摘要：Objectives. Using a mixed-method, participatory research approach, we investigated factors related to community health worker (CHW) community advocacy that affect social determinants of health. Methods. We used cross-sectional survey data for 371 CHWs to assess demographics, training, work environment, and leadership qualities on civic, political, and organizational advocacy. We present advocacy stories to further articulate CHW activities. The data reported are from the recently completed National Community Health Workers Advocacy Study. Results. CHWs are involved in advocacy that is community-focused, although advocacy differs by intrinsic leadership, experience, training, and work environment. We propose a framework to conceptualize, support, and evaluate CHW advocacy and the iterative processes they engage in. These processes create opportunities for community voice and action to affect social and structural conditions that are known to have wide-ranging health effects on communities. Conclusions. The framework presented may have utility for CHWs, their training programs, and their employers as well as funders and policymakers aiming to promote health equity. Community health workers (CHWs) are essential to effective and comprehensive health systems throughout the world. 1,2 In the United States, CHWs have been recognized as integral to providing patient-centered care and reducing health inequalities among disenfranchised groups. 3 The workforce impact of CHWs is far-reaching in the realms of the prevention and control of chronic and infectious disease, 4–13 the reduction of health care costs, 14–16 and improved outreach, communication, and adherence, 17–20 as well as in connecting clients to existing services. 21 The recognition of the CHW model has resulted in increased integration of CHWs into the health delivery system. Although beneficial in terms of health care delivery, the institutionalization of the role of CHWs within systems of care may result in the devaluation of another CHW core function, that of building community capacity to address the social determinants of health (SDH) through advocacy and organizing. 22–24 Studies have documented the influence of CHWs on the quality of the health care delivery system 25,26 and on community-engaged strategies to address public housing 27 and decrease community violence. 28 Balcazar et al. 21 underscore the importance of maintaining the full spectrum of CHW roles within a changing health care delivery system, which includes not only influencing how care is delivered but also addressing power relationships that underlie the SDH. The World Health Organization’s Commission for Social Determinants of Health recently revised their conceptualization of SDH to include structural determinants of health, which are defined as macroeconomic and social policies related to labor, housing, and land and public policies concerning health, education, and social protection. 29 Such structural determinants have been recognized as powerful predictors of health status. 30 In responding to specific disease areas, CHWs report the need for a broad range of skills to effectively address the complex issues that they confront working with individuals and communities. 31,32 We document the findings of a mixed quantitative–qualitative national survey investigating CHW involvement in community-level advocacy, defined as working for a cause or a change to improve the health of a community. We propose a framework to conceptualize, support, and measure the intrinsic, training, and work environment characteristics associated with CHW community advocacy. The framework also describes the iterative process in which CHWs, by creating opportunities for community voice and action, positively affect social and structural conditions that determine the health of a community.
