Introduction

As of November 29, 2022, the United States reported 1,075,779 cumulative deaths due to COVID-19 [1], with Black and Latinx communities reporting an outsized burden. This is reflective of the disproportionate impact that COVID-19 had on Black and Latinx communities in terms of exposure risk, case rate, hospitalization rate, mortality rate, economic hardship, and psychosocial consequences [2], [3], [4], [5], [6]. Such disparities are explained by structural racism—namely, residential segregation, neighborhood disinvestment, restrictive immigration policies, gaps in healthcare access, barriers to education and career opportunities, and disenfranchisement [4]. It is important to note, however, that health and social inequities did not arise in the wake of COVID-19, but instead, extant, entrenched, systemic inequities, were exacerbated by the pandemic’s unequal impact. When COVID-19 vaccines were made widely available in the United States, there were notable disparities, by race and ethnicity, in vaccination outcomes due to differences in vaccine access and confidence [7]. At present, Latinx/Hispanic Americans, nationally, boast a vaccination rate higher than non-Hispanic white counterparts, but in California, the vaccination rate remains 11 percentage points lower among Latinx individuals, compared to non-Hispanic white individuals [8].

The outreach and vaccination campaign ¡Andale! ¿Que Esperas? (which translates to, “Come on! What are you waiting for?”), abbreviated as AQE, was created to respond to the stark disparities observed across the state of California. AQE leveraged findings from previous evaluations of Latino Health Access (LHA), a grassroots public health organization in southern California that employs a CHW model anchored in Freire’s popular education framework [9]. Popular education asserts individuals’ capacity to bring about social change by engaging those who have historically lacked power, increasing awareness of their capacity as change agents, and developing critical consciousness—by identifying injustices they have experienced firsthand and reflecting on root causes—to work towards collective, structural change [10, 11]. Evaluations of LHA’s COVID-19 response efforts that used popular education as a conceptual model, have identified the value and pertinence of CHWs in effective and equitable interventions [12, 13]. This informed AQE’s campaign model development into one that would be led and driven by CHWs. AQE was implemented with five partners across the state (Fig. 1), comprising four federally qualified health centers (FQHCs)—AltaMed, Golden Valley Health Center (GVHC), La Clinica de la Raza (LC), and San Ysidro Health (SYH)—and one community-based organization (CBO), LHA. All five partners serve predominantly Latinx populations in medically underserved regions with high social vulnerability indices (SVI) [14] and either (a) had an existing CHW model or (b) had the requisite capacity or infrastructure, made possible through AQE funding, to institute a CHW model.

Fig. 1
figure 1

Centers participating in the AQE Campaign to Deliver COVID-19 Vaccine Outreach superimposed on a map of California shaded according to social vulnerability Index (SVI). Five centers (AltaMed, LHA, GVHC, LC, SYH) representing Alameda, Contra Costa, Los Angeles, Merced, Orange, San Diego, Solano, and Stanislaus counties (all of which have considerable Latinx populations and social vulnerabilities) participated in the AQE campaign. Image adapted from the Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry/Geospatial Research, Analysis, and Services Program. CDC/ATSDR Social Vulnerability Index [2018] Database [California]. Accessed on [7/1/2022]. https://www.atsdr.cdc.gov/placeandhealth/svi/data_documentation_download.html

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CHWs, or promotores de salud, have long played a role in the U.S. health care workforce by (a) improving access to care, (b) facilitating navigation of fragmented systems and linkage to social services, (c) reducing healthcare costs, (d) providing peer-to-peer support and accompaniment [9, 15], (e) imparting access to trusted, reliable information [16],and (f offering culturally and linguistically responsive health education, all of which is key to addressing health inequities [17,18,19].

An emerging tenet of the CHW model that lies central to the AQE campaign is the role of CHWs in activating community for social and policy change [12, 20]. Since the onset of the COVID-19 pandemic, multifaceted CHWs programs have played an essential role on the frontlines, managing contact tracing and testing, addressing barriers to vaccination, combatting mis/disinformation about the vaccine, attending to social and emotional needs, providing critical ground-level information to health and governing systems to strengthen pandemic response, and advocating for state and federal policies related to evictions [19, 21]. For many healthcare systems, CHW programs provide the infrastructure to reach communities that are often systematically excluded and labeled “hard-to-reach,” and the pandemic has illuminated the importance of CHWs to public health writ large, attracting the attention of policymakers and health systems. While improvements are needed to better integrate CHWs into U.S. healthcare and public health systems, the effectiveness of CHWs is threatened by a transition from its community-based roots to a medicalized model [22].

This mixed-methods evaluation aims to elucidate the importance of CHW models in the COVID-19 era and beyond, with an exploration of how systems of care (FQHCs vs non-FQHCs) moderate the effectiveness and sustainability of these models for community strengthening.

Methods

All data collection procedures described herein were approved by the Institutional Review Board (IRB) at Claremont Graduate University (IRB # 4084). This study makes use of a parallel mixed methods evaluation design [23], such that qualitative and quantitative data were collected and analyzed independently to understand the role of CHWs in COVID-19 response, recovery, and rebuilding.

Quantitative Data Capture and Analysis

Developed as a community outreach campaign, AQE was designed to increase vaccination rates in structurally vulnerable, Latinx communities in California by increasing the CHW workforce. AltaMed and subcontracted state coordinating entity, Latino Coalition for a Healthy California (LCHC), provided central administration support to implementation partner organizations (GVHC, LC, LHA, and SYH). All five partner sites were responsible for (1) hiring CHWs to conduct community outreach by either activating their existing CHW program or launching one, (2) facilitating the direct connection to vaccinations, and (3) delivering supportive services to communities in their service area. After hiring, each CHW was asked to complete a survey to capture a demographic profile of AQE-affiliated CHWs. For each outreach initiative, CHWs completed surveys via REDCap (Research Electronic Data Capture) hosted at the Ohio State University [24], documenting (a) number of people reached, (b) number of individuals vaccinated, (c) number of vaccine appointments scheduled, and (d) number of supportive services provided. All data entries were made with each CHW’s unique ID, enabling analysis of vaccination and outreach outcomes at the individual CHW-level. Two linear regression models were developed, using R Statistical Software (R Foundation for Statistical Computing, version 1.2.5033), to assess predictors (ethnicity, language spoken, previous outreach experience, education level, sex, employment status, age, sexual orientation, and residence) of (a) vaccination volume and (b) number of people reached. Prior to developing regression models, correlation matrices were constructed to identify collinearity and simplify model inputs (predictors).

Throughout the AQE campaign, data entered into REDCap fed into a dashboard system, which was updated weekly and accessible to CHWs, FQHC and CBO administrators. Access to this dashboard provided a high-level overview of campaign activities to inform outreach strategies and enable data-driven decision making for AQE programming.

Qualitative Data Collection

Focus groups were conducted with (1) community members and (2) CHWs and CHW-based organizations, at all five participating sites. Program managers and administrators at the five partner sites recruited CHWs and community members, using email and flyers, to participate in focus groups. Community members and CHWs were kept separate, such that all participants in the focus group came from one of the two groups. In total, ten (10) focus groups were conducted, with the size of each group ranging from 7 to 14 participants, netting a total sample of 95 individuals, of whom 43 were CHWs, 45 were community members, and 7 were employed by implementation partner sites but do not serve as CHWs. Audio, but not video, was recorded for purposes of transcription, and all participants provided informed consent (IRB # 4084). Focus groups met for 90 min to discuss the following topics: (a) AQE campaign and lessons learned, (b) COVID-19 vaccine access in the community, (c) best practices for reaching the community, (d) successes and looming challenges of the campaign, (e) needs of the community, and (f) role of CHWs. Focus groups, when needed, were conducted in Spanish, with a translator present to ask questions and transcribe responses. All participants were compensated for their time with $25 Amazon gift cards.

Focus group transcripts underwent thematic analysis [25], with transcripts coded line-by-line with three a priori codes: (1) importance of CHW model (i.e., what do CHWs do?), (2) need for CHWs (i.e., how do CHWs engage the community?), and (3) perils of CHW model (i.e., what challenges do CHWs face?), to identify emergent themes and subthemes [25]. Illustrative quotes were extracted for each theme and subtheme, when applicable, and findings were reviewed for consensus by other team members involved in focus group implementation. Importantly, this approach is grounded in the principle of co-development [26], with members of community-based clinics and academic partners engaged in the design, implementation, and evaluation, including the validation of themes and subthemes.

Results

Outreach and Vaccination Outcomes led by CHWs

Sociodemographic characteristics of CHWs hired by AQE partners (N = 146) between June 2021 and May 2022 are presented in Table 1. CHWs conducted 6297 outreach initiatives, facilitated 130,414 vaccinations and 28,660 vaccine appointments, and delivered 313,796 supportive services.

Table 1 Sociodemographic Profile of CHWs
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A number of implementation challenges with data collection were encountered, creating a need for retrospective data entry. Because retrospective data entry was typically performed by a non-CHW employee of the FQHC or CBO, errors were made, such that some outreach activities and vaccinations could not be linked to a particular CHW. Therefore, the resulting dataset is limited to the activities of 106 CHWs (72.6% of all CHWs hired for AQE), who performed 2439 outreach initiatives that (a) reached 716,343 people and (b) facilitated 20,156 vaccinations. No sociodemographic characteristics of CHWs were significant predictors of vaccination volume (0.138 ≤ P ≤ 0.889) nor number of people reached (0.062 ≤ P ≤ 0.985), with the exception of employment status. Employment status (working as a CHW part-time as opposed to full-time, where part-time was defined as < 40 h/week) was a significant predictor (P = 0.0047) of number of people reached (coefficient [95% CI]: 9256.0 [3031.2–16,020.9]), but not vaccination volume (coefficient [95% CI]: − 39.2 [− 118.8–40.5], P = 0.330). Complete results from linear regression models are summarized in Table 2.

Table 2 Predictors of CHW outcomes (vaccination volume and number of people reached)
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Importance of CHWs

In describing the role of CHWs throughout the AQE campaign, four themes emerged (Table 3); CHWs were key actors in (1) instilling confidence, (2) attending to mental health needs, (3) overcoming barriers to vaccination, and (4) ensuring that the community is represented in COVID-19 response and recovery efforts. The AQE messaging was viewed favorably by CHWs and community members alike, but one community member criticized the framing due to the entrenched structural barriers present in the community, noting, “It was always ¡Andale! ¡Andale! What are you waiting for? But the community encountered so many obstacles and myths.” CHWs were vital assets that allowed community members to respond to the urgent call of the AQE campaign by instilling confidence in the vaccine and addressing barriers to vaccine access, in tandem. Vaccine confidence was accomplished by (a) addressing mis/disinformation, especially “myths about the vaccine online on social media,” and (b) consolidating and distilling information in the face of information saturation, making information accessible in English and Spanish, especially to those with limited access.

Table 3 Thematic analysis to elucidate the importance of, need for, and perils of the CHW model (N = 95)
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Beyond education, CHWs helped community members overcome barriers to COVID-19 vaccination and recovery by (a) meeting people where they are, (b) confronting structural vulnerabilities and addressing more than just the virus, and (c) building technological competencies to bridge the digital divide. “Meeting people where they are” undergirded CHWs’ outreach strategy; as one CHW aptly noted, “we didn’t wait for them to come to the clinic.” CHWs were “offering services and vaccines in high traffic spaces…places where people were already going,” including flea markets, schools, churches, stores, community buildings, parks, homes, homeless encampments, and supermarkets. Having a presence at flea markets was especially important in reaching undocumented and low-income communities. For other “hard-to-reach” groups, such as farmworkers, CHWs went to them directly, with one promotora recounting,

[Initially] not many of them were willing. But [CHWs] gave them a class. They wanted it then and there. And we [the CHWs] had to make the second trip with vaccines. They [the farmworkers] convinced each other to get vaccinated.

Timing of outreach initiatives and vaccination clinics was equally important to CHWs’ strategy in meeting people where they were, so events were facilitated “at the crack of dawn” and over the weekends to accommodate work schedules.

Effectively overcoming barriers to COVID-19 vaccination meant addressing more than just the virus, acknowledging and confronting structural barriers. CHWs assisted community members in addressing a number of social needs, including food insecurity, rental and financial assistance, and transportation. CHWs offered “help that wouldn’t even be given to us [community members] at a hospital,” with one community member sharing,

I told her [CHW] I need food and diapers. We [the family] were so sick. And that day they [the CHWs] arrived with diapers and food. She [CHW] called to ask for more information and what my other needs were. I told her [CHW] we needed help with rent. She [CHW] said they’d look into it. They [CHWs] even helped me pay my rent. They [CHWs] keep checking in on me, help[ing] with gas cards and bus passes. They [CHWs] hype us up–they lift our self esteem. They [CHWs] check in on us and motivate us.

This approach of addressing more than just the virus and responding to community members’ social needs as a way of increasing vaccination rates was expanded upon by one CHW, who shared,

From day one, we [CHWs] started working. Contact tracing, support groups, outreach, and we could do all of this work because we could talk to them about other things, too. We would connect them to other resources: emergency food, other resources like rent, and then the vaccine can come to the forefront.

CHWs sought to address many structural vulnerabilities, with technology being a prominent barrier. CHWs worked to bridge the digital divide by building technological competencies, teaching community members how to register for appointments online and how to utilize Zoom and Facebook Live.

Discussions of structural vulnerabilities exacerbated by the pandemic, along with the disparate impacts of COVID-19, were central to conversations among CHWs and community members. The mental health impacts of the pandemic were brought up in all focus groups, with community members sharing how CHWs provided much needed peer support to address anxiety and depression. Strikingly, suicide was explicitly named and discussed in eight out of ten focus groups. The nature of these discussions varied, but consistently, CHWs were called upon to assist community members who (a) had lost a child to suicide, (b) had endured a suicide attempt in the family, or (c) had experienced suicidal ideation themselves, underscoring the role of CHWs in attending to the mental health needs of the community.

From overcoming barriers and attending to community mental health needs to instilling collective confidence, CHWs described the importance of their role in ensuring the community is represented and included in COVID-19 response and recovery efforts. As one CHW framed it, “Without the promotora [CHW], who do you think would have done this job?” This sentiment was echoed by a number of CHWs, who noted their role as messengers in the community and asked, “If I wasn’t here, who would give the information?” These illustrative quotes serve to emphasize the unique position of CHWs as community advocates in public health response.

Need for CHWs

After identifying the essential roles and responsibilities of CHWs, two themes emerged in understanding what qualities of CHWs contribute to their effectiveness in engaging the community: (1) shared lived experience and (2) trusted presence. Shared lived experience recognizes that, as one CHW put it, “[as] a part of community (sic), I know what it’s like to live here.” This local expertise of the community’s needs—and where those folks work and reside—informs CHWs’ outreach and vaccination strategies.

Equally important is the trusted presence of CHWs, which can be attributed to their (a) recognition in the community and (b) accessibility to community members. Regarding recognition in the community, CHWs’ recognizable and consistent uniforms helped community members recognize them as messengers, or ambassadors, for the vaccine. One CHW, whose implementation site rolled out blue shirts for CHWs, shared that some community members referred to them as “the angels in blue because of all of the information [they] had.” CHWs play a crucial role in modeling and setting the example for the community, such that community members “can see us [CHWs] doing the things we preach.” This contributes to the CHWs’ ability to instill confidence in the vaccine, with one CHW sharing that community members “would feel safer if I told them I was already vaccinated—and would then ask where they could go to get vaccinated.” Conversations with community members depend upon the accessibility of CHWs, who often receive phone calls from community members directly.

Perils of CHW Model

Focus group participants were asked about the challenges CHWs face in the context of the current CHW model, during which three themes emerged: (1) funding instability, (2) inadequate resources to address entrenched problems, and (3) need for mental health training. Funding constraints were the foremost concern among CHWs, noting that grants are the current funding mechanism by which CHW programs operate, causing discontinuities for both (a) CHWs themselves, who face hour reductions, and (b) communities, who are still in need of services and programming after the grant period has ended. The lack of stable funding disrupts community members’ access to services, but also has the potential to erode community trust, as one CHW pointed out: “As promotoras, they cut us back, but community (sic) doesn’t know why we’re not there anymore.” Community members similarly acknowledged the pitfalls of the current funding structure, stating, “The promotoras are paid 5 days, but she works 7 [days], advocating for things. They [CHWs] understand the world needs action.”

In addition to the funding instability, focus group participants voiced concerns about having inadequate resources to address entrenched problems. CHWs recounted the horrors endured by several community members facing so many interlocking forms of oppression and wondering, “how else can I help?” This sentiment was echoed by a community member who works in agriculture, explaining how undocumented individuals did not have the same working conditions or tools for infection control or prevention, simply because of their immigration status. CHWs recognized their heightened exposure to grief and stressors, working with community members who (a) experienced the deportation of their children, (b) had terminal illnesses, and (c) faced evictions. One CHW asked, “How can these things be happening? We didn’t know what to do at the height of the pandemic.” Looking to the future, they drew attention to the need for mental health training, affording them the opportunity to prepare mentally and have training to adequately respond to the needs of their community.

Discussion

CHWs have long been recognized as critical assets and trusted partners in health promotion, bridging the gap between health and social services [27]. Globally, CHWs often contribute to disaster relief, vaccinations, nutrition, and maternal and child health [27]. In the wake of the COVID-19 pandemic in the U.S., CHWs were on the frontlines, attending to communities facing grave inequities by leading contact tracing efforts and addressing emergent social needs [19, 28]. The role of CHWs in pandemic preparedness and public health system strengthening—evidenced by CHWs’ ongoing role in long-term recovery beyond the pandemic—has brought newfound attention to the CHW workforce, namely the functions, sustainability, and financing of CHW models [29,30,31]. This mixed-methods evaluation adds to this discussion by elucidating the importance, needs, and perils of CHW models in the COVID-19 era and beyond. Summary of salient findings are as follows: (1 146 CHWs facilitated 159,074 vaccinations and vaccine appointments in Latinx communities across California with low vaccination rates by (a distilling information and addressing mis/disinformation to instill confidence, (b addressing more than just the virus, especially mental health challenges, (c meeting people where they are to overcome barriers in vaccine access, (2 building trust with the community through CHW engagement that (a centered shared lived experience and (b increased community recognition and ongoing accessibility to supportive services, providing a pulse on community needs; and (3 funding instability presents the most pressing challenge in sustaining the advances made by CHWs.

Null findings from the regression model indicate that the successes achieved by CHWs, whether number of people reached or vaccinated, cannot be reduced to or predicted by mere demographic characteristics. While employment status was a significant predictor of the number of people reached by CHWs, with part-time CHWs reaching a higher number of people, this is likely the result of part-time CHWs’ use of social media for outreach, affording greater flexibility with regard to time commitment. While social media outreach reaches larger audiences, this does not necessarily translate to higher vaccination volume, which could explain why part-time status was a significant predictor of number of people reached but not vaccination volume.

The effectiveness of CHWs lies in their connection to the community, as community members themselves, to understand the unique and unmet needs, which allows them to better facilitate services that are culturally and linguistically responsive. CHWs’ shared lived experience informed strategies utilized by the AQE campaign to meet people where they are, overcoming barriers to care vis-à-vis vaccine access. This philosophy informed the campaign’s efforts in (a) education, identifying prominent sources of mis/disinformation and streamlining messaging and (b) vaccine delivery, pinpointing areas where people already worked and lived, offsetting transportation barriers and time poverty. The idea of “meeting people where they are” extends to what services were offered in the first place. In order for the vaccine to come to the forefront of people’s concerns, CHWs needed to address social, economic, and mental health impacts of the pandemic—and its disparate impact—by actively seeking out community members and attending to their needs through direct service and policy advocacy. CHWs “didn’t wait for them to come to the clinic,” as one CHW astutely noted during a focus group, which draws attention to the fact that while community clinics and CBO partners have physical infrastructure in communities rendered most vulnerable, it is insufficient. Effective responses depend on action at the neighborhood-level, guided by the expertise of those in the community, like CHWs, to (a) provide peer support and direct services, (b) develop swift and strategic interventions that consider the needs and challenges of this specific community rather than relying on blanket narratives or assumptions (e.g., vaccine hesitancy among communities of color), (c) advocate for policy change at the organization/agency and municipal/county/state levels, and (d) gather community feedback to adapt and improve interventions to meet community needs. This underscores the role of CHWs as accompagnateurs, a key function of CHWs well established by Farmer and colleagues at Partners in Health [32], but also as agents of social change and community activation. This crucial role makes CHWs well positioned to respond in times of crises but also work towards long-term recovery and rebuilding, fostering community resilience.

The effectiveness of CHWs is threatened by funding instability—a point of discussion that was raised in most focus groups, among both community members and CHWs alike. Current financing models of CHW programs depend on cyclical grant funding, which affects (a) CHWs’ direct financial wellbeing, who are often paid substandard wages and face hour reductions, both of which cause economic uncertainty and precarity and (b) community members, who are left with lingering needs beyond the grant period, which would later create barriers for CHWs to build and renew trust. This notably impairs program sustainability, hampering progress towards health equity and eroding community trust, emphasizing the need for sustainable funding models that invest in maintaining the presence of CHWs in neighborhoods.

Recent successes of CHW models in COVID-19 response have brought renewed attention to funding for CHW models [33, 34]. These calls draw on the extant evidence base that demonstrate the cost-effectiveness of CHWs for health systems and payers, citing a positive return on investment (ROI) for Medicaid by addressing patients’ social determinants of health (SDoH) [35]. To institutionalize the CHW workforce and solidify funding models via Medicaid reimbursement, states must develop plans that outline (a) services CHWs can provide, (b) supervision and oversight requirements for the CHW workforce, (c) payments and rates, and (d) requisite training, experience, and credentialing for CHWs [36]. Mechanisms do exist to cover certain pathways of care provided by CHWs, often linked to chronic disease management [37], but efforts related to building community resiliency—often efforts that require significant time investment in building trust with the community—are not considered reimbursable services. Steps are needed to formalize and expand mechanisms of continuous, sustainable funding for CHW programs. Careful attention should be directed to ensure CHW programs are not medicalized, reducing the area of focus to healthcare alone [22], but instead, remain rooted in community and emphasizing the role of CHWs in community activation and social change.

Conclusions

Community health workers (CHWs) have long served an essential—and cost-effective—role in crisis response and care navigation, but significant expansions have been made to the CHW workforce over the course of the COVID-19 pandemic. The ¡Andale! ¿Que Esperas? (AQE) vaccination campaign invested in the CHW workforce in California, expanding access to and instilling confidence in COVID-19 vaccines among Latinx communities. These findings elucidate the importance of CHWs in both immediate crisis response and long-term recovery, both of which are imperiled by funding instability for CHW programs.