Community Trust and Credibility (Cont.) Community vs. Employer Accountability

[SPEAKER]

Like all professions, CHWs have a set of values concerning ethical obligations to the individuals they serve and how to balance those obligations with responsibilities to an employer.

Because relationship is so central to effectiveness, the CHW must be on guard to effectively balance creating and maintaining good relationships with the need to meet assigned objectives. She must monitor the quality of her relationships but also think of “getting the numbers”; that is, delivering the interventions or results expected by her supervisor. If she spends all of her time and attention on task and results, she risks alienating the people she serves, but if she spends all her time on relationship, she may never get the results for which she is responsible.

CHWs cannot be effective without a strong sense of commitment to the community they serve. But if they are also responsible to an employer who provides a paycheck, they can find themselves balancing conflicting values and accountabilities. The employer may ask the CHW to provide services that the community does not regard as a high priority or, in a more extreme case, that the community regards as risky or dangerous, such as promoting immunizations.

Traditionally, Latin American promotores are grassroots volunteers who defined the community’s priorities and learned the skills necessary to help pursue those priorities. Few CHWs employed by U.S. health care institutions have the same latitude to define and pursue community interests. This difference has led some in the U.S. to describe promotores as fundamentally different from CHWs, even though the CHW occupation grew in part out of the promotora tradition.

National leaders in the CHW movement are attempting to gain acceptance for the term “CHW” as an umbrella category including promotores. The most accurate depiction of the accountabilities of CHWs is probably a continuum with grassroots volunteer CHWs and promotores at one end, accountable only to the community, and CHWs who are primarily accountable to an employer at the other end. In practice, most CHWs operate somewhere toward the middle.