Individual and Systemic Barriers Blocking Community Health Workers from Helping the Seriously Ill

Abstract

Background:

Palliative care is a valuable component of health care that improves a patient's quality of life, yet its availability to patients with serious chronic illness remains relatively low. Due to their knowledge of community preferences and ability to improve patient education and access to care, community health workers (CHWs) can increase palliative care usage by patients. Notably, barriers to CHWs helping patients with serious chronic illness remain poorly understood.

Objective:

Explore the perception of barriers CHWs feel they face when attempting to support the health care of patients with serious chronic illness.

Design:

Qualitative semistructured individual interviews of CHWs and qualitative descriptive analysis.

Setting/Subjects:

Twelve CHWs who have worked with patients with serious chronic illness were recruited from the Johns Hopkins Healthcare LLC and the Baltimore Alliance for Careers in Healthcare organizations to virtually participate.

Results:

CHWs perceived both active and passive barriers that obstructed their efforts to work with seriously ill patients. CHWs shared that these barriers were dependent on themselves, their peers, and their work environments. Prevalent themes included interprofessional conflict, poor health care worker understanding of the CHW's role, and lack of access to quality resource organizations. CHWs noted job-specific training, better means to identify needed resources for patients, and inclusive health care teams as solutions to support their professional goals, while helping patients with serious illness.

Conclusions:

There are multiple perceived barriers to CHWs helping seriously ill patients. CHWs aiding patients with serious illness can be supported through better job training, better resource management tools, and improved communication between health care team members.

Introduction

Providing high-quality palliative care can lead to improved quality of life and increased likelihood of patients with serious illness dying in their preferred environments.^1–3 Serious illness conditions are defined as any health condition carrying a high mortality risk and either negatively impacting a person's daily function/quality of life or excessively straining their caregivers.⁴ Notably, palliative care and its benefits can begin from the initial diagnosis of serious illness to a patient's end of life. However, palliative care remains underutilized due to a number of factors, including the limited palliative care workforce and low physician referral rates, among other patient/family-, provider-, and system-level factors.^5–7 Recently, community health workers (CHWs) have been employed to address these multilevel barriers to palliative care use through culturally appropriate patient education and direct resource linkage.^8–14

While CHWs have a strong track record of effectiveness in multiple chronic disease states both in the United States and abroad, to improve receipt of evidence care and resultant outcomes, their role among patients with serious illness and receipt of palliative care is relatively new.^15,16 Currently, robust studies show CHWs can increase palliative care access and utilization, while decreasing health care costs, especially in underserved communities.^13,17–20 However, similar to other chronic diseases, poorly defined roles, poor buy-in from staff, and lack of CHW effectiveness metrics continue to hinder CHW integration into health care teams.^12,21–25 To better aid the implementation and sustainability of these effective CHW models, studies are needed to further evaluate and explore these barriers to CHW integration into interprofessional teams involved in serious illness, inclusive of those in need of palliative and end-of-life care.²⁰

We aimed to fill this gap in the literature by conducting semistructured interviews of CHWs to explore barriers to CHWs aiding patients with serious illness, including CHWs' attempts to augment patient access to palliative health care and to provide aspects of palliative care themselves. Second, we report solutions offered by CHWs to increase their utilization, performance, and positive experiences, while working among patients with serious illness.

Methods

Study design

We used a qualitative descriptive approach with semistructured interviews to explore barriers to CHWs working among patients with serious illness, who may be eligible for palliative care. The World Health Organization's definition of palliative care was used, which detailed the practice as, “an approach that improves the quality of life of patients (adults and children) and their families who are facing problems associated with life-threatening illness. It prevents and relieves suffering through the early identification, correct assessment, and treatment of pain and other problems, whether physical, psychosocial, or spiritual.”²⁶

Interview recruitment and participation

Participants were recruited through an email recruitment letter explaining the study background and inclusion criteria. The email recruitment letter was shared with two Baltimore-based organizations, the Johns Hopkins Healthcare LLC and Baltimore Alliance for Careers in Healthcare. These two organizations hire and train CHWs to work in diverse specialties and health care settings, which aligned with the team's interests in hearing from a diverse set of CHW perspectives. After a CHW expressed initial interest, a meeting was conducted over Zoom to further explain the study background and to answer any question before confirming their interview interest. A final Zoom session was then held to conduct the interview. Participants were required to be employed CHWs, who reported they worked with or thought of working with patients with “significant, serious illness.”⁴ Participants were monetarily compensated after completing their interview session.

Interview guide preparation

Interview guide questions were derived from experts on the research team. FJ and JW generated the initial interview guide questions based upon their expertise in palliative medicine and CHW models of care. This initial interview guide was piloted in two interviews by JR and EP. The full research team then met to discuss changes to make to the guide based on areas of poor clarity and/or inadequate exploration of barriers. In total, two versions of the interview guide were generated and piloted. The final interview guide included 16 questions (Supplementary Data S1). The interview guide explored a CHW's self-perceived barriers through contextualizing each CHW's patient population, work motivations, opinions on CHW utility in palliative care, and perceived barriers to their work in these populations.

Collection of qualitative data and study setting

All participants were provided with an oral consent statement. Interviews were conducted by one of three investigators (J.T.R., O.S., or E.P.) over a Health Insurance Portability and Accountability Act (HIPAA) of 1996-approved Zoom platform (Zoom; Version: 5, 2021; Zoom Video Communications, Inc., San Jose, CA). The Zoom platform was also used to record interviews and generate transcripts. Interview recordings ranged from 40 to 90 minutes. The transcripts were reviewed and edited afterward for accuracy and de-identification. Interviews were held until saturation was reached, which occurred after 12 interview sessions. Saturation was defined as the point during analysis when no new theme could be identified from the data.²⁷ All interview data, including piloted interview guide data, were included in the study analysis.

Coding and analysis

Transcripts of Zoom interviews were analyzed by two investigators (J.T.R. and O.S.) using thematic analysis, as described by Braun and Clarke.²⁸ More specifically, an interpretative methodology was used under a constant comparative framework for analysis, and investigator incongruity was resolved through consensus discussions.²⁹ During each of the five total meetings, the team discussed codes, the emergence of new themes, and the relevance of previously established themes. The specific number of participants included under the decided upon themes can be found listed within (Supplementary Table S1). Codes were constantly reexamined to accept or reject earlier conclusions as new data were collected. The research team applied qualitative description analysis as there was no framework to describe barriers to palliative care from a CHW perspective.

NVivo software (NVivo qualitative data analysis software; Version 12, 2020; QSR International Pty, Ltd., Burlington, MA) was used for coding and to facilitate analysis. Following thematic analysis, findings were found to fit the socioecological model, facilitating a unifying representation of how study themes interconnect to describe CHW behavior and role perceptions. The study was approved by the Johns Hopkins Medical Institution Institutional Review Board on 8/7/2020 (IRB00250583) and conducted January to September 2021.

Results

Thematic saturation was met after interviewing 12 participants. While 18 CHWs initially expressed interest, 6 did not respond to schedule an interview after attempts at contact through email/phone during the recruitment process, and recruitment continued until thematic saturation was met. CHW contextual data can be found summarized within Table 1. Seven major themes were conceptualized from participant data. These major themes were categorized under individual, interpersonal, or systemic domains (Fig. 1).

Table 1.

Participant Contextual Data

Category	n (%)
Total participants interviewed	12 (100)
Age in years
30–40	2 (17)
41–50	3 (25)
51–60	1 (8)
No response	6 (50)
Gender
Female	12 (100)
Male	0 (0)
Race/Ethnicity
African American	5 (42)
Caucasian	1 (8)
Latinx	1 (8)
No response	5 (42)
Years in profession
1–5	5 (42)
6–10	1 (8)
No response	6 (50)
Patient population ailments
Congestive heart failure	3 (25)
Drug addiction	1 (8)
Sickle cell crises	1 (8)
Variety of serious conditionsa	7 (58)
Identified roles
Case management and resource connection	7 (58)
Patient education	4 (33)
Emotional and psychosocial support	6 (50)
Patient advocacy and liaison work	5 (42)
Direct aid (medication and supplies delivery)	2 (17)
Proportion of a CHW's patient population with serious chronic illness (%)
<10	1 (8)
11–40	1 (8)
41–70	3 (25)
71–100	7 (58)

^a Illnesses included HIV, cancer, kidney disease, heart failure, drug addiction, and chronic diabetes.

CHWs, community health workers.

FIG. 1.

Social ecological model applied to CHW self-perceived barriers. CHW, community health worker.

Individual-level barriers

CHW attitudes and professionalism

One recurring theme was that CHWs could impose barriers on themselves by lacking a high appreciation for their work (Table 2). A CHW noted,

Table 2.

Themes Inhibiting Community Health Workers Working With Patients With Serious Chronic Illness

Individual-level themes	Representative quotes
CHW Attitude and Professionalism	“And so, one of the biggest challenges like I mentioned before is a [CHW] that is not passion driven.” (ID 10)

Interpersonal-level themes	Representative quotes
Interprofessional Conflict	“I mean, I'm not talking about examples. I'm talking about stuff I have witnessed where I've been made to feel less than, but I actually knew a lot of stuff. So yeah, that's a barrier right there. [Healthcare workers] still don't honor our thoughts or that there is something of importance that we can tell you because [healthcare workers] are the licensed.” (ID 5) “And at some point, you're no longer going to have that desire and motivation to get up every day and go to work, because the first thing you're thinking about is not the patient, but you're thinking about these care team members who think that you don't know what you are doing or that there is no need for you here.” (ID 4)
Misunderstanding of CHW Role	“I can honestly say until I came with this organization. They didn't really know what a community health worker was and what was the purpose of the community health worker in this organization.” (ID 10) “I think one of the challenges will be the fact that when a lot of people think of palliative care they think clinical…People will automatically assume that we are not qualified to provide any type of palliative service, although we just read the definition and clinical medical care is not the only type of palliative service that we're looking for.” (ID 1)
Poor Patient Engagement or Life Factors	“Sometimes if they're not in in a safe place…you know, if you don't have the, the quiet, or the structured environment to assist them, you know, then they can't focus on what it is that I'm trying to help them with, because there's so many other things going on” (ID 10) “Another challenge would be, you know, I'd make plans on a daily basis with these patients to get certain things accomplished, and it never goes as planned. They don't show up on time for appointments.” (ID 6)
Provider-Patient Communication Barriers	“Even being in palliative care… I've gone into a number of clinic appointments with members… the member could be talking, and a doctor will have their back faced and their fingers clicking on a computer. There is never that social connection.” (ID 1) “And doctors are using medical terms and different things that maybe the patient doesn't understand. A lot of them will say ‘okay yeah they get it’ but really, they didn't” (ID 5)

System-level themes	Representative quotes
Pandemic-exacerbated health care hesitancy or resource shutdown	“Well again you know the special circumstance when I came on board. It was during COVID so there were definitely barriers and challenges to trying to get patients connected to facilities and different things of that nature.” (ID 3)
Resource Organization Inadequacy	“And that is very, very frustrating as a community health worker because—hence the name, hence the title, hence our position—we are COMMUNITY health workers. We collaborate with the community… So, if we are out in the community trying to find resources for the members in palliative care, and we're not able to find anything that's effective, that can actually come through and help this particular member, then it's like trying to find a needle in the haystack.” (ID 8) “I think [the transportation service] is a useful service for the patients who need it, for the residents of Baltimore who need it, but I think their customer service is horrible.” (ID 6)
Job Rigor and Preparation	“Having a large, large caseload … you aren't afforded the time to spend with each patient that is really needed to, you know, to get to know your patient and their family.” (ID 2) “I think there needs to be more specific training for palliative care as CHW, we all completed our training together. So, I think, while the training was like I said very extensive I think training, that would be specific to palliative care would be needed to have a large group of CHWs working in palliative care” (ID 2)

“A patient is dealing with more things than you can even imagine because it's not, it's not just a terminal illness they're dealing with, they have levels of care. And so for one, that is one of the biggest challenges that I have had since I've started in this field of people who are not passion driven about being a community health worker” (ID 10)

Relatedly, multiple CHWs expressed the significant level of respect they have for their jobs and their roles as patient liaisons and trusted community members.

Interpersonal-level barriers

Interprofessional conflict

Another obstacle was active and passive barriers generated by conflict between health care professionals (Table 2). Active barriers were those generated with intent from the initiator, such as a co-worker choosing not to share resource organization information or exclusion from team meetings. Passive barriers lacked specific intent and typically were more systemic, multifactorial domains, such as a culture of low respect, which led to suboptimal environments for CHW job success. Participants noted that certain attitudes, such as superiority over workers without a degree and tensions regarding job encroachment, created these feelings of low respect. One CHW shared,

“And so, in the beginning I was not recognized, I was not recognized at all. I felt like they just [thought] that the patients were just coming in, just because it was a brand-new day and they all of a sudden had transportation just because the bus pulled up. No, it was because I worked.”

CHWs who expressed feelings of being undervalued by health care workers noted promoting a culture of inclusivity as a partial solution (Table 3).

Table 3.

Community Health Worker Generated Solutions to Decrease Common Barriers, While Working With Patients With Serious Chronic Illness

Barrier	Representative CHW proposed solution	Implementation strategya
Poor job preparation and onboarding	“Job-specific training”	Create a multiday job training course tailored to the specific field the CHW will be working in.50
Out of date/disorganized resources information for patient referral	“Better ways to identify & obtain the needed resources for patients”	Increase knowledge of resource hubs such as www.FindHelp.org during onboarding process51
Interprofessional conflict from lack of respect	“In order for the CHW to be effective, the care team has to be inclusive”	Allow and encourage inclusion of CHWs in meetings with the entire care team after a clear introduction of roles/responsibilities to share their unique perspective on treatment plans48
Poor patient engagement in their health care	“We have to build our patient up to actually doing things for themselves”	Invest in policies and initiatives that bolster patient health literacy; interventions/strategies to encourage and support patient empowerment, self-efficacy52
Medical jargon and poor patient understanding of disease implications	“It wouldn't matter if [the clinic meeting] is 10 minutes or 30 minutes. It's all about how that information or the conversation, what's delivered how it's delivered”	Counsel providers to use active listening assessment and teach back techniques to help impart information at patient level, in addition to supporting patient and CHW communication engagement with providers53

^a Implementation strategy examples were researched and proposed by the authors, not the CHW participants themselves.

Misunderstanding of the CHW role

Poor understanding of the CHW role by other health care workers created barriers to CHWs working within the palliative care realm (Table 2). CHWs shared that other health care professionals lacked an awareness of the role a CHW served or assumed the role significantly overlapped with others. Moreover, health care workers who did not appreciate the psychosocial and spiritual dimensions of palliative care underemphasized the value CHWs added. One CHW noted,

“We are not here to be the social worker or the case manager, so your jobs are not in jeopardy, we are just a layer, another layer on to the team.”

Poor patient engagement or life factors

CHWs noted that patients themselves or their contextual experiences could hinder CHW support (Table 2). More specifically, participants noted that poor patient attitude, readiness to change, or lack of trust were key barriers. One CHW noted,

“The very first [barrier] is when a patient does not understand when they really need help. And they, they agreed to help, but they never communicated. They never follow up with you.”

In addition, participants emphasized that socioeconomic factors greatly increased the job difficulty. Participants noted that patients with poor health literacy, underinsured patients, and homeless patients presented practical dilemmas. CHWs noted the importance of supporting patients in taking agency over their health care to increase their health care utilization. One CHW noted,

“Sometimes I don't feel like I'm even equipped to do [action items] for 12 patients in one day… Sometimes I have to tell whoever I didn't get to meet that day I need you to come back tomorrow. So I think if we could get our patients, a little bit more self-empowered, a little bit more independent and stop doing every single thing for each and every patient we will get better results because I tell my patients all the time if you really want something, you're not going to wait on me to get it.” (Table 3)

Provider-patient communication barriers

CHWs noted that providers can hinder the care of patients with serious illness (Table 2). Participants cited short visits and ineffective communication between providers and patients as domains that hindered patient understanding of their disease and decreased the probability of health care engagement. One CHW stated,

“If you [are] just briefly running in and don't have a connection with the patient, that's a barrier right there. If the patient is in any way, shape, form, or fashion feeling as though that they are not being listened to or heard or any of that, that's a barrier. You haven't built no type of trust.”

Another CHW shared,

“The patient being undereducated is the biggest [barrier]. The doctor will use terms that we understand in the healthcare industry… if the doctor would you know say it's important for you to take this medication because it will help you stop having headaches throughout the day or your legs won't swell up… just a little bit more time to educate the patient about what their disease is, it can help the patient want to transition into the palliative care model.”

Multiple CHWs noted the importance of assessing patient understanding during health care interactions to decrease communication barriers (Table 3).

System-level barriers

Pandemic exacerbated health care hesitancy and resource shut down

CHWs noted that working during a pandemic created challenges revolving around resource organization access (Table 2). CHWs expressed that patients skipped health care appointments to minimize COVID-19 exposure risk. A CHW noted,

“And then the people who don't have [COVID-19], they're at home suffering with their illnesses because they're afraid to come in because they don't want to come in contact with people that have it, or possibly have it.”

In addition, resource organizations offered a smaller range of services due to limitations related to in-person interactions. Overall, these limitations hindered the CHWs' abilities to connect patients to resources aimed at helping their serious illness.

Resource organization inadequacy

Multiple CHWs emphasized that poor quality of resource organizations created further obstacles for CHWs (Table 2). Participants expressed struggles to find resource organizations to fulfill certain needs, and also noted that certain low-quality organizations showed low initiative to provide outreach to their respective communities, a lack of an online presence, and consistently poor customer service. One CHW expressed,

“You have a lot of community agencies out there, but they are not putting themselves out there to help the community…You find a particular agency that says, ‘hey we do this.’ When you call them … they don't have the resource, or there is some kind of negative response”

CHWs noted having better tools to find resources would help decrease this poor community outreach effort and/or resource organization quality barrier (Table 2).

Poor job preparation, logistical difficulty, and emotional difficulty

Multiple CHWs shared that certain CHW job components made it harder to meet their professional goals (Table 2). CHWs reported that a lack of training led to difficulty regarding how to perform their job and confusion surrounding what their specific role was. CHWs noted that receiving both clear expectations and specific training would be a solution (Table 3). Other CHWs knew their job expectations, but struggled still because of the emotional gravity inherent to working with seriously ill patients. One CHW explained,

“Many times, I would break down in my car because you see the limitations, you're faced with…It can be really tough… I went home and slept the entire night and the entire day the next day, because of how emotionally drained I was.”

Discussion

This study explored the poorly researched area of barriers to CHWs working among patients with serious chronic illnesses. CHWs collectively elucidated individual, interpersonal, and systemic barriers. Mechanistically, these barriers either actively created an obstacle CHWs had to overcome or passively created an environment inconducive to learning, job performance, or teamwork. Participants also recommended actions to decrease the impact of barriers: enhanced and targeted job training, more interconnected work environments, better resource management software and organizational tools, and better patient counseling/education from providers to facilitate patient understanding of and engagement in their own care.

In this study, CHWs discussed interprofessional conflict as a barrier, which aligns with findings from previous reviews that examine interdisciplinary palliative care teamwork.^30,31 When it occurs, interprofessional conflict commonly obstructs professionals from advancing their work goals.³⁰ This conflict leads to worse team dynamics and patient outcomes, and increases the probability of workers leaving their jobs.^31,32 Studies of professionals working with seriously ill patients found the likelihood of interprofessional conflict increases with the presence of risk factors such as role blurring³³ and low mutual respect.^34–37 Indeed, CHWs within this study emphasized perceived role overlap with social workers and low respect from colleagues were catalysts for interprofessional conflict.

The unproductive confusion that comes from poor boundaries between social workers and patient navigators is not a new concept,³⁸ and this study supports the notion that there remains a need to clarify CHW role boundaries.³⁹ Regarding low workplace respect, CHWs perceived they were respected less because they lacked degrees, a sentiment shared by workers in multiple fields.⁴⁰ CHWs in this study shared that inclusion within team meetings can decrease friction among workers and feel more recognized. Without this inclusion, CHWs felt a decreased motivation to come to the workplace.

CHWs also emphasized barriers dependent on system-level factors. One notable system-level barrier was pandemic-exacerbated health care hesitancy or resource shut down. CHWs reported struggling to engage seriously ill patients due to COVID-19 hesitancy and poor resource maintenance. Participants noted that restrictions on in-person appointments and patient desire to decrease exposure risk led to significant declines in diagnostic, screening, outpatient, and primary care appointments, aspects of health care critical to the patient population with serious illness.

Our participant experiences align with literature demonstrating that the COVID-19 pandemic decreased outpatient health care engagement, including specialty palliative care services.⁴¹ While the demands of the pandemic make their job harder, CHWs are also positioned to help the logistical and clinical problems, which occurred throughout the pandemic. Researchers have noted the potential for CHWs to bolster psychosocial support and mental health services, decrease logistical and financial challenges faced by minority populations, and build community awareness and contact tracing in the United States.^42,43

Globally, CHWs have been mobilized most significantly through well-established government-run CHW programs in low- and middle-income countries, bolstering community awareness, while aiding in contact tracing efforts.⁴⁴ In short, CHWs have been invaluable in responding to the increased pandemic health care needs, especially within marginalized populations across the globe. Further research exploring CHWs' abilities to help patients with serious illnesses belonging to communities of low socioeconomic status and/or communities of color is needed to optimize the aid to these populations with disproportionately worse health care outcomes.

Clearly, CHWs add value to the health care team and deserve to be supported in their profession. Current research is exploring different types of support such as coupling CHWs with digital technology to maintain community health care access, as well as characterizing the best job training modalities.^45,46

Notably, CHWs in this study expressed desires for more specialized training. For example, participants reported that they felt inadequately prepared to share the nuanced set of resources for significant health conditions, such as heart failure, and noted increased specialized training would better prepare them for workplace success. These sentiments align with a systematic review that found CHWs felt they lacked training specific to palliative care, and were ill prepared to manage the emotional distress of patients at the end of life and within themselves.⁴⁷ Results from this study can be used to understand how CHWs define their professional role and to disrupt barriers to their professional success.

Together, the individual, interpersonal, and systemic barriers apply multiple influences over CHWs and their work. The influences these barriers place on CHWs can be conceptually organized in terms of the socioecological framework, a tool used to understand the distinct factors that impact a system⁴⁸ (Fig. 1). Previous studies have applied the socioecological framework to understand the roles of CHWs and sustainable CHW programs across progressively broadening individual, interpersonal, and systemic domains.^18,49 For example, researchers have previously conceptualized certain factors of CHW program sustainability under intrapersonal (e.g., Client characteristics), interpersonal (e.g., Client-CHW relationship), and community (e.g., Linkages and service integration) domains.⁴⁷ Similarly, our study uses the social ecological framework to conceptualize the barriers to CHW work through individual (e.g., CHW attitudes and professionalism), interpersonal (e.g., interprofessional conflict), and systemic (e.g., resource organization inadequacy) domains.⁴⁸

Strengths

There are notable strengths of this study. Our qualitative approach allowed for the creation of a framework to understand future discussions revolving around CHWs' professional identities and barriers in palliative care. Confusion remains around the roles of CHWs in the workplace, and this study provides frameworks to understand barriers CHWs perceive in executing their roles and provides suggestions for addressing those barriers. CHWs positively influence clinical aspects and social aspects of care, functioning as a cost-effective adjunct to the health care team. As future health care organizations and lawmakers act to integrate CHWs into health care teams further and reimburse for their work, studies such as this one are positioned to add value to that integration process.

Furthermore, our findings can aid a doubly vulnerable patient population, the underserved and patients with serious illnesses. CHWs commonly work with underserved patient populations, namely patients of low socioeconomic status and belonging to communities of color, while the seriously ill represent a patient population with increased health requirements and decreased margins for patient error.

Limitations

There are a few limitations to this study. Sampling from two CHW network hubs led to perceptions weighted to the views of CHWs in the Baltimore area. While CHWs are overwhelmingly female,⁵⁰ further interviews are needed from perspectives that represent greater diversity in sex/gender to increase transferability of these findings. Furthermore, there is an element of potential participant bias, as CHWs who were more familiar with palliative care and more educated in coordinating access to palliative may have been more likely to participate.

CHWs less familiar with these palliative care elements would be less likely to respond to the email advertisement even if their work overlays this domain partially. In addition, we choose to minimize use of some demographic information, given the small group of CHWs and the desire to avoid the risk of identifying information. This limits the generalizability of our study findings and the ability to extrapolate demographically relevant conclusions. Yet generalizability is not the purpose of this work and these findings provide a framework for future larger scale work, which may aid in the implementation and sustainability of CHW-based interventions.

Conclusion

This study adds to the scant body of knowledge regarding the roles and attitudes of CHWs as they work with patients with serious illnesses. Through semistructured interviews, a greater understanding of the CHW experience within the health care system was fostered, showing that barriers across both individual and systemic domains place great strain on CHWs as they try to meet their professional goals. Finally, potential solutions to overcome certain barriers were collected, highlighting a need for better job training, better tools, and improved communication between health care team members and their patients.

Authors' Contributions

(1) Conception and design: J.T.R., E.P., J.W., and F.M.J. (2) Administrative support: F.M.J. and J.W. (3) Provision of study materials or patients: all authors. (4) Collection and assembly of data: J.T.R., E.P., and O.S. (5) Data analysis and interpretation: all authors. (6) Article writing: all authors. (6) Final approval of article: all authors.

Data Management

The data and analysis material related to this study are maintained and managed according to organizational guidelines and ethical regulations. In the interest of participant confidentiality and anonymity, this information will not be made publicly available. Requests for further information can be directed to the corresponding author.

Funding Information

This work was supported by the Dissemination and Implementation of a Community Health Worker Intervention for Disparities in Palliative Care (DeCIDE PC) grant; grant no. 5R01CA252101.

Author Disclosure Statement

No competing financial interests exist.

Supplementary Material

Supplementary Data S1

Supplementary Table S1