Straight to the people: Community health worker advances in training, practice, and policy

International Community Health Services (ICHS) is a nonprofit community health center offering affordable medical, dental, pharmacy, acupuncture, & health education services primarily to the API communities of Seattle & King County, Washington. Our primary medical care services include in-language and culturally appropriate prevention, diagnosis, screening and early intervention/treatment of acute and chronic illnesses and minor injuries; infant/well-child checkups, immunizations and vaccinations; and minor surgeries.  ICHS also offers obstetrics and gynecological care, home visits for new mothers and seniors, Women’s Preventative Health Services, Family Planning and teen/young adult health services, a REACH Coalition diabetes program, Hepatitis B education and treatment, information and referrals, HIV testing and counseling, on-site mental health counseling, nutrition counseling and Women, Infant, and Children (WIC) Food Program enrollment, and eligibility assistance for insurance enrollment.  Dental services include screenings and general exams, cleaning and hygiene education, preventive and restorative care, dentures, emergency care, specialty care referrals and minor oral surgery.  During our more than 30-year history, ICHS has attracted an API population increasingly more diverse in language, culture, and age. The majority of ICHS patients continue to be low-income recent immigrants or refugees and over 70% have limited or no English proficiency. We currently provide medical, dental and health education services in over 15 different languages and dialects through our more than 200 staff members and dozens of volunteers, caring for 15,986 unduplicated patients in 2007.

Community advocacy is a foundation of our agency’s history and we have developed full time positions to serve the diverse API communities seeking care at ICHS. Community Advocates address general education issues about ICHS and health care access, women’s health, and diabetes. External funding from the Komen Foundation for the Cure and contracts with the local Public Health Department help offset some costs to the agency. The group level diabetes program was initially developed in 1999 as part of the Racial and Ethnic Approaches to Community Health (REACH) Program, a research program funded by the CDC.  ICHS collaborated with Public Health Seattle and King County and other community health organizations to develop and implement the program.  Through REACH our Community Advocates were trained to provide group level interventions and community education activities for both ICHS and non-ICHS patients in the following communities: Chinese (Cantonese and Mandarin), Filipino (Ilocano, Tagalog, and English), Samoan, and Vietnamese.  The program offers Self Management classes, education classes, support groups, and patient case coordination to link ICHS clinic and education services. ICHS relies on community partnerships to conduct our work. Results show that diabetes outcomes are improving.   For diabetes classes, successes include serving over 1000 unduplicated participants since 2000 and solid data from each intervention detailing that the daily behavior of participants has changed.  Program staff has worked on innovative approaches such as an in-language, healthy, culturally appropriate cookbook.  Through REACH funding, ICHS was able to implement and sustain a successful program and organization leadership acknowledged this success through continuing to fund the program after the grant cycle.  Outreach and education on women’s health and general health is similarly structured so that Community Advocates act as trusted sources of information within the communities they live and are both bi-cultural and bi-lingual. And results show that more women are being screened. Successes have included over 5000 education encounters in the community in 2007 – Community Advocates have provided linguistically, culturally appropriate 1-to-1 and group breast health outreach and education, including PowerPoint presentations.  They have used in-language media outreach and education using popular local media relied on in target communities to run pieces generating community awareness and endorsement of breast health practices. They have recruited participants and facilitated “Talk Story” groups to explore breast health, beliefs about cancer and barriers to screenings and other preventive practices. Community Advocates have also provided enabling and supportive services using patient and cultural navigation strategies to facilitate women scheduling and keeping screening and follow-up appointments.  Interventions have been provided at community organizations, community centers, churches, stores, health fairs, community events and festivals, senior centers, libraries, and many other places. Community Advocates have developed and maintained community-based partnerships with formal and informal community leaders to introduce and reinforce their credibility and message.  Community Advocates have planned and sponsored community events and health fairs offering mammogram screenings through a mobile unit – they have scheduled screening appointments, made reminder calls, provided on-site interpretation and offered follow-up as needed and appropriate.  Through funding from Komen Foundation for the Cure, ICHS has begun the salon project in the Vietnamese community.  Workers at three salons have been trained on how to speak with their clients about breast and cervical health with the goal of promoting the importance of screening and referring them to ICHS to obtain their annual exams.  Referrals through the work of the Community Advocates resulted in 2221 preventative health screenings in 2007. 

One of the major challenges has been staff turnover.  The diabetes program previously functioned using contracted peer educators to work in each community.  Women’s health was supported by outreach workers, but diabetes education was treated as a separate entity.  Two years ago the health education program cross-trained existing community advocates (outreach workers) on diabetes interventions.  Since that time there have been fewer turnovers and a solid and knowledgeable staff working on diabetes education and women’s preventative health in the community.  Recruiting participants has presented a challenge for both diabetes interventions and to women’s health screenings particularly in some communities where it is not acceptable to acknowledge a disease such as diabetes or to discuss preventative health.  Program staff has worked to find new and innovative ways to overcome such barriers through activities such as the health fairs and the salon project.  Community Advocates have worked hard to become trusted leaders in their community so that their messages of preventative health and diabetes education are better received and their services are requested and responded to.   Another challenge has been linking the work Community Advocates are doing with clinic services.  Both clinic staff and community advocacy have worked together to create standard community messages and referral systems to ensure smooth entry for community members to use clinic services.  ICHS has learned several important lessons.  First cross-training existing staff on diabetes education proved extremely beneficial and effective in retaining dedicated and qualified people.  Furthermore acknowledging traditional forms of medicine and having an understanding of their use and importance is crucial.  Another practicality was to include the diabetes education program in the federally funded health disparities collaborative at the clinic.  This helped integrate the diabetes education program into clinic flow which aided in patient case coordination.  Standardization of messages and referral systems particularly for women’s health have proved very beneficial to tracking screening cases and doing follow-up after a woman’s exam.  Collaboration is important, not only with other community agencies, but also amongst the community advocacy staff serving multiple communities and languages.  An open atmosphere where staff can discuss challenges, ask questions, and offer suggestions is crucial.