REVIEW ARTICLE

Year : 2009  |  Volume : 22  |  Issue : 2  |  Page : 378

Guest Editorial: The Role and Impact of Indigenous Community Health Workers

T Parker, A Kaufman
The University of New Mexico Health Sciences Center - School of Medicine, Albuquerque, USA

Correspondence Address:
T Parker
3304 Hastings, NE, Albuquerque, NM 87106
USA

Source of Support: None, Conflict of Interest: None

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PMID: 20029757

Community health workers should be members of the communities where they work, should be selected by the communities, should be answerable to the communities for their activities, should be supported by the health system but not necessarily a part of its organization, and have shorter training than professional workers.

Description of CHWs, World Health Organization, January 2007 Policy Brief

http://www.who.int/hrh/documents/community_health_workers_brief.pdf

As guest co-editors of this special section on indigenous community health workers (CHWs), our aim is to increase public knowledge about the education, training and roles of these cultural liaisons. While there is no universally accepted definition of the term “indigenous”, in our call for papers we used Martínez Cobo’s work (1987) as a starting point to define indigenous as follows: “Indigenous refers to communities, peoples and nations having a historical continuity with pre-invasion and pre-colonial societies that developed on their territories, consider themselves distinct from other sectors of the societies now prevailing on those territories, or parts of them. They form at present non-dominant sectors of society and are determined to preserve, develop and transmit to future generations their ancestral territories, and their ethnic identity, as the basis of their continued existence as peoples, in accordance with their own cultural patterns, social institutions and legal system.” A caveat to our use of this term is acknowledging that indigenous peoples have the right to define and assign meaning for themselves.



Our particular interest in indigenous CHWs stems from the recognition that indigenous health, even in industrialized nations, is often characterized by high health disparities and health inequities (Gracey & King, 2009; King et al., 2009). The lower health status cannot be attributed solely to indigenous peoples’ locations in rural and remote settings as many now reside in urban areas. A growing belief in indigenous communities worldwide is that “historical trauma”, a condition that has its roots in the processes of colonization and that continues to be reinforced through socioeconomic disadvantage and racism and discrimination, is a barrier to the achievement of healthy indigenous communities (“Where Are We Now with Indigenous Health?”, 2009). As a result of historical trauma, a generalized distrust by indigenous peoples of the dominant culture, including Western healthcare practices and interactions, is prevalent in many indigenous communities. The inclusion of indigenous CHWs in both rural/remote and urban healthcare settings can provide a vital and trusted cultural connection between underserved indigenous communities and Western healthcare facilities, practices and interventions. In their primary roles of increasing access and promoting quality healthcare and its delivery, indigenous CHWs bring not only health knowledge to bear on the persistent health inequities found throughout their communities but also the indigenous language, local cultural practices and protocols and, importantly, an understanding of the social, political and historical memories of events that have contributed to their population’s current state of health.



This special section of Education for Health features three studies that examined the challenges of preserving the unique qualities of indigenous CHWs while at the same time ensuring opportunities for occupational recognition and protection. A common approach across the studies is the authors’ use of qualitative methods, e.g., interviews, focus groups and participant observation to elucidate opportunities, needs and barriers to the training and education of a CHW workforce. We now turn to our brief review of selected similarities and differences among the studies.



In two studies - Boulton et al. and Minore et al.- national government policy for indigenous health offer tremendous opportunities for the indigenous communities to assert and strengthen the vital principles of tribal governance, self-determination and autonomy. As presented by the authors of those studies, the role of indigenous CHWs has a fundamental structure of sustaining healthcare delivery and interpreting indigenous health policy in what are often fledgling indigenous healthcare systems operated by and for indigenous peoples. For instance, in Canada, paraprofessional health workers comprise greater than 40% of the First Nation health providers, thus, without them, the indigenous healthcare system would collapse. In New Zealand, Māori CHWs are the cultural interpreters and leaders in determining meaning for the delivery of a system of government health contracts intended to uphold tribal core cultural values. In both studies, it is clear that indigenous CHWs play central roles in implementing governmental policies that connect indigenous health to self-determination and tribal governance – a powerful and decolonizing strategy for achieving indigenous community health and well-being. In proactive stances to advance and enhance the status of indigenous CHWs, the Canadian and New Zealand authors explore the need for further clarity of the CHW role by developing national practice standards and core competencies that result in targeted training, education and career laddering. Intended outcomes of those efforts include fair remuneration, decreased strain and burnout from mounting and unfocused demands and enhancing interactions with health professionals and healthcare leaders.



The third study by Felton-Busch et al. diverges from the other two. The Australian team examined educational/training opportunities not from the perspective of enhancing competencies and internal career ladders related to the Aboriginal health worker (AHW) occupation, but from the standpoint of moving AHWs out of their paraprofessional role and into mid-level and professional health occupations in response to national health workforce needs. Interviews with AHWs and community key stakeholders led Felton-Busch et al. to a finding that the qualities of deep community-rootedness and extensive family ties that lead AHWs into their indigenous grassroots healthcare roles also hinder their contemplation of advanced study. Likewise, other considerations, such as childcare and work release time and anticipated concerns such as racism, were identified as barriers to pursuing higher education. The authors point out that at the local level there is abundant interest in maintenance of the AHW role while, at the same time, national and indigenous policies are promoting indigenous representation across the range of health occupations. In their brief report, the authors identified preliminary but important intervention points (remediation of barriers) for the alignment of multiple career ladders that build on the AHW role and the progressive certification process.



In conclusion, the observation that indigenous CHW care represents an “ancient method of communal care and health protection…and a system of cultural mediation” (Satterfield et al., 2002) is by all accounts supported in this special section. We sincerely thank the authors of the studies and their community health partners for sharing their inspiring work with us. We also thank the Co-Editors of this journal, Drs. Michael Glasser and Donald Pathman; Associate Editor Dr. Jane Westberg for her early and continued guidance; Managing Editor Marie-Louise Panis; and the reviewers for their timely submissions.



Comments or inquiries should be directed to Dr. Parker at the following e-mail address: [email protected].

Tassy Parker, PhD, RN (indigenous affiliation: Seneca Nation)

Guest Editor

The University of New Mexico Health Sciences Center – School of Medicine

Assistant Professor of Family and Community Medicine,

Director of Research, Center for Native American Health, and

Director of Community Engaged Research, Office for Community Health



Arthur Kaufman, MD

Guest Editor

The University of New Mexico Health Sciences Center – School of Medicine

Vice President for Community Health and

Professor of Family and Community Medicine

References



Gracey, M., & King, M. (2009). "Indigenous Health Part 1: Determinants and Disease Patterns." Lancet, 374.9683:65-75.



King, M., Smith, A., & Gracey, M. (2009). "Indigenous Health Part 2: the Underlying Causes of the Health Gap." Lancet, 374.9683:76-85.



Martínez Cobo, J.R. (1987). Study of the Problem of Discrimination Against Indigenous Populations, Volume V, Conclusion, Proposals and Recommendations. United Nations Geneva. UN Doc, p. E/CN.4/Sub.2/1986/7, para 362.



Satterfield, D. B.C., Valdez, L., Hosey, G., & Eagle Shield, J. (2002). The "In-Between People": Participation of Community Health Representatives in Diabetes Prevention and Care in American Indian and Alaska Native Communities. Health Promotion Practice, 3(2):166-175.



"Where Are We Now with Indigenous Health? " (2009). Lancet, 374.9683:2.