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J Community Health (2017) 42:1197–1203
DOI 10.1007/s10900-017-0370-3
ORIGINAL PAPER
Community Health Workers Promote Civic Engagement
and Organizational Capacity to Impact Policy
Samantha Sabo1 · Melissa Flores2 · Ashley Wennerstrom3,4 · Melanie L. Bell5 ·
Lorena Verdugo6 · Scott Carvajal1 · Maia Ingram1
Published online: 6 June 2017
© Springer Science+Business Media New York 2017
Abstract Community health workers (CHW) have historically served to link structurally vulnerable populations
to broad support systems. Emerging evidence suggests
that CHWs engage in various forms of advocacy to promote policy and systems change. We assessed the impact
of CHW community advocacy on community change,
defined as civic engagement, organizational capacity and
policy and systems change. Data are drawn from the 2014
National Community Health Worker Advocacy Survey
(N = 1776) aimed to identify the state of the CHW profession, and their impact on health disparities through community advocacy and policy engagement. Our primary
analysis used multiple linear regression to assess the association between CHW advocacy and community change.
As predicted, there was a significant, positive association
between CHW advocacy and change in community conditions. Additionally, both adjusted and sensitivity models
had similar standardized beta estimates for advocacy, and
adjusted R2 statistics. CHW advocacy predicts positive
change in community conditions and further advances the
CHW Community Advocacy Framework designed to support and monitor CHW community advocacy to reduce
health disparities through advocacy and policy change.
* Samantha Sabo
[email protected]
2
Family Studies and Human Development, College
of Agriculture and Life Sciences, University of Arizona,
1295 N. Martin Ave., Drachman Hall A240, Campus PO
Box: 245211, Tucson, AZ 85724, USA
3
Louisiana Community Health Worker Institute, Tulane
University School of Medicine, New Orleans, LA, USA
4
Tulane Prevention Research Center, 1430 Tulane Avenue,
SL‑16, New Orleans, LA 70112, USA
5
Division of Epidemiology and Biostatistics, Zuckerman
College of Public Health, University of Arizona, 1295
N. Martin Ave., Drachman Hall A240, Tucson, AZ 85724,
USA
6
El Rio Community Health Center, Cordinadora de Ventanilla
de Salud, Consulado de Mexico, 3480 E. Britannia
Dr. Ste. 120, Tucson, AZ 85706, USA
Melissa Flores
[email protected]
Ashley Wennerstrom
[email protected]
Melanie L. Bell
[email protected]
Lorena Verdugo
[email protected]
Scott Carvajal
[email protected]
Maia Ingram
[email protected]
1
Keywords Community health worker · Policy ·
Advocacy · Leadership · Health disparities
Arizona Prevention Research Center, Department of Health
Promotion Sciences, Zuckerman College of Public Health,
University of Arizona, 1295 N. Martin Avenue, Drachman
Hall A268, Campus PO Box: 245209, Tucson, AZ 85724,
USA
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1198
Introduction
As a global workforce, community health workers (CHW)
have historically linked structurally vulnerable populations
to health, social, economic and educational systems [1]. As
trusted individuals with an intimate understanding of the
lived experience of the communities they serve, CHWs are
often regarded as ‘trusted members of community opinion’ [1]. They encourage self-sufficiency among underresourced communities through activities such as outreach
and community education, informal counseling and encouragement, social support, community capacity building, and
advocacy [9]. The intimate knowledge of, and connection
to, the communities they serve positions CHWs to promote
health equity through advocacy and policy change [7, 10].
Emerging evidence suggests that CHWs engage in various forms of organizational, civic and political advocacy
and are highly effective in advocating on behalf of their
own profession [11]. CHW participation in communitylevel advocacy is associated with individual intrinsic qualities, experience with leadership and advocacy training, and
a work environment that allows autonomy to engage with
key thought leaders within civic society and formal governance structures [11]. CHWs’ participation in advocacy
and capacity building strengthen the opportunity for, and
involvement of, marginalized communities by taking community concerns through the ranks of power and decision
making to effect environmental and systems change.
Yet, less is known about the mechanisms by which
CHWs contribute to increased civic engagement among
marginalized populations and how such activity may contribute to a health equity agenda. The primary objective of
this study was to assess the relationship between the effect
of community-level advocacy by CHWs to promote civic
and organizational engagement to improve community conditions. Our central hypothesis was that more community
advocacy by CHWs will predict more community change,
defined as civic engagement and organizational capacity to
improve community wellbeing through policy and systems
change.
Methods
Sample
We used anonymous, cross-sectional, data from the 2014
National Community Health Worker Advocacy Survey
(NCHWAS). The purpose of the NCHWAS was to understand and identify the state of CHWs as a profession, and
their impact on health disparities through community
advocacy and policy engagement. The methods for conducting the study have been described in detail elsewhere
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J Community Health (2017) 42:1197–1203
[6]. Briefly, the NCHWAS was distributed on line and in
some cases through hard copy via CHW professional associations and networks located in both local and state health
departments, federally qualified community health centers,
and private and nonprofit organizations across the United
States. The survey was available in English, Spanish, and
Korean. The resulting convenience sample included 1767
paid and volunteer CHWs from 47 states and four US territories. Unpaid, or volunteer CHWs were omitted from the
current analysis because the variables under study, which
measured CHW community level advocacy and community
change were predicated on work-training and work environment, and, volunteers would not necessarily be exposed to
these experiences.
Measures
Primary Outcome: Change to Improve Community
Conditions
Change to improve community conditions was measured by the CHW Community Conditions Change Scale
(CHW-CCC), a 9-item scale created for this study (Fig. 1).
Responses for items range from “strongly disagree”, to
“strongly agree” on a four-item Likert scale. An example item is as follows, “How much do you agree that your
work for a cause or change to improve community conditions, including community health has led to more community members voicing ideas or concerns about community
issues?” These items were summed together to create a
sum-score variable, with higher scores indicating more perceived changes in community conditions brought about by
a CHW. The range of possible scores was 9–36.
The CHW Community Conditions Change Scale (CHWCCC) contains items that fall in to a hierarchical structure
such that some change items involve substantially more
effort by a CHW (Fig. 1). Foundational to the CHW-CCC
are public health systems frameworks [4] and development
theory [5] for understanding, promoting and monitoring the
impact of civic participation and multi sectorial engagement in advocacy and policy change to improve community
wellbeing. Based on these theories of change, the CHWCCC is hierarchical ranging from lower level or lower
impact change inclusive of increased community awareness on an issue, better services in the CHW home agency,
increased collaboration among the CHW’s home agency
with other health and social service agencies; medium level
or medium impact change inclusive of more organizations
working together to produce solutions to community problems, increased civic engagement among community members through voicing concerns and opinions and participating in public meeting in which decisions are made; high
level or high impact change broadly defined as increased
J Community Health (2017) 42:1197–1203
High
Level
Change
Medium
Level
Change
Lower
Level
Change
1199
• A concrete policy change in your community.
• Community Leaders took acon on an issue.
• Parcipaon in vong in elecons.
• More community members aending public meengs, such as school board, city,
county, and tribal government meengs.
• More community member’s voicing ideas or concerns about community issues.
• More agencies or coalions working together to solve community issues.
• More or beer collaboraon between your organizaon and other agencies or
coalions.
• More or beer services or programs in CHW own agency.
• An increased awareness of a community issue.
Fig. 1 Community Health Worker Change in Community Conditions scale (CHW-CCC) arranged from lowest to highest impact and effort
required by the CHW
civic engagement through voting, community leaders taking action on an issue and a concrete policy change that
benefited the community. For example, a change that
includes an increased awareness about a community issue
may take less effort by the CHW and may have less of an
impact than effectuating a concrete change in local policy.
Items of the CHW-CCC are not mutually exclusive but a
continuum of efforts that contribute to a range of impacts
that contribute to civic and organizational engagement
and policy and systems change to promote wellbeing. The
9-items of the CHW-CCC are organized into three ordered
levels: low-level/impact change, medium-level/impact
change, and high-level/impact change (Fig. 1). The total
sum-score of the change scale items does not take this hierarchy into account, thus a sensitivity analysis addressed this
issue by using a weighting technique.
Community and Political Advocacy Variables
CHW community and political advocacy was measured
using a summed total of 7-items on scale ranging from
“strongly disagree” to “strongly agree,” (1–4) created
for this study and used previously to characterize CHW
community level advocacy [10]. Example items include,
“I have identified the people or organizations that influence change in my community,” and “I have made new
relationships with people or organizations to work on a
common goal to benefit the community.” Higher scores
of this variable indicate more engagement in community
and political advocacy. The possible range of scores was
7–28.
Statistical Methods
Our primary analysis used multiple linear regression to
assess the association between change and CHW advocacy,
adjusted for age, sex, race, level of education, individual
income, years working as a CHW, and type of agency (federally qualified community health center, and other). Age,
and years worked as a CHW were mean-centered to assist
the interpretability of model estimates. Control variables
were chosen based on background literature and expert
knowledge. The internal consistency of the change and
advocacy scales, Cronbach’s alpha statistic was calculated
for both scales. Our secondary analysis aimed to understand
the unique association of CHW community advocacy and
each item in the change scale. Each of the 9-items in the
scale were dichotomized to include the levels ‘agree’ and
‘disagree.’ Nine multiple logistic regression models were
fit, adjusting for age, sex, race, level of education, individual income, years working as a CHW, and type of agency.
A Bonferroni correction was used to account for multiple
tests. The alpha level was set to 0.05/9 models = 0.006.
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J Community Health (2017) 42:1197–1203
Sensitivity Analyses
Table 1 Descriptive characteristics of a convenience sample of 1138
community health workers in the United States
The outcome change (sum-score) does not consider the
apparent hierarchy in the change in community conditions scale, thus we undertook two sensitivity analyses to
address this issue. A weighting technique was implemented
using the following values: low-level change items = 0.33,
medium-level change items = 0.66, and high-level change
items = 1. If a participant rated a 3 out of 4 on a low-level
item in the change scale this 3 was then multiplied by 0.33
to produce a 0.99 for that item. Each individually weighted
item was then summed in to a weighted, total sum-score
for change. This version of the change outcome was used
in a multiple linear regression model to assess the association between weighted change and advocacy adjusting for
age, sex, race, level of education, individual income, years
working as a CHW, and type of agency.
Our second sensitivity analysis used a structural equation model with three latent variables: low-level change,
medium-level change, and high-level change with their
respective items from the change in communities scale as
indicator variables. These latent variables were then predicted by latent variable representing CHW advocacy.
Additionally, the CHW-CCC scale was used to create
sub-scales of change based on the hierarchy in Fig. 1. A
total, sum-score of the items in the low-level change category was used to create a “low-level change” outcome
variable. This process was repeated for medium and highlevel change. Three multiple linear regression models were
fit using total sum-scores of the three combined low-level,
medium-level, and high-level change items as outcomes.
A Bonferroni correction was used to account for multiple
tests, with alpha set to 0.05/3 models = 0.02. All statistical
analyses were conducted using R statistical computing software, version 3.2.2 [12].
N = 1138
Results
Primary Analysis
A total of 1138 participants reported being paid CHWs.
The majority of participants reported being female (89.3%),
and Latina/o ethnicity (45.1%). The median reported age
was 46 years, and the median years working as a CHW
was four. Other descriptive characteristics for participants
are presented in Table 1. Both the change and advocacy
scales exhibited good internal consistency: Cronbach’s
alpha for the change scale was 0.91, and the advocacy scale
was 0.87. Missing data were minimal: only 52 out of 1138
responses were missing in the outcome.
The mean (standard deviation, SD) reported change in
community conditions by CHWs was 26.5 (5.26), with a
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Gender (%)
Male
Female
Age (median)
Race/ethnicity (%)
White
Black
Latino
Asian/Pacific Islander
American Indian/Alaska Native
Other/multi-race
Education (%)
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