Community health workers can experience the same challenges as those they serve, Baltimore study shows

For more than 80 years, Bi-Rite, a family-owned grocery store on Belair Road, gave residents of Northeast Baltimore a place to buy affordable produce, send money and cash checks.

But by the time a community health worker snapped a photo of the site where the store once stood for a report published Monday in the health policy journal, Health Affairs, all that remained of it was a towering red, white and blue sign.

“This was our local market,” the worker said in the study, which illustrates the challenges faced by community health workers in Baltimore through firsthand accounts and photographs. “During COVID it shut down. We are not getting a new market.”

Community health workers are the public health workers employed by health centers, nonprofits and other organizations who typically don’t have medical degrees, but possess a deep, nuanced understanding of the communities they serve. Though they’ve long been recognized for the critical role they play in connecting marginalized groups with resources, previous studies have focused on their cost-savings benefits and success at reducing health disparities — not on the difficulties the workers face themselves.

Monday’s report highlights those community health workers, instead of their clients. It paints a picture of an empathetic and compassionate workforce, many of whom grew up or currently live in the communities they serve. The ties workers have to marginalized identities and neighborhoods mean they’re better able to earn their clients’ trust and understand their needs. But it also means they experience many of the same obstacles — from food insecurity and structural and interpersonal racism to financial precariousness, transportation problems and language barriers.

“All of us are burnt out, especially throughout this COVID period,” said Chidinma Ibe, an assistant professor at the Johns Hopkins University School of Medicine and the report’s lead author. “But I think what makes community health workers so unique is also the very thing that makes them vulnerable to these types of things, where they’re coming from these communities that are already at a disadvantage — historically, structural, socially, in so many different ways.

“Through their own empathy and compassion and resourcefulness, they’re able to help other people address their issues, but it takes a toll on them.”

To better understand the challenges that community health workers face, Ibe and her co-authors recruited 16 of these workers, most of whom were women and reported their race as Black or African American or Hispanic or Latino — similar to the demographics of the country’s overall community health workforce.

About half of the community health workers had experienced housing or transportation instability at times, and about a third had worried about food within the past year.

Using a research technique called “photovoice,” the report’s authors asked the participants to take photos of the environments where they live and work. As discussions around the photos unfolded, Ibe said, it was striking how frequently community health workers pointed to systemic racism as the explanation for the struggles faced by themselves and their neighbors, or described having experienced implicit or explicit racism on the job.

Tiffany Scott, one of the study’s co-authors and chair of the Maryland Community Health Worker Association, recalled what it was like to start her first job as a community health worker at a federally qualified health center.

Even after she was hired for the position, she said, it felt like she had to prove herself to her co-workers. Once she accomplished that, her caseload leapt from about 20 clients to 200.

“We know what it looks like to have or do without, and to make the very best of what we have. We understand being set aside, overlooked, underpaid, not appreciated, not given the opportunity, not given a chance,” Scott said.

Now that the study has been published, Ibe and her colleagues plan to present the report’s findings and recommendations to a group of local policymakers, philanthropists and leaders of organizations that employ community health workers.

In the study, researchers urged organizations to better include community health workers in program and policy development, and provide trauma-informed supervision and anti-racism training to their colleagues. They also highlighted the need for more robust safety procedures giving workers guidelines for what to do in potentially dangerous situations, besides to trust their “gut feeling.”

Lastly, researchers asked policymakers to expand funding for community health worker programs to improve the workers’ financial security. “Patchwork funding,” the report explains, is an unfortunate hallmark of these programs in the U.S., and contributes to periodic food, transportation and housing insecurity experienced by the workers.

With federal funding drying up, community organizations across the country — including in Baltimore, Scott said — are laying off community health workers they hired during the pandemic. Other community health workers are leaving the workforce to get their nursing or social work degree, because they’re tired of living grant to grant, Scott said.

Organizations need better think about their workers’ well-being beyond the funding period, Scott said. They should offer professionalism and resume-building workshops for community health workers, or connect them with future job opportunities.

“How do you think I feel working and giving my all, all the way up to the end, and then, the very next day, I’m unemployed?” Scott said.

Traci Kodek, CEO of HealthCare Access Maryland — a nonprofit that helps people enroll in health insurance and navigate the health care system — said the organization is working with the Public Justice Center to conceive a strategy for creating more sustainable funding sources for community health worker programs. Next year, they hope to push for state legislation to make services provided by community health workers billable under Medicaid.

Kodek estimates HealthCare Access Maryland employs about two dozen community health workers, who work with pregnant women, people struggling with substance use disorder and those leaving prison or jail, as well as other outreach programs. The workers tell the organization what’s needed in communities, Kodek said, and what residents’ struggles are.

“They’re the boots on the ground,” she said.