Racial and ethnic minorities that live in or around cities represent about two-thirds of individuals with diabetes globally.⁷ While social and cultural factors still play a role in the prevalence of diabetes in urban areas, the convenience of travel (think mass public transportation), the reduced physical demand required to provide food, and the increased availability of low-cost, highly processed foods contribute to the promotion of diabetes in this setting.⁷ This is why CHWs expertise in outreach and health education is crucial. CHWs know where and how community members purchase their foods and build relationships with these establishments to collaborate on initiatives.

For example, a study of the program, Vida Sana Hoy y Mañana (Healthy Life Today and Tomorrow), used Community Health Workers to promote the consumption of fruits and vegetables inside local Hispanic focused grocery stores often referred to as bodegas. The study found that individuals in this store reported an increase in fruit and vegetable consumption by about one additional serving per day.¹⁶

Community Health Workers are also great at group facilitation which allows them to educate large groups of people at once, on topics that have implications for diabetes and other chronic conditions. An example of this is the Harlem Health Advocacy program in New York City. CHWs conducted outreach and provided health coaching to individuals that lived in public housing complexes and senior centers. The results of the program found that 94% of participants continued to stay active for at least 6 months and blood pressure control increased significantly.¹⁵

In the U.S., overall, residents in rural populations are less likely to have private health insurance than those in urban areas.11 However, factors such as affordability, unemployment, and misconceptions about the health care system still leave many individuals who live in urban settings without coverage. In many cities in America, the unemployment rates are higher for blacks and Hispanics that live in and around large cities.8 This means that a large part of this population is without employer-based coverage or cannot afford private insurance.

Because Community Health Workers serve as a bridge between health care systems and the communities they come from, they know what low-cost or free services are available at a local and federal level. They can provide education to individuals in the language they are comfortable with which is a big help when it comes time to dispel myths on the health care process. These skills also allow CHWs to help individuals with the application process. They can promote open enrollment periods, deadlines, and requirements in a way that their population can understand.

Like in rural areas, urban populations face challenges when trying to locate and access services they can identify with culturally. African Americans, Hispanics, and Native Americans account for nearly one-third of the population but only represent 9% of physicians, 7% dentists, 10% of pharmacists, and 6% of registered nurses.5,12 This is why CHWs use their trusting relationships with community members to build stronger connections between individuals and their health care providers. This trust allows for a more effective exchange of information between provider and client.

Further, CHWs consider more than just an individual’s medical needs. They work with community partners to address the social and economic barriers that prevent people from getting the help they need. For example, a CHW will know if an individual does not have bus or train fare to make it to a medical appointment and can connect them to organizations that cover these fares for qualifying individuals. Understanding small details such as this is what sets CHWs apart from other health professionals and what allows them to minimize barriers individuals face when seeking services.

The variety of work CHWs perform allows for flexibility in the way organizations implement CHW programs in their communities. Because CHW programs can be tailored to fit the needs of specific populations, definitions within the profession vary. Although variations exist, there are key themes shared across all of the ways CHWs are described. MHP Salud has compiled these themes and used over 35 years of experience implementing CHW programs to define Community Health Workers as…

a trusted member of the community who empowers their peers through education and connections to health and social resources.

In urban areas, there are a variety of health professional positions that share similar qualities of Community Health Workers. For example, Health Educators and Outreach Workers are titles used to describe health professionals who provide health information and education. Healthcare Workers and Navigators may be used to describe CHWs that focus on connecting individuals to health care services. These positions share a similar responsibility with CHWs, to serve as a bridge between the health care system and the community.

However, what makes CHWs unique is that they must be a member of the community they are serving. This qualification means that CHWs are equipped with a deep understanding of the cultural norms and practices within their community. They can use this understanding to strategize the use of the most effective methods to perform the duties of their role.

MHP Salud implements CHW-led programs in predominantly Hispanic urban communities in the Tampa and Orlando region of Florida, on the topic of Healthy Relationships. These programs provide information, resources, and support to survivors of domestic violence, intimate partner violence, and sexual assault. Although many individuals are victims of these crimes, Latinas face unique challenges.

50% of Latinas who experience abuse never report it to authorities due in part to the fact that Latina survivors prefer to talk with trusted family members and friends.^13,14  The nature of the relationship between CHWs and those they serve through our Healthy Relationship programs allows them to fill the role of that trusted member. CHWs also had established connections with local organizations and groups which helped identify individuals who needed services and offered safe spaces for groups to meet. These collaborations are crucial in urban areas where resources are often limited because of high demand. Further, they help establish a continuum in which CHWs can refer individuals to services that are available within the same space of the program.

These programs demonstrate that whether CHWs implement programs in rural or urban settings, the services they provide are crucial in connecting communities that face barriers to health to the services they need.

1. https://academic.oup.com/heapol/article/35/1/91/5607274
2. Vlahov D, Freudenberg N, Proietti F et al. Urban as a determinant of health. Journal of Urban Health 84: 16–26. https://link.springer.com/article/10.1007/s11524-007-9169-3
3. https://srhrc.tamhsc.edu/docs/chw-policy-brief.pdf
4. https://www.who.int/health-topics/urban-health
5. http://urbanuniversitiesforhealth.org/media/documents/Fact_Sheet_on_Health_Disparities_and_Urban_Health_Workforce.pdf
6. Cyr, M.E., Etchin, A.G., Guthrie, B.J. et al.Access to specialty healthcare in urban versus rural US populations: a systematic literature review. BMC Health Serv Res 19, 974 (2019). https://doi.org/10.1186/s12913-019-4815-5
7. http://www.citieschangingdiabetes.com/content/dam/cities-changing-diabetes/magazines/CCD-briefing-book.PDF
8. https://www.brookings.edu/blog/the-avenue/2019/06/26/black-workers-are-being-left-behind-by-full-employment/
9. https://www.who.int/bulletin/volumes/88/4/10-010410/en/
10. https://www.census.gov/library/visualizations/interactive/rural-urban-uninsured.html
11. http://nciom.org/rural-urban-uninsured-gap-persists-but-more-north-carolinians-have-insurance/
12. https://www.pewsocialtrends.org/2018/01/09/diversity-in-the-stem-workforce-varies-widely-across-jobs/
13. https://www.decimosnomas.org/wp-content/uploads/4.16-NO-MAS-STUDY-media-findings-FINAL-FINAL-updated-Avon-logo-11.16.15.pdf
14. Cuevas, C.A., K.A. Bell, and C. Sabina, Victimization, psychological distress, and help-seeking: Disentangling the relationship for Latina victims. Psychology of Violence, 2014. 4(2): p. 196-209. https://psycnet.apa.org/record/2014-12472-003
15. https://www.cdc.gov/pcd/issues/2019/18_0623.htm
16. https://www.ncbi.nlm.nih.gov/books/NBK208027/

Promotora de Salud Resources

In order to do their complex work, Promotores and Promotoras must possess or build communication and interpersonal skills to conduct effective outreach in their communities. In addition, they must develop the skills to facilitate educational sessions and be able to coordinate assistance from many different resources to many different individuals who understand information better when it is in Spanish. And due to the sensitive nature of some of the issues they address; Promotores and Promotoras need personal strength as it’s possible that they’ll be working with individuals they already have relationships with.

It is crucial that Promotores and Promotoras feel supported in their unique roles. MHP Salud has used over 35 years of experience to develop free resources to help Promotores and Promotoras de Salud strengthen and increase their skills, and resources to help Supervisors and Managers support them.

MHP Salud provides opportunities to organizations interested in the Community Health Worker (CHW) profession to grow their knowledge base on how to design, implement, and evaluate CHW programs for their populations. We offer training for CHWs, CHW Supervisors, along with professionals and grant writers working with CHW programs. We also offer CHW program consulting and guided implementation packages that can be tailored to meet the needs of any organization. Our services are affordable and available both in-person and virtually. Learn more by visiting our CHW Training and Consulting page.