The In-Between People: Community Health Workers in the Circle of Care

The In-Between People: Community Health Workers in the Circle of Care

This program is presented by the Centers for Disease Control and Prevention.

[Woman 1] Oh CHR’s? They’re our eyes and our ears and, you know, our feet. They go out into the community. They connect with all of our patients in their home settings.

[Man 1] Well, I see community health representatives, just like a nurse aide in a hospital, only they’re like a nurse aide in the community setting.

[Man 2] I love what they do. I love the fact that they are connected with the community.

[Woman 2] They are fantastic. They allow us to establish rapport with the people that we’re working with in the communities. Without their assistance, it would be very difficult to make the contacts with the important people that we need to attend to and have our educational programs and so forth.

[Woman 1] They probably don't fit in the system, but they fit in the real world. They're, they’re what connects health care to the community, and it would be cliché to call it glue, but we kind of see things as whole systems rather than, you know, isolated disease processes stuck in an environment.

[Woman 2] They’re the grassroots people. They know what’s going on in the colonias and they can help us.

[Narrator] The landscape of American society is changing. We have an increasingly diverse population. Simultaneously, chronic illnesses are on the rise. But not all illnesses affect all communities in the same way. Diseases like diabetes take a disproportionate toll on Native American and Latino families.

[Narrator] In order to address health problems across the country, our health care system must reach out to every community. This means confronting some major challenges, challenges like isolation, language barriers, cross cultural communication, and trust. Meeting these challenges is not easy, but it can’t be ignored. Our society’s health and people’s lives depend on it.

[Narrator] The role of the community health worker is rooted in tradition. There have always been those who attend to the health and well-being of others, and community health workers honor that tradition as they help people connect to the health care system. Community health workers have many names: home health aide; lay health worker; navigator; community health representative, or CHR, in the Indian Health Service; promotoras de salud, or health promoters in Latino communities. But no matter the name, community health workers are people who can communicate in both worlds, bridging the gap between community and the health care system.

[Narrator] From the system's perspective, Native American and Latino communities are special populations. To community health workers, they are family. Community health workers are the In-Between People. Community Health workers serve native and Latino communities in all parts of our country.

…I love the people… I like to help people… I visit with clients serviced through the health department……tenga ganas de server a su gents…they have a good rapport, they have a good people personality…I’m very accepted…

[Narrator] In the mountain valley town of Covelo, California, primary health needs of the local Native community are served by community health worker Dorothy Eddy.

[Dorothy Eddy] I’m Dorothy Eddy and I’m Athabascan Indian and I was born in Tanana, Alaska. I was adopted, so I left when I was five days old, and I’ve lived in different states; my dad was in the military. And my son and I moved up here six years ago and we bought a house and this is where I’m laying down my roots, here. Most of the people were born and raised here, and they don’t like leaving the community. They don’t move out. So, at first I wasn’t accepted by everybody, going out into the community. The longer I’ve been here and they know, they can see that I’m not going anywhere and that I’m here to stay, I’m very accepted and they trust me.

[Narrator] Navigating the health care system can be challenging – even for those who are healthy or who feel connected to the system. For the Native community in this isolated valley, cultural and language barriers are added problems, problems that the community health workers help overcome.

[Dorothy Eddy] We have some patients that go to dialysis and they have to travel two hours to get there, then be on dialysis for three hours, then travel back the two hours, three days a week. So it’s really hard for people to have to have a specialty doctor and go out of the valley. Besides doing the vitals and the home visits, I also go into the doctor’s office with them.

[Narrator] On the other side of the county from Covelo, California, the American Indian community housed in New York City serves Native people in the most urban of settings.

[Irwin Wesley] Speaking in a Native American language. So I just said my name is Irwin Wesley. I’m from Moosonee, Ontario, from northern Canada. I work here at the American Indian Community House and part-time at the CUNY Graduate Center, and I’m also studying human behavior, psychology. According to the latest US census, there’s 48,000 Native Americans living in the five boroughs of New York City, with an additional, I believe 40(000) or 38,000 claiming some Native ancestory. So we’re dealing with – in the city – with the five boroughs of a population of eight million over 90,000 (?) multitude nations from Alaska all the way down to Central America, South America, Canadian tribes come here also, including the American tribes. So we’re part of that circle of community where the different nations come together. And that’s the unique thing about living in New York is it’s a melting pot of different cultures and it’s a unique experience for Native Americans because we get mistaken for all sorts of cultures. So, it gives me an opportunity to educate people about Native Americans living in New York City. We’re invisible here. Working at the American Indian Community House has exposed me to working with a lot of different agencies. There’s a common, universal need – human needs, basic needs.

[Narrator] Community health workers, like Irwin, provide a wide variety of services, based on the needs of their individual communities. From delivering food to following up on medical treatments.

(Knock on a door)

[Leona] Hello?

[Irwin Wesley] Leona, it’s me. I have your food.

[Leona] Oh, wow.

[Irwin Wesley] Ah, it’s heavy.

[Leona] Thank you so much.

[Irwin Wesley] You’re welcome. Oh what’s the cute dog’s name?

[Leona] This is Frezgeg.

[Irwin Wesley] Can you see me clearly?

[Leona] Uh, not really. You’re like a shadow.

[Irwin Wesley] Let me see?

[Leona] I mean if you do it like this. You, know, it’s like a shadow.

[Irwin Wesley] What about the, are you coming to the next elders luncheon? I know you like to come there and meet people…

[Leona] Oh, yeah. I… I…

[Irwin Wesley] …have lunch.

[Leona] I do want to go to the elder’s lunch. I like to meet he elders.

[Irwin Wesley] Yeah.

[Leona] I don’t consider myself an elder but they do and…

[Irwin Wesley] Hey, hey, 49, 49 is the criteria, yeah.

[Leona] I’m 54, so…

[Irwin Wesley] So you’re an elder, yeah.

[Leona] Yeah, I’m an elder, but it’s so funny, you know, it’s like you get the respect, you know, and you get people really. And you I learn a lot from because you always ask me questions and stuff and I feel you respect me and I go “Wow, that’s something different.”

[Irwin Wesley] Yeah.

[Leona] Nothing I’ve experienced before in my life.

[Irwin Wesley] Yeah and you get to meet other…

[Irwin Wesley] To treat people as human beings, not as a tribal member. Yes, you’ll understand they’re from a tribe reservation, but get to the key point. They need access to services. They’re a human being in need.

[Narrator] In the heart of the country, the Cheyenne Arapaho Tribal Community Health Representative Program covers 18 counties of northwestern Oklahoma. Language and transportation are challenges to Norma Smith and her colleagues who serve a population of 9,500 people.

[Norma Smith] Some of the elderlies just don’t have a way of going to the doctor. Those that didn’t have vehicles, their families didn’t have vehicles. Cause the elderlies, they, they don’t drive. Somebody has to take ‘em. And sometimes I tell ‘em, in Indian, and I tell my elderlies, I tell ‘em what the doctor is saying, in Indian, so they’ll know.

[Narrator] In many ways, the role of the community health worker is a familiar part of traditional cultures where there have always been those whose purpose is to share knowledge of health and healthy living.

Nowadays, like, you know, we talked about before. It’s a better lifestyle, it’s a better economic status. Sometimes you just can’t afford to eat healthy or you don’t have the time. You can’t afford, you either can’t afford to eat healthy or you can’t afford the time.

There is a role for traditional healing in this world. And, if not, then there needs to be made one. They need to go back to those ways and remember what our people taught us. There’s a lot of plants, trees, roots, you know, everything in this natural world that we’ve got, you know, it all played a part.

Our older people used to exercise a lot. They walked all the time. And we don’t do that anymore over here. We jump in our cars and go down the street a block or two instead of walking which will help us. And then we go to the store, a place to eat, and we get a hamburger and French fries and Coke which is not good for us. But that’s what we do. That’s our way of living now.

[Narrator] In the border town of Brownsville, Texas, volunteer health workers survey a large community of recent immigrants and Latinos whose language and primary cultural ties are on the other side of the border. The growing number of uninsured is also a problem. The promotoras use outreach programs and home visits to educate the community about health care, then follow up with translation and other practical assistance to secure the care they need.

(Speaking in a Spanish language)

Translation: The patients trust the promoters more than the doctors. If the doctors were a little more open with the patients, it would be better. There would be better communication. Even if they live here, they become shy when they go to a place like this where there are a lot of people, or they’re afraid to approach the receptionist, so we try to go with them.

[Narrator] Problems like those in Brownsville are not unique to the border area. Since the 1930s, for instance, migrant agricultural workers have been following the work from Texas to Minnesota. At Central Campesina in Owatonna, Minnesota, a group of committed community health care volunteers work to improve the lives of migrant workers. After 12 hour days in the field or in agricultural processing, their role as promotoras is a second job.

(Speaking in Spanish)

Translation: Good afternoon. My name is Rebecca Lopez. I’m a health promoter. I have been a health promoter for two years. They feel very satisfied with our program and they thank us. They tell us to continue with the program because it has helped them a lot with all types of help, like vaccines, tests for cancer, and a lot of advice.

(Speaking in Spanish)

Translation: My name is Gloria M. Contrarance. In the area where I work, the promoters work 12 hours a day. They do outreach and illness prevention.

[Narrator] There are many reasons that people become isolated from the health care system - language or cultural differences, economic challenges, lifestyle diseases, or simply age or geography. And there are many ways that community health representatives can make a difference within their circle of community.

…I tell them what the doctor is saying, in Indian, so they’ll know…give me an opportunity to educate people about Native Americans living in New York City…There is a role for traditional healing…I help them order – if they need medications, clinic appointments, transportation to the clinic…

[Narrator] Interaction with their communities is at the heart of the community health representative’s work.

[Dorothy Eddy] Anything that they might need, whether it’s just to sit down and talk, you know. That’s what I’m there for.

[Norma Smith] My elderlies, I go in with them when they go in to see the doctor at the clinics and I always ask the doctor, can you tell ‘em what’s wrong in simple words where they can understand you?

(Speaking in Spanish)

Translation: Since the doctor’s in a hurry, they don’t feel comfortable enough to ask questions. Then they talk more and start getting to know us. And as they are getting to know us, they get more comfortable and I feel that we give them that power to do things.

[Dorothy Eddy] I’m very respectful. You know, I wait until I’m invited to sit down. And I listened. That was the main thing. I’d ask ‘em questions and listen. I wasn’t there to tell ‘em you can’t so this, you should do this, and so, by listening, the more they opened up and the more they were able to understand why I was there…

[Irwin Wesley] You get overwhelmed by the multitude of resources. It’s better just to mobilize and be patient. Listen to the client; make it a client-centered approach. Listen to them more. Yes, you’ll understand they’re from a tribe reservation, but get to the key point. They need access to services. They’re a human being in need.

(Speaking in Spanish)

Translation: We provide help to them. For example, we take them to the clinic. We set the appointments. We look for transportation for them, and we look for people to provide support for them, like an interpreter. It makes a big impact. Not so much in the promoters, but with the agencies or the clinics that many times don’t know what is exactly each person’s culture. And that makes the work difficult, for them, as well as for the community.

[Narrator] It’s easy for people to feel lost in a culture they don’t understand. Community health workers have a unique ability to help bridge this gap.

[Irwin Wesley] No matter how much of these Western theoretical concepts I learn ways of looking at the world, when I speak Cree, I feel more simple, less stressed, and my world view is more simple, more nature-based. The lack of cultural sensitivity becomes too much for some people, coming from the rural parts of this country where they’re used to being visible and recognized and understood. We worked with a woman who was fleeing a domestic violence situation, with her son. Her son had a mental disorder, psychiatric disorder, which required psychiatric assessment. So, we had to set up a referral to a hospital. A team of psychiatrists interviewed the mother and son. During the session, the doctor asked the son, who’s six years old, if he smokes a peace pipe and other questions a six year old wouldn’t know, so we advocated for the mother and held the doctor accountable and tried to teach them some cultural sensitivity.

[Dorothy Eddy] Yeah, I’d say about 70 percent of my job is home visits and the other part is doing the paperwork. Since we’re such a rural area, I travel to people’s homes. When you have a chronic disease like diabetes, it takes a big lifestyle change. I mean, you can imagine, all of a sudden, you’re diagnosed with diabetes, and here you are in this little room with the doctor and the doctor says, “Well, you’ve gotta change your diet, you have to take this medication, and you gotta exercise.” And then they leave the room, overwhelmed, oh, “And by the way, you gotta check your blood sugar twice a day.” Well, it’s overwhelming so, as CHRs, we’re able to go into the home and help them transition to a healthier lifestyle.

[Dorothy Eddy] We’re also a patient advocate, you know, between the provider and the patient. And so there are certain things that the doctor might not know about the patient. For instance, if they’re eating a lot of candy and drinking soda, when the provider asks, “How’s your diet?” and they’ll say, “Good.” and their blood sugars tell a different story. And then of course, I’m in the home and I can see what they eat and what they have around and that helps the doctor, too, be able to teach and help the patient.

[Dorothy Eddy] CHRs have more of an opportunity than the providers do to get out in the community, to get the word out, and we’re able to have prevention classes. We’re a teacher. We go to the schools and teach the young children. We have the time to be able to do that. One of the success(es) I’ve had is starting a diabetic support group, which I just love. It’s once a month and people come and they share their stories and they open up to each other. Because a lot of times, people feel like they’re all alone.

Now they get 10, 12 people to show up for their diabetic groups, and sometimes its 20. That’s an amazing success when you think of all those families that are going to go out and spread the word to a small community, like ours. That’s a big success. And that’s the message that the community’s getting now that they weren’t getting before. You know, it’s kind of like, “Well, your Indian, you’re going to get diabetes.” “Well, I’m Indian, I’m going to get diabetes.” And so we’re trying to change that social norm. But it wasn’t too long ago, we had a meeting here and a little girl said that very thing, that she knew she was going to get diabetes. It doesn’t have to happen at all. And the CHRs are totally integral in that. They make it real for the patient. Maybe over time, chronic disease is treated a lot differently, you know, over time.

[Narrator] Community Health Care Workers are the In-Between People who connect America’s diverse communities to the health care system. It is through the commitment of workers like Dorothy and Irwin, Norma, Rebecca, Alvia, and so many more that the benefits of the health care system can reach every community and ultimately benefit the health of our society, as a whole.

…I’m very accepted and they trust me…need access to services. They are a human being in need… speaking in a Spanish language…I listened…it’s better to listen…I help them…we advocated for the mother…and so we’re trying to change that social norm…we’re part of that circle of community where the different nations come together.

For the most accurate health information, visit www.cdc.gov, or call 1-800-CDC-INFO.