Authors

Authors: Kerstin M. Reinschmidt PhD, MPH¹,Marshan Oliver-Marick, DrPH, MPH, ², Adam Warren, MPH³

Affiliations:

1. Oklahoma Public Health Training Center, University of Oklahoma Health Sciences Center

2. School of Community Health Sciences, Counseling, and Counseling Psychology, Oklahoma State University

3. Department of Biostatistics and Epidemiology ,University of Oklahoma Health Sciences Center

Suggested Reference

Warren, A., Oliver Marick, M., Reinschmidt, K.M., (2022). Final Report of the Community Health Worker COVID-19 Impact Survey: Oklahoma Results. Oklahoma Public Health Training Center at Hudson College of Public Health at Oklahoma University Health Sciences Center. Oklahoma City, Oklahoma.

This report is available online at:

https://ophtc.ouhsc.edu/Resources

http://www.opha.net

http://www.vaxok.org

Community Health Workers

Definition, C3 CHW Core Consensus project, and relevant information

Community Health Workers are part of the public health worker network, tasked to work directly in communities building foundational tight knit connections. In their practice, CHWs form deep understandings and knowledgeability of the communities they serve. The benefit to closely positioning these allies into communities results in trusted accord in providing exhaustive resources as is needed. A trusted definition of the CHW is provided from The American Public Health Associations CHW Section: A community health worker is a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served. This trusting relationship enables the worker 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.¹⁴

The title Community Health Worker may divide into differing names and has been used and reported in the field as CHWs, Community Health Representatives (CHR), Promotoras/es de Salud, Outreach Workers, and Patient Navigators. Along with the varying names, CHWs perform multiple roles, practice many skills, and have a special connection to the communities they serve. Efforts directed towards encapsulating the CHWs were put forth by researchers, CHWs, and public health professionals nationwide. Results were comprised into the Community Health Worker Core Census (C3) Project, a reliable consensus on CHW core roles and competencies to be used for CHW education, practices, and policies. The C3 Project lists 10 CHW core roles¹⁵:

1. Cultural mediation among individuals, communities, and health and social service systems

2. Providing culturally appropriate health education and information

3. Care coordination, case management, and system navigation

4. Providing coaching and social support

5. Advocating for individuals and communities

6. Building individual and community capacity

7. Providing direct service

8. Implementing individual and community assessments

9. Conducting outreach

10. Participating in evaluation and research

When implementing what is listed above, CHWs are delivering beneficial meaningful impacts into the communities they serve. As has been shown in the literature, CHW efforts have been successful in helping address infectious diseases in the past.¹⁶ The communities utilizing CHWs see improved health outcomes and are delivered more culturally competent care.^12,13,17,20 Now working as part of the COVID-19 response in their respective communities, CHWs are tasked with utilizing their roles and skills to navigate those they serve through the pandemic. As they are part of the public health worker umbrella, their work in the pandemic response was subject to increased risk of exposure to COVID-19. As might be expected, this is not the sole factor CHWs have seen affected by COVID-19. Results of last year’s iteration of this study showed that CHWs perceived of their communities as increasingly unwell with the presence of the pandemic.¹⁸ Other indications of what CHWs have faced during the pandemic are seen in the roles and skills CHWs performed, work settings, and community engagements. Referring again to what was observed last year; roles and skills were not notably different from before to during the pandemic. CHW’s did report changes to their work environment, including the digital transition mentioned earlier.¹⁸ Lastly, from results of the prior survey, community engagement was restricted and limited.¹⁸ Literature and results from a rapid evidence synthesis of similar studies report findings mirroring CHW work environment and community engagements. However, the summary of skills expressed from multiple other CHW groups, reported pandemic induced changes. Mostly, tailoring actions to abide by COVID restrictions and addition of pandemic specific tasks like contact tracing.¹⁹ These aspects are relevant to what is being considered in this COVID-19 Impact Survey study.

Oklahoma Public Health Training Center

The Oklahoma Public Health Training Center (OPHTC) at the Hudson College of Public Health at Oklahoma University Health Sciences Center is one of several partners of the Region 6 South Central Public Health Training Center (R6SCPHTC). The R6SCPHTC is one of 10 regional public health training centers funded by the Health Resources & Services Administration (HRSA), and is housed at the Tulane University School of Public Health and Tropical Medicine (OPHTC, 2021). In alignment with the mission of the R6SCPHTC, which is to strengthen the technical, managerial, and leadership competence of the current public health workforce and to advance the knowledge and skills of the future public health workforce (R6SCPHTC, 2021), the OPHTC strives to Strengthen Oklahoma’s Public Health Workforce (OPHTC, 2021). Within this context, the OPHTC is committed to supporting the CHW workforce by identifying timely training topics, and developing and implementing trainings for CHWs.

In August 2020, the OPHTC was invited to replicate the CHW COVID-19 Impact Survey that was originally conducted in collaboration between the Maternal and Child Health (MCH) Training Program at the University of Texas, Houston Health School of Public Health, and the Community Health Worker Core Consensus Project (C3 Project) at the El Paso Texas Tech (St. John et al. 2021). Since the survey sought insight into the extent to which the COVID-19 pandemic had affected CHWs in the U.S., and explored related training needs, replicating the survey was of interest to the OPHTC. The mixed quantitative and qualitative survey examined CHW experiences and perceptions during the pandemic with a focus on changes to their workforce and training needs, and priority needs of CHWs and the communities they served. After receiving OUHSC IRB approval to implement the survey in Oklahoma, the English version was distributed through REDCap via CHW networks and associations from January 11 to February 1, 2021. Following success of this first iteration, the OPHTC formulated plans to distribute a second iteration of the survey in 2022. Part of the R6SCPHTC funding allowed for a student stipend to be added to the project. This was awarded to a student (1^st author) from the Hudson College of Public Health’s Biostatistics program, the student utilized this study as their Culminating Practicum Experience as part of their Masters in Public Health. This student collaborated in conducting a CHW Townhall in preparation of revising and updating the survey and led distribution and analyses of survey results.

Study Objectives and Research Question

With the extension into year two of OPHTC’s efforts to survey COVID-19 impact on CHWs, a large focus was taking the previous survey and making relevant revisions. Utilizing community-based participatory research principles, a townhall was planned and conducted to learn firsthand what CHW’s felt about the survey itself as well as its results. Discussion, themes, and ideas from this summit were analyzed by the research team and an advisory committee of three CHWs. The survey was revised accordingly and distributed through REDCap via CHW networks and associations. New survey aspects deliberately added by the will of the research team were varying responses to indicate temporal status of occurring changes. Specifically, Before the Pandemic, Year 1 of the Pandemic, and Year 2 of the Pandemic. These efforts provided the desired opportunity to address our research question, and subsidiary interest. What were the Impacts of COVID-19 on professional and personal aspects in the current Oklahoma Community Health Worker labor force? Does the addition of improved pandemic response, distinctively vaccination efforts, provide any association in COVID-19 impact for CHWs?

CHWs were provided a generous amount of opportunities to respond in open-ended formats. So that these responses are appropriately analyzed, the research team followed qualitative analyses methods. Accumulating themes were reviewed to match the C3 Project roles and skills framework and Social Determinants of health (SDOH) framework depending on what was appropriate for the question. As the C3 project is describe above, this framework details and lines out varying aspects of the CHW efforts and how those competencies address different aspects of the communities served by CHWs. The SDOH framework was used when CHWs described components of their communities. This allowed for a dissection of these responses in understanding possible socioeconomic factors or health outcome determinates of the communities they represent.

For the three weeks the survey was available, 03/22/22 – 04/05/22, 60 CHWs provided responses to the survey. Overall completion rate for our survey was 80%, but this did not tell the story of the percentage of questions participants actually answered. Item response rates were calculated for each section to better understand participation: Demographics (86.67%), Personal Impacts of COVID-19 (77.50%), Impact of COVID-19 on CHW Employment, Job, and Community (96.59%), Impact of COVID-19 on CHW Roles and Skills (56.40%), community concerns as observed by CHWs (97.30%), Training (77.97%). Averaging these item response rates by section, 82.07% of questions were appropriately responded to. While the small number of survey respondents does not allow for the CHW experiences, perceptions, and needs reported to be generalized to CHWs across Oklahoma, the findings offer valuable insights that may be applicable to other CHWs in the state. The survey allowed CHWs to describe their experiences of working at organizations and with communities before and during the COVID-19 pandemic. Hopefully, the information shared in this report will help prepare the current and future CHW workforce with trainings and sustained support during public health emergency responses.

Perceived Threat of COVID-19

Personal impacts were assessed on perceived threat to CHW livelihood and risk of severe illness of COVID-19. Figure 1 reports the breakdown of 51 responses for perceived threat from Not a threat, Minor threat, or Major threat. CHWs found the virus to mostly be a minor threat towards their personal health, financial situation, job security, and day to day life in their community (51.0%, 47.1%, 44.0%, 41.2%, respectively). However, for the health of their state populations as a whole, COVID-19 was disclosed as a major threat. Contextual responses addressed this concept as well, twenty-five respondents expressed perceived threats of COVID-19 impacted the health,finances, lifestyle, as well as work of themselves and their families. CHWs’ descriptions portrayed how threat shifted behaviors; following COVID-precautions, job loss, pandemic inflation, and social life.

Increased Risk Severe Illness of COVID-19

CHWs were asked to identify increased risk of severe illness of COVID-19 for themselves, their families, and the populations they serve. CHWs were given the following information from the CDC to define those with increased risk: older adults, people with underlying medical conditions, and those pregnant and recently pregnant. Depicted in Figure 2, increased personal and family risk of severe illness was not of concern for over half of CHWs (53.7% and 52.8%, respectively). However, large margins (40.7% and 41.5%, respectively) of CHWs did express increased personal and family risk for those vulnerable populations. Compared to personal and family risk, CHWs viewed the communities they serve with drastic differences for increased risk. 80.0% of CHWs assessed the community they serve as vulnerable and having increased risk to severe illness from COVID-19. For analytical purposes, CHWs’ views of personal and family risk were combined and were observed as statistically different (39.6% vs 81.8%; p>0.001) from community risk.

Close Proximity to Positive COVID-19 Case Through Work

Concluding this section of Personal Impact of COVID-19, Figure 3 provides information on whether CHWs were in close proximity to anyone who has tested positive for COVID-19 through their work. The relative frequencies by responses differed significantly (p =0.003). At work throughout the pandemic, over half of CHW responses (21, 60%) stated close proximity to a positive case of COVID-19. Remaining responses were fairly uniform between No or Unsure (6, 17.1% vs 8, 22.9%).

Respondent Job Titles

Of important note from Table 2, the majority of our respondents identified their current or most recent job title as Community Health Worker (CHW). The other representative job title provided was Community Health Representative (CHR). Some respondents did not have either of these titles, those selecting other (7, 12.5%) identified with 5 varying titles.

CHW Work Status in Past 6 Months

Further looking at respondents’ employment, Table 3 represents work status for the past six months. Notably, the majority (63.8%) of respondents indicate their time as a CHW has established for the past 6 months. The proportion of CHWs hired in response to the pandemic was 15.5%. The proportion of CHWs hired after COVID-19 arrived, but NOT in response to COVID-19 was marginally higher (17.2%). Two CHWs reported no longer continuing with this line of employment. These responses were split by a decision to stop CHW work in response to COVID-19 and a COVID-19 furloughed CHW who continued CHW work unpaid/as a volunteer.

Insurance

Another aspect to consider on Employment and job impact is Insurance status of CHWs (Table 4). Employer provided insurance made up the majority of insurance types, 39/49. The remaining insured CHWs were about evenly distributed by utilizing family members insurance, Medicaid, Medicare, or purchasing their own health insurance.

COVID-19 Restrictions at the State of Local Level

Beginning the discussion of COVID-19 ramifications for the CHW workforce, one survey question asked: Have COVID-19 restrictions at the state or local level changed the way you perform your job? Feedback from last year’s responding CHW’s acknowledged that COVID-19 restrictions did have an impact on the way they performed their job (78.26%). Contrasted with CHWs survey answer this year, data was not strong enough to report the responses was statistically different (p=0.5582). Specifically, Table 5 displays 70.59% of 2022 respondents had COVID-19 restrictions that changed the way they performed their job. This question was followed with an opportunity to provide additional comments, how has it changed? For the twenty-two unique responses submitted on the topic, two distinct themes were reported. The restrictions changed and challenged workplace precautions and guidelines as well as work-related interactions. CHWs noted introduction of virtual work, PPE (mask), social distancing, travel restrictions, and safety-first mentality were COVID-19 precautions/restrictions that changed their efforts in the workplace. Documented in CHWs functionality of work-related interactions, inability to work directly in communities, no home visits or limited access, and events being cancelled or postponed were unfavorable results of restrictions. Described are the CHW comments relevant to the two determined themes. Other mentions describe desire to return to normalcy, increased efforts/outreach, and difficulties with disregard of COVID-19 restrictions.

CHW Efforts over Pandemic Timeline by Settings

Figures 4&5 and supporting tables (Tables 6&7), review the changes from before the pandemic to year 1 of the pandemic to year 2 of the pandemic for the employment of CHWs. CHWs were to report their work setting and organizations worked for across these time periods.

Additionally, CHWs describe their efforts by location as well. CHWs noted working 38.2% (13/34) in Large Cities, 2.9% (1/34) in suburbs of a large city, 35.3% (12/34) in a small city or town, and 23.5% (8/34) in a rural area.

CHWs reported of work settings as generally uniform from past to present (Figure 4; Table 6). Noted as having the largest increase over the pandemic time frame, were Health department, Remotely from home, and Out in the community. An association was not observed for these work settings (p: 0.0552, 0.0792, 0.0979, respectively) by pandemic time periods, nor any other reported settings. Still of interest, the estimated odds of a CHWs to report working in one of these settings in year 2 of the pandemic were 2.06, 2.79, and 1.43 times that of reporting working in the respective setting before the pandemic.

CHW Efforts over Pandemic Timeline by Organizations

Survey responses for the type of Organizations CHWs worked with discerned some volatility by pandemic time points (Figure 5; Table 7).

Increasing trends for CHWs were found in working with Government, Community-based, Indian/Tribal Health, and Education Program organizations. Decreasing trends were observed in Clinical, University, and Private Organizations. Significant differences in the type of organizations CHWs worked though the pandemic time points were not reported. A compelling statistic in this reporting is related to the increase in working in Community-based organizations. CHW involvement counts with these organizations (before: 10, Year 1: 11, Year 2: 18) were not statistically different (p=0.053). Still this increase was of the largest magnitude among the type of Organizations.

CHW Reported Job Experiences

Two questions addressed aspects surveyed on the job of CHWs. Frequency of various positive and negative experiences were reported, and agreement levels for employer support. Responses are represented by Figures 6 and 7 as well as Tables 8 and 9.

The experiences tried to model mood, effects of work, and opinions of the work CHWs perform. For the eleven listed experiences, CHWs were to reflect how frequently they experienced these things in the last 30 days (Rarely or Never, Sometimes, Often). Experiences can more or less be generalized as positive or negative. Categorizing as such, positive experiences were Often and sometimes (n = 132) felt by CHWs while negative experiences were Rarely or Never (n = 116) felt. The frequency of experiences in responses that was reported shared a statistically association with the categorized experience (p < 0.001).

CHW Reported Employer Support

Support by employer during the pandemic was ascertained by levels of agreement stated by CHWs. Levels were disagree, neutral, agree, strongly agree; disagree is a combination of disagree and strongly disagree due to sample size limitations.

CHWs unanimously expressed they agreed or strongly agreed their employer provided support in all categories. Newly added to this iteration of the survey are responses:

• Employer has integrated me into care team by explaining my CHW roles & Skills

• Employer helps with establishing connections with providers

These methods of employer support were derived directly from conversations with CHWs during our Townhall. For these newly added options, CHWs report disagreeing with this type of support only 5.9% (n = 2) of the time. Totaling both agree and strongly agree, 70%> of responding CHWs felt their employer provided support with establishing connection with providers and team integration with the team knowing the CHW roles and skills.

CHW Efforts over Pandemic Timeline by Populations

The communities CHWs serve will be the last characteristic addressed for COVID-19 impacts in this section. Following similar to work setting and organizations, CHWs provided survey responses indicating their involvement with distinct populations and defined the racial/ethnic groups they served across the pandemic time line.

Confirmation as to what populations CHWs served are graphically represented and in table format. (Figure 8; Table 10) Survey results identified overall, CHWs performed the most work with families, women, and older adults. Of these populations, evidence concluded CHWs involvement was not considered equal from before the pandemic to year 1 to year 2 for families and women (p = 0.020; p = 0.030). CHW work has increased for both populations since the beginning of the pandemic. Estimated odds of a CHW to report working with families in year 2 of pandemic response are 1.84 times the odds of a CHW reporting working with families before the pandemic. Similarly, estimated odds of a CHW to report working with women in year 2 of pandemic response are 1.31 times the odds of a CHW reporting working with women before the pandemic.

CHW Efforts over Pandemic Timeline by Racial/Ethnic Groups

Equivalent investigation is provided for the racial/ethnic groups CHWs serve (Figure 9; Table 11).

The pandemic was not reported to disturb how CHWs work with any group. Hispanic, Latino or Spanish origin populations that CHW’s reported working with saw the largest margin of difference. CHW work in this racial/ethnic population grew by five CHWs from before the pandemic to year 2. Decreased CHW work was observed in Asian and also Native Hawaiian or other Pacific Islander since the start of the pandemic to year 2.

Rating Community Well-being Before and After Pandemic

The last question to assess COVID-19 impacts on job, employment, and community asked CHW’s to rate the well-being of their community (Table 12). Ratings were given as Unwell, Neutral, and Well.

Most notably, an increasing trend was observed in those rating their communities as unwell since COVID-19. However, this trend and magnitude of CHWs ranking their communities as unwell is less drastic in the current responding CHW’s compared to the previous responding CHWs (Unwell after pandemic: 11% vs 13%; Past vs Present). Though this contrast is observed, community rating is not significantly different by the responding CHW groups (p>0.05).

CHW Roles Before and After the Pandemic

Addressing the frequencies reported for roles, Figure 10 shows CHWs frequency of all ten roles was Some or Often over 70% of the time.

Figure 11 and Table 13 distribute the frequency of roles during the pandemic. Across all ten roles, no change in role frequency was observed most. Five roles saw large increase of being performed more since the pandemic. CHWs were spending more efforts providing culturally appropriate health education; care coordination, case management & system navigation; advocating for individuals & communities, providing direct support; and conducting outreach. Most of the pandemic impact of reducing roles could be considered mild by CHWs responses. However, cultural mediation, providing direct services, and conducting research have 30% of their respective distributions represented by performing this task less for some CHWs. A large decrease was described for the role of participating in evaluation and research.

CHW Skills Before and After the Pandemic

Similarly presented in Figure 12 is the CHW specified frequency of Skills pre-pandemic. CHWs shared that all ten skills were used often. Communication; interpersonal & relationship-building; outreach; and professional skills & conduct were the skills CHWs were using often the most. For addressing how these skills may have changed after inception of the pandemic, CHWs were concrete in responding No Change as the most prevalent skill frequency (Figure 13; Table 14). Increased use of CHWs skills, MORE, was the second highest response across all Skills. Interpersonal & relationship building skills and outreach skills, while being reported as some of the most used skills before the pandemic saw the two largest response rates for I do this LESS since the start of COVID-19.

COVID-19 Specific Roles

Aside from addressing roles and skills from the C3 framework, CHWs also had the opportunity to speak on new roles they picked up related to COVID-19. From Table 15, roles related to vaccination efforts and distribution of COVID specific health information were the two most prevalent, both representing about 21% of the responses. Scheduling COVID-19 test was the next most reported answer (17.22%), followed by PPE distribution (15%), and Contact Tracing (13.9%). Quarantine coordination was only reported for 8.9% of responding CHWs and only four respondents reported other new COVID-19 specific roles.

Qualities

Concluding this section on CHW roles and competencies, CHWs were asked to rank 10 of the C3 CHW core qualities. The exercise was to determine on a scale of 1-10, which qualities were most important before the pandemic, and which were most important after the pandemic. Rankings were considered with 1 being most important. CHWs unanimously considered Connected to the Community as the most important quality before and after the pandemic. Honest and Dependable were ranked 2^nd and 3^rd respectively, also before and after the pandemic. Empathetic was considered as 4^th before the pandemic but was dropped all the way to Least important following the pandemic. Outgoing replaced the fourth quality spot. Courageous, which ranked fifth amongst CHWs before the pandemic also fell to the Bottom of the list during COVID-19. Open-minded claimed this spot of importance (Table 16).

Does your Community Understand your Roles?

Concluding discussion on the roles and skills of CHWs, the final question CHWs were survey on asked: In what ways have your community members shown that they understand your roles? Reverberated through the discussions of our CHW summit, the topic of whether or not communities fully understand what CHWs do was a burning question that needed to be added to this survey iteration. CHWs reflections are reported in Table 17. Helping with health care, and finding COVID-19 testing, and COVID-19 vaccine assistance were reported as ways how communities utilize CHWs by over half of our survey participants (35+/60). The answer choice with the lowest share of response was for interest in exercise habits, this still accounted for a fourth of all respondents. Seventeen of the twenty-four CHWs who selected ‘Desired your help with access to other’ resources provided short explanations on the topic. Qualitative analysis grouped responses into themes according to CHW C3 roles, which led to five distinct roles:

• Cultural Mediation Among Individuals, Communities, and Health and Social Service systems.

• Providing Culturally Appropriate Health Education and Information

• Care Coordination, Case Management, and System Navigation

• Advocating for Individuals and Communities

• Providing Direct Service

Discussing Cultural Mediation, was not only present here in survey responses but it was also a heavily discussed topic during the CHW Townhall. In the survey setting - building health literacy and cross-cultural communication were the reported links for Cultural Mediation. Explicitly stated by CHWs, Information and education on health were prevalent in what was reported, and addressed by culturally appropriate health education and information. Of note, tobacco cessation and prevention were found as part of this role response. The Care Coordination, Case Management, and System Navigation role was reflected by answers themed towards health care access and resources. Answers ranged from addressing specific needs of the communities such as audiologist, dentist, and mental health to broader needs such as social service and transportation. Advocating for Individuals and Communities and Providing Direct Support overlap in this CHW role framework. Advocating is listed to connect resources and advocate for basic needs while direct support is providing and meeting basic needs and services. The communities of the sampled CHWs voiced their need for help with food, financial resources, housing, utilities, and transportation. Both CHW roles address these responses. Based on CHW accounts, the communities they serve are exploring and utilizing the roles of CHWs here in Oklahoma.

Most Concerning Community Issues BEFORE Pandemic

Defining issues in the communities they served, CHWs listed three issues of most concern pre-pandemic and then rated their perceived level of change in concern on the topic since the start of the pandemic (Scale of 1-5, 5 most change). Narrative responses to this question were provided by 19 CHWs, totaling to 57 issues as some respondents did not provide three issues. The social determinants of health (SDOH) framework was used to categorize the answers. Illustrated in Figure 14, SDOH that represented CHWs reporting include Health, Health Care Access/Quality; Economic Stability; Neighborhood and Built Environment; and Social and Community Context. Visually presented in Figure 15 and listed below are the issues of concern reported in response to the narrative question:

- Access to health care, health disparities, medication, physical and mental needs, case management (Health, Health Care Access/Quality)

- Finances, Public assistance, food insecurities, housing (Economic Stability)

- Transportation, crime, access to higher standard of living (Neighborhood and Built Environment)

- Education, politics, safety (Social and Community Context)

Utilizing ratings CHW’s provided on these issues, Figure 14 quantitatively represents CHWs most change in concern was in Economic Stability; Health,Health Care Access/ Quality; and Neighborhood and Built Environment. Health, Health Care Access/Quality was the most frequent answer. It was reported the most as having little change (1), moderate change (3), and most change (5).

[Figure 15: Most Concerning Issue BEFORE pandemic](Plots/htmlreport/wordcloud_1.png “Figure 15” “Figure 15”)

Most Helpful Resource to Community BEFORE Pandemic

Following the question on pre-pandemic community issues, CHWs were asked an open-ended question to share what they believed to be the most helpful non-monetary resources to community members before the pandemic. The social determinants of health (SDOH) framework also served to categorize these answers. Similarly, SDOH that represented CHWs’ reporting included Health, Health Care Access/Quality; Economic Stability; Neighborhood and Built Environment; Social and Community Context; and Education Access and Quality. The most helpful resources (Figure 16) proposed included:

- Better health care, community clinics, insurance (Health, Health Care Access/Quality)

- Finances, Utility assistance, food insecurities, housing (Economic Stability)

- Transportation, more gyms and recreational activities, access to higher standard of living, stronger law enforcement presence (Neighborhood and Built Environment)

- Advocacy, Communication, Empathy & patients towards others (Social and Community Context)

- Education programs, guidance, networking assistance (Education Access and Quality)

Figure 16: Most helpful resource to community BEFORE pandemic

Trusted Avenues of Communication

Inquiry into CHWs communication efforts asked the question: Does your Community have trusted avenues of communication? CHWs were asked to give examples if possible as well as specify if these avenues were used to give the community health information. If they did not have trusted avenues of communication, CHWs were given the opportunity to address wanted/suggested avenues they believed could be useful/helpful. Overwhelmingly, 33 out of 43 CHWs expressed they had established trusted communication avenues in their communities. Of these CHWs, only two survey results indicated these avenues were not used for health information communication. Detailing what the CHWs provided, answers for communication were described by modes of avenues and community-based examples of avenues. Exploration of what modes were present in the answers included local media, social media, fliers, phone messages, and websites. The other aspect of the CHWs communication description included utilizing community-based avenues including: Places of worship, clinics, health department, CHWs, and leaders in the communities. The few CHWs without reported trusted avenues of communication brainstormed several options: CHWs, stronger partnership with health department, and an emergency Facebook page.

Methods to Connect, Gain, and/or Build Trust with your Community

Additionally, looking at trust within their respective communities, CHWs were asked: Have you used any of the following methods to connect, gain, and / or build trust with your community? Answer choices to this question were provided directly by CHWs responses in the Townhall and by the CHW advisory group. To answer, CHWs were asked to specify if they had utilized these methods within their communities before the pandemic, in year 1, or year 2. Results displayed show that all methods increased in prevalence from before the pandemic to year 2 of the pandemic except for In-Person Visits, which was highest pre-pandemic (Figure 17 and Table 18, Generalized Estimated Equations Models Table). Zoom/Facetime, Social Media, and Community Outreach were reported as statistically different when exploring the relationships of CHWs reported efforts by points across the pandemic timeline (p = 0.007, 0.033, 0.0129). Estimating the odds of a CHW reporting efforts in Zoom/Facetime, Social Media, and Community Outreach to build trust in Year 2 of the pandemic were 4.04, 1.29, and 1.51 times as high as the estimated odds of a CHW reporting these efforts before the pandemic. In-Person Visits also observed a significant relationship in reporting of CHWs efforts by varying pandemic time points (p <0.0001). However, its interpretation is better stated as, estimated odds of a CHW reporting efforts for In-Person Visits in Year 1 of the pandemic were 0.33 times that of estimated odds of a CHW reporting efforts for In-Person Visits before the pandemic.

One Thing CHWs Learned about their Community during Pandemic

To finish the results of this section, CHWs were given a proposition to impart one thing they learned about or from their community specific to COVID-19 in the past two years. CHWs had a wide array of anecdotes and messages to tell of the communities they serve. The three themes pronounced by CHW responses described communities’ barriers, perceptions of information and systems, and communitie’s support and positives. During the pandemic response, CHWs were able to observe that their constituents expressed a lack of support as well as feelings of under-representation as barriers. CHWs also noticed the desire for more resources, specifically vaccine efforts. Responses also addressed their communities’ perceptions of information and systems. As outlined by CHWs, some community members were not trusting of the government or systems. Misinformation was found to be dangerous in compounding this distrust and causing skepticism on COVID-19 information. However, the theme communities’ support and positives, described that some CHWs recognized optimistic things about their communities specific to COVID-19 in the past two years. Support for each other, desire for education, and results of vaccines and masks working comprised CHWs learned reflections.

CHW EXCERPTS

CHWs were allotted a space at the end of the survey to share their experience as CHW: Please share a short story of your challenges / successes during the pandemic. The pandemic has been a difficult time, and answers spoke to the challenges of CHWs work during the pandemic response. Frustrations, health impacts, and restrictions posed were some topics covered in these CHWs stories. However, almost half of the thoughtful responses provided spoke to CHW feelings of the job being a rewarding career of finding true passion in their work. The following quotes from CHWs working hard here in Oklahoma reflect challenges and rewards experience by the CHWs over the past two years.

“The challenges I had during the pandemic was not being able to interact with my family, community and co-workers freely.  The successes was being able to be there for my community by helping provide the services they were needing to be safe for themselves, their families and communities.”

“Some parts of the community were unappreciative of the services we provided.”

“I was told to work from home and re-assigned to contact tracing. I felt isolated working from home and it wasn’t good for my mental health.”

“Being a CHW is the most rewarding career I have ever had. It means a lot for families to trust in you to be a shoulder to lean on during this pandemic.”

“I was there. Time, effort and caring increases and builds trust for the community. It is not a job being a CHW, it is a passion for people.”

Generalized Estimates Equation Models Table

Provided is the Table for univariate GEE models of various CHW efforts across the pandemic time line. Highlight cells indicate significance at the alpha 0.05 level. N/A cells did not observe enough counts to report Odds Ratio Estimates.