Acknowledgments
This guide was developed by the CHRs WITH uS! initiative (Community Health Representative Workforce Integration in Tribal Health Systems to Address COVID-19), which is a consortium of Arizona Community Health Representative Programs, the Arizona Advisory Council on Indian Health Care, and Northern Arizona University’s Center for Health Equity Research. These materials are informed by in-depth interviews with CHRs and managers, CHR program and Tribal emergency response plans and policies, and a literature review on CHR integration within public health emergency response plans and efforts. Photo credit: J. Daniel Hud.Prepared by:
Northern Arizona University Center for Health Equity Research
Janet Yellowhair, MPH Research Coordinator
Louisa O’Meara, MPH Research Coordinator Senior
Samantha Sabo, DrPH, MPH Professor Health Sciences
In collaboration with:
Brook Bender Hualapai Tribe Senior Services Department
Marianne Bennett Salt River Pima-Maricopa Indian Community Community Health Services
Fernando Flores Jr. Colorado River Indian Tribes Community Health Representative Program
Joyce Hamilton Hopi Tribe Department of Health and Human Services
Rema Metts Gila River Health Care Corporation Public Health Nursing
J.T. Neva Nashio White Mountain Apache Tribe Community Health Representative Program
Sheryl Taylor Cocopah Indian Tribe Tribal Health Maintenance Program
With review by:
Arizona Tribal Executive Committee Public Health Emergency Preparedness
Arizona Advisory Council on Indian Health Care Tribal Pandemic Coalition Coordinator
Indian Health Service Phoenix Area Community Health Representative - Public Health Nursing Office
Public health emergency preparedness and response
2023 CHR Integration Tools Series, No. 1
Community health representatives in emergency response
The COVID-19 pandemic demonstrated the need for all communities to prepare for public health emergencies, including infectious diseases, pandemics, and natural disasters. Community health workers play a critical role in emergency response efforts and teams, serving as a vital link between official response agencies and local populations. Tribally employed community health workers, called community health representatives (CHRs), are critical to comprehensive Tribal emergency response plans and efforts. Their local expertise, trust-building capacity, and cultural awareness are invaluable to emergency managers’ understanding of the social vulnerability characteristics of their communities and the assurance of equitable risk reduction for all community members.
The Federal Emergency Management Agency (FEMA) identifies community health representatives as part of the following Emergency Support Function (ESF) Annexes:
#6 Mass Care, Emergency Assistance, Housing, and Human Services
#8 Public Health and Medical Services
For more information, visit FEMA Emergency Support Function Annexes.
Key roles for community health representatives in public health emergency response
- Risk communication: Act as a critical link between the health system and the community to provide accurate and culturally competent messaging about response efforts.
- Identification and support: Provide information and services needed to ensure that socially vulnerable populations, such as the elderly, the unhoused, and those with chronic illnesses get the help they need.
- Health promotion and education: Promote effective disease prevention and risk reduction strategies.
- Data collection: Gather health data as trusted members of their communities, to guide equitable response and recovery strategies.
- Logistical support: Assist in the organization and distribution of essential supplies, including vaccines, PPE, food, and water.
During the COVID-19 pandemic…
Community health representatives were highly involved in supporting the priority aims of the Indian Health Service’s Strategic Response (1)
PREVENT
- Organize and carry out effective public education campaigns.
- Deliver food, medication, and other essential supplies to vulnerable residents.
- Support and coordinate vaccination deployment.
DETECT
- Assist with testing events and clinics.
- Distribute home test kits.
- Learn the signs and symptoms of disease.
- Identify high-risk community members.
RECOVER
- Assist with the coordination of health care services (medical supplies, prescriptions, staffing) to support Tribal communities.
- Share best practices.
- Support individual and community resilience.
TREAT
- Monitor clients’ symptoms.
- Support the rapid referral of people who require hospitalization to appropriate services, including transportation.
- Provide follow-up care and assessment.
Community health representatives are a national workforce
The Indian Health Services (IHS) Community Health Representatives (CHRs) Program was developed in 1968 and is the oldest federally funded community health worker workforce in the country. As a highly trained workforce with a nationally recognized scope of practice, more than 1,600 CHRs representing over 250 Tribes operate in all 12 IHS areas.
Community health representatives are a unique workforce
Community health representatives (CHRs) are unique from other health professionals because they often are members of the Tribal community that they serve, speak the same language, and have a deep understanding of the cultural and traditional knowledge of their clients. CHRs improve the social determinants of health and decrease health inequities in Tribal communities. Integrating CHRs in interdisciplinary health teams and interventions is an evidence-based practice. When involved, CHRs improve chronic disease prevention and management, mental health, and utilization and quality of healthcare.
Community health representatives impact the social determinants of health
Social determinants of health are the conditions and factors outside of medical care that play a fundamental role in health and quality-of-life outcomes for a population.(2) As trusted frontline community health workers, community health representatives are highly engaged in activities that improve key social determinants of health, such as:
- access to healthcare
- social and cultural cohesion
- social justice
- environmental quality
- quality housing
- food access
These factors contribute to the health and well-being of individuals and the greater Tribal community.
CHR integration in public health emergency preparedness and response
Download and print checklists
This checklist was adapted from: “Checklist for Administrators, Managers, and Clinicians to Integrate Community Health Workers in Vaccine Outreach, Acceptance, and Distribution Strategies.” Prepared for the Association of Clinicians for the Underserved by the National Association of Community Health Workers. (2021)
Endnotes
(1) IHS Covid-19 Response 100 Day Review. Indian Health Service. (2020) Accessed July 10, 2023. https://www.ihs.gov/sites/coronavirus/themes/responsive2017/display_objects/documents/IHS_COVID_100DayReview.pdf
(2) Office of Disease Prevention and Health Promotion. (n.d.). Social determinants of health. Healthy People 2030. U.S. Department of Health and Human Services. https://health.gov/healthypeople/priority-areas/social-determinants-health
(3) A Playbook for Local Health Departments to Advance CHW Engagement in COVID-19 Response Strategies. The Community-Based Workforce Alliance. (2021) https://communityhealthalignment.org/wp-content/uploads/ 2020/11/CBWA-Playbook-for-CHW-Engagement-Summary.pdf
(4) CHR Standards of Practice. Indian Health Services. (1991) https://www.ihs.gov/ihm/pc/part-3/p3c16/
(5) Resource Guide for Health Centers: Community Health Workers and COVID-19 Vaccine. MHP Salud. (2021) https://mhpsalud.org/portfolio-items/healthcenters-chws/
(6) HIPAA Training and Resources. U.S. Department of Health and Human Services. (2023) https://www.hhs.gov/hipaa/for-professionals/training/index.html
(7) Crisis and Emergency Risk Communication Training. Centers for Disease Control and Prevention. (2018) https://emergency.cdc.gov/cerc/training/index.asp
(8) National Incident Management System (NIMS). Federal Emergency Management Agency (FEMA). (2015) https://training.fema.gov/nims/
(9) National Preparedness Report: December 2022. Federal Emergency Management Agency (FEMA), National Preparedness Assessment Division. (2022) https://www.fema.gov/sites/default/files/documents/fema_2022-npr.pdf
Funding Acknowledgement: This publication was supported by the Centers for Disease Control and Prevention of the U.S. Department of Health and Human Services (HHS) (NU58DP006992) Coronavirus Aid, Relief, and Economic Security Act (“CARES Act”) Public Law 116-136 Public Health Service Act 42 U.S.C. 301(a). The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by CDC/HHS, or the U.S. Government.