWs) into health care organizations. Journal of Community Health, 42(5), 983–​990. Paz, K., & Massey, K.  P. (2016). Health disparity among Latina women:  Comparison with non-​Latina women. Clinical medicine insights. Women’s Health, 9(Suppl 1), 71–​74. Peak, S. A., Hanson, E. J., Eadeh, F. R., & Lambert, A. J. (2016). On the light versus dark side of empathy: Implications for intergroup dynamics in a diverse society. In H. T. Frierson (Ed.), The crisis of race in higher education: A day of discovery and dialogue (pp. 153–​176). Sommerville, MA.: Emerald Group. Pederson, A.  P. (2016). Sex, gender and health promotion:  Assessing the potential for health promotion interventions to address health and gender inequities. PhD dissertation, University of British Columbia, Vancouver, B.C., Canada. Pedraza, F. I., & Zhu, L. (2015). Immigration enforcement and the “chilling effect” on Latino Medicaid enrollment. http://​healthpolicyscholars.org/​sites/​healthpolicyscholars.org/​ files/​pedrazazhu_​m edicaid.pdf Pelicand, J., Fournier, C., Le Rhun, A., & Aujoulat, I.  (2015). Self‐care support in paediatric patients with type 1 diabetes: Bridging the gap between patient education and health promotion? A review. Health Expectations, 18(3), 303–​311. Pellegrino, E. D. (1983). What is a profession? Journal of Allied Health, 12(3), 168–​176. Peretz, P.  J., Matiz, L.  A., Findley, S., Lizardo, M., Evans, D., & McCord, M.  (2012). Community health workers as drivers of a successful community-​based disease management initiative. American Journal of Public Health, 102(8), 1443–​1446.

References  221 Perez-​Escamilla, R., & Melgar-​Quinonez, H.  (Eds.) (2011). At risk:  Latino children’s health. Houston, TX: Arte Publico Press. Perez, G., Della Valle, P., Paraghamian, S., Page, R., Ochoa, J., Palomo, F., . . . Corbie-​ Smith, G. (2015). A community-​engaged research approach to improve mental health among Latina immigrants ALMA Photovoice. Health Promotion Practice, 17(3), 429–​439. Pérez, L. M., & Martinez, J. (2008). Community health workers: Social justice and policy advocates for community health and well-​being. American Journal of Public Health, 98(1),  11–​14. Pérez, M. A., & Luquis, R. R. (2013). Cultural competence in health education and health promotion. New York, NY: John Wiley & Sons. Pérez-​Pena, R.  (2003, November 6). Hair styling, plus cancer education:  Brooklyn Health project goes where the women are: Under the dryer. The New York Times, A28. Perry, H., & Zulliger, R. (2012). How effective are community health workers. An overview of current evidence with recommendations for strengthening community health worker programs to accelerate progress in achieving the health-​related Millennium Development Goals. Baltimore, MD: Johns Hopkins Bloomberg School of Public Health. Perry, H. B., Dhillon, R. S., Liu, A., Chitnis, K., Panjabi, R., Palazuelos, D., . . . Nyenswah, T.  (2016). Community health worker programmes after the 2013–​2016 Ebola outbreak. Bulletiin of the World Health Organization, 94, 551–​553. Perry, H. B., Zulliger, R., & Rogers, M. M. (2014). Community health workers in low-​, middle-​, and high-​income countries: An overview of their history, recent evolution, and current effectiveness. Annual Review of Public Health, 35(March), 399–​421. Pharr, J., & Chino, M. (2013). Barriers to health care for people with disabilities and practice administrators’ knowledge of the ADA: Nevada compared with the nation. https://​ works.bepress.com/​jennifer_​pharr/​11/​ Philbin, S. P., & Ayón, C. (2016). Luchamos por nuestros hijos: Latino immigrant parents strive to protect their children from the deleterious effects of anti-​immigration policies. Children and Youth Services Review, 63, 128–​135. Philbin, M. M., Flake, M., Hatzenbuehler, M. L., & Hirsch, J. S. (2018). State-​level immigration and immigrant-​focused policies as drivers of Latino health disparities in the United States. Social Science & Medicine, 199(Feb.), 29–​38. file://​/​C:/​Users/​delgado/​ Downloads/​State-​level%20policy%20and%20Latino%20Health_​Philbin_​PAA%20 2017.pdf Phuka, J., Maleta, K., Thomas, M., & Gladstone, M. (2014). A job analysis of community health workers in the context of integrated nutrition and early child development. Annals of the New York Academy of Sciences, 1308(1), 183–​191. Pinho, A.  C., & Gonçalves, E.  (2016). Are amyotrophic lateral sclerosis caregivers at higher risk for health problems?. Acta Médica Portuguesa, 29(1),  56–​62. Pink, S. (2007). Doing visual ethnography. Thousand Oaks, CA: Sage. Pinto, R. M., da Silva, S. B., & Soriano, R. (2012). Community health workers in Brazil’s unified health system: A framework of their praxis and contributions to patient health behaviors. Social Science & Medicine, 74(6), 940–​947. Pittman, M., Sunderland, A., Broderick, A., & Barnett, K. (2015). Bringing community health workers into the mainstream of US health care. Washington, DC:  Institute of Medicine of the National Academies. Plough, A.  L. (2014). Building a culture of health. American Journal of Preventive Medicine, 47(5), S388–​S390.

222 References Plowden, K.  O., Adams, L.  T., & Wiley, D.  (2016). Black and blue:  Depression and African American men. Archives of Psychiatric Nursing, 30(5), 630–​635. Pobutsky, A., Cuaresma, C., Kishaba, G., Noble, C., Leung, E., Castillo, E., & Villafuerte, A. (2015). The social, cultural and behavioral determinants of health among Hawaii Filipinos:  The Filipino Healthy Communities Project. California Journal of Health Promotion, 13(1),  1–​12. Pocock, L., & Sutton, J. (2015). Health needs of prisoners. InnovAiT, 8(1),  24–​29. Poole, J., Rife, J., Moore, W., & Pearson, F. (2016). The congregational social work education initiative: Toward a vision for community health through religious tradition and philanthropy. Religions, 7(6), 62. http://​www.mdpi.com/​2077-​1444/​7/​6/​62/​htm Poteat, T., Wirtz, A.  L., Radix, A., Borquez, A., Silva-​ Santisteban, A., Deutsch, M. B., . . . Operario, D. (2015). HIV risk and preventive interventions in transgender women sex workers. The Lancet, 385(9964), 274–​286. Powell, T.  (2015, November). Supporting community health workers after a disaster:  Findings from a mixed-​ methods evaluation study. Presented at the 143rd APHA Annual Meeting and Exposition (October 31–​November 4, 2015). Chicago, IL: APHA. Powell, W., Adams, L.  B., Cole-​ Lewis, Y., Agyemang, A., & Upton, R.  D. (2016). Masculinity and race-​related factors as barriers to health help-​seeking among African American men. Behavioral Medicine, 42(3), 150–​163. Power, E. M., Little, M. H., & Collins, P. A. (2015). Should Canadian health promoters support a food stamp-​style program to address food insecurity? Health Promotion International, 30(1), 184–​193. Power, R.  (2013). Implications of employing drug users as indigenous fieldworkers. In M. Bolton (Ed.), Challenge & innovation: Methodological advances on HIV/​AIDS (pp. 97–​110. New York, NY: Routledge. Pozgar, G.  D. (2014). Legal and ethical issues for health professionals. Burlington, MA: Jones & Bartlett. Prentiss, T., Tamler, I., Plum, A., Parke, D., Zervos, J., Tanniru, M., . . . Kaljee, L. (2017, January). Community health workers as innovators: Methods and results from a tele-​ education pilot for community health workers in Detroit, Michigan. In Proceedings of the 50th Hawaii International Conference on System Sciences. Prezio, E.  A., Cheng, D., Balasubramanian, B.  A., Shuval, K., Kendzor, D.  E., & Culica, D.  (2013). Community Diabetes Education (CoDE) for uninsured Mexican Americans: A randomized controlled trial of a culturally tailored diabetes education and management program led by a community health worker. Diabetes Research and Clinical Practice, 100(1),  19–​28. Price, J. H., & Khubchandani, J. (2016). Health education research and practice literature on Hispanic health issues have we lost sight of the largest minority population? Health Promotion Practice, 17(2), 172–​176. Primero, M. S. E. (2015). My health comes first. Washington, D.C.: National Council of La Raza. http://​peersforprogress.org/​wp-​content/​uploads/​2015/​04/​150421-​mi-​salud-​ es-​primero-​program-​guide.pdf Probst, J. C., Barker, J. C., Enders, A., & Gardiner, P. (2018). Current state of child health in rural America: How context shapes children’s health. The Journal of Rural Health, 34(51), s3–​s12. Prüll, L.  (2016). The self-image of transident women since 1945. Journal of Health & Culture, 1(1). https://​w ww.researchgate.net/​profile/​Ilhan_​Ilkilic/​publication/​

References  223 304785506_​New_​Journal_​Journal_​of_​Health_​and_​Culture_​Vol_​1_​Issue_​1_​2016/​ links/​577b633408a ece6c20fbed7a.pdf Purnell, L.  D. (2012). Transcultural health care:  A culturally competent approach. Philadelpia, PA: FA Davis. Purnell, T.  S., Calhoun, E.  A., Golden, S.  H., Halladay, J.  R., Krok-​Schoen, J.  L., Appelhans, B. M., & Cooper, L. A. (2016). Achieving health equity: Closing the gaps in health care disparities, interventions, and research. Health Affairs, 35(8), 1410–​1415. Purtilo, R. B., & Doherty, R. F. (2015). Ethical dimensions in the health professions (6th ed.). St. Louis, MO: Elsevier Health Sciences. Purvis, R.  S., Bing, W.  I., Jacob, C.  J., Lang, S., Mamis, S., Ritok, M., . . . McElfish, P.  A. (2017). Community health warriors:  Marshallese community health workers’ perceptions and experiences with CBPR and community engagement. Progress in Community Health Partnerships:  Research, Education, and Action, 11(3), 315–​320. Quick, J. C., Gatchel, R. J., & Cooper, C. L. (2015). Health and wellbeing. In J. Michie & C. Copper (Eds.), Why the social sciences matter (pp. 30–​44). London, UK: Palgrave Macmillan UK. Quinton, S.  (2017, April 19). Matching ex-​offenders with hard-​to-​fill health care jobs. Philadelphia, PA:  Pew Charitable Trust. http://​www.pewtrusts.org/​en/​research-​ and-​ a nalysis/​ b logs/ ​ s tateline/ ​ 2 017/ ​ 0 4/ ​ 1 9/ ​ m atching-​ e x-​ o ffenders-​ w ith-​ h ard​to-​fill-​health-​care-​jobs Rachlis, B., Naanyu, V., Wachira, J., Genberg, B., Koech, B., Kamene, R., . . . Braitstein, P. (2016). Community perceptions of community health workers (CHWs) and their roles in management for HIV, tuberculosis and hypertension in Western Kenya. PloS One, 11(2), e0149412. Ramanadhan, S., Nagler, R.  H., McCauley, M.  P., Lora, V., Minsky, S., Bruff, C., . . . Viswanath, K.  (2016). Much ventured, much gained:  Community-​ engaged data collection by adolescents and young adults. Progress in Community Health Partnerships: Research, Education, and Action, 10(2), 217–​224. Raphael-​Greenfield, E. I., & Gutman, S. A. (2015). Understanding the lived experience of formerly homeless adults as they transition to supportive housing. Occupational Therapy in Mental Health, 31(1),  35–​49. Rapkin, B. (2015). The role of community health workers in implementing community-​ oriented primary and preventive services across the life span. In E.  Mpofu (Ed.), Community-​ oriented health services. Practices across disciplines (pp.  87–​116). New York, NY: Springer. Rashid, M., Caine, V., & Goez, H.  (2015). The encounters and challenges of ethnography as a methodology in health research. International Journal of Qualitative Methods, 14(5). Rasoal, D., Kihlgren, A., & Skovdahl, K.  (2017). Balancing different expectations in ethically difficult situations while providing community home health care services:  A focused ethnographic approach. http://​www.diva-​portal.org/​smash/​record. jsf?pid=diva2%3A1094939&dswid=-​8765 Rauscher, K.  J., & Myers, D.  J. (2016). Occupational fatalities among young workers in the United States:  2001–​2012. American Journal of Industrial Medicine, 59(6), 445–​452. Read, M.  (2013). Culture, health and disease:  Social and cultural influences on health programmes in developing countries. New York, NY: Routledge.

224 References Reardon, S.  (2017). Health toll of immigration policies begins to emerge. Nature.com https://​www.nature.com/​polopoly_​fs/​1.21812.1492101960!/​menu/​main/​topColum ns/​topLeftColumn/​pdf/​544148a.pdf?origin=ppub Redelsheimer, C.  L., Boldenow, R., & Marshall, P.  (2015). Adding value to the profession: The role of accreditation. Journal of Forestry, 113(6), 566–​570. Redfield, R., Linton, R., & Herskovits, M. J. (1936). Memorandum for the study of acculturation. American Anthropologist, 38(1), 149–​152. Rein, M.  (1969). Social planning:  The search for legitimacy. Journal of the American Institute of Planners, 35(4), 233–​244. Reinschmidt, K. M., Ingram, M., Schachter, K., Sabo, S., Verdugo, L., & Carvajal, S.  (2015). The impact of integrating community advocacy into community health worker roles on health-​focused organizations and community health workers in Southern Arizona. The Journal of Ambulatory Care Management, 38(3), 244–​2 53. Remster, B.  (2013). Invisible men:  A longitudinal analysis of homelessness among ex-​ inmates. PhD dissertation, The Pennsylvania State University, State College, PA. Repper, J., Aldridge, B., Gilfoyle, S., Gillard, S., Perkins, R., & Rennison, J. (2013). Peer support workers:  Theory and practice. London, UK:  Centre for Mental Health and Mental Health Network, NHS Confederation. Rhodes, D., Visker, J., Cox, C., Banez, J. C., & Wang, A. (2017). Level of integration of community health workers in Missouri health systems. Journal of Community Health, 42(3), 598–​604. Rich, J.  D., Chandler, R., Williams, B.  A., Dumont, D., Wang, E.  A., Taxman, F. S., . . . Osher, F. C. (2014). How health care reform can transform the health of criminal justice–​involved individuals. Health Affairs, 33(3), 462–​467. Riegelman, R., & Wilson, C.  (2016). Community colleges and public health new opportunities for health education. Pedagogy in Health Promotion, 2(1),  16–​19. Rifkin, S.  B. (2014). Examining the links between community participation and health outcomes:  A review of the literature. Health Policy and Planning, 29 (Suppl.  2), ii98–​ii106. Rincon, A.  (2009). Practicing cultural humility. In T.  Berthold, J.  Miller, & A.  Avila-​ Esparza (Eds.), Foundations for community health workers (pp.  135–​ 154). San Francisco, CA: Jossey-​Bass. Ring, J., Nyquist, J., & Mitchell, S.  (2016). Curriculum for culturally responsive health care:  The step-​ by-​ step guide for cultural competence training. Boca Raton, FL: CRC Press. Rios, V.  (2016). Frontline workers:  Urban solutions for developing a sustainable workforce in the homeless services sector of Los Angeles County. PhD dissertation, Antioch University, Los Angeles, CA. Rios-​Ellis, B., Garcia-​Vega, M., Frank, G., Gatdula, N., & Galvez, G. (2014). Comienzo sano: Familia saludable. In V. M. Brennan, S. K. Kumanyika, & R. E. Zambrana (Eds.), Obesity interventions in underserved communities: Evidence and directions (pp. 255–​ 262). Baltimore, MD: The Johns Hopkins University Press. Rios-​ Ellis, B., Nguyen-​ Rodriguez, S.  T., Espinoza, L., Galvez, G., & Garcia-​ Vega, M. (2015). Engaging community with promotores de salud to support infant nutrition and breastfeeding among Latinas residing in Los Angeles County:  Salud con Hyland’s. Health Care for Women International, 36(6), 711–​729.

References  225 Rivero, E.  (2015, February 10). Rate of Latino physicians shrinks, even as Latino population wells. UCLA Newsroom. http://​newsroom.ucla.edu/​releases/​ rate-​of-​latino-​physicians-​shrinks-​even-​as-​latino-​population-​swells Robert Woods Johnson Foundation. (2016). Columbia George region, Oregon and Washington RWJF 2016 Culture of Health Prize Winner. Princeton, NJ: RWJF. Roberts, S. K. (2015). Aging in prison: Reducing elder incarceration and promoting public safety. New York: Center for Justice, Columbia University. Roberts, T. K., & Fantz, C. R. (2014). Barriers to quality health care for the transgender population. Clinical Biochemistry, 47(10), 983–​987. Robinson, J. (2015). Community health workers: Bridging the gap between the examination room and the shelter. The Journal of Ambulatory Care Management, 38(3), 211–​212. Robinson, M., Raine, G., Robertson, S., Steen, M., & Day, R. (2015). Peer support as a resilience building practice with men. Journal of Public Mental Health, 14(4), 196–​204. Robles, F. (2018, February 14). Meth, closer and deadlier, is surging back. The New York Times, A1, A12. Rodgers, M.  A., Grisso, J.  A., Crits-​Christoph, P., & Rhodes, K.  V. (2017). No quick fixes:  A mixed methods feasibility study of an urban community health worker outreach program for intimate partner violence. Violence Against Women, 23(1), 287–​308. Rodríguez, D. C., & Peterson, L. A. (2016). A retrospective review of the Honduras AIN-​ C program guided by a community health worker performance logic model. Human Resources for Health, 14(1), 1.  https://​human-​resources-​health.biomedcentral.com/​ articles/​10.1186/​s12960-​016-​0115-​x Rodríguez, J. E., Campbell, K. M., & Pololi, L. H. (2015). Addressing disparities in academic medicine: What of the minority tax? BMC Medical Education, 1, 1. Rodríguez, Y.  R. D., Casanova, C.  A. R., & Rodríguez, M.  D. C.  P. (2016). Activades para desarrollar la responsabilidad sexual y estilo de vida saludables en los jovenes, Márgenes, 3. Roessler, R. T., Rumrill Jr, P. D., Li, J., Daly, K., & Anhalt, K. (2016). High-​priority employment concerns of Hispanics/​Latinos with multiple sclerosis in the United States. Journal of Vocational Rehabilitation, 45(2), 121–​131. Rogers, E.  A., Manser, S.  T., Cleary, J., Joseph, A.  M., Harwood, E.  M., & Call, K.  T. (2018). Integrating community health workers into medical homes. The Annals of Family Medicine, 16(1),  14–​20. Rojas, E., Gerber, B.  S., Tilton, J., Rapacki, L., & Sharp, L.  K. (2015). Pharmacists’ perspectives on collaborating with community health workers in diabetes care. Journal of the American Pharmacists Association, 55(4), 429–​433. Rollins, A. L., Kukla, M., Morse, G., Davis, L., Leiter, M., Monroe-​DeVita, M., . . . Collins, L. (2016). Comparative effectiveness of a burnout reduction intervention for behavioral health providers. Psychiatric Services. https://​ps.psychiatryonline.org/​doi/​abs/​ 10.1176/​appi.ps.201500220 Rosenfield, S., & Mouzon, D. (2013). Gender and mental health. In C. A. Aneshensel, J. C. Phelan, & A. Bierman (Eds.), Handbook of the sociology of mental health (pp. 277–​ 296). Rotterdam, Netherlands: Springer Netherlands. Rosenthal, E.  L. (2009). The evolution of the CHW field in the United States:  The shoulders we stand on. In T. Berthold, J. Miller, & A. Avila-​Esparza (Eds.), Foundations for community health workers (pp. 23–​44). San Francisco, CA: Jossey-​Bass.

226 References Rosenthal, E. L., & Brownstein, J. N. (2016). The shoulders we stand on. Foundations for community health workers. New York, NY: John Wiley & Sons. Rosenthal, E. L., Brownstein, J. N., Rush, C. H., Hirsch, G. R., Willaert, A. M., Scott, J. R., & Fox, D. J. (2010). Community health workers: Part of the solution. Health Affairs, 29(7), 1338–​1342. Rosenthal, E.  L., Wiggins, N., Brownstein, J.  N., Johnson, S., Borbon, J.  A., Rael, R., . . . Blomder, L. (1998). The final report of the National Community Health Advisor Study: Weaving the future. Tucson: University of Arizona and Annie E. Casey Foundation. Roth, B. J., & Allard, S. W. (2016). (Re)defining access to Latino immigrant-​serving organizations:  Evidence from Los Angeles, Chicago, and Washington, DC. Journal of the Society for Social Work and Research, 7(4), 729–​753. Rothschild, S. K., Martin, M. A., Swider, S. M., Tumialán Lynas, C. M., Janssen, I., Avery, E. F., & Powell, L. H. (2014). Mexican American trial of community health workers: A randomized controlled trial of a community health worker intervention for Mexican Americans with type 2 diabetes mellitus. American Journal of Public Health, 104(8), 1540–​1548. Rowan, K., McAlpine, D. D., & Blewett, L. A. (2013). Access and cost barriers to mental health care, by insurance status, 1999–​2010. Health Affairs, 32(10), 1723–​1730. Rowe, M., Styron, T., & David, D. H. (2016). Mental health outreach to persons who are homeless: Implications for practice from a statewide study. Community Mental Health Journal, 52(1),  56–​65. Ruano, A. L., Hernández, A., Dahlblom, K., Hurtig, A. K., & Sebastián, M. S. (2012). It’s the sense of responsibility that keeps you going’: Stories and experiences of participation from rural community health workers in Guatemala. Archives of Public Health, 70(1),  1–​8. Rubero, G.  (2015). Let those who have been there guide reentry. In S.  K. Roberts. Aging in prison: Reducing elder incarceration and promoting public safety (pp. 59–​61). New York, NY: Center for Justice, Columbia University. Ruotsalainen, J. H., Verbeek, J. H., Mariné, A., & Serra, C. (2015). Preventing occupational stress in healthcare workers. The Cochrane Library. http://​onlinelibrary.wiley. com/​doi/​10.1002/​14651858.CD002892.pub5/​pdf Rush, C.  H. (2012). Return on investment from employment of community health workers. The Journal of Ambulatory Care Management, 35(2), 133–​137. Ryan, J.  P., Choi, S., Hong, J.  S., Hernandez, P., & Larrison, C.  R. (2008). Recovery coaches and substance exposed births: An experiment in child welfare. Child Abuse & Neglect, 32(11), 1072–​1079. Sabo, S. (2015, November). Impact of community health workers (CHW) in the primary health care setting. Presented at the 143rd APHA Annual Meeting and Exposition (October 31–​November 4, 2015). Chicago, IL: APHA. Sabo, S., Allen, C.  G., Sutkowi, K., & Wennerstrom, A.  (2017). Community health workers in the United States: Challenges in identifying, surveying, and supporting the workforce. American Journal of Public Health, 107(12),  e1–​e6. Sabo, S., Ingram, M., Reinschmidt, K. M., Schachter, K., Jacobs, L., Guernsey de Zapien, J., . . . Carvajal, S.  (2013). Predictors and a framework for fostering community advocacy as a community health worker core function to eliminate health disparities. American Journal of Public Health, 103(7), e67–​e73.

References  227 Sabo, S., Wennerstrom, A., Phillips, D., Haywoord, C., Redondo, F., Bell, M.  L., & Ingram, M.  (2015). Community health worker professional advocacy. Journal of Ambulatory Care Management, 38(3), 225–​235. Sahebihagh, M. H., Hosseini, S. Z., Hosseinzadeh, M., & Shamshirgaran, S. M. (2017). Knowledge, attitude and practice of community health workers regarding child abuse in Tabriz Health Centers in 2015–​2016. International Journal of Community Based Nursing and Midwifery, 5(3), 264–​274. Sairenji, T., Wilson, S. A., D’Amico, F., & Peterson, L. E. (2016). Training family medicine residents to perform home visits: A CERA survey. Journal of Graduate Medical Education. http://​dx.doi.org/​10.4300/​JGME-​D-​16-​00249.1 Salvy, S. J., Haye, K., Galama, T., & Goran, M. I. (2017). Home visitation programs: An untapped opportunity for the delivery of early childhood obesity prevention. Obesity Reviews, 18(2), 149–​163. Salyers, M.  P., Rollins, A.  L., Kelly, Y.  F., Lysaker, P.  H., & Williams, J.  R. (2013). Job satisfaction and burnout among VA and community mental health workers. Administration and Policy in Mental Health and Mental Health Services Research, 40(2),  69–​75. San Miguel, S. L., Ayala-​Marín, A., Briant, K. J., Desai, N., Gatus, L., Gómez-​Aristizabal, D., . . . Ortiz, R. (2016). Abstract A31: National outreach network community health educators: An effective framework to reduce cancer health disparities among Latinos. Cancer Epidemiology Biomarkers & Prevention, 25(3 Supplement), A31–​A31. Sanchez, K., Ybarra, R., Chapa, T., & Martinez, O.  N. (2015). Eliminating behavioral health disparities and improving outcomes for racial and ethnic minority. Psychiatric Services, 67(1),  13–​15. Sanders, M.  (Ed.). (2016). Substance use disorders in African American communities: Prevention, treatment and recovery. New York, NY: Routledge. Sanders, S. J., & Stover, G. N. (2011). Community health workers—​practice and promise. American Journal of Public Health, 101(12), 2198–​2199. Sanjari, M., Bahramnezhad, F., Fomani, F.  K., Shoghi, M., & Cheraghi, M.  A. (2014). Ethical challenges of researchers in qualitative studies: The necessity to develop a specific guideline. Journal of Medical Ethics and History of Medicine, 7–​14. https://​www. ncbi.nlm.nih.gov/​pmc/​articles/​Pmc4263394/​ Sanou, A.  K., Jegede, A.  S., Nsungwa-​Sabiiti, J., Siribié, M., Ajayi, I.  O., Turinde, A., . . . Kyaligonza, J. (2016). Motivation of community health workers in diagnosing, treating, and referring sick young children in a multicountry study. Clinical Infectious Diseases, 63(suppl_​5), S270–​S275. Sarin, E., & Lunsford, S.  S. (2017). How female community health workers navigate work challenges and why there are still gaps in their performance:  A look at female community health workers in maternal and child health in two Indian districts through a reciprocal determinism framework. Human Resources for Health, 15(1), 44. https://​human-​resources-​health.biomedcentral.com/​articles/​10.1186/​ s12960-​017-​0222-​3 Sarin, E., Lunsford, S. S., Sooden, A., Rai, S., & Livesley, N. (2016). The mixed nature of incentives for community health workers: Lessons from a qualitative study in two districts in India. Frontiers in Public Health, 4. http://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC4789362/​

228 References Sassenrath, C., Pfattheicher, S., & Keller, J.  (2017). I  might ease your pain, but only if you’re sad: The impact of the empathized emotion in the empathy-​helping association. Motivation and Emotion, 41(1), 96–​106. Save the Children. (2011). Health workers reach index. 2011. http://​www.savethechildren. org.uk/​sites/​default/​files/​docs/​HealthWorkerIndexmain_​4.pdf Schachter, K. A., Ingram, M., Jacobs, L., Hafter, H., Guernsey De Zapien, J., & Carvajal, S.  (2014). Developing an action learning community advocacy/​leadership training program for community health workers and their agencies to reduce health disparities in Arizona border communities. Journal of Health Disparities Research and Practice, 7(2), 3. http://​digitalscholarship.unlv.edu/​jhdrp/​vol7/​iss2/​3/​ Schmidt, B., Campbell, S., & McDermott, R.  (2015). Community health workers as chronic care coordinators: Evaluation of an Australian Indigenous primary health care program. Australian and New Zealand Journal of Public Health, 40(S1), S107–​S114. Schneider, H., Hlophe, H., & van Rensburg, D. (2008). Community health workers and the response to HIV/​AIDS in South Africa: Tensions and prospects. Health Policy and Planning, 23(3), 179–​187. Schneider, H., & Lehmann, U. (2016). From community health workers to community health systems: Time to widen the horizon? Health Systems & Reform, 2(2), 112–​118. Schoenberg, N. E., Ciciurkaite, G., & Greenwood, M. K. (2017). Community to clinic navigation to improve diabetes outcomes. Preventive Medicine Reports, 5,  75–​81. Schubert, K. (2015). Building a culture of health: Promoting healthy relationships and reducing teen dating violence. Journal of Adolescent Health, 56(2),  S3–​S4. Shulman, C., Hudson, B. F., Low, J., Hewett, N., Daley, J., Kennedy, P., . . . Stone, P. (2018). End-​of-​life care for homeless people: A qualitative analysis exploring the challenges to access and provision of palliative care. Palliative Medicine, 32(1),  36–​45. Schwingel, A., Wiley, A.  R., Teran-​Garcia, M., McCaffrey, J., Gálvez, P., & Vizcarra, M.  (2017). Promotoras and the semantic gap between Latino community health researchers and Latino communities. Health Promotion Practice, 18(3), 444–​453. Scorgie, F., Nakato, D., Harper, E., Richter, M., Maseko, S., Nare, P., . . . Chersich, M. (2013). “We are despised in the hospitals”: Sex workers’ experiences of accessing health care in four African countries. Culture, Health & Sexuality, 15(4), 450–​465. Seelye, K.  Q. (2018, January 21). One son, six hours, four overdoses. The New  York Times, 1, 20. Segura-​Pérez, S., Balcazar, H., & Morel, K.  (2011). Impact of promotores de salud on pregnancy and child health outcomes. In R. Pérez-​Escamilla & H. Melgar-​Quiñonez (Eds.), At risk: Latino children’s health (pp. 39–​63). Houston, TX: Arte Público Press. Semien, D.  S. (2013). The diversity of re-​entry social. Race, Gender & Class, 20(3/​4), 205–​225. Seo, J. Y., Bae, S. H., & Dickerson, S. S. (2016). Korean immigrant women’s health care utilization in the United States: A systematic review of literature. Asia-​Pacific Journal of Public Health, 28(2), 107–​133. Serrata, J.  V., Hernandez-​Martinez, M., & Macias, R.  L. (2016). Self-​empowerment of immigrant Latina survivors of domestic violence: A promotora model of community leadership. Hispanic Health Care International, 14(1),  37–​46. Shah, M., Heisler, M., & Davis, M. (2014). Community health workers and the Patient Protection and Affordable Care Act:  An opportunity for a research, advocacy, and policy agenda. Journal of Health Care for the Poor and Underserved, 25(1),  17–​24.

References  229 Shaw, G. (2015). Community health workers bridge gap to hearing loss treatment. The Hearing Journal, 68(5),  8–​10. Shelton, R. C., Dunston, S. K., Leoce, N., Jandorf, L., Thompson, H. S., Crookes, D. M., & Erwin, D.  O. (2016). Predictors of activity level and retention among African American lay health advisors (LHAs) from The National Witness Project: Implications for the implementation and sustainability of community-​based LHA programs from a longitudinal study. Implementation Science, 11(1), 1. https://​implementationscience. biomedcentral.com/​articles/​10.1186/​s13012-​016-​0403-​9 Shelton, R. C., Dunston, S. K., Leoce, N., Jandorf, L., Thompson, H. S., & Erwin, D. O. (2017). Advancing understanding of the characteristics and capacity of African American women who serve as lay health advisors in community-​based settings. Health Education & Behavior, 44(1), 153–​164. Shepherd-​Banigan, M., Hohl, S. D., Vaughan, C., Ibarra, G., Carosso, E., & Thompson, B.  (2014). “The promotora explained everything” Participant experiences during a household-​level diabetes education program. The Diabetes Educator, 40(4), 507–​515. Shin, J.  K., Poltavskiy, E., Kim, T.  N., Hasan, A., & Bang, H.  (2017). Help-​seeking behaviors for serious psychological distress among individuals with diabetes mellitus:  The California Health Interview Survey, 2011–​2012. Primary Care Diabetes, 11(1),  63–​70. Shippee, N. D., Shippee, T. P., Hess, E. P., & Beebe, T. J. (2014). An observational study of emergency department utilization among enrollees of Minnesota Health Care Programs:  Financial and non-​financial barriers have different associations. BMC Health Services Research, 14(1), 1. Shishehgar, S., Gholizadeh, L., DiGiacomo, M., Green, A., & Davidson, P.  M. (2017). Health and socio-​cultural experiences of refugee women:  An integrative review. Journal of Immigrant and Minority Health, 19(4), 959–​973. Shommu, N. S., Ahmed, S., Rumana, N., Barron, G. R., McBrien, K. A., & Turin, T. C. (2016). What is the scope of improving immigrant and ethnic minority healthcare using community navigators: A systematic scoping review. International Journal for Equity in Health, 15(1), 6. https://​equityhealthj.biomedcentral.com/​articles/​10.1186/​ s12939-​016-​0298-​8 Shortell, S. M. (2013). Bridging the divide between health and health care. Journal of the American Medical Association, 309(11), 1121–​1122. Shulman, C., Hudson, B. F., Low, J., Hewett, N., Daley, J., Kennedy, P., . . . Stone, P. (2018). End-​of-​life care for homeless people: A qualitative analysis exploring the challenges to access and provision of palliative care. Palliative Medicine, 32(1),  36–​45. Shumskiy, I., Raju, R. M., & Tschudy, M. M. (2016). Home visits: Advancing pediatric training by preserving past traditions. Pediatrics, 138(3), e20162015. Siantz, E., Henwood, B., & Gilmer, T. (2016). Implementation of peer providers in integrated mental health and primary care settings. Journal of the Society for Social Work and Research, 7(2). https://​www.journals.uchicago.edu/​doi/​abs/​10.1086/​686644 Siemon, M., & Mendelson, C.  (2012). Perceptions of certification and standardization of training of community health workers among health care professionals and social workers in New Mexico. https://​works.bepress.com/​mark_​siemon/​1/​ Siemon, M., Shuster, G., & Boursaw, B. (2015). The impact of state certification of community health workers on team climate among registered nurses in the United States. Journal of Community Health, 40(2), 215–​221.

230 References Silva, R., Amouzou, A., Munos, M., Marsh, A., Hazel, E., Victora, C., . . . RMM Working Group. (2016). Can community health workers report accurately on births and deaths? Results of field assessments in Ethiopia, Malawi and Mali. PloS One, 11(1), e0144662. Simonsen, S.  E., Ralls, B., Guymon, A., Garrett, T., Eisenman, P., Villalta, J., . . . Hayes, S.  (2017). Addressing health disparities from within the community:  Community-​ based participatory research and community health worker policy initiatives using a gender-​based approach. Women’s Health Issues, 27, S46–​S53. Singer, A., Svajlenka, N.  P., & Wilson, J.  H. (2015). Local insights from DACA for implementing future programs for unauthorized immigrants. Washington, D.C.: Brookings Institute. Singer, M.  K. (2012). Applying the concept of culture to reduce health disparities through health behavior research. Preventive Medicine, 55(5), 356–​361. Singer, M.  K., Dressler, W., George, S., Baquet, C.  R., Bell, R.  A., Burhansstipanov, L., . . . Gravlee, C. C. (2016). Culture. Social Science and Medicine, 170, 237–​246. Singh, D., Cumming, R., & Negin, J. (2015). Acceptability and trust of community health workers offering maternal and newborn health education in rural Uganda. Health Education Research, 30(6), 947–​958. Singh, D., Cumming, R., Mohajer, N., & Negin, J.  (2016). Motivation of community health volunteers in rural Uganda: The interconnectedness of knowledge, relationship and action. Public Health (July), 166–​171. Singh, D., Negin, J., Orach, C. G., & Cumming, R. (2016). Supportive supervision for volunteers to deliver reproductive health education:  A cluster randomized trial. Reproductive Health, 13(1), 126. Singh, P., & Chokshi, D.  A. (2013). Community health workers—​a local solution to a global problem. New England Journal of Medicine, 369(10), 894–​896. Singh, P., & Sachs, J.  D. (2013). 1  million community health workers in sub-​Saharan Africa by 2015. The Lancet, 382(9889), 363–​365. Sips, I., Mazanderani, A.  H., Schneider, H., Greeff, M., Barten, F., & Moshabela, M.  (2014). Community care workers, poor referral networks and consumption of personal resources in rural South Africa. PloS one, 9 (4), e95324. Slesnick, N., Feng, X., Guo, X., Brakenhoff, B., Carmona, J., Murnan, A., . . . McRee, A. L. (2016). A test of outreach and drop-​in linkage versus shelter linkage for connecting homeless youth to services. Prevention Science, 17(4), 450–​460. Smith, S., Deveridge, A., Berman, J., Negin, J., Mwambene, N., Chingaipe, E., . . . Martiniuk, A.  (2014). Task-​shifting and prioritization:  A situational analysis examining the role and experiences of community health workers in Malawi. Human Resources for Health, 12(1), 24. https://​human-​resources-​health.biomedcentral.com/​ articles/​10.1186/​1478-​4491-​12-​24 Smith, S.  A., & Blumenthal, D.  S. (2012). Community health workers support community-​based participatory research ethics: Lessons learned along the research-​ to-​practice-​to-​community continuum. Journal of Health Care for the Poor and Underserved, 23(4 Suppl.), 77–​87. Smith, V.  C., & Jemal, A.  (2015). Addressing the health of formerly imprisoned persons in a distressed neighborhood through a community collaborative board. Health Promotion Practice, 16(5), 733–​744. Smylie, J., Kirst, M., McShane, K., Firestone, M., Wolfe, S., & O’Campo, P.  (2016). Understanding the role of Indigenous community participation in Indigenous

References  231 prenatal and infant-​toddler health promotion programs in Canada: A realist review. Social Science & Medicine, 150 (Feb.), 128–​143. Snyder, S. M., Hartinger-​Saunders, R., Brezina, T., Beck, E., Wright, E. R., Forge, N., & Bride, B. E. (2016). Homeless youth, strain, and justice system involvement: An application of general strain theory. Children and Youth Services Review, 62,  90–​96. Sobo, E. J. (2016). Culture and meaning in health services research: An applied approach. New York, NY: Routledge. Socías, M.  E., Shoveller, J., Bean, C., Nguyen, P., Montaner, J., & Shannon, K.  (2016). Universal coverage without universal access:  Institutional barriers to health care among women sex workers in Vancouver, Canada. PloS One, 11(5), e0155828. Sokan, A. E., & Davis, T. (2016). Immigrant LGBT elders. In D. A. Harley & P. B. Teaster (Eds.), Handbook of LGBT elders (pp. 261–​284). New York, NY: Springer International Publishing. Sokol, R., & Fisher, E. (2016). Peer support for the hardly reached: A systematic review. American Journal of Public Health, 106(7),  e1–​e8. Sommers, B.  D. (2015). Health care reform’s unfinished work—​remaining barriers to coverage and access. New England Journal of Medicine, 373(25), 2395–​2397. Soofi, S., Ariff, S., Sadiq, K., Habib, A., Bhatti, Z., Ahmad, I., . . . Bhutta, Z.  A. (2017). Evaluation of the uptake and impact of neonatal vitamin A supplementation delivered through the Lady Health Worker programme on neonatal and infant morbidity and mortality in rural Pakistan:  An effectiveness trial. Archives of Disease in Childhood, 102(3), 216–​223. Somsanith, D. (2009). The role of CHWs. In T. Berthold, J. Miller, & A. Avila-​Esparza (Eds.), Foundations for community health workers (pp.  4–​ 22). San Francisco, CA: Jossey-​Bass. Sorkin, D.  H., Murphy, M., Nguyen, H., & Biegler, K.  A. (2016). Barriers to mental health care for an ethnically and racially diverse sample of older adults. Journal of the American Geriatrics Society, 64(10), 2138–​2143. Sosa, E.  T., Biediger-​Friedman, L., & Yin, Z.  (2013). Lessons learned from training of promotores de salud for obesity and diabetes prevention. Journal of Health Disparities Research and Practice, 6(1), 1. http://​digitalscholarship.unlv.edu/​jhdrp/​vol6/​iss1/​1/​ South, J., Bagnall, A., Hulme, C., Woodall, J., Longo, R., Dixey, R., . . . Wright, J. (2014). A  systematic review of the effectiveness and cost-​ effectiveness of peer-​ based interventions to maintain and improve offender health in prison settings. Health Services and Delivery Research, 2(35). http://​eprints.leedsbeckett.ac.uk/​1015/​2/​ FullReport-​hsdr02350.pdf South, J., Kinsella, K., & Meah, A. (2012). Lay perspectives on lay health worker roles, boundaries and participation within three UK community-​based health promotion projects. Health Education Research, 27(4), 656–​670. South, J., Meah, A., & Branney, P. E. (2012). “Think differently and be prepared to demonstrate trust”: Findings from public hearings, England, on supporting lay people in public health roles. Health Promotion International, 27(2), 284–​294. Spencer, G. (2016). “Troubling” moments in health promotion: Unpacking the ethics of empowerment. Health Promotion Journal of Australia, 26(3), 205–​209. Spencer, M. S., Gunter, K. E., & Palmisano, G. (2010). Community health workers and their value to social work. Social Work, 55(2), 169–​180. Sprague-​Martinez, L. S., Reich, A. J., Flores, C. A., Ndukue, U. J., Brugge, D., Gute, D. M., & Perea, F. C. (2017). Critical discourse, applied inquiry and public health action with

232 References urban middle school students:  Lessons learned engaging youth in critical service-​ learning. Journal of Community Practice, 25(1),  68–​89. Sprague Martinez, L., Reisner, E., Campbell, M., & Brugge, D.  (2017). Participatory democracy, community organizing and the Community Assessment of Freeway Exposure and Health (CAFEH) partnership. International Journal of Environmental Research and Public Health, 14(2), 149. http://​www.mdpi.com/​1660-​4601/​14/​2/​149/​ htm Sprague Martinez, L., Richards-​Schuster, K., Teixeira, S., & Augsberger, A. (2018). The power of prevention and youth voice:  A strategy for social work to ensure youths’ healthy development. Social Work, 63(2), 135–​143. Squires, A., & O’Brien, M.  J. (2012). Becoming a promotora a transformative process for female community health workers. Hispanic Journal of Behavioral Sciences, 34(3), 457–​473. Stacciarini, J. M. R., Rosa, A., Ortiz, M., Munari, D. B., Uicab, G., & Balam, M. (2012). Promotoras in mental health: A review of English, Spanish, and Portuguese literature. Family & Community Health, 35(2), 92–​102. Stanczak, G.  C. (2007). Visual research methods:  Image, society, and representation. Thousand Oaks, CA: Sage. Standing, H., & Chowdhury, A. M. R. (2008). Producing effective knowledge agents in a pluralistic environment: What future for community health workers? Social Science & Medicine, 66(10), 2096–​2107. Steers, P.  A. (2012). The corrections health system and continuity of care for former inmates. https://​research.libraries.wsu.edu/​xmlui/​handle/​2376/​3698 Steen, R. M. (2014, November). Dientes Fuertes, Vida Sana: A culturally competent program to prevent primary tooth decay in low-​income Latino children. Presented at the 142nd APHA Annual Meeting and Exposition (November 15–​November 19, 2014). New Orleans, LA: APHA. Steinberg, E.  M., Valenzuela-​ Araujo, D., Zickafoose, J.  S., Kieffer, E., & DeCamp, L.  R. (2016). The “battle” of managing language barriers in health C=care. Clinical Pediatrics, 55(14), 1318–​1327. Stelzig, D. (2015, November). Community Health Worker Reimbursements: Implementing Federal Policy at State Level. In 143rd APHA Annual Meeting and Expo (Oct. 31-​Nov. 4, 2015). APHA., Chicago, IL. Stone, B. (2015). The Future of Prison Radio: Does inmate-​produced media have a place in the American prison system? (Thesis, University of Oregon, Eugene, OR.). https://​ scholarsbank.uoregon.edu/​xmlui/​handle/​1794/​19107 Stone, J. R., & Parham, G. P. (2007). An ethical framework for community health workers and related institutions. Family & Community Health, 30(4), 351–​363. Story, L., & To, Y.  M. (2016). Evaluating Community Health Advisor (CHA) Core Competencies: The CHA Core Competency Retrospective Pretest/​Posttest (CCCRP). Journal of Transcultural Nursing, 27(3), 218–​225. Strachan, D.  L., Källander, K., Nakirunda, M., Ndima, S., Muiambo, A., & Hill, Z.  (2015). Using theory and formative research to design interventions to improve community health worker motivation, retention and performance in Mozambique and Uganda. Human Resources for Health, 13(1), 25. https://​human-​resources-​health. biomedcentral.com/​articles/​10.1186/​s12960-​015-​0020-​8 Strachan, D. L., Källander, K., ten Asbroek, A. H., Kirkwood, B., Meek, S. R., Benton, L.,  .  .  .  Hill, Z.  (2012). Interventions to improve motivation and retention of

References  233 community health workers delivering integrated community case management (iCCM):  Stakeholder perceptions and priorities. The American Journal of Tropical Medicine and Hygiene, 87 (5 Suppl), 111–​119. Strang, H., & Braithwaite, J.  (Eds.). (2017). Restorative justice:  Philosophy to practice. New York, NY: Routledge. Subtirelu, M., Rincon-​Subtirelu, M., Pickett, M., & Heath, G. W. (2014). Promoting active living and healthy eating among inner-​city youth through community health workers: From clinic to neighborhood. Health, 6(17), 2342–​2347. Suarez, N., Mendoza, I., Garrett, S., Scarinci, I., & Ellerbeck, E.  F. (2012). Success of “Promotores de Salud” in identifying immigrant Latino smokers and developing quit plans. International Public Health Journal, 4(3), 343–​353. Subramoney, S.  (2016). The effects of racial group membership and cognitive load on empathy and helping behavior. PhD dissertation, University of Cape Town, South Africa. Subtirelu, M., Rincon-​Subtirelu, M., Pickett, M., & Heath, G. W. (2014). Promoting active living and healthy eating among inner-​city youth through community health workers: From clinic to neighborhood. Health, 6(17), 2342. Sue, S., Cheng, J. K. Y., Saad, C. S., & Chu, J. P. (2012). Asian American mental health: A call to action. American Psychologist, 67(7), 532–​544. Suiter, S. V. (2017). Community health needs assessment and action planning in seven Dominican bateyes. Evaluation and Program Planning, 60, 103–​111. Sullivan, J.  E., & Zayas, L.  E. (2013). Passport biopsies:  Hospital deportations and implications for social work. Social Work, 58(3), 281–​284. Sun, W.  H., Miu, H.  Y. H., Wong, C.  K. H., Tucker, J.  D., & Wong, W.  C. W.  (2018). Assessing participation and effectiveness of the peer-​led approach in youth sexual health education: Systematic review and meta-​analysis in more developed countries. The Journal of Sex Research, 55(1),  31–​44. Surgeon General. (2014). Quite heroes. Public Health Reports, 129(6), 470–​471. Suther, S., Battle, A.  M., Battle-​ Jones, F., & Seaborn, C.  (2016). Utilizing health ambassadors to improve type 2 diabetes and cardiovascular disease outcomes in Gadsden County, Florida. Evaluation and Program Planning, 55 (April), 17–​26. Sutton, M. Y., & Parks, C. P. (2013). HIV/​AIDS prevention, faith, and spirituality among black/​African American and Latino communities in the United States: Strengthening scientific faith-​based efforts to shift the course of the epidemic and reduce HIV-​ related health disparities. Journal of Religion and Health, 52(2), 514–​530. Svan, Y. (2015). Takes one to know one? An evaluation of peer mentoring in the drug dependency treatment sector. Howard League of Prison Reform:  ECAN Bulletin, 27,  30–​31. Swanberg, J. E., Clouser, J. M., Bush, A., & Westneat, S. (2016). From the horse worker’s mouth: A detailed account of injuries experienced by Latino horse workers. Journal of Immigrant and Minority Health, 18(3), 513–​521. Swartz, A., & Colvin, C.  J. (2015). “It’s in our veins”:  Caring natures and material motivations of community health workers in contexts of economic marginalisation. Critical Public Health, 25(2), 139–​152. Syed, S. T., Gerber, B. S., & Sharp, L. K. (2013). Traveling towards disease: Transportation barriers to health care access. Journal of Community Health, 38(5), 976–​993. Synder, J. E. (2016). Community health workers: Roles and opportunities in health care delivery system reform. https://​aspe.hhs.gov/​sites/​default/​files/​pdf/​168956/​CHWPolicy.pdf

234 References Takasugi, T., & Lee, A.  C. K.  (2012). Why do community health workers volunteer? A qualitative study in Kenya. Public Health, 126 (10), 839–​845. Tanaka, K. (2014). Advanced marginalization and re-​criminalization of undocumented workers in the U.S. In R.  Rinehart, K.  Barbour, & C.  Pope (Eds.), Ethnographic worldviews (pp. 39–​48). Dordrecht, the Netherlands: Springer. Tang, T.  S., Funnell, M., Sinco, B., Piatt, G., Palmisano, G., Spencer, M.  S., . . . Heisler, M. (2014). Comparative effectiveness of peer leaders and community health workers in diabetes self-​ management support:  Results of a randomized controlled trial. Diabetes Care, 37(6), 1525–​1534. Tapestry Health. (Undated). About Us. Florence, Massachusetts. https://​www.idealist. org/​en/​nonprofit/​bcaf412b38964038b03e654f3d3074b7-​ tapestry-​health-​florence Tarp, H.  C., Fore, M.  E., Nies, M.  A., & Febles, C.  G. (2017). What does it mean to be healthy? Hispanics in the Southeastern Idaho agricultural industry. Journal of Immigrant and Minority Health, 19(5), 1253–​1255. Tavernise, S.  (2012, September 11). Door to door in the heartland, preaching healthy living. The New York Times (Science Times), D1, D6. Tavernise, S. (2018, June 21). Whites a minority in the U.S.? The transion is accelerating. The New York Times, A1, A9. Taylor, B., Mathers, J., & Parry, J. (2018). Who are community health workers and what do they do? Development of an empirically derived reporting taxonomy. Journal of Public Health, 40(1), 198–​209. Taylor, B., Mathers, J., & Parry, J. (2019). A conceptual framework for understanding the mechanism of action of community health workers services: The centrality of social support. Journal of Public Health, 41(1), 138–​148. Teitel, Y.  H. (2016). Medical and mental health needs of unaccompanied, undocumented adolescents in New York City: A qualitative, interview-​based study. Journal of Adolescent Health, 58(2), S44–​S45. Teixeira, S., & Gardner, R. (2017). Youth-​led participatory photo mapping to understand urban environments. Children and Youth Services Review, 82, 246–​253. Tejeda, S., Gallardo, R. I., Ferrans, C. E., & Rauscher, G. H. (2017). Breast cancer delay in Latinas: The role of cultural beliefs and acculturation. Journal of Behavioral Medicine, 40(2), 343–​351. Telleen, S., Kim, R., Young, O., Chavez, N., Barrett, R. E., Hall, W., & Gajendra, S. (2012). Access to oral health services for urban low‐income Latino children: Social ecological influences. Journal of Public Health Dentistry, 72(1),  8–​18. Terpstra, J., Coleman, K.  J., Simon, G., & Nebeker, C.  (2011). The role of community health workers (CHWs) in health promotion research: Ethical challenges and practical solutions. Health Promotion Practice, 12(1),  86–​93. Tervalon, M., & Murray-​ Garcia, J.  (1998). Cultural humility versus cultural competence:  A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9(2), 117–​125. Thom, D.  H., Ghorob, A., Hessler, D., De Vore, D., Chen, E., & Bodenheimer, T.  A. (2013). Impact of peer health coaching on glycemic control in low-​income patients with diabetes: A randomized controlled trial. The Annals of Family Medicine, 11(2), 137–​144. Thomas, D. S., Anthamatten, P., Root, E. D., Lucero, M., Nohynek, H., Tallo, V., . . . Simões, E. A. (2015). Disease mapping for informing targeted health interventions: Childhood

References  235 pneumonia in Bohol, Philippines. Tropical Medicine & International Health, 20(11), 1525–​1533. Thomas, E. G., Spittal, M. J., Heffernan, E. B., Taxman, F. S., Alati, R., & Kinner, S. A. (2016). Trajectories of psychological distress after prison release:  Implications for mental health service need in ex-​prisoners. Psychological Medicine, 46(3), 611–​621. Thompson, J.  (2017). Urban youth homelessness:  The role that past trauma has upon housing instability. St. Catherine University University of St. Thomas, School of Social Work. http://​sophia.stkate.edu/​cgi/​viewcontent.cgi?article=1802&context=msw_​ papers Thompson, N. (2016). Anti-​discriminatory practice: Equality, diversity and social justice. New York, NY: Palgrave Macmillan. Toledo, P. (2014, April 30). The US needs more Hispanic medical students. Northwestern Medical News. http://​www.northwestern.edu/​newscenter/​stories/​2014/​04/​opinion-​ quartz-​toledo-​hispanic-​medical-​students.html Torres, J. M., & Young, M. E. D. (2016). A life-​course perspective on legal status stratification and health. SSM-​Population Health, 2, 141–​148. Torres, S., Balcázar, H., Rosenthal, L.  E., Labonté, R., Fox, D., & Chiu, Y.  (2018). Community health workers in Canada and the US: Working from the margins to address health equity. Critical Public Health, 27(5), 533–​540. Torres, S., Spitzer, D. L., Labonté, R., Amaratunga, C., & Andrew, C. (2013). Community health workers in Canada: Innovative approaches to health promotion outreach and community development among immigrant and refugee populations. The Journal of Ambulatory Care Management, 36(4), 305–​318. Torri, M.  C. (2014). Micro-​ entrepreneurship programs and sexual health prevention among sex workers in Cambodia: Is an integrative approach the way forward? International Journal of Health Promotion and Education, 52(3), 153–​162. Tosone, C., Nuttman-​Shwartz, O., & Stephens, T. (2012). Shared trauma: When the professional is personal. Clinical Social Work Journal, 40(2), 231–​239. Tourangeau, A. E., Patterson, E., Saari, M., Thomson, H., & Cranley, L. (2017). Work-​ related factors influencing home care nurse intent to remain employed. Health Care Management Review, 42(1),  87–​97. Tovar, A. (2015, November). Community health workers: Research, education, and advocacy. Experience of the field in the context of Community-​based Participatory Research Projects. Presented at the 143rd APHA Annual Meeting and Exposition (October 31–​ November 4, 2015). Chicago, IL: APHA. Transitions Clinic. (2015, December 27). Post prison health workers/​ California Association of Community Health Workers. http://​www.cachw.org/​1623-​2/​ Trejo, G., Arcury, T. A., Grzywacz, J. G., Tapia, J., & Quandt, S. A. (2013). Barriers and facilitators for promotoras’ success in delivering pesticide safety education to Latino farmworker families: La familia sana. Journal of Agromedicine, 18(2),  75–​86. Tremblay, M. C., Martin, D. H., Macaulay, A. C., & Pluye, P. (2017). Can we build on social movement theories to develop and improve community‐based participatory research? A  framework synthesis review. American Journal of Community Psychology, 59(3–​4), 333–​362. Trinh, T.  A., & Le, T.  P. L.  (2016). Motorcycle helmet usage among children passengers: Role of parents as promoter. Procedia Engineering, 142(1),  10–​17. Tripathi, A., Kabra, S. K., Sachdev, H. P. S., & Lodha, R. (2016). Home visits by community health workers to improve identification of serious illness and care seeking

236 References in newborns and young infants from low-​and middle-​income countries. Journal of Perinatology, 36(1), S74–​S82. Tripathy, J. P., Goel, S., & Kumar, A. M. (2016). Measuring and understanding motivation among community health workers in rural health facilities in India—​a mixed method study. BMC Health Services Research, 16(1), 366. Trujillo, M.  D., & Plough, A.  (2016). Building a culture of health:  A new framework and measures for health and health care in America. Social Science & Medicine, 165 (September), 206–​213. Tsai, J., Kasprow, W. J., Kane, V., & Rosenheck, R. A. (2014). Street outreach and other forms of engagement with literally homeless veterans. Journal of Health Care for the Poor and Underserved, 25(2), 694–​704. Tsai, J., O’toole, T., & Kearney, L. K. (2017). Homelessness as a public mental health and social problem: New knowledge and solutions. Psychological Services, 14(2), 113–​117. Tsai, J., & Rosenheck, R.  A. (2012). Incarceration among chronically homeless adults:  Clinical correlates and outcomes. Journal of Forensic Psychology Practice, 12(4), 307–​324. Tsai, J., Rosenheck, R. A., Kasprow, W. J., & McGuire, J. F. (2014). Homelessness in a national sample of incarcerated veterans in state and federal prisons. Administration and Policy in Mental Health and Mental Health Services Research, 41(3), 360–​367. Tsoh, J.  Y., Sentell, T., Gildengorin, G., Le, G.  M., Chan, E., Fung, L.  C., . . . Burke, A. (2016). Healthcare communication barriers and self-​rated health in older Chinese American immigrants. Journal of Community Health, 41(4), 741–​752. Tulenko, K., Mgedal, S., Afzal, M.  M., Frymus, D., Oshin, A., Pate, M., . . . Zodpey, S. (2013). Community health workers for universal health-​care coverage: From fragmentation to synergy. Bulletin of the World Health Organization, 91(11), 847–​852. Tumusiime, D. K., Agaba, G., Kyomuhangi, T., Finch, J., Kabakyenga, J., & MacLeod, S. (2014). Introduction of mobile phones for use by volunteer community health workers in support of integrated community case management in Bushenyi District, Uganda: Development and implementation process. BMC Health Services Research, 14(Suppl 1), S2. Twamley, K., Craig, F., Kelly, P., Hollowell, D.  R., Mendoza, P., & Bluebond-​Langner, M.  (2014). Underlying barriers to referral to paediatric palliative care services: Knowledge and attitudes of health care professionals in a paediatric tertiary care centre in the United Kingdom. Journal of Child Health Care, 18(1),  19–​30. Twombly, E. C., Holtz, K. D., & Stringer, K. (2012). Using promotores programs to improve Latino health outcomes:  Implementation challenges for community-​ based nonprofit organizations. Journal of Social Service Research, 38(3), 305–​312. Ulibarri, M.  D., Roesch, S., Rangel, M.  G., Staines, H., Amaro, H., & Strathdee, S.  A. (2015). “Amar te duele” (“Love hurts”):  Sexual relationship power, intimate partner violence, depression symptoms and HIV risk among female sex workers who use drugs and their non-​commercial, steady partners in Mexico. AIDS and Behavior, 19(1),  9–​18. Unger, J. B., Cabassa, L. J., Molina, G. B., Contreras, S., & Baron, M. (2013). Evaluation of a fotonovela to increase depression knowledge and reduce stigma among Hispanic adults. Journal of Immigrant and Minority Health, 15(2), 398–​406. Urrutia-​Rojas, X., & Luna-​Hollen, M.  (2012). Community health workers. In S.  Loue & M.  Sajatovic (Eds.), Encyclopedia of immigrant health (pp.  470–​473). New  York, NY: Springer.

References  237 US Department of Health and Human Services. (2017). 2016 National Healthcare Quality and Disparities Report Agency for Healthcare Rsearch and Quality. Rockville, MD: Author. US Department of Labor. (2015). Occupational Employment and Wages, May 2015 21–​ 1094 Community Health Workers. Washington, D.C.: Author. Uwemedimo, O. T., Monterrey, A. C., & Linton, J. M. (2017). A Dream Deferred: Ending DACA Threatens Children, Families, and Communities. Pediatrics, e20173089. Valdiserri, R., Khalsa, J., Dan, C., Holmberg, S., Zibbell, J., Holtzman, D., . . . & Compton, W. (2014). Confronting the emerging epidemic of HCV infection among young injection drug users. American Journal of Public Health, 104(5), 816–​821. Valentine, P. (2010). Peer-​based recovery support services within a recovery community organization: The CCAR experience. In J. F. Kelley & W. L. White (Eds.), Addiction recovery management (pp. 259–​279). New York, NY: Humana Press. Valera, P., Boyas, J. F., Bernal, C., Chiongbian, V. B., Chang, Y., & Shelton, R. C. (2018). A validation of the group-​based medical mistrust scale in formerly incarcerated black and Latino Men. American Journal of Men’s Health, 12(4), 844–​850. Van Boekel, L. C., Brouwers, E. P., Van Weeghel, J., & Garretsen, H. F. (2013). Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery:  Systematic review. Drug and Alcohol Dependence, 131(1),  23–​35. van Heerden, A., Harris, D.  M., van Rooyen, H., Barnabas, R.  V., Ramanathan, N., Ngcobo, N., . . . Comulada, W. S. (2017). Perceived mHealth barriers and benefits for home-​based HIV testing and counseling and other care:  Qualitative findings from health officials, community health workers, and persons living with HIV in South Africa. Social Science & Medicine, 183, 97–​105. Van Wormer, R.  T. (2012). Risk factors for homelessness among community mental health patients with severe mental illness. PhD dissertation, Portland State University, Portland, OR. Vandebroek, I., Balick, M. J., Yukes, J., Durán, L., Kronenberg, F., Wade, C., . . . Robineau, L. (2007). Use of medicinal plants by Dominican immigrants in New York City for the treatment of common health conditions. A  comparative analysis with literature data from the Dominican Republic.Traveling Cultures and Plants. In A.  Pieroni & I.  Vanderbroek (Eds.), The ethnobiology and ethnopharmacy of human migrations (pp. 39–​64). New York, NY: Berghahn Books. Vargas, E. D., & Ybarra, V. D. (2017). US citizen children of undocumented parents: The link between state immigration policy and the health of Latino children. Journal of Immigrant and Minority Health, 19(4), 913–​920. Vargas, R. (2016). How health navigators legitimize the Affordable Care Act to the uninsured poor. Social Science & Medicine, 165 (September), 263–​270. Vaughan, K., Kok, M. C., Witter, S., & Dieleman, M. (2015). Costs and cost-​effectiveness of community health workers:  Evidence from a literature review. Human Resources for Health, 13(1), 71. http://​human-​resources-​health.biomedcentral.com/​articles/​ 10.1186/​s12960-​015-​0070-​y Vaughn, L.  M., Jacquez, F., Lindquist-​Grantz, R., Parsons, A., & Melink, K.  (2016a). Immigrants as research partners:  A review of immigrants in community-​based participatory research (CBPR). Journal of Immigrant and Minority Health, 19, 1457–​1468.

238 References Vaughn, L.  M., Jacquez, F., Marschner, D., & McLinden, D.  (2016b). See what we say:  Using concept mapping to visualize Latino immigrant’s strategies for health interventions. International Journal of Public Health, 61(7), 837–​845. Vaz, M., Page, J., Rajaraman, D., Rashmi, D. J., & Silver, S. (2014). Enhancing the education and understanding of research in community health workers in an intervention field site in South India. Indian Journal of Public Health Research & Development, 5(3), 178–​182. Vega, W. A., & Lopez, S. R. (2001). Priority issues in Latino mental health services research. Mental Health Services Research, 3(4), 189–​200. Velez, D., Palomo-​Zerfas, A., Nunez-​Alvarez, A., Ayala, G. X., & Finlayson, T. L. (2017). Facilitators and barriers to dental care among Mexican migrant women and their families in North San Diego County. Journal of Immigrant and Minority Health, 19(5), 1216–​1226. Verhagen, I., Ros, W. J. G., Steunenberg, B., Uysal-​Bozkir, Ö., May, F., & De Wit, N. J. (2015). Effectiveness of a community health worker intervention programme for older immigrants: Results from a quasi-​experimental study in the Netherlands. Community health workers: Bridging the gap between health needs of immigrant elderly and health-​ and welfare services in the Netherlands. University of Utrecht, Utrecht, Netherlands. http://​www.mighealth.net/​nl/​images/​c/​c8/​2015_​phd_​Verhagen.pdf#page=57 Verissimo, A. D. O., & Grella, C. E. (2017). Influence of gender and race/​ethnicity on perceived barriers to help-​seeking for alcohol or drug problems. Journal of Substance Abuse Treatment, 75,  54–​61. Vermeulen, E., Miltenburg, A.  S., Barras, J., Maselle, N., van Elteren, M., & van Roosmalen, J. (2016). Opportunities for male involvement during pregnancy in Magu district, rural Tanzania. BMC Pregnancy and Childbirth, 16(1), 1. Vesel, L., Waller, K., Dowden, J., & Fotso, J. C. (2015). Psychosocial support and resilience building among health workers in Sierra Leone: Interrelations between coping skills, stress levels, and interpersonal relationships. BMC Health Services Research, 15 (Suppl 1), S3. Villa Torres, L.  (2013, November). Are men willing to participate?:  A participatory research approach to involving Latino men in sexual and reproductive health promoter programs. Presented at the 141st APHA Annual Meeting and Exposition (November 2-​November 6, 2013). Boston, MA: APHA. Villa-​Torres, L., Fleming, P.  J., & Barrington, C.  (2015). Engaging men as Promotores de Salud:  Perceptions of community health workers among Latino men in North Carolina. Journal of Community Health, 40(1), 167–​174. Villatoro, A.  P., Dixon, E., & Mays, V.  M. (2016). Faith-​based organizations and the Affordable Care Act:  Reducing Latino mental health care disparities. Psychological Services, 13(1), 92–​104. Viner, R.  M., Ozer, E.  M., Denny, S., Marmot, M., Resnick, M., Fatusi, A., & Currie, C. (2012). Adolescence and the social determinants of health. The Lancet, 379(9826), 1641–​1652. Viruell-​ Fuentes, E.  A., Miranda, P.  Y., & Abdulrahim, S.  (2012). More than culture: Structural racism, intersectionality theory, and immigrant health. Social Science & Medicine, 75(12), 2099–​2106. Voekel, P. (2016). Organizing for freedom. NACLA Report on the Americas, 48(1),  68–​78. Wagner, J., Bermudez-​Millan, A., Damio, G., Segura-​Perez, S., Chhabra, J., Vergara, C., & Perez-​Escamilla, R. (2015). Community health workers assisting Latinos manage

References  239 stress and diabetes (CALMS-​D): Rationale, intervention design implementation, and process outcomes. Translational Behavioral Medicine, 5(4), 415–​424. Walker, G., & Bryant, W.  (2013). Peer support in adult mental health services:  A metasynthesis of qualitative findings. Psychiatric Rehabilitation Journal, 36(1),  28–​34. Walsh, M. (2016). The effect of Indian community health workers: Multiple tasks and few results. PhD thesis, Stanford University, Palo Alto, CA. Walters, K.  L., Spencer, M.  S., Smukler, M., Allen, H.  L., Andrews, C., Browne, T., . . . Uehara, E.  (2016). Eradicating health inequalities for future generations. American Academy of Social Work & Social Welfare. http://​aaswsw.org/​wp-​content/​ uploads/​2016/​01/​WP19-​with-​cover2.pdf Wang, E. (2014, November). Housing and healthcare: Successes and challenges facing formerly incarcerated individuals. Presented at the 142nd APHA Annual Meeting and Exposition (November 15–​November 19, 2014). New Orleans, LA: APHA. Wang, E.  A., Hong, C.  S., Shavit, S., Sanders, R., Kessell, E., & Kushel, M.  B. (2012). Engaging individuals recently released from prison into primary care: A randomized trial. American Journal of Public Health, 102 (9), e22–​e29. Wang, N., & Xie, X.  (2017). The impact of race, income, drug abuse and dependence on health insurance coverage among US adults. The European Journal of Health Economics, 18(5), 537–​546. Watson-​ Thompson, J.  (2016). Community development for population health and health equity. In P. C. Erwin & R. C. Brownson (Eds.), Scutchfield and Keck’s principles of public health practice (4th ed., pp. 443–​459). Boston, MA: Centage Learning. Waycott, J., Davis, H., Warr, D., Edmonds, F., & Taylor, G.  (2016). Co-​constructing meaning and negotiating participation:  Ethical tensions when “giving voice” through digital storytelling. Interacting with Computers, 29(2), 237–​247. https://​ academic.oup.com/ ​ i wc/ ​ a rticle- ​ a bstract/ ​ d oi/ ​ 1 0.1093/​ i wc/​ i ww025/​ 2 607839/​ Co-​constructing-​Meaning-​and-​Negotiating Webb, B., Bopp, M., & Fallon, E.  A. (2011). A  qualitative study of faith leaders’ perceptions of health and wellness. Journal of Religion and Health, 52(1), 235–​246. Webber, W., Stoddard, P., Rodriguez, M., Gudiño, P., Chagoya, T., Jauregui, D., . . . Garcia, A.  P. (2016). Improving rigor in a door-​to-​door health survey:  A participatory approach in a low-​ income Latino neighborhood. Progress in Community Health Partnerships: Research, Education, and Action, 10(1), 103–​111. Weil, T.  P. (2015). Insufficient dollars and qualified personnel to meet United States mental health needs. The Journal of Nervous and Mental Disease, 203(4), 233–​240. Weller, S. (2017). Using internet video calls in qualitative (longitudinal) interviews: Some implications for rapport. International Journal of Social Research Methodology, 20(6), 613–​625. Wells, J.  N. (2015, July). Speaking locally, influencing globally:  Promotoras evaluate a culturally sensitive intervention to promote Mexican-​ American cancer caregiver coping and health. In Sigma Theta Tau International’s 26th International Nursing Research Congress. STTI. San Juan, PR. Wennerstrom, A.  (2014, November). Supporting community health workers in New Orleans and beyond:  Expansion of the Louisiana Community Health Outreach Network. Presented at the 142nd APHA Annual Meeting and Exposition (November 15–​November 19, 2014). New Orleans, LA: APHA. Wenzel, J., Jones, R., Klimmek, R., Szanton, S., & Krumm, S.  (2012, May). Exploring the role of community health workers in providing cancer navigation: Perceptions of

240 References African American older adults. In Oncology nursing forum (Vol. 39, No. 3, p. E288). NIH Public Access. West, B.  S., Abramovitz, D., Staines, H., Vera, A., Patterson, T.  L., & Strathdee, S.  A. (2016). Predictors of injection cessation and relapse among female sex workers who inject drugs in two Mexican-​US border cities. Journal of Urban Health, 93(1), 141–​154. West, C. (2014, November). California community health workers: Balancing regional diversity with professional unity. Presented at the 142nd APHA Annual Meeting and Exposition (November 15–​November 19, 2014). New Orleans, LA: APHA. West, C., McGinnis, S., Gutierrez, M., Beidas, R., Kenyon, C., Apter, A. J., . . . Jacob, A. H. (2017). Understanding the problem and designing a comprehensive intervention to reduce asthma disparities. American Journal of Respiratory Critical Care Medicine, 195, A2234. West, J. F. (2013). To fight bad suga’, or diabetes, my neighborhood needs more health educators. Health Affairs, 32(1), 184–​187. Weston, S. (2016). The everyday work of the drug treatment practitioner: The influence and constraints of a risk-​based agenda. Critical Social Policy, 36(4), 511–​530. WestRasmus, E. K., Pineda-​Reyes, F., Tamez, M., & Westfall, J. M. (2012). Promotores de salud and community health workers:  An annotated bibliography. Family & Community Health, 35(2), 172–​182. Whatley, M., Erikson, C., Sandberg, S., & Jones, K.  (2017). Community health workers:  An underused resource, rediscovered. Academic Medicine. https://​pdfs. semanticscholar.org/​87e5/​11cd385bf6b1ec5ec9d54693d57b793e845  5.pdf White, R.  M., & Camper, L.  (2016). Breast self-​ examination education among Dominican women: A pilot study. Global Journal of Health Education and Promotion, 17(1),  38–​52. White, W. (2004). The history and future of peer-​based addiction recovery support services. Prepared for the SAMHSA Consumer and Family Direction Initiative, March 22–​ 23. Washington, D.C. White, W., Humphreys, K., Bourgeois, M., Chiapella, P., Evans, A., Flaherty, M., & Taylor, P.  (2012). The status and future of addiction recovery support services in the United States. Betty Ford Institute Consensus Statement on Recovery Support Services. White, W., & Kurtz, E.  (2006). Linking addiction treatment and communities of recovery: A primer for addiction counselors and recovery coaches. Pittsburgh, PA: IRETA/​ NeATTC. http://​citeseerx.ist.psu.edu/​viewdoc/​download?doi=10.1.1.627.3169&rep= rep1&ty pe=pdf White, W. L. (2010). Nonclinical addiction recovery support services: History, rationale, models, potentials, and pitfalls 1. Alcoholism Treatment Quarterly, 28(3), 256–​272. White, W.  L., Kelly, J.  F., & Roth, J.  D. (2012). New addiction-​ recovery support institutions:  Mobilizing support beyond professional addiction treatment and recovery mutual aid. Journal of Groups in Addiction & Recovery, 7(2–​4), 297–​317. Wieland, M.  L., Weis, J.  A., Hanza, M.  M., Meiers, S.  J., Patten, C.  A., Clark, M. M., . . . Levine, J. A. (2016). Healthy immigrant families: Participatory development and baseline characteristics of a community-​based physical activity and nutrition intervention. Contemporary Clinical Trials, 47(1),  22–​31. Wiggins, N. (2011). Popular education for health promotion and community empowerment: A review of the literature. Health Promotion International, 27(3), 356–​371.

References  241 Wiggins, N., Johnson, D., Avila, M., Farquhar, S. A., Michael, Y. L., Rios, T., & Lopez, A.  (2009). Using popular education for community empowerment:  Perspectives of community health workers in the Poder es Salud/​Power for Health program. Critical Public Health, 19(1),  11–​22. Wiggins, N., Kaan, S., Rios-​Campos, T., Gaonkar, R., Morgan, E.  R., & Robinson, J.  (2013). Preparing community health workers for their role as agents of social change:  Experience of the Community Capacitation Center. Journal of Community Practice, 21(3), 186–​202. Wight, D., & Fullerton, D. (2013). A review of interventions with parents to promote the sexual health of their children. Journal of Adolescent Health, 5(1),  4–​27. Wilkinson, G.  (2013, November). Creating a state certification program for community health workers. Presented at the 141st APHA Annual Meeting (November 2–​ November 6, 2013). Boston, MA: APHA. Wilkinson, G.  W., Mason, T., Hirsch, G., Calista, J.  L., Holt, L., Toledo, J., & Zotter, J.  (2016). Community health worker integration in health care, public health, and policy:  A partnership model. The Journal of Ambulatory Care Management, 39(1),  2–​11. Williams, J. (2010). Fifty-​the new sixty? The health and social care of older prisoners. Quality in Ageing and Older Adults, 11(3),  16–​24. Willmott, D., & van Olphen, J.  (2005). Challenging the health impacts of incarceration: the role for community health workers. Californian Journal of Health Promotion, 3(2),  38–​48. Willock, R. J., Mayberry, R. M., Yan, F., & Daniels, P. (2015). Peer training of community health workers to improve heart health among African American women. Health Promotion Practice, 16(1),  63–​71. Wilson, C., & Riegelman, R.  (2016). A  place for community colleges in public health education:  Two curricular frameworks. Community College Journal of Research and Practice, 40(6), 554–​557. Witt, D., Benson, G., Campbell, S., Sillah, A., & Berra, K. (2016). Measures of patient activation and social support in a peer-​led support network for women with cardiovascular disease. Journal of Cardiopulmonary Rehabilitation and Prevention, 36(6), 430–​437. Wong, M. J. (2017). Culture-​bound syndromes: Racial/​ethnic differences in the experience and expression of Ataques de nervios. PhD dissertation, University of California, Los Angeles, CA. Woodall, J., Dixey, R., & South, J. (2013). Prisoners’ perspectives on the transition from the prison to the community:  Implications for settings-​based health promotion. Critical Public Health, 23(2), 188–​200. Woodall, J., South, J., Dixey, R., de Viggiani, N., & Penson, W. (2015). Expert views of peer-​based interventions for prisoner health. International Journal of Prisoner Health, 11(2),  87–​97. Woods, L.  N., Lanza, A.  S., Dyson, W., & Gordon, D.  M. (2013). The role of prevention in promoting continuity of health care in prisoner reentry initiatives. American Journal of Public Health, 103(5), 830–​838. World Health Organization. (2010). Increasing access to health workers in remote and rural areas through improved retention:  Global policy recommendations. Geneva, Switzerland: Author.

242 References World Health Organization. (2017). Ethics guidance for the implementation of the End TB strategy. Geneva, Switherland: Author. Xavier, D., Gupta, R., Kamath, D., Sigamani, A., Devereaux, P. J., George, N., . . . Yusuf, S. (2016). Community health worker-​based intervention for adherence to drugs and lifestyle change after acute coronary syndrome:  A multicentre, open, randomised controlled trial. The Lancet Diabetes & Endocrinology, 4(3), 244–​253. Yanez, B., McGinty, H. L., Buitrago, D., Ramirez, A. G., & Penedo, F. J. (2016). Cancer outcomes in Hispanics/​ Latinos in the United States:  An integrative review and conceptual model of determinants of health. Journal of Latino/​a Psychology, 4(2), 114–​129. Yates-​Doerr, E., & Carney, M. A. (2016). Demedicalizing health: The kitchen as a site of care. Medical Anthropology, 35(4), 305–​321. Yin, H.  S., Dreyer, B.  P., Vivar, K.  L., MacFarland, S., van Schaick, L., & Mendelsohn, A. L. (2012). Perceived barriers to care and attitudes towards shared decision-​making among low socioeconomic status parents: Role of health literacy. Academic Pediatrics, 12(2), 117–​124. Yin, R. K. (2013). Case study research: Design and methods. Thousand Oaks, CA: Sage. Yin, R. K. (2017). Case study research and applications: Design and methods. Thousand Oaks, CA: Sage Publications. Young, M., Wolfheim, C., Marsh, D.  R., & Hammamy, D.  (2012). World Health Organization/​United Nations Children’s Fund joint statement on integrated community case management:  An equity-​focused strategy to improve access to essential treatment services for children. The American Journal of Tropical Medicine and Hygiene, 87(5 Suppl), 6–​10. Zachariah, R., Ford, N., Philips, M., Lynch, S., Massaquoi, M., Janssens, V., & Harries, A.  D. (2009). Task shifting in HIV/​AIDS:  Opportunities, challenges and proposed actions for sub-​Saharan Africa. Transactions of the Royal Society of Tropical Medicine and Hygiene, 103(6), 549–​558. Zambruni, J.  P., Rasanathan, K., Hipgrave, D., Miller, N.  P., Momanyi, M., Pearson, L., . . . Peterson, S.  (2017). Community health systems:  Allowing community health workers to emerge from the shadows. The Lancet Global Health, 5(9), e866–​e867. Zandee, G. L., Bossenbroek, D., Slager, D., & Gordon, B. (2013). Teams of community health workers and nursing students effect health promotion of underserved urban neighborhoods. Public Health Nursing, 30(5), 439–​447. Zeiders, K.  H., Umaña-​Taylor, A.  J., Jahromi, L.  B., Updegraff, K.  A., & White, R.  M. (2016). Discrimination and acculturation stress:  A longitudinal study of children’s well-​being from prenatal development to 5 years of age. Journal of Developmental & Behavioral Pediatrics, 37(7), 557–​564. Zhang, D., & Unschuld, P. U. (2008). China’s barefoot doctor: Past, present, and future. The Lancet, 372(9653), 1865–​1867. Zhang, X., Yang, S., Sun, K., Fisher, E. B., & Sun, X. (2016). How to achieve better effect of peer support among adults with type 2 diabetes: A meta-​analysis of randomized clinical trials. Patient Education and Counseling, 99(2), 186–​197. Zlotnick, C., Zerger, S., & Wolfe, P.  B. (2013). Health care for the homeless:  What we have learned in the past 30 years and what’s next. American Journal of Public Health, 103(S2), S199–​S205.

References  243 Zuckerman, K. E., Perrin, J. M., Hobrecker, K., & Donelan, K. (2013). Barriers to specialty care and specialty referral completion in the community health center setting. The Journal of Pediatrics, 162(2), 409–​414. Zulliger, R., Moshabela, M., & Schneider, H.  (2014). “She is my teacher and if it was not for her I would be dead”: Exploration of rural South African community health workers’ information, education and communication activities. AIDS Care, 26(5), 626–​632. Zurawski, A., Komaromy, M., Ceballos, V., McAuley, C., & Arora, S.  (2016). Project echo brings innovation to community health worker training and support. Journal of Health Care for the Poor and Underserved, 27(4),  53–​61.

Index Figures are indicated by f following the page number For the benefit of digital users, indexed terms that span two pages (e.g., 52–​53) may, on occasion, appear on only one of those pages. ACA. See Patient Protection and Affordable Care Act Accessible resources, 69 Access to health care, 21, 54–​58 Accountable Care Organizations, 5 Accredited Social Health Activist (ASHA) program, 48 Acculturation, 23, 28, 39, 44–​46, 65–​66,  110–​11 Action research, 63 Activism, 90 Addiction counselors, 146–​47 Addiction recovery, 147. See also Recovery: persons in Addictions, 145–​46. See also Substance use disorders Adherence to medication, 14 Adults definition of, 123–​24 population group, 71f, 71 Advanced care directives, 50 Advancement, 118, 128–​29, 164–​65 Advocacy, 29, 67, 69, 128–​29 Affordable Care Act. See Patient Protection and Affordable Care Act (ACA) African Americans/​Blacks health promotion, 25 homeless, 139 incarcerated or formerly incarcerated, 124, 127 men, 124 women, 43 Age groups, 71 Aging population, 7, 25 Agriculture, 22 Alaska,  115–​16

Alcohol abuse, 24, 143, 144. See also Substance use disorders costs of, 144 stigma associated with, 148 treatment of, 145 Alma Ata Declaration (WHO), 6, 19 Alternative health systems, 41 Altruism,  94–​95 Alzheimer’s disease, 22 American Association of Community Health Workers, 108 American Journal of Public Health, 80, 127 American Public Health Association, 75–​76,  116 Amigas Latinas Motivando el Alma, 25 Amyotrophic lateral sclerosis, 24 ASHA (Accredited Social Health Activist) program, 48 Asian Americans, 10–​11 incarcerated or formerly incarcerated adults, 124 older adults, 25 unauthorized, 133 Assets/​strengths first, 66 Association of Schools and Programs of Public Health, 78 Asthma risk, 21 Australia, 8 Autism spectrum disorders, 22 Baby boomers, 71 Barefoot doctors, 18 Behavioral health care efforts that address disparities, 49 for homeless, 139 Bello, Elizur, 141–​42 Bicultural staff, 28, 66

246 Index Bidirectional learning, 171 Big data, 156 Bilingual/​bicultural staff, 28, 66 Birmingham, Alabama, 130–​31 Blacks. See African Americans/​Blacks Blood pressure treatment, 88 Bonaparte, Napoleon, 18 Boston, Massachusetts, 124, 149 Boston University School of Social Work, 149 Botanicas, 38 Breast examination, 24 Breastfeeding, 25 Buddy systems, 127 Bureaucracy, 146–​47, 164 Burnout, 142 California community health workers (CHWs), 77, 81 peer providers, 145 work-​related injuries, 50 Call to action, 90 Canada community health workers (CHWs), 8 community navigators, 74 Cancer prevention, 24 Cancer screening, 24, 89 Capital, social, 28, 65 Cardiovascular risk reduction, 24, 25 Casa Esperanza, 149–​50, 151 Casa Ruby, 142 Case illustrations, 30–​31, 121–​51 Case studies, 173 CBPR (community-​based participatory research),  170–​72 Center for Social Policy and Community, 81 Centers for Disease Control and Prevention, 115 Certification, 77–​78, 82–​83, 167. See also specific programs common components, 80 example programs, 78 key themes, 82 questions that state authorities must answer,  81–​82 rewards and challenges, 87 state programs, 80, 81, 83, 87

Chicago, Illinois, 131–​32 Child abuse and neglect, 24 Children, 88 chronic health conditions, 14 Latinx, 54 Maternal, Infant, and Early Childhood Home Visiting Program, 99, 102 risk for asthma, 21 unauthorized,  134–​35 Chilling effect, 40 China, 7–​8, 18 Chronic care, 14, 24, 25 City College of San Francisco Community Health Worker Certificate, 78 Post-​Prison Health Worker Certificate, 131 Clinics, workplace, 153 Code of ethics, 108 Cohabiters, 139 Collectivism,  17–​18 Colon cancer screening, 24 Commitment, 98 Community, 35 Community assets paradigm, 69–​70 Community-​based participatory research (CBPR),  170–​72 Community-​built paradigm, 68 Community capacity enhancement of, 68–​70, 146 key components, 69 Community-​centered services, 66, 140, 164 Community Colleges and Public Health Report, 78 Community health, 155 challenges of working in, 161–​67 community-​organizational conflicts,  106–​7 culturally competent/​humility-​based services for, 66 motivation for working in, 158 Community health advisors, 80–​81 Community health fairs, 70 Community health teams, 165 Community Health Worker Appreciation Month, 79 Community Health Worker Certificate (City College of San Francisco), 78

Index  247 Community Health Worker Certificate (Thomas Jefferson University), 78 Community Health Worker Certificate (University of Hawaii Maui College), 78 Community Health Worker Code of Ethics, 108 Community health workers (CHWs), 73–​ 109. See also Promotores de salud advancement, 118, 128–​29, 164–​65 appeal,  7–​8 call to action, 90 capacity-​building roles, 69 care models that lend themselves to incorporating, 85 certification, 77–​78, 80, 81–​83, 87, 167 challenges, 73–​109,  161–​67 classification, 76, 83–​85, 105–​7, 114 of color, 166–​67 community-​organizational conflictual demands on, 106–​7 conceptual foundation, 61–​72 conceptual frameworks, 67–​71 core competencies, 80–​81 core factors for effectiveness, 91 costs and cost-​effectiveness, 89–​90 definition, 75–​76, 77, 161–​62 definitional challenges, 105–​7 demand for, 8, 76, 154 effectiveness, 38, 50, 84, 86–​90 evolving roles, 154–​56 expansion, 5, 9, 23–​25, 164 ex–​sex workers, 32 formerly homeless or unhoused, 137–​43 formerly incarcerated, 123–​32 formerly unauthorized, 132–​36 framework,  61–​72 functions, 84, 85 geographic-​bound studies,  84–​85 global importance of, 6 glue for effectiveness, 90–​98 groups that can benefit from, 32 historical origins, 18–​20 immigrants, 102, 135 impact, 3–​4, 23–​24, 32–​33,  87–​88 importance, 6, 162–​63 increase in number of, 9 indigenous, 10, 17, 26, 158

initiatives in AA and NHPI communities,  10–​11 job description, 63 job satisfaction, 103 key motivators, 95 key themes for increasing effectiveness, 88 Latinx, 157 lay health advisors (LHAs), 86–​87, 88–​89 legitimization, 167 male, 27, 95 marginalized, 84 minority tax, 166–​67 motivation, 93–​95, 158 names and titles, 75 new approaches and models, 153 overview,  3–​34 peer leaders, 14–​18 peer providers, 32 persons in recovery, 143–​51 place-​based,  101 practical approaches, 29 praxis, 5 professional, 12–​14, 167 vs PSSs, 154–​55 recommendations for research and practice, 152–​59,  160–​76 reflections from the field, 119 research by, for, and on, 156–​58 researchers,  169–​70 research roles, 156, 157, 168–​70 resources, 115 roles, 30, 32–​33, 69, 84, 85, 90, 105–​6, 154–​56,  162–​63 scope of practice, 84–​85 for special population groups, 32–​33 standardization, 167 as synthetic social support, 153 task shifting, 106, 114 theoretical foundations, 61–​118 training, 29–​30, 81, 157 values and principles guiding, 28–​31,  61–​67 violence against, 30 volunteers, 13–​14, 17, 89, 110–​18, 158, 166 work parameters, 73 youth, 16, 54

248 Index Community institutions, 104–​5 Community knowledge, 69, 95–​96 Community leadership, 69 Community-​led mapping,  173–​74 Community-​led research, 175 Community navigators, 74 Community nutrition workers, 163 Community-​organizational conflictual demands,  106–​7 Community participation, 64 Community partnerships, 68 Community research, 157 Community resources, 69–​70, 163 Compassion fatigue, 111 Concept maps, 135 Conceptual foundation, 61–​72 Conceptual frameworks, 67–​71 Conferences, 116 Confidentiality, 175 Consultation, 116 Contra Carias initiative, 22 Cooperation,  17–​18 Corado, Ruby, 142 Core competencies, 80–​81 Core factors, 91 Correctional involved, 123 Correctional settings, 16–​17, 125 Costs and cost-​effectiveness, 55, 57, 89–​90 organizational, 161 out-​of-​pocket,  112 Credentialing, 82. See also Certification Criminal justice, 17 Crystal meth, 145 Cuban women, 45–​46 Cultural assets paradigm, 69–​70, 79 Cultural beliefs, 14, 57 Cultural competence, 63–​64, 96–​97 barriers to, 23 bilingual/​bicultural staff, 28, 66 initiatives with, 22 Cultural humility, 38, 63–​64 Cultural/​language barriers, 57 Cultural navigators, 169–​70 Cultural values, 57 Culture,  35–​46 of health, 36 importance of, 80 role of, 35–​36

DACA (Deferred Action for Parents of Americans),  132–​33 Data, standardized, 161 Decision making, shared, 56–​57 Deferred Action for Parents of Americans (DACA),  132–​33 Democracy, participatory, 64 Demographics, 7, 53 key profiles and trends, 53–​54 projected increases, 40–​41 promoters de salud, 30 Dental care, 22 Denver, Colorado, 112 Dependence recovery, 143. See also Recovery: persons in Deportations, 40 Depression, 24, 139 Diabetes, 22, 50, 88 type 2, 101 Diabetes research, 157 Digital storytelling, 31, 174–​75 Disability benefits, 140 Discharge planning, 57 Discrimination, 23, 47–​48 racial, 23, 45–​46, 55, 56–​57 Diversity, 41 Doctors barefoot doctors, 18 injection doctors, 16 Latinx,  40–​41 shortage,  6–​7 Documentation, 55 Doubled-​up persons, 140 Dreamers or DACA (Deferred Action for Parents of Americans), 132–​33 Drinking. See Alcohol abuse; Substance use disorders Drinking water, 24 Drug abuse, 143. See also Substance use disorders costs of, 144 stigma associated with, 148 treatment of, 145 Dual eligibles, 24 Dyslexia, 139 Early preventive dental care, 22 Education, 55

Index  249 EEOC (Equal Employment Opportunity Commission),  131–​32 E-​learning,  83 Emergency room visits, 21–​22 Empathy, 97–​98,  128–​29 Empowerment, 29, 63 Equal Employment Opportunity Commission (EEOC), 131–​32 Equitable relationships, 108 Ethical dilemmas, 104, 107–​9, 164 Community Health Worker Code of Ethics, 108 research conflicts and considerations, 175 Ethnic disparities, 49 Ethnic identity, positive, 28, 66 Ethnographic research, 157, 172–​73, 175 Ethnography, visual, 25, 31 European Americans, 133 Ex-​convicts. See Formerly incarcerated Experiential knowledge, 96 Experts, resident, 171 Eye care, 24 Familismo, 17–​18, 94 Family-​focused interventions,  17–​18 Family planning, 24 Feedback, voice-​and Web-​based, 5–​6 Field reflections, 119 Field workers and their families, 22 Financial barriers, 57–​58 Financial incentives, 94–​95 Financial support, 112 annual wages, 112 compensation, 109 per diems, 166 remuneration, 109 Florida, 77 Folk-​based health care, 38 Folk beliefs, 38 Foreign-​born population, 133 Former CHWs, 13–​14 Formerly homeless or unhoused, 32–​33,  137–​43 age subgroups, 138 case illustration, 141–​43 demographic profile, 138 group definition, 70, 71f,  137–​38

invisibility, 129 major issues that confront, 138–​41 youth, 142 Formerly incarcerated, 32–​33, 122–​32 age subgroups, 124 barriers to health care, 56 case illustration, 130–​32 definition of, 123–​24 demographic profile, 124 employment,  129–​30 invisibility, 129 major issues that confront, 124–​30 population group, 70, 71f Post-​Prison Health Worker Certificate for, 131 themes related to successful reentry,  128–​29 Formerly unauthorized or undocumented, 32, 132–​36 age subgroups, 133 barriers to health care, 134 case illustration, 134–​36 definition of, 132–​33 demographic profile, 133 health initiatives specifically targeted to, 135 major issues that confront, 133–​34 population group, 70, 71f ways to enlist and support, 136 Former sex workers, 32 Free clinics, 153 Funding, 29 Gambling, 24 Genomic literacy, 25 Geographically displaced clients, 38 Geographical/​physical barriers, 56 Geographic-​bound studies,  84–​85 Geographic information systems (GIS),  173–​74 Geography, local, 40 George Washington University, 116 Geriatric population. See Older adults Ghettos, 31 GIS (geographic information systems),  173–​74 Glue metaphor, 90–​98 Guiding principles, 28–​31, 61–​62, 64–​67

250 Index Hawaii,  48–​49 HCWs (health care workers). See Community health workers (CHWs); Health workers Healing systems, 41 Health concept of, 36–​37 cultural context, 35–​46 social determinants of, 9, 49 Health care assumptions underpinning efforts that address disparities, 49 behavioral, 49 folk-​based,  38 global crisis, 6 home care, 7, 175 as human right, 52 indigenous, 39 self-​care, 26–​27,  39 Health care access, 21, 54–​58 Health care delivery challenges and barriers, 52–​58 home visiting, 98–​104 in low-​income settings, 8 in low-​resource settings, 5–​6 to marginalized communities, 3–​34 responsibilities in, 108 urban, 3–​4,  52–​58 Health care teams, 88, 165 home health teams, 165 Health care workers (HCWs). See Community health workers (CHWs); Health workers Health clinics, 153 Health educators, 76–​77 Health fairs, 70 Health food consumption, 22 Health inequity, 20–​23, 43–​44, 47–​51 assumptions underpinning efforts that address, 49 definition and overview, 48–​50 among marginalized groups, 42 race-​related,  50 Health insurance, 47–​48, 57 Health literacy, 89 Health navigators, 74, 164 Health outcomes, 37 Health professionals, 6–​7, 40–​41

Health programs, 68–​69 Health promotion, 25, 155 in correctional settings, 125 by parents, 26 Health risks, 108 Health workers. See also Community health workers (CHWs) agenda for, 165 global demand for, 8 lay health care workers, 109, 114 shortage of, 6–​7 Hearing loss, 24 Heart disease training, 115 Heart failure, 24 Help-​seeking patterns, 13 Hepatitis C, 145 Herbal medicine, 39 Hispanic folk illnesses, 14 Historical context, 43 Historical origins, 18–​20 HIV/​AIDS, 56, 144, 145 HIV/​AIDS initiatives, 16, 47–​48, 88, 161 HIV-​positive transgender women, 142 Home health care, 7 ethical conflicts and considerations, 175 home visiting, 98–​104 Home health teams, 165 Homeless persons, 122, 137–​40. See also Formerly homeless or unhoused major issues that confront, 138–​39 Home visiting, 98–​104 funding, 99 illustrations,  99–​100 logistical and safety challenges, 103–​4 Maternal, Infant, and Early Childhood Home Visiting Program, 99, 102 safety challenges, 103–​4 safety recommendations, 103–​4 Honduras, 163 Hospital deportations, 40 Hours of operation, 57 Houses of worship, 25–​26, 68–​69 Housing, 137. See also Formerly homeless or unhoused public, 101 supportive, 140 Humility, 23, 38, 63–​64, 96–​97

Index  251 Humility-​based community health services, 66 Hypertension, 22 Identity positive ethnic identity, 28, 66 professional identity, 167 role identity theory, 30 Illinois, 130 Immigrants, 102, 135, 172 Immigration policy, 134 Incarcerated persons. See also Formerly incarcerated prison peer programs, 16 Incentivization, 96, 109, 112 India, 48, 94, 163 Indigenous CHWs, 17, 26, 158. See also Community health workers (CHWs) Indigenous health care, 39 Indigenous health promoters, 10 Infant nutrition, 25 Maternal, Infant, and Early Childhood Home Visiting Program, 99, 102 Information technology, 31 Initiatives and programs, 76 Injection doctors, 16 Innovation, 89 Innovative interventions, 25–​27 Institute of Emerging Professions, 78 Institute of Medicine, 76 Institution users, 139 Intersectionality, 42–​44, 108 definition of, 42 historical context, 43 relevance for health, 43 Intimate community knowledge, 95–​96 Intimate partner violence, 24, 25, 38 Islamic religious leaders, 26 Job classification, 76, 105–​7 Job descriptions, 63, 83 Job satisfaction, 103 Job titles, 75, 77 Johns Hopkins University, 131–​32 Kerrigan, Linda, 99–​100 Key research questions, 113 Key themes, 82

Knowledge coconstruction of, 171 experiential, 96 intimate,  95–​96 Labor issues, 161 Langeloth Foundation, 130–​31 Language issues, 8, 45, 55, 96–​97 bilingual/​bicultural staff, 28, 66 cultural/​language barriers, 57 Latinxs, 10–​11, 13, 79 advanced care directives, 50 barriers to health care, 55 border populations, 25 botanicas, 38 caregivers, 14 children, 54 community health workers (CHWs), 157 cultural traditions and beliefs, 39–​40 demographic patterns, 40–​41, 53–​54 deportations, 40 doctors,  40–​41 early preventive dental care, 22 field workers and their families, 22 first-​generation,  17–​18 health care, 22, 57 health concepts, 42 health inequities, 50, 134 health promotion, 25, 26, 80 immigrants, 25 incarcerated or formerly incarcerated, 124, 127, 128 men, 124 minority tax, 166–​67 newcomers, 89 older adults, 25 risk for asthma, 21 unauthorized, 133 work-​related injuries, 50 Lay health advisors (LHAs), 86–​87,  88–​89 Lay health workers, 109, 114. See also Community health workers (CHWs); Health workers Leadership, 29, 69 Islamic religious leaders, 26 peer leaders, 14–​18

252 Index League for Innovation in the Community College, 78 Learning bidirectional, 171 e-​learning,  83 Legal status, 57 Legitimization, 167 LEP (limited English proficiency), 57 LGBTQ youth, 142 LHAs (lay health advisors), 86–​87, 88–​89 Life course perspective, 70–​71, 71f Limited English proficiency (LEP), 57 Literacy genomic, 25 health, 89 Literature review, 23–​24 LMICs (noncommunicable diseases prevention and control), 88 Local contexts, 41, 66 Logistical and safety challenges, 103–​4 Long-​term care, 7 Lopez, Richard, 149–​50, 151 Los Angeles, California, 142 Low-​income communities health care delivery to, 3–​4, 8 health inequity, 48 rural,  3–​4 Low-​resource settings,  5–​6 Lyme disease, 50 Malaria, 88 Malcom X College (City of Chicago), 78 Male CHWs, 27. See also Community health workers (CHWs) key motivators, 95 promotores de salud, 27 Mapping, community-​led,  173–​74 Marginalized CHWs, 84. See also Community health workers (CHWs) Marginalized communities health care delivery to, 3–​34 health inequity, 42, 48 special population groups, 32–​33 urban,  25–​26 Massachusetts, 80, 81, 146 Massachusetts General Hospital, 146 Maternal, Infant, and Early Childhood Home Visiting Program, 99, 102

Maternal and infant care, 24, 88 Maternal health, 27 MDGs (Millennium Development Goals), 8, 88 Meaning,  128–​29 Medicaid, 24 Medical homes, 153 Medicare, 24 Medication management, 89 adherence to medications, 14 self-​medication,  39 Men. See Male CHWs Mental health care, 7, 24 for homeless, 139 settings for, 25–​26 Mentoring,  16–​17 Meth, crystal, 145 Mexican Americans, 133 Mexican women, 45–​46 Michigan, 79 Migrant workers, 3–​4 Millennium Development Goals (MDGs), 8, 88 Minority tax, 166–​67 Missouri, 161 Mobile technology, 83, 111 Monitoras, 163 Montgomery, Alabama, 112 Mothers Maternal, Infant, and Early Childhood Home Visiting Program, 99, 102 maternal and infant care, 24, 88 maternal health, 27 Motivation, 93–​95, 111, 128–​29 for community health work, 158 key factors, 94–​95 key motivators for male CHWs, 95 for volunteer CHWs, 158 Napoleon Bonaparte, 18 National Community Health Advocacy Study, 75 National Council of La Raza, 29, 79 National Employment Law Project,  131–​32 Native Hawaiians and Pacific Islanders (NHPIs),  10–​11 Natural disasters, 24

Index  253 Negotiation skills, 80–​81 Neighborhood health aides, 19 Nelson, Tara, 99–​100 Netherlands, 8 New approaches and models, 153 Newcomers, 38, 89, 135 New England, 13, 77 New Mexico, 81 New Orleans, Louisiana, 25 New York, 77 New York City, New York, 84–​85 The Next Door, 141–​42 NHPIs (Native Hawaiians and Pacific Islanders),  10–​11 Nigeria, 26 Noncommunicable diseases, 88, 113 North Carolina, 136 Nurses, 6–​7. See also Community health workers (CHWs) Nutrition, 24, 88 Obesity,  88–​89 Occupational stress, 166 Office of Management and Budget, 76 Ohio, 80, 116 Older adults, 155 advanced care planning, 50 community-​based participatory research with, 171 demographic patterns, 7, 25, 53 formerly incarcerated, 123–​24 homeless, 138–​39, 140 population group, 70, 71f, 71 Operational/​financial barriers,  57–​58 Opioids, 145 Oral health promotion, 22, 24 Organizational access barriers, 54–​58 Organizational costs, 161 Organizational demands, 106–​7 Organizational support, 117 Out-​of-​pocket costs,  112 Outreach educators, 163 Overdose, 145 Paid promotores, 110–​18. See also Promotores de salud Pakistan, 111 Palliative care, 24, 142

Paraprofessionals, 114 Parents, 26 Participatory democracy, 64 Participatory research, community-​based,  170–​72 Paternalism, 39 Patient education interventions, 26 Patient Protection and Affordable Care Act (ACA), 5, 9–​10 effects on health care access and use, xi, 8–​9, 52–​53, 57, 79 Maternal, Infant, and Early Childhood Home Visiting Program, 99, 102 responses from institutions of higher learning,  78–​79 roll out, 164 Peer interventions, 14–​18, 27, 32, 128 effectiveness,  88–​89 funding for, 29 for mental health and substance abuse,  145–​46 peer-​to-​peer training,  88–​89 in prisons, 125–​26 recovery coaches, 146, 147, 149–​50 Peer supporters (PSS), 154–​55 Peer volunteers, 17 Pennsylvania, 77, 130 Per diems, 166 Perinatal care, 24 Pesticides, 22 Pets, 99 Pew Charitable Trust, 130 Photography, 31 Photovoice, 25, 31, 172 Physical barriers, 56 Place-​based CHWs, 101. See also Community health workers (CHWs) Polio workers, 111 Politics,  106–​7 Population. See under Demographics Positive ethnic identity, 28, 66 Posthospital visits, 101 Post-​Prison Health Workers, 130–​31 Practical approaches, 29 Praxis, 5 Preventive dental care, early, 22 Priorities, 28 Prison peer programs, 16

254 Index Productivity, 111 Professional advancement, 118, 128–​29,  164–​65 Professional associations, 81 Professionalism, 12–​14, 108, 167 Professional supports, 112 Promotores de salud, 74–​83. See also Community health workers (CHWs) definition,  74–​75 demographic profiles, 30 importance, 79 initiatives led by, 22 key motivators, 95 male, 27 names for, 74, 75 overview, 10, 11, 21–​22, 27 paid,  110–​18 photovoice, 25 recommendations for research and practice, 163 recruitment, 29, 110–​18 support for, 29, 110–​18 training, 29, 110–​18 volunteer,  110–​18 work parameters, 73 PSS (peer supporters), 154–​55 Psychiatric rehabilitation, 24 Psychological barriers, 56–​57 Public housing, 101 Public transportation, 55 Puerto Rican children, 21 Puerto Rican women, 45–​46 Puerto Rico, 130–​31 Puerto Rico Pentecostal ministries, 147 Qualitative research, 175 Quality care, 55 Race-​related inequities, 49, 50 Racial discrimination or racism, 23, 45–​46, 55,  56–​57 Recognition, social, 94 Recommendations for research and practice, 152–​59,  160–​76 Recovery: persons in, 32–​33, 117 age subgroups, 143–​44 case illustration, 149–​51 as CHWs, 143–​51

definition of, 143 demographic profile, 143–​44 major issues that confront, 144–​49 population group, 70, 71f Recovery capital, 146 Recovery coaches, 17, 146 peer, 146, 147, 149–​50 Recruitment, 29, 110–​18 Referral procedures, 57 Reflections from the field, 119 Rehabilitation, psychiatric, 24 Relapse, 148, 149 Relationship-​centered approach, 92 Relationships, 28 equitable, 108 importance of, 65 Religious communities, 25–​26 Renters, 139 Research action research, 63 by, for, and on CHWs, 156–​58 case studies, 173 CHW-​initiated and -​involved,  168–​70 CHW roles, 156, 157, 168–​70 community, 157 community-​based,  170–​72 community-​led, 173–​74,  175 conventional approaches, 170 emerging approaches, 170, 174–​75 ethical conflicts and considerations, 175 ethnographic, 157, 172–​73, 175 key questions, 113 participatory, 169, 170–​72 promising methods and approaches,  170–​75 qualitative, 175 recommendations for, 152–​59, 160–​76 unorthodox approaches, 170 visually informed, 172 youth-​led,  175 Research approaches, 27 Resident experts, 171 Resilience, 126 Resources, 115 accessible, 69 community,  69–​70 Respect, 55 Responsibility professional, 108

Index  255 social, 94 Rhode Island, 140 Rights, professional, 108 Role identity theory, 30 Runaways, 138 Rural health care delivery, 3–​4, 18 Safer Foundation, 131–​32 Safety challenges, 103–​4, 111 Salaries, 112 Sanchez, Maria Antonia Plascencia de,  141–​42 Santa Maria, California, 112 Scheduling home visits, 103 Screening,  113–​14 Self-​care, 26–​27,  39 Self-​efficacy,  94 Self-​medication,  39 Service delivery guiding principles, 67 new approaches and models, 153 Service providers, 108. See also Community health workers (CHWs); Doctors Sex workers, 32 barriers to health care, 56 transgender women, 47–​48 Shared decision making, 56–​57 Shearer, Martha, 130–​31 Sickle cell, 24 Sleep education, 24 Smoking cessation, 24, 88 Social capital, 28, 65 Social change efforts, 67 Social determinants of health, 9, 49 Socialization, professional, 14 Social justice, 28, 42, 43, 46, 62–​63, 67 Social media, 31, 83 Social networking, 116 Social recognition, 94 Social relationships, 28, 65, 108 Social responsibility, 94 Social support, synthetic, 153 Social variables, 27 Social workers, 163–​64 Spanish language, 97 Special populations, 32–​33. See also specific groups case illustrations, 121–​51

group characteristics, 122 life course perspective on, 70–​71, 71f Springfield, Massachusetts, 149 Staff, bilingual/​bicultural, 66 Staff turnover, 112, 142 Standardization, 161, 167 Standard Occupational Classification System, 76 State certification programs, 81, 83, 87. See also specific programs common components, 80 key themes, 82 questions that authorities must answer,  81–​82 State-​sponsored home visiting programs, 99, 102 Stigma, 56, 147, 148–​49 Storytelling, 31, 174–​75 Street credit, 142 Street youths, 138, 139 Strengths first, 66 Stress acculturation,  44–​46 occupational, 166 Stroke training, 115 Sub-​Saharan Africa, 13 Substance use disorder recovery, 143. See also Recovery: persons in Substance use disorders, 117, 143, 144, 145 demographic profile, 143–​44 health insurance coverage for, 47–​48 among homeless, 139–​40 Supervision, 111–​12,  114–​17 Support, 110–​18,  128–​29 organizational, 117 peer, 14, 16, 17 professional, 112 synthetic social support, 153 Supportive housing, 140 Systems youths, 138 Tacoma, Washington, 112 Tanzania, 94 Tapestry Program, 149, 150, 169–​70 Task shifting, 106, 114 Team-​based care, 33, 128–​29, 163, 165 Technology information technology, 31 mobile, 83, 111

256 Index Telephone calls, 103 Temple University, 81 Terminology, 8, 75 Texas, 77, 80 Theoretical foundations, 61–​118 Therapy dogs, 99 Thomas Jefferson University (Philadelphia, PA), 78 Throwaways, 138 Tobacco cessation, 24, 88 Training, 29–​30, 111, 114–​17 curriculum, 157 key themes, 82 peer-​to-​peer,  88–​89 print materials, 115–​16 resources,  115–​16 Training programs, 81 Transgender women HIV-​positive,  142 sex workers, 47–​48 Transitions Clinic, 130–​31 Transportation, public, 55 Trauma, 139 Trauma care, 140 Trust, 91–​93, 117, 172 Tuberculosis, 88 Uganda, 163 Unauthorized children, 134–​35 Unauthorized or undocumented persons, 32–​33,  39–​40 case illustration, 136 definition of, 132–​33 demographic profile, 133 health care, 58 health needs, 134 targeting, 136 Unhoused persons. See Homeless persons United Kingdom, 8, 16–​17 United States biomedical belief systems, 14 CHW initiatives and programs, 76 community health workers (CHWs), 8, 9, 18–​19, 77, 94, 112, 154, 161 community navigators, 74 demand for CHWs, 8, 76, 154 demographic profiles and trends, 4, 7,  53–​54

diversity, 41 dual eligibles, 24 foreign-​born population, 133 healing systems, 41 health care, 20–​21, 41 health care delivery, 19 health care system, 49–​50, 54–​58 health crisis, 20 health inequity, 48–​49 health navigators, 74, 164 homelessness, 138 Latinx population, 54 mental health needs, 7 Patient Protection and Affordable Care Act (ACA), xi, 5, 8–​10, 52–​53, 57, 78–​79, 99, 102, 164 United States Department of Health and Human Services, 78 definition of homelessness, 137–​40 findings on CHWs, 165–​66 United States Department of Justice, 123–​24 United States Department of Labor, 76, 77 University of Hawaii Maui College, 78 Unsheltered, 139 Urban communities health inequity, 48 marginalized,  25–​26 substance abuse, 143 Urban health care delivery, 3–​4, 52–​58 Urban transition clinics, 125 Urban youth, 71 Values, 28–​31,  62–​64 cultural, 57 familismo, 94 Veterans, homeless, 139, 140–​41 Villabona, Spain, 125 Violence against CHWs, 30 Visual ethnography, 25, 31 Voice-​based feedback,  5–​6 Volunteer CHWs, 13–​14, 89, 166. See also Community health workers (CHWs) motivation for, 158 peers, 17 recruiting, training, and supporting,  110–​18

Index  257 Wages, 112 Wait time, 57 War zones, 111 Washington, D.C., 112, 142 Water, drinking, 24 Web-​based feedback,  5–​6 Women HIV-​positive transgender women, 142 HIV prison peer programs, 16 Maternal, Infant, and Early Childhood Home Visiting Program, 99, 102 maternal and infant care, 24, 88 maternal health, 27 Work environment, 111 Workplace clinics, 153 Work-​related injuries, 50 World Health Organization (WHO), 6, 19 Young children, 102 Young CHWs, 16, 54. See also Community health workers (CHWs)

Youth, 155 classification of, 123–​24 of color, 53–​54 community-​based participatory research with, 171 demographics,  53–​54 formerly homeless, 142 homeless, 138 incarcerated, 124 Latinx, 54 LGBTQ, 142 population group, 70, 71f, 71 runaways, 138 street youths, 138, 139 systems youths, 138 throwaways, 138 urban, 71 Youth empowerment, 29 Youth-​led research, 175 Youth peers (YPs), 15