Community Health Workers Should be Worker Advocates

Abstract

Community health workers (CHWs) are frontline health workers who connect underserved populations to the health care system, provide health education, and advocate for their clients. CHWs can be particularly helpful to their clients in addressing social determinants of health that affect many chronic illnesses such as asthma, high blood pressure, poor mental health, and kidney and heart diseases. However, in one social determinant—the world of work—CHWs do not often play a role as facilitators and advocates. Low-income and other disadvantaged workers experience many hazards to their health and well-being, and knowledgeable CHWs could play a significant role in assisting them to confront such challenges.

Keywords

community health worker occupational health and safety training social determinants of health

Introduction

Community health workers (CHWs) are extensively employed to connect low-income and ethnic minority populations with the health care system. The American Public Health Association defines CHWs as “frontline public health workers who are trusted members of and/or have an unusually close understanding of the community served.”¹ In particular, CHWs reach out to, and serve, patients who have chronic conditions such as asthma, diabetes, high blood pressure, mental illness, heart and kidney diseases, among many others. However, the training and employment of CHWs in occupational safety and health has been minimal.² This paper will explore how CHWs—if properly trained—could be of great help to their clients who work in low-wage, hazardous occupations. And, as described below, workers are receptive to the training and information from CHWs.

Over the last 40 to 50 years, the economy and workforce in the United States have undergone major changes that have increased the population and the social and health problems of potential CHW clients. While there was substantial—and widely shared—economic growth in the quarter-century after the Second World War, “Beginning in the 1970s, economic growth slowed, and the income gap widened. Income growth for households in the middle and lower parts of the distribution slowed sharply, while incomes at the top continued to grow strongly.”³

One major factor in this decline was the nation’s de-industrialization, with skilled and highly paid jobs moving to low-income countries. Since 1980, the number of manufacturing jobs has declined by about 7.5 million.⁴

These trends have led to an increased demand for a workforce of low-wage immigrants. According to the Pew Foundation, in 2017, there were 29 million immigrants in the United States, comprising 17% of the labor force. Approximately 8 million of those immigrant workers were undocumented.⁵ Statistical and anecdotal studies of the working conditions of immigrants indicate that they are more likely to hold more hazardous jobs than other workers.⁶ Undocumented immigrants may be at even greater risk, in part because they have fewer alternatives⁶ and fear deportation for asserting their workplace rights. And indeed, their fear of deportation is well-founded. A report by the National Employment Law Project has documented numerous such cases, and noted that under a Florida law, at least 130 injured workers were arrested and put at risk of deportation when they applied for workers’ compensation. In Massachusetts, an injured worker’s employer contacted the Immigration and Customs Enforcement (ICE) agency to have him arrested after the worker met with his employer about his recently filed workers’ compensation claim.⁷

Unions, which can provide important workplace protections and higher wages, have lost considerable membership, as a percentage of the total workforce, in the private sector (although they have gained membership in the public sector). The proportion of workers covered by union contracts declined from 27.0% to 11.6% between 1979 and 2019. Immigrants appear to be unionized at a slightly lower rate than native workers.⁸

Recognition that immigrants and other low-wage workers face unacceptable vulnerability on the job has apparently increased recently with the COVID-19 pandemic. Numerous unionization campaigns have been initiated in industries heretofore considered impregnable—Starbucks, Amazon, and national fast-food restaurant chains prominent among them.⁹ The federal government has shown at least token interest. In 2020, the Equal Employment Opportunity Commission established a Vulnerable Workers Task Force to examine how the agency could better serve the needs of vulnerable workers.¹⁰ Most recently, President Biden, with his quip, “Amazon, here we come,” expressed public support for that unionization effort.¹¹

Because the workforce is now composed of many more low-wage immigrants and other disadvantaged workers—who have fewer workplace protections—the need for CHWs who can advocate and provide culturally appropriate services for their clients is greater than ever.

Work is a Social Determinant of Health

The major focus of CWHs in assisting their clients are social determinants of health, defined in “Healthy People 2030” (U.S. Office of Disease Prevention and Health Promotion) as “the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”¹² In the workplace, there can be numerous threats to a worker’s health and well-being: toxic chemicals, repetitive and strenuous motions, excessively fast work pace, abusive supervisors, discrimination, sexual harassment, inconvenient and changing work schedules, among others. Yet the obstacles to preventing or ameliorating such health and safety risks are numerous and well known, including fear of retaliation (such as losing one’s job, reduced work hours, and in the case of undocumented immigrants, deportation); ignorance of workplace rights; and language barriers. CHWs trained in workplace issues would be in a position to educate their clients on their workplace rights, so they may take the actions that are appropriate in their situation: filing a complaint with a government agency, speaking directly to a supervisor, organizing with co-workers, etc.

CHWs—an Underdeveloped Resource for low-Income Workers

CHWs are also known as promotores, lay health advisors, and frontline workers, among several others; however, they all usually share a common set of skills, typically known as “core competencies.”¹³ These skills enable CHWs to serve as resources to their communities, connecting them to health and social services and advocating for them at both individual and policy levels.^13,14 Research showing their effectiveness is extensive. The Association of State and Territorial Health Officials and the National Association of Community Health Workers compiled a list of 840 CHW studies conducted from 1964 to 2016, including 574 between 2014 and 2016.¹⁵ Both reviews of CHW interventions and randomized control trials showed modest to robust improvement in patient outcomes.^16–19

Peer-to-peer worker training, in which trainers come from a similar socioeconomic and cultural background, has long been shown to be effective in communicating health and safety information.^20,21 CHWs of course, do not have the work environment of their clients. However, they do often share a similar ethnic and cultural background that, with their mastery of the CHW “core competencies” and training in the basics of occupational health and safety, can enable them to provide valuable assistance to their working clients.

Some of these CHW competencies are directly or indirectly useful in assisting clients with workplace issues. One such skill is the ability to educate clients to promote healthy behaviors. The Massachusetts Department of Public Health notes that “CHWs work with clients, family and community members and providers to address issues that may limit (emphasis added) opportunities for healthy behavior. The CHW acts as educator and coach, using a variety of techniques to motivate and support behavior change to improve health.”²² As noted above, CHWs with training in occupational safety and health would be in a position to help their employed clients to identify and address their workplace hazards.

Coordinating health care and navigating that system—another core competency—means that CHWs can help clients obtain the care that they need. For instance, worker clients may not know the importance for workers’ compensation of informing their health care provider that their injury was work-related; and physicians may not know to write in the medical record that an injury or health problem originated at the patient’s work.

CHWs also learn to use public health concepts and approaches, including the specific health topics that are most relevant to their clients. Prominent among the diseases affecting the populations that CHWs serve are asthma, heart disease, cancer, mental health disorders, hypertension, and kidney disease. These conditions (among others) are common among low-wage and minority workers, in part because they are often exposed to toxic substances such as lead, cleaning chemicals and industrial solvents; harassment and bullying; irregular and unpredictable schedules; nonpayment of wages.

Unfortunately, many workers are unaware of the laws and government programs that exist to protect them from these adverse conditions. A report by the Massachusetts Department of Public Health of a study at 5 community health centers noted that many patients were unaware of the Occupational Safety and Health Administration (OSHA) or workers’ compensation.²³ And as noted above, for undocumented immigrants, fear of deportation can severely limit their willingness to avail themselves of their workplace rights. While there is no “silver bullet” to resolve this issue, CHWs have the skills, resources, and characteristics to help overcome this challenge. They typically come from the same or similar class and ethnic group, and their training in the “core competencies” enables them to fully engage with their clients. With training in workplace issues, CHWs could appropriately guide their clients and make referrals to the resources (unions, worker centers, and government agencies) that could better assist them.

Community health centers are often the first places that injured, low-income workers turn to for care of work-related problems. Even those workers who have nominal access to occupational health services are often reluctant to use them for fear of retaliation by their employer. Numerous studies have also shown that many, if not most, workplace injuries and illness are not reported to the employer’s workers’ compensation carrier.²⁴ As a result, a large portion of the financial burden of workplace injuries is carried by the injured workers and their families, taxpayers and the community health centers that serve low-income workers. The CHWs who are based at community health centers are in a position to help workers obtain the benefits of workers’ compensation.

The prevention of injury and disease is, of course, a key public health goal. In 2019, nearly 16 million workers were injured at a cost of $171 billion²⁵ The total cost per year of all workplace injuries and illnesses has been estimated at $250 billion.²⁶ Primary prevention in the workplace involves eliminating or minimizing health and safety hazards. Workers who can recognize workplace hazards, understand their rights, and feel empowered to take action are in a position to prevent avoidable injuries and illnesses. CHWs who have a basic knowledge of occupational health and safety can educate their worker clients and make referrals to the relevant government agencies (such as OSHA) and worker-oriented organizations (such as labor unions and worker centers).

Secondary prevention is primarily the provision of health care at the first stage of disease or injury. In the occupational context, a worker would receive prompt and appropriate screening or medical care at the first sign of exposure or illness, or immediate attention in the case of injury. Knowledgeable CHWs can facilitate communication between patient and health care provider and assist and advocate for their clients who qualify for workers’ compensation.

The Centers for Disease Control and Prevention (CDC) defines tertiary prevention as: “managing disease post diagnosis to slow or stop disease progression through measures such as chemotherapy, rehabilitation, and screening for complications.”²⁷ Work-related tertiary illness prevention is exemplified by long-term care for chronic conditions, such as asthma and other lung diseases, kidney disease, heart disease, and hypertension. Serious injuries from falls, electric shock, and repetitive strain disorders also may require long-term rehabilitation. The failure to provide appropriate medical care for work-related injuries frequently leads to abuse of addictive substances, such as opioids, requiring extensive recovery services. Several studies have linked the overuse of opioids to workplace injuries. National Institute for Occupational Safety and Health (NIOSH) analysis of Bureau of Labor Statistics (BLS) data showed an increase of 24% in drug-related workplace deaths between 2011 and 2016.²⁸ In Massachusetts, workers in construction, accommodations/food service, and real estate had the highest number of drug-related deaths.^29,30 In a Washington state study, 42% (781 of 1843) of workers with back pain received opioid prescriptions, and among the longer-term users, opioid doses increased without clinical improvement.³¹ CHWs with the relevant training and information (eg, on workers’ compensation, drug addiction services) could be of immense assistance to their worker patients with counseling and referrals.

Some authors have promoted the role of CHWs as advocates in the public health sphere.¹⁴ In the workplace arena, CHWs can be no less valuable as agents for change. They see, on a daily basis, the effects of unsafe and abusive working conditions. Their immigrant, minority, and low-wage patients suffer from numerous chronic and acute illnesses and serious injuries with little access to preventive services and treatment. This firsthand knowledge can be employed to engage with legislators, regulators, labor unions, worker centers, researchers, and others who make or influence workplace policy. CHWs often serve as medical interpreters, and as such see themselves as patient advocates. In this role, they can ensure that the occupational source of an injury or illness is addressed.³²

Current status of CHWs

As of February 2020, there were 12 state-operated CHW training and certification programs, 7 privately operated programs, and 2 programs under development.³³ In addition to the core competencies, many training providers offer classes in special health topics, such as diabetes, heart health, hypertension, mental health, obesity, and many others. Missing from this list of important health subjects, however, is occupational safety and health. The author’s internet search of CHW training organizations that taught that subject yielded only one (Make the Road New York, a worker training and advocacy organization).

Although they work in a wide variety of organizations, CHWs are primarily employed in 5 industries: “individual and family services,” “local government (excluding hospitals),” “outpatient care centers,” “general medical and surgical hospitals,” and “offices of physicians.” According to the BLS, there are currently over 64,000 CHWs, with approximately 40% of them concentrated in 5 states: California, New York, Texas, Washington, and Ohio.³⁴

The role of CHWs as valued members of the health care workforce has gained recognition over the last several years. CHWs have established professional and advocacy associations in over 35 states.³⁵ In 2009, the U.S. Department of Labor recognized CHW as a distinct occupation,³⁶ and the Patient Protection and Affordable Care Act lists CHWs as health professionals who are members of health care teams.³⁷

Several training projects and research studies have shown the potential for employing CHWs as occupational safety and health advocates and educators.^38–42 A review in 2018 of CHWs’ role in occupational safety and health research identified 17 published studies, with the majority taking place in agriculture.⁴³ Most, however, involved surveys and trainings that ended with the conclusion of the research project.

CHWs themselves (and their supervisors) have expressed an interest in occupational health and safety training. In a study of community health center clinicians and CHWs, participants recognized the role of work in their adult patients’ health, however, “Clinicians reported not utilizing occupational information during clinical encounters and identified competing priorities, limited appointment time, and lack of training as key barriers. They cited workers’ compensation as a source of confusion and frustration. However, most participants [including community health workers] recognized occupation as an important social determinant of health and expressed interest in additional training and resources.”⁴⁴ In Massachusetts, the CHWs who participated in a focus group expressed more than a passing interest in learning about OSHA in order to both help their clients and protect themselves (focus group conducted by the MA Department of Public Health and the author).

With regard to physicians, 1 long-term strategy to improve clinical occupational health care would be additional medical school training in occupational health; a recent report on occupational health medical education by the American College of Occupational and Environmental Medicine noted that occupational and environmental curricula in medical school are “uncommon.”⁴⁵ Another way of encouraging physician engagement with occupational health issues is a collaborative project with labor organizations, as developed in Chicago by the Healthy Work Collaborative at the University of Illinois Chicago.⁴⁶

Some training has been either offered to the CHWs of a particular employer or were focused on 1 targeted disease. After a Texas community health center approached the Harvard University School of Public Health, that institution, along with a worker training and advocacy organization and the Massachusetts Department of Public Health Occupational Health Surveillance Program, developed and presented a comprehensive 16-hour course that included workplace rights and common health and safety hazards (including COVID-19), to the health center’s CHW staff (curriculum available from Occupational Health Outreach office of Harvard Public Health). A similar course was presented to CHWs employed by the Manchester, New Hampshire health department. And during the COVID-19 pandemic, the same Massachusetts worker organization (Massachusetts Coalition for Occupational Safety and Health) conducted 2 presentations for the state CHW association on the workplace hazards of the virus (author participated in all 4 of the above classes). Although it would be useful to know how effective those training have been, to date they have not been evaluated. And crucially, what has also been lacking, are continuing occupational health and safety courses by conventional CHW training providers.

Conclusion

CHWs trained in the basics of occupational safety and health are in a unique position to assist workers who are injured or made ill at their place of employment, or who may recognize a workplace hazard, but are unaware of their health and safety rights. CHWs who receive training on the workplace regulatory agencies (OSHA; workers’ compensation agencies; wage and hour enforcement agencies; workplace discrimination commissions, etc.) would be in a position to assist their employed clients in issues that are of greatest concern to them. In addition, CHWs would be in a position to refer and connect injured and other at-risk employees to other resources, such as advocacy organizations, immigrant groups, adult education classes, legal assistance.

Low-income and other disadvantaged workers experience many hazards to their health and well-being, and knowledgeable CHWs could play a significant role in assisting them to confront such challenges.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Richard Rabin

Author Biography

Richard Rabin is the trainer and technical consultant for the Massachusetts Coalition for Occupational Safety and Health (MassCOSH). He has given numerous classes and presentations to community health workers on occupational safety and health. Previously, he directed the Occupational Lead Poisoning Registry at the Massachusetts Department of Labor for more than 20 years. He has published several articles on both child and adult lead poisoning.

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