Improving Access to Health Care with Community Health Workers
Growing up in California, Kimberly Dong, N02, MG17, saw how linguistic and cultural barriers made it hard for her grandmother, who spoke only Cantonese, to receive compassionate medical care.
“I remember this one incident, going to the hospital with my parents to visit her, and going to her room and hearing her crying,” Dong said. “People were trying to pin her down to put an IV in. She didn’t understand what was happening or why. They would do things without her consent or understanding.”
Today, as an associate professor in the Department of Public Health and Community Medicine at Tufts University School of Medicine, Dong has heard similar stories from community partners in Chinatown and other Boston neighborhoods. Sometimes the stories are about poor communication during health care encounters and other times they are about people not able to access health care at all. “We have such advances in medicine and we’re lucky to have that,” Dong said, “but it doesn’t trickle down to everybody.”
In response to the need, she created a program to train community health workers. “What better way to try to help bridge the gap than to train community members as community health workers to be the front line to engage people into care?” Dong said.
The program, now in its third year, is called COHERE, which stands for Community Health Workers Engaging in Integrated Care. Alice Tang, professor in the Department of Public Health and Community Medicine, and Kenneth Chui, associate professor, serve as co-evaluators of the program.
Tufts is one of about a dozen institutions in the state offering training that can lead certification in community health work.
Building Linguistic Capacity and Cultural Responsiveness
Community health workers (CHW) typically work in health systems or community-based nonprofits. As their name implies, CHWs are often members of the communities they engage. “They are from that community and understand the layout of the neighborhood and the social determinants of health,” Dong said. “They are from similar cultures and speak similar languages. There’s this built-in connection, that instant connectivity to be able to provide credible information.”
As trusted neighbors, CHWs can help people navigate the American health care system. They can also help connect people with other community resources that support health, wellbeing, and safety. “A lot of the trainees help navigate access to social determinants of health—food resources, electricity bills, housing,” Dong said. “Health care is so expensive, so the more we can move things into prevention, the better. CHWs can help do that.”
Language is often the first and most pressing barrier for people seeking health care or basic needs; more than a third of people living in Boston speak a language other than English at home, and about a sixth have limited abilities in English.
“I really wanted the emphasis to be on building linguistic capacity for our health care workforce,” Dong said. COHERE’s first cohort of 38 trainees spoke 15 languages, and the second cohort of 57 spoke 23.
While trainees are familiar with their community’s culture, COHERE’s training provides a deeper understanding of many different cultures, especially beliefs and practices related to health and health care.
Gladys Valentin-Agneta, the director of Chelsea substance use disorder services at Community Action Program Inter-City, Inc. (CAPIC), speaks Spanish. She said she learned a lot from COHERE about cultural practices among Spanish speakers from different countries. “Chelsea is predominantly Latino,” she said. “For me, that’s a comfort zone because I’m Latina. My parents are Puerto Rican. But what someone in Puerto Rico would say or do is not the same as someone from Central America.” For example, nutrition advice can get lost in translation due to variations in vocabulary and cultural dietary patterns.
Like most of the other trainees, Valentin-Agneta came to COHERE with a wealth of professional and lived experience. In addition to her current job connecting people who have substance use disorder to treatment, housing, and other resources, she has worked as a bilingual advocate at local police departments for victims of domestic violence and as a certified nursing assistant.
COHERE provides a framework for trainees to share that kind of knowledge and experience with each other. Lydia Adjetey, who speaks Ga and Twi, said, “It was fun interacting with other people from all different cultural and professional backgrounds and learning about what they did,” she said. “We created a resource list that we can access. And if I have a question, I can reach out to my former classmates.”
Empowering CHWs
Both Adjetey and Valentin-Agneta now teach in COHERE, which is a direct result of Dong’s desire for the program to be “CHW-led.”
Valentin-Agneta never expected to be a teacher. “I found myself doing a two-hour domestic violence class,” she said. “I surprised myself. It’s given me more confidence to apply what I know.”
Adjetey also got a confidence boost from COHERE. She now teaches one of the core competences—care coordination—as well as prevention and education around HIV and sexually transmitted infections. Before COHERE, Adjetey worked as an HIV community health worker and educator. Now she is a program director at a detox facility. “COHERE pushed me to challenge myself,” she said. “Once I started doing the teaching, I realized that I have the ability to do more. So I went for this high position that I currently have.”
To meet the needs of a wide variety of participants, COHERE has three tracks. Track 1 is a training program for new CHW trainees and Track 2 is for upskilling those already practicing in the field.
Valentin-Agneta attended Track 1 the first year, followed by Track 2 the second year. Adjetey, who has been a certified CHW for about 10 years, attended Track 2 to brush up on her skills and to meet and network with others.
Track 3 is the Boston Emergency Medical Services (Boston EMS) Apprenticeship Program, which offers graduates of Track 1 a stipend to complete the Boston EMS Recruit Academy followed by one year’s paid work with Boston EMS. The program, funded by a grant from the U.S. Health Resources and Services Administration (HRSA), was designed in collaboration with Boston EMS.
Working in Partnership
The relationship with Boston EMS is just one of many that are integral to COHERE. Other community partners include Boston Chinatown Neighborhood Center, CAPIC, Latino Support Network, and ICNA Relief.
Representatives from these organizations serve on the COHERE advisory board, help recruit participants, and provide feedback on the curriculum.
“This is a really good model of how community partners and academia can work together,” Dong said. “It’s just been really rewarding.”
As she looks to the future, Dong is committed to continuing to work with local communities to grow and strengthen COHERE. She’s also looking for policy solutions that would expand the role of CHWs in the American health system—for example, formalizing their role on health care teams and developing more sustainable payment mechanisms. She believes more widespread use of CHWs would improve access to the health system, help prevent the kind of experiences her grandmother had, and create new professional opportunities for people interested in community health work.
“As we start to train more people,” she said, “we want to make sure that they’re going into a profession where they’ll have job security and economic mobility.”