Community Health Representatives Research Articles

Providers’ perceptions of barriers to the management of type 2 diabetes in remote Aboriginal settings

Objectives. To examine providers’ perspectives of the barriers to providing diabetes care in remote First Nation communities in the Sioux Lookout Zone (SLZ) of Northwestern Ontario, Canada.Study design. A qualitative study involving key informant interviews and focus groups was conducted with health care providers working in remote First Nation communities in SLZ.Methods. Twenty-four nurses, doctors, diabetes educators and community health representatives (CHRs) participated in qualitative interviews and focus groups. Data collected from the interviews and focus groups was coded and thematically analysed using NVIVO software.Results. Barriers to diabetes care were grouped into patient, clinic and system factors. Providers’ perceptions of patient factors were divided between those advocating for a patient–provider partnership and those advocating for greater patient responsibility. Clinic-related barriers such as short staffing, staff turnover and system fragmentation were discussed, but were often overshadowed by a focus on patient factors and a general sense of frustration among providers. Cultural awareness and issues with clinic management were not mentioned, though they are both within the providers’ control.Conclusions. This study characterizes a range of barriers to diabetes care and shows that patient-related factors are of primary concern for many providers. We conclude that patient-focused interventions and cultural competence training may help improve patient–provider partnerships. Funding and supporting quality improvement initiatives and clinic reorganization may increase the providers’ knowledge of the potential for clinical strategies to improve patient outcomes and focus attention on those factors that providers can change. Future research into the factors driving quality of care and strategies that can improve care in Aboriginal communities should be a high priority in addressing the rising burden of diabetes and related complications.

Emergency Preparedness Training of Tribal Community Health Representatives

This study describes the development and evaluation of online Public Health Emergency Preparedness (PHEP) training adapted to the learning styles and needs of tribal Community Health Representatives (CHRs). Working through a university-tribal community college partnership, the Arizona Center for Public Health Preparedness at the University of Arizona and Diné College of the Navajo Nation delivered a blended online and face-to-face public health preparedness certificate program based on core public health emergency preparedness competencies. This program was carefully adapted to meet the environmental and learning needs of the tribal CHRs. The certificate program was subsequently evaluated via a scenario-based decision-making methodology. Significant improvements in five of six competency areas were documented by comparison of pre- and post-certificate training testing. Based on statistical support for this pedagogical approach the cultural adaptations utilized in delivery of the certificate program appear to be effective for PHEP American Indian education.

American Indian Grand Families: A Qualitative Study Conducted with Grandmothers and Grandfathers Who Provide Sole Care for Their Grandchildren

A qualitative study was conducted to determine the rationale for 31 American Indian grandparents' who provide sole care of their grandchildren, the impact of historical trauma on their decision making process in accessing services, the value of American Indian Child Welfare policies in addressing care issues, and custody status of the grand families. Indian Outreach Workers, Community Health Representatives, Elder Program Directors, and tribal community leaders were key in the recruitment of participants. The grandparents were informed of the purpose of the study and participated in face-to-face, paper and pencil, individual interviews. The subjects included 29 grandmothers and two grandfathers; age 43-86 years, with 20 who lived off reservation land and 11 who lived on reservation land in Michigan. A phenomenological approach of the "world of the lived experience" informed the design of the study. The researchers recorded the subjects' responses via field notes, conducted a comparison of responses to assess internal reliability, and entered the responses into the qualitative data analysis Nvivo program. Findings included; (1) reasons for providing sole care of grandchildren (2) stressors and rewards of providing sole care (3) grandparents decisions affected by historical traumas which focused on the boarding school issues and the removal of children from their homes due to cultural differences causing a reluctance to seek and access national and state programs (4) grandparents preference was to seek and access services provided by their Tribal Nations, and/or American Indian urban agencies (5) most lacked legal custodial status which is an indicator the grandparents' may have benefited from knowledge of the Indian Child Welfare Act (ICWA).

Use of the Talking Circle for Comanche Women’s Breast Health Education

As breast cancer screening is critical to early detection and treatment, it is imperative to furnish health care providers with effective educational materials for the populations they serve. To do so for Comanche American Indian women requires understanding the cultural constructs that influence the use of screening and treatment recommendations. The purpose of this article is to describe the health-illness beliefs and barriers to breast health for a group of Comanche women. This was a descriptive, qualitative study guided by the principles of community-based participatory research. Seven community health representatives serving Comanche women participated in a "Talking Circle," an indigenous method of making decisions and conducting group process among American Indian people. Themes were Barriers to Information, Barriers to Screening, Economic Barriers, Barriers to Follow-up, and Protecting Our Women. This study provided insight into barriers to breast health for women in the Comanche Nation. These findings contribute to a foundation for enhancements needed to make breast health education and interventions culturally appropriate. These findings also add to the cultural knowledge of nurses for use in the practice area to improve understanding and communication with American Indian patients.

Utilization of the Native American Talking Circle to Teach Incident Command System to Tribal Community Health Representatives

The public health workforce is diverse and encompasses a wide range of professions. For tribal communities, the Community Health Representative (CHR) is a public health paraprofessional whose role as a community health educator and health advocate has expanded to become an integral part of the health delivery system of most tribes. CHRs possess a unique set of skills and cultural awareness that make them an essential first responder on tribal land. As a result of their distinctive qualities they have the capability of effectively mobilizing communities during times of crisis and can have a significant impact on the communities' response to a local incident. Although public health emergency preparedness training is a priority of federal, state, local and tribal public health agencies, much of the training currently available is not tailored to meet the unique traits of CHRs. Much of the emergency preparedness training is standardized, such as the Federal Emergency Management Agency (FEMA) Training Programs, and does not take into account the inherent cultural traditions of some of the intended target audience. This paper reports on the use of the Native American Talking Circle format as a culturally appropriate method to teach the Incident Command System (ICS). The results of the evaluation suggest the talking format circle is well received and can significantly improve the understanding of ICS roles. The limitations of the assessment instrument and the cultural adaptations at producing changes in the understanding of ICS history and concepts are discussed. Possible solutions to these limitations are provided.

Social support, material circumstance and health behaviour: Influences on health in First Nation and Inuit communities of Canada

An expansive literature describes the links between social support and health. Though the bulk of this evidence emphasizes the health-enhancing effect of social support, certain aspects can have negative consequences for health (e.g., social obligations). In the Canadian context, the geographically small and socially interconnected nature of First Nation and Inuit communities provides a unique example through which to explore this relationship. Despite reportedly high levels of social support, many First Nation and Inuit communities endure broad social problems, thereby leading us to question the assumption that social support is primarily health protective. We draw from narrative analysis of interviews with 26 First Nation and Inuit Community Health Representatives to critically examine the health and social support relationship, and the social structures through which social support influences health. Findings indicate that there are health-enhancing and health-damaging properties of the health–social support relationship, and that the negative dimensions can significantly outweigh the positive ones. Social support operates at different structural levels, beginning with the individual and extending toward family and community. These social structures are important as they reinforce an individual's sense of belonging, however, these high-density networks can also exert conformity pressures and social obligations that promote health-damaging behaviours such as domestic violence and smoking. The poor material circumstances that characterize so many First Nation and Inuit communities add another layer of complexity as limited resources can trap individuals within the confines of their immediate social contexts. Research and policy interventions must pay close attention to the social context within which social support, health behaviours and material circumstances interact to influence health outcomes among First Nation and Inuit communities.

The determinants of First Nation and Inuit health: A critical population health approach

Environmental dispossession disproportionately affects the health of Canada's Aboriginal population, yet little is known about how its effects are sustained over time. We use a critical population health approach to explore the determinants of health in rural and remote First Nation and Inuit communities, and to conceptualize the pathways by which environmental dispossession affects these health determinants. We draw from narrative analysis of interviews with 26 Community Health Representatives (CHRs) from First Nation and Inuit communities across Canada. CHRs identified six health determinants: balance, life control, education, material resources, social resources, and environmental/cultural connections. CHRs articulated the role of the physical environment for health as inseparable from that of their cultures. Environmental dispossession was defined as a process with negative consequences for health, particularly in the social environment. Health research should focus on understanding linkages between environmental dispossession, cultural identity, and the social determinants of health.

Narratives of social support and health in Aboriginal communities.

Societies that foster high-quality social relationships and social support seemingly produce healthier populations. Existing research identifies social support as a significant dimension and determinant of Canadian Aboriginal health, yet patterns of morbidity and mortality overwhelmingly reflect social causes (e.g., violence, suicide), thereby suggesting that social support may not be widely accessible within this population. This paper seeks to understand how broader societal factors (e.g., colonialism) work to influence access to social support in the everyday social environments of Aboriginal communities. Narrative analysis of interviews with 26 Aboriginal Community Health Representatives (CHRs) from across Canada. Sources of social support are institutional (e.g., those employed to provide support) and intimate (e.g., family). In terms of access to social support, CHRs' stories reflected a narrative detailing the post-colonial context. Key elements of this narrative include the child-parent relationship, group-belonging, trust, socio-economic dependence, and the changing nature of help. Findings suggest that features of the broader societal context (e.g., poverty) have manifested as local social conditions (e.g., providing help has come to be seen as a possible source of income), thereby reducing access to social support. Access to this resource is also affected as institutional and intimate supports tend to overlap in Aboriginal communities, many of which are small in terms of size and population. Research and policy options must recognize the post-colonial influences that affect the everyday realities of Aboriginal communities and study the complex interactions between these influences, and how health determinants--like social support--play out in local places as a result of this legacy.

Narratives of Social Support and Health in Aboriginal Communities

Societies that foster high-quality social relationships and social support seemingly produce healthier populations. Existing research identifies social support as a significant dimension and determinant of Canadian Aboriginal health, yet patterns of morbidity and mortality overwhelmingly reflect social causes (e.g., violence, suicide), thereby suggesting that social support may not be widely accessible within this population. This paper seeks to understand how broader societal factors (e.g., colonialism) work to influence access to social support in the everyday social environments of Aboriginal communities.Narrative analysis of interviews with 26 Aboriginal Community Health Representatives (CHRs) from across Canada.Sources of social support are institutional (e.g., those employed to provide support) and intimate (e.g., family). In terms of access to social support, CHRs' stories reflected a narrative detailing the post-colonial context. Key elements of this narrative include the child-parent relationship, group-belonging, trust, socio-economic dependence, and the changing nature of help. Findings suggest that features of the broader societal context (e.g., poverty) have manifested as local social conditions (e.g., providing help has come to be seen as a possible source of income), thereby reducing access to social support. Access to this resource is also affected as institutional and intimate supports tend to overlap in Aboriginal communities, many of which are small in terms of size and population.Research and policy options must recognize the post-colonial influences that affect the everyday realities of Aboriginal communities and study the complex interactions between these influences, and how health determinants--like social support--play out in local places as a result of this legacy.

Doctor–patient communications in the Aboriginal community: Towards the development of educational programs

Objective Aboriginal people in Canada have poorer health than the rest of the population. Reasons for health disparities are many and include problems in communication between doctor and patient. The objective of this study was to understand doctor–patient communication in Aboriginal communities in order to design educational interventions for medical students based on the needs and experiences of patients. Methods Experiences of good and poor communication were studied by semi-structured interviews or focus groups with 22 Aboriginal community members, 2 community health representatives and 2 Aboriginal trainee physicians. Transcribed data were coded and subjected to thematic analysis. Results Positive and negative experiences of communicating with physicians fell into three broad and interrelated themes: their histories as First Nations citizens; the extent to which the physician was trusted; time in the medical interview. Conclusion Aboriginal peoples’ history affects their communication with physicians; barriers may be overcome when patients feel they have a voice and the time for it to be heard. Practice Implications Physicians can improve communication with Aboriginal patients by learning about their history, building trust and giving time.

Evaluation of a Training Program to Prepare Community Health Representatives to Promote Breast and Cervix Cancer Screening Among Native American Women

Native American women have very poor 5-year breast and cervix cancer survival rates compared to other US population groups. We evaluated a training program that prepares community health representatives (CHRs) to promote prevention and early detection of these diseases. Two questions guided the evaluation: (1) Are CHRs an appropriate focus of training? and (2) Does training empower CHRs and, indirectly, their facilities to educate about breast and cervix cancer, promote screening, and teach breast self-exam skills to American Indian and Alaska Native women? Twenty CHRs (3 Indian Health Service regions, 9 separate employers) responded to a telephone survey consisting of Likert scale and multiple option and short-answer questions. Analysis relied on descriptive statistics and measures of central tendency. By tenure, cultural and community membership, and ability to adapt to audience needs and setting demands, CHRs make appropriate training recipients. Training improves skills and their use and appears to increase employers' reliance on CHRs for screening promotion and education about cancer. Posttraining, more women hear and heed the screening message. CHRs are an appropriate focus of training. Training leads to increased screening-related activities and should be continued and expanded.

Healthy living in Nunavut: an on-line nutrition course for inuit communities in the Canadian arctic

Objectives. It is recognized that empowerment of Indigenous Peoples through training and education is a priority. The objective was to design a course that would provide an innovative training approach to targeted workers in remote communities and enhance learning related to the Nunavut Food Guide, traditional food and nutrition, and diabetes prevention.Study Design. A steering committee was established at the outset of the project with representation from McGill University and the Government of Nunavut (including nutritionists, community nurses and community health representatives (CHRs), as well as with members of the target audience. Course content and implementation, as well as recruitment of the target audience, were carried out with guidance from the steering committee.Methods. An 8-week long course was developed for delivery in January - March, 2004. Learning activities included presentation of the course content through stories, online self-assessment quizzes, time-independent online discussions and telephone-based discussions. Invitations were extended to all prenatal nutrition program workers, CHRs, CHR students, home-care workers, Aboriginal Diabetes Initiative workers and public health nurses in Nunavut.Results. Ninety-six health-care workers registered for Healthy Living in Nunavut, with 44 actively participating, 23 with less active participation and 29 who did not participate.Conclusions. Despite having to overcome numerous technological, linguistic and cultural barriers, approximately 40% of registrants actively participated in the online nutrition course. The internet may be a useful medium for delivery of information to target audiences in the North. (Int J Circumpolar Health 2004; 63(3):243–250)

Barriers to managing mental health in Western Australia.

To explore the views of community-care and mental health workers on barriers to the management of mental health problems in rural Western Australia, and how these could be addressed. Qualitative content analysis of semi-structured interviews. Community and mental health services in Esperance. One hundred per cent of relevant mental health workers, 86% of community health professionals and representatives from a wide range of community organisations were interviewed (n = 38). The views of community-care and mental health workers on barriers to the management of mental health, and how these could be addressed. Barriers included confusion about the role of mental health services, limited after-hours access and help for those in situational crisis, communication problems between services, differences in working practices and difficulties in dealing with the stigma of mental illness in rural communities. Suggested solutions were an expansion of counselling services and multi-agency shared care with clinical streams for adults, those aged > 65 and children. This study revealed a number of barriers that are being addressed through a memorandum of understanding between services. Initiatives to foster collaboration between rural mental health services and general practitioners have not included other providers of primary care. We wished to explore the views of community-care and mental health workers on barriers to the management of mental health problems in rural Western Australia and how these could be addressed. We identified a number of barriers to collaboration between mental health and community-based services, including poor communication, difficulties with referral and cultural differences between services. Of all these themes, the most significant was the lack of communication at individual, case management and organisational levels.

The “In-Between People”: Participation of Community Health Representatives in Diabetes Prevention and Care in American Indian and Alaska Native Communities

Respected members of American Indian and Alaska Native communities are a critical resource in helping communities mobilize efforts in diabetes prevention and care. Possessing cultural and historical knowledge and training in health promotion and social support, community health representatives (CHRs) are uniquely equipped to broker the needed relationship between a world shaped by culture and history and the world of conventional scientific knowledge. Grounded in principles of social support and interpersonal communication, as well as an understanding of their community’s strengths and history in health protection, CHRs are bridges distinctively positioned to connect these two worlds. With additional training and mentoring in diabetes care and prevention, CHRs, in their self-described roles as “in-between people,” can serve both as caring and knowledgeable community members and valuable members of the health care team.

The “In-Between People”: Participation of Community Health Representatives in Diabetes Prevention and Care in American Indian and Alaska Native Communities

The “In-Between People”: Participation of Community Health Representatives in Diabetes Prevention and Care in American Indian and Alaska Native Communities

Indian Summer.

This story is about my experience with the Oglala Lakota (Sioux) on the Pine Ridge Indian Reservation in South Dakota. For 6 weeks, as part of my last elective in the Community Health Intercultural Nursing Program at the University of Maryland, I made home visits with a Community Health Representative (CHR). Dianne Iron Bird, the CHR with whom I traveled, and a woman who was close to my age and stage of life, was largely responsible for my view of the reservation and for the level of acceptance I had in people's homes. My experience was rich and rewarding. It afforded me the opportunity to participate in a different kind of health care. I used this exercise in story‐telling to test my knowledge and understanding of the Lakota's world view. By definition, it is my view of both my world and theirs. Using literal rather than abstract language helped me to see both worlds from a new perspective.

Prevalence of Smoking Among Adult American-Indian Clinic Users in Northern California

Background. The American Indian Cancer Control Project is a B-year program funded by the National Cancer Institute designed to promote smoking cessation among adult Indians living in Northern California. This article describes the result of our smoking prevalence survey. Our Indian-specific program combines the physician′s anti-smoking message with the efforts of Indian Community Health Representatives, who have access to the Indian patients′ families and communities. The study sites consist of 4 urban and 14 rural American Indian clinics in Northern California, This article reports on the results of the smoking prevalence study conducted in the first phase of the project, Methods. A total of 1,369 adult Northern California Indian patients at 18 Indian health clinics completed a questionnaire designed to assess smoking rates and patterns as well as health problems. Participants were adult American Indians attending 1 of 18 Indian health care clinics in Northern California during 1991, The participants included patients waiting for appointments with the clinic physician, dentist, and nurses. Results. Forty percent (37.35, 42.64; 95% confidence interval) of the adult population in the sample smoke cigarettes; they hold lenient attitudes toward smoking and began smoking at an early age, These patients rate obesity as the No, 1 health problem, followed by high blood pressure, arthritis/rheumatism, and problems with alcohol. The survey also found that the highest smoking rate was among the Sioux (62%), a non-California tribe. This was followed by high rates among native California tribes: Maidu (46%), Pit River (39%), Pome (38%), Hupa (37%), and Yurok (32%).

Food habits and consumption patterns of California Indian homemakers living in rural areas

This study examined the food habits and consumption patterns of American Indian homemakers living at 4 geographically diverse sites in California: Trinidad (coastal woodlands), Banning (desert), Bishop (high plains), and Tule River (mountainous interior). Participants, who had at least one child between the ages of 2 and 8 years of age, were recruited by local health clinics serving the Native population. Trained Community Health Representatives obtained demographic information, administered a food habits questionnaire, and recorded a 24-hour food recall for each participant. Demographic information included homemaker's age and educational level, family size and income, monthly food expenditures, and participation in federal food assistance programs. Food habits topics included food aquisition and preparation practices, meal and snack patterns, child feeding practices, traditional foods, knowledge and perception of health status, and perceived nutrition education needs and interests. A total of 204 American Indian women participated in the study. Computer nutrient analysis of the 24-hour food recalls revealed a diet high in fat (mean 35.4% calories from fat) but relatively nutrient dense. A number of healthy food practices, such as breast feeding and late introduction of solids, were prevalent in this population.

Panic Disorder Among American Indians: A Descriptive Study

Little is known about panic disorder among American Indians. In a pilot project involving two Northwest Coast Indian villages, community health representatives screened the population for panic disorder, substance abuse, and major depression using DSM-III criteria. Accompanying the screening were subsequent patient education and further evaluation by a psychiatrist, a social worker, and primary care physicians. Of fifty community residents who agreed to take the screening examination, seven were found who met diagnostic criteria for panic disorder. Four of the seven had symptoms of alcohol abuse which complicated the course and diagnosis of panic disorder, and individuals with panic disorder reported more than twice the lifetime prevalence of depression in comparison with other community members. Limitations of the study and refinements of study design are needed in future study discussions.

Community Health Representatives: A Valuable Resource for Providing Coronary Heart Disease Health Education Activities for Native Americans

(1989). Community Health Representatives: A Valuable Resource for Providing Coronary Heart Disease Health Education Activities for Native Americans. Health Education: Vol. 20, No. 6, pp. 16-31.