Results are organized into two main sections. The first main section discusses salient qualities of the CHW-client relationship and is comprised of three sections describing sub-themes that emerged for the core concept “building trust-based relationships.” The second main section describes the numerous ways this trust-based relationship impacted the health and well-being of clients.
Salient Aspects of the CHW-Client Relationship
Many participants used words such as “trust” and “like family” to describe their relationships with CHWs, attesting to the closeness of the connections formed over the course of the CHW intervention. Three key sub-themes emerged as critical to the formation of meaningful CHW-client connections: emotional attendance, authenticity, and prioritization of clients’ needs.
Sub-theme 1: Emotional attendance
Emotional attendance took many forms in CHW-client interactions: Clients consistently reported that they formed strong personal bonds with CHWs as a result of CHWs’ "emotional support,” “listening/communication,” and “just being there.” For some mothers, a shared emotional and spiritual connection was comforting. This connection was particularly important for clients with few other sources of support.
That’s the biggest part for me, that she’s there for me mentally, she’s there for me emotionally and in some ways, on a spiritual connection we can converse, we can connect. And that’s the biggest thing for me…the spiritual part. It helps keep you grounded, and in your struggles, I’m not by myself anymore. (Client, Philadelphia)
Other clients reported receiving affirmation or reassurance around stressful issues, and in some cases credited the CHW with preventing the onset of postpartum depression. Many participants explicitly discussed the value of talking through problems with their CHW, and of CHWs being good listeners. This open communication served to not only strengthen the CHW-mother bond, but also relieved stress and provided comfort.
She came …to make sure I was ok, to make sure I wasn’t stressed, to make sure I didn’t go through postpartum [depression]. And she basically did all of those things and plus a little more. You know, whenever I needed to talk she was there to listen. (Client, Philadelphia)
Me having multiple kids at home, I don’t wanna be in depression or stressed out, you know, when I give birth. So being able to talk about some of the issues that I’m dealing with that are personal and she’s like, “I’ll help you with that,” “We can research this together,” “We can do this together,” you know, “I’ll try to figure it out with you,” “You’re not alone.” (Client, Philadelphia)
For the subsample of immigrant clients, who generally reported feeling isolated in a US context, CHW companionship was an especially important aspect of care.
If they [CHWs] were not there…really, today, it would be better for me to go back to my own country, even if I suffer there, than to stay here. Because she really helps a lot. Yeah. If you have them, you do not have your mom, your dad, you will be satisfied, you will not even know that you are lacking something because you have someone to talk to at any time when you have the need to share something. Human beings cannot hold everything inside, it must often be shared and she [the CHW] is there. They really listen and they give advice. (Client, New York City)
CHWs recognized the importance of fostering trust and reported being very deliberate in how they built rapport with clients. They emphasized taking specific, intentional measures to establish an open and comfortable environment with clients, who, in turn, reported CHWs took a genuine interest in their lives and were "easy to talk to.””
You gotta understand that some of the moms are already being dictated and told what to do and how to do it. And they’re tired. They are tired of hearing it…. When we sit there, we sit back and just pause for a moment and just listen to them. It makes them feel comfortable…. So I think those doors are open when you sit back and just not try to dictate and tell them what to do. (Community health worker, Philadelphia)
She was really pleasant and awesome… it’s hard to stick with someone, especially in situations where you need help, you need… someone to talk to, and you need to be directed to the right places, and she was just extremely easy to talk to… I think that was probably the best part. Like, I was extremely comfortable. (Client, Camden)
In general, the benevolent behaviors on the part of CHWs characterized here as ’emotional attendance’ led clients to trust and feel comfortable with CHWs, which in turn enabled future interactions that more firmly established trust and closeness. This positive feedback loop, in which the trustee consistently meets or exceeds the expectations of the trustor, forms the basis of trust development in interpersonal relationships [30].
Sub-theme 2: Authenticity
By definition, CHWs are members of and/or have an unusually close understanding of the community they serve. Several CHWs in this study discussed similarities between themselves and their clients. Their motivation to engage in this work stemmed, in part, from this shared understanding with clients.
We kill ourselves with our clients. We have to love what we do to continue to do it. Because we ourselves have trouble feeding our families. So we are not too farfetched from the clients that we help. We don’t do this because we are going to get rich. We do this because we love it. (Community health worker, New York)
CHWs were described by clients as being authentic, selfless, and compassionate. Their consistent understanding and patience showed clients that they were motivated by a desire to help them achieve their goals, rather than by self-interest. This was particularly meaningful for women who had felt judged by providers in the past.
… it’s not like she [the CHW] feels pressured to do it… I mean she volunteers to help. When you don’t have nobody in your corner, when you don’t have no support system, this like goes a long way. She’s helped me in numerous ways that I needed. (Client, Philadelphia)
… never once did it [participating in the CHW program] make me feel like less of a woman or less of a mom for coming from that background [history of substance use]. That’s a huge thing. You can ask any addict like just someone treating you like a totally normal person… it makes a world of difference. (Client, Camden)
Sub-theme 3: Prioritization of clients’ needs
CHWs’ scope of practice addresses a broad range of pregnant women’s medical and social needs (i.e., instrumental, informational, emotional). Clients’ needs determined the services provided, and CHWs were described as going "above and beyond” to help their clients in any way possible. The prioritization of clients’ needs and flexibility in services offered based on those needs were factors mothers talked about as helping them build close, trusting relationships with CHWs.
She helps with everything, it’s amazing. It’s a really good service, it’s for the people. (Client, Camden)
Clients described CHWs as always being present with them—whatever else they might have going on, the client felt like the CHW was fully there to support her:
She never came sad. She’s always happy, always smiling. She never let her outside business interfere with us…. (Client, Camden)
CHWs’ flexibility and availability—their willingness to work around a client’s schedule, meet her anywhere she needed, and let her needs and priorities determine the content and timing of interactions—reinforced the sense that the client was the CHW’s top priority.
…what makes this program work for me is they adjust to my schedule. Like if she’s [the CHW is] like, “Oh well what’s best for you, you wanna go meet here? I can meet you.” They’ll come and meet you at your appointments and everything. (Client, Philadelphia)
CHW Impact
Women have diverse medical, as well as social and psychological, needs during pregnancy. The support they received from CHWs fell into three broad categories—instrumental, informational, and emotional—and, according to clients, resulted in greater engagement with the healthcare system, improved health behaviors, and reduced stress.
Multiple clients reported that CHWs provided material goods they needed for their baby or other children when obtaining those things themselves would have been burdensome or unfeasible. Such items included diapers, breast pumps, clothing, car seats, toys, and furniture.
When the baby was in the hospital, it was like 12 days, they went to my house and brought me a crib, a stroller, they brought me a car seat because I didn’t have one. They brought me baby bottles, clothes. I didn’t have any of that. (Client, New York City)
Beyond the provision of material goods, CHWs supported timely and appropriate access to care by assisting clients with scheduling and attending medical appointments, including by accompanying them to visits or facilitating transportation. Some clients reported that their CHW reminded them to adhere to medication regimens.
‘Cause there is a lot of women out there that could need a little push. That’s what it is too, it’s like a push for us. Her [CHW] making our appointments. Her calling us. If she didn’t do that I would never show up. (Client, Camden)
I have seizures. And I was kinda like, I don’t even know how to say it, neglecting them? Like, putting them off? Cause they’re not like…[a] major issue and once I got pregnant, um… the neurologist I usually go to was a little far, and she [CHW] helped me find a neurologist that was closer. (Client, Camden)
CHWs were also instrumental in helping clients obtain important documentation, such as birth certificates and personal identification cards, and apply for jobs and stable housing.
And they’re [CHWs] not there to just help with the baby. They help you with your other children, they help you with other things you need. Like other issues you have in life and that’s like, that’s what I really like most about the program. (Client, Philadelphia)
I ask them what are the three goals that they [clients] would like to work on as part of the program. So, if it’s housing or something like that, we’ll look for it on Craigslist, different ads, or we’ll get one of our housing specialists to come out and help them…. We’ll connect them to social services so they can get income, social security cards, or certificates…. (Community health worker, Camden)
CHWs provided health education and skills-building to empower clients to better manage their chronic health conditions and improve their health behaviors. Topics covered included nutrition, physical activity, breast feeding, medications, and self-care.
They’ve [CHWs] offered me nutrition classes and I’ve come to those. They also support you with breastfeeding. I have changed the way I eat thanks to one of those programs they offer…. They had one about juices, juices and soda. Wow. I learned a lot of things that day that I had no clue about. After that day, I tried to drink more natural juices…. And water, lots of water. No soda, in our house we don’t drink soda. We have made a lot of changes…. And for her [daughter], for her when she grows up she knows how to eat right. (Client, New York City)
I’m happy with it [CHW program] because it has helped me a lot. I have maintained my blood sugar because it was very high and she taught me about vegetables and stuff.” (Client, New York City)
Clients universally described feeling that CHWs were always there for them, especially in times of need, which in turn enabled them to take steps to address stressors they faced in daily life.
… she make me feel so, so, so, so secure and that I have somebody to talk to and somebody to help me out. And really, really looking out like [for me], like I never thought [possible] before. So yeah I feel very, very confident that we’re gonna get, I’m gonna get my stuff done, my stuff together. (Client, Philadelphia)
Many women expressed a desire to continue communicating with their CHW indefinitely, a testament to the high value women placed on relationships with CHWs.
I’m really grateful. Because it [the CHW program] has helped a great deal. And I’m gonna say this for the record, [CHW] has been my rock for the past five months. And I hope, you know even I don’t know how long the program runs for, but I always want her to be a part of my life. (Client, Philadelphia)
Regardless of the duration, CHWs and clients viewed their relationships as having long- lasting impacts.
Because we not only impact the women, but the family as a whole. And it’s also work that is generational. What we teach them, they go and they teach their daughters or their sons or another family member. So we not only touch them, but we touch everybody else that they touch. And that’s what makes me want to do this kind of work. (Community health worker, New York City)
…it is like a dose of courage that we come to get [from CHWs] every week to continue for the rest of the week, to confront other things and matters of everyday life that they would not be able to manage by themselves. And every week, we are in a hurry to come and give an account of what we have done, how we have improved. And each one of us today can remember her first day here, in which condition she came in, and where she is at today…we really feel an improvement, not only in terms of health or maternal protection but in terms of the overall living environment. (Client, New York City)