Establishing voluntary certification of community health workers in Arizona: a policy case study of building a unified workforce.

BACKGROUND: Community health workers (CHWs) are widely recognized as essential to addressing disparities in health care delivery and outcomes in US vulnerable populations. In the state of Arizona, the sustainability of the workforce is threatened by low wages, poor job security, and limited opportunities for training and advancement within the profession. CHW voluntary certification offers an avenue to increase the recognition, compensation, training, and standardization of the workforce. However, passing voluntary certification legislation in an anti-regulatory state such as Arizona posed a major challenge that required a robust advocacy effort. CASE PRESENTATION: In this article, we describe the process of unifying the two major CHW workforces in Arizona, promotoras de salud in US-Mexico border communities and community health representatives (CHRs) serving American Indian communities. Differences in the origins, financing, and even language of the population-served contributed to historically divergent interests between CHRs and promotoras. In order to move forward as a collective workforce, it was imperative to integrate the perspectives of CHRs, who have a regular funding stream and work closely through the Indian Health Services, with those of promotoras, who are more likely to be grant-funded in community-based efforts. As a unified workforce, CHWs were better positioned to gain advocacy support from key health care providers and health insurance companies with policy influence. We seek to elucidate the lessons learned in our process that may be relevant to CHWs representing diverse communities across the US and internationally. CONCLUSIONS: Legislated voluntary certification provides a pathway for further professionalization of the CHW workforce by establishing a standard definition and set of core competencies. Voluntary certification also provides guidance to organizations in developing appropriate training and job activities, as well as ongoing professional development opportunities. In developing certification with CHWs representing different populations, and in particular Tribal Nations, it is essential to assure that the CHW definition is in alignment with all groups and that the scope of practice reflects CHW roles in both clinic and community-based settings. The Arizona experience underscores the benefits of a flexible approach that leverages existing strengths in organizations and the population served.

Community Health Representative Workforce: Integration across systems and teams to address the social determinants of indigenous health and wellbeing.

Tribally employed, Community Health Representatives (CHRs) serving Indigenous and American Indian and Alaskan Native (AIAN) peoples are culturally and linguistically embedded community leaders, with the unique ability to serve as the link and intermediary between community members and systems. Unique to the CHR workforce scope of practice is the expectation for high level integration within the medical and social service care team. This explicit role outlined in the scope of work sets an expectation for both CHR and care teams to deliver integrated patient, family, and systems level care coordination and case management. This paper aims to build from our previous manuscript published in Volume 1 of the special issue Community Health Workers Practice from Recruitment to Integration. In that Volume, we explored through a Community Case Study CHR Managers' perspectives on the challenges and opportunities for full CHR integration into health systems and teams serving AIAN. In this paper, we offer new information about the current CHR and CHR Managers' involvements and perceived level of integration within health care teams and the broader public health systems addressing the social and structural determinants of health. We approach this topic considering the COVID-19 pandemic and how CHRs and CHR Programs were included and not included in tribal pandemic response efforts.

Adapting a Cancer Screening Education Program for Native American Women with Disabilities.

Like other minoritized groups, people with disabilities experience lack of access to health care. People with intellectual and developmental disabilities (IDD), which are lifelong disabilities diagnosed in childhood requiring varying levels of support for completing daily activities, are less likely to receive preventive health care such as cancer screening. Furthermore, Native American women are less likely than White women to receive cancer screenings. In this qualitative research with Native American women with IDD, their caregivers, healthcare and service providers, and community leaders, we asked, "What are the influences on breast and cervical cancer screening for Native American women with IDD?" with the goal of adapting an existing cancer screening education program. Semi-structured in-depth interviews (N = 48) were audio recorded and transcribed verbatim for analysis. Two coders used a constant comparative method to code and revise the a priori codebook with subthemes and new codes. Results highlighted individual, interpersonal, and community/institutional influences on screening, emphasizing the individual effects of social inequity on this population, the importance of ableist bias in recommending cancer screenings, and opportunities to integrate traditional ways of knowing with allopathic medicine. Results of this work were used to adapt a cancer screening education program for Native American women with IDD.

Community Health Representative Workforce: Meeting the Moment in American Indian Health Equity.

In 2018, the Community Health Representative (CHR) workforce celebrated their 50th year and serve as the oldest and only federally funded Community Health Worker (CHW) workforce in the United States. CHRs are a highly trained, well-established standardized workforce serving the medical and social needs of American Indian communities. Nationally, the CHR workforce consists of ~1,700 CHRs, representing 264 Tribes. Of the 22 Tribes of Arizona, 19 Tribes operate a CHR Program and employ ~250 CHRs, equivalent to ~30% of the total CHW workforce in the state. Since 2015, Tribal CHR Programs of Arizona have come together for annual CHR Policy Summits to dialogue and plan for the unique issues and opportunities facing CHR workforce sustainability and advancement. Overtime, the Policy Summits have resulted in the Arizona CHR Workforce Movement, which advocates for inclusion of CHRs in state and national level dialogue regarding workforce standardization, certification, training, supervision, and financing. This community case study describes the impetus, collaborative process, and selected results of a 2019-2020 multi-phase CHR workforce assessment. Specifically, we highlight CHR core roles and competencies, contributions to the social determinant of health and well-being and the level to which CHRs are integrated within systems and teams. We offer recommendations for strengthening the workforce, increasing awareness of CHR roles and competencies, integrating CHRs within teams and systems, and mechanism for sustainability.

Factors that support change in the delivery of midwifery led care in hospital settings. A review of current literature.

PROBLEM: In hospital units, the network of interdependent relationships between midwives and doctors has positioned midwives within hierarchical relationships of power. Others argue that the physical layout of hospital wards created by biomedicine makes it difficult for midwives to provide midwifery led care. The aim of this review is to identify factors that support change in the delivery of the midwifery led care in hospital settings. METHODS: A narrative review was chosen as this method allows for greater flexibility in the selection of studies and can lead to the inclusion of a wider range of literature. RESULTS: Eight high quality papers from the UK, Sweden, Canada and Australia were selected for review. Papers focused on improving the delivery of midwife led care in hospital midwifery units, labour and postnatal wards. Key themes were identified as supporting change in the delivery of midwifery led care were ownership of change, capability to change and transformational leadership. CONCLUSION: The findings demonstrate the importance of social support and clinical leadership in bringing about subtle changes in hospital based midwifery led care. Ultimately improved understanding of the factors that support the delivery of the midwifery led care in hospital settings may improve women's choice and highlight the role of the midwife as the practitioner of normal childbirth.

Effecting change in midwives' waterbirth practice behaviours on labour ward: an action research study.

INTRODUCTION: the use of water immersion for labour and birth has been shown to be beneficial for women in normal labour (Cluett et al, 2009). It was decided to use problem solving coordinator workshops to change in the way waterbirth practice was promoted and organised on labour ward. Findings from the first Action Research phase (Russell, 2011) led to the development of a waterbirth questionnaire to measure midwives' personal knowledge of waterbirth practice, waterbirth self-efficacy, social support and frequency of hydrotherapy and waterbirth practice. The aim of this paper is to share the questionnaire findings from an on-going action research study. METHOD: prior to the first workshop 62 questionnaires were distributed to midwives (Bands 5, 6 and 7) working on labour ward. Subsequent questionnaires (n=53) were sent to Bands 5/6 midwives not involved in the workshops, at four (Group 2) and eight months (Group 3). N.B only Bands 5/6 midwives completed post workshop questionnaires. In total 169 questionnaires were distributed. One-way ANOVA with Tukey post-hoc test and the χ(2) test were used to determine statistical significance. FINDINGS: 96 questionnaires were returned (57%). Midwives' personal knowledge of waterbirth practice differed significantly between groups, (F2,85=3.67, p<0.05) with midwives in Group 1 giving significantly higher scores (X¯=45.6, 95% CI [43.0, 48.2]), than those in Group 3, (X¯=41.7, 95% CI [40.0, 43.3]), p<0.05. Midwives' waterbirth self-efficacy did not differ significantly between groups (F2,88=3.15, p>0.05). However scores for social support did differ (F2,75=4.011, p=0.022), with midwives in Group 1 giving significantly lower scores (X¯=8.0, 95% CI [6.4, 9.5]) than those in Group 3 (X¯=10.5, 95% CI [9.4, 11.6]), p=0.016. Fifty-five per cent of Group 1 midwives facilitated a waterbirth in the previous three months compared with 87% in Group 3. Changes in the frequency of waterbirth for these groups were statistically significant (x(2)=4.369, p<0.05, df=1). CONCLUSIONS: it appears that the co-ordinators were able to influence waterbirth practice because of changes in social support and frequency of waterbirth practice. Given the widespread and continued impact of the intervention, on midwives who attended workshops and those that did not, we feel it likely that a significant proportion of this change could be attributed to the introduction of problem solving waterbirth workshop. The findings from this study suggest that problem solving waterbirth workshops based on an action research format have the potential to normalise midwifery care within medically dominated hospital birthing environments.

Clones of Streptococcus zooepidemicus from outbreaks of hemorrhagic canine pneumonia and associated immune responses.

Acute hemorrhagic pneumonia caused by Streptococcus zooepidemicus has emerged as a major disease of shelter dogs and greyhounds. S. zooepidemicus strains differing in multilocus sequence typing (MLST), protective protein (SzP), and M-like protein (SzM) sequences were identified from 9 outbreaks in Texas, Kansas, Florida, Nevada, New Mexico, and Pennsylvania. Clonality based on 2 or more isolates was evident for 7 of these outbreaks. The Pennsylvania and Nevada outbreaks also involved cats. Goat antisera against acutely infected lung tissue as well as convalescent-phase sera reacted with a mucinase (Sz115), hyaluronidase (HylC), InlA domain-containing cell surface-anchored protein (INLA), membrane-anchored protein (MAP), SzP, SzM, and extracellular oligopeptide-binding protein (OppA). The amino acid sequences of SzP and SzM of the isolates varied greatly. The szp and szm alleles of the closely related Kansas clone (sequence type 129 [ST-129]) and United Kingdom isolate BHS5 (ST-123) were different, indicating that MLST was unreliable as a predictor of virulence phenotype. Combinations of conserved HylC and serine protease (ScpC) and variable SzM and SzP proteins of S. zooepidemicus strain NC78 were protectively immunogenic for mice challenged with a virulent canine strain. Thus, although canine pneumonia outbreaks are caused by different strains of S. zooepidemicus, protective immune responses were elicited in mice by combinations of conserved or variable S. zooepidemicus proteins from a single strain.

Net protein oxidation is adapted to dietary protein intake in domestic cats (Felis silvestris catus).

Cats have a requirement for dietary protein two to three times that of omnivores and herbivores. This was reported to be due to the hepatic catabolic enzymes of this species being set to a permanently high level and, therefore, showing little adaptation to low dietary protein. A major mechanism for adapting to dietary protein in other species is amino acid oxidation (hereafter referred to as protein oxidation), and the objective of this study was to determine whether protein oxidation in cats was correlated with protein intake. Net protein and net fat oxidation in six adult cats were studied directly from gas exchanges using indirect calorimetry, after feeding moderate protein (MP; 35% energy) and high protein (HP; 52% energy) diets. Protein oxidation was significantly higher (P < 0.05) when cats were fed the HP diet (28.4 plus minus 0.7 mg/min) rather than the MP diet (20.4 plus minus 0.8 mg/min). Fat oxidation was significantly higher (P < 0.05) when cats consumed the MP diet (9.0 plus minus 0.7 mg/min) rather than the HP diet (4.7 plus minus 0.5 mg/min). Protein oxidation was significantly correlated (linear regression, R(2) = 46.0, P < 0.05) with protein intake such that the mean ratio of 18-h oxidation: 18-h intake was 1.2 on both diets. Fat oxidation was significantly correlated (linear regression, R(2) = 18.9, P < 0.05) with fat intake such that the mean ratio of 18-h fat oxidation: 18-h fat intake was 1.1 (MP) and 0.9 (HP). This study demonstrated that cats adapt net protein oxidation at these levels of protein intake, and the reason for the high dietary protein requirement of this species is, therefore, unclear.