Community Health Workers: Social Justice and Policy Advocates for Community Health and Well-Being

Abstract

Community health workers are resources to their communities and to the advocacy and policy world on several levels.

Community health workers can connect people to health care and collect information relevant to policy. They are natural researchers who, as a result of direct interaction with the populations they serve, can recount the realities of exclusion and propose remedies for it. As natural researchers, they contribute to best practices while informing public policy with the information they can share.

In this light, community health workers may also be advocates for social justice.

COMMUNITY HEALTH WORKERS are the integral link that connects disenfranchised and medically underserved populations to the health and social service systems intended to serve them.1^–3 Worldwide, community health workers—also known as promotoras, natural helpers, doulas, lay health advisers, and frontline workers—increase access to care and provide health services ranging from health education and immunization to complex clinical procedures in remote areas where they are often the only source of health care.4

Community health workers have appeared repeatedly throughout history as those who heal others and help communities thrive.5^,6 Although the central role of community health workers is to be outreach workers who help clients access health or social services, they do more than merely link individuals to a doctor’s office. Community health workers play a paramount role in connecting people to vital services and helping to address the economic, social, environmental, and political rights of individuals and communities. They are also “natural researchers”—they can observe and relay community realities to outsiders—placing them in a position to influence policies that affect public health. Their history and the breadth and scope of the roles they serve distinguish them as social justice and policy advocates for underserved communities across the world. Their work is linked to social justice precisely because it focuses on ensuring that individuals and communities share equally in the benefits society has to offer.7 Likewise, as policy advocates with close relationships with the communities they serve, community health workers are in the position to inform policies based in reality. This role as social justice and policy advocates must be upheld in community health workers’ development and as they become critical figures in the integrated system of health care.

Public health literature has examined the relationship between community health workers, community health work in general, and social justice.8^–10 Farmer et al.11 espoused the value of community health workers as advocates for patients’ health. Their discussion focuses on the history and importance of community-based participation in health care and on the broader vision of health and human rights. Specifically, they see a practical benefit in community health work, not only in the connection of patients to care and services but also in community health workers demonstrating how the issues that people face in their lives, both those directly related to health and those that result from social, economic, cultural, or political exclusions, impact their life conditions, which may be the more relevant unit of analysis for an illness than illness itself.

Others look at the subject from a broader community health lens, focusing on how community health work and partnerships in the community succeed in promoting better community health outcomes, including more-equitable environments and personal economies.9 Politzer et al.10 have discussed the importance of community health centers, specifically their efforts to reduce racial and ethnic health disparities in low-income communities.

Along this theoretical construct of defining health and assessing outcomes in health is the following question: are diseases to blame for illness, or are established health and social policies and structures the more germane unit of analysis?12^,13 In other words, what are the perceptions, decisions, policies, and structures that determine one’s health before the disease? Considering this body of work and its significance in pointing to some of the root causes of poverty and ill health (broadly defined), we also ask what else is required to fill the gaps. Who else is necessary to raise consciousness about those most excluded and their needs and rights? In this context, the work of community health workers must be understood on 2 levels, as those who can connect people to care and as advocates who can attest to the realities of marginalization and how it must be remedied. The natural research component of community health work activities is critical to contributing to best practices in the field and also to influencing thoughts and paradigms. Those working on the front lines in the community are concerned about changing the social ills, institutions, and policies that contribute to disease. In this light, community health workers are natural helpers and researchers and advocates for social justice. Here, we share our thoughts about the importance of recognizing community health workers’ function and about their historical and current role as advocates for health, social justice, and human rights.

ORIGINS OF COMMUNITY HEALTH WORKERS

The history of community health work can be traced to the early 17th century. During a shortage of doctors in Russia, laypeople known as feldshers received training in the field to provide basic medical care to military personnel.5 Also known as “barber-surgeons,” the feldshers provided low-cost health care to a marginalized population. The formalization of these healers became the foundation of the training of “barefoot doctors” in China.6 The barefoot doctors were laypersons, many of whom could not afford shoes, and were educated in setting broken bones, delivering babies, treating wounds, and meeting other basic medical needs. Their mission was to take primary health care to remote rural areas that were without doctors.

Promotores became a powerful force in Latin America in the 1950s, when labor rights and liberation theology—a Catholic dissident movement that sought to empower the poor against their oppressors14—were on the rise. Community health workers thrived throughout the region, their role being to help remedy an unequal distribution of health resources and to bring health care to the poor. They employed popular education theory, which seeks to help people organize their knowledge and use it to benefit their communities.15 Community health workers played an essential role in connecting people to needed services and in transferring the advocacy capacity to their constituencies.

In the 1960s, community health workers began to emerge in the United States as part of the Great Society domestic programs. The mission of the Great Society efforts was to end poverty, promote equality, improve education, rejuvenate cities, and protect the environment.16 As part of the Great Society’s new careers program, the government created and promoted community health work jobs as entry-level positions for career development. In the early 1960s, the federal government began to formally support community health work programs through the Federal Migrant Health Act of 196217 and the Economic Opportunity Act of 1964.18 Both pieces of legislation mandated outreach efforts to low-income neighborhoods and migrant worker camps. The first community health work programs established under the Economic Opportunity Act of 1964 were part of neighborhood community health centers such as the Columbia Point Housing Project in Dorchester, Mass.19

In 1968, the Indian Health Service founded its community health representative program to work with tribal managers in the federally recognized American Indian and Alaska Native communities. Since then, the Indian Health Service has maintained the only categorical community health work programs in predominantly American Indian communities in the United States.20

The rising prominence of community health work programs began to wane in the 1970s and early 1980s. In the late 1980s and early 1990s, community health work programs resurged in migrant and seasonal farm-working communities. Programs established during this period include the Camp Health Aide Program, sponsored by the Midwest Migrant Health Information Office; the Border Vision Fronteriza Program, based at the University of Arizona; and Nuestra Comunidad Sana, based in Hood River, Ore. All of these programs remain an integral component to the health care delivery system of their respective states.

Throughout history, community health workers have emerged and reemerged as a critical response to a health care crisis—a crisis that was identified during a social or political upheaval that sought to redress social injustice and inequity. In the United States, as witnessed in the 1960s and later in the 1980s and 1990s, community health workers became vehicles for social justice in socially and politically charged contexts. For example, the health and social challenges of marginalized migrant communities, and the legislation that recognized them as well as other civil rights–influenced policies, helped to create a role for community health workers as those who link vulnerable populations to needed services and information.

On health outcomes, research has suggested that the reliance on community health workers and techniques that are part of a cultural competency model could theoretically improve the ability of health care providers to deliver appropriate services to diverse populations, helping to improve health outcomes and reducing health disparities.21 Moreover, there is evidence that the efforts of community health workers have improved pregnancy and birth outcomes as well as health- and screening-related behaviors.22 A growing body of evidence documents the effectiveness of community health workers in diabetes care and education efforts.23

Community health workers play the role of the trusted adviser and health navigator in the community, but at the same time they share their communities’ issues with different policymakers. They are people who influence health outcomes both through their ability to connect people to care and through their participation in public policymaking.24

The course of history, as it relates to the rising role of community health workers, continues to define the impact and scope of the influence of these workers on the health system of the United States. The need for these types of workers has also defined the characteristics and qualifications of the community health work role. The auxiliary responsibilities to improve social, environmental, and economic conditions to affect health are essential to the role of a community health worker.

Community health workers in different parts of the United States work for the rights of inclusion of the most marginalized. In communities densely populated with new immigrants, for example, community health workers play a critical role in helping to advise communities of their rights on immigration laws and, in some cases, helping their clients navigate highly bureaucratic systems.24 They also help people register to vote, and they help victims of domestic abuse find shelter and counsel their clients as to their rights under the law. Working in an economically and socially oppressed neighborhood in Miami, Fla, one community health worker recounted,

Ninety-five percent of my work is helping people get basic needs [met] like food, shelter, employment, and [a] safe and decent environment, even before we begin to talk about diabetes or asthma. (K. Joseph, Human Services Coalition of Dade County, oral communication, July 2006)

When asked to explain her work in one sentence, she said “it is about getting people from poverty to prosperity and doing whatever it takes to get there.” Social, environmental, and political issues affect the communities community health workers serve, so they must approach health in a holistic manner. If there is not a good quality of life in the social, environmental, or political spheres of individual or community existence, it will affect individual and community health.

Community health workers’ translation of these complex cases for policy advocacy is as important as their ability to connect a client to care. As one public policy director expressed (A. Colon, Human Services Coalition of Dade County, oral communication, July 2006),

Public opinion shapes public policy and community health workers are the gatekeepers of the public’s opinion. They are in the field living the stories with the people. They create the case and convey the message; they rally the troops and add credibility to policy changes we advocate for.

The role of community health workers is vital as this advocacy group “engages the people who are really in crisis.” As the director explains, “the most profound stories, these are the ones the community health workers come back and share with us, these are the ones that enact change for the greater good.”

Community health workers are powerful and credible because they emerge from contexts in which there is a need for connection to the mainstream precisely because of conditions of health, social, economic, environmental, or political exclusion. The role has flourished, historically and presently, because there is a community need for an ombudsman, an advocate. Community health workers understand the complexity of the needs and are able to translate the issues to others in decisionmaking positions.

CONCLUSIONS

We support the current definitions and multiple functions elaborated in the literature on the role and functions of community health workers as part of the US health care system. However, we strongly caution that the history and underlying purposes of these workers should not be lost in translation in the midst of efforts to institutionalize their role. Our nation will equally benefit from a cost-efficient health care system as much as it would from working to change the root causes of illness.

As we continue to uncover the inequities that limit access to social, economic, political, and environmental well-being, the foundation and history of community health workers as advocates for social justice becomes increasingly relevant. Although health care access and quality care remains a laudable goal, the fact is that, day to day, too many people still do not have access to these benefits. Community health workers play a critical role in responding to and voicing the call for inclusion. They must be understood as a critical component of integrated systems of health care and as advocates for the myriad issues that keep people outside of the grasp of life, liberty, and the pursuit of happiness.

From a health policy perspective, the practical role of community health workers and the information that they have access to can inform how health practitioners and policymakers define health and well-being and how they can improve these areas. Their knowledge can improve system structures and inform how resources are allocated. Community health workers have the ability to serve as connectors and navigators of the health system, which is critical, but their work and firsthand knowledge must also be harnessed and expanded to ensure their capacity to affect policies and inform decisionmakers. Community health workers are resources to not only their communities as connectors to care, but also to advocates and policymakers, for the information they bring and the potential to create change.

Figure 1.

A group of children play at the garbage dump la Chureca in Nicaragua. Close to 2 million people in Nicaragua live in poverty, representing 70% of the population. Source. Photograph by Antonio Aragon. Printed with permission of Corbis.