1. Role of Community Health Representatives in Building Resilience in Native Communities Pathways to Resilience III Conference Pathways to Resilience III Conference Halifax, Nova Scotia, Canada Halifax, Nova Scotia, Canada June 17th-19th, 2015 Teufel-Shone NL, Begay MG, Sabo SJ, Dreifuss HM, Reinschmidt KM and Chico TM

2. History of Community Health Representations (CHRs) In the 1960s, Native communities in the US requested support for local paraprofessionals to improve cross-cultural communication between Native communities and predominantly non-Native health care providers. The Indian Health Service (IHS) funded the CHR Program. Today, CHRs provide services in most of the 566 federally recognized tribes and in many urban centers serving Native clients.

3. Roles and Evaluation CHRs share language and life experiences with community members. CHRs are trained to perform home-based health assessments and culturally relevant health education. Evaluation has focused on patient contact and services. Although their role as health advocates is clearly outlined by IHS, their role as community leaders and change agents supporting healthy behaviors and building community resilience is less well documented.

4. Purpose of Listening Project Gather information to understand CHR in –community advocacy –building community resilience Assess the feasibility of adapting an evidence- based curricula developed by University of Arizona for community health workers serving Hispanic communities to the needs of CHRs

5. Document –CHRs’ experiences and opportunities to engage in community advocacy and resilience by engaging in systems and environmental change –CHRs’ interest in advocacy and resilience training Discuss based on listening outcomes –interest in public health workforce training efforts related to advocacy and resilience Specific Aims

6. Methods Written notes documenting listening sessions with CHR supervisors and CHR of three separate Arizona CHR programs Qualitative analysis of notes to identify common issues within and across listening sessions Outcomes shared with CHR programs Identify next steps in workforce development

7. Results Similarities and difference in CHRs’ role in community advocacy and building resilience were evident

8. Community Advocacy CHRs described: CHRs described: Presenting at township meetings or appealing to local leadership on behalf of clients, families and communities Writing proposals to purchase exercise equipment and solar panels for homes Promoting social engagement –Encouraging community members to attend monthly township meetings –Organizing fun events to bring people together to talk about issues

9. Community Advocacy Topics often addressed environmental health and safety –Creation of bike and walking trails –Expansion of household electricity –Development of wheel chair ramps –Household septic tank cleaning services –Resources and care for homebound elder –Pavement of dirt roads

10. Advocacy CHRs described: Client and community apathy attributed to paternalistic systems of education and health care Absence of proactive culture, e.g., passive patient- provider exchange related to language barrier and fear or mistrust of the system Lack of support systems for HIV/AIDS, cancer, and diabetes outside the clinic Strained relationships: IHS and CHR program

11. Building Community Resilience CHRs interpreted resilience as helping clients and the community to adapt to challenges CHRs engage in the following actions –Encourage and motivate clients and their community to make their voices heard to outside leaders and policy makers –Inform clients and communities to access resources –Combine personal and family support to improve community infrastructure “ When we do something, we bring people to the table and it works out better. We get people involved.”

12. Supporting CHRs to Build Community Resilience Address CHR burn-out by providing –Stress relief training and techniques –Bereavement outlet for CHRs who loose clients Enhance communication skills Address IHS and CHR relation by –Informing providers of CHRs’ ability to improve health care utilization and health literacy –Training clients to effectively interact providers

13. Broad Themes of Advocacy and Resilience in Three CHR Programs CHR advocacy and resilience support is evident at the local level but does not impact system level change CHRs’ skill set as potentially grassroots leaders is not realized or recognized Community apathy is a barrier to change Need for better integration with IHS outreach and collaborations with outside resources

14. Recommendations Recognize and foster CHRs’ experiences and community-based strategies as a local resource Integrate advocacy training into standard CHR preparation programs to enhance community resilience Offer skills to prevent CHR burn-out

15. Acknowledgements We would like to thank the CHR program staff for their time and insights shared in these listening sessions. Funded by –Arizona Area Health Education Centers –Arizona Health Sciences Center Senior Vice President for Health Sciences Office –Center for American Indian Resilience, Grant #: 1P20MD006872 The content is solely the responsibility of the authors and does not necessarily represent the official views of funding agencies.

16. Contact Information Samantha J. Sabo, DrPH, MPH sabo@email.arizona.edu Kerstin M. Reinschmidt, PhD, MPH kerstin@email.arizona.edu Nicolette I. Teufel-Shone, PhD teufel@email.arizona.edu