The Critical Role Hawai‘i's Community Health Workers Are Playing in COVID-19 Response Efforts

Abstract

Community health workers play an instrumental role in the health care system and are critical partners in pandemic response. In Hawai‘i, community health workers are working to reduce the burden of chronic disease among Pacific Islander, Filipino, and Native Hawaiian populations in partnership with government agencies and health care organizations. This commentary reviews the role community health workers in Hawai‘i are playing in assisting with the COVID-19 response. Utilizing their skills and the community's trust, they are optimally positioned to reach marginalized and vulnerable populations hit hardest by COVID-19; community health workers educate, screen, and provide social service referrals to community members.

Highlights

• Community health workers (CHWs) are an integral part of the healthcare system, especially during a time of crisis

• CHWs use their unique connection with the community to outreach to vulnerable populations

• CHWs must rely on partnerships with state and local entities to provide education and resources to communities on COVID-19

Introduction

Community health workers (CHWs) are trusted members of the communities they serve and play critical roles in the COVID-19 pandemic response.^1.2 CHWs in Hawai‘i are employed by various organizations, including but not limited to federally qualified health centers (FQHCs), hospitals, nonprofit organizations, insurance companies, and state agencies. CHWs bridge the community and the health care system by increasing access to care and advocating on behalf of patients.³ As cultural mediators between patients and systems of care, CHWs provide culturally appropriate health education, information, and direct services.⁴ CHWs promote health equity by addressing social determinants of health and improve health outcomes for people with chronic diseases through education and outreach efforts.^5,6 The purpose of this article is to describe social, economic, and health inequities that impact marginalized populations, and CHWs' efforts to promote equity during the COVID-19 pandemic. In addition, the article addresses how CHWs can contribute to the COVID-19 response in partnership with other organizations. Finally, the article describes potential training topics that may be helpful for CHWs' COVID-19 response work with marginalized and vulnerable communities.

Inequities During COVID-19

The COVID-19 pandemic exacerbated and highlighted existing inequities in Hawai‘i, particularly among Pacific Islanders. In June 2021, Pacific Islanders (PIs) accounted for 20% of the COVID-19 cases in Hawai‘i, although they made up only 4% of its population.⁷ In the same month, Filipinos had a disproportionately higher percentage of COVID-19 cases (20% of Hawai‘i COVID-19 cases) compared to their proportion in the population (16% of the population), while cases among Native Hawaiians were about equal to the proportion of their population (20% of cases, and 21% of the population).⁷

Several factors have likely contributed to health inequities around COVID-19, such as overcrowded housing, low-paying jobs for essential workers, and the prevalence of chronic conditions.⁸ Multigenerational households and overcrowded living situations could contribute to COVID-19 infection risk, creating challenges for people who are likely to live in these situations, such as Native Hawaiians, Pacific Islanders, and Filipinos (NHPIFs).^9,10 Employment is also a likely factor in high COVID-19 infection risk among NHPIFs, as they tend to hold occupations in industries deemed essential during the COVID-19 shutdown: health care; restaurants/foodservice; tourism; hotels/cleaning services; construction; security; retail sales; airport/airline services; and delivery services.^8,10–12 Finally, higher prevalences of diabetes, heart disease, stroke, and hypertension among NHPIFs increase risks for more severe forms of COVID-19 illness, highlighting how pandemics can deepen health inequities for marginalized and vulnerable populations.^13–16 To address the health disparities and higher COVID-19 infection risks among NHPIFs, CHWs play an essential role during the pandemic: They navigate the complex systems of care, increase access to health care, disseminate information, and improve health outcomes.³

CHWs Role During the Pandemic

The Hawai‘i Public Health Institute (HIPHI) conducted an informal needs assessment and focus groups between June and December 2020 to learn if and how CHWs' roles in Hawai‘i have changed during the COVID-19 pandemic. ^17–19 Of the 35 CHW participants in the needs assessment, 32 CHWs experienced a shift in their job duties due to COVID-19.¹⁷ CHWs saw their workload increase and COVID-19 responsibilities replacing their other work.¹⁷ Many CHWs noted changes to their daily duties, including adopting new technology and telehealth (due to challenges in meeting face to face and maintaining their relationships with clients); educating the community on PPE and clinic safety protocols; conducting screenings with clients; and other duties focused on COVID-19, including medication and grocery delivery.^17,18 Multilingual CHWs reported serving as interpreters in their communities. For example, CHWs utilized their language skills to serve as medical interpreters in the COVID-19 testing tents during the pandemic.¹⁸ The needs assessment and focus group were conducted before vaccination efforts began and does not include information describing CHW roles during this phase of pandemic recovery.

CHWs in the 2020 focus group shared that they helped develop culturally appropriate and relevant resources materials on COVID-19 in NHPIF languages.¹⁸ The rapid changes and updates to information created a challenging dilemma, and CHWs shared information verbally rather than relying on the traditional approach of disseminating written resources/information.¹⁸ In addition to serving as translators, CHWs served as cultural translators for local agencies trying to effectively reach communities; CHWs used their knowledge of cultural beliefs, attitudes, and practices to develop effective strategies for communication and messaging. Thus, CHWs play an integral role in ensuring that communities have culturally and linguistically appropriate information.

During the early days of the pandemic, CHWs successfully expanded partnerships to ensure that communities received adequate health education about COVID-19. ¹⁸ For example, in the Kona District of Hawai‘i Island, CHWs increased their outreach efforts from 3 to 13 farms, addressing the importance of mask-wearing, physical distancing, and hygiene with migrant workers in Spanish and Thai.¹⁸ CHWs also worked closely with NHPIF populations through racial/ethnic community associations to ensure they received current and accurate information.¹⁸ Community collaborations and new partnerships were formed to distribute limited resources necessary for basic needs and COVID-19 prevention.¹⁹ For example, CHWs distributed hundreds of meals, personal hygiene packages, produce boxes, and cleaning supplies to NHPIF communities across the state.¹⁸

CHWs can partner with community-based and governmental organizations to create and disseminate educational materials and public service announcements (PSAs), ensuring that messaging is culturally appropriate for NHPIF communities. Employing CHWs to send culturally appropriate messages to the community may help to reduce the burdens that marginalized and vulnerable populations face during the pandemic. As cultural mediators between patients and health care systems, CHWs provide culturally appropriate health education, information, or direct services and effectively educate and promote the COVID-19 vaccine.⁴ Furthermore, in their position as trusted community members, they can effectively address the misinformation, fear, and stigma surrounding COVID-19 infection and vaccines by providing relevant, accurate information on how people can protect themselves and their families.⁴ CHWs also serve as models for the community by observing and abiding by safety recommendations.¹⁸

CHWs are often under-utilized when responding to infectious disease outbreaks, and additional roles for CHWs in promoting pandemic preparedness exist.^20,21 CHWs can share resources with a broad audience through telehealth visits or community events such as food drives. Some CHWs relied on phone calls to their homeless clients in Hilo, ensuring access to food, medication, and formula for infants.¹⁸ On Lāna‘i, CHWs delivered food and masks to clients who were homebound.¹⁹ Leaders from the Marshallese community in Kona conducted outreach to families who were physically distancing, providing education on COVID-19 and distributing donations of food, water, and traditional home remedies.¹⁸

Lessons Learned and Next Steps

CHWs play many critical roles in response to the pandemic and desire to be involved with COVID-19 prevention and control, such as contact tracing. CHWs' connection to the communities they serve means they are passionate advocates for their communities and need to be included in statewide and local COVID-19 prevention and vaccination efforts, especially when they work with NHPIF populations. As trusted members of the communities they professionally serve, CHWs have unique access to marginalized and vulnerable populations in Hawai‘i through in-person outreach. CHWs link marginalized patients to various services to meet basic human needs, including health care. CHWs serve as linguistic and cultural translators (mediators), provide health education, and collect information about their communities. CHWs are also links between NHPIF communities and nonprofit, private, and governmental organizations: They disseminate critical information from federal, state, and local agencies to the communities they serve. The creation of trusting work relationships and partnerships between CHWs and organizations can enhance public health initiatives that necessitate access and trust with communities, such as outreach in homes, businesses, community groups, faith-based organizations, and with NHPIF populations. CHWs can and are helping partners in the COVID-19 prevention and vaccination efforts. They are assisting with community needs assessments, contact tracing, health education, translation services, community vaccine drives, and service/treatment referrals.

The Centers for Disease Control and Prevention (CDC) describe CHWs as frontline public health professionals, who can use their understanding of communities and cultural context of residents in educating and engaging communities about contact tracing, collecting data, navigating patients through the healthcare system, and supporting home-based care for quarantined individuals.²² For example, CHWs in Washington, DC conducted contact tracing by home-visits when phone contact was not possible.²³ Although initially, most CHWs in Hawai‘i did not meet the eligibility criteria to be contact tracers, such as minimum educational degree, Hawai‘i's DOH and The University of Hawai‘i (UH) announced that CHW-students would join the UH-DOH Contact Tracing Training Program in August 2020.²⁴ DOH's decision to include CHWs in the contact tracing effort is encouraging. Moving forward, CHWs will be an invaluable resource to bring to the table as decision-makers develop comprehensive strategies to reach populations that may be vaccine-hesitant or reluctant to engage with contact tracers. As vaccination rates rise, cases of COVID-19 infection fall, and contact tracing of small outbreaks become a viable method of tracking viral infections, CHWs' input may reduce poor health outcomes for marginalized and vulnerable communities such as NHPIFs populations.

Ongoing COVID-19 training for CHWs will provide them with up-to-date information and equip them with the knowledge and skills to serve their communities. During HIPHI's 2020 focus group, CHWs said they were confident about their knowledge and skills to share information on COVID-19 prevention but are only somewhat confident in sharing information on treatment and care.¹⁸ CHWs could benefit from training, such as current resources to address social needs (i.e., food assistance, housing needs, and health care), mental health, prevention guidelines, ongoing updates on state and local restrictions and mandates, the relationship between chronic disease and COVID-19, and contact tracing.¹⁸ Many CHWs perceive they lack the opportunity to participate in training as part of their work responsibilities due to scheduling issues and lack of power within their organizations. With the vital role CHWs play in pandemic response efforts, it is equally important to acknowledge and recognize that CHWs are an integral part of the health care system. Some employers recognize the valuable role CHWs play in health care and challenge the broader public health, healthcare community, and leadership to do so as well. Professional development, resource allocation, compensation, and job security should reflect their role in the healthcare system. CHWs are the eyes and ears of the community, and they now want to be the voice, too.¹⁸

Conclusion

Proximity and strong relationships between CHWs and marginalized and vulnerable populations can enhance the efficacy of public health interventions and health messaging to prevent COVID-19 infection, reduce disease risk factors, and ensure positive health outcomes. Decision-makers, who are developing strategies for Hawai‘i's COVID-19 prevention and control planning, could benefit from listening to CHWs' voices and investing in CHWs' work and training to continue improving the health outcomes of marginalized and vulnerable populations such as NHPIFs. CHWs must be included in planning and implementation efforts, especially when marginalized populations are most susceptible to deleterious health outcomes due to viral pandemics.

Abbreviations

CHWs

community health workers

FQHC

federally qualified health center

HIPHI

Hawai‘i Public Health Institute

DOH

Hawai‘i State Department of Health

NHPIF

Native Hawaiian/Pacific Islander/Filipino

PI

Pacific Islanders

PPE

personal protective equipment

PSA

public service announcement

Conflict of Interest

None of the authors identify a conflict of interest.