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Open Access Publications from the University of California

Scholarly Works (5 results)

  • Thesis
  • Peer Reviewed
UC Berkeley Electronic Theses and Dissertations (2020)

Community health workers (CHWs) are trusted members of the community who have an intimate understanding of the populations and communities they serve. They deliver culturally informed interventions to their communities and leverage their shared experiences and linguistic and cultural relationships to bridge their community to health care and social services. Historically successful in developing countries, CHWs promote chronic disease management, improve health outcomes, and reduce health care costs.

Despite the evidence, CHWs are not widely utilized within the health care system. The National Academy of Medicine declares barriers to working with CHWs, such as inconsistent scope of practice, variable training and qualifications, and lack of professional recognition by other health care providers. States are investigating ways to standardize the CHW workforce, such as certification, to set workforce entry standards and integrate CHWs into health care systems.

Currently, the CHW workforce faces a crossroads. One path leads to a standardized CHW workforce integrated into health care systems via formalized training and qualifications. The other path holds CHWs as part of the communities where they live and work, valuing their relationships and embodied knowledge. While both paths are options for the CHW workforce, CHWs and CHW stakeholders must determine if or how these two paths can coexist. California is the perfect case study because there is continued debate across CHW stakeholders about the stakes of certifying CHWs. California’s diverse CHW workforce represents varying CHW types with contrasting ideologies of care, such as clinical and community-based CHWs and promotores de salud, a subset of CHWs who primarily serve Latinx communities and are grounded in a social, rather than medical, model of care. California’s size and social characteristics pose implementation factors that are relevant for the diverse issues other states will have to address for their own CHW workforce.

This dissertation identifies the unique contributions offered by CHWs to fill health system gaps and challenges differently than other health care providers. The research then describes feelings of opportunity and exclusion related to CHW certification in California. Finally, this dissertation presents strategic options for California stakeholders to develop an appropriate CHW certification model.

    Cover page: It's important for us to get recognized and be somebody: Community health worker attributes, attitudes towards certification, and certification options in California
    • Article
    • Peer Reviewed
    UC Berkeley Previously Published Works (2020)
    Swachh Bharat Abhiyan, India's flagship sanitation intervention, set out to end open defecation by October 2019. While the program improved toilet coverage nationally, large regional disparities in construction and use remain. Our study used ethnographic methods to explore perspectives on open defecation and latrine use, and the socio-economic and political reasons for these perspectives, in rural Bihar. We draw on insights from social epidemiology and political ecology to explore the structural determinants of latrine ownership and use. Though researchers have often pointed to rural residents' preference for open defecation, we found that people were aware of its many risks. We also found that (i) while sanitation research and "behavior change" campaigns often conflate the reluctance to adopt latrines with a preference for open defecation, this is an erroneous conflation; (ii) a subsidy can help (some) households to construct latrines but the amount of the subsidy and the manner of its disbursement are key to its usefulness; and (iii) widespread resentment towards what many rural residents view as a development bias against rural areas reinforces distrust towards the government overall and its Swachh Bharat Abhiyan-funded latrines in particular. These social-structural explanations for the slow uptake of sanitation in rural Bihar (and potentially elsewhere) deserve more attention in sanitation research and promotion efforts.
      Cover page: Understanding Open Defecation in the Age of Swachh Bharat Abhiyan: Agency, Accountability, and Anger in Rural Bihar.
      • Article
      • Peer Reviewed
      UC Berkeley Previously Published Works (2019)
      Scholarship on idioms of distress has emphasized cross-cultural variation, but devoted less attention to intra-cultural variation-specifically, how the legitimacy of distress may vary according to the context in which it is expressed, social position, and interaction with medical categories of distress. This variation can pose challenges for interventionists seeking to establish culturally acceptable ways of identifying distress and creating relevant resources for recovery. We describe efforts over three years (2014-2016) to identify and adapt a culturally appropriate evidence-based intervention for depressed rural Appalachian women. Though the prevalence of depression among rural women is high, limited services and social barriers restrict treatment access. Formative research revealed varied understandings of distress. Depression was (a) medicalized as a treatable condition, (b) stigmatized as mental illness, (c) accepted as a non-pathological reaction to regional poverty and gendered caregiving responsibilities, (d) rejected as a worthy justification for seeking individual care, and (e) less represented in comparison to other competing forms of distress (i.e., multiple morbidities, family members' distress). In a small pilot trial, we applied an implementation science perspective to identify and implement appropriate evidence-based programming for the context. We outline how we reached Appalachian women despite these diverse understandings of depression and established a flexible medicalization of depression that enabled us to legitimize care-seeking, work with varied rural healthcare professionals, and engender culturally relevant support. Our adaptation and implementation of the concept of "mental health recovery" enabled the development of programming that furthered non-pathological communicative distress while resisting the normalization that silences women in the context of deep health disparities.
        Cover page: Building interventions when distress is under debate: a case study from Appalachia
        • Article
        • Peer Reviewed
        UC Berkeley Previously Published Works (2016)
        Social networks influence health behavior and health status. Within social networks, "key players" often influence those around them, particularly in traditionally underserved areas like the Appalachian region in the USA. From a total sample of 787 Appalachian residents, we identified and interviewed 10 key players in complex networks, asking them what comprises a key player, their role in their network and community, and ideas to overcome and increase colorectal cancer (CRC) screening. Key players emphasized their communication skills, resourcefulness, and special occupational and educational status in the community. Barriers to CRC screening included negative perceptions of the colonoscopy screening procedure, discomfort with the medical system, and misinformed perspectives on screening. Ideas to improve screening focused on increasing awareness of women's susceptibility to CRC, providing information on different screening tests, improving access, and the key role of health-care providers and key players themselves. We provide recommendations to leverage these vital community resources.
          Cover page: Colorectal cancer prevention: Perspectives of key players from social networks in a low-income rural US region
          • Article
          • Peer Reviewed
          UC Berkeley Previously Published Works (2023)
          Cash transfers are increasingly used to motivate adherence to HIV care. However, evidence on cash transfers and intimate partner violence (IPV) is mixed and little is known about their safety for women living with HIV. We conducted in-depth interviews with women living with HIV who participated in a randomized trial providing 6 months of cash transfers (~$4.5 or $11 USD) conditional on HIV clinic attendance in Shinyanga, Tanzania to assess how receiving cash affects IPV and relationship dynamics. Eligible participants were 18-49 years, received cash transfers, and in a partnership at baseline. Data were analyzed in Dedoose using a combined inductive-deductive coding approach. 25 interviews were conducted between November 2019-February 2020. Women's employment was found to be a source of household tension and violence. None of the participants reported physical or sexual IPV in relation to cash transfers, however, some women experienced controlling behaviors or emotional violence including accusations and withholding of money, particularly those who were unemployed. Cash transfers were predominantly used for small household expenses and were not viewed as being substantial enough to shift the financial dynamic or balance of power within relationships. Our findings suggest that small, short-term cash transfers do not increase physical or sexual IPV for women living with HIV however can exacerbate controlling behaviors or emotional violence. Modest incentives used as a behavioral nudge to improve health outcomes may affect women differently than employment or larger cash transfers. Nonetheless, consultations with beneficiaries should be prioritized to protect women from potential IPV risks.
            Cover page: Risks of Intimate Partner Violence for Women Living with HIV Receiving Cash Transfers: A Qualitative Study in Shinyanga, TanzaniaCreative Commons 'BY' version 4.0 license
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