In Teófilo Otoni, Brazil, community health workers like Creude Mendes de Souza play a vital role in connecting people to medical and social services.
Like good friends, Creude Mendes de Souza sits next to Maria dos Anjos Timótio de Souza at a round table covered with a yellow, crocheted tablecloth in Maria’s small home in Teófilo Otoni, Brazil. As light streams through the bars of the open top of Maria’s solid metal front door, Creude asks Maria questions that even the closest of friends would not venture to ask.
Are you on Bolsa Família (welfare)? Are you up to date on your vaccines? Are you taking your high blood pressure drugs? Are your grandchildren eating well? Is your daughter-in-law pregnant? Did you have diarrhea this week? Is the backyard cleaned properly? Do you need to visit the clinic?
When the questions concluded that bright July day, Maria said:
“We try to do everything properly so that there will be no nasty surprises later, right?”
“Exactly,” Creude replied.
As it turns out, Maria was speaking from experience. Before community health workers like Creude began to visit, she was no stranger to “nasty surprises.”
When Maria was pregnant at the age of 16, she started having fainting spells and uncontrollable nose bleeds. Ultimately, Maria was diagnosed with pre-eclampsia, which is characterized by a rapid rise in blood pressure among pregnant women or those who just had their baby. This condition led to a lifetime of chronic kidney disease, high blood pressure and hard-to-control pain for Maria. She also was told she couldn’t have any more children.
Her doctors told her she had to be careful about what and how much she eats and drinks, and that she had to take pills for her high blood pressure. There came a point in her life when it got to be too much for her.
“You know what it's like when people are discouraged? When your life isn’t going anywhere? You cannot eat this, you cannot eat that, that's what went through my mind,” Maria said. “I did not like it, I cried a lot, I not could accept it.”
She became very depressed about her condition and was about to quit treatment. But then she began to get visits from a community health worker, who would check in to see how she was doing and make recommendations for how she could feel better.
Creude said she sees many other seniors in the area like Maria, and they need attention, too. “I stay longer and we talk more,” she said.
“Often, the patient has no one to vent to, no one to talk to,” Creude said. “In most cases, patients want to cry on my shoulder, get things off their chest. I listen and give guidance.”
Having a community health worker like Creude check in on her once a month has helped Maria – and her family – stay on top of issues related to their health and well-being. For example, one of the recommendations to Maria was regular exercise, which was not only good for her overall health, but it also helped control her pain.
“Before I had pain all over,” Maria said. “Nowadays, I exercise at home and the pain is gone.”
And it’s not just that she feels better physically – Maria is more positive in how she thinks and feels about her life.
Creude visits about 200 homes every month. Many of the visits last an hour or even two, as Creude and her clients catch up on each other’s personal lives after they’ve gone through a checklist of questions related to health and wellness. Throughout Brazil, community health workers serve as vital connections between the community and health professionals. The community health workers take their checklist of information back to a clinic nurse to create an overall health strategy for the patient – which sometimes might include arranging for the patient or a family member to come into the clinic for an exam. They also identify potential warning signs of violence, neglect, truancy or drug use, and look for risk factors to overall health such as smoking.
In addition to home visits, community health workers assist connecting patients to relevant health professionals including physicians, nutritionists, physical educators, psychologists, and pharmacists. Community health workers also help those healthcare professionals in a variety of duties at the clinic including support groups, health education, cooking classes, and exercise programs.
The World Health Organization (WHO) sees community health workers as a key strategy to address the growing shortage of clinical health workers like doctors and nurses, particularly in low-income countries or low-income areas within countries.[i] WHO officials see community health workers as vital to achieving Sustainable Development Goals (SDGs),[ii] particularly the goal related to good health and well-being.
One country that has made particularly effective use of community health workers is Brazil, where one out of four of its 200 million residents live in poverty and there are only 17 physicians per 10,000 residents.[iii] In 1994, Brazil established Programa Saúde da Família (Family Health Strategy), a population health initiative based around community health care workers.
As a result of the program, Brazil’s infant mortality rate dropped from 114 deaths per 1,000 live births in 1975 to 19 deaths per 1,000 live births in 2008, and remarkable progress has been made in reducing or eliminating AIDS/HIV, polio, measles, diphtheria and Chagas disease.[iv] Community health workers also are crucial to the government’s response to the Zika virus, dengue fever and chikungunya, providing health advice and incidence reporting and helping the military to identify mosquito breeding sites.[v] Brazil now has 236,000 community health workers as part of 33,000 family healthcare teams, serving nearly two-thirds of Brazil’s population.[vi]
The success of this approach has made Brazil a global leader and role model in community-based healthcare for other countries, including the United States, according to an article in the New England Journal of Medicine.[vii] [viii]
Improving health efficiency for underserved populations and advancing the SDGs are both important to the Medtronic Foundation and are part of the reason why we work with partners to support community health workers around the world.
Bisharo Farah, a community health worker, works for a program in Faribault, Minn., which is about 50 miles south of Minneapolis. The program, which is a partnership between hospitals, clinics and local non-profit organizations with support from the Medtronic Foundation, helps economically disadvantaged people access primary care, free and low-cost medications, health education and wellness programs to better manage their health needs proactively and avoid complications.
There is a significant need for a program like this in Rice County, where Faribault is located, due to residents who are older, uninsured or lack transportation options, Bisharo said. Many of the residents, such as those who emigrated from Somalia, Sudan, Mexico, Central America or other non-English-speaking countries, also face language barriers, she said.
One of Bisharo’s patients, a long-time neighbor, had diabetes. Since this patient could not read or write, she had a hard time making physician’s appointments. She was isolated, rarely leaving her house and with few friends to check in on her.
“She said she was fine on the phone, but we discovered that she was not taking her medications,” Bisharo said. “She was not checking her blood sugars. She was not getting out of the house at all.”
Bisharo began to regularly visit the patient at her home. She introduced her to other neighbors. She convinced her to join a walking group. Finally, the patient began to socialize and exercise. Her health improved and so did her life.
“She called me to tell me, ‘I will pray for you every day for the rest of my life because you have gotten me out of that house,’ ” Bisharo said. “It makes me feel amazing to hear something like that.”
Another example of the power of visiting patients in their homes comes from Tiffany Barnes, a community health worker in the North Market Wellness Resource Center in North Minneapolis. Among other duties, Tiffany makes home visits with people with chronic diseases like diabetes and high blood pressure. Like her community health worker peers, Tiffany tries to get to know what is going on in the patient’s life and provides guidance or helps set up medical appointments.
“When patients come into the hospital or the clinics they don’t tell their doctor everything that’s going on,” Barnes said. At home “they feel more comfortable telling us what’s going on sharing that they don’t have food or transportation to get to the doctor or other personal problems. We get to know what they need on a personal level and we can help them.”
Sometimes, helping is as simple as accompanying a person while they grocery shop. Tiffany has worked with people to teach them how to eat better (less sugar, less salt, more portion control) and promotes a healthy lifestyle, including regular exercise.
Community health workers have made a big difference for Gillian Lovald, a North Market customer. She is exercising, eating better and, if she is having health problems, is no longer is quick to dial 911 – she is more likely to call her primary doctor.
“I do 30 minutes every day of exercise,” she said. “I could be sitting on the couch exercising my legs, standing by the counter cooking, doing leg presses. I didn’t know … that while I’m standing in the kitchen, I could do exercise.”
Too often, the problems in healthcare seem overwhelming and discouraging to those trying to create change. Shortages of doctors and nurses serving underserved populations is real and has a significant impact on the health of those populations. And yet, whether it’s a small city in Brazil, or a rural or urban area in Minnesota, community health workers can make a significant difference in global health one community at a time. Community health workers serve as a health counselor, social worker and friend wrapped into one. They improve their patients’ health and also the quality of their lives. Our support of these individuals and this care model of the future is one of the ways we are trying to expand access to health and ultimately improve health outcomes for underserved populations around the world.
[i] Lehmann U, Sanders D. Community health workers: What do we know about them? The state of the evidence on programmes, activities, costs and impact on health outcomes of using community health workers. WHO (2007). http://www.who.int/hrh/documents/community_health_workers.pdf
[ii] Fairall L, Bateman E. Health workers are vital to sustainable development goals and universal health coverage BMJ (2017); 356
[iii] Novotny L. 3-minute case study: Health workers from the community. AthenaInsight, une 12, 2018 https://www.athenahealth.com/insight/3-minute-case-study-health-workers-community
[iv] Zulliger R. The Community Health Agent Program of Brazil. CHW Central. 2018. http://www.chwcentral.org/blog/community-health-agent-program-brazil
[v] Wadge H, et al. Brazil’s Family Health Strategy: Using Community Health Care Workers to Provide Primary Care. The Commonwealth Fund, Dec. 13, 2016. https://www.commonwealthfund.org/publications/case-study/2016/dec/brazils-family-health-strategy-using-community-health-care-workers
[vi] Macinko J, Harris MJ. Brazil’s Family Health Strategy – Delivering Community-Based Primary Care in a Universal Health System. NEJM (2015) ;372: 2177-2181
[vii] Macinko J, Harris MJ. Brazil’s Family Health Strategy – Delivering Community-Based Primary Care in a Universal Health System. NEJM (2015) ;372: 2177-2181
[viii] Johnson CJ, et al. Learning from the Brazilian Community Health Worker Model in North Wales. Globalization and Health (2013) 9(1):25 ·32.