Being a Community Health Worker Means Advocating

Abstract

Community health workers (CHWs) participate in advocacy as a crucial means to empower clients in overcoming health disparities and to improve the health and social well-being of their communities. Building on previous studies, this article proposes a new framework for conceptualising CHW advocacy, depending on the intended impact level of CHW advocacy. CHWs participate in three ‘levels’ of advocacy, the micro, the macro, and the professional. This article also details the challenges they face at each level. As steps are taken to institutionalise these workers throughout the United States and abroad, there is a danger that their participation in advocacy will diminish. As advocacy serves as a primary conduit through which to empower clients, enshrining this role in steps to integrate these workers is essential. Finally, this article provides justification for the impacts of CHWs in addressing the social determinants of health and in helping their communities strive towards health equity.

Full text

This article is distributed under the terms of the Creative Commons A ribution Noncommercial No
Derivatives 4.0 International license (h ps://creativecommons.org/licenses/by-nc-nd/4.0/). For uses
beyond those covered in the license contact Berghahn Books.
Anthropology in Action, 26, no. 2 (Summer 2019): 9–18 © Berghahn Books and the Association for Anthropology in Action
ISSN 0967-201X (Print) ISSN 1752-2285 (Online)
doi:10.3167/aia.2019.260202
Being a Community Health Worker
Means Advocating
Participation, Perceptions, and Challenges in Advocacy
Ryan I. Logan
ABSTRACT: Community health workers (CHWs) participate in advocacy as a crucial means
to empower clients in overcoming health disparities and to improve the health and social
well-being of their communities. Building on previous studies, this article proposes a new
framework for conceptualising CHW advocacy, depending on the intended impact level of
CHW advocacy. CHWs participate in three ‘levels’ of advocacy, the micro, the macro, and the
professional. This article also details the challenges they face at each level. As steps are taken
to institutionalise these workers throughout the United States and abroad, there is a danger
that their participation in advocacy will diminish. As advocacy serves as a primary conduit
through which to empower clients, enshrining this role in steps to integrate these workers is
essential. Finally, this article provides justifi cation for the impacts of CHWs in addressing the
social determinants of health and in helping their communities strive towards health equity.
KEYWORDS: advocacy, community health workers, health equity, health disparities, Indiana,
social determinants of health
Advocacy is perhaps the most unique component
of the community health worker (CHW) model. The
American Public Health Association (APHA 2018)
defi nes a CHW as ‘a frontline public health worker
who is a trusted member of and/or has an unusually
close understanding of the community served’. The
APHA also states that these workers draw on the
‘trusted relationship’ that they have with their cli-
ents to serve as an intermediary between health and
social services. Furthermore, the APHA defi nition of
a CHW also states that he or she builds individual
and community capacity through fostering self-
suffi ciency by participating in variety of activities
including community education, outreach, social
support, and advocacy (APHA 2018). Participation
in advocacy is central to the CHW–client relation-
ship and can be defi ned as empowering not only the
client and but also the broader community so as to
overcome social determinants of health and thereby
a ain health equity and social well-being.
CHWs have been documented participating in ad-
vocacy for their clients, their communities, and their
position in the United States and abroad (Closser
2015; Ingram et al. 2008; Maes 2015; Nading 2013;
Sabo et al. 2013, 2015; Wiggins et al. 2014). Especially
as these workers typically come from the communi-
ties with which they work, their intimate knowledge
and shared structural vulnerability with their clients
provides them with a foundation from which to eff ec-
tively participate in advocacy. The term ‘community’,
for the purposes of this article, refers to the o en
politically and socially marginalised (including Afri-
can American, immigrant, and refugee) populations
within which CHWs in the below sample operate.

AiA
|
Ryan I. Logan
10
|
Their participation and membership within these com-
munities also aids in demonstrating the dynamic na-
ture of this term and highlights the shared and unique
social determinants aff ecting each of these margin-
alised populations. Their participation in advocacy
serves as a means to address social determinants of
health and empower their clients and communities
(Ingram et al. 2008, 2014; Rosenthal et al. 2011; Sabo
et al. 2013; Silverman et al. 2018). As a result, CHWs
participate in advocacy in order to move their clients
and communities towards greater health equity. This
important contribution has also been recognised in
federal legislation in the Aff ordable Care Act of 2010
(ACA), which emphasised the role of CHW advocacy
as a means to improve individual and community
health (Bovbjerg et al. 2013a; Martinez et al. 2011;
Shah et al. 2014).
As CHWs have found increasing acceptance
within the healthcare workforce of the United States,
steps have been taken within states to formalise
and integrate these workers into larger systems
of care. Several states have successfully integrated
CHW programmes within their broader healthcare
workforces, including Massachuse s, Minnesota, and
Oregon (Kangovi et al. 2015; Rosenthal et al. 2010).
However, as governments and stakeholders integrate
CHWs into their workforces, there is a risk of over-
medicalising their roles and diminishing their in-
volvement in advocacy (Nading 2013; Pérez and Mar-
tinez 2008; Rosenthal et al. 2011). It is vital that CHWs
be allowed to take part in offi cial decisions in the de-
velopment of their position and that steps to integrate
these workers do not sacrifi ce their role in advocacy.
Building on previous research regarding the cat-
egorisations of CHW advocacy (Ingram et al. 2008;
Sabo et al. 2013, 2015), the purpose of this article is
to reframe discussions related to the advocacy of
CHWs into three primary levels of impact. Previous
research has analysed survey data from CHWs and
has categorised civic, organisational, and political
advocacy (Sabo et al. 2013). I assert that CHW advo-
cacy occurs at three primary impact ‘levels’: the mi-
cro-level, the macro-level, and the professional level.
Each level corresponds to the primary health and
social service needs of the CHW’s client or broader
community and/or the professional impact of the
CHW’s advocacy. In recognising these various levels
and distinguishing them as such, further insights can
be gained regarding the specifi c impact of CHWs and
regarding the retention of their unique contribution
to healthcare. Finally, this article concludes with a
discussion of the challenges of advocacy, a theoreti-
cal analysis of the impact of policy development on
advocacy, and an explanation of the need to maintain
advocacy in formal steps towards CHW integration.
Methods
The themes discussed in this article come from fi nd-
ings from a dissertation project carried out in the
state of Indiana between 2017 and 2018. The project
was qualitative in nature and utilised a collaborative
approach between the researcher and CHW partici-
pants. Several methods were utilised throughout this
project including semi-structured interviews, partici-
pant observation, focus groups, and photovoice. Par-
ticipants were recruited through snowball sampling
and were asked whether they identifi ed with the
title ‘community health worker’. As this occupation
was not and has not been fully integrated within
the workforce, participants were employed under a
variety of diff erent titles (e.g. health access advocate,
patient advocate, community liaison). However, par-
ticipants in this sample all self-identifi ed with the
title ‘community health worker’ despite potentially
having worked under a diff erent title. These partici-
pants had been employed to fulfi l a number of roles
but typically included working closely with clients
and communities in health education, preventative
healthcare, chronic disease management, nutrition,
and/or advocacy.
The bulk of the data collected for this project came
from interviews, in which 47 self-identifi ed CHWs
participated. These interviews were approximately
45 to 60 minutes in length, audio-recorded, and tran -
scribed verbatim for further data analysis. All data
were de-identifi ed to protect the privacy of the partic-
ipants, and the names in this article are pseudonyms.
The use of qualitative methods in this project was
vital in order to explore the nuances of advocacy con-
ducted by CHWs and to gain a deep understanding
of their engagement in the three above-mentioned
levels. The project was approved by the University of
South Florida Institutional Review Board.
Findings
Levels of Advocacy
Participation in advocacy is a crucial component of
the CHW model and sets CHWs apart from other
members of the healthcare workforce. As many CHWs
in the sample came from structurally marginalised
populations, participating in advocacy was viewed
as a crucial means of garnering positive health and

Being a Community Health Worker Means Advocating | AiA
| 11
social outcomes for their communities. Lucia, a CHW,
explained where this motivation to participate in ad-
vocacy emerges:
[CHWs] because they are from the community, they
are from an oppressed people group. Naturally. We
are fi rst from an oppressed group. And we are learn-
ing to stand up to defend our people and what hap-
pens is you come against resistance and . . . we need
to understand that we have a right [to advocate] and
we were one of the oppressed and we do have the
voice to speak for all the people behind us.
In taking on the mantle of the CHW position, Lu-
cia asserted that these workers have a right and the
voice to speak up for their clients and broader com-
munities. In using their voice for advocacy, CHWs
promote positive health and social well-being.
While previous research has assessed survey data
regarding CHWs and advocacy, the fi ndings in this
article reframe CHW advocacy regarding its primary
area of impact. The fi ndings in this article build on
a framework from a 2010 study on CHW advocacy
(Sabo et al. 2013) but also provide additional nu-
ances regarding advocacy, its challenges, and issues
of institutionalisation. During data collection, I en-
countered CHWs participating in several diff erent
forms of advocacy, which they argued had a positive
impact on their clients and communities at vari-
ous levels. Additionally, CHWs described having to
advocate for the legitimacy of their position and at
other times advocated to their own employers for
their own needs. Thus, I assert that CHW advocacy
can be divided into three distinct levels: the micro-
level, the macro-level, and the professional.
While there is some overlap in impact between
micro- and macro-level advocacy, micro-level advo-
cacy seeks to create smaller-scale change that benefi ts
individual clients and makes organisational changes
whereas macro-level advocacy tends to focus on ad-
vocacy that creates broader community and societal
impacts. Professional-level advocacy consists of ad-
vocacy in which the CHW advocates for awareness
and for the legitimacy of their job (Sabo et al. 2015).
Moreover, this includes CHWs advocating to their
employer or other staff for resources that are needed
in their organisations. Previous scholarship has docu-
mented CHWs advocating for the legitimacy of their
own occupation to employers, medical professionals,
and non-governmental organisations (Closser 2015;
Sabo et al. 2015).
I have arranged these three distinct levels of advo-
cacy in Table 1 in order to show the primary impact
area of each in addition to a brief listing of example
activities. Parsing out the advocacy of CHWs in this
manner provides simple grouping structures that
demonstrate the various activities and impact areas
that each advocacy level is aimed at addressing. These
categorisations also provide practical means for em-
ployers, potential employers, and medical profes-
sionals to view this kind of work and how they can
work towards incorporating these into the work of
their current [or future] CHW employees.
Micro-Level Advocacy
All of the CHWs in the sample participated in micro-
level advocacy. This level of advocacy focused on
creating impacts predominantly with clients but
Table 1. Examples of Activities at Each Level of Advocacy.
Advocacy Level:
Level of Impact
Micro-
Individual
Macro-
Community/Society
Professional-
Professional/Employer
Examples Changing hospital, clinic,
and/or organisational policy
A ending political rallies
and/or demonstrations
Advocating to employer to
keep a specifi c programme
Speaking up to medical pro-
fessionals and/or insurance
company representatives on
behalf of clients
Participating in community
coalitions and in community
mobilising to address issues
Advocating for the legitimacy
of their position directly to
a medical or social services
professional
Locating resources for clients
to improve their health and
living situation
Meeting and/or working with
politicians to address health
and community needs and
other issues
Finding ways to spread
awareness and legitimacy of
their position to the public
and broader workforce
Educating and empowering
clients towards self-suffi ciency
Encouraging clients to
meet/contact political
representatives

AiA
|
Ryan I. Logan
12
|
also within organisations and clinics/hospitals. The
ultimate goal of micro-level advocacy was described
by participants as achieving self-suffi ciency and em-
powerment on the part of the client (Bovbjerg et al.
2013b; Brownstein et al. 2011; Ingram et al. 2014). A
commonly discussed form of micro-level advocacy
was connecting clients to resources and doing so via
through follow-up. This included connecting them
with transportation options (Medicaid cabs, public
bus passes), making them aware of insurance bene-
fi ts, signing them up for insurance, and helping them
purchase minutes on their cell phone. Depending
on their employers, some CHWs had access to bus
passes or small amounts of funds to help their clients.
Others had to occasionally draw on their connec-
tions within the community to negotiate with utility
companies to delay turning off their clients’ utilities
and to help locate resources for their clients, one such
resource being a new furnace, which was donated by
a local organisation in Indianapolis.
The CHWs would then follow-up with clients
to ensure that the resource was acquired and, if so,
that it was satisfactory. Additionally, the participants
stressed that they would teach their clients skills to
eff ectively advocate or seek resources themselves so
that there would be ‘transference of power’ from the
CHWs to their clients. While the participants identi-
fi ed empowerment of their clients as the primary
goal of the CHW–client relationship, they stressed
that they were always available to help their clients if
additional issues were to come up.
Other forms of micro-level advocacy included ad-
vocating on behalf of their clients in order to change
hospital, clinic, or organisational policies to be er
facilitate their clients’ care. Examples of this included
changing signs to help clients fi nd the resources or ser-
vices they needed in addition to advocating for pro-
viding forms in Spanish or in other languages, de-
pending on the client’s needs. For many CHWs in the
sample, it fell on them to either translate the forms
themselves, fi nd these forms online to provide to their
clients, or advocate on behalf of their clients to the
organisation in order to have the organisation provide
these forms. Other CHWs, who worked predomi-
nantly in the Latino immigrant community, served as
trustworthy individuals in accessing healthcare. Ca-
mila, a CHW who worked in one of Indianapolis’ larg-
est hospitals, explained that she tells immigrant clients
where they can get care and that she assures them that
they will not be reported to Immigration and Customs
Enforcement (ICE) if they go and seek care.
Several CHWs explained how they have spoken
up to insurance company representatives and medi-
cal professionals in order to get a client’s question
answered, receive a clearer diagnosis for their client,
and address issues of discrimination against their
client. Additionally, CHWs identifi ed that a crucial
aspect of this level of advocacy was to empower their
clients, as was demonstrated by their own eff orts to
learn how to advocate for themselves. Many of the
participants asserted that the end goal was not to
perpetually ‘hold the client’s hand’ but rather to em-
power them to gain the self-confi dence to speak up
on their own behalf.
Macro-Level Advocacy
This level of advocacy sought to eff ect change in the
community and society. Previous scholarship has
noted that broader involvement in the community,
political engagement, and the addressing of social
justice issues were o en primary markers of this cat-
egory (Findley et al. 2014; Ingram et al. 2008; Sabo et
al. 2013). However, CHWs in this sample were also
involved in community coalitions that were focused
on fostering non-political community events. While
this level of advocacy was not as prevalent as micro-
level advocacy in this CHW sample, there were still
many CHWs who participated in a variety of macro-
level activities. These activities included a ending
political rallies (such as those in support of Deferred
Action for Childhood Arrivals [DACA], those in
support of the ACA, and those whose aim it was to
stop deportations of undocumented immigrants),
mobilising the community to address various issues,
encouraging clients to a end public meetings and/or
meet with their representatives, and participating in
community coalitions. Some CHWs were present at
social justice demonstrations revolving around such
issues as socio-economics, race, and healthcare. These
various macro-level activities were a unique and vital
component of the advocacy practised by many CHWs
with the aim of fostering steps towards health equity.
Unlike micro-level advocacy, macro-level advocacy
was almost always done off the clock – especially due
to the fact that the pertinent activities could blur into
political issues and/or were not considered as ful-
fi lling the specifi c job responsibilities set out by the
CHWs’ employers. Beverly, a CHW, explained that,
while not working, she volunteers her time for a coali-
tion that seeks to improve the life of a community in
a major city in Indiana with a large African American
population. She described advocating for a variety of
needs for the African American community that are
already available in other parts of the city. Her par-
ticipation in this coalition is an important way to help
implement positive policy changes that will benefi t

Being a Community Health Worker Means Advocating | AiA
| 13
her community, which is in dire need for changes in
order to produce improved health outcomes. How-
ever, Beverly advocated at the macro-level during
her free time – o en a er having put in a full day’s
work. This demonstrates her commitment to her
community, but also highlights the unpaid labour
component of her identity as a CHW. Thus, even if
unable to participate in macro-level advocacy during
work hours, CHWs are making strides in fostering
broader community and societal changes that ulti-
mately infl uence the health and well-being of those
living around them.
Similarly, other participants volunteered as mem-
bers of collaborative groups or coalitions in order to
improve their communities by uniting a neighbour-
hood or a minority group in order to network and
pool resources. This might include reaching out to lo-
cal, state, or federal politicians or at least implement-
ing measures to improve an issue in the community
such as addressing ‘food deserts’ (areas lacking
healthy and aff ordable food choices, especially fruits
and vegetables), crime rates, or public transporta-
tion. Others encouraged their clients to write le ers
to their local, state, and federal legislators or call on
them to seek positive changes. Patricia, a CHW, re-
marked how she would tell her clients to ask ‘who
has the power?’ when considering what changes
need to be made in the community. She argued that
she simply ‘transferred the power’ to her clients in
giving them the tools to be able to seek the change
they wanted for their communities.
The CHWs themselves were also directly involved
in political forms of macro-level advocacy. Marcia,
who is a CHW and the executive director of a health
outreach organisation in a large city in Indiana,
called her local legislators to inform them of health
and social issues occurring in the community. Marcia
also invited her legislators to town halls that she or-
ganizes quarterly in order to discuss community is-
sues. She then had two other CHWs employed in her
organisation do outreach and fi nd people aff ected
by the problem to speak with these legislators. Mar-
cia explained that she and her colleagues had been
involved in helping to inform their legislators on
transportation, potable water, infant mortality, and
health translation issues in their community. Other
CHWs spoke about writing le ers to their politicians
in support of DACA and/or meeting with politicians
in person to express their support for the ACA and
Indiana’s version of the Medicaid expansion called
the ‘Healthy Indiana Plan (HIP) 2.0’.
Other participants also took part in macro-level
forms of advocacy that were not part of a political
trend or movement. Several took part in chamber
of commerce meetings and neighbourhood commit-
tees to address various issues in their communities
or even to plan events such as a Latino heritage
festival. CHWs also blended macro-level advocacy
into micro-level changes. For example, Miguel took
part in several forms of macro-level advocacy during
his free time, participating in numerous fundrais-
ing events to provide aid and resources to Puerto
Rico following the devastation of Hurricane Maria
in 2017. He also blended micro-level advocacy in his
overarching work to help bring 30 families from the
island and help to fi nd them jobs and address their
other needs. As illustrated by Miguel’s case, CHWs
are able to seamlessly blend advocacy at a variety of
levels to foster positive eff ects for individual clients
and the broader community.
Professional-Level Advocacy
Professional-level advocacy occurs in two distinct
forms. The fi rst includes activities in which CHWs
must advocate for the legitimacy of their profession
to their employer, potential employers, medical pro-
fessionals, the public, and any other stakeholders. Pre-
vious scholarship has documented CHWs expressing
their need to advocate for their jobs and to medi-
cal professionals for the legitimacy of their position
(Closser 2015; Sabo et al. 2013, 2015). The second form
of this level of advocacy is when CHWs advocate
directly to their employers for the particular needs
of their clients. This is similar to how CHWs partici-
pated in micro-level advocacy in that they advocated
for an organisation, hospital, and/or clinic to make
specifi c changes to be er serve a client or population;
however, in this case, the CHWs advocated directly
to their employing organisations, clinics, or hospitals
and advocated to their bosses or medical profession-
als for change. Other scholarship has examined how
CHWs abroad have formed labour movements in
order to protest for fairer wages and rights (Closser
2015; Maes 2017).
Several CHWs in the sample were actually em-
ployed as medical interpreters (a fi eld in which they
had also received professional training and certi-
fi cation) rather than as CHWs. These participants
worked as medical interpreters in a hospital or clinic
and revealed that they had advocated to doctors and
other medical staff . At the same time, many of these
‘medical- interpreter-employed’ CHWs felt restricted
in their scope of care, since they were unable to ad-
vocate while in their role as interpreter during their
offi cial working hours. They explained to me that as
interpreters their sole responsibility was to translate,

AiA
|
Ryan I. Logan
14
|
word-for-word, between the medical professional
and the patient. As a result, they were unable to ad-
vocate for the patient or serve in any capacity as a
CHW while on the clock as an interpreter. However,
these participants still advocated to medical staff to
increase the number of interpreters, for more re-
sources for their clients, and for the expansion of
their responsibilities as interpreters so they could
provide be er care to the patients they encountered.
At other times, medical-interpreter-employed CHWs
stepped out of their roles as interpreters. For ex-
ample, Carmen explained that she would advocate
by asking the doctor if the patient’s medication was
the cheapest alternative. She explained that engaging
in this professional-level advocacy almost served as
a ‘reality check’ for some doctors, who were unaware
that their patients may be unable to aff ord the medi-
cations that they were being prescribed.
Still at other times, participants described having
to advocate to their employers in order to have them
not cut CHW programmes and interventions from
their organisations. For example, Marcellus, a CHW,
explained:
Because I’m always advocating for the community,
it’s not just about the programme itself . . . basi-
cally every time the community loses a programme
it’s a disadvantage but if they have to lose a com-
munity health worker programme it’s double the
disadvantage.
His professional-level advocacy highlights the
need for CHW integration into the broader workforce
but also the need to institutionalise funding streams
for CHWs and/or CHW programmes. Many CHW
positions are grant-funded positions and thus exist
only for the short term. Similarly, Alisha has argued
with her employer for a larger role in the implemen-
tation process of CHW programmes. In justifying the
benefi ts of employing a CHW, she asserted, ‘com-
munity health workers are the ROI [return on invest-
ment], we are the ROI’. This is a pertinent issue, as
there are several studies that have demonstrated the
cost-eff ectiveness or positive return on investment of
CHWs. These studies have positively demonstrated
their cost-eff ectiveness both with regard to short-
term health outcomes (Allen et al. 2014; Cross-Barnet
et al. 2018; Fedder et al. 2003; Krieger et al. 2011) and
with regard to long-term cost-eff ectiveness (Brown
et al. 2012). In these ways, the CHWs participated in
professional-level advocacy in order to secure and
justify funding for their positions.
Overall, participants in this sample described the
need to advocate for the legitimacy of their position
and/or the retention of CHW programmes, thereby
highlighting their professional-level advocacy. One
CHW, Mike, explained some of his interactions with
medical professionals: ‘If we didn’t have to explain
what we were doing every time we talked to some-
one fi rst, it would be easier’. As a result, professional-
level advocacy served not only as a means for CHWs
to advocate for the legitimacy of their roles but also
as a way to make changes within their employing
organisations so as to be er facilitate their work and
produce additional positive outcomes for their clients.
Challenges of Advocacy
Despite the wide prevalence of advocacy on one
or multiple levels among the CHWs in the sample,
there were several who discussed specifi c challenges
regarding this role. There were unique challenges for
each of the levels in addition to some that cut across
each of the levels. At times, clients who seemingly
were disinterested or not meeting expectations in
terms of empowerment presented a challenge for
CHWs in micro-level advocacy. For Frank, and for
many of the participants, there was an expectation
that his clients would eventually be empowered to
become self-suffi cient through his advocacy work.
Frank stressed that knowing when to step back was
vital in his work: when his clients seemingly refused
to become self-suffi cient. Other CHWs expressed
similar sentiments in that through micro-level advo-
cacy clients should eventually become empowered.
Frank and these other participants still expressed
their willingness to help and stand up for their clients,
but they expected their clients to eventually take con-
trol of their own health and/or other concerns even if
they might sometimes be unwilling to do so.
For some participants, macro-level advocacy was
not about participating in social justice activism or
demonstrations related to some political leaning but
about making broader positive changes to the health
and well-being of their communities. These CHWs
explained that they would rather not be involved po-
litically and that they simply wanted to do what was
best for their communities. Similarly, other CHWs
eschewed participating in advocacy that could be
construed as political activism, such as public dem-
onstrations or protest marches. Valeria explained: ‘I
try to steer clear of political agendas. Only because I
see myself as a community advocate for good. I don’t
want to be seen as I’m on this side or on that side. I
try to keep myself neutral’. She expanded that hav-
ing a level of neutrality was vital in order for her cli-
ents to be more readily able to identify with her. For
the majority of CHWs, participating in micro-level

Being a Community Health Worker Means Advocating | AiA
| 15
forms of advocacy or in professional-level advocacy
was how they believed they could make the most of
their advocacy work. Several CHWs explained that
participating in macro-level forms of advocacy was
either too much for them or that they did not feel
comfortable doing so.
For some participants, advocacy at the macro-
level or advocacy that consisted of working with
a larger group of actors was challenging. Frank, a
CHW and probation offi cer, explained that collabo-
rating with people can be tiring, and that, when the
overarching system itself is broken, participating in
advocacy can cause disillusionment. Challenges that
lead to disillusionment and/or demoralisation not-
withstanding, other CHWs stated that they do not
have the time to do much more than what they do
on the clock. Carmen explained that she was already
overstretched in terms of her obligations but that
she did participate off and on in activism. Patricia
also expressed that she wished that she could par-
ticipate more in advocacy for her community but felt
overcommi ed and was busy in her current state of
employment.
There were also challenges at the professional
level of advocacy. There is a lack of a central hub
where CHWs can air their grievances or fi nd support.
Furthermore, regardless of advocacy at the profes-
sional level, many CHW-trained medical interpreters
are unable to take on more roles due to hospital pol-
icy regarding the scope of care of interpreters. This is
why, in my sample, professional-level advocacy did
not result in expanded roles for medical interpreters
in the form of more CHW-specifi c responsibilities.
In spite of these challenges, the CHWs continued to
practise all forms of advocacy in the fi ght to improve
the health of their communities.
Finally, at the time of this project, the state govern-
ment had convened a workgroup, which comprised
various stakeholders, in order to develop policy re-
garding the integration of the CHW model into the
workforce in addition to a set of services that would
be reimbursable through Medicaid. Although the
overarching goal of the workgroup was to amelio-
rate health issues through the professional integra-
tion of CHWs, the reimbursable services currently
do not include activities that specifi cally address
social determinants of health, and this devalues the
contributions of advocacy. Employers (and potential
employers) will likely have their CHWs focus on
activities that are reimbursable. Thus, aside from the
above-mentioned issues faced by CHWs at the three
levels of advocacy, the steps that have been recently
taken to develop policy and institutionalise the CHW
position in the health workforce may challenge their
ability to even participate in advocacy.
Discussion
Building on previous research, this article reframes
approaches to CHW advocacy and seeks to deter-
mine the specifi c impacts that CHW participation has
in these three diff erent levels of advocacy. Advocacy
serves as a central aspect in the CHW–client relation-
ship and can instil empowerment at both the indi-
vidual and community levels to improve well-being.
Previous public health literature has documented the
important role that advocacy plays amongst these
workers (Ingram et al. 2008, 2014; Rosenthal et al.
2011; Sabo et al. 2013, 2015). The qualitative fi ndings
presented here help to further contextualise advo-
cacy at the three above-mentioned levels. Parsing out
the various advocacy activities in which CHWs are
involved reveals the particular successes that they
have enjoyed and the specifi c challenges that they
have faced at the grassroots level. Overall, advocacy
serves as the conduit through which CHWs can em-
power their clients and broader communities.
Micro-level advocacy was a ubiquitous activity
for all participants in this study. As many CHWs
come from politically and/or socially marginalised
populations, it is precisely the political economic en-
vironment that spurs both their desire and their enti-
tlement to advocate for their respective populations.
For those CHWs who came from the communities
they worked within, this commitment to advocacy
was an obligation: they had to give their communi-
ties a voice to speak out against injustice. This shared
structural vulnerability is crucial in understanding
the position of these workers in relation to not only
what their community members experience in terms
of health and social disparities but also in relation to
the exclusion that CHWs may face from the broader
medical workforce (as indicated by their need to
participate in professional-level advocacy). Other
scholars have noted how these workers share the
structural barriers experienced by their fellow com-
munity members (Closser 2015; Nading 2013; Sabo et
al. 2015). This sense of shared vulnerability strongly
shapes the obligation that participants felt towards
their communities. This form of advocacy, though,
came with an expectation that the client would even-
tually gain self-suffi ciency and become empowered
through the guidance of the CHW.
CHW participation in micro-level advocacy is a
vital service and a unique contribution to the current

AiA
|
Ryan I. Logan
16
|
healthcare landscape of the United States. Moreover,
this level of advocacy is crucial because it guides
clients towards empowerment and self-suffi ciency,
specifi cally through overcoming social determinants
of health. Since this level involves the most direct
connection between the CHW and their clients, the
former are able to work closely with the la er in
order to help them develop the skills and strategies
required to address their individual struggles.
Macro-level advocacy was a more divisive topic
amongst CHWs in the study sample. For some,
political and/or social justice activism was not ap-
pealing. This sentiment was seemingly echoed by
employers, as those CHWs that did participate in
macro-level advocacy did so off the clock. While it is
understandable that employers may not want their
employees participating in political causes on the
clock, non-political forms of community mobilisation
or participation in community coalitions may qualify
as eff ective time spent in working hours. It should
be noted that macro-level forms of advocacy may
remove the strictly political aspect of this designation
and instead consist of activities that are performed in
order to create an impact within the community or
broader society. This was especially true, as several
participants were part of coalitions that sought to
unite the community and have it participate in local
events (e.g. health fairs, food festivals, fundraising
events, cultural events). In this way, macro-level forms
of advocacy are nuanced and include activities that
are not strictly political in scope.
However, which levels of advocacy and the extent
to which CHWs should engage in advocacy activities
stands as an issue that may aff ect their integration
within the healthcare workforce. These workers may
be hindered from participating in macro-level advo-
cacy, at least while they are on the clock. This might
also include not being allowed to encourage their cli-
ents to speak with their representatives or meet with
politicians during community outreach events. More-
over, as the CHW model becomes formalised and
integrated within the healthcare workforce, there is
concern that advocacy will be a role that becomes
diminished (Nading 2013; Rosenthal et al. 2011). This
highlights how – despite sharing structural vulner-
abilities with their client population – CHWs as
advocates may not be welcome within the broader
healthcare workforce.
Anthropologist Miriam Ticktin’s (2011) ‘regimes of
care’ concept provides a top-down theoretical frame-
work that considers movements, groups, and other
responses to iniquity as a set of discourses that start
out with a moral imperative to relieve suff ering. Re-
gimes of care are seen in Indiana with regard to gov-
ernmental action regarding the institutionalisation,
funding, and hiring of CHWs as part of the broader
healthcare workforce and as part of Medicaid-reim-
bursable activities. Many organisations may receive
a short-term grant that will fund such a position. As
a result, these positions may not last more than one
to two years and may be dependent on securing ad-
ditional grant funding. Marcellus invoked this time
constraint in his defence that it is a ‘double disad-
vantage’ to the community if his employer decided
to stop funding his CHW position. While his position
may help to improve the health of the community
and ameliorate social determinants of health, the suf-
fering would only be removed temporarily unless his
position can become permanently funded. This over-
arching discourse related to how suff ering is relieved
(i.e. the regime of care) cra s the political economic
context in which CHWs operate.
Alex Nading (2013) has detailed that a shi away
from the social justice and advocacy component
of the CHW model began in the 1990s in favour of
an ‘apolitical, “technical orientation”’. He describes
how steps towards the institutionalisation of the
CHW position risks a loss of the CHW’s role as an
advocate. This is being potentially seen in Indiana,
as reimbursable services currently do not cover time
spent helping clients address the social determinants
of health – issues best ameliorated through advocacy.
This echoes the warnings posited by scholars that
speak to issues arising from the institutionalisation,
and potential medicalisation, of this position (Bovb-
jerg et al. 2013a; Nading 2013; Rosenthal et al. 2011).
Thus, reassessing the nuances of advocacy and the
potential for salutogenic health impacts is vital to
ensuring that the integration of these workers does
not risk losing this vital role.
Other scholars have cautioned against the loss of
this core role of CHWs and the fundamental change
that it would have on the position (Bovbjerg et al.
2013b; Pérez and Martinez 2008). In order to ensure
the inclusion of the advocacy component, scholars
have argued for CHWs to be included in the cre-
ation, development, and institutionalisation of pro-
grammes and policies regarding their workforces
(Catalani et al. 2009; Pérez and Martinez 2008; Rosen-
thal et al. 2011; Sabo et al. 2013). These steps will help
ensure that CHWs are the primary directors of their
positions and can advocate for their jobs in this posi-
tion of power.
In conclusion, while previous research has as-
sessed CHW advocacy through survey data and as
civic, organisational, and political advocacy (Sabo et

Being a Community Health Worker Means Advocating | AiA
| 17
al. 2013), reframing advocacy with regard to levels of
impact presents one strategy to further assess their
inclusion within the unique contributions of CHWs.
Previous research has assessed CHW advocacy
through survey data, and this article highlights the
nuanced experiences of CHWs who participated in
micro-, macro-, and professional-level advocacy.
Stakeholders, employers, and potential employers
can view the various eff ects of CHW advocacy
through the lens of the three diff erent levels. More-
over, employers should consider advocacy at the
micro- and macro-levels as additional means of
overcoming social determinants of health that will
ultimately result in a reduction of health disparities.
These forms of advocacy have the potential to lead
communities to greater health equity. Additionally,
institutionalising the funding of CHW positions will
help maintain the positive benefi ts of their advocacy.
Finally, CHWs must maintain autonomy over the
development of legislation regarding their positions
– especially in order to ensure that advocacy will
not be lost in the steps that will be taken towards
further integration. Advocacy is a vital component
of the CHW–client relationship and can help achieve
greater health equity for the most vulnerable popula-
tions in the United States.
RYAN I. LOGAN is an Assistant Professor of Medical
Anthropology at California State University Stanis-
laus. His research interests include medical parapro-
fessionals, health disparities, collaborative research,
and social justice.
E-mail: rilogan@csustan.edu
Acknowledgements
Many thanks to the research participants in this study.
Without their collaboration and their critique of my
research, this article would not have been possible.
References
Allen, J. K., C. R. Dennison Himmelfarb, S. L. Szanton,
and K. D. Frick (2014), ‘Cost-Eff ectiveness of Nurse
Practitioner/Community Health Worker Care to
Reduce Cardiovascular Health Disparities’, Journal
of Cardiovascular Nursing 29, no. 4: 308–314, h ps://
doi.org/10.1097/JCN.0b013e3182945243.
American Public Health Association (APHA) (2018),
‘Community Health Workers’, American Public
Health Association, 28 October, h ps://www
.apha.org/apha-communities/member-sections/
community-health-workers.
Bovbjerg, R. B., L. Eyster, B. Ormond, T. Anderson,
and E. Richardson (2013a), ‘Opportunities for
Community Health Workers in the Era of Health
Reform’, The Urban Institute, 31 October, h p://
www.urban.org/sites/default/fi les/alfresco/pub
lication-pdfs/413071-Opportunities-for-Community-
Health-Workers-in-the-Era-of-Health-Reform.PDF.
Bovbjerg, R. B., L. Eyster, B. Ormond, T. Anderson, and
E. Richardson (2013b), ‘Integrating Community
Health Workers into a Reformed Health Care
System’, The Urban Institute, 31 October, h p://
webarchive.urban.org/UploadedPDF/413070-
Intergrating-Community-Health-Workers-Into-A-
Reformed-Health-Care-System.pdf.
Brown, H. S., K. J. Wilson, J. A. Pagán, C. M. Arcari,
M. Martinez, K. Smith, and B. Reininger (2012),
‘Cost-Eff ectiveness Analysis of a Community
Health Worker Intervention for Low-Income
Hispanic Adults with Diabetes’, CDC Preventing
Chronic Disease 9: 1–9, h p://doi.org/10.5888/pcd9
.120074.
Brownstein, J. N., G. R. Hirsch, E. L. Rosenthal, and
C. H. Rush (2011), ‘Community Health Workers
“101” for Primary Care Providers and Other Stake-
holders in Health Care Systems’, Journal of Ambula-
tory Care Management 34, no. 3: 210–220, h ps://
doi.org/10.1097/JAC.0b013e31821c645d.
Catalani, C. E., S. E. Findley, S. Matos, and R. Rodri-
guez (2009), ‘Community Health Work Insights on
Their Training and Certifi cation’, Progress in Commu-
nity Health Partnerships 3, no. 3: 227–235, h ps://
doi.org/10.1353/cpr.0.0082.
Closser, S. (2015), ‘Pakistan’s Lady Health Worker La-
bor Movement and the Moral Economy of Heroism’,
Annals of Anthropological Practice 39, no. 1: 16–28,
h ps://doi.org/10.1111/napa.12061.
Cross-Barnet, C., S. Ruiz, M. Skillman, R. Dhopesh-
warkar, . . . and E. Colligan (2018), ‘Higher Quality
at Lower Cost: Community Health Worker Interven-
tions in the Health Care Innovation Awards’, Journal
of Health Disparities Research and Practice 11, no. 2:
150–164, h ps://digitalscholarship.unlv.edu/jhdrp/
vol11/iss2/10.
Fedder, D. O., R. J. Chang, and G. Nichols (2003),
‘The Eff ectiveness of a Community Health Worker
Outreach Program on Healthcare Utilization of
West Baltimore’, Ethnicity & Disease 13, no. 1: 22–27,
h ps://www.ncbi.nlm.nih.gov/pubmed/12723008.
Findley, S., S. Matos, A. Hicks, J. Chang, and D. Reich
(2014), ‘Community Health Worker Integration into
the Health Care Team Accomplishes the Triple Aim
in a Patient-Centered Medical Home: A Bronx Tale’,

AiA
|
Ryan I. Logan
18
|
Journal of Ambulatory Care Management 37, no. 1:
82–91, h ps://doi.org/10.1097/JAC0000000000000011.
Ingram, M., S. Sabo, J. Rothers, A. Wennerstrom, and
J. G. de Zapien (2008), ‘Community Health Work-
ers and Community Advocacy: Addressing Health
Disparities’, Journal of Community Health 33, no. 6:
417–424, h ps://doi.org/10.1007/s10900-008-9111-y.
Ingram M., K. A. Schachter, S. Sabo, K. M. Rein-
schmidt, S. Gomez, J. G. de Zapien, and S. C.
Carvajal (2014), ‘A Community Health Worker In-
tervention to Address the Social Determinants of
Health Through Policy Change’, Journal of Primary
Prevention 35, no. 2: 119–123, h ps://doi.org/10.1007/
s10935-013-0335-y.
Kangovi, S., D. Grande, and C. Trinh-Shevrin (2015),
‘From Rhetoric to Reality – Community Health
Workers in Post-Reform US Health Care’, New
England Journal of Medicine 372, no. 24: 2277–2279,
h ps://doi.org/10.1056/NEJMp1502569.
Krieger, J. W., T. K. Takaro, L. Song, and M. Weaver
(2011), ‘The Sea le-King County Healthy Homes
Project: A Randomized, Controlled Trial of a Com-
munity Health Worker Intervention to Decrease
Exposure to Indoor Asthma Triggers’, American
Journal of Public Health 95, no. 4: 652–659, h ps://
doi.org/10.2105/AJPH.2004.042994.
Maes, K. (2015), ‘“Volunteers Are Not Paid Because
They Are Priceless”: Community Health Worker
Capacities and Values in an AIDS Treatment Inter-
vention in Urban Ethiopia’, Medical Anthropology
Quarterly 29, no. 1: 97–115, h ps://doi.org/10.1111/
maq.12136.
Maes, K. (2017), The Lives of Community Health Workers:
Local Labor and Global Health in Urban Ethiopia (New
York: Routledge).
Martinez, J., M. Ro, N. W. Villa, W. Powell, and J. R.
Knickman (2011), ‘Transforming the Delivery of
Care in the Post-Health Reform Era: What Role
Will Community Health Workers Play?’, American
Journal of Public Health 101, no. 12: e1–e5, h ps://
doi.org/10.2105/AJPH.2011.300335.
Nading, A. (2013), ‘“Love Isn’t There in Your Stom-
ach”: A Moral Economy of Medical Citizenship
among Nicaraguan Community Health Workers’,
Medical Anthropology Quarterly 27, no. 1: 84–102,
h ps://doi.org/10.1111/maq.12017.
Pérez, L. M. and J. Martinez (2008), ‘Community
Health Workers: Social Justice and Policy Advocates
for Community Health and Well-Being’, American
Journal of Public Health 98, no. 1: 11–14, h ps://
doi.org/10.2105/AJPH.2006.100842.
Rosenthal, E. L., J. L. Brownstein, C. H. Rush, G.
R. Hirsch, . . . and D. J. Fox (2010), ‘Community
Health Workers: Part of the Solution’, Health Af-
fairs 29, no. 7: 1338–1342, h ps://doi.org/10.1377/
hlthaff .2010.0081.
Rosenthal, E. L., N. Wiggins, M. Ingram, S. Mayfi eld-
Johnson, and J. G. de Zapien (2011), ‘Community
Health Workers Then and Now: An Overview of
National Studies Aimed at Defi ning the Field’, Jour-
nal of Ambulatory Care 34, no. 3: 247–259, h ps://
doi.org/10.1097/JAC.0b013e31821c64d7.
Sabo, S., M. Ingram, K. M. Reinschmidt, K. Schachter,
. . . and S. C. Carvajal (2013), ‘Predictors and a
Framework for Fostering Community Advocacy as a
Community Health Worker Core Function to Elimi-
nate Health Disparities’, American Journal of Public
Health 103, no. 7: e67–e73, h ps://doi.org/10.2105/
AJPH.2012.301108.
Sabo, S., A. Wennerstrom, D. Phillips, C. Haywoord, F.
Redondo, M. L. Bell, and M. Ingram (2015), ‘Com-
munity Health Worker Professional Advocacy’,
Journal of Ambulatory Care Management 38, no. 3: 225–
235, h ps://doi.org/10.1097/JAC.0000000000000089.
Shah, M., M. Heisler, and M. Davis (2014), ‘Commu-
nity Health Workers and the Patient Protection and
Aff ordable Care Act: An Opportunity for Research,
Advocacy, and Policy Agenda’, Journal of Health Care
for the Poor and Underserved 25, no. 1: 17–24, h ps://
doi.org/10.1353/hpu.2014.0019.
Silverman, J., J. Krieger, G. Sayre, and K. Nelson
(2018), ‘The Value of Community Health Workers
in Diabetes Management in Low-Income Popula-
tions: A Qualitative Study’, Journal of Community
Health 43, no. 5: 842–847, h ps://doi.org/10.1007/
s10900-018-0491-3.
Ticktin, M. (2011), Causalities of Care: Immigration and
the Politics of Humanitarianism in France (Berkeley:
University of California Press).
Wiggins, N., A. Hughes, A. Rodriguez, C. Po er, and
T. Rios-Campos (2014), ‘La Palabra Es Salud (The
Word Is Health): Combining Mixed Methods and
CBPR to Understand the Comparative Eff ectiveness
of Popular and Conventional Education’, Journal of
Mixed Methods Research 8, no. 3: 278–298, h ps://
doi.org/10.1177/1558689813510785.