The Utility of Community Health Workers in Disaster Preparedness,Recovery,and Resiliency

Introduction

An innovative approach to health care reform in the United States is an increased reliance on lay health workers as a cost-effective means of improving both health care access and health outcomes. Established roles for lay health workers focus primarily on helping patients understand health-related issues, improving patient access to needed health services, and increasing patient compliance with medical directives. These activities can take place in a clinical setting or as part of a broader community education and outreach effort.

Our thesis is that expanding the activities of lay health workers to play a greater part in emergency management efforts can provide significant benefits to the communities served. The most direct role is in education and outreach to promote disaster preparedness, which helps to ensure the safety and survival of the public during emergencies. Lay health workers can also contribute to post-disaster recovery efforts both as “boots on the ground” and in serving as a link between the community and emergency response and recovery officials. In fulfilling these roles, lay health workers help to establish relationships of trust and an understanding of shared interest among community members, thus providing a mechanism to improve the effectiveness of emergency management by increasing social capital and enhancing community resiliency.

To elaborate this applied approach, we focus on a specific type of general purpose lay health worker called Community Health Workers (CHW). We describe the characteristics of successful CHWs and their typical roles and functions, and review research on the effectiveness of CHWs as they currently operate in the health care system. We then explore the relationship between social capital, community resiliency, and effective emergency management, elaborating the potential utility of CHWs in this area. To maximize this utility, we propose curricula for supplemental lay health worker training in three critical areas: (1) conducting education and outreach activities to encourage disaster preparedness, (2) managing chronic diseases and conditions associated with or aggravated by disasters, and (3) mitigating the psychosocial impacts of disasters through peer listening and counselor referrals. We conclude with a succinct review of the potential to improve emergency management through building social capital and thereby enhancing community resiliency.

Lay Health Worker Variations

“Lay health worker” is a generic term that encompasses a wide variety of different positions including CHWs, community health advocates, promotores de salud (health promoters), patient navigators, peer health educators, peer health advocates, and so on. Despite these variations, lay health workers can be classified into three broad groups. The first includes those with advanced training related to a specific disease, such as cancer or diabetes, who typically work in a clinical setting, “navigating” patients through their treatments, and educating and encouraging patients to self-manage their diseases. These are most commonly called patient navigators, and they usually work in salaried clinical positions. At the other end of the spectrum is a grassroots level of lay health workers who undergo limited training with emphasis on community outreach to encourage health literacy, healthy lifestyles, and the sharing of information about health care access and resources. These are often referred to as community health advisors or peer health advocates and typically serve as volunteers, often working on an individual basis within their communities or working with community-based organizations (CBOs). Somewhere in between are CHWs, who usually hold salaried positions in either health clinics or CBOs. CHWs typically undergo a broad training in areas such as health literacy, cultural sensitivity, social determinants of health, the fundamentals of public health, patient case management, and peer listening skills.

For the purposes of this paper, we focus on CHWs as the category of lay health worker with the greatest potential utility for emergency management and disaster response. However, it is also important to note that despite our focus on CHWs, we suggest that all lay health workers, if appropriately trained, could contribute to enhancing disaster preparedness, facilitating disaster recovery, and improving social capital to enhance community resiliency.

Current Role and Utility of CHWs

In an important policy statement supporting the expanded use of CHWs, the American Public Health Association offers the following definition:

Community health workers are frontline public health workers who have a close understanding of the community they serve. This trusting relationship enables them to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery. Community health workers also build individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support and advocacy. (American Public Health Association 2009)

This definition appropriately emphasizes the importance of the community social connection in the functioning of CHWs. With this in mind, we can describe the successful and effective CHW as a person who:

Although there is a general consensus regarding the appropriate characteristics of successful CHWs, there is no standard job description. This is due, at least in part, to the fact that there are two different primary tracks for CHWs. Some work in health care delivery sites such as hospitals, hospices, and health clinics, while others operate outside the health care system in community-based or faith-based organizations. Even in the absence of a standardized job description, it is possible to identify a set of tasks and duties commonly associated with CHWs:

Of course, not all CHWs will be involved in all of these activities. Note that the list is ordered to reflect the two different tracks of CHWs, such that activities at the top are associated with community outreach, while those at the bottom are more directly related to clinical practice. Accordingly, the first four items would commonly be undertaken by CHWs working in community-based or faith-based organizations, while the last four constitute typical tasks for those based in hospitals or clinics, and the middle four activities overlap these two basic tracks.

Demonstrated Utility and Effectiveness of CHWs

Health care costs in the Unites States have been characterized by “undeniable unsustainability based upon impossible economics” (Smith and Topol 2013). Consequences of this reality are nowhere more evident than in the communities with large proportions of underserved and disadvantaged minorities, many of whom are either uninsured or under-insured. The prevalence of unhealthy lifestyles and the lack of preventive care result in both heavy demand on the health care system and in significant socioeconomic disparities in health outcomes. These difficulties are compounded in southern states by vulnerability to disasters in the form of hurricanes and oil spills, and a political environment hostile to increased government involvement in health care funding and delivery (Bevc, Nicholls, and Picou 2010). As a result, our current health care delivery system falls far short in its ability to meet current needs.

Although numerous reforms designed to increase the capacity and efficiency of health care delivery have been suggested by policymakers and health care providers, among the most promising are two trends that relate directly to the utility of CHWs. The first involves increasing emphasis on preventive care. CHWs can be key players in this effort through community outreach and education aimed at enhancing health literacy and encouraging healthy lifestyles (Balcazar et al. 2011; Martinez et al. 2011; Smith and Topol 2013). The second interrelated trend involves the increased use of multidisciplinary teams that include a variety of professional and paraprofessional participants (Bodenheimer, Chen, and Bennett 2009; Goodwin and Tobler 2008). These teams are often associated with “patient-centered medical homes” and are designed to foster early intervention and more effective management of patients with chronic diseases (Sweeney et al. 2012). Lay health workers, primarily in the form of CHWs, have consistently been identified as critical components of such teams (Balcazar et al. 2011; Bodenheimer et al. 2009; Martinez et al. 2011).

Thus, academic research has confirmed the utility of CHWs as a means of increasing primary and behavioral health care capacity, improving outcomes for individuals suffering from both acute and chronic health problems, lowering the overall cost of care for those served through lifestyle changes and preventive medicine, and reducing socioeconomic disparities within the health care delivery system.

Although effectiveness may vary by disease or condition, evaluations of CHW programs have shown positive impacts on individuals’ health outcomes in a wide variety of areas, including cancer (Nguyen et al. 2009; Russell et al. 2010), diabetes (Otero-Sabogal et al. 2010; Valen, Narayan, and Wedeking 2012), cardiovascular disease (Krantz et al. 2013), and hypertension (Brownstein et al. 2007; Ravenell et al. 2013). Studies have also revealed that the involvement of CHWs in both health promotion and screening, early intervention, and the management of chronic disease can significantly lower health care costs for those already affected by health problems (Esperat et al. 2012; Jaskiewicz and Tulenko 2012; Viswanathan et al. 2009). In addition, research has demonstrated that CHWs’ interventions targeting underserved and marginalized populations in a culturally sensitive and community-based approach can make a positive contribution to reducing socioeconomic disparities in the morbidity and mortality associated with chronic diseases and other health conditions (Esperat et al. 2012; Henderson, Kendall, and See 2011; Peretz et al. 2012).

In recognition of the demonstrated utility of CHWs, the Patient Protection and Affordable Care Act directs the Centers for Disease Control and Prevention (CDC) to facilitate their use “to promote positive health behaviors and outcomes for populations in medically underserved communities” (PP&ACA 2010). A recent article in the New England Journal of Medicine sums up the general consensus that “scaling up the community health workforce in the United States could improve health outcomes, reduce health care costs, and create jobs” (Prabhjot 2013: 894).

Social Capital, Community Resiliency, and Emergency Management

In his seminal work on social capital, Robert Putnam (1995) defines the concept as “the features of social organization such as networks, norms, and social trust that facilitate coordination and cooperation for mutual benefit” (p. 5). Accordingly, community social capital consists of networks and relationship among community members that are built on trust, understanding, and acceptance of cultural norms, particularly the norm of reciprocity and a recognition of shared interests. These characteristics allow community members to effectively pursue mutual benefits. Putnam identifies examples of the benefits of social capital as including “better school performance, lower crime rates, better public health, reduced political corruption, improved market performance, and so on” (Clark 2004). The mutual benefit of interest in this paper is a community’s enhanced ability to deal with disasters (Adeola and Picou 2014).

It is important to recognize that the link between social capital and effective emergency management reflects community resiliency. Chandra et al. (2011) offer the following comprehensive definition of resiliency:

The ongoing and developing capacity of the community to account for its vulnerabilities and develop capabilities that aid in: preventing, withstanding, and mitigating the stress of an incident; recovering in a way that restores the community to self-sufficiency and at least the same level of health and social functioning as before the incident; and using knowledge from the response to strengthen the community’s ability to withstand the next incident. (P. 9)

This definition is applicable whether the disaster involves a storm, disease epidemic, hazardous materials spill, economic stress, and so on. It is also most relevant in relation to our expectation that communities with higher levels of social capital are more resilient, and more resilient communities will be better at preparing for, withstanding, and recovering from disasters.

CHWs can help to build social capital and thereby enhance community resiliency simply by fulfilling their essential roles and functions. In their basic outreach function, CHWs are directly connecting with community members and establishing trusting relationships and a recognition of shared interests (i.e., building social capital). This might include educational efforts aimed at improving health literacy, participation in health fairs to promote preventive care, recruiting participants in health screening programs, and distributing information on accessing needed health services. In their clinical roles, CHWs serve as liaison between community members and health care providers, translating confusing health concepts and terminology, helping patients with intake questionnaires and consent forms, and promoting compliance with treatment guidelines and drug therapies. These activities not only build trusting relationships; they also contribute to the creation of networks that can insure effective communications among relevant parties during emergencies.

It is also important to note that much of the work of CHWs contributes to the overall health of their communities. Thus, a community with a lower incidence of chronic diseases will have, on average, residents who are more mobile for evacuation and recovery activities, who will make fewer demands on scarce health-related resources during emergencies, and who are less vulnerable to disaster-related disruptions in medical and pharmaceutical services. All these characteristics contribute positively to disaster preparedness and recovery capabilities, and thereby reflect a more resilient community.

These theoretical expectations are supported by a growing body of research establishing the importance of social capital in enhancing community resiliency (Cox and Perry 2011; Morton and Lurie 2013; Plough et al. 2013; Ritchie and Gill 2010). It has also been demonstrated on an individual level that social capital in the form of greater community engagement, networking, and trust is positively associated with higher levels of concern regarding future emergencies and personal emergency preparedness (Hausman, Hanlon and Seals 2007). As a result, programs designed to enhance community resiliency have been encouraged as a means of improving emergency management efforts (Dynes 2002; Eisenman et al. 2009; Norris et al. 2008).

Our contention is that CHWs can contribute significantly to building social capital through outreach and networking, which, in turn, will improve community resiliency, lessen the impact of natural and technological disasters, and facilitate post-disaster recovery. We expect that CHWs will be particularly effective in this capacity due to their positions of trust and sensitivity to cultural norms within their communities. In support of this expectation, there have been repeated calls in the literature for a greater role for community members and local organizations in disaster preparedness and recovery efforts (Cox and Perry 2011; Gamboa-Maldonado et al. 2012; Morton and Lurie 2013; Norris et al. 2008).

Although there is limited research making a direct link between CHWs and the building of social capital, it has been demonstrated that lay health workers, trained as peer listeners, can mitigate the negative mental and behavioral health impacts of the disaster experience, build social capital, and speed disaster recovery in the communities they serve (Picou 2009, 2011). CHWs can also play a significant role in overcoming racial and ethnic disparities in post-disaster mental health care (Springgate, Wennerstrom, and Carriere 2011). Furthermore, preliminary results of a pilot project utilizing promotoras de salud (health promoters) to increase awareness and knowledge about emergency preparedness within the Latin/Hispanic community resulted in a 100 percent increase in emergency preparedness practices (Montgomery County Department of Health and Human Services 2008).

Expanded CHW Training in Emergency Management

CHWs can contribute significantly to effective emergency management efforts through increasing social capital and enhancing community resiliency, but only if they are appropriately trained to do so. Although the initial training of CHWs provides basic competencies in the areas of advocacy, outreach, peer listening, mediation, and communication, supplemental training in disaster-related competencies can ensure the effective application of basic skills and capabilities to tasks associated with helping communities prepare for, withstand, and recover from disasters. This supplemental training can be organized into three core modules:

Educational Outreach

The educational outreach function of CHWs is particularly relevant in efforts to promote disaster preparedness and community resiliency. One focus of outreach is for CHWs to convey to community residents an understanding and appreciation of the dangers posed by various disasters. CHWs can also provide practical information on appropriate steps needed to ensure the safety and survival of community members during and after an emergency. They also have an important role to play in identifying and disseminating information on needed resources and the most effective means of accessing such resources.

In addition to topics directly related to disasters, other outreach activities can contribute indirectly to resiliency and recovery. These include activities designed to enhance general health literacy and promote healthy lifestyles. Regarding the latter, there is helpful overlap with the chronic disease module (presented below) in that changing health risk behaviors in just four areas could drastically reduce the incidence and impact of many diseases; these include lack of physical activity, poor nutrition, tobacco use, and excessive alcohol consumption (CDC, Chronic Disease Prevention and Health Promotion).

In fulfilling these roles, CHWs have a distinct advantage over other emergency workers. Because CHWs are, by definition, trusted members of their communities, those targeted for outreach should be more open and receptive to their educational efforts. With appropriate training, CHWs have great potential to boost preparedness, build social capital, and enhance resiliency through culturally sensitive and community-based outreach. To fulfill this potential, core components of the training module for disaster-related educational outreach should include (1) understanding and appreciating the dangers of disasters, (2) guiding practical preparedness and survival, (3) identifying and sharing disaster-related resources, and (4) improving general health literacy and promoting healthy lifestyles.

Chronic Disease Management

Although there is no universally accepted definition of “chronic disease” in the medical literature, common characteristics include the following: a departure from well-being of long duration (a year or more), the necessity for medical intervention, some limitation in activity and function, a non-contagious nature, and non-amenability to cure (Goodman et al. 2013). Based upon these characteristics, the eight most common chronic diseases can be identified as arthritis, asthma, cancer, chronic obstructive pulmonary disease, diabetes, heart disease, HIV-AIDS, and hypertension. The incidence of chronic disease in the United States is very high and steadily increasing. Approximately 50 percent of American adults have at least one chronic disease and 25 percent have two or more (Ward and Schiller 2013). The number of Americans suffering with at least one chronic disease is predicted to top 150 million by the year 2020 (Bodenheimer et al. 2009).

The presence of large numbers of people suffering from chronic diseases creates serious complications when it comes to preparing for, withstanding, and recovering from disasters, especially natural or technological disasters that involve spills of hazardous substances. The typical problems associated with disasters tend to fall more heavily on those with chronic diseases. It is apparent that evacuation is more difficult for those with limited mobility. Family separation has a greater impact where family members are primary caregivers. Disasters often disrupt treatment routines and severely limit the availability of needed medications. Those with chronic diseases are more susceptible to toxic agents and hazardous materials associated with disasters, and they are more likely to be affected by extremes of heat and cold resulting from utility disruptions.

To help minimize these negative effects, CHW training should be organized around core competencies for each of the major categories of chronic diseases: arthritis, asthma, cancer, COPD, diabetes, heart disease, HIV-AIDS, and hypertension. Each of these diseases will be addressed according to the following rubric: (1) general definition, (2) variations, (3) etiology and risk factors, (4) prognosis and complications, (5) potential for prevention, (6) typical symptoms, (7) treatment procedures and medications, and (8) special needs. In addition, specific implications of chronic disease management as it relates to disaster preparedness, resiliency, and recovery should be discussed and elaborated from a disease-specific perspective.

Psychosocial Dimensions

One of the most detrimental consequences of all disasters involves the psychosocial impact on survivors. The term psychosocial refers to the interrelationship of social context and psychological health and well-being. Post-disaster social context is commonly characterized by economic loss related to disruption in fishing and tourism, financial hardships due to unemployment and limited access to funds, the ongoing disturbance of normal routines, and even injury and death of community members. These experiences can lead to self-medication and stress reduction with increased intake of alcohol and other drugs, heightening the potential for substance abuse. This can exacerbate other mental and behavioral health problems and result in self-isolation, domestic violence, and even suicide.

In addition, “secondary disasters” often emerge in the post-disaster period, including anxiety associated with ecological contamination and exposure, perceived inequities in claims payments, and potential involvement in formal litigation. These secondary disasters contribute to the development of “corrosive communities,” characterized by social conflict, hopelessness, and despair (Gill, Picou, and Ritchie 2011; Picou, Marshall, and Gill 2004). Despite these harmful effects, psychosocial health typically does not receive the attention it deserves in post-disaster recovery efforts.

There are three primary factors that limit the extent to which people seek and receive mental health services in post-disaster periods. First, many people fail to address their own mental and behavioral health needs because there are simply too many other problems and issues demanding their attention. Understandably, the need for money, food, water, shelter, and physical health issues take precedence over feelings of stress or depression. Second, there is likely to be limited availability of mental health care providers after large-scale disasters due to the increased numbers of people needing care and the diminished capacity of the health care system to deliver such services. Finally, disaster survivors are often reluctant to seek mental health care due to the stigma associated with poor mental health; they do not want fellow community members to think they are “crazy.” The situation is particularly problematic because a combination of two or three of these obstacles is likely to apply to many disaster survivors (Picou at al. 2009). Fortunately, appropriately trained CHWs can have a positive impact in all three areas.

In emergency management, the role of CHWs in identifying needed resources and assisting community members in accessing such resources is critical. This would include linking people in need with emergency services, such as distribution locations for food and water, and helping people apply for post-disaster recovery assistance. CHWs can also serve as peer listeners, supplementing professional mental health care providers as front-line interveners, providing informal counseling where appropriate, and referrals to professional services when needed. In addition, informal counseling in a peer listening encounter with a fellow community member would not carry the stigma associated with seeking professional care at a mental health facility. Of course, the ability of CHWs to fulfill these roles is dependent on proper training.

To maximize the utility and effectiveness of CHWs in mitigating the psychosocial impacts of disasters, the competency-based training curriculum will help CHWs to understand and appreciate these critical components: (1) the post-disaster social context, (2) variations in consequences and needs according to the type of disaster, (3) common psychosocial symptoms (e.g., depression, PTSD, substance abuse), (4) the logistics of good listening, (5) identifying and sharing resources and referrals, and (6) coping strategies for both peer listeners and disaster survivors (Picou 2011)