Hearing the ‘photovoice’ of Baltimore’s community health workers

The term may not be as common as “doctor” or “nurse,” but community health workers play a significant role in the public’s health. Chidinma Ibe, PhD is an assistant professor in the Johns Hopkins School of Medicine and the Associate Director of Community Engagement for Johns Hopkins Center for Health Equity (CHE). Dr. Ibe was the lead investigator on the study Voices, Images, And Experiences Of Community Health Workers: Advancing Antiracist Policy And Practice published in the October 2023 issue of the journal Health Affairs. Along with senior author Lisa A. Cooper, MD, MPH, additional authors included Dr. Anika Hines, Nico Dominguez Carrero, Shannon Fuller, Alison Trainor, Tiffany Scott, and Rev. Debra Hickman. Dr. Ibe’s study was supported by the National Heart, Lung, and Blood Institute, National Institutes of Health, and by CHE.

Using photographs and extended interviews, Dr. Ibe and her colleagues examined the experiences and perspectives of 16 Baltimore community health workers (CHW), frontline public health workers who are trusted members of, and have a deep understanding of, the communities they serve. To gain some behind-the-scenes insight into the photovoice research method used, as well as to learn about why a better understanding of the experiences of community health workers is important, we invited Dr. Ibe for a Q & A session. The discussion was edited for clarity.

Can you tell me what a community health worker is and what they do?

Ibe: Community health workers (CHWs) are frontline public health workers, and they tend to come from the communities they are working in or trying to support. They have a deep understanding of that community, or a close relationship with members of those communities. They serve as a bridge between members of historically marginalized, structurally disadvantaged communities, who withstand the worst of health inequities in this country and the healthcare system or social services or resources in their communities.

Are they paid people or volunteers?

Ibe: Well, it depends. They tend to be paid in healthcare settings and are often paid when they work for community-based organizations or non-profits. However, there are many instances where CHWs are unpaid, and they do this on a volunteer basis.

Can you elaborate on the scope of work for community health workers?

Ibe: Let us say a family comes into a local clinic and they have kids with health conditions that require additional support. While other members of the team might focus on health-related issues, a community health worker can help screen for different social risk factors. They can find out things like, does this family have housing? Do you have transportation? What's food looking like for you? What neighborhood do you live in? Are you able to live in a way that enhances your quality of life? If not, why is that?

They can also get a sense of the family environment, which social workers can do very well, too. Where a community health worker is different is that community health workers are coming from the same neighborhoods and communities of their patients or clients. Patients or clients view them as someone who feels familiar. Have you ever met someone and discovered they were from your hometown? There is just a different bond with them that you do not have with others. You feel like they can have an implicit sense of where you are coming from, because you live on XY Street, and they live right around the corner. In the case of a community health worker, patients tend to view them and think, “They know me, they get where I’m coming from.” That sense of knowing and familiarity, combined with community health workers’ interpersonal skills, helps patients feel affirmed that the community health worker knows what they need and understands the landscape of resources and services in their communities.

It sounds like patients are more likely to tell a community health worker something they might not share with a social worker or physician.

Ibe: Exactly, and then the community health worker can advocate for that patient. A physician might see a patient and think they are not taking their medication. The community health worker could then find out that the medication needed to be refrigerated, and that the patient does not have power in their house because their utilities were shut off. The community health worker could link them up to specific services to help them address that issue, for example, linking them up with churches or organizations who sometimes give out that form of aid.

Here is another example: during the RICH LIFE study, we listened to the audio-recorded encounters between CHWs, and patients enrolled in the trial. One of the recordings that stands out was when a CHW learned that a patient was struggling with food insecurity. The CHW immediately said, "Oh, I've helped clients get food from this church. Go to this church on this day and bring your ID and an extra bag. Make sure you go at this time so that you are more likely to get fresh food.”

This is an extremely fast mental calculation that I think is undervalued. The CHW remembers where those resources are, thinks about the optimal time to access those resources, and then shares that with the client in less than 30 seconds. Those skills need to be valued.

What did you ask the community health workers to do for this study?

Ibe: We asked them to take pictures of the neighborhoods where they lived or had lived in the past, or in the neighborhoods where they worked most often. We wanted them to highlight the different social determinants of health in those neighborhoods.

Can you explain to me what a social determinant of health is?

Ibe: The World Health Organization defines a social determinant of health as the social factors that affect how people live, work, worship, and play. Some people face adverse social determinants of health or negative social determinants of health. For those social determinants experienced negatively at the individual level, those become health-related social risk factors. That is what we asked the community health workers to focus on: What are some of the social risk factors you face that you have either faced yourself or that you help others address when you are doing your work?

Tell me about the photovoice research method.

Ibe: Photovoice allows people to tell the story of how they see the world through photographs that serve as the basis for facilitated group discussions. It is a participatory research method, meaning those conducting the study work closely with the people participating in it, in a way that values the expertise of the study participants. We wanted to get a sense of how community health workers view the world, what their past and current individual experiences have been and how they inform their professional experiences.

We had 16 CHWs in our study, who were divided into four cohorts. We would meet once a week for five weeks over Zoom. The first session was an orientation to the study. They were taught how to use the camera and how to use images to tell a story. The sessions after that were discussion-based. We would go through the questions in the SHOWED framework. When they discussed their pictures, they always began by describing the image itself – where they took it and why they selected it. This would lead to a broader discussion of the underlying, beneath-the-surface issues that compelled them to take the picture in the first place. For example, this is a picture of a place that used to be a grocery store, and it is now shut down. This is an example of the city putting in a library and saying, “we think you need this,” and the residents saying, “no, we do not need a library or a clothing store. We need food or these other resources.”

One of the exciting things that happened was that naturally, over time, each CHW would produce the story in their head of what they were seeing. They would take pictures that were centered on that theme. Then, what we did on the research side was to listen and facilitate these discussions to draw information and perspectives from the community health workers who participated. We also recorded and transcribed each session. We used qualitative analysis methods to determine the significant themes to help us conclude what the community health workers said during their sessions.

What were some of the most significant things the CHWs mention?

Ibe: One of the major social determinants of health they addressed was the impact of structural racism. They mentioned how racism affected their work from the standpoint of the neighborhoods and the resources within neighborhoods that have been Black and Brown. These neighborhoods have experienced disinvestment. There were several policies and practices implemented in the city that strengthened some neighborhoods at the expense of other neighborhoods, in terms of access to healthy food, green space, commerce, the quality of housing, and the quality of schools in those neighborhoods, to name a few factors. The neighborhoods that have been systematically weakened, historically, have been Black, Brown, and low-income.

Can you give me an example of an image that showed racism?

Ibe: We had a cohort made up primarily of Latine community health workers, or those of Hispanic or Latin American descent. One of the participants took a picture of a flag that read, “close the border.” As Latine community health workers, they saw that and knew that whoever it was or whatever neighborhood they were in, they were likely to encounter those kinds of sentiments.

The Photovoice method really allowed us to get to understand and appreciate where the community health workers were coming from. ~ Chidinma Ibe

What did you think of the photo voice method? It seems interesting.

Ibe: I love everything about it. I loved the pictures the community health workers took; they were so meaningful. I loved the conversations that we had. This method really allowed us to get to understand and appreciate where the community health workers were coming from. There was one session where a couple of the CHWs got choked up because they were talking about the difference between what the neighborhoods looked like when they were younger versus how they look now. I will never forget how one participant answered the question, “what are you seeing here?” And their response was, “the degradation of the neighborhood.” Photovoice reminds me of the appeal of oral history, which is essential in African culture. You pass on stories, insights, and lessons learned by talking. If a parent wants to teach their child a lesson, they will not say what to do immediately. They will tell you through a story. My parents are Nigerian and that is how I grew up; this applies across the African diaspora.

Also, I just loved the community health workers in this study. They were so amazing. I appreciated their commitment to the project. We would tell them, "This session is going to be 90 minutes long." And then at the 90-minute mark, we would have to ask for more time because we did not get through each participant’s pictures or touch on all the points they wanted to make. Some of them still reach out to me to say hi or check in and show their love for the people they work for and with. It is very inspiring. The least I can do is serve as a vessel for their experiences.

Based on this study, what would you want people to know about community health workers?

Ibe: What I want is for them to know, first, who community health workers are because many times, people are not aware of the role that they play and their importance in helping people address their health conditions. The other thing I want them to know is that community health workers support people who are from marginalized communities, but because many of them are from the same marginalized, structurally disadvantaged communities, they are wrestling with the same issues that they have helped others address. This makes the workforce much more vulnerable than other types of public health workers or frontline healthcare workers. They are unique precisely because they are from communities that have had a more challenging time accessing resources, healthcare, and otherwise.

An additional thing that I want people to understand is that being a community health worker is a particularly challenging job. Unfortunately, CHWs are not paid in a manner that is commensurate with the level of difficulty associated with their roles. On top of that, because of who they are and because of the social risks that are prevalent in the communities that they go into, CHWs face several types of occupational hazards that their counterparts in other professions do not experience. They risk their physical safety, but they also may risk their emotional and psychological safety when they work for organizations where they are disenfranchised from their colleagues. This can happen due to beliefs about the importance of CHWs and what they do, or from latent biases that can affect people’s willingness to engage CHWs in team-based care or as frontline public health workers.

Finally, we do not have systems that adequately support CHWs based on who they are and their unique identities. This is problematic because it places CHWs at risk of remaining perpetually overlooked, underpaid, and undervalued.

I would also like for people to really grasp that community health workers are not medical providers. They are not epidemiologists. They are not pseudo-nurses, or certified medical assistants, or mini-social workers. They have their own professional identity that demands respect. I say this because one of the more troubling issues I have seen over the years is this growing tendency to impose an academic medical and/or public health approach on a community-based workforce that is truly rooted in the power of leveraging assets within communities.

Our study helps to shed light on the degree to which CHWs draw from their own lived experiences to help provide appropriate support for their patients and clients. Plus, good CHWs tend to be empathetic, personable, compassionate, forward-thinking, and solution oriented. They deploy these skills in a way that helps people feel comfortable and seen. They do all these wonderful things, yet our paper highlights that we need to reframe the way we think about CHWs as a workforce. This is what led us to recommend that policies and practices related to CHWs should be founded in a deep understanding of who CHWs are on a personal level. We proposed that adopting a CHW-centered approach to creating and establishing policies and practices within organizations, all the way up to the federal government, is a form of advancing health equity and anti-racism.

To continue learning about community health workers, visit the Central Maryland Health Education Center website.