Uncovering the Role of Community Health Worker/Lay Health Worker Programs in Addressing

437 Pages·2013·3.73 MB·English

Uncovering the Role of Community Health Worker/Lay Health Worker Programs
in Addressing Health Equity for Immigrant and Refugee Women in Canada:
An Instrumental and Embedded Qualitative Case Study

Sara Torres Ospina

Thesis submitted in partial
fulfilment of the requirements for
the PhD degree in Population Health

Faculty of Graduate and Postdoctoral Studies
University of Ottawa

© Sara Torres Ospina, Ottawa, Canada, 2013
Uncovering the role of Community Health Worker/Lay Health Worker
Programs in addressing health equity for immigrant and refugee women in
Canada:
An instrumental and embedded qualitative case study

Abstract

“Why do immigrants and refugees need community health workers/lay health workers (CHWs) if
Canada already has a universal health care system?” Abundant evidence demonstrates that despite
the universality of our health care system marginalized populations, including immigrants and
refugees, experience barriers to accessing the health system. Evidence on the role of CHWs
facilitating access is both lacking and urgently needed. This dissertation contributes to this evidence
by providing a thick description and thorough analytical exploration of a CHW model, in Edmonton,
Canada. Specifically, I examine the activities of the Multicultural Health Brokers Co-operative (MCHB
Co-op) and its Multicultural Health Brokers from 1992 to 2011 as well as the relationship they have
with Alberta Health Services (AHS) Edmonton Zone Public Health. The research for this study is
based on an instrumental and embedded qualitative case study design. The case is the MCHB Co-op,
an independently-run multicultural health worker co-operative, which contracts with health and
social services providers in Edmonton to offer linguistically- and culturally-appropriate services to
marginalized immigrant and refugee women and their families. The two embedded mini-cases are
two programs of the MCHB Co-op: Perinatal Outreach and Health for Two, which are the raison
d’être for a sustained partnership between the MCHB Co-op and AHS. The phenomenon under
study is the Multicultural Health Brokers’ practice.

I triangulate multiple methods (research strategies and data sources), including 46 days of
participant and direct observation, 44 in-depth interviews (with Multicultural Health Brokers,
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mentors, women using the programs, health professionals and outsiders who knew of the work of
the MCHB Co-op and Multicultural Health Brokers), and document review and analysis of policy
documents, yearly reports, training manuals, educational materials as well as quantitative analysis
of the Health Brokers’ 3,442 client caseload database. In addition, data include my field notes of
both descriptive and analytical reflections taken throughout the onsite research. I also triangulate
various theoretical frameworks to explore how historically specific social structures, economic
relationships, and ideological assumptions serve to create and reinforce the conditions that give rise
to the need for CHWs, and the factors that aid or hinder their ability to facilitate marginalized
populations’ access to health and social services.

Findings reveal that Multicultural Health Brokers facilitate access to health and social services as
well as foster community capacity building in order to address settlement, adaptation, and
integration of immigrant and refugee women and their families into Canadian society. Findings also
demonstrate that the Multicultural Health Broker model is an example of collaboration between
community-based organizations and local systems in targeting health equity for marginalized
populations; in particular, in perinatal health and violence against women. A major problem these
workers face is they provide important services as part of Canada’s health human resources
workforce, but their contributions are often not recognized as such. The triangulation of methods
and theory provides empirical and theoretical understanding of the Multicultural Health Brokers’
contribution to immigrant and refugee women and their families’ feminist urban citizenship.

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Acknowledgements

In one of my colleagues’ PhD defense someone said “it takes a village” for a student to complete a
PhD. This statement could not have been truer in my journey to finish this program. Words of
thanks go to everyone who helped me in so many ways. The participants in my study: the
Multicultural Health Brokers Co-op, the Multicultural Health Brokers, Alberta Health Services
Edmonton Zone and its health professionals, who let me into their world, shared their stories, and
trusted me to share their experiences with others in a scholarly way. I want to specially mention
Yvonne Chiu, Executive Director of the MCHB Co-op, who taught me a lot during my study journey,
and Lorraine Green of AHS, who made it possible for me to navigate the many research structures of
the health system. Thank you.

My thesis supervisor, Denise L. Spitzer, and thesis committee members – Carol Amaratunga,
Caroline Andrew, and Ronald Labonté – have my enduring admiration and respect for their
insightful comments and guidance throughout this process. Thank you. My friends who helped me
in so many ways – with graphic design, Excel and editorial work – even when they were under
pressure with their own jobs, and who also gave me moral support, socialized with me, and all too
frequently had to understand my very limited time for non-academic activities (Madeleine Bachand,
Shellie Bird, Ethel Broder, Jennifer Castro , Alma Estable, Nupur Gogia, Beth Greenhorn, Lois Marion,
Lise Martin, Mechthild Meyer, Marika Morris, Janet Mrenica, Steffi Ortiz, Maguy Robert, John
Young, Xavier Van de Maele, and Bessa Whitmore). Thank you. To my first official editor, Hilary
Burke, for her patience and teachings: Thank you. Thanks also to my university colleagues who were
there to share many narratives on my progress and roadblocks. The PhD program staff (particularly,
Roseline Savage) who were always patient and had clear answers to my queries. Merci. My
daughters, Tamara and Melisa Pubil-Torres, who were always there for me and kept encouraging
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me by saying, “Mom, it is time for you to finish”, and my relatives – my Mom, Alba Lilia Ospina, and
my sisters, Ana, Angelica, Beatriz, Lilia, Lucrecia, Matilde, Oliva, and Rachel Torres, and all my other
extended family – including my nieces and nephews, who are too many to name, but who gave
moral and spiritual support, and also understood why I missed several family gatherings. Mil gracias.
And, my long-time partner, Peter Broder, who listened, supported, and encouraged me in many
ways, but without whom this journey would not have been possible. Thank you.

I am proud to have you in my village and I will endeavor to support and encourage you in future in
any way possible. This phase of my journey is ending, but many others are just beginning. Do count
on me as well.

I also want to mention three people although they are not physically part of my village; they are still
part of this journey. First, Michèle Kerisit, who was a member of my thesis committee until her
passing, and even when she was seriously ill asked me about how I was progressing in my program.
Second, Ana Osorio, a long-time friend and colleague with whom I shared many international
development experiences in El Salvador. Third, my brother, José Sibar Torres, who also did not live
long enough to allow me to tell him that I am done, but with whom I am celebrating in spirit. The
loss of these three people brings to mind a poem of a famous Chilean musician, Facundo Cabral,
who wrote once in Spanish: “El que murió, simplemente Se nos adelantó, porque para allá vamos
todos. Además, lo mejor de él, amor, sigue en tu Corazón”. [Free translation: He/she who died, just
left ahead of us, because we are all going in that direction. What is important is that the best of
he/she stays with us, love, continues to be in your heart].
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Dedication

I dedicate this thesis to my mother who showed me the importance of perseverance, commitment
and loyalty in every aspect of my life. Mother you are my source of strength, love and desire to
achieve the unachievable.
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Table of Contents
Abstract .......................................................................................................................... ii
Acknowledgements ........................................................................................................ iv
Table of Contents .......................................................................................................... vii
List of Tables ............................................................................................................... xviii
List of Figures ................................................................................................................ xix
Definitions ..................................................................................................................... xx
Chapter 1 ........................................................................................................................ 1
Introduction .................................................................................................................... 1
Statement of the problem .................................................................................................... 8
Chapter 2 ...................................................................................................................... 10
Theoretical framework .................................................................................................. 10
Theorizing the Community Health Worker Field in Canada ............................................... 10
Introduction ........................................................................................................................ 10
Situating myself ........................................................................................................ 10
Theorizing Health Brokers’ practice ................................................................................... 17
Multicultural health brokering theory .......................................................................... 17
A health promotion empowerment approach .............................................................. 19
Theorizing authoritative and experiential knowledge .................................................. 21
Theorizing agency and relational autonomy ................................................................. 24
Theorizing feminist urban citizenship ........................................................................... 30
Theorizing Feminist political economy .......................................................................... 34

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The social location of health brokers within Canada’s health human
resources workforce................................................................................................. 40
Gender and class ...................................................................................................... 41
Conclusion .......................................................................................................................... 43
Chapter 3 ...................................................................................................................... 45
Literature Review .......................................................................................................... 45
Who are Community Health Workers and why are they important? ................................ 45
Method ..................................................................................................................... 47
Results ...................................................................................................................... 49
Community Health Workers in Canada and in other countries .................................... 50
The micro view ......................................................................................................... 52
Effectiveness and improving health outcomes ........................................................ 52
Universality and workforce size ............................................................................... 53
CHW activism in the U.S. .......................................................................................... 53
Scope of practice ...................................................................................................... 54
Training ..................................................................................................................... 55
Supervision and technical support ........................................................................... 56
Service provision versus community development ................................................. 57
Cultural approach or concordance workers ............................................................. 58
A global view of CHWs as health human resources workforce ............................... 58
Typology of CHW models in Canada ........................................................................ 61
Characteristics of Canada’s CHW workforce ............................................................ 63
Background on Co-operatives ....................................................................................... 65
An overview .............................................................................................................. 65
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The European experience ........................................................................................ 67
Principles of Health Co-operatives ........................................................................... 68
Successes in establishing worker Co-operatives ...................................................... 69
Internal factors ......................................................................................................... 69
External factors ........................................................................................................ 70
Challenges in sustaining worker Co-operatives ....................................................... 70
Ethnocultural and immigrant Co-operatives ............................................................ 71
Chapter 4 ...................................................................................................................... 73
Research Design ............................................................................................................ 73
About this narrative ............................................................................................................ 73
Research questions ....................................................................................................... 75
Case study theoretical propositions ......................................................................... 76
Selection of the Case ..................................................................................................... 80
Limitations of case study research ........................................................................... 82
Research methodology .................................................................................................. 82
Transformatory-Emancipatory ................................................................................. 82
Research strategies ....................................................................................................... 84
Participant observation ............................................................................................ 84
Direct observation .................................................................................................... 85
Face-to-face in-depth interviews ............................................................................. 86
Sampling ................................................................................................................... 86
Obtaining consent .................................................................................................... 87
Transcription of interviews and note taking ............................................................ 89
Pilot testing and interviewing .................................................................................. 90
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Document review ..................................................................................................... 90
Archival data............................................................................................................. 91
Health Brokers caseload database ........................................................................... 91
The choice of pseudonyms ....................................................................................... 93
Coding and analysis .................................................................................................. 93
Theoretical triangulation .......................................................................................... 95
Field notes ................................................................................................................ 95
Ensuring scientific quality/Trustworthiness ............................................................. 96
Member checking ..................................................................................................... 96
Methodological strengths and drawbacks ............................................................. 100
Critical reflexivity .................................................................................................... 100
Chapter 5 .................................................................................................................... 102
The Multicultural Health Brokers Co-operative: The Case ............................................. 102
Targeting health equity by integrating theory, practice, and democratic
principles .......................................................................................................................... 102
A holistic approach ........................................................................................................... 102
How this Chapter is organized ............................................................................... 104
Gender composition of Health Co-op members and workers ............................... 105
a) Developing a market niche ................................................................................ 105
Health Co-op’s Programs summary ....................................................................... 107
Participating in research with academic institutions ............................................. 113
Creating social enterprises (small business) .......................................................... 114
Creating a sister organization with charitable status ............................................. 115
b) Enhancing the internal capacity of the organization ......................................... 116
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