Community Health Workers Use of Self and Transformation for Health Elizabeth A. Thomas PhD, MPH, RNC Lynda Billings, PhD, MFA Anita Thigpen Perry School of Nursing Texas Tech University Health Sciences Center Lubbock, Texas
Presentation Objectives 1. Explain how a theoretical perspective can be reflected in the case management work of community health workers. 2. Discuss how community health workers can integrate a theoretical perspective into their perception of their own unique practice with patients. 3. Explore how nurses and community health workers can be educated and mentored toward collaborative practice within case management programs, moving them beyond medical regimen compliance activities into empowering health building interventions.
Community Health Workers Improving Population Health CHWs used extensively worldwide for health education, to extend basic health services in vulnerable populations and for resource poor communities (e.g. Directly Observable Therapy (DOT) for TB & HIV/AIDs medications), organized CHW programs began in US in 1960s. CHWs reduce health care expenses for clients, hospitals & State/ Federal government by lowering emergency room and hospital admissions (Swider, 2002). US Health Resources and Services Administration, Community Health Worker National Workforce Study (2007) analysis of many reports, studies reported evidence of CHW effectiveness in delivery of health care, prevention and health education for underserved communities.
Definition of CHWs Community health workers are lay members of communities, who work either for pay or as volunteers in association with the local health care system in both urban and rural environments and usually share ethnicity, language, socioeconomic status and life experiences with the community members they serve. Identified by many titles: community health advisors, lay health advocates, promotores(as), outreach educators, community health representatives, peer health promoters, and peer health educators. (US Department Health & Human Services, 2007)
CHWs in Health Promotion & Chronic Care Management Using CHWs is an intervention strategy that has been found to be an effective way to reach people who because of culture, language, socioeconomics or inability to come to terms with failing health, need a communication bridge to health care professionals. CHWs provide health education, promote life-style changes & direct patients to social services; increasingly used in chronic care case management health interventions, such as Patient Navigator programs. (Esperat, et al., 2012)
CHWs Study Integration of Health Empowerment Theory in CHW Certification and Practice Study purpose: To explore how CHWs applied or integrated a health empowerment theory, (Transformation for Health, TFH) into their chronic care case management. Study Objectives: 1. Examine how CHWs perceptions of TFH influenced their relationships with clients, their roles as CHWs and their understanding of the nature of health & illness. 2. Explore how non-licensed paraprofessional CHWs introduced to theoretical concepts in a CHW certification program, process and apply health promotion theories with chronic disease clients.
Transformation for Health Retrieved from : Esperat, et al. (May 31, 2012). Transformacion Para Salud: A Patient Navigator model for chronic disease self-management. OJIN: The Online Journal of Issues in Nursing, Vol. 17., No. 2, Manuscript 2. DOI: 3912/OJIN.Vol17No02Man02
CHW TFH Study Design: Qualitative study, modified grounded theory, audio-taped, semi-structured interviews conducted by a SON faculty member not connected with the TTUHSC School of Nursing nurse-managed clinic or CHW certification program but experience in working with CHWs. Participants: Five women, aged 38 71 years (4 Hispanics & 1 African American) recruited from TTUHSC nurse-managed community clinic. Eligibility: Completed or were enrolled in a 40 week, CHW certification course where the TFH was presented; 4 CHWS were employed at the clinic, working in the Patient Navigator program; 1 participant was finishing up certification training and was working in a maternal-infant health education program with low-income pregnant young women.
CHW TFH Study Procedure: Recruitment by posted flyers, email to membership on regional CHW organization list-serve, announcement in CHW certification class, emails to agencies employing CHWs in the area, presentation of study and invitation to participate by PI, snowballing, word of mouth. Interviews were conducted in the PI s office; 1 interview in the clinic in a private office. Analysis: Audio tapes were transcribed by professional transcriptionist. Transcripts were reviewed and analyzed to identify codes, first using open coding (line by line) then moving to selective coding and constant comparative analysis. PI and Co-PI did analysis of transcripts.
Study Findings: Main : Concepts Heritage of Healing: family legacy, coming from a family of healers, committed to neighbors, the needy Personal Calling: personal sense of being called for the work, mission mentality Being a Bridge: seeing oneself as a connection between two different worlds, health care providers world and the world of clients in need Sharing of Self: willingness to share one s vulnerability, past struggles, listen with empathy having been who has been there Sharing a Vision of the Other: How the future can be shaped by the client; sharing transformation possibility.
Study Findings: Main : Concepts Heritage of Healing: Parents, grandmothers who served the community (e.g. sharing food garden, serving as foster parents, helping community members in need). Often the CHWs were the persons in their family who was always involved in caring the sick or elderly, going to doctor and social service agencies with family members. Personal Calling: Feeling compelled to be involved in some type of job helping people, often not really knowing why. Being a Bridge: A phrase they learned from CHW certification course but shared the many ways that they themselves were the bridge, stretching at both ends, getting clients connected to the other side, keeping them connected to world of doctors & nurses.
Study Findings: Main : Concepts Sharing of Self: I see why everything I have done since practically the day I was born, everything comes together for me with this job and I m just so elated to be using what I have been given and what I ve learned and what people have shared with me to be able to actually touch lives and help them change (Annabeth, 69 years old). CHWs connected their own experiences with poverty, family issues, personal illness (cancer as a child, diabetes), challenges in working through health care systems, built on their experiences to hear what clients were saying.
Study Findings: Main : Concepts Sharing a Vision of the Other: Nobody is 100% healthy, not you not I, not my instructor, everybody has places where can improve, we re emotionally wounded. We re there s psychological wounds there that come from way back. I have them from way back in my childhood and so they there is nobody that is immune and nobody is 100 % healthy and so what we can do is work together toward that goal.
Study Findings: Main : Concepts We help see the pathways they can take and facilitate their ability to get on that pathway, it s like a escalator see and its continually moving and we can see them get on this step you know when you re watching [an] escalator you have to put your foot down at the exact moment or you re going to get tripped or thrown backwards.... So we can help them get on that escalator and help them hold on to the railings. We give them help in such a way that they see that they re going toward a goal and that they can make it. (Annabeth)
Study Findings: Living : TFH I realized that you can t teach it if you don t live it, you can t hope to influence somebody to change their diet because of advanced diabetes if you go in looking like you don t care about yourself. (Annabeth)
CHW TFH Limitations Complex social and political dynamics in the area. Few participants, difficult to recruit participants who worked in other agencies, pressure from employers (?) not to become involved. Perceived community competition between TTUHSC clinic and other large community clinic in town, one CHW actually agreed to participate then became impossible to contact. Later discovered she had switched jobs as working on developing a CHW program similar to the TTUHSC clinic program..
CHW TFH Limitations Participant Eligibility criteria too narrow. Set eligibility as those CHWS involved in chronic disease case management and therefore excluded many CHWs involved in maternal-infant or pediatric case management programs. If chronic disease was defined as less restrictive more participants could have been recruited. (Consider the chronic fatalism as community chronic disease.) Qualitative methodology needed strengthening. Needed more memo-ing; better examination of own biases, questioning what we (PI & Co-PI) thought was the work of CHWs, what are their roles. Needed more theoretical sampling, consider other sources of data, need to re-examine the transcripts for more in depth coding. Still need to fully explicate the grounded theory of CHWS TFH.
CHWs as Transformers for Health CHWs described a being there and being with instead of a doing, recognizing new horizons of what they could bring to being with the clients; saw themselves as more than helping as care plan compliance agents extensions of care providers. They were embracing a sense of practice, use of self as transformers, not applying the TFH theory but being the TFH.
CHWs Helping Clients to Take That Step
Acknowledgements Acknowledgement Ms. Debra Flores, MHRM, the project coordinator of the Texas Tech University Health Sciences Larry Combest Community Health & Wellness Center (LCCHWC) Patient Navigator program when the study was conducted and developer/ instructor of the 160 hour curriculum certified by the Texas Department of State Services used to train the CHWs who participated in this study. She is now affiliated with Covenant Health Systems, in Lubbock and will be defending her dissertation in Educational Psychology this summer. E-mail: floresde@covhs.org
References Esperat, M.C., Flores, D., McMurry, L., Feng, D., Song, H., Billings, L. & Masten, Y. (May 31, 2012). Transformacion Para Salud: A Patient Navigator Model for chronic disease self-management. OJIN: The Online Journal of Issues in Nursing, 17 (2), Manuscript 2. doi: 10.3912/OJIN.Vol17No02Man02. Esperat, M.C., Feng, D., Zhang, Y., Masten, Y., Allcorn, S., Velten, L., Billings, L., Pence, B., Boylan, M. (2008). Transformation for Health: A Framework for conceptualizing health behaviors in vulnerable populations. Nursing Clinics of North America, 43, 381-395. doi:10.1016/j.cnur.2008.04.004. Swider, S. (2002). Outcome effectiveness of community health workers: An integrative literature review. Public Health Nursing, 19(1), 11-20. Southwest Rural Research Center, Texas A & M University, School of Rural Public health (2005). Community Health Worker (CHW) Certification and Training: A National Survey of Regionally and State-Based Programs. Retrieved from ttp://medqi.bsd.uchicago.edu/documents/chw_cert_final2005.
References U.S. Department of Health & Human Services, Health Resources and Services Administration and bureau of Health professionals (2007). Community health worker national workforce study. Retrieved from http://bhpr.hrsa.gov/healthworkforce/reports/chwstudy2007.pdf
Contact Information Lynda Billings, PhD, MFA Associate Professor, Anita Thigpen Perry School of Nursing, Texas Tech University Health Sciences Center 3601 4th Street, STOP 6264 Lubbock, TX 79430 E-mail: lynda.billings@ttuhsc.edu Elizabeth A. Thomas, PhD, MPH, RNC, Assistant Professor, Anita Thigpen Perry School of Nursing, Texas Tech University Health Sciences Center 3601 4th Street, STOP 6264 Lubbock, TX 79430 E-mail: betsy.thomas@ttuhsc.edu