Assets in Primary Care: Community Health Workers Tackle Inequities in Texas

Community health workers (CHWs), or promotores de salud, serve as liaisons between the community and health system, contributing to individual and population health.^1,3 Due to the respect and confidence communities have in CHWs and CHWs’ ability to tailor to community members’ specific needs, they are able to provide culturally-appropriate resources.^2,4 CHW contributions are especially advantageous in primary care due to the comprehensive, whole-person approach to care. CHWs/promotores often spend more time with individuals than is allotted for physicians, and thus gain greater knowledge to address barriers to well-being.^1,2 As Houston, Texas remains medically underserved with populations of poor health status, especially within its Third Ward and East End communities, we evaluated CHW roles from the patient, community, and CHW perspectives, to demonstrate how CHWs address health disparities and enable a more robust and equitable healthcare system.

The University of Houston Institutional Review Board approved a research study (study number STUDY00002927) that we undertook among CHWs, CHW clients, and stakeholders who have worked with CHWs in the past 5 years. In our study, six virtual focus groups with 25 participants were the primary mode of data collection.⁵ Surveys were distributed to capture a larger population (149 total, for a 90.3% response rate). Recruitment included advertising methods at community and professional events and snowballing. Qualitative thematic analysis identified themes addressing CHWs’ roles, opportunities, and impact.

Data analysis yielded five major themes: (1) the complexity of CHW’s work and titles, (2) how CHWs build trust, (3) CHW’s being undervalued, (4) challenges CHWs face, and (5) future expansion for CHWs. Focus group participants discussed the diverse work and varying titles across institutions employing CHWs, including community health assistant, patient navigator, and promotoras de salud. A significant challenge is that without standardized CHW titles, confusion around CHWs roles leads to employers underutilizing and undervaluing them. CHWs foster relationships to ensure clients access necessary services such as health education, transportation, access to healthy foods and health care for better outcomes. The trust between clients and CHWs takes time to develop through one-on-one interactions including off-hours communication and outreach.

CHWs bring positive change to the communities they work in. This work highlights the diversity in support and resources that CHWs provide to communities in efforts to achieve health equity with resource awareness and access. Establishing a standardized description of CHWs could create a more universal understanding of the value CHWs bring to the health care team and allow their benefit to be maximized. Future opportunities exist to expand the reach of CHWs within nursing homes, primary schools, and medical education, all in ways that impact primary care. Moreover, CHWs being integrated into the medical school experience aids in advancing outcomes within the field of primary care because medical students become equipped to navigate the SDoH that drive patient health. Models such as this present another valuable opportunity for CHWs to impact primary care long term at the population health level. Increasing awareness and collaborations between primary care physicians and CHWs could allow for more equitable patient care and outcomes.