Community Health Workers: Walking In The Shoes of Those They Serve
By harnessing trust, community health workers are becoming a powerful force for achieving health equity.
It didn’t take long last Spring for Dr. Shreya Kangovi to realize that the COVID-19 pandemic would create a tsunami of inequity where inequity already long existed. Then the murder of George Floyd led to a national racial reckoning, too. Kangovi knew that community health workers (CHWs)—a field she is helping to pioneer and advance—are first responders on all those fronts.
A recipient of a 2019 RWJF Award for Health Equity, Kangovi is a primary care doctor in Philadelphia, a health policy researcher, and a professor who works to improve health equity. Kangovi developed IMPaCT, a community health worker program that relies on trustworthy individuals to help their community members improve their health and well-being. In randomized controlled trials, IMPaCT has improved chronic disease control, primary care access, mental health, and quality of care while reducing hospital admissions. It is the nation’s most widely disseminated CHW program.
Kangovi shared insights about the ways CHWs advance equity and better health, and the role they can play as we cope with and recover from the coronavirus pandemic.
Who are community health workers and how do they advance health equity?
There is tremendous variation, but CHWs are trustworthy individuals who share life experiences with those they serve. They understand what it’s like to face injustice or be overlooked. They also have a personality type defined in sociology literature as “natural helpers.” So it’s a combination of demography and ideology.
CHWs are trained to navigate systems, such as health, housing, and legal support, and to link community and clinical services to help people in their own communities lead healthier lives. They meet people where they are, get to know them as human beings, learn their life stories, then ask them how they want to improve their life and health. They may need help connecting to food assistance, planting a community garden, battling an eviction notice, running an anti-racism training for police, or navigating other issues.
Dr. Kangovi discusses IMPaCT, a standardized, scalable community health worker program which has been proven in three randomized controlled trials to improve chronic disease, primary care access, mental health and quality of care while reducing hospital admissions.
If you haven’t been in the shoes of the person you are working with, you are more likely to be biased. Clinicians may believe we know what our patient needs, and screen and refer her. That’s neither effective nor trustworthy. CHWs change this dynamic.
In rural Tennessee, a CHW might work at a faith-based organization. He will meet somebody at a church, food pantry or local hospital. He’ll take an hour to get to know that person—to learn where he was born, what happened in his life, what challenges he faces, his successes, and how he wants to improve his life and health. There is some shared life experience. CHWs always reflect back to the person and ask: What do you want to do about that? Then they create a step-by-step plan together. It might include battling an eviction notice, organizing a virtual funeral for someone who died of COVID, or going together to a doctor's appointment.
What role are community health workers playing in the pandemic and what role should they be playing?
COVID disparities are a symptom of an underlying pandemic of injustice that has persisted through history. Headlines have shown that Black and Brown people are disproportionately dying of COVID. Millions of Americans are going hungry in a new Great Depression while others are getting rich. Ultimately this all stems from the same problem: the trajectory of health inequities.
That’s why CHWs are an incredibly valuable workforce. They don’t just address symptoms or disease; they go straight to the root and identify solutions. We had a pandemic of racial and economic injustice long before COVID. So we need more than a vaccine. The hardest thing is to address the full range of social determinants of health but it’s the only way to advance health equity.
Can community health workers help overcome reluctance or resistance to vaccination?
As a public health scientist myself, I want to help people get better and vaccination is critical. CHWs can help with access and information, but they are trusted because they are trustworthy. Being trustworthy means not having an agenda and just offering help. It’s incumbent on us in public health to communicate the good science we have done in a very accessible way so people can make their own decisions about whether or not they want to take the vaccine.
What gives you hope right now?
On the policy front, I think this is our moment. This work began as grassroots and it still is. CHWs are meeting people on their porches and at their bedsides, asking them how we should build this workforce. Community-engaged scientists are doing strong randomized trials that not only demonstrate that CHWs can be effective, but also how. We’re working with the National Committee for Quality Assurance (NCQA) to translate that science into standards for the CHW workforce. So I think we're ready for scale.
There are approximately 50,000 CHWs in the county. That’s not nearly enough. President Biden’s proposal to create jobs for 150,000 CHWs would get us a lot closer to where we need to be. We helped inform the Biden proposal. We worked with bipartisan lawmakers on proposals to pay CHWs for the full range of work they do. We’ve had great conversations with the Centers for Medicare & Medicaid Services (CMS) about allowing Medicaid to fund the full range of supports CHWs provide. That’s the most momentum we’ve seen in this field. That gives me great hope.